RESUMO
Background: Guidelines for acute upper gastrointestinal bleeding (UGIB) recommend use of proton pump inhibitors (PPI) administered by continuous IV infusion (CI). Although data suggest comparable outcomes with CI and IV push (IVP) dosing post-endoscopy, there are limited data to support IVP PPI as the pre-endoscopy regimen. Objective: To evaluate the impact of a pharmacist-managed protocol for reducing PPI CIs and substitution of PPI IVP dosing in hemodynamically stable patients with suspected acute upper gastrointestinal bleeding (UGIB) prior to endoscopic intervention. Design, Setting, and Participants: Retrospective study; Tertiary-care community teaching hospital; Hemodynamically stable adults with confirmed or suspected UGIB. Hemodynamic stability was defined as a systolic blood pressure >90 mmHg, heart rate <100 beats, mean arterial pressure >65 mmHg, and no requirement for vasopressors. Intervention: All iterations of treatment recommendations encouraged an initial pantoprazole 80 mg IVP dose. In the pre-intervention group, patients were then treated at the at the provider's discretion with the majority receiving CI pantoprazole. After implementation of the original protocol (Phase I), all hemodynamically stable patients were allowed 1 bag of CI pantoprazole (80 mg infused over 10 hours) before being transitioned by the pharmacist to pantoprazole 40 mg IVP every 12 hours. After internal analysis, the protocol was revised to allow patients to be immediately transitioned to IVP dosing without an initial CI (Phase II). Main Outcome: Incidence of continued bleeding or re-bleeding within 7 days of initial PPI dose. Results: A total of 325 patients were included across all 3 study phases. The median number of CI bags per patient was reduced from 4 pre-intervention, to 1.5 in phase I, and to 0 in phase II (P < .001). The primary endpoint of continued bleeding or re-bleeding within 7 days was similar across all 3 groups (5.0% vs 6.5% vs 5.2%, P = .92). Mean intravenous pantoprazole costs were reduced by $21.73/patient. Conclusions: Movement toward preferential use of IVP PPI prior to endoscopy for hemodynamically stable patients with confirmed or suspected UGIBs resulted in similar rates of continued bleeding or re-bleeding and generated modest cost savings. These findings warrant further investigation.
RESUMO
BACKGROUND: Anticoagulation (AC) management of the Impella varies considerably among treatment centers. Published data regarding the management of complications including heparin-induced thrombocytopenia, bleeding and thrombosis are limited. OBJECTIVE: A multidisciplinary team was assembled to 1) identify baseline knowledge of nurses and pharmacists involved in Impella anticoagulation management; 2) develop an educational tool specific to Impella anticoagulation; 3) reassess knowledge following implementation of the tool. METHODS: A team consisting of pharmacists, nurses and a physician developed surveys that were subsequently distributed to 28 nurses and 17 pharmacists. Survey questions measured knowledge in 4 areas of anticoagulation management: product selection, administration, monitoring and therapeutic recommendation. A pocket card containing flow diagrams for Impella anticoagulation management was developed. Following distribution of the card and education on its application, surveys were redistributed to measure the change in knowledge. RESULTS: The frequency (%) of correct answers for all survey questions for both pharmacists and nurses significantly increased from 38% to 84% (p < 0.00001) and 63% to 93% (p < 0.00001), respectively. Substantial increases in the frequency of correct answers in the majority of question categories were observed for both pharmacists and nurses postintervention. CONCLUSION AND RELEVANCE: Using a multidisciplinary approach, an institution-specific pocket card addressing the complexities of Impella anticoagulation was developed. Following dissemination of the card and education on its application, improved knowledge across the scope of Impella anticoagulation management was observed in both pharmacists and nurses.
