PURPOSE:Two to three percent of patients admitted to medical-surgical Intensive Care Units (ICUs) have clinically significant stress ulcer bleeding, which is associated with a 50% mortality. Several different agents are available for stress ulcer prophylaxis (SUP) and have different costs. The ability of a computerized physician order entry (CPOE) protocol to decrease the use of more expensive SUP agents is unknown.
METHODS:Given the lack of widely accepted guidelines, the choice of when to prescribe SUP and which agent to use is left to the ordering physician at our institution. Intravenous pantoprazole has been widely used and is more expensive than PO pantoprazole or omeprazole or IV famotidine. Coincident to the deployment of CPOE, a pharmacist-driven protocol for stress ulcer prophylaxis was implemented in January 2007 without any publicity or detailing for the ordering physicians. Given the cost of IV pantoprazole, the protocol was designed to preferentially select lower-cost, PO pantoprazole or omeprazole or IV famotidine in patients appropriate for SUP. IV pantoprazole usage and UGI bleed rates for a year prior to and a year after the protocol implementation were measured.
RESULTS:In 2006, the year prior to the implementation of the protocol, 2417 doses of IV pantoprazole were given in 4106 ICU patient days (58.9%). In 2007, 2616 doses of IV pantoprazole were given in 4172 patient days, (62.7%). In 1539 ICU admits in 2007, the protocol was used only 130 times (8.4%). The percentage of ICU patients diagnosed with an UGI bleed during their hospitalization remained unchanged from 2006 to 2007, (10.2% vs 10.6%).
CONCLUSION:Despite its inclusion as an order in CPOE, the SUP per pharmacy protocol order was not frequently used and had no effect on the overall usage of IV pantoprazole.
CLINICAL IMPLICATIONS:Attention is warranted both to protocol validation and to deployment if CPOE is to have significant effects on physician behavior or the cost of care. Future study should examine the ways CPOE protocols can improve the quality of ICU care.
DISCLOSURE:Christopher Dale, No Financial Disclosure Information; No Product/Research Disclosure Information