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121 INTRAVENOUS PPI ORDERING PATTERN IN A COMPUTERIZED PHYSICIAN ORDER ENTRY SYSTEM: DOES IT PREVENT INAPPROPRIATE USE? A Nguyen, D Lowe, F Habal BACKGROUND AND AIMS: Intravenous (IV) proton pump inhibitor (PPI) use is widely accepted in treatment of suspected upper gastrointestinal bleeding (UGIB) or in patients who cannot tolerate oral medications (ie NPO) but require PPI for other reasons. Various rates of inappropriate utilization of IV PPI have been reported previously. Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors. The aim was to determine the rate and appropriateness of IV PPI use in an institution with a CPOE that has specific prompts for indications of IV PPI in the ordering protocol. This prompt includes only 2 accepted indications: initial treatment for suspected UGIB, with mandatory gastroenterology (GI) consultation, and all other indications requires GI approval.
University Health Network, University of Toronto, Toronto, Ontario
METHODS: In a prospective study over 1 month period, all patients who had IV PPI ordered during their hospital visit (inpatient or emergency room) were reviewed for indication, appropriateness of dose for indication, and whether GI service was consulted. Indications for use were divided into 3 categories: suspected/known UGIB, NPO, or other indications. A very liberal accepted appropriate dosing for suspected UGIB was used, including a regimen of an 80mg bolus followed by 8mg/hr IV continuous drip of pantoprazole or any IV intermittent dose. Accepted dosing for NPO status included any IV intermittent dose but not continuous IV drip.
RESULTS: Over the study period, a total of 60 patients had IV PPI ordered as part of their medical treatment. Of the total, 35 patients (58.3%) received IV PPI for UGIB, and of these, 3 (8.6%) received an inappropriate dose, and 4 (11.4%) did not have a GI consultation as part of their medical treatment. However, after GI consultation, only 21/31 patients (67.7%) underwent endoscopy, 7/31 (22.6%) were deemed high risk for endoscopy, and 3/31 (9.7%) had alternative diagnoses. IV PPI for NPO status was ordered in 16 (26.7%) patients and of these, 7 (43.8%) received an inappropriate dose (continuous drip rather than IV intermittent), and only 3 (18.8%) received GI consultation. Neither suspected UGIB nor NPO status was the indication for IV PPI was found in 9 patients; 3 for rectal bleeding with stable hemodynamics, 4 for anemia without any overt GI bleeding symptoms and 2 for abdominal pain. Of these 9 patients, 4 received IV bolus followed by continuous IV drip while 5 had IV intermittent dosing. GI consultation was obtained for 7 of the 9 patients.
CONCLUSION: In a setting of CPOE, appropriate use of IV PPI use appears to be very high in patients with suspected UGIB. However, when the indication for IV PPI use is not UGIB related, the rate of inappropriate use is unacceptably high.