De-Prescribing Efforts Reduce Inappropriate Continued Acid Suppression Therapy

A multidisciplinary approach using formalized stress ulcer prophylaxis criteria, an electronic handoff tool, and provider education decreases the number of acid suppression therapy prescriptions inappropriately continued after patients are discharged from the intensive care unit (ICU), according to study findings from The American Journal of Medicine.

Researchers conducted a single-center quality improvement initiative to reduce ICU-initiated acid suppression therapy discharge prescriptions by 25%. Using a Plan-Do-Study-Act (PDSA) model, researchers conducted the following 3 interventions over 8 months: an interim handoff tool, a formal handoff tool and indication requirements, and standardized stress ulcer prophylaxis criteria. Data were collected from 163 ICU-initiated acid suppression therapy discharge prescriptions, and the pharmacist handoff tool was used for 530 acid suppression therapy prescriptions.

The primary outcome was the number of ICU-initiated acid suppression therapy discharge prescriptions. Secondary outcomes were the number of de-prescribing workflow failures, the percentage of inappropriate discharge prescriptions given for acid suppression therapy, and the incidence of gastrointestinal (GI) bleeding due to stress ulcers.

Patients included in the study were 18 years and older, admitted to an adult ICU, and received a prescription for acid suppression therapy while hospitalized. Acid suppression therapy included lansoprazole (enteral), pantoprazole (enteral or parenteral), and famotidine (enteral or parenteral).

Patients who were on an acid suppression medication prior to ICU admission were excluded.

For the first PDSA cycle, pharmacists used the handoff tool to assess the potential discontinuation of acid suppression treatment after it was prescribed.

In cycle 2, the handoff tool required providers to select an indication (stress ulcer prophylaxis, GI bleeding, gastroesophageal reflux disease, Helicobacter pylori infection, or other), and a multidisciplinary team reassessed treatment daily. Providers were required to provide rationale for continuing treatment if a patient was discharged on acid suppression therapy.

In cycle 3, the hospital’s Critical Care Executive Committee standardized guidelines for stress ulcer prophylaxis. Indications for acid suppression therapy included mechanical ventilation for more than 48 hours, coagulopathy, and patients with aneurysmal subarachnoid hemorrhage displaying elevated intracranial pressure or vasospasm. The committee recommended discontinuing stress ulcer prophylaxis once patients on mechanical ventilation were clinically stable or if they were meeting enteral nutritional goals.

The average rate of ICU-initiated prophylactic acid suppression therapy decreased by 55% over 2 weeks, from 10.8 at baseline to 4.9 during the first cycle. The number of discharge prescriptions for acid suppression remained below the baseline mean for 28 weeks. This reduction was maintained through cycles 2 and 3 but were not further reduced.

After implementing the handoff tool, the median number of pharmacist workflow errors was 6% over 2 weeks. There were no errors in the final 8 weeks of the study period.

There were no changes observed in the percentage of patients who continued therapy after being inappropriately prescribed acid suppression therapy upon discharge. No patients experienced gastrointestinal bleeding due to gastric ulcers.

Study limitations include the observation period occurring during the COVID-19 pandemic, variances in provider prescribing preferences, incorrect selection of therapy indications, and an inability to confirm all home medications and past medical history for ICU patients.

“Multidisciplinary education helped to bring awareness to the issue of inappropriate continuation of ICU medications post-discharge at this institution, and this education along with improved pharmacist-to-pharmacist communication via an electronic handoff tool were found to be primary drivers in reduction of the number of ICU-initiated acid suppression therapy prescriptions inadvertently or inappropriately continued at discharge,” the study authors wrote. “Future QI initiatives are warranted to confirm whether this framework may be extrapolated to other ICU-initiated medications or applied to different healthcare settings.”