1. Post-implementation study on appropriate GI prophylaxis in the Inpatient Setting David Nguyen 5/14/12

2. Side effects of PPI Indications for stress ulcer/GI prophylaxis Adverse effects of proton pump inhibitor

3. Pathophysiology Impaired gastric mucosal protection from poor perfusion caused by intense physiologic stress Hypersecretion of gastric acid Complication Overt GI bleeding: Usually shallow and from capillary bed 1.5-8.5% in all ICU patients Up to 15% if no GI prophylaxis Perforation: Rare. < 1% in SICU patients Treatment PPI > H2 blocker > Sucralfate = antacid

4. C diff-associated diseases (CDAD) Increased risk of community acquired and nosocomial pneumonia Prolonged hypergastrinemia Gastric atrophy Chronic hypochlohydria Increased risk of fractures Hypomagnesemia Iron and B12 malabsorption Interaction with Plavix

5. Major risk (need at least 1) Coagulopathy (INR > 1.5, Plt 2x normal) Mechanical ventilation > 48hrs GI ulceration or bleeding within the past year Traumatic brain or spinal cord injury Severe burn (>35% of the body surface area) Minor risk (need > 2) Sepsis ICU stay > 1 week Occult GI bleeding > 6 days High dose glucocorticoid therapy (>250mg hydrocortisone or equiv.) Enteral feeding (on case basis)

6. ED/Clinic Admissions (N = 50) PPI ordered on admission (N = 32)(64%) Home med (N=13)(26%)* Discharge with PPI (N=10) Meet PPI indication (N=20)(40%) Discharge with PPI (N=10) Do not meet PPI indication (N=12)(24%) Discharge with PPI (N=1) PPI not ordered on admission (N = 18)(36%) Meet PPI indication (N=1) Discharge with PPI (N=0) Do not meet PPI inidcation (N = 17) Discharge with PPI (N=0) * There were 5-7 patients who were placed on PPI as outpatient without indications

7. 12 out of 50 (24%) admitted patients were placed on PPI inappropriately If not counting the “continuation of home medication group”, the % of inappropriate rises to 34% Total cost of inappropriate PPI orders: $45/day 10 cups of coffee 4 drinks 5-8 meals in cafeteria $1,350/month > 1/3 of resident monthly salaries

8. Study Overview Background: Recent retrospective review of ED/clinic admissions showed ~ 24% of pt had inappropriate PPI ordered for GI prophylaxis. As a result, informational posters and emails were sent out emphasizing the importance of appropriate PPI use Escalating health care expenditures and The need for thoughtfulness on the part of physicians to reduce costs while maintaining/enhancing quality of care. Goal: follow-up review of appropriate PPI use for GI prophylaxis on the medicine ward teams.

9. Study Overview Retrospective study: chart review Inclusion Criteria: 52 ED/clinic admissions to medicine ward teams period 4/25 – 5/2/12 Indications to order PPI: Continuation of home medication H/o GERD, gastritis, GI bleeding, or presenting symptoms concerning for above diseases Exclusion: ICU admissions and transfers

10. Results ED/clinic admission N = 52 PPI ordered on admission N = 21 or 40% Home Med N = 10 or 19% Met PPI indication N = 8 or 15% NO PPI indication N = 3* or 5.6% No PPI admission N = 31 or 60% Met PPI indication N = 0 NO PPI indication N = 31 or 60% * One case where PPI initially ordered but discontinued following day

11. Results/Conclusions Before: 12 out of 50 or 24% After: 3 out of 52 or 6% were ordered inappropriately Residents are taking heed of the proper indications for GI prophylaxis with PPI and implementing into daily use In 1 case, d/c’ed PPI the following day

12. Future Direction Provide appropriate reminders for the new residents and incoming interns. Analyze ICU admissions, transfers from ICU and OSH Look into “home medication” group and see if these patients need to be discharged on PPI