Brian L Erstad

PMID: 9377882;Abstract:

Objective: To determine the appropriateness and medication cost of stress ulcer prophylaxis before and after a targeted educational intervention. Design: In the preintervention cohort (phase 1), 264 patients were evaluated over 2 months, using stress ulcer prophylaxis guidelines developed by s comprehensive literature search. Targeted educational programs were subsequently used to inform trauma housestaff on appropriate usage of stress ulcer prophylaxis medications with emphasis on using sucralfate. The postintervention cohort (phase 2) involved concurrent evaluation of 279 patients. Length of inappropriate stress ulcer prophylaxis (i.e., did not meet approved guidelines) between phases was com pared using a Student's t- test for independent samples (α = .05). Setting: A 365-bed university medical center. Patients: Patients admitted to any of the intensive care units and all patients who were placed on histamine-2-antagonists or sucralfate for stress ulcer prophylaxis. Interventions: Educational intervention regarding appropriate stress ulcer prophylaxis directed at the trauma service. Measurements and Main Results: Patient demographics in the two phases were similar and there was no difference in the number of patient risk factors for stress-induced bleeding. The mean length of inappropriate stress ulcer prophylaxis was 5.78 ± 4.36 days in phase 1 and 4.66 ± 3.10 days in phase 2 (p .05). Eighty-nine patients in phase 1 received inappropriate stress ulcer prophylaxis for a drug cost of $2,272.00 (mean $25.53 ± 25.52) compared with 90 patients in phase 2 with a drug cost of $1,417.00 (mean $15.75 ± 13.06). Three patients in each phase had clinically important bleeding (hemodynamic compromise or transfusion); all were receiving ranitidine. The mean total cost (fixed and variable) of hospitalization was $69,288.00 and $74,709.00 for the three patients who bled in each phase compared with $19,850.00 and $15,812.00 for all patients admitted to the intensive care unit in phases 1 and 2, respectively. The mean length of hospital stay was 30.00 days and 29.33 days for the three patients who bled in each phase compared with 11.54 days and 10.27 days for all patients admitted to the intensive care unit in phases 1 and 2, respectively. Conclusions: Cost savings are associated with more appropriate stress ulcer prophylaxis. Clinically important bleeding is uncommon but results in prolonged hospital stays and increased costs.

PMID: 10423587;Abstract:

Objective: To evaluate whether initial orders of pain medications by physicians for trauma patients were in accordance with published guidelines. Design: Concurrent, nonrandomized investigation conducted over 4 months. Materials and Methods: All adult trauma patients admitted to the intensive care unit within 12 hours of injury who stayed for at least 1 hour were eligible for study admission. Patients with injuries prohibiting accurate pain assessment (e.g., Glasgow Coma Score 8, spinal cord injury) were excluded. Initial orders for pain medications were compared to published guidelines; correlations between dose and patient demographics were studied. Results: Of the 30 patients enrolled in the study, 83% were prescribed appropriate pain control regimens. The average dose of morphine administered during each of the 8-hour dosing intervals was approximately 12 mg. No relationship was found between patient age, sex, Glasgow Coma Score, and morphine dose; however, there was a positive correlation found between Injury Severity Score and dose. Conclusions: The majority of patients in this investigation were initially prescribed appropriate doses and intervals for pain management.

The purpose of this investigation was to perform a cost-effectiveness analysis of adjunctive oral and intravenous proton pump inhibitor (PPI) therapies for patients with acute peptic ulcer-related bleeding of sufficient severity to warrant hospitalization.