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Pharmacist-Initiated De-Prescribing Efforts Reduce Inappropriate Continuation of Acid-Suppression Therapy Initiated in the ICU

Published:September 25, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.09.003

      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.

      Keywords

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      References

        • Cook DJ
        • Fuller HD
        • Guyatt GH
        • et al.
        Risk factors for gastrointestinal bleeding in critically ill patients.
        N Engl J Med. 1994; 330: 377-381
        • Erstad BL
        • Grant KL
        • Boucher BA
        • et al.
        ASHP therapeutic guidelines on stress ulcer prophylaxis.
        Am J Health-Syst Pharm. 1999; 56: 347-379
        • Krag M
        • Perner A
        • Møller MH.
        Stress ulcer prophylaxis in the intensive care unit.
        Curr Opin Crit Care. 2016; 22: 186-190
        • Buendgens L
        • Koch A
        • Tacke F
        Prevention of stress-related ulcer bleeding at the intensive care unit: Risks and benefits of stress ulcer prophylaxis.
        World J Crit Care Med. 2016; 5: 57-64
        • Shiddapur A
        • Kistler CE
        • Whitehead-Busby J
        • Austin CA
        Association of histamine-2 blockers and proton pump inhibitors with delirium development in critically ill adults: a retrospective cohort study.
        Crit Care Explor. 2021; 3: e0507
        • Wohlt PD
        • Hansen LA
        • Fish JT
        Inappropriate continuation of stress ulcer prophylactic therapy after discharge.
        Ann Pharmacother. 2007; 41: 1611-1616
        • Buckley MA
        • Park AS
        • Anderson CS
        • et al.
        Impact of a clinical pharmacist stress ulcer prophylaxis management program on inappropriate use in hospitalized patients.
        Am J Med. 2015; 128: 905-913
      1. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) worksheet. Available at: http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx. Accessed June 7, 2021.

        • Ali D
        • Barra ME
        • Blunck J
        • et al.
        Stress-related gastrointestinal bleeding in patients with aneurysmal subarachnoid hemorrhage: a multicenter retrospective observational study.
        Neurocrit Care. 2021; 35: 39-45
      2. Institute for Healthcare Improvement. QI Essentials Toolkit: Run chart & control chart. Available at: https://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx. Accessed August 30, 2022.

        • Jaisak KD
        • Middleton EA
        • Camamo JM
        • Erstad BL
        • Snyder LS
        • Huckleberry YC
        Evaluation of discontinuation of atypical antipsychotics prescribed for ICU delirium.
        J Pharm Pract. 2012; 26: 252-256
        • Kram BL
        • Schultheis JM
        • Kram SJ
        • Cox CE
        A pharmacy-based electronic handoff tool to reduce discharge prescribing of atypical antipsychotics initiated in the intensive care unit: a quality improvement initiative.
        J Pharm Pract. 2019; 32: 434-441
        • Krag M
        • Marker S
        • Perner A
        • et al.
        Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU.
        N Engl J Med. 2018; 379: 2199-2208
        • Marik PE
        • Vasu T
        • Hirani A
        • Pachinburavan M
        Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis.
        Crit Care Med. 2010; 38: 2222-2228
        • Huang H
        • Jiang W
        • Wang C
        • Qin HY
        • Du B
        Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis.
        Crit Care. 2018; 22: 20
        • Halli-Tierney AD
        • Scarbrough C
        • Carroll D
        Polypharmacy: evaluating risks and deprescribing.
        Am Fam Physician. 2019; 100: 32-38
        • Rech MA
        • Gurnani PK
        • Peppard WJ
        • et al.
        PHarmacist Avoidance or Reductions in Medical costs in CRITically ill adults: PHARM-CRIT study.
        Crit Care Explor. 2021; 3: e0594