Ensuring Guideline Adherence and Cost Savings in Stress Ulcer Prophylaxis Practices in the Intensive Care Unit: a Pre-Post Education Study

Background Intensive care unit (ICU) patients are prone to developing stress-related gastrointestinal (GI) bleeding, which is associated with increased morbidity and mortality. Respiratory failure, hypotension, coagulopathy, and especially prolonged mechanical ventilation (MV) are the most critical clinically significant risk factors for GI bleeding in patients. Many studies have shown that invasive MV for 48 hours or longer and coagulopathy are two independent risk factors for clinically significant upper GI bleeding in ICU patients.

Stress ulcer prophylaxis (SUP) is widely practiced in ICUs worldwide and is often (up to 70%) used inappropriately. Proton pump inhibitors (PPI) are among the most commonly used medications in critically ill patients for SUP. However, the inappropriate and quite inconsistent use of PPIs in ICUs has added unnecessary costs, enhanced risks related to adverse drug reactions, and possible complications like pneumonia, Clostridium difficile infections, hypomagnesemia, and bone fractures.

A few studies have assessed adherence with SUP guidelines and institutional standards under the surveillance of a pharmacist. The results of these studies implied that pharmacist supervision reduced the inappropriate use of SUP in patients and its associated healthcare costs. One of these studies noted that the intervention and adjustment of pharmacists reduced the incidence of inappropriate use of SUP and its associated costs from $26.75 and $2433 per 100 patient days pre-intervention to $7.14 and $239.80 per 100 patient days post-intervention with p<0.001. The same study emphasized that a comprehensive multidisciplinary approach must be implemented to decrease inappropriate SUP use in the ICU.

The aim of this study is to enhance adherence to the guidelines through an educational program focused on reducing inappropriate use of SUP in the ICU. The goal is to promote appropriate use of SUP based on indications, leading to cost savings.

Methods Study Design and Participants This study was designed as a non-randomized, controlled, prospective study created according to the pre-post education evaluation model. It was conducted in the anesthesia and reanimation ICU of a training and research hospital between January 2024 and July 2024 (6 months). The study was conducted in pre-education (PreEd) and post-education (PostEd). In PreEd, the SUP use of patients in the ICU was observed observationally for three months (January 1, 2024 - April 1, 2024). In the study, the SUP education program in the ICU was implemented for ICU physicians after examining the patient data in the first three months of the study. In the 3-month PostEd after the education program (April 3, 2024 - July 3, 2024), SUP was only used in patients in the ICU, and no intervention was observed. Throughout the study period, the appropriateness of SUP uses for the indication was evaluated according to the Sociedade Portuguesa de Cuidados (SPC) SUP guideline].