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van Gestel LC, Adriaanse MA, Kanis SL, Mensink-Bout SM, Schoones JW, Numans ME, Kiefte-de Jong JC, van den Brink G. Determinants of and interventions for Proton Pump Inhibitor prescription behavior: A systematic scoping review. BMC PRIMARY CARE 2024; 25:208. [PMID: 38862886 PMCID: PMC11165893 DOI: 10.1186/s12875-024-02459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Proton Pump Inhibitors (PPI) are frequently prescribed. Long-term use is associated with side-effects and patients often lack a valid indication. Inappropriate PPI prescribing thus needs to be addressed. This review aims to scope 1) what determinants are studied as reasons for PPI prescribing, 2) what strategies are used for changing PPI (de)prescribing, and 3) whether important determinants are addressed in these interventions. METHODS We searched eight databases for papers on determinants of physician PPI prescribing. Studies were included if they were conducted in a Western country and focused on oral PPIs for an adult population. By following the Behaviour Change Wheel, we extracted information regarding PPI prescribing behavior, behavioral determinants and intervention strategies. FINDINGS We included 74 papers. Most focused on the determinants knowledge and beliefs about consequences. The latter was consistently related to PPI prescribing. Results for knowledge were mixed. Most interventions used education or enablement (e.g., algorithms, quality check improvements, involvement of pharmacists) as strategies. Enablement consistently improved PPI prescribing, while results for education were mixed. INTERPRETATION There is an overemphasis on reflective processes in studies on PPI prescribing. Future research should comprehensively identify behavioral determinants, focusing on reflective and impulsive processes, such that interventions can address the most important determinants.
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Affiliation(s)
- L C van Gestel
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands.
| | - M A Adriaanse
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S L Kanis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - S M Mensink-Bout
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J W Schoones
- Directorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - J C Kiefte-de Jong
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - G van den Brink
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Zhao JL, Tofani C, Infantolino A. An Updated Review and a Case Report: Stress Ulcer Prophylaxis. Cureus 2024; 16:e60811. [PMID: 38910681 PMCID: PMC11190804 DOI: 10.7759/cureus.60811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/25/2024] Open
Abstract
After encountering a unique patient case, we revisit the updated literature on stress ulcer prophylaxis with more updated studies. A 47-year-old male came to the hospital and was found to have acute cholecystitis. After undergoing urgent cholecystectomy, the patient developed melena and a 6 mg/dL drop from 12.5 g/dL to 6.5 g/dL in hemoglobin. He was found to have a gastric ulcer and was started on a proton pump inhibitor, which posed the question of whether or not stress ulcer prophylaxis was indicated. Therefore, the pathophysiology of stress ulcer prophylaxis is refreshed, discussing the various mechanisms through which stress ulcers form in a clinical context. Then, the main risk factors and indications for stress ulcer prophylaxis are defined based on current literature, further investigating whether or not stress ulcer prophylaxis has shown benefit and protection in various patient groups. Additionally, this review discusses the adverse effects of stress ulcer prophylaxis, including dysbiosis, community-acquired pneumonia, nutritional deficiencies, drug interactions, and fractures. Finally, inappropriate stress ulcer prophylaxis and contributing factors to overutilization are discussed, and alternative approaches to prevent stress ulcer formation are covered, including early enteral nutrition. Overall, there are mixed conclusions on the effectiveness of stress ulcer prophylaxis in noncritical patients. There are many adverse effects and unnecessary costs associated with inappropriate administration, and many studies have found that it should be reserved for specific clinical indications.
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Affiliation(s)
- Joy L Zhao
- Department of Gastroenterology and Hepatology, Sidney Kimmel Medical College, Philadelphia, USA
| | - Christina Tofani
- Division of Gastroenterology and Hepatology, Cooper University Hospital, Mount Laurel, USA
| | - Anthony Infantolino
- Division of Gastroenterology and Hepatology, Cooper University Hospital, Mount Laurel, USA
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Tsige AW, Beyene DA, Wondmkun YT, Endalifer BL, Habteweld HA, Gebretadik FA, Gebeyehu AA, Azene BA, Alamneh MA, Tesfaye DZ, Fered MA, Girma MT, Mekonen MB, Dessie TY, Ayele SG. Assessment of the appropriateness of stress ulcer prophylaxis use and its determinants among admitted surgical patients at Debre Berhan University Hakim Gizaw Hospital, Ethiopia. A hospital-based cross-sectional study. Front Med (Lausanne) 2024; 11:1345144. [PMID: 38646554 PMCID: PMC11026640 DOI: 10.3389/fmed.2024.1345144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/07/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction Pharmacological stress ulcer prophylaxis (SUP) has been recommended for many years to reduce the risk of clinically significant upper gastrointestinal (GI) bleeding caused by stress ulcers (SUs). Stress-related ulcer bleeding in surgical patients significantly increases morbidity and mortality. Therefore, preventing stress-induced hemorrhage is the most appropriate measure for patients who are at increased risk. However, the inappropriate use of SUP has increased in recent years, and its use in Ethiopian surgical patients has not been well studied. Objective The aim of this study was to assess the appropriateness of SUP use and its determinants among admitted surgical patients at Debre Berhan University Hakim Gizaw Hospital (DBUHGH), Ethiopia. Methods We randomly selected 230 patients from the whole cross-sectional group of all surgical patients at DBUHGH from 1 February to 30 June 2023. The risk of stress ulcer (SU) development was assessed using the modified American Society of Health-System Pharmacists (ASHP) guidelines. For data analysis, we used SPSS version 25. Results The mean age of study participants was 47.2 years (SD ± 20.4), and out of the total of 230, 130 (56.5%) were women. Approximately 66% of study participants took inappropriate SUP based on ASHP guidelines criteria. The most commonly used drug class for SUP was histamine-2 receptor blockers 115 (50%). Study participants who have a Charlson Comorbidity Index Score of moderate and GI bleeding have been significantly associated with the inappropriate use of SUP. Conclusion In our study, inappropriate SUP use was common in the surgical ward of DBUHGH. This may be an area that requires further and more focused working together among clinical pharmacists and medical professionals in an institution-specific SUP protocol that aids clinicians in identifying appropriate candidates for SUP medication.
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Affiliation(s)
- Abate Wondesen Tsige
- Department of Pharmacy, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Dessale Abate Beyene
- Department of Pharmacy, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | | | - Bedilu Linger Endalifer
- Department of Pharmacy, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | | | | | - Aregahegn Adafir Gebeyehu
- Department of Pharmacy, College of Health Sciences, Debre Berhan Health Science College, Debre Berhan, Ethiopia
| | - Belayneh Abebaw Azene
- Department of Pharmacy, Debre Berhan University Hakim Gizaw Hospital, Debre Berhan, Ethiopia
| | - Misganaw Abebaw Alamneh
- Department of Pharmacy, Debre Berhan University Hakim Gizaw Hospital, Debre Berhan, Ethiopia
| | - Daniel Zebene Tesfaye
- Department of Pharmacy, Debre Berhan University Hakim Gizaw Hospital, Debre Berhan, Ethiopia
| | - Misganaw Aynalem Fered
- Department of Pharmacy, Debre Berhan University Hakim Gizaw Hospital, Debre Berhan, Ethiopia
| | - Mandefro Teje Girma
- Department of Pharmacy, Debre Berhan University Hakim Gizaw Hospital, Debre Berhan, Ethiopia
| | | | - Tigist Yazezew Dessie
- Department of Pharmacy, Debre Berhan University Hakim Gizaw Hospital, Debre Berhan, Ethiopia
| | - Siraye Genzeb Ayele
- Department of Midwifery, School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Casal GL, Bittner EA. Pump the Breaks on the Slide to Harm From Nonindicated Proton Pump Inhibitors After Critical Illness! Crit Care Med 2024; 52:334-337. [PMID: 38240512 DOI: 10.1097/ccm.0000000000006126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
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Crosby A, Jennings JK, Mills AT, Silcock J, Bourne RS. Economic evaluations of adult critical care pharmacy services: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:574-584. [PMID: 37607337 DOI: 10.1093/ijpp/riad049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 07/05/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice. METHODS A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded. RESULTS The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities. CONCLUSIONS Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally.
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Affiliation(s)
- Alex Crosby
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jennifer K Jennings
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anna T Mills
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Jonathan Silcock
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Richard S Bourne
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
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Fan X, Chen D, Bao S, Dong X, Fang F, Bai R, Zhang Y, Zhang X, Tang W, Ma Y, Zhai X. Prospective prescription review system correlated with more rational PPI medication use, better clinical outcomes and reduced PPI costs: experience from a retrospective cohort study. BMC Health Serv Res 2023; 23:1014. [PMID: 37730673 PMCID: PMC10512621 DOI: 10.1186/s12913-023-09931-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Proton pump inhibitor (PPI) abuse poses an overwhelming threat to the allocation of medical resources and places a heavy burden on global medical expenses. In this study, we put forward our prospective prescription review system and evaluated the effects of this system on clinical outcomes, rational medication use and costs related to PPIs. METHODS A retrospective cohort study was conducted in which the included patients were divided into a preintervention group (2019.10-2020.09) and a postintervention group (2020.10-2021.09). To reduce the bias of patients' baseline characteristics, the propensity score matching (PSM) method was employed. The primary endpoints were the incidence of stress ulcers (SUs), the improvement and cure rates of gastrointestinal haemorrhage, the defined daily dose (DDD), the drug utilization index (DUI) and the DDD/100 patient-days. The secondary endpoints included the types of unreasonable medication orders for PPIs, the PPI utilization rate and PPI costs. RESULTS A total of 53,870 patients were included to evaluate the secondary endpoints, and 46,922 patients were paired by PSM and assessed to evaluate the primary endpoints. The number of PPIs used and PPI costs were significantly lower in the postintervention group than in the preintervention group (P < 0.001). The rationality evaluation results showed that the frequency of PPI use and the number of drug interactions were significantly higher in the preintervention group than in the postintervention group (P < 0.01). The proportion of patients taking oral PPIs was significantly increased in the postintervention group (29.30% vs. 34.56%, p < 0.01). For the utilization of PPIs both for prevention and treatment, the DUI and DDD/100 patient-days were substantially decreased in the postintervention group (P < 0.001 and P < 0.05, respectively). The incidence of SUs in the postintervention group was 44.95%, and that in the preintervention group was 51.93% (p < 0.05). CONCLUSION The implementation of the prospective prescription review system on rational PPI use correlated with reduced PPI costs, more rational PPI medication use and better clinical outcomes, and this system is worthy of long-term implementation for further improvement of rational drug use.
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Affiliation(s)
- Xiucong Fan
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Danxia Chen
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Siwei Bao
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Xiaohui Dong
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Fang Fang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Rong Bai
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Yuyi Zhang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Xiaogang Zhang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Weijun Tang
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China
| | - Yabin Ma
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China.
| | - Xiaobo Zhai
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200123, China.
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Forehand C, Keats K, Amerine LB, Sikora A. Rethinking justifications for critical care pharmacist positions: Translating bedside evidence to the C-suite. Am J Health Syst Pharm 2023; 80:1275-1279. [PMID: 37254868 DOI: 10.1093/ajhp/zxad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 06/01/2023] Open
Affiliation(s)
- Christy Forehand
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, and Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Lindsey B Amerine
- Department of Pharmacy, University of North Carolina Medical Center, Morrisville, NC, USA
| | - Andrea Sikora
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, and Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
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Han F, Zhang C, Li T, Song Z, Xu S. Impact of a multifaceted intervention on non-guideline-recommended prescribing of acid suppressive medications for stress ulcer prophylaxis in critically ill patients. Curr Med Res Opin 2023; 39:1077-1084. [PMID: 37409359 DOI: 10.1080/03007995.2023.2233826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/04/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To promote an effective strategy to improve the non-guideline-recommended prescribing (NGRP) of acid suppressive medications for stress ulcer prophylaxis (SUP) in critically ill patients and to evaluate the impact and barriers of a multifaceted intervention on NGRP in critically ill patients. RESEARCH DESIGN AND METHODS A retrospective, pre- post-intervention study was performed in the medical-surgical ICU. This study included pre-intervention and post-intervention period. There was no SUP guideline and intervention in the pre-intervention period. In the post-intervention period, the multifaceted intervention included five features: a practice guideline, an education campaign, medication review and recommendations, medication reconciliation, and pharmacist rounding with the ICU team. RESULTS A total of 557 patients were studied (305 in the pre-intervention group and 252 in the post-intervention group). Patients who underwent surgery, stayed in ICU more than 7 days, or used corticosteroids experienced significantly higher rate of NGRP in the pre-intervention group. The average percentage of patient days of NGRP was significantly reduced from 44.2% to 23.5% (p < .001) by implementing the multifaceted intervention. The percentage of patients with NGRP decreased from 86.7% to 45.5% in terms of all 5 criteria (indication, dosage, IV to PO, duration, and ICU discharge; p = .003). Per-patient NGRP cost decreased from $45.1 (22.6, 93.0) to $11.3 (11.3, 45.1; p = .004). The main barrier influencing NGRP was the factors of the patient, including the concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs), the number of comorbidities, and undergoing surgery. CONCLUSION The multifaceted intervention was effective in improving NGRP. Further studies are needed to confirm whether our strategy is cost-effective.
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Affiliation(s)
- Furong Han
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Zhang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Tong Li
- Intensive Care Unit, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhihui Song
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shanshan Xu
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Sikora A. Critical Care Pharmacists: A Focus on Horizons. Crit Care Clin 2023; 39:503-527. [PMID: 37230553 DOI: 10.1016/j.ccc.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 120 15th Street, HM-118, Augusta, GA 30912, USA; Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.
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10
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Cascone AE, Sullivan J, Ackerbauer K, Patel S, Lindale DK, Tatro H, Feeney ME. Pharmacist-Initiated De-Prescribing Efforts Reduce Inappropriate Continuation of Acid-Suppression Therapy Initiated in the ICU. Am J Med 2023; 136:186-192. [PMID: 36170933 DOI: 10.1016/j.amjmed.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Stress ulcer prophylaxis initiated for intensive care unit (ICU)-specific indications is often continued upon transfer or discharge despite lack of indication. This quality improvement initiative aimed to achieve a 25% reduction from baseline in ICU-initiated acid suppression therapy prescriptions by May 2021. METHODS This initiative was conducted in adult ICU patients at Boston Medical Center from July 2020 through May 2021. A multidisciplinary approach to de-prescribing was utilized, including the implementation of formalized stress ulcer prophylaxis criteria and an electronic handoff tool used to identify patients appropriate for assessment of acid suppression therapy continuation post-ICU stay. The primary outcome measure was the number of discharge prescriptions for ICU-initiated acid suppression therapy. Secondary endpoints included incidence of de-prescribing workflow failures, percentage of acid suppression therapy discharge prescriptions with inappropriate indications, and incidence of stress ulcer-related gastrointestinal bleeding. RESULTS A 55% decrease in ICU-initiated acid suppression therapy discharge prescriptions occurred after implementing the multidisciplinary workflow. The decrease was sustained for 28 weeks through the completion of the study. CONCLUSIONS Implementation of a pharmacist-initiated electronic handoff tool along with provider education and creation of formalized stress ulcer prophylaxis criteria may reduce the number of ICU-initiated acid suppression therapy prescriptions inadvertently or inappropriately continued at discharge.
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Affiliation(s)
- Ava E Cascone
- Department of Pharmacy, Boston Medical Center, Mass.
| | | | | | - Shyam Patel
- Department of Pharmacy, Boston Medical Center, Mass
| | | | - Hayley Tatro
- William Jennings Bryan Dorn: VA Health Care System, Columbia, SC
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Dumlu HI, Sancar M, Ozdemir A, Okuyan B. Impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients: a non-randomized controlled study. Int J Clin Pharm 2022; 44:914-921. [PMID: 35449351 DOI: 10.1007/s11096-022-01394-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/09/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The potentially inappropriate use of the proton pump inhibitors is prevalent in older adults. AIM To evaluate the impact of a clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy in older hospitalized patients. METHOD This parallel nonrandomized controlled study was conducted at an internal medicine service of a tertiary training and research hospital between September 2019 and August 2021. Older patients (≥ 65 years old and received proton pump inhibitors within 48 h of admission) were allocated to two groups according to their number of medical file records, whether odd or even, two groups: control and clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy (including medication reconciliation and medication review) during the hospital stay. Primary outcome measures were the rate of appropriate use of proton pump inhibitors during hospitalization and potentially inappropriate proton pump inhibitor use at discharge. RESULTS The rate of appropriate proton pump inhibitor use during hospitalization was significantly higher in the clinical pharmacist-led program (n = 100) than in the control group (n = 97) (46.4% vs. 79.0%; P < 0.001). The rate of potentially inappropriate proton pump inhibitor use at discharge was significantly lower (61.7% vs. 35.1%; P < 0.05) in the clinical pharmacist-led program among the older patients discharged with a proton pump inhibitor prescription. CONCLUSION A clinical pharmacist-led stewardship program for the appropriate use of acid suppression therapy improved the rate of appropriate proton pump inhibitor use and reduced the potentially inappropriate proton pump inhibitor use during the hospital stay. TRIAL REGISTRATION NCT05113667 (17 October 2021-registered retrospectively).
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Affiliation(s)
- Hatice Ikra Dumlu
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Mesut Sancar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Ali Ozdemir
- Department of Internal Medicine, Health Sciences University, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Betul Okuyan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Marmara University, Istanbul, Turkey.
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Jones CA, Betthauser KD, Lizza BD, Juang PA, Micek ST, Kollef MH. Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study. Hosp Pharm 2022; 57:510-517. [PMID: 35898251 PMCID: PMC9310319 DOI: 10.1177/00185787211061371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Purpose Recent data highlight unclear efficacy and potential negative sequelae of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). Minimizing SUP exposure has pertinent clinical and other implications. This study assessed medication use and clinical outcomes before and after implementation of a practice guideline promoting early discontinuation of SUP in mechanically ventilated ICU patients. Methods Retrospective, single-center, pre-post cohort study within a medical ICU at a large, academic medical center. Adult patients requiring mechanical ventilation and receiving SUP via a histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) were eligible for inclusion. The clinical practice guideline was implemented on January 1, 2020. The impact of implementation was assessed via percent of patient-days with inappropriate SUP. Incidence of clinically important GI bleed was the primary safety outcome. Results A total of 137 pre-guideline and 112 post-guideline patients were included. Comorbidity burden was similar between groups. A higher prevalence of baseline vasopressor receipt (39% vs 67%, P < .01) and acute kidney injury (56% vs 69%, P = .04) was observed in post-guideline patients. Post-guideline patients experienced a significantly lower percentage of patient-days of inappropriate SUP (25% vs 50%, P < .01) as well as higher rates of SUP discontinuation before extubation (71% vs 12%, P < .01) and during ICU stay (93% vs 50%, P < .01). Post-guideline patients observed a significantly lower incidence of SUP at hospital discharge (4% vs 35%, P < .01). No differences in bleeding outcomes were observed, though post-guideline patients experienced longer durations of mechanical ventilation, ICU stay, and hospital stay. Conclusions Implementation of an early SUP discontinuation guideline was associated with significant improvements in SUP prescribing practices. Baseline differences between groups likely explain observed differences in clinical outcomes.
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Affiliation(s)
| | | | | | - Paul A. Juang
- Barnes-Jewish Hospital, Saint Louis, MO, USA
- University of Health Sciences and Pharmacy, St. Louis- College of Pharmacy, Saint Louis, MO, USA
| | - Scott T. Micek
- Barnes-Jewish Hospital, Saint Louis, MO, USA
- University of Health Sciences and Pharmacy, St. Louis- College of Pharmacy, Saint Louis, MO, USA
| | - Marin H. Kollef
- Washington University School of Medicine, Saint Louis, MO, USA
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Li H, Li N, Jia X, Zhai Y, Xue X, Qiao Y. Appropriateness and Associated Factors of Stress Ulcer Prophylaxis for Surgical Inpatients of Orthopedics Department in a Tertiary Hospital: A Cross-Sectional Study. Front Pharmacol 2022; 13:881063. [PMID: 35721126 PMCID: PMC9203048 DOI: 10.3389/fphar.2022.881063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/21/2022] [Indexed: 01/30/2023] Open
Abstract
Background: Stress ulcer prophylaxis (SUP) prescribed in patients admitted to surgical wards with a low risk of stress-related mucosal disease (SRMD) accounted for a considerable proportion of improper use of proton pump inhibitors (PPIs). This study aimed to analyze the appropriateness of SUP prescribing patterns and identify its associated factors in the orthopedics department of a tertiary hospital in the Northwestern China. Methods: In this cross-sectional study, information regarding the demographic and clinical characteristics of 1,200 fracture inpatients who underwent surgical operations from January 2020 to August 2021 were collected from medical records. Established criteria were used to assess the appropriateness of the prescribing pattern for SUP, and the incidence of inappropriate SUP medication was calculated. Logistic regression analyses were used to identify factors associated with inappropriate SUP medication. Results: Approximately, 42.4% of the study population was interpreted as inappropriate prescription of SUP. A total of 397 (33.1%) patients received SUP without a proper indication (overprescription), and the incidence of inappropriate SUP medication was calculated to be 43.11 per 100 patient-days. In addition, 112 (9.3%) inpatients for whom SUP was indicated did not receive SUP (underprescription). PPIs were prescribed in 96.1% of the inpatients who used acid suppression therapy (AST), and intravenous PPIs accounted for 95.3% thereof. In a multivariate logistic regression analysis, age above 65 years and prolonged hospitalization were associated with overprescription of SUP. Increased number of drugs excluding PPIs, the concurrent use of systemic corticosteroids, comorbidity of hypertension, and unemployed or retired status in inpatients were associated with a reduced likelihood of overprescription for SUP. Conversely, prolonged hospitalization, the concurrent use of systemic corticosteroids or anticoagulants, and unemployed status in inpatients were positively associated with underprescription of SUP. Conclusion: There was a high prevalence of inappropriate SUP prescription among noncritically ill inpatients of fracture who underwent surgical operations. We delineated the associated factors with inappropriate SUP medication, which indicated that more information was required for clinicians about rationality and efficiency of their prescribing practices. Effective intervention strategies should be executed by clinical pharmacists to reduce improper SUP medication.
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Affiliation(s)
- Haiyan Li
- Department of Pharmacy, Xi'an People's Hospital (Xi'an Fourth Hospital), The Affiliated Hospital of Northwestern Polytechnical University, Xi'an, China
| | - Ning Li
- Department of Pharmacy, Xi'an People's Hospital (Xi'an Fourth Hospital), The Affiliated Hospital of Northwestern Polytechnical University, Xi'an, China
| | - Xiaoni Jia
- Department of Science and Education, Xi'an Mental Health Center, Xi'an, China.,Department of Pharmacy, Xi'an Mental Health Center, Xi'an, China
| | - Yuyao Zhai
- Department of Pharmacy, Xi'an People's Hospital (Xi'an Fourth Hospital), The Affiliated Hospital of Northwestern Polytechnical University, Xi'an, China
| | - Xiaorong Xue
- Department of Pharmacy, Xi'an People's Hospital (Xi'an Fourth Hospital), The Affiliated Hospital of Northwestern Polytechnical University, Xi'an, China
| | - Yi Qiao
- Department of Pharmacy, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
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14
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Bourne RS, Jennings JK, Panagioti M, Hodkinson A, Sutton A, Ashcroft DM. Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. BMJ Qual Saf 2022; 31:609-622. [PMID: 35042765 PMCID: PMC9304084 DOI: 10.1136/bmjqs-2021-013760] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/14/2021] [Indexed: 12/26/2022]
Abstract
BackgroundPatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.MethodsThe systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations.ResultsSeventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I2=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I2=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I2=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I2=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process.ConclusionsMulticomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.
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Affiliation(s)
- Richard S Bourne
- Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jennifer K Jennings
- Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Maria Panagioti
- National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (PSTRC), School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Alexander Hodkinson
- National Institute for Health Research (NIHR) School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Anthea Sutton
- School of Health and Related Sciences (ScHARR), The University of Sheffield, Sheffield, Sheffield, UK
| | - Darren M Ashcroft
- National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre (PSTRC), School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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15
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Fan X, Chen D, Bao S, Bai R, Fang F, Dong X, Zhang Y, Zhang X, Ma Y, Zhai X. Integrating Multidisciplinary Individualized Medication Recommendations Into the Traditional Pharmacists' Consultation Method: A Retrospective Study Using Propensity Score Matching Analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580221081437. [PMID: 35610968 PMCID: PMC9136448 DOI: 10.1177/00469580221081437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chinese clinical pharmacists consider improving the quantity and quality of consultations to be an important task in providing better pharmaceutical care. To achieve this goal, we developed a clinical pharmacist consultation method using multidisciplinary individualized medication recommendations (MIMRs) and studied the effects of its implementation. A retrospective study of 812 clinical pharmacist-led consultations was conducted. In the pre-intervention group, medication advice was given based on the purpose of the consultation. In the post-intervention group, a consultation method using MIMRs was implemented, in which clinical pharmacists with specialties in anticoagulation, gastroenterology, and nutrition were asked to give individualized medication recommendations. Outcomes, including the effectiveness rate of consultations (ERC) and acceptance rate of consultations (ARC), were compared between the two groups using propensity score matching method. Patterns and numbers of consultations and individualized medication recommendations were also compared. The results showed that the ERC in the post-intervention group compared with the ERC in the pre-intervention group was 83.3% vs 74.0%, respectively (P < .05). Significant difference was also shown between the two groups in ARC (98.4% vs 92.2%, P < .05). The total number of consultations increased, as did the number of general consultations, multidisciplinary/difficult consultations, anti-infection consultations, and non–anti-infection consultations specifically. As a result, we proposed that the implementation of MIMRs can improve the effects of treatment and increase the number of consultations by pharmacists, which is worthy of further promotion to better serve physicians and patients.
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Affiliation(s)
- Xiucong Fan
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Danxia Chen
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Siwei Bao
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Rong Bai
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Fang Fang
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Xiaohui Dong
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Yuyi Zhang
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Xiaogang Zhang
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Yabin Ma
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
| | - Xiaobo Zhai
- Department of Pharmacy, 66324Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200123, China
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16
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Rech MA, Gurnani PK, Peppard WJ, Smetana KS, Van Berkel MA, Hammond DA, Flannery AH. PHarmacist Avoidance or Reductions in Medical Costs in CRITically Ill Adults: PHARM-CRIT Study. Crit Care Explor 2021; 3:e0594. [PMID: 34913039 PMCID: PMC8668016 DOI: 10.1097/cce.0000000000000594] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To comprehensively classify interventions performed by ICU clinical pharmacists and quantify cost avoidance generated through their accepted interventions. DESIGN A multicenter, prospective, observational study was performed between August 2018 and January 2019. SETTING Community hospitals and academic medical centers in the United States. PARTICIPANTS ICU clinical pharmacists. INTERVENTIONS Recommendations classified into one of 38 intervention categories (divided into six unique sections) associated with cost avoidance. MEASUREMENTS AND MAIN RESULTS Two-hundred fifteen ICU pharmacists at 85 centers performed 55,926 interventions during 3,148 shifts that were accepted on 27,681 adult patient days and generated $23,404,089 of cost avoidance. The quantity of accepted interventions and cost avoidance generated in six established sections was adverse drug event prevention (5,777 interventions; $5,822,539 CA), resource utilization (12,630 interventions; $4,491,318), individualization of patient care (29,284 interventions; $9,680,036 cost avoidance), prophylaxis (1,639 interventions; $1,414,465 cost avoidance), hands-on care (1,828 interventions; $1,339,621 cost avoidance), and administrative/supportive tasks (4,768 interventions; $656,110 cost avoidance). Mean cost avoidance was $418 per intervention, $845 per patient day, and $7,435 per ICU pharmacist shift. The annualized cost avoidance from an ICU pharmacist is $1,784,302. The potential monetary cost avoidance to pharmacist salary ratio was between $3.3:1 and $9.6:1. CONCLUSIONS Pharmacist involvement in the care of critically ill patients results in significant avoidance of healthcare costs, particularly in the areas of individualization of patient care, adverse drug event prevention, and resource utilization. The potential monetary cost avoidance to pharmacist salary ratio employing an ICU clinical pharmacist is between $3.3:1 and $9.6:1.
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Affiliation(s)
- Megan A Rech
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL
| | - Payal K Gurnani
- Department of Internal Medicine, Rush Medical College, Chicago, IL
| | - William J Peppard
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Keaton S Smetana
- Department of Pharmacy, Ohio State University Medical Center, Columbus, OH
| | | | - Drayton A Hammond
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL
- Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL
- Department of Internal Medicine, Rush Medical College, Chicago, IL
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
- Department of Pharmacy, Ohio State University Medical Center, Columbus, OH
- Department of Pharmacy, Erlanger Medical Center, Chattanooga, TN
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Alexander H Flannery
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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17
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Xu P, Yi Q, Wang C, Zeng L, Olsen KM, Zhao R, Jiang M, Xu T, Zhang L. Pharmacist-Led Intervention on the Inappropriate Use of Stress Ulcer Prophylaxis Pharmacotherapy in Intensive Care Units: A Systematic review. Front Pharmacol 2021; 12:741724. [PMID: 34759821 PMCID: PMC8573417 DOI: 10.3389/fphar.2021.741724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Pharmacist's direct intervention or participation in multidisciplinary management teams can improve the clinical outcome and quality of life of patients. We aimed to determine the effectiveness of pharmacist-led interventions on the inappropriate use of stress ulcer prophylaxis (SUP) pharmacotherapy in intensive care units (ICUs). Methods: A systematic review was performed for relevant studies using searched PubMed, EMBASE (Ovid), the Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and four Chinese databases from the establishment of databases to 12 March 2020. We conducted a descriptive analysis of participants, the intervention content and delivery, and the effects on inappropriate medication rates. Results: From 529 records, 8 studies from 9 articles were included in the systematic review. The time of appropriateness judgment and the criteria of "appropriate" varied from included studies. Pharmacist interventions mainly included clarifying indications for SUP pharmacotherapy, education and awareness campaign, reviewed patients on SUP pharmacotherapy during rounds, and adjustments of drug use. Five (62.5%) studies found a significant intervention effect during hospitalization, while 2 (25%) studies at ICU transfer and 2 (25%) studies at hospital discharge. 4 (50%) studies identified the complications related to SUP pharmacotherapy and found no significant difference. 4 (50%) studies declared the pharmacist-led interventions were associated with cost savings. Conclusion: Pharmacist-led intervention is associated with a decrease in inappropriate use of SUP pharmacotherapy during hospitalization, at ICU transferred and hospital discharged, and a lot of medical cost savings. Further research is needed to determine whether pharmacist-led intervention is cost-effective.
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Affiliation(s)
- Peipei Xu
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiusha Yi
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Cuitong Wang
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Keith M Olsen
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Mingyan Jiang
- Department of Pharmacy, the First Hospital of China Medical University, Shenyang, China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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18
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Current Practice of Stress Ulcer Prophylaxis in Surgical Departments in Mecklenburg Western Pomerania, Germany. Healthcare (Basel) 2021; 9:healthcare9111490. [PMID: 34828536 PMCID: PMC8625761 DOI: 10.3390/healthcare9111490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/31/2021] [Accepted: 10/31/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Despite the growing concern over its potentially severe side effects and considerable economic burden, stress ulcer prophylaxis (SUP) is still frequently prescribed to patients in medical non-intensive care units. Recent data indicate that the situation is similar in surgical departments. Currently, data on the concepts within and regulation of routine SUP practice in surgical departments are sparse. The present study was designed to examine the current practice of SUP in Mecklenburg West Pomerania, Germany, and to identify possible reasons for the dissociation of medical literature and clinical practice. Methods: A questionnaire-based survey was conducted to elucidate current SUP practices in surgical departments of acute care hospitals in Mecklenburg Western Pomerania, Germany. Results: In most surgical departments (68%), a standard operating procedure (SOP) for SUP had not been developed. In departments with an existing SOP, 47.6% of responding medical staff members (MSM) with prescribing authority did not know of its existence. Of the MSMs aware of the existence of an SUP-SOP, only 42.9% indicated that they were familiar with its content. Critical re-evaluation of SUP indications upon transfer from the intensive care unit (ICU) to the general hospital ward (GHW) and before hospital discharge was performed frequently or systematically by only about half of the responding MSMs. Discussion: In the face of continued massive over-prescription of SUP in the perioperative routine, the development of easy-to-use local guidelines and their strict implementation in the clinical routine, as well as intensified medial education on this subject, may be effective tools to reduce acid-suppressive medication (ASM) associated side effects and economic burden.
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19
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Blackett JW, Faye AS, Phipps M, Li J, Lebwohl B, Freedberg DE. Prevalence and Risk Factors for Inappropriate Continuation of Proton Pump Inhibitors After Discharge From the Intensive Care Unit. Mayo Clin Proc 2021; 96:2550-2560. [PMID: 33308869 DOI: 10.1016/j.mayocp.2020.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/28/2020] [Accepted: 07/23/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To determine the prevalence and risk factors for inappropriate discharge on proton pump inhibitor (PPI) therapy started in the intensive care unit (ICU) for stress ulcer prophylaxis. PATIENTS AND METHODS This was a retrospective cohort study of adults initiated on treatment with a PPI in any of 9 affiliated ICUs from January 1, 2014, to December 31, 2018. Patients were excluded if they had an appropriate long-term PPI indication. Logistic regression modeling was used to identify characteristics associated with discharge on treatment with an inappropriate PPI. RESULTS Of 24,751 patients admitted to an ICU, 4127 were initiated on treatment with a new PPI, with 2467 (60%) lacking a long-term PPI indication. Of these 2467, a total of 1122 (45%) were continued on PPI therapy after transfer to the floor and 668 (27%) were discharged on PPI therapy. On multivariable analysis, risk factors for inappropriate discharge on PPI therapy included having an upper endoscopy (adjusted odds ratio [aOR], 1.70; 95% CI, 1.08-2.66), admission to the surgical compared with medical ICU (aOR, 2.03; 95% CI, 1.32-3.10), and discharge to a nursing home or rehabilitation facility (aOR, 1.43; 95% CI, 1.04-1.96; and aOR, 2.29; 95% CI, 1.62-3.24, respectively). CONCLUSION Among patients started on treatment with a PPI in the ICU without an indication for outpatient PPI use, 27% (668 of 2467) were nonetheless discharged on PPI therapy. Medically complex and surgical ICU patients are at increased risk for receiving PPIs without appropriate documented indications, and careful review of medication lists at discharge should occur in these high-risk groups.
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Affiliation(s)
- John W Blackett
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York.
| | - Adam S Faye
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York
| | - Meaghan Phipps
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York
| | - Jianhua Li
- Department of Biomedical Informatics, New York Presbyterian Columbia University Medical Center, New York
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York
| | - Daniel E Freedberg
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York.
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20
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Newsome AS, Murray B, Smith SE, Brothers T, Al-Mamun MA, Chase AM, Rowe S, Buckley MS, Murphy D, Devlin JW. Optimization of critical care pharmacy clinical services: A gap analysis approach. Am J Health Syst Pharm 2021; 78:2077-2085. [PMID: 34061960 PMCID: PMC8195049 DOI: 10.1093/ajhp/zxab237] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Andrea Sikora Newsome
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.,Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Todd Brothers
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, RI, and Department of Pharmacy, Roger Williams Medical Center, Providence, RI, USA
| | - Mohammad A Al-Mamun
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston, RI, USA
| | - Aaron M Chase
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, and Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Sandra Rowe
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA
| | - Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, AZ, USA
| | - David Murphy
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - John W Devlin
- Northeastern University School of Pharmacy, Boston, MA, and Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
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21
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Abstract
OBJECTIVES To provide a multiorganizational statement to update recommendations for critical care pharmacy practice and make recommendations for future practice. A position paper outlining critical care pharmacist activities was last published in 2000. Since that time, significant changes in healthcare and critical care have occurred. DESIGN The Society of Critical Care Medicine, American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health-Systems Pharmacists convened a joint task force of 15 pharmacists representing a broad cross-section of critical care pharmacy practice and pharmacy administration, inclusive of geography, critical care practice setting, and roles. The Task Force chairs reviewed and organized primary literature, outlined topic domains, and prepared the methodology for group review and consensus. A modified Delphi method was used until consensus (> 66% agreement) was reached for each practice recommendation. Previous position statement recommendations were reviewed and voted to either retain, revise, or retire. Recommendations were categorized by level of ICU service to be applicable by setting and grouped into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. MAIN RESULTS There are 82 recommendation statements: 44 original recommendations and 38 new recommendation statements. Thirty-four recommendations represent the domain of patient care, primarily relating to critical care pharmacist duties and pharmacy services. In the quality improvement domain, 21 recommendations address the role of the critical care pharmacist in patient and medication safety, clinical quality programs, and analytics. Nine recommendations were made in the domain of research and scholarship. Ten recommendations were made in the domain of training and education and eight recommendations regarding professional development. CONCLUSIONS Critical care pharmacists are essential members of the multiprofessional critical care team. The statements recommended by this taskforce delineate the activities of a critical care pharmacist and the scope of pharmacy services within the ICU. Effort should be made from all stakeholders to implement the recommendations provided, with continuous effort toward improving the delivery of care for critically ill patients.
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22
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Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients. J Healthc Qual 2021; 42:e39-e49. [PMID: 31157697 DOI: 10.1097/jhq.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Proton pump inhibitors (PPIs) are a risk factor for hospital-acquired Clostridium difficile infection (CDI). Much PPI use is inappropriate, and interventions to reduce PPI use, such as for stress ulcer prophylaxis in all critically ill patients, are essential to reduce CDI rates. This mixed-methods study in a combined medical-surgical intensive care unit at a tertiary academic medical center used a human factors engineering approach to understand barriers and facilitators to optimizing PPI prescribing in these patients. We performed chart review of patients for whom PPIs were prescribed to evaluate prescribing practices. Semistructured provider interviews were conducted to determine barriers and facilitators to reducing unnecessary PPI use. Emergent themes from provider interviews were classified according to the Systems Engineering Initiative for Patient Safety model. In our intensive care unit, 25% of PPI days were not clinically indicated. Barriers to optimizing PPI prescribing included inadequate provider education, lack of institutional guidelines for stress ulcer prophylaxis, and strong institutional culture favoring PPI use. Potential facilitators included increased pharmacy oversight, provider education, and embedded decision support in the electronic medical record. Interventions addressing barriers noted by front line providers are needed to reduce unnecessary PPI use, and future studies should assess the impact of such interventions on CDI rates.
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23
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Impact of clinical pharmacists on adherence to stress ulcer prophylaxis protocol in critically ill Egyptian patients: a comparative study. DRUGS & THERAPY PERSPECTIVES 2021. [DOI: 10.1007/s40267-020-00786-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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Singh-Franco D, Mastropietro DR, Metzner M, Dressler MD, Fares A, Johnson M, De La Rosa D, Wolowich WR. Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis. PLoS One 2020; 15:e0243134. [PMID: 33270710 PMCID: PMC7714117 DOI: 10.1371/journal.pone.0243134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
Objective Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST). Methods To identify studies, the following databases were systematically searched on October 14th, 2018 and repeated on September 12th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review. Results Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I2 = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I2 = 36%). Conclusion This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.
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Affiliation(s)
- Devada Singh-Franco
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
- * E-mail:
| | - David R. Mastropietro
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Miriam Metzner
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Michael D. Dressler
- Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Amneh Fares
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
| | - Melinda Johnson
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Daisy De La Rosa
- Martin and Gail Press Health Professions Division Library, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - William R. Wolowich
- Department of Pharmacy Practice, Nova Southeastern University, College of Pharmacy, Fort Lauderdale, Florida, United States of America
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Stephenson C, Mohabbat A, Raslau D, Gilman E, Wight E, Kashiwagi D. Management of Common Postoperative Complications. Mayo Clin Proc 2020; 95:2540-2554. [PMID: 33153639 DOI: 10.1016/j.mayocp.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/26/2020] [Accepted: 03/06/2020] [Indexed: 01/28/2023]
Abstract
Postoperative complications are common. Major guidelines have been published on stratifying and managing adverse cardiovascular events and thromboembolic events, but there is often less literature supporting management of other, more common, postoperative complications, including acute kidney injury, gastrointestinal complications, postoperative anemia, fever, and delirium. These common conditions are frequently seen in hospital and can contribute to longer lengths of stay and rising health care costs. These complications are often due to the interplay between both patient-specific and surgery-specific risk factors. Identifying these risk factors, while addressing and optimizing modifiable risks, can mitigate the likelihood of developing these postoperative complications. Often, a multidisciplinary approach, including care team members through all phases of the surgical encounter, is needed. Cardiovascular and thrombotic complications have been addressed in prior articles in this perioperative series. We aim to cover other common postoperative complications, such as acute renal failure, postoperative gastrointestinal complications, anemia, fever, and delirium that often contribute to longer lengths of stay, rising health care costs, and increased morbidity and mortality for patients.
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Affiliation(s)
| | - Arya Mohabbat
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - David Raslau
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Wight
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Deanne Kashiwagi
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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26
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Zhang Y, Yang H, Kong J, Liu L, Ran L, Zhang X, Yun J, Gu Q. Impact of interventions targeting the inappropriate use of proton-pump inhibitors by clinical pharmacists in a hepatobiliary surgery department. J Clin Pharm Ther 2020; 46:149-157. [PMID: 33015848 DOI: 10.1111/jcpt.13273] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE At present, studies on the usage of proton-pump inhibitors (PPIs) have universal significance. In clinical practice, PPIs are widely used to treat a variety of acid-related diseases, but they can be inappropriately prescribed, leading to increased medical costs and patient harm. The study comprehensively evaluated the clinical effects of a clinical pharmacist intervention on inappropriate PPI prescriptions in a tertiary general hospital hepatobiliary surgery ward. METHODS A retrospective, single-centre intervention study covering the periods of July-December 2018 and July-December 2019 was conducted. In the intervention group, clinical pharmaceutical care was initiated by a clinical pharmacist in the hepatobiliary surgery ward. Outcomes, including the clinical pattern of PPI utilization, the rate of inappropriate PPI use and safety outcomes, were compared between the two periods. RESULTS AND DISCUSSION In total, 1150 patients were admitted to the hepatobiliary surgery ward in our hospital in the study periods. Of these, 717 patients met the inclusion criteria for this study, and 420 and 297 patients were included in the preintervention and post-intervention groups, respectively. The PPI utilization rates before and after the intervention were 82.0% and 55.0%, respectively. The rates of inappropriate PPI use before and after the intervention were 48.9 and 22.7 per 100 patient-days, respectively. Clinical safety outcomes were nearly identical between before and after the intervention, but patients treated with PPIs were more likely to experience nosocomial pneumonia (2.4% vs. 0.6%). WHAT IS NEW AND CONCLUSION The implementation of a clinical pharmacist intervention for PPI use decreased inappropriate PPI use during hospitalization without sacrificing clinical safety outcomes.
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Affiliation(s)
- Ying Zhang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui Yang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jian Kong
- Department of Hepatobiliary Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lihong Liu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li Ran
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xi Zhang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Juping Yun
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qing Gu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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27
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Buckley MS, Agarwal SK, Lansburg JM, Kopp BJ, Erstad BL. Clinical Pharmacist–Led Impact on Inappropriate Albumin Utilization and Associated Costs in General Ward Patients. Ann Pharmacother 2020; 55:44-51. [DOI: 10.1177/1060028020935575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Inappropriate albumin use in clinical practice remains problematic. Health-systems face continued challenges in promoting cost-appropriate use. Objective: To evaluate the clinical and economic impact of a clinical pharmacist–led intervention strategy targeting inappropriate albumin use in general ward patients. Methods: A retrospective cohort study evaluated all adult (≥18 years) general ward patients administered ≥1 dose of albumin at a university medical center over a 2-year period. The intervention consisted of a clinical pharmacist–led strategy intervening on all albumin orders not in accordance with institutional guidelines. The primary end point was to compare inappropriate albumin utilization before and after implementation. Secondary end points compared the rates of inappropriate albumin use adjusted for hospital admission and patient-days as well as associated costs by appropriateness between study periods. Results: A total of 4420 patients were screened, with 1971 (44.6%) patients meeting inclusion criteria. The clinical pharmacist strategy significantly reduced inappropriate albumin (grams) utilization by 86.0% ( P < 0.001). A 7-fold reduction of inappropriate albumin administered adjusted for the number of patient admissions was found from the preimplementation period following clinical pharmacist intervention strategy implementation (415.3 ± 83.2 vs 57.5 ± 34.2 g per 100 general ward hospital admissions, respectively; P < 0.001). Also, the adjusted inappropriate albumin rate was reduced from 62.2 ± 12.3 to 8.6 ± 5.2 g per 100 patient-days in the preimplementation and postimplementation periods, respectively ( P < 0.001). Annual cost savings were $421 455 overall, with $341 930 resulting from mitigation of inappropriate use. Conclusion and Relevance: Clinical pharmacist–led interventions significantly reduced inappropriate albumin use and costs in hospitalized patients.
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Affiliation(s)
| | | | | | - Brian J. Kopp
- Banner—University Medical Center Tucson, Tucson, AZ, USA
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28
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Newsome AS, Anderson D, Gwynn ME, Waller JL. Characterization of changes in medication complexity using a modified scoring tool. Am J Health Syst Pharm 2020; 76:S92-S95. [PMID: 31586396 DOI: 10.1093/ajhp/zxz213] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
PURPOSE The purpose of this study was to characterize dynamic changes in medication regimen complexity over time in critically ill adults and to validate a modified version of the medication regimen complexity-intensive care unit (MRC-ICU) scoring tool. SUMMARY A single-center, retrospective, observational chart review was conducted with a primary aim of assessing changes in medication regimen complexity over time, as measured by both the 39-item MRC-ICU scoring tool and a modified version (the mMRC-ICU) containing just 17 items. Secondary aims included validation of the mMRC-ICU and exploration of relationships between medication regimen complexity and ICU length of stay (LOS), inpatient mortality, and patient acuity. Adults admitted to a medical ICU from November 2016 through June 2017 were included. The medication regimens of a total of 130 patients were scored in order to test, modify, and validate the MRC-ICU and mMRC-ICU tools. The modified tool was validated by evaluating correlation of mMRC-ICU scores with MRC-ICU scores and with patient outcomes including patient acuity, ICU LOS, and inpatient mortality. mMRC-ICU scores were collected at 24 and 48 hours after admission and at ICU discharge to evaluate changes over time. Significant changes in medication regimen complexity over time were observed, with the highest scores observed at 24 hours after admission. CONCLUSION Medication regimen complexity may provide valuable insights into pharmacist activity and resource allocation. Further validation of the MRC-ICU and mMRC-ICU scoring tools in other critically ill populations and at external sites is required.
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Affiliation(s)
- Andrea Sikora Newsome
- College of Pharmacy, University of Georgia, Augusta, GA, and Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Daniel Anderson
- Department of Pharmacy, Emory Healthcare, Atlanta, GA, and College of Pharmacy, University of Georgia, Augusta, GA
| | - Morgan E Gwynn
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC
| | - Jennifer L Waller
- Department of Population Health Sciences, Division of Biostatistics and Data Science, Augusta University, Augusta, GA
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29
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Talon B, Perez A, Yan C, Alobaidi A, Zhang KH, Schultz BG, Suda KJ, Touchette DR. Economic evaluations of clinical pharmacy services in the United States: 2011-2017. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1199] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Brian Talon
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Alexandra Perez
- Department of Sociobehavioral and Administrative Pharmacy; Nova Southeastern University; Fort Lauderdale Florida
| | - Connie Yan
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Ali Alobaidi
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Katherine H. Zhang
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Bob G. Schultz
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
| | - Katie J. Suda
- Department of Medicine, Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Daniel R. Touchette
- Department of Pharmacy Systems, Outcomes & Policy; University of Illinois at Chicago; Chicago Illinois
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30
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Choi YJ, Sim J, Jung YT, Shin S. Impact of a multidisciplinary quality improvement initiative to reduce inappropriate usage of stress ulcer prophylaxis in hospitalized patients. Br J Clin Pharmacol 2019; 86:903-912. [PMID: 31840265 DOI: 10.1111/bcp.14197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/21/2022] Open
Abstract
AIMS To promote effective methods to improve overutilization patterns of acid-suppressive therapy in hospitalized patients and to evaluate the impact of multidisciplinary team efforts to reduce inappropriate use of stress ulcer prophylaxis in low-risk patients. METHODS A multidisciplinary quality improvement initiative incorporating education, medication use reviews and reconciliation, and pharmaceutical intervention was implemented in June 2018 for surgical patients hospitalized via emergency department. For the pre-post analysis and time series analysis, patients admitted during April and May were classified into the pre-intervention cohort and those admitted during July and August into the post-intervention cohort. RESULTS Three hundred and seventeen patients were included in this study (153 and 164 in the pre- and post-intervention cohorts, respectively). The multidisciplinary program was effective in reducing overuse of stress ulcer prophylaxis and healthcare expenses associated with it. Biweekly education on risk factors warranting stress ulcer prophylaxis was provided for clinicians, and acid-suppressive therapy was removed from a preset list of admission orders. The incidence of inappropriate prophylaxis use declined substantially following intervention in overall patients (OR = 0.51, P = 0.01) and a significant decrease was primarily observed among non-ICU patients (OR = 0.50, P = 0.01). Interrupted time series analysis confirmed the significant decline in inappropriate use post intervention (coefficient = -0.63, P < 0.001). The total healthcare expenses associated with such overuse decreased by 58.5% from US$ 19.39 to US$ 8.04 per 100 patient-days. CONCLUSIONS Our multidisciplinary team efforts were associated with improvement in stress ulcer prophylaxis overuse patterns, resulting in a substantial decrease in the incidence of inappropriate use, especially in general wards, and associated healthcare costs.
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Affiliation(s)
- Yeo Jin Choi
- Clinical Trial Center, Hallym University Hospital, Anyang, Republic of Korea
| | - Joohyun Sim
- Department of Surgery, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Yun Tae Jung
- Department of Surgery, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Sooyoung Shin
- Department of Clinical Pharmacy, College of Pharmacy, Ajou University, Suwon, Republic of Korea.,Research Institute of Pharmaceutical Science and Technology (RIPST), Ajou University, Suwon, Republic of Korea
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31
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Buckley MS, Knutson KD, Agarwal SK, Lansburg JM, Wicks LM, Saggar RC, Richards EC, Kopp BJ, Erstad BL. Clinical Pharmacist-Led Impact on Inappropriate Albumin Use and Costs in the Critically Ill. Ann Pharmacother 2019; 54:105-112. [PMID: 31544470 DOI: 10.1177/1060028019877471] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background:Optimal albumin use in the intensive care unit (ICU) remains challenging with inappropriate use approaching 50%. No published reports have described clinical pharmacist impact aimed at mitigating inappropriate albumin use in the ICU. Objective: To evaluate the clinical and economic impact of a clinical pharmacist-led intervention strategy targeting inappropriate albumin in the ICU. Methods: A retrospective cohort study evaluated all adult (≥18 years) ICU patients administered albumin at an academic medical center over a 2-year period. Institutional guidelines were developed with clinical pharmacists targeting inappropriate albumin use. The primary end point was to compare inappropriate use of albumin administered before and after pharmacist intervention implementation. Secondary analyses compared the overall albumin use between study periods. In-hospital mortality, length of stay, and albumin-related costs between study periods were also compared. Results: A total of 4419 patients were identified, with 2448 (55.4%) critically ill patients included. The pharmacist-led strategy resulted in a 50.9% reduction of inappropriate albumin use (P < 0.001). The rate of inappropriate albumin use was 44.3 ± 10.5 and 5.5 ± 2.9 g per patient-day in the preimplementation and postimplementation periods, respectively (P < 0.001). Costs associated with overall and inappropriate albumin use in the ICU decreased by 34.8% and 87.1%, respectively. Total annual cost-savings was $355 393 in the ICUs. No differences in clinical outcomes were found. Conclusion and Relevance: Clinical pharmacist-led interventions reduced overall and inappropriate albumin use and costs without negatively affecting clinical outcomes.
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Affiliation(s)
| | | | - Sumit K Agarwal
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Jake M Lansburg
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Laura M Wicks
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Rajeev C Saggar
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | | | - Brian J Kopp
- Banner - University Medical Center Tucson, Tucson, AZ, USA
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32
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Mafi JN, May FP, Kahn KL, Chong M, Corona E, Yang L, Mongare MM, Nair V, Reynolds C, Gupta R, Damberg CL, Esrailian E, Sarkisian C. Low-Value Proton Pump Inhibitor Prescriptions Among Older Adults at a Large Academic Health System. J Am Geriatr Soc 2019; 67:2600-2604. [PMID: 31486549 DOI: 10.1111/jgs.16117] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Older adults are particularly vulnerable to complications from proton pump inhibitor (PPI) drugs. We sought to characterize the prevalence of potentially low-value PPI prescriptions among older adults to inform a quality improvement (QI) intervention. METHODS We created a cohort of patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. We identified patients currently prescribed any PPI using the electronic health record (EHR) medication list (current defined as September 1, 2018). A geriatrician, a gastroenterologist, a QI expert, and two primary care physicians (PCPs) created multidisciplinary PPI appropriateness criteria based on evidenced-based guidelines. Supervised by a gastroenterologist and PCP, two internal medicine residents conducted manual chart reviews in a random sample of 399 patients prescribed PPIs. We considered prescriptions potentially low value if they lacked a guideline-based (1) short-term indication (gastroesophageal reflux disease [GERD]/peptic ulcer disease/Helicobacter pylori gastritis/dyspepsia) or (2) long-term (>8 weeks) indication (severe/refractory GERD/erosive esophagitis/Barrett esophagus/esophageal adenocarcinoma/esophageal stricture/high gastrointestinal bleeding risk/Zollinger-Ellison syndrome). We used the Wilson score method to calculate 95% confidence intervals (CIs) on low-value PPI prescription prevalence. RESULTS Among 69 352 older adults, 8729 (12.6%) were prescribed a PPI. In the sample of 399 patients prescribed PPIs, 63.9% were female; their mean age was 76.2 years, and they were seen by 169 PCPs. Of the 399 prescriptions, 143 (35.8%; 95% CI = 31.3%-40.7%) were potentially low value-of which 82% began appropriately (eg, GERD) but then continued long term without a guideline-based indication. Among 169 PCPs, 32 (18.9%) contributed to 59.2% of potentially low-value prescriptions. CONCLUSION One in eight older adults were prescribed a PPI, and over one-third of prescriptions were potentially low-value. Most often, appropriate short-term prescriptions became potentially low value because they lacked long-term indications. With most potentially low-value prescribing concentrated among a small subset of PCPs, interventions targeting them and/or applying EHR-based automatic stopping rules may protect older adults from harm. J Am Geriatr Soc 67:2600-2604, 2019.
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Affiliation(s)
- John N Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California.,RAND Corporation, Santa Monica, California
| | - Folasade P May
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Katherine L Kahn
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California.,RAND Corporation, Santa Monica, California
| | - Michelle Chong
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Edgar Corona
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Liu Yang
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Margaret M Mongare
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Vishnu Nair
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Courtney Reynolds
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Reshma Gupta
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Eric Esrailian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Catherine Sarkisian
- Division of Geriatrics, David Geffen School of Medicine at UCLA and Veterans Affairs (VA) Greater Los Angeles Healthcare System Geriatric Research Education and Clinical Center, Los Angeles, California
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Barletta JF, Buckley MS, MacLaren R. The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis? Hosp Pharm 2019; 55:96-101. [PMID: 32214442 DOI: 10.1177/0018578719867687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of stress ulcer-induced, clinically important bleeding (CIB). Recently, the value of SUP has been questioned due to the perceived decline in CIB and the potential for infectious complications secondary to acid suppressive therapy. The SUP-ICU trial is a large, randomized controlled trial comparing intravenous pantoprazole with placebo for the indication of SUP. It is hoped that this trial would answer many of the questions pertaining to the overall value of SUP. This article will provide an in-depth assessment of the SUP-ICU trial in the context of the overall body of literature in this area. Furthermore, applications for clinical practice and recommendations on the provision of SUP are provided. Summary: The SUP-ICU trial revealed no difference in the primary outcome of 90-day mortality with pantoprazole but lower rates of CIB were noted (which was a secondary outcome). Overall, these data provide important insight into the value of SUP along with other questions related to the provision of SUP such as the relationship between CIB and mortality, infectious complications, and enteral nutrition. Conclusions: The SUP-ICU trial is a landmark trial describing the value of SUP in a modern-day setting of intensive care unit (ICU) practice. The provision of SUP should be continued in high-risk patients. Future studies are ongoing that will add further insight to this routine practice.
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Mersfelder TL, Jacob C, Lam JK, Kavanaugh KJ, Molnar CM. Evaluation of a Pharmacist-Driven Protocol to Reduce Inappropriate Use of Acid-Suppressive Medications In the Non-ICU Setting. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2019; 44:471-473. [PMID: 31447534 PMCID: PMC6679947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 blockers) continue to be over utilized for stress ulcer prophylaxis (SUP). Our study aims to evaluate the effectiveness and feasibility of a pharmacist-driven termination protocol in a community teaching hospital to limit the inappropriate use of acid-suppressive medications in the non-intensive care unit (ICU) setting. METHODS Patient charts were evaluated for the appropriate use of PPIs or H2 blockers. A centralized pharmacist contacted healthcare providers for medication discontinuation if the acid suppressant use was deemed inappropriate. The primary outcome of the study was the number of patients who had acid-suppressive medication discontinued after the implementation of the pharmacist-driven termination protocol. RESULTS Acid-suppressive medication was inappropriately prescribed for nine patients. It was discontinued for eight of those patients based on the pharmacist-driven termination protocol; this was a statistically significant decrease (P < 0.001). The pharmacist spent, on average, less than one minute on each patient's chart. CONCLUSION Our study revealed that a pharmacist-driven termination protocol resulted in a 6% overall reduction rate in inappropriately used acid-suppressive medications, with little impact on pharmacist workflow. Implementing such a termination protocol could help to decrease the inappropriate use of acid-suppressive medications in an inpatient hospital service.
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35
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Newsome AS, Smith SE, Olney WJ, Jones TW, Forehand CC, Jun AH, Coppiano L. Medication regimen complexity is associated with pharmacist interventions and drug-drug interactions: A use of the novel MRC-ICU scoring tool. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1146] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy; University of Georgia College of Pharmacy; Augusta Georgia
- Department of Pharmacy; Augusta University Medical Center; Augusta Georgia
| | - Susan E. Smith
- Department of Clinical and Administrative Pharmacy; University of Georgia College of Pharmacy; Augusta Georgia
| | - William J. Olney
- Department of Clinical and Administrative Pharmacy; University of Georgia College of Pharmacy; Augusta Georgia
| | - Timothy W. Jones
- Department of Clinical and Administrative Pharmacy; University of Georgia College of Pharmacy; Augusta Georgia
| | | | - Ah Hyun Jun
- Department of Pharmacy; Augusta University Medical Center; Augusta Georgia
| | - Lindsey Coppiano
- Department of Clinical and Administrative Pharmacy; University of Georgia College of Pharmacy; Augusta Georgia
- Department of Pharmacy; Augusta University Medical Center; Augusta Georgia
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36
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Ko EYJ, Carpenter CM, Gagnon DJ, Andrle AM. Pharmacist-Managed Inpatient Dofetilide Initiation Program: Description and Adherence Rate Post-Root Cause Analysis. J Pharm Pract 2019; 33:784-789. [PMID: 30935279 DOI: 10.1177/0897190019834130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this article is to describe the pharmacist-managed dofetilide initiation program at Maine Medical Center (MMC), assess the adherence rate to 8 core clinical metrics, and review adverse effects before and after a root cause analysis (RCA). Core clinical metrics included pharmacist note entered within 4 hours of dose administration, dose chosen correctly per renal function, QTc measurements obtained and reviewed 2 hours after each dose, appropriate dose adjustment per the most recent QTc measurement, documentation of patient education, and assessment of conduction abnormality, drug-drug interactions, and serum potassium and magnesium concentrations. The primary outcome was adherence rate to all 8 core clinical metrics before and after the RCA. The safety outcome was the total number of adverse events. One hundred patients undergoing elective dofetilide initiation were evaluated: 50 pre-RCA and 50 post-RCA. Adherence rate to all core metrics was 14% in the pre-RCA group and 44% in the post-RCA group (P < .001). Torsade de pointes occurred 3 times in the pre-RCA group and never in the post-RCA group. After the RCA, adherence to MMC's pharmacist-managed inpatient dofetilide initiation program significantly improved.
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Affiliation(s)
| | - Charles M Carpenter
- Department of Cardiology, Maine Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - David J Gagnon
- Department of Pharmacy Practice, Maine Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Anne M Andrle
- Department of Pharmacy Practice, Maine Medical Center, Portland, ME, USA
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Masood U, Sharma A, Bhatti Z, Carroll J, Bhardwaj A, Sivalingam D, Dhamoon AS. A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 55:46958018759116. [PMID: 29502481 PMCID: PMC5843103 DOI: 10.1177/0046958018759116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was $2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to $239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% (P < .001). Furthermore, we were able to decrease the costs by approximately $2200/month.
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Affiliation(s)
- Umair Masood
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Anuj Sharma
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Zabeer Bhatti
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jessica Carroll
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Amit Bhardwaj
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
| | | | - Amit S Dhamoon
- 1 State University of New York Upstate Medical University, Syracuse, NY, USA
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Mendes JJ, Silva MJ, Miguel LS, Gonçalves MA, Oliveira MJ, Oliveira CDL, Gouveia J. Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit. Rev Bras Ter Intensiva 2019; 31:5-14. [PMID: 30843949 PMCID: PMC6443317 DOI: 10.5935/0103-507x.20190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/08/2018] [Indexed: 12/18/2022] Open
Abstract
Critically ill patients are at risk of developing stress ulcers in the upper
digestive tract. Agents that suppress gastric acid are commonly prescribed to
reduce the incidence of clinically important stress ulcer-related
gastrointestinal bleeding. However, the indiscriminate use of stress ulcer
prophylaxis in all patients admitted to the intensive care unit is not warranted
and can have potential adverse clinical effects and cost implications. The
present guidelines from the Sociedade Portuguesa de Cuidados
Intensivos summarizes the current evidence and gives six clinical
statements and an algorithm aiming to provide a standardized prescribing policy
for the use of stress ulcer prophylaxis in the intensive care unit.
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Affiliation(s)
| | - Mário Jorge Silva
- Departamento de Gastrenterologia, Centro Hospitalar de Lisboa Central E.P.E. - Lisboa, Portugal
| | - Luís Silva Miguel
- Centro de Medicina Baseada em Evidência, Faculdade de Medicina, Universidade de Lisboa - Lisboa, Portugal
| | | | - Maria João Oliveira
- Departamento de Farmácia, Hospital Prof. Doutor Fernando da Fonseca E.P.E. - Amadora, Portugal
| | | | - João Gouveia
- Sociedade Portuguesa de Cuidados Intensivos - Lisboa, Portugal
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Horsa BA, Ayele Y, Ayalew MB. Assessment of pharmacologic prophylaxis use against stress ulcer in the medical wards of University of Gondar Hospital. SAGE Open Med 2019; 7:2050312119827409. [PMID: 30746144 PMCID: PMC6360640 DOI: 10.1177/2050312119827409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Background Critically ill patients with moderate-to-severe physiologically stressful event are at high risk of developing stress ulcers. The use of pharmacological prophylaxis significantly reduces the incidence of stress ulcer in high-risk patients. Objective The aim of this study was to assess the use of pharmacological prophylaxis for stress ulcer in the medical wards of University of Gondar Hospital. Methods A cross-sectional study design was used. In total, 234 patients were selected through simple random sampling technique. The risk of stress ulcer development was assessed using Evidence-Based Medicine Guideline for stress ulcer prepared by Orlando Regional Medical Center. SPSS version 21 was used for data analysis. Result The most common acute risk factor to stress ulcer was coagulopathy (18.4%), followed by hypoperfusion (9.8%). The concomitant non-steroidal anti-inflammatory drug use (16.7%), mild-to-moderate brain or spinal cord injury (11.1%), and concomitant or recent corticosteroid use (9.4%) were frequently seen risk factors that necessitate administration of a prophylaxis. In total, 82 (35%) study participants were given stress ulcer prophylaxis, among which 52 (63.4%) were given without indication. The most commonly used drug class in the prevention of stress ulcer was proton pump inhibitors (76/82, 92.7%). In total, 43 (18.4%) study subjects were not given stress ulcer prophylaxis while there was clear indication. Patients with a long hospital stay and a diagnosis of central nervous system disorders had significant risk for inappropriate stress ulcer prophylaxis use. Conclusion In this study, inappropriate use of prophylaxis for stress ulcer was common. The higher proportion of inappropriateness was due to the use of stress ulcer prophylaxis while there was no enough indication. We recommend future researchers to assess the cost and impact of inappropriate stress ulcer prophylaxis use, and the physicians should be adherent to the standard guidelines.
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Affiliation(s)
- Boressa Adugna Horsa
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yohanes Ayele
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mohammed Biset Ayalew
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Evaluation of Adherence to American Society of Health-System Pharmacists Guidelines: Stress Ulcer Prophylaxis in Shiraz, Iran. Gastroenterol Nurs 2018; 40:491-495. [PMID: 29210818 DOI: 10.1097/sga.0000000000000278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Overuse of stress ulcer prophylaxis has a considerable cost burden on patient and healthcare systems. This study aimed to determine the adherence level of stress ulcer prophylaxis use with American Society of Health-System Pharmacists guidelines in a teaching hospital in Shiraz, Iran. From March to September 2013, we enrolled all eligible patients admitted to the general medical wards of Shahid Faghihi Hospital, Shiraz, Iran. According to American Society of Health-System Pharmacists guidelines, patients who had at least one major or two minor risk factors for stress ulcers and received stress ulcer prophylaxis were labeled as adherent, others were considered nonadherent. During the study period, 441 patients enrolled, of which 257 (58.3%) were women. The mean ±SD age of patients was 54.7 ± 20 years. The mean ±SD length of hospital stay for patients was 11.3 ± 6 days. Overall, 354 patients (80.2%) received proton pump inhibitors as stress ulcer prophylaxis. There were 127 patients who properly received stress ulcer prophylaxis. Total adherence to American Society of Health-System Pharmacists guidelines in our hospital was 28.8%. We observed a high frequency of unnecessary use of stress ulcer prophylaxis in hospitalized, noncritically ill patients with inappropriate continuation after discharge.
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Wan A, Halpape K, Talkhi SC, Dixon C, Dossa H, Tabamo J, Roberts M, Dahri K. Evaluation of Prescribing Appropriateness and Initiatives to Improve Prescribing of Proton Pump Inhibitors at Vancouver General Hospital. Can J Hosp Pharm 2018; 71:308-315. [PMID: 30401997 PMCID: PMC6209498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) have proven clinical efficacy for a variety of indications. However, there is emerging evidence of adverse events associated with their long-term use. The emergence of these adverse events has reinforced the need to regularly evaluate the appropriateness of continuing PPI therapy, and to use only the lowest effective dose for the minimally indicated duration. OBJECTIVES To characterize the appropriateness of PPI orders continued or initiated in the internal medicine and family practice units of Vancouver General Hospital, to detect adverse events associated with PPI use, and to explore the impact of multidisciplinary teaching and provision of educational resources on health care practitioners' views about PPI use. METHODS A chart review was conducted for patients admitted (for at least 24 hours) between January 1 and December 31, 2015, for whom a hospital formulary PPI was prescribed. An educational initiative, which included interprofessional in-service sessions, a PPI prescribing infographic, a PPI prescribing card, and a patient counselling sheet, was implemented. The impact of these interventions was assessed using a qualitative survey of health care practitioners. RESULTS Of the 258 patients whose charts were reviewed, 175 had a PPI prescription before hospital admission, and 83 were initiated on PPI therapy during their hospital stay. Overall, 94 (36%) of the patients were receiving PPIs without an appropriate indication. Community-acquired pneumonia and Clostridium difficile infections were the most common adverse events potentially associated with PPI use. In-service sessions and educational resources on PPI prescribing were reported to affect the clinical practice of 24 (52%) of the 46 survey respondents. CONCLUSIONS The results of this study emphasize the need for ongoing re-evaluation of long-term PPI therapy at the time of admission, during the hospital stay, and upon discharge. Implementing multidisciplinary teaching and providing educational resources may encourage more appropriate prescribing.
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Affiliation(s)
- Andrea Wan
- , BSc(Pharm), ACPR, is with the Department of Pharmacy, St Paul's Hospital, Vancouver, British Columbia
| | - Katelyn Halpape
- , BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia
| | - Shirin C Talkhi
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Claire Dixon
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Hafeez Dossa
- , BSc(Pharm), was, at the time of this study, an undergraduate student in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Jenifer Tabamo
- , RN, is with the Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia
| | - Mark Roberts
- , MD, is with the Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia
| | - Karen Dahri
- , BSc, BSc(Pharm), ACPR, PharmD, is with the Faculty of Pharmaceutical Sciences, The University of British Columbia, and the Department of Pharmacy Vancouver General Hospital, Vancouver, British Columbia
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Newsome AS, Chastain DB, Watkins P, Hawkins WA. Complications and Pharmacologic Interventions of Invasive Positive Pressure Ventilation During Critical Illness. J Pharm Technol 2018; 34:153-170. [PMID: 34860978 DOI: 10.1177/8755122518766594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the fundamentals of invasive positive pressure ventilation (IPPV) and the common complications and associated pharmacotherapeutic management in order to provide opportunities for pharmacists to improve patient outcomes. Data Sources: A MEDLINE literature search (1950-December 2017) was performed using the key search terms invasive positive pressure ventilation, mechanical ventilation, pharmacist, respiratory failure, ventilator associated organ dysfunction, ventilator associated pneumonia, ventilator bundles, and ventilator liberation. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language original research and review reports were evaluated. Data Synthesis: IPPV is a common supportive care measure for critically ill patients. While lifesaving, IPPV is associated with significant complications including ventilator-associated pneumonia, sinusitis, organ dysfunction, and hemodynamic alterations. Optimization of pain and sedation management provides an opportunity for pharmacists to directly affect IPPV exposure. A number of pharmacotherapeutic interventions are related directly to prophylaxis against IPPV-associated adverse events or aimed at reduction of duration of IPPV. Conclusions: Enhanced knowledge of the common complications, associated pharmacotherapy, and monitoring strategies facilitate the pharmacist's ability to provide increased pharmacotherapeutic insight in a multidisciplinary intensive care unit setting.
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Affiliation(s)
- Andrea Sikora Newsome
- The University of Georgia, Augusta, GA, USA.,Augusta University Medical Center, Augusta, GA, USA
| | | | | | - W Anthony Hawkins
- The University of Georgia, Augusta, GA, USA.,The University of Georgia-Albany, GA, USA
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43
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Is A Diagnosis of Sepsis Sufficient to Warrant Stress Ulcer Prophylaxis? Crit Care Med 2018; 44:1450-2. [PMID: 27309174 DOI: 10.1097/ccm.0000000000001750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Affiliation(s)
- Deborah Cook
- From the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- From the Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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45
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Faust AC, Echevarria KL, Attridge RL, Sheperd L, Restrepo MI. Prophylactic Acid-Suppressive Therapy in Hospitalized Adults: Indications, Benefits, and Infectious Complications. Crit Care Nurse 2018; 37:18-29. [PMID: 28572098 DOI: 10.4037/ccn2017720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Acid-suppressive therapy for prophylaxis of stress ulcer bleeding is commonly prescribed for hospitalized patients. Although its use in select, at-risk patients may reduce clinically significant gastrointestinal bleeding, the alteration in gastric pH and composition may place these patients at a higher risk of infection. Although any pharmacologic alteration of the gastric pH and composition is associated with an increased risk of infection, the risk appears to be highest with proton pump inhibitors, perhaps owing to the potency of this class of drugs in increasing the gastric pH. With the increased risk of infection, universal provision of pharmacologic acid suppression to all hospitalized patients, even all critically ill patients, is inappropriate and should be confined to patients meeting specific criteria. Nurses providing care in critical care areas may be instrumental in screening for appropriate use of acid-suppressive therapy and ensuring the drugs are discontinued upon transfer out of intensive care or when risk factors are no longer present.
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Affiliation(s)
- Andrew C Faust
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas. .,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas. .,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas. .,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas. .,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas.
| | - Kelly L Echevarria
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
| | - Rebecca L Attridge
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
| | - Lyndsay Sheperd
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
| | - Marcos I Restrepo
- Andrew C. Faust is a critical care clinical pharmacist primarily working in the medical intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Kelly L. Echevarria is an infectious diseases and critical care clinical pharmacist, Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, Texas.,Rebecca L. Attridge is an associate professor, Department of Pharmacy Practice, University of the Incarnate Word Feik School of Pharmacy, and an adjunct assistant professor, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health San Antonio, San Antonio, Texas.,Lyndsay Sheperd is a critical care clinical pharmacist primarily working in the surgical-trauma intensive care unit, Department of Pharmacy, Texas Health Presbyterian Hospital Dallas, Dallas, Texas.,Marcos I. Restrepo is an associate professor in pulmonary and critical care medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, and Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, Texas
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Abstract
This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.
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Sridharan K, Sivaramakrishnan G, Gnanaraj J. Pharmacological interventions for stress ulcer prophylaxis in critically ill patients: a mixed treatment comparison network meta-analysis and a recursive cumulative meta-analysis. Expert Opin Pharmacother 2017; 19:151-158. [DOI: 10.1080/14656566.2017.1419187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- Prosthodontics, School of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Jerome Gnanaraj
- Department of Medicine, Johns Hopkins Bayview Medical Center, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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48
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Luo H, Fan Q, Xiao S, Chen K. Impact of clinical pharmacist interventions on inappropriate prophylactic acid suppressant use in hepatobiliary surgical patients undergoing elective operations. PLoS One 2017; 12:e0186302. [PMID: 29045435 PMCID: PMC5646810 DOI: 10.1371/journal.pone.0186302] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/28/2017] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the impact and cost-benefit of clinical pharmacist interventions on inappropriate use of prophylactic acid suppressant in hepatobiliary surgical patients in a Chinese tertiary hospital. Methods A retro-prospective intervention study of patients undergoing elective operations was performed in the Department of Hepatobiliary Surgery of the Affiliated Hospital of Southwest Medical University. Patients admitted from October to December 2015 and from October to December 2016, served as the pre-intervention and the post-intervention group, respectively. Clinical pharmacist interventions in the post-intervention group included real-time monitoring medical records and recommending that surgeons prescribe prophylactic acid suppressants according to the criteria established by the hospital administration. Then, the clinical outcomes of post-intervention group were compared with the pre-intervention group which lacked pharmacist interventions. In addition, cost-benefit analysis was conducted to determine the economic effects of implementing the clinical pharmacist interventions in acid suppressant prophylaxis in perioperative period. Results Clinical pharmacist interventions significantly decreased the rate of the use of no indications for prophylactic acid suppressant and of the cases of inappropriate drug selection, dose, route, replacement and prolonged duration of prophylaxis (P < 0.05 or P < 0.001), resulting in significant increase by 10.65% in the percentage of cases adhering to all the criteria (P < 0.001). Moreover, significant reductions were found in the average usage quantity (P<0.001), mean cost (P = 0.03) and mean duration (P < 0.001) of prophylaxis acid suppressant. The ratio of the mean cost savings for acid suppressants to the mean cost of pharmacist time was 13.61:1. Conclusion The clinical pharmacist’s real-time interventions facilitated the rational use of prophylactic acid suppressant and resulted in favorable economic outcomes in hepatobiliary surgery.
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Affiliation(s)
- Hongli Luo
- Department of Pharmacy, the Affiliated Hospital of Southwest Medical University, Luzhou, China
- * E-mail:
| | - Qingze Fan
- Department of Pharmacy, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shunlin Xiao
- Department of Pharmacy, the Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Kun Chen
- Department of Pharmacy, the Affiliated Hospital of Southwest Medical University, Luzhou, China
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49
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Abstract
Health care costs are rising in the United States with a significant amount of this spend attributed to pharmaceutical costs. The reasons for rising pharmaceutical costs are multifactorial and may include the increase in single source manufacturers of generic medications, drug shortages, the Food and Drug Administration's unapproved drug approval initiative, and generic rebranding. Many of these factors impact the intensive care unit directly creating the need to implement cost-savings strategies to ensure the financial health of an organization and reduce the financial burden for patients. To mitigate rising costs, we have outlined a number of both operational and clinical cost-savings measures derived from the literature and from institutional experience. Engaging the multidisciplinary team in the development and implementation of these initiatives will ensure their success and will maximize their impact.
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50
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Hammond DA, Killingsworth CA, Painter JT, Pennick RE, Chatterjee K, Boye B, Meena N. Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults. Pharm Pract (Granada) 2017; 15:948. [PMID: 28943978 PMCID: PMC5597806 DOI: 10.18549/pharmpract.2017.03.948] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
Background: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB). Objective: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST. Methods: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests. Results: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively). Conclusion: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.
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Affiliation(s)
- Drayton A Hammond
- Assistant Professor of Pharmacy Practice. Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | | | - Jacob T Painter
- Assistant Professor of Pharmacy Practice. Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | - Rose E Pennick
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy. Little Rock, AR (United States).
| | - Kshitij Chatterjee
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| | - Bradley Boye
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
| | - Nikhil Meena
- Assistant Professor of Medicine. Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences College of Medicine. Little Rock, AR (United States).
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