2025 Southeastern Residency Conference

Title: Optimizing Stress Ulcer Prophylaxis in Critically Ill Patients: A Pharmacist-Driven Approach to Discontinuation

Authors: Ciana Wallace, Sarah Adams, Jamie McCarthy 

Objective: To assess SUP medication management before and after the implementation of a standardized, pharmacist-driven guidance. 

Background: Stress ulcers are superficial ulcerations that typically occur in the fundus and body of the stomach due to hospitalization. Specifically, patients in the intensive care unit (ICU) are at higher risk for stress ulcer development. Frequently, stress ulcer prophylaxis (SUP) is initiated in the ICU but infrequently discontinued when no longer indicated. The purpose of this study was to reduce inappropriate SUP continuation during hospitalization and at discharge at Piedmont Athens Regional through implementation of a pharmacist guidance document for discontinuation. 

Methods: This is a single-center, pre-post interventional study on patients admitted to the medical or cardiac ICU and initiated on SUP. A standardized pharmacist-driven SUP guidance was developed to provide criteria for discontinuation of SUP and approved by critical care providers. The SUP guide was designed to discontinue SUP based on a lack of risk factors for stress ulcers. Patient charts were reviewed before and after the intervention of the SUP guide. The pre-intervention group included 50 randomly selected patients admitted between November 2023 and January 2024. The post-intervention group included 50 randomly selected patients admitted between November 2024 and January 2025. Patients ≥ 18 years of age with medical or cardiac ICU admission > 24 hours and on a proton pump inhibitor (PPI) or histamine-2-receptor antagonist (H2RA) were automatically included. The primary outcome was the number of days patients were continued on inappropriate SUP. The secondary outcome was the number of patients discharged on inappropriate SUP. Statistical analysis was completed using Microsoft Excel. Continuous data was analyzed using the Mann-Whitney U test and reported as median with interquartile range data. Categorical data was analyzed using the Chi-Square test and reported as a frequency. Statistical significance was assessed with a significance level of 0.05.

Results:  A total of 100 patients were included in the study with 50 patients in both the pre-intervention and post-intervention groups. There were no significant differences in the baseline characteristics between both groups. For the primary outcome, the post-intervention group had fewer days of inappropriate SUP continuation compared to the pre-intervention group (1.1 days vs 0.2 days (p = 0.04). The post-intervention group had fewer days of SUP continuation compared to the pre-intervention group (4.1 days vs 5.7 days, p = 0.03). There were less patients discharged from the ICU and CICU on SUP between the pre-intervention and post-intervention groups (76% vs 54%, p = 0.021). No statistically significant difference was found in the number of patients discharged from the hospital on SUP; however, there were less patients discharged overall between the pre-intervention and post-intervention groups (20% vs 14%, p = 0.424).

Conclusions: The study emphasizes the impactful role of pharmacists in optimizing SUP management with a clear reduction in both overall SUP continuation and inappropriate use. These results reinforce the value of implementing a standardized approach to routinely assess SUP appropriateness. Moving forward, incorporating this guidance into an institutional protocol could help ensure consistent practice and long-term improvements in SUP management.