AN EVALUATION OF A CLINICAL PHARMACIST DIRECTED-INTERVENTION TO RATIONALIZE OVERUSE OF STRESS ULCER PROPHYLAXIS IN INTESIVE CARE UNIT. Ibrahim Labouta, Akram Fayed, Ghada Abu Shesha, Mohamed Mosly, Nahla Kandil, Abeer Hassan, Muhammad Zaitoun Andalusia Group - Al-Salama Hospital, Egypt

Introduction : Routine pharmacologic stress ulcer prophylaxis (SUP) among critically ill patients has been questioned. Prophylaxis is Recommended 1 in patients (adults) with : Coagulopathy (platelet count <50,000 mm3, INR >1.5, or PTT >2× control value) Respiratory failure (mechanical ventilation ≥48 hours) Spinal cord injuries. Multiple trauma 2 (Multiple trauma with Injury Severity Score of ≥ 16). Hepatic failure (total bilirubin level >5 mg/dL, AST >150 U/L (3× ULN), or ALT >150 U/L (3× ULN)) Thermal Injuries 2 (>35% of body surface area) (1 ) According to : American Society of Health-System Pharmacists Commission on Therapeutics. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health-Syst Pharm. 1999; 56:347-79. (2) Excluded from our study.

Introduction (continue) Head injury (Glasgow coma score of ≤10 or inability to obey simple Commands) Partial hepatectomy. Hepatic or renal transplantation. History of gastric ulceration or bleeding during year before admisson. Severe sepsis and septic Shock 3 . Have at least 2 of the following risk factors: A) Sepsis B) ICU stay longer than 1 week C) Occult bleeding lasting 6 days or Longer 2 D) Use of more than 250 mg hydrocortisone or the equivalent therapy. (2) Excluded from our study. (3) From Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 – Page 7

Objectives: The purpose of this study is to compare prescription patterns according to whether stress ulcer prophylaxis is indicated or not, and the estimated cost savings pre and post the intervention of the clinical pharmacists to prescribe stress ulcer prophylaxis to patients indicated for prophylaxis only. The types of the indicated patients here are according to ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis(1999) and International guidelines for management of severe sepsis and septic shock (2008).

Method: Design: The current study is an intervention pretest-posttest study (without control group). Study Population : Fifty four patients were identified for inclusion and evaluated in terms of adherence to the guidelines for two month. Then, the SUP guidelines were presented to the intensivists. Subsequently, 48 ICU patients were assessed prospectively for 6 weeks for proper indication of SUP.

Method: (continue) Interventions: The study was conducted by the clinical pharmacists, it consisted of: sending an educative email to the intensivists with a list of risk factors that predispose patients to stress ulcer so as to limit prescription of SUP to these patients; this list was also posted on the ICU board, and then followed by individual verbal communication. setting: The study was conducted at the Intensive Care Unit of Al Salama Hospital, Alexandria; Egypt.

Outcome Measure(s): The Number and percentage of ICU patients with and without correct prescription of SUP according to indication pre and post intervention were compared. The resulting costs pre and post intervention were also compared as the secondary measurement outcome.

Percentage of the SUP prescription among non-indicated ICU patients Results: Percentage of the SUP prescription among non-indicated ICU patients Bar Chart of the distribution of the percentage of the SUP prescription (with or without) among the non indicated ICU patients pre and post the clinical pharmacists intervention at Alsalama Hospital , Alexandria, Egypt at 2010.

Results: (continue) The clinical pharmacy intervention reduced the inappropriate prescription of overall stress ulcer prophylaxis by 9.5 percent (2 cases) (Fisher’s Exact test, p = .534). The improvement of inappropriate prescription according to indication did not differ significantly; however it was less frequent. No patients developed clinically significant gastrointestinal bleeding in the post-intervention phase. The estimated annual savings of 12,460.14(Min.=5,825.52-Max.=19,094.76) 2011L.E in patient charges and 10,333.32(Min.=4,829.76-Max.=15,830.88) 2011L.E in actual drug costs in our intensive care unit were decreased.

Conclusions: The interventions made by the Clinical Pharmacy Department in the form of sending an educative email and hanging posters as well as individual verbal communication were not effective in changing the prescription habits of SUP of the intensivists to meet the guidelines criteria. Limiting use of SUP to high risk patients can significantly reduce patient charges.