A Multi-Faceted Implementation Strategy to Improve Acid Suppression Prophylaxis Among Patients Admitted to the Cardiac Intensive Care Unit: Results of a Longitudinal Study

Abstract

Acid suppressive therapy (AST) can reduce the development of stress and medication-related mucosal disease when prescribed appropriately. Previous data by our group show suboptimal prescribing of AST in the hospital among cardiac patients. The aim of this quality improvement study was to improve appropriate AST in patients admitted to the cardiac intensive care unit (CCU) of a quaternary care hospital. An AST guideline was first established through collaboration among cardiology, gastroenterology, and pharmacy divisions based on the following risk factors: intubation, organic coagulopathy, use of anticoagulant and antiplatelet agents, and use of high-dose steroids (Figure 1). A retrospective chart review of all patients admitted to the CCU from September 1, 2016 to January 4, 2017 was performed to identify the percentage of patients on appropriate AST based on this guideline. A root-cause analysis was then performed identifying the following targets for intervention: provider awareness, unstructured rounding protocols, and lack of an automated alert system. A stepwise implementation strategy was developed targeting these factors, which was rolled out in 4 Plan-Do-Study-Act (PDSA) cycles. Data on AST were prospectively collected from the date of the first intervention on December 15, 2017 through August 31, 2017. These data were then analyzed to determine rates of appropriate AST pre- and post-intervention. During the pre-intervention phase, 264 patients were admitted to the CCU, of which only 72.9% were prescribed appropriate AST. After the first PDSA cycle, which included development and dissemination of an evidence-based AST guideline, 102 patients were admitted, 81.1% of which had appropriate AST. After the second PDSA cycle, which focused on structuring morning rounds to include AST discussion, compliance rates improved to 84.0% of 31 patients. The third PDSA cycle included incorporation of an electronic automated high-risk patient tracker, which increased appropriate AST to 86.1% of 428 patients (Figure 2). These results were sustained through the duration of the study. Through a multi-faceted implementation strategy that included development of guidelines, a new rounding structure, and an electronic dashboard to highlight opportunities for intervention, our group increased appropriate AST from 72.9% to 86.1% of all patients admitted to our hospital’s CCU. Considering the deleterious effects of both under- and overprescribing of AST, particularly in high-risk patient populations, such as those with cardiac disease who are critically ill, this improvement may lead to enhanced patient outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)