ASHP Best Practices Award Mortar and Pestle

Award Information

Impact of a Clinical Pharmacist Acid Suppression Therapy Management Program on Inappropriate Use in Intensive Care Unit and General Ward Patients

Mitchell S. Buckley, Pharm.D., FASHP, FCCM, FCCP, BCPS, Andrew S. Park, Pharm.D., Clint S. Anderson, Pharm.D., BCPS, Jeffrey F. Barletta, Pharm.D., FCCM, Dale Bikin, Pharm.D., Laura M. Wicks, Pharm.D., Cheryl O’Malley, M.D., FACP, Richard Gerkin, M.D., Roxanne Garcia-Orr, M.D. Sandra L. Kane-Gill, Pharm.D., M.Sc., FCCM, FCCP

 

Banner Good Samaritan Medical Center, Phoenix, Arizona

Critically ill patients are at risk of experiencing gastrointestinal (GI) bleeding resulting from stress-related mucosal disease. Although acid suppression therapy (AST) for stress ulcer prophylaxis (SUP) is appropriate for patients at highest risk, inappropriate use remains a concern. Reports have found rates of inappropriate AST approaching 70% in general ward and intensive care unit (ICU) patients. At our institution, we observed inappropriate rates of about 30% in both ICU and general ward patients. The purpose of this program was to improve the clinical and economic impact of inappropriate AST in our hospitalized patients.


Under a collaborative prescriptive authority practice agreement pharmacists initiated, modified, or discontinued therapy as deemed clinically appropriate. Patients taking AST prior to admission were continued on therapy during hospitalization; however the pharmacist changed the patient’s home regimen as needed. Pharmacists were allowed to discontinue AST lacking an appropriate indication or once major risk factors for SUP resolved. Famotidine is the preferred agent for SUP at our institution. Pharmacists were authorized to substitute histamine-2 receptor antagonists in place of protein pump inhibitors in ICU patients with major risk factors. Stress ulcer prophylaxis in non-ICU patients was considered inappropriate so these agents were discontinued.


Implementation occurred in October 2011 with data collected during January 1-31, 2011 and January 1-31, 2012 for the pre- and post-implementation phase, respectively. A total of 16,415 patient-days (n=1134) comprising both pre- and post-implementation groups were included in our analysis. The relative reduction of inappropriate SUP days in ICU patients with no risk factors was 58%. The relative reduction of inappropriate SUP continuation upon transfer from the ICU to the general ward was 42.6% (p<0.001). The relative reduction of inappropriate SUP days in the general ward patient population was 84.1%. Clinical pharmacists decreased the mean duration of inappropriate SUP by 2.1 days and 2.3 days in ICU and general ward patients (p<0.001), respectively. The rate of inappropriate SUP continuation upon hospital discharge in ICU and general ward patients after program implementation decreased by 88.0% and 85.1%, respectively (p<0.001). Total inpatient costs associated with SUP therapy was $20,052.70 pre-implementation and $3,280.49 post-implementation (p<0.001) resulting in an estimated cost-savings of >$200,000 annually. No differences in clinical outcomes were observed.


Implementation of a clinical pharmacist program with prescriptive authority for SUP improved the cost-effective use of AST in the critically ill, while decreasing inappropriate use in all hospitalized patients. This strategy demonstrated significant cost-savings and maintained low rates of medication-related risks.