(—THIS SIDEBAR DOES NOT PRINT—) D E S I G N G U I D E

This PowerPoint 2007 template produces a 42”x90” presentation poster. You can use it to create your research poster and save valuable time placing titles, subtitles, text, and graphics.

We provide a series of online answer your poster production questions. To view our template tutorials, go online to PosterPresentations.com and click on HELP DESK.

When you are ready to print your poster, go online to PosterPresentations.com

Need assistance? Call us at 1.510.649.3001

Q U I C K S T A R T

Zoom in and out As you work on your poster zoom in and out to the level that is more comfortable to you. Go to VIEW > ZOOM.

Title, Authors, and Affiliations

Start designing your poster by adding the title, the names of the authors, and the affiliated institutions. You can type or paste text into the provided boxes. The template will automatically adjust the size of your text to fit the title box. You can manually override this feature and change the size of your text.

T I P : The font size of your title should be bigger than your name(s) and institution name(s).

Adding Logos / Seals Most often, logos are added on each side of the title. You can insert a logo by dragging and dropping it from your desktop, copy and paste or by going to INSERT > PICTURES. Logos taken from web sites are likely to be low quality when printed. Zoom it at 100% to see what the logo will look like on the final poster and make any necessary adjustments.

T I P : See if your company’s logo is available on our free poster templates page.

Photographs / Graphics You can add images by dragging and dropping from your desktop, copy and paste, or by going to INSERT > PICTURES. Resize images proportionally by holding down the SHIFT key and dragging one of the corner handles. For a professional-looking poster, do not distort your images by enlarging them disproportionally.

Image Quality Check Zoom in and look at your images at 100% magnification. If they look good they will print well.

ORIGINAL DISTORTED

Corner handles

Good

print

ing qu

ality

Bad p

rintin

g qua

lity

Q U I C K S TA R T ( c o n t . )

How to change the template color theme You can easily change the color theme of your poster by going to the DESIGN menu, click on COLORS, and choose the color theme of your choice. You can also create your own color theme. You can also manually change the color of your background by going to VIEW > SLIDE MASTER. After you finish working on the master be sure to go to VIEW > NORMAL to continue working on your poster.

How to add Text The template comes with a number of pre-formatted placeholders for headers and text blocks. You can add more blocks by copying and pasting the existing ones or by adding a text box from the HOME menu.

Text size

Adjust the size of your text based on how much content you have to present. The default template text offers a good starting point. Follow the conference requirements.

How to add Tables

To add a table from scratch go to the INSERT menu and click on TABLE. A drop-down box will help you select rows and columns.

You can also copy and a paste a table from Word or another PowerPoint document. A pasted table may need to be re-formatted by RIGHT-CLICK > FORMAT SHAPE, TEXT BOX, Margins.

Graphs / Charts You can simply copy and paste charts and graphs from Excel or Word. Some reformatting may be required depending on how the original document has been created.

How to change the column configuration RIGHT-CLICK on the poster background and select LAYOUT to see the column options available for this template. The poster columns can also be customized on the Master. VIEW > MASTER.

How to remove the info bars

If you are working in PowerPoint for Windows and have finished your poster, save as PDF and the bars will not be included. You can also delete them by going to VIEW > MASTER. On the Mac adjust the Page-Setup to match the Page-Setup in PowerPoint before you create a PDF. You can also delete them from the Slide Master.

Save your work Save your template as a PowerPoint document. For printing, save as PowerPoint or “Print-quality” PDF.

Student discounts are available on our Facebook page. Go to PosterPresentations.com and click on the FB icon.

©2015PosterPresenta/ons.com2117FourthStreet,UnitCBerkeleyCA94710posterpresenter@gmail.com

K. Gandhi, MD (Associate), S. Dhital, MD (Associate), S. Khan, MD (Associate), S. Basnyat, MD (Associate), F. Bofarrag, MD (Associate), T. Maduke, MD (Associate), B. Qureshi, MD (Associate), Y. Goite, MD (Associate), F. Balis, MD (Fellow) and H. Kawsar, MD, Ph.D (Fellow)

Department of Medicine, St. Luke’s Hospital, Chesterfield, MO

A SEEMINGLY BENIGN DRUG IN THE SPOTLIGHT: AN EDUCATIONAL INTERVENTION TO REDUCE INAPPROPRIATE USE OF PPI

INTRODUCTION

Overutilization of Proton pump inhibitors (PPI) in hospitalized patients is a well-recognized problem. In our previous study at St. Luke’s Hospital, we found that the lack of published guidelines for PPI use in non-critically ill patients results in overutilization of PPI in hospitalized patients. We conducted an educational intervention program to address this problem. METHODS

We retrospectively reviewed 200 patient charts who received PPI while admitted to the medical floor at St. Luke’s Hospital in 2014. It showed a high number of patients were on PPI inappropriately. To improve this practice, we conducted an interventional program to educate residents on appropriate use of PPI by emails, flyers, holding brief meetings and providing them with quick reference cards as well as by setting up high risk pharmacy alert for Protonix use on EMR. The effect of this intervention was measured by reviewing EMR of 179 qualified patients admitted to medical floors between March and May 2016. RESULTS

The majority of patients were Caucasian (90%) with female predominance (56%). PPI was used or continued appropriately in 92% (84%, pre intervention) patient during admissions and 85% (48%, pre intervention) during discharge. The most common indications for PPI use in our study was gastro-esophagitis or GERD (72%) and history of GI bleeding (12%). Six percent of patients had a history of Barrett’s esophagus or hiatal hernia. There was no documented reason for PPI use in 3% of patients, and 5% of them were discharged home on PPI. DISCUSSION

Overutilization of PPI in non-critically ill hospitalized patients is a known problem in medical practice. Use of PPI has been implicated in number of adverse consequences including but not limited to Clostridium difficile infection, pneumonia, and osteoporosis.

DISCUSSION

In recent studies, PPI was found to be associated with increased in-hospital mortality, increased risk of cardiovascular events, dementia and chronic renal failure (CRF). We studied the magnitude of the problem in our hospital and employed an educational intervention program, which resulted in a significant reduction of inappropriate use of PPI in the hospital. There were several limitations to our study. This was a retrospective study where we noted a lack of proper documentation for outpatient use of PPI. We also were unable to precisely determine for how long the patients were taking PPI as outpatients. Our post interventional data was only from medical residents (a total of 41), as a result, we are unable to determine the effect of the educational intervention on the clinical practice of NPs, hospitalists and PCPs. CONCLUSION

PPIs have long been considered as relatively harmless drugs. In recent years, it has been implicated in several adverse effects that increases patient morbidity and mortality along with increased healthcare expenditure. Our data shows that proper education and ongoing surveillance, especially during admission and discharge can significantly reduce overutilization of PPI. REFERENCES

1. ASHP therapeutic guidelines on stress ulcer prophylaxis. Am J Health Syst Pharm. 1999; 56:347-79. 2. Chia, C., Lim, W, and Vu, C. (2014). Singapore Medical Journal Smedj, 55 (7), 363-366. 3. Hussain, S., Stefan, M., Visintainer, P. et al. (2010). Southern Medical Journal, 103(11). 4. Ladd, A., Panagopoulos, G., Cohen, J. et al. (2014). The American Journal of the Medical Sciences, 347(6), 446-451. 5. Heidelbaugh, J., Kim, A., Chang, R. et al. Therapeutic Advances in Gastroenterology, 219-232. 6. Lazarus, B, Chen. Y, Francis P. et al. (2016) JAMA Intern Med. 2016;176(2) 7. 7.Gomm, W., Holt, V K, and Thomé, F (2016); JAMA Neurol. 2016;73(4):410- 416. 8. Protonix® (pantoprazole) prescribing information, Retrieved August 2015

ACKNOWLEDGEMENT We would like to thank Dr. Daina Zhang, Dr. Belmaya Ghale, Dr. Luke Sung, Dr. Ali Entezari, and Dr. Mohamed Gashouta for their contribution during pre-intervention phase of the study. We also thank Dr. Sajid Zafar, MD, Department of Gastroenterology and Hepatology for his valuable advice. Thanks to Ms. Tami Strand, Director of Clinical Performance and Improvement, and Mr. Way Huey, Pharm D, BCPS, FCCM, Assistant Director of Pharmacy Services, for their help with patient data.

Residents NPs PCP Hospitalist

33% 30%

19% 16%

28% 24%

16%

29%

Prescribers of PPI Inappropriate Appropriate

84%

16%

Appropriate Vs Inappropriate Appropriate Inappropriate

48%

42%

10%

PPI on discharge Continued Discontinued Unnown

Recommendations: Put a STOP Date Additional wks. if needed

Esophagitis/Gastritis/GERD – Erosive 8 weeks – STOP 4-8 weeks Esophagitis/Gastritis/GERD - Nonerosive but symptomatic Peptic Ulcer Disease Without H. Pylori 4-8 weeks – STOP 4 weeks

With H. Pylori Triple/Dual therapy 14 days -STOP 14 days

>= 2 of minor criteria

1. Severe sepsis 2. ICU stay more than 1 week 3. Occult GI bleeding for >=6 days 4. High Dose Glucocorticoid therapy (Hydrocortisone>250, Prednisone >62.5, methylprednisolone >50)

4 weeks – STOP 4 weeks

OTC use for Frequent heartburn Use for < 14 days – STOP May repeat after 4 months Chronic NSAID therapy Continue daily – Max 6 months 6 months – STOP Pathological hypersecretory conditions Daily – Possible lifetime use

STOP: 1. If C. Diff positive - until treatment completion 2. If does not know why taking it and denies dyspepsia 3. If acute interstitial nephritis develops

5%

85%

10%

PPI on discharge Continued Discontinued Unknown

92%

3% 5%

Appropriate Vs Inappropriate Appropriate Inappropriate Undetermined

Pre Post

16% 3%

84% 92%

PPI on Admission Inappropriate Appropriate

Pre Post

42%

5%

48%

85%

PPI on Discharge Continued Discontinued

Pre intervention Post intervention Sample size 200 179 Age 72 72

Gender Male 56% 44% Female 44% 56%

Race Caucasian 91% 90% African-Americans 6% 8% Others 3% 2%

72%

12%

6% 4% 3% 3%

Reasons for PPI use

Esophagitis/Gastritis/GERD GI Bleeding

Hiatal hernia/Barrett's esophagus PUD/H.Pylori

Others

No Known Indication

Table 2. Patient characteristics

Table 1. Guidelines for PPI use