An interprofessional approach to reducing the overutilization of stress ulcer prophylaxis in adult medical and surgical intensive care units

Abstract

Background: Overutilization of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) is common. Acid-suppressive therapies routinely used for SUP are best reserved for patients with greatest risk of clinically important bleeding as they have been associated with nosocomial pneumonia, Clostridium difficile infection and increased hospital cost.

Objective: The primary objective was to reduce inappropriate utilization of SUP in 2 adult medical and surgical ICU settings at the University of California, San Francisco Medical Center. Secondary objectives included reduction of inappropriate continuation of SUP at ICU and hospital discharge.

Methods: To attain the study objective, an interprofessional team developed a bundled quality improvement initiative, including an institution SUP guideline, pharmacist-led intervention, and an education and awareness campaign. To assess the impact of these interventions, we conducted a retrospective cohort study comparing data on prescribing practices at baseline before and after the intervention. Since computerized prescriber order entry (CPOE) was implemented during this time frame, preintervention data collection consisted of 2 periods, one before and one after CPOE implementation.

Results: The incidence of the inappropriate use of SUP was not significantly different between the pre-CPOE and post-CPOE groups (20 and 19 per 100 patient-days, respectively; P = .88), but the incidence of inappropriate use of SUP was significantly lower in the postintervention group versus the post-CPOE group (9 and 19 per 100 patient-days, respectively; P = .03). At ICU discharge, 4% of patients in the post-intervention group were discharged inappropriately on SUP compared with 8% in the post-CPOE group (P = .54). At hospital discharge, none of the patients in the postintervention group were discharged inappropriately on SUP compared with 7% in the post-CPOE group (P = .22).

Conclusions: Implementation of an interprofessional bundled quality improvement initiative is effective in decreasing inappropriate use of SUP in adult medical and surgical ICUs at a university-affiliated, tertiary care academic medical center.

Keywords: critical care; gastrointestinal prophylaxis; histamine-2 receptor antagonist; proton pump inhibitor; quality improvement; stress ulcer prophylaxis.