Impact of Trauma Stress Ulcer Prophylaxis Guidelines on Drug Cost and Frequency of Major Gastrointestinal Bleeding

Abstract

Trauma patients are routinely prescribed stress ulcer prophylaxis despite evidence suggesting such therapy be limited to patients with identifiable risk factors for bleeding. With surgeons' consensus, we developed and implemented trauma stress ulcer prophylaxis guidelines, and measured the impact of clinical pharmacists on implementing the guidelines and the effect of the guidelines on drug cost and frequency of major gastrointestinal bleeding. Two groups of 150 consecutive patients admitted with multiple trauma were evaluated before and after guideline implementation and stratified by Injury Severity Score (ISS) to minor (ISS < 9) or moderate to severe (ISS > or = 9) trauma groups. The number of patients prescribed stress ulcer prophylaxis, length and cost of this therapy, and number of patients experiencing major gastrointestinal bleeding (decrease in consecutive hemoglobin > or = 2 g/dl in conjunction with coffee-ground emesis, hematemesis, melena, or hematochezia) were measured. All pharmacist interventions pertaining to stress prophylaxis were collected. Fewer patients were prescribed stress ulcer prophylaxis after guideline implementation (105/150, 70% vs 39/150, 26%, p<0.0001), leading to a decrease in total drug cost of $4558. Use decreased more in patients with minor (40/54, 74% vs 9/59, 15%, p<0.0001) than moderate to severe (65/96, 68% vs 30/91, 33%, p<0.0001) trauma. Neither length of therapy nor agent of choice (> 95% cimetidine) differed between groups. Fifteen (38%) of 38 postguideline prophylaxis orders were determined by the pharmacist not to meet guideline criteria. Recommendations to discontinue therapy were accepted in 9 (60%) of 15 instances. The frequency of major gastrointestinal bleeding remained unchanged between groups (1/150 vs 0/150, p=1.0). Implementation of trauma stress ulcer prophylaxis guidelines limiting therapy to patients with risk factors for bleeding led to a 80% decrease in drug cost and did not affect the frequency of major gastrointestinal bleeding.

Stress ulcer prophylaxis guidelines: Are they being implemented in Lebanese health care centers?

“…Our study suggests that the inadequacy in administering the drugs is due to the misconception that parenteral medications are more effective that oral ones. However, studies [54][55][56] failed to show any efficacy or safety advantages of one formulation over the other. Thus, to minimize the potential adverse effects and additional costs of parenteral administration [9,[54][55][56] the parenteral route should be reserved for patients who cannot tolerate oral medications.…”

Brief report: Reducing inappropriate usage of stress ulcer prophylaxis among internal medicine residents

“…Finally, although theoretically there may have been a confounding trend toward a decrease in SUP usage at that time, our preintervention rates of prophylaxis were similar to that seen in other studies and we know of no secular trends or other newly enacted hospital policies designed to reduce SUP usage during the time of this intervention. 10,12,13 Perhaps most intriguing is what may appear to be an ongoing enhancement of effect seen at 6 months, as evidenced by the lower rate of inappropriate discharge use. This may simply reflect the small study size and may not be truly lower.…”

Stress Prophylaxis in Intensive Care Unit Patients and the Role of Enteral Nutrition

“…A later prospective study by the same group determined that instituting a stress ulcer prophylaxis protocol reduced AST from 70% to 26%, whereas the rates of major GI bleeding were equivocal. Although the authors did not report the percentage of patients receiving EN, the use of EN was an indication for AST discontinuation in the protocol 100 . Taken together, these studies indicate the possible role of using EN in place of AST for stress prophylaxis without the risk of increased GI bleeding.…”