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FACTORS AFFECTING INAPPROPRIATE INTRAVENOUS PROTON PUMP INHIBITOR USE IN A COMPUTERIZED ORDER ENTRY SYSTEM
A Nguyen, F Habal
University Health Network, University of Toronto, Toronto, Ontario
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 and factors associated with inappropriate use 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 of inappropriate usage of IV PPI and determine any factors associated with improper use.
METHODS: In a prospective study over 2 month period, all patients who had computer generated orders for IV PPI during their hospital visit (inpatient, emergency room, or elective post-operatively) were reviewed within 24 hours of initiation of the order, for indication, appropriateness of dose, 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 infusion of pantoprazole or any IV intermittent dose. Accepted dosing for NPO status included any IV intermittent dose but not continuous IV drips.
RESULTS: Over the study period, a total of 101 patients had computer-generated orders for IV PPI as part of their medical treatment. Of the total, 69 patients (68.3%) received IV PPI for possible UGIB, and of these, 16 (23.2%) had IV PPI ordered inappropriately. IV PPI for NPO status was ordered in 18 (17.8% of total) patients and of these, 11 (61.1%) patients had inappropriate usage (either wrong dose or not strictly NPO). Neither suspected UGIB nor NPO status was the indication for IV PPI use in 14 (13.9% of total) patients, all of whom are considered inappropriate. Overall, the rate of inappropriate usage was 39.6% (40/101), with the majority of inappropriate use in the non-UGIB categories (25/41). Factors that appear to be associated with inappropriate use were non-UGIB (combined NPO and other indications), orders generated after hours (1700-0800 and on weekends), and when ordered by surgical subspecialties. Age and gender did not affect appropriateness of IV PPI use.
CONCLUSION: In a setting of computerized physician order entry, inappropriate use of IV PPI remains unacceptably very high, particularly in the setting of non-UGIB indications. The factors associated with inappropriate ordering practices include orders generated after hours and those generated by surgical subspecialties.