Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients

Area of Science:

• Critical Care Medicine
• Infectious Diseases
• Health Systems Engineering

Background:

• Proton pump inhibitors (PPIs) are associated with hospital-acquired Clostridium difficile infection (CDI).
• Inappropriate PPI use, particularly for stress ulcer prophylaxis in critically ill patients, is common.
• Reducing unnecessary PPI use is crucial for decreasing CDI rates.

Purpose of the Study:

• To identify barriers and facilitators to optimizing PPI prescribing in a medical-surgical intensive care unit (ICU).
• To understand prescribing practices and provider perspectives on PPI use.
• To inform interventions aimed at reducing inappropriate PPI utilization.

Main Methods:

• Mixed-methods study employing chart review and semistructured provider interviews.
• Human factors engineering approach to analyze prescribing practices.
• Classification of emergent themes using the Systems Engineering Initiative for Patient Safety model.

Main Results:

• 25% of PPI days in the ICU were clinically unwarranted.
• Key barriers included inadequate provider education, lack of institutional guidelines, and a culture favoring PPI use.
• Facilitators identified were increased pharmacy oversight, provider education, and electronic medical record decision support.

Conclusions:

• Interventions targeting identified barriers are necessary to reduce unnecessary PPI use in ICUs.
• Optimizing PPI prescribing can potentially lower CDI rates.
• Future research should evaluate the impact of interventions on CDI incidence.