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Sustainability of a Performance Improvement Project: Inappropriate Use of Gi Prophylaxis In Non-ICU Hospitalized Patients

Sustainability of a Performance Improvement Project: Inappropriate Use of Gi Prophylaxis In Non-ICU Hospitalized Patients

Amreen Dinani, M.D., Steven Reichert, M.D., F.A.C.P.
Department of Medicine, New York Hospital Queens, Flushing, New York

Background:
The use of anti-secretory therapy (AST) is recommended for stress ulcer prophylaxis in ICU patients and certain patients in non-ICU settings. The inappropriate use of anti-secretory therapy has been well established. Previous studies have reported that the over utilization of acid-suppressive therapy results in economic costs and complications associated with its use. A previous performance improvement initiative at New York Hospital Queens analyzed the institutional utilization of AST prophylaxis. A subsequent performance improvement initiative demonstrated improved prophylactic usage of AST.  The aim of this study is to reexamine the institutional over utilization of AST and determine the long-term sustainability of the prior performance improvement initiative. 

Methods:
Randomized retrospective consecutive chart review of patients admitted to general medical floors at a 439-bed university-affiliated multi-specialty tertiary care teaching community hospital. 3 sets of data was collected: initial chart review, before intervention (Group 1), 4 months after intervention (Group 2) and 1 year after intervention (Group 3). Individual reviewers evaluated each chart for appropriate use of AST at admission compared to recommended published guidelines (Table 1). After initial chart review, (Group 1) multidisciplinary educational interventions were made which included didactic lectures, e-mail alerts, posting of recommended guidelines and frequent reminders by research collaborators. House staff was provided with feedback on their practice patterns, including results of the initial, pre-intervention results. Data was collaborated on Excel and analyzed using Chi-square analysis.

Table 1: Indications for Anti-secretory therapy
Gastroesophageal Reflux Disease
Peptic Ulcer Disease
Upper GI Bleed
Gastritis
Steroid and NSAID and /or ASA use
Stress Ulcer Prophylaxis· 

  • Prolonged Intubation- >48hours
  • Coagulopathy- INR>1.5 or platelets <50,000 
  • Hepatic Failure- any 2 of the following: T bilirubin >8.8, AST>500, Albumin <4.1 or clinical signs of hepatic failure.
  • Renal Failure- CrCl<40 or Urine Output <55cc/day or Cr>2.8
  • Sepsis- SIRS with known or suspected infection

Results:
221 charts were initially reviewed for the appropriateness of use of anti-secretory therapy. 225 charts were subsequently reviewed four months and 199 charts were reviewed one year after intervention. Demographic characteristics and admitting diagnosis of the patients are listed in Table 2.


Table 2: Demographic Characteristics of Study Population
Group 1 / Group 2 / Group 3
No of patients (%) / No of patients (%) / No of patients (%)

Gender

  • Female: 132 (60%) / 130 (58%) / 107 (54%)
  • Male:  89 (40%) / 95 (42%) / 107 92 (46%)

Admitting Diagnosis (majority)

  • Gastroenterology: 29 (13.1%) / 26 (11.6%) / 21 (11.0%)
  • Pulmonary: 30 (13.6%) / 19 (8.5%) / 19 (9.6%)
  • Cardiac: 66 (30.0%) / 25 (11.2%) / 13 (6.6%)
  • Infectious Disease: 21 (9.5%) / 11 (4.9%) / 123 (6.6%)

At baseline, 72.1% of patients who had no indication for AST were inappropriately started on AST on admission. Four months after intervention, 40.3% patients and one year after intervention, 34.4% patients were inappropriately started on AST. This study demonstrates a significant reduction in inappropriate administration of AST at both 4 months and one year after multidisciplinary interventions were made (p<0.0001 for both groups).

We also observed a significant reduction in the appropriate prophylaxis against stress ulcer prophylaxis (p<0.0001). Prior to educational intervention, 94% of patients (93/99) were appropriately started on AST prophylaxis at admission. This rate dropped to 84% at four months and 69% at one year.

All groups showed that house staff are reconciling medication adequately when it comes to anti-secretory therapy. In Group 1, initial chart review, 50/99 patients who had an indication for AST and previously taking a form of AST, 49 patients (98%, p= 0.65) were appropriately continued on AST. Similarly 93.9% and 84.9% patients in Group 2 and Group 3 respectively were appropriately continued on AST when they had an indication and were previously taking AST (p= 0.038 and p= 0.82 respectively).

Conclusion:
This study demonstrates that patients admitted to general medical floors were inappropriately started on AST. It also shows that a simple educational intervention based on published guidelines for stress ulcer prophylaxis in general medical floors can positively cut down the inappropriate use of AST. It further illustrates the sustainability of the interventions made to reduce the inappropriate use of anti-secretory therapy.  Unfortunately the improvement in prophylaxis also led to a reduction in the appropriate use of AST at admission. 

 

 

 
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