Implementation of a Pharmacy Consult for Stress Ulcer Prophylaxis Management in the ICU

Service or Program: We aim to describe the development and implementation of a novel method to ensure appropriate discontinuation of acid suppression therapy (AST) in the ICU.  A pharmacy consult was created and embedded within several order sets containing stress ulcer prophylaxis (SUP) medications.  The consult advances the clinical role of the ICU pharmacist who is now responsible for AST assessment, evaluation, and potential discontinuation on a daily basis.  Justification/Documentation: There is a high incidence of inappropriate SUP utilization in the inpatient setting.  Inappropriate utilization of AST, specifically proton pump inhibitors, has been associated with an increased risk of Clostridium difficile infections (CDIs) and pneumonia. Inadvertant continuation of AST at the time of hospital discharge is also problematic.  Exposure to chronic AST can put a patient at further risk for bone fractures, drug interactions, and arrhythmias.  Interventions to decrease AST exposure in patients without an active indication are warranted to limit these morbidities.  Transferability: Including a pharmacy consult for AST management is beneficial to patients on the general medical ward in addition to those in the ICU.  Due to the over-the-counter availability of AST and its widespread use in the outpatient setting, the potential for expansion of this service into the community is substantial.  Patients on AST therapy outside of the hospital setting continue to be at risk for CDIs and the adverse effects of long term AST.  Impact: The implementation and utilization of this novel pharmacy consult has the potential to decrease medication costs and improve patient outcomes.  It will also increase awareness about the appropriate prescribing of stress ulcer prophylaxis within the institution.  The impact of a pharmacist-driven AST management service enhances the role of the clinical pharmacist and encourages further development of innovative pharmacy services.