Impact of the stress ulcer prophylactic protocol on reducing the unnecessary administration of stress ulcer medications and gastrointestinal bleeding : A single-center, retrospective pre-post study

概要

Background
Stress ulcer prophylaxis is an important concern in intensive care. Some previous studies have reported that 5% to 25% of critically ill patients without stress ulcer prophylaxis develop upper gastrointestinal bleeding due to the severity of illness and/or invasive treatments. A systematic review and meta-analysis showed that histamine type 2 receptor blockers and proton pump inhibitors significantly reduced the incidence of upper gastrointestinal bleeding in critically ill adult patients. Nonetheless, these drugs have been shown to increase the incidence of hospital-acquired pneumonia and Clostridioides difficile infection.

Currently, medical checklists are widely used to maintain the compliance of medications and interventions in intensive care units. Previous studies have reported that utilizing medical checklists improved the quality of patient care and reduced patient mortality and length of ICU stay.

However, the efficacy of medical checklists in terms of reducing the incidence of upper gastrointestinal bleeding and unnecessary administration of stress ulcer prophylactic medications has not been sufficiently explored yet.

This study aimed to investigate the incidence of upper gastrointestinal bleeding and rate of administering stress ulcer prophylactic medications before and after setting administration criteria for stress ulcer prophylaxis and introducing a medical checklist in critically ill adults.

Methods
This was a retrospective pre-post study at a single-center, tertiary adult and pediatric mixed ICU. Adult patients (≥18 years) who were admitted to the ICU for reasons other than gastrectomy, esophagectomy, pancreatoduodenectomy, and gastrointestinal bleeding were analyzed. A medical checklist and stress ulcer prophylaxis criteria were introduced on December 22, 2014, and the patients were classified into the preintervention group (from September to December 21, 2014) and the postintervention group (from December 22, 2014, to April 2015). The primary outcome was the incidence of upper gastrointestinal bleeding, and the secondary outcome was the proportion administered stress ulcer prophylaxis medications.

Results
One hundred adult patients were analyzed. The incidence of upper gastrointestinal bleeding in the pre- and postintervention groups were both 4.0%［95% confidence interval, 0.5-13.7%］. The proportion administered stress ulcer prophylaxis medications decreased from 100% to 38% between the pre- and postintervention groups.

Conclusions
After the checklist and the criteria were introduced, the administration of stress ulcer prophylaxis medications decreased without an increase in upper gastrointestinal bleeding in critically ill adults. Prospective studies are necessary to evaluate the causal relationship between the introduction of them and gastrointestinal adverse events in critically ill adults.