Arjun Gupta, MD

Proton pump inhibitors (PPIs) are among the most commonly used drugs worldwide to treat dyspepsia and prevent gastrointestinal bleeding (GIB).¹ Between 40% and 70% of hospitalized patients receive acid-suppressive therapy (AST; defined as PPIs or histamine-receptor antagonists), and nearly half of these are initiated during the inpatient stay.^2,3 While up to 50% of inpatients who received a new AST were discharged on these medications,² there were no evidence-based indications for a majority of the prescriptions.^2,3

Growing evidence shows that PPIs are overutilized and may be associated with wide-ranging adverse events, such as acute and chronic kidney disease,⁴Clostridium difficile infection,⁵ hypomagnesemia,⁶ and fractures.⁷ Because of the widespread overuse and the potential harm associated with PPIs, a concerted effort to promote their appropriate use in the inpatient setting is necessary. It is important to note that reducing the use of PPIs does not increase the risks of GIB or worsening dyspepsia. Rather, reducing overuse of PPIs lowers the risk of harm to patients. The efforts to reduce overuse, however, are complex and difficult.

This article summarizes evidence regarding interventions to reduce overuse and offers an implementation guide based on this evidence. This guide promotes value-based quality improvement and provides a blueprint for implementing an institution-wide program to reduce PPI overuse in the inpatient setting. We begin with a discussion about quality initiatives to reduce PPI overuse, followed by a review of the safety outcomes associated with reduced use of PPIs.

A focused search of the US National Library of Medicine’s PubMed database was performed to identify English-language articles published between 2000 and 2018 that addressed strategies to reduce PPI overuse for stress ulcer prophylaxis (SUP) and nonvariceal GIB. The following search terms were used: PPI and inappropriate use; acid-suppressive therapy and inappropriate use; PPI and discontinuation; acid-suppressive (or suppressant) therapy and discontinuation; SUP and cost; and histamine receptor antagonist and PPI. Inpatient or outpatient studies of patients aged 18 years or older were considered for inclusion in this narrative review, and all study types were included. The primary exclusion criterion was patients aged younger than 18 years. A manual review of the full text of the retrieved articles was performed and references were reviewed for missed citations.

We identified a total of 1,497 unique citations through our initial search. After performing a manual review, we excluded 1,483 of the references and added an additional 2, resulting in 16 articles selected for inclusion. The selected articles addressed interventions falling into three main groupings: implementation of institutional guidelines with or without electronic health record (EHR)–based decision support, educational interventions alone, and multifaceted interventions. Each of these interventions is discussed in the sections that follow. Table 1, Table 2, and Table 3 summarize the results of the studies included in our narrative review.

Institutional Guidelines With or Without EHR-Based Decision Support

Table 1 summarizes institutional guidelines, with or without EHR-based decision support, to reduce inappropriate PPI use. The implementation of institutional guidelines for the appropriate reduction of PPI use has had some success. Coursol and Sanzari evaluated the impact of a treatment algorithm on the appropriateness of prescriptions for SUP in the intensive care unit (ICU).⁸ Risk factors of patients in this study included mechanical ventilation for 48 hours, coagulopathy for 24 hours, postoperative transplant, severe burns, active gastrointestinal (GI) disease, multiple trauma, multiple organ failure, and septicemia. The three treatment options chosen for the algorithm were intravenous (IV) famotidine (if the oral route was unavailable or impractical), omeprazole tablets (if oral access was available), and omeprazole suspension (in cases of dysphagia and presence of nasogastric or orogastric tube). After implementation of the treatment algorithm, the proportion of inappropriate prophylaxis decreased from 95.7% to 88.2% (P = .033), and the cost per patient decreased from $11.11 to $8.49 Canadian dollars (P = .003).

Van Vliet et al implemented a clinical practice guideline listing specific criteria for prescribing a PPI.⁹ Their criteria included the presence of gastric or duodenal ulcer and use of a nonsteroidal anti-inflammatory drug (NSAID) or aspirin, plus at least one additional risk factor (eg, history of gastroduodenal hemorrhage or age >70 years). The proportion of patients started on PPIs during hospitalization decreased from 21% to 13% (odds ratio, 0.56; 95% CI, 0.33-0.97).

Michal et al utilized an institutional pharmacist-driven protocol that stipulated criteria for appropriate PPI use (eg, upper GIB, mechanical ventilation, peptic ulcer disease, gastroesophageal reflux disease, coagulopathy).¹⁰ Pharmacists in the study evaluated patients for PPI appropriateness and recommended changes in medication or discontinuation of use. This institutional intervention decreased PPI use in non-ICU hospitalized adults. Discontinuation of PPIs increased from 41% of patients in the preintervention group to 66% of patients in the postintervention group (P = .001).

In addition to implementing guidelines and intervention strategies, institutions have also adopted changes to the EHR to reduce inappropriate PPI use. Herzig et al utilized a computerized clinical decision support intervention to decrease SUP in non-ICU hospitalized patients.¹¹ Of the available response options for acid-suppressive medication, when SUP was chosen as the only indication for PPI use a prompt alerted the clinician that “[SUP] is not recommended for patients outside the [ICU]”; the alert resulted in a significant reduction in AST for the sole purpose of SUP. With this intervention, the percentage of patients who had any inappropriate acid-suppressive exposure decreased from 4.0% to 0.6% (P < .001).

Table 2 summarizes educational interventions to reduce inappropriate PPI use.

Agee et al employed a pharmacist-led educational seminar that described SUP indications, risks, and costs.¹² Inappropriate SUP prescriptions decreased from 55.5% to 30.5% after the intervention (P < .0001). However, there was no reduction in the percentage of patients discharged on inappropriate AST.

Chui et al performed an intervention with academic detailing wherein a one-on-one visit with a physician took place, providing education to improve physician prescribing behavior.¹³ In this study, academic detailing focused on the most common instances for which PPIs were inappropriately utilized at that hospital (eg, surgical prophylaxis, anemia). Inappropriate use of double-dose PPIs was also targeted. Despite these efforts, no significant difference in inappropriate PPI prescribing was observed post intervention.

Hamzat et al implemented an educational strategy to reduce inappropriate PPI prescribing during hospital stays, which included dissemination of fliers, posters, emails, and presentations over a 4-week period.¹⁴ Educational efforts targeted clinical pharmacists, nurses, physicians, and patients. Appropriate indications for PPI use in this study included peptic ulcer disease (current or previous), H pylori infection, and treatment or prevention of an NSAID-induced ulcer. The primary outcome was a reduction in PPI dose or discontinuation of PPI during the hospital admission, which increased from 9% in the preintervention (pre-education) phase to 43% during the intervention (education) phase and to 46% in the postintervention (posteducation) phase (P = .006).

Liberman and Whelan also implemented an educational intervention among internal medicine residents to reduce inappropriate use of SUP; this intervention was based on practice-based learning and improvement methodology.¹⁵ They noted that the rate of inappropriate prophylaxis with AST decreased from 59% preintervention to 33% post intervention (P < .007).

Table 3 summarizes several multifaceted approaches aimed at reducing inappropriate PPI use. Belfield et al utilized an intervention consisting of an institutional guideline review, education, and monitoring of AST by clinical pharmacists to reduce inappropriate use of PPI for SUP.¹⁶ With this intervention, the primary outcome of total inappropriate days of AST during hospitalization decreased from 279 to 116 (48% relative reduction in risk, P < .01, across 142 patients studied). Furthermore, inappropriate AST prescriptions at discharge decreased from 32% to 8% (P = .006). The one case of GIB noted in this study occurred in the control group.

Del Giorno et al combined audit and feedback with education to reduce new PPI prescriptions at the time of discharge from the hospital.¹⁷ The educational component of this intervention included guidance regarding potentially inappropriate PPI use and associated side effects and targeted multiple departments in the hospital. This intervention led to a sustained reduction in new PPI prescriptions at discharge during the 3-year study period. The annual rate of new PPI prescriptions was 19%, 19%, 18%, and 16% in years 2014, 2015, 2016, and 2017, respectively, in the internal medicine department (postintervention group), compared with rates of 30%, 29%, 36%, 36% (P < .001) for the same years in the surgery department (control group).

Education and the use of medication reconciliation forms on admission and discharge were utilized by Gupta et al to reduce inappropriate AST in hospitalized patients from 51% prior to intervention to 22% post intervention (P < .001).¹⁸ Furthermore, the proportion of patients discharged on inappropriate AST decreased from 69% to 20% (P < .001).

Hatch et al also used educational resources and pharmacist-led medication reconciliation to reduce use of SUP.¹⁹ Before the intervention, 24.4% of patients were continued on SUP after hospital discharge in the absence of a clear indication for use; post intervention, 11% of patients were continued on SUP after hospital discharge (of these patients, 8.7% had no clear indication for use). This represented a 64.4% decrease in inappropriately prescribed SUP after discharge (P < .0001).

Khalili et al combined an educational intervention with an institutional guideline in an infectious disease ward to reduce inappropriate use of SUP.²⁰ This intervention reduced the inappropriate use of AST from 80.9% before the intervention to 47.1% post intervention (P < .001).

Masood et al implemented two interventions wherein pharmacists reviewed SUP indications for each patient during daily team rounds, and ICU residents and fellows received education about indications for SUP and the implemented initiative on a bimonthly basis.²¹ Inappropriate AST decreased from 26.75 to 7.14 prescriptions per 100 patient-days of care (P < .001).

McDonald et al combined education with a web-based quality improvement tool to reduce inappropriate exit prescriptions for PPIs.²² The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month to 18.5% per month (P = .03).

Finally, the initiative implemented by Tasaka et al to reduce overutilization of SUP included an institutional guideline, a pharmacist-led intervention, and an institutional education and awareness campaign.²³ Their initiative led to a reduction in inappropriate SUP both at the time of transfer out of the ICU (8% before intervention, 4% post intervention, P = .54) and at the time of discharge from the hospital (7% before intervention, 0% post intervention, P = .22).

Proton pump inhibitors are often initiated in the hospital setting, with up to half of these new prescriptions continued at discharge.^2,24,25 Inappropriate prescriptions for PPIs expose patients to excess risk of long-term adverse events.²⁶ De-escalating PPIs, however, raises concern among clinicians and patients for potential recurrence of dyspepsia and GIB. There is limited evidence regarding long-term safety outcomes (including GIB) following the discontinuation of PPIs deemed to have been inappropriately initiated in the hospital. In view of this, clinicians should educate and monitor individual patients for symptom relapse to ensure timely and appropriate resumption of AST.

Our literature search for this narrative review and implementation guide has limitations. First, the time frame we included (2000-2018) may have excluded relevant articles published before our starting year. We did not include articles published before 2000 based on concerns these might contain outdated information. Also, there may have been incomplete retrieval of relevant studies/articles due to the labor-intensive nature involved in determining whether PPI prescriptions are appropriate or inappropriate.

We noted that interventional studies aimed at reducing overuse of PPIs were often limited by a low number of participants; these studies were also more likely to be single-center interventions, which limits generalizability. In addition, the studies often had low methodological rigor and lacked randomization or controls. Moreover, to fully evaluate the sustainability of interventions, some of the studies had a limited postimplementation period. For multifaceted interventions, the efficacy of individual components of the interventions was not clearly evaluated. Moreover, there was a high risk of bias in many of the included studies. Some of the larger studies used overall AST prescriptions as a surrogate for more appropriate use. It would be advantageous for a site to perform a pilot study that provides well-defined parameters for appropriate prescribing, and then correlate with the total number of prescriptions (automated and much easier) thereafter. Further, although the evidence regarding appropriate PPI use for SUP and GIB has shifted rapidly in recent years, society guidelines have not been updated to reflect this change. As such, quality improvement interventions have predominantly focused on reducing PPI use for the indications reflected by these guidelines.

The following are our recommendations for successfully implementing an evidence-based, institution-wide initiative to promote the appropriate use of PPIs during hospitalization. These recommendations are informed by the evidence review and reflect the consensus of the combined committees coauthoring this review.

For an initiative to succeed, participation from multiple disciplines is necessary to formulate local guidelines and design and implement interventions. Such an interdisciplinary approach requires advocates to closely monitor and evaluate the program; sustainability will be greatly facilitated by the active engagement of key stakeholders, including the hospital’s executive administration, supply chain, pharmacists, and gastroenterologists. Lack of adequate buy-in on the part of key stakeholders is a barrier to the success of any intervention. Accordingly, before selecting a particular intervention, it is important to understand local factors driving the overuse of PPI.

1. Develop evidence-based institutional guidelines for both SUP and nonvariceal upper GIB through an interdisciplinary workgroup.

• Establish an interdisciplinary group including, but not limited to, pharmacists, hospitalists, gastroenterologists, and intensivists so that changes in practice will be widely adopted as institutional policy.
• Incorporate the best evidence and clearly convey appropriate and inappropriate uses.

2. Integrate changes to the EHR.

• If possible, the EHR should be leveraged to implement changes in PPI ordering practices.
• While integrating changes to the EHR, it is important to consider informatics and implementation science, since the utility of hard stops and best practice alerts has been questioned in the setting of operational inefficiencies and alert fatigue.
• Options for integrating changes to the EHR include the following:
  • Create an ordering pathway that provides clinical decision support for PPI use.
  • Incorporate a best practice alert in the EMR to notify clinicians of institutional guidelines when they initiate an order for PPI outside of the pathway.
  • Consider restricting the authority to order IV PPIs by requiring a code or password or implement another means of using the EHR to limit the supply of PPI.
  • Limit the duration of IV PPI by requiring daily renewal of IV PPI dosing or by altering the period of time that use of IV PPI is permitted (eg, 48 to 72 hours).
  • PPIs should be removed from any current order sets that include medications for SUP.

3. Foster pharmacy-driven interventions.

• Consider requiring pharmacist approval for IV PPIs.
• Pharmacist-led review and feedback to clinicians for discontinuation of inappropriate PPIs can be effective in decreasing inappropriate utilization.

4. Provide education, audit data, and obtain feedback.

• Data auditing is needed to measure the efficacy of interventions. Outcome measures may include the number of non-ICU and ICU patients who are started on a PPI during an admission; the audit should be continued through discharge. A process measure may be the number of pharmacist calls for inappropriate PPIs. A balancing measure would be ulcer-specific upper GIB in patients who do not receive SUP during their admission. (Upper GIB from other etiologies, such as varices, portal hypertensive gastropathy, and Mallory-Weiss tear would not be affected by PPI SUP.)
• Run or control charts should be utilized, and data should be shared with project champions and ordering clinicians—in real time if possible.
• Project champions should provide feedback to colleagues; they should also work with hospital leadership to develop new strategies to improve adherence.
• Provide ongoing education about appropriate indications for PPIs and potential adverse effects associated with their use. Whenever possible, point-of-care or just-in-time teaching is the preferred format.

Excessive use of PPIs during hospitalization is prevalent; however, quality improvement interventions can be effective in achieving sustainable reductions in overuse. There is a need for the American College of Gastroenterology to revisit and update their guidelines for management of patients with ulcer bleeding to include stronger evidence-based recommendations on the proper use of PPIs.²⁷ These updated guidelines could be used to update the implementation blueprint.

Quality improvement teams have an opportunity to use the principles of value-based healthcare to reduce inappropriate PPI use. By following the blueprint outlined in this article, institutions can safely and effectively tailor the use of PPIs to suitable patients in the appropriate settings. Reduction of PPI overuse can be employed as an institutional catalyst to promote implementation of further value-based measures to improve efficiency and quality of patient care.

Proton pump inhibitors (PPIs) are among the most commonly used drugs worldwide to treat dyspepsia and prevent gastrointestinal bleeding (GIB).¹ Between 40% and 70% of hospitalized patients receive acid-suppressive therapy (AST; defined as PPIs or histamine-receptor antagonists), and nearly half of these are initiated during the inpatient stay.^2,3 While up to 50% of inpatients who received a new AST were discharged on these medications,² there were no evidence-based indications for a majority of the prescriptions.^2,3

Growing evidence shows that PPIs are overutilized and may be associated with wide-ranging adverse events, such as acute and chronic kidney disease,⁴Clostridium difficile infection,⁵ hypomagnesemia,⁶ and fractures.⁷ Because of the widespread overuse and the potential harm associated with PPIs, a concerted effort to promote their appropriate use in the inpatient setting is necessary. It is important to note that reducing the use of PPIs does not increase the risks of GIB or worsening dyspepsia. Rather, reducing overuse of PPIs lowers the risk of harm to patients. The efforts to reduce overuse, however, are complex and difficult.

This article summarizes evidence regarding interventions to reduce overuse and offers an implementation guide based on this evidence. This guide promotes value-based quality improvement and provides a blueprint for implementing an institution-wide program to reduce PPI overuse in the inpatient setting. We begin with a discussion about quality initiatives to reduce PPI overuse, followed by a review of the safety outcomes associated with reduced use of PPIs.

A focused search of the US National Library of Medicine’s PubMed database was performed to identify English-language articles published between 2000 and 2018 that addressed strategies to reduce PPI overuse for stress ulcer prophylaxis (SUP) and nonvariceal GIB. The following search terms were used: PPI and inappropriate use; acid-suppressive therapy and inappropriate use; PPI and discontinuation; acid-suppressive (or suppressant) therapy and discontinuation; SUP and cost; and histamine receptor antagonist and PPI. Inpatient or outpatient studies of patients aged 18 years or older were considered for inclusion in this narrative review, and all study types were included. The primary exclusion criterion was patients aged younger than 18 years. A manual review of the full text of the retrieved articles was performed and references were reviewed for missed citations.

We identified a total of 1,497 unique citations through our initial search. After performing a manual review, we excluded 1,483 of the references and added an additional 2, resulting in 16 articles selected for inclusion. The selected articles addressed interventions falling into three main groupings: implementation of institutional guidelines with or without electronic health record (EHR)–based decision support, educational interventions alone, and multifaceted interventions. Each of these interventions is discussed in the sections that follow. Table 1, Table 2, and Table 3 summarize the results of the studies included in our narrative review.

Institutional Guidelines With or Without EHR-Based Decision Support

Table 1 summarizes institutional guidelines, with or without EHR-based decision support, to reduce inappropriate PPI use. The implementation of institutional guidelines for the appropriate reduction of PPI use has had some success. Coursol and Sanzari evaluated the impact of a treatment algorithm on the appropriateness of prescriptions for SUP in the intensive care unit (ICU).⁸ Risk factors of patients in this study included mechanical ventilation for 48 hours, coagulopathy for 24 hours, postoperative transplant, severe burns, active gastrointestinal (GI) disease, multiple trauma, multiple organ failure, and septicemia. The three treatment options chosen for the algorithm were intravenous (IV) famotidine (if the oral route was unavailable or impractical), omeprazole tablets (if oral access was available), and omeprazole suspension (in cases of dysphagia and presence of nasogastric or orogastric tube). After implementation of the treatment algorithm, the proportion of inappropriate prophylaxis decreased from 95.7% to 88.2% (P = .033), and the cost per patient decreased from $11.11 to $8.49 Canadian dollars (P = .003).

Van Vliet et al implemented a clinical practice guideline listing specific criteria for prescribing a PPI.⁹ Their criteria included the presence of gastric or duodenal ulcer and use of a nonsteroidal anti-inflammatory drug (NSAID) or aspirin, plus at least one additional risk factor (eg, history of gastroduodenal hemorrhage or age >70 years). The proportion of patients started on PPIs during hospitalization decreased from 21% to 13% (odds ratio, 0.56; 95% CI, 0.33-0.97).

Michal et al utilized an institutional pharmacist-driven protocol that stipulated criteria for appropriate PPI use (eg, upper GIB, mechanical ventilation, peptic ulcer disease, gastroesophageal reflux disease, coagulopathy).¹⁰ Pharmacists in the study evaluated patients for PPI appropriateness and recommended changes in medication or discontinuation of use. This institutional intervention decreased PPI use in non-ICU hospitalized adults. Discontinuation of PPIs increased from 41% of patients in the preintervention group to 66% of patients in the postintervention group (P = .001).

In addition to implementing guidelines and intervention strategies, institutions have also adopted changes to the EHR to reduce inappropriate PPI use. Herzig et al utilized a computerized clinical decision support intervention to decrease SUP in non-ICU hospitalized patients.¹¹ Of the available response options for acid-suppressive medication, when SUP was chosen as the only indication for PPI use a prompt alerted the clinician that “[SUP] is not recommended for patients outside the [ICU]”; the alert resulted in a significant reduction in AST for the sole purpose of SUP. With this intervention, the percentage of patients who had any inappropriate acid-suppressive exposure decreased from 4.0% to 0.6% (P < .001).

Table 2 summarizes educational interventions to reduce inappropriate PPI use.

Agee et al employed a pharmacist-led educational seminar that described SUP indications, risks, and costs.¹² Inappropriate SUP prescriptions decreased from 55.5% to 30.5% after the intervention (P < .0001). However, there was no reduction in the percentage of patients discharged on inappropriate AST.

Chui et al performed an intervention with academic detailing wherein a one-on-one visit with a physician took place, providing education to improve physician prescribing behavior.¹³ In this study, academic detailing focused on the most common instances for which PPIs were inappropriately utilized at that hospital (eg, surgical prophylaxis, anemia). Inappropriate use of double-dose PPIs was also targeted. Despite these efforts, no significant difference in inappropriate PPI prescribing was observed post intervention.

Hamzat et al implemented an educational strategy to reduce inappropriate PPI prescribing during hospital stays, which included dissemination of fliers, posters, emails, and presentations over a 4-week period.¹⁴ Educational efforts targeted clinical pharmacists, nurses, physicians, and patients. Appropriate indications for PPI use in this study included peptic ulcer disease (current or previous), H pylori infection, and treatment or prevention of an NSAID-induced ulcer. The primary outcome was a reduction in PPI dose or discontinuation of PPI during the hospital admission, which increased from 9% in the preintervention (pre-education) phase to 43% during the intervention (education) phase and to 46% in the postintervention (posteducation) phase (P = .006).

Liberman and Whelan also implemented an educational intervention among internal medicine residents to reduce inappropriate use of SUP; this intervention was based on practice-based learning and improvement methodology.¹⁵ They noted that the rate of inappropriate prophylaxis with AST decreased from 59% preintervention to 33% post intervention (P < .007).

Table 3 summarizes several multifaceted approaches aimed at reducing inappropriate PPI use. Belfield et al utilized an intervention consisting of an institutional guideline review, education, and monitoring of AST by clinical pharmacists to reduce inappropriate use of PPI for SUP.¹⁶ With this intervention, the primary outcome of total inappropriate days of AST during hospitalization decreased from 279 to 116 (48% relative reduction in risk, P < .01, across 142 patients studied). Furthermore, inappropriate AST prescriptions at discharge decreased from 32% to 8% (P = .006). The one case of GIB noted in this study occurred in the control group.

Del Giorno et al combined audit and feedback with education to reduce new PPI prescriptions at the time of discharge from the hospital.¹⁷ The educational component of this intervention included guidance regarding potentially inappropriate PPI use and associated side effects and targeted multiple departments in the hospital. This intervention led to a sustained reduction in new PPI prescriptions at discharge during the 3-year study period. The annual rate of new PPI prescriptions was 19%, 19%, 18%, and 16% in years 2014, 2015, 2016, and 2017, respectively, in the internal medicine department (postintervention group), compared with rates of 30%, 29%, 36%, 36% (P < .001) for the same years in the surgery department (control group).

Education and the use of medication reconciliation forms on admission and discharge were utilized by Gupta et al to reduce inappropriate AST in hospitalized patients from 51% prior to intervention to 22% post intervention (P < .001).¹⁸ Furthermore, the proportion of patients discharged on inappropriate AST decreased from 69% to 20% (P < .001).

Hatch et al also used educational resources and pharmacist-led medication reconciliation to reduce use of SUP.¹⁹ Before the intervention, 24.4% of patients were continued on SUP after hospital discharge in the absence of a clear indication for use; post intervention, 11% of patients were continued on SUP after hospital discharge (of these patients, 8.7% had no clear indication for use). This represented a 64.4% decrease in inappropriately prescribed SUP after discharge (P < .0001).

Khalili et al combined an educational intervention with an institutional guideline in an infectious disease ward to reduce inappropriate use of SUP.²⁰ This intervention reduced the inappropriate use of AST from 80.9% before the intervention to 47.1% post intervention (P < .001).

Masood et al implemented two interventions wherein pharmacists reviewed SUP indications for each patient during daily team rounds, and ICU residents and fellows received education about indications for SUP and the implemented initiative on a bimonthly basis.²¹ Inappropriate AST decreased from 26.75 to 7.14 prescriptions per 100 patient-days of care (P < .001).

McDonald et al combined education with a web-based quality improvement tool to reduce inappropriate exit prescriptions for PPIs.²² The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month to 18.5% per month (P = .03).

Finally, the initiative implemented by Tasaka et al to reduce overutilization of SUP included an institutional guideline, a pharmacist-led intervention, and an institutional education and awareness campaign.²³ Their initiative led to a reduction in inappropriate SUP both at the time of transfer out of the ICU (8% before intervention, 4% post intervention, P = .54) and at the time of discharge from the hospital (7% before intervention, 0% post intervention, P = .22).

Proton pump inhibitors are often initiated in the hospital setting, with up to half of these new prescriptions continued at discharge.^2,24,25 Inappropriate prescriptions for PPIs expose patients to excess risk of long-term adverse events.²⁶ De-escalating PPIs, however, raises concern among clinicians and patients for potential recurrence of dyspepsia and GIB. There is limited evidence regarding long-term safety outcomes (including GIB) following the discontinuation of PPIs deemed to have been inappropriately initiated in the hospital. In view of this, clinicians should educate and monitor individual patients for symptom relapse to ensure timely and appropriate resumption of AST.

Our literature search for this narrative review and implementation guide has limitations. First, the time frame we included (2000-2018) may have excluded relevant articles published before our starting year. We did not include articles published before 2000 based on concerns these might contain outdated information. Also, there may have been incomplete retrieval of relevant studies/articles due to the labor-intensive nature involved in determining whether PPI prescriptions are appropriate or inappropriate.

We noted that interventional studies aimed at reducing overuse of PPIs were often limited by a low number of participants; these studies were also more likely to be single-center interventions, which limits generalizability. In addition, the studies often had low methodological rigor and lacked randomization or controls. Moreover, to fully evaluate the sustainability of interventions, some of the studies had a limited postimplementation period. For multifaceted interventions, the efficacy of individual components of the interventions was not clearly evaluated. Moreover, there was a high risk of bias in many of the included studies. Some of the larger studies used overall AST prescriptions as a surrogate for more appropriate use. It would be advantageous for a site to perform a pilot study that provides well-defined parameters for appropriate prescribing, and then correlate with the total number of prescriptions (automated and much easier) thereafter. Further, although the evidence regarding appropriate PPI use for SUP and GIB has shifted rapidly in recent years, society guidelines have not been updated to reflect this change. As such, quality improvement interventions have predominantly focused on reducing PPI use for the indications reflected by these guidelines.

The following are our recommendations for successfully implementing an evidence-based, institution-wide initiative to promote the appropriate use of PPIs during hospitalization. These recommendations are informed by the evidence review and reflect the consensus of the combined committees coauthoring this review.

For an initiative to succeed, participation from multiple disciplines is necessary to formulate local guidelines and design and implement interventions. Such an interdisciplinary approach requires advocates to closely monitor and evaluate the program; sustainability will be greatly facilitated by the active engagement of key stakeholders, including the hospital’s executive administration, supply chain, pharmacists, and gastroenterologists. Lack of adequate buy-in on the part of key stakeholders is a barrier to the success of any intervention. Accordingly, before selecting a particular intervention, it is important to understand local factors driving the overuse of PPI.

1. Develop evidence-based institutional guidelines for both SUP and nonvariceal upper GIB through an interdisciplinary workgroup.

• Establish an interdisciplinary group including, but not limited to, pharmacists, hospitalists, gastroenterologists, and intensivists so that changes in practice will be widely adopted as institutional policy.
• Incorporate the best evidence and clearly convey appropriate and inappropriate uses.

2. Integrate changes to the EHR.

• If possible, the EHR should be leveraged to implement changes in PPI ordering practices.
• While integrating changes to the EHR, it is important to consider informatics and implementation science, since the utility of hard stops and best practice alerts has been questioned in the setting of operational inefficiencies and alert fatigue.
• Options for integrating changes to the EHR include the following:
  • Create an ordering pathway that provides clinical decision support for PPI use.
  • Incorporate a best practice alert in the EMR to notify clinicians of institutional guidelines when they initiate an order for PPI outside of the pathway.
  • Consider restricting the authority to order IV PPIs by requiring a code or password or implement another means of using the EHR to limit the supply of PPI.
  • Limit the duration of IV PPI by requiring daily renewal of IV PPI dosing or by altering the period of time that use of IV PPI is permitted (eg, 48 to 72 hours).
  • PPIs should be removed from any current order sets that include medications for SUP.

3. Foster pharmacy-driven interventions.

• Consider requiring pharmacist approval for IV PPIs.
• Pharmacist-led review and feedback to clinicians for discontinuation of inappropriate PPIs can be effective in decreasing inappropriate utilization.

4. Provide education, audit data, and obtain feedback.

• Data auditing is needed to measure the efficacy of interventions. Outcome measures may include the number of non-ICU and ICU patients who are started on a PPI during an admission; the audit should be continued through discharge. A process measure may be the number of pharmacist calls for inappropriate PPIs. A balancing measure would be ulcer-specific upper GIB in patients who do not receive SUP during their admission. (Upper GIB from other etiologies, such as varices, portal hypertensive gastropathy, and Mallory-Weiss tear would not be affected by PPI SUP.)
• Run or control charts should be utilized, and data should be shared with project champions and ordering clinicians—in real time if possible.
• Project champions should provide feedback to colleagues; they should also work with hospital leadership to develop new strategies to improve adherence.
• Provide ongoing education about appropriate indications for PPIs and potential adverse effects associated with their use. Whenever possible, point-of-care or just-in-time teaching is the preferred format.

Excessive use of PPIs during hospitalization is prevalent; however, quality improvement interventions can be effective in achieving sustainable reductions in overuse. There is a need for the American College of Gastroenterology to revisit and update their guidelines for management of patients with ulcer bleeding to include stronger evidence-based recommendations on the proper use of PPIs.²⁷ These updated guidelines could be used to update the implementation blueprint.

Quality improvement teams have an opportunity to use the principles of value-based healthcare to reduce inappropriate PPI use. By following the blueprint outlined in this article, institutions can safely and effectively tailor the use of PPIs to suitable patients in the appropriate settings. Reduction of PPI overuse can be employed as an institutional catalyst to promote implementation of further value-based measures to improve efficiency and quality of patient care.

Proton pump inhibitors (PPIs) are among the most commonly used drugs worldwide to treat dyspepsia and prevent gastrointestinal bleeding (GIB).¹ Between 40% and 70% of hospitalized patients receive acid-suppressive therapy (AST; defined as PPIs or histamine-receptor antagonists), and nearly half of these are initiated during the inpatient stay.^2,3 While up to 50% of inpatients who received a new AST were discharged on these medications,² there were no evidence-based indications for a majority of the prescriptions.^2,3

Growing evidence shows that PPIs are overutilized and may be associated with wide-ranging adverse events, such as acute and chronic kidney disease,⁴Clostridium difficile infection,⁵ hypomagnesemia,⁶ and fractures.⁷ Because of the widespread overuse and the potential harm associated with PPIs, a concerted effort to promote their appropriate use in the inpatient setting is necessary. It is important to note that reducing the use of PPIs does not increase the risks of GIB or worsening dyspepsia. Rather, reducing overuse of PPIs lowers the risk of harm to patients. The efforts to reduce overuse, however, are complex and difficult.

This article summarizes evidence regarding interventions to reduce overuse and offers an implementation guide based on this evidence. This guide promotes value-based quality improvement and provides a blueprint for implementing an institution-wide program to reduce PPI overuse in the inpatient setting. We begin with a discussion about quality initiatives to reduce PPI overuse, followed by a review of the safety outcomes associated with reduced use of PPIs.

A focused search of the US National Library of Medicine’s PubMed database was performed to identify English-language articles published between 2000 and 2018 that addressed strategies to reduce PPI overuse for stress ulcer prophylaxis (SUP) and nonvariceal GIB. The following search terms were used: PPI and inappropriate use; acid-suppressive therapy and inappropriate use; PPI and discontinuation; acid-suppressive (or suppressant) therapy and discontinuation; SUP and cost; and histamine receptor antagonist and PPI. Inpatient or outpatient studies of patients aged 18 years or older were considered for inclusion in this narrative review, and all study types were included. The primary exclusion criterion was patients aged younger than 18 years. A manual review of the full text of the retrieved articles was performed and references were reviewed for missed citations.

We identified a total of 1,497 unique citations through our initial search. After performing a manual review, we excluded 1,483 of the references and added an additional 2, resulting in 16 articles selected for inclusion. The selected articles addressed interventions falling into three main groupings: implementation of institutional guidelines with or without electronic health record (EHR)–based decision support, educational interventions alone, and multifaceted interventions. Each of these interventions is discussed in the sections that follow. Table 1, Table 2, and Table 3 summarize the results of the studies included in our narrative review.

Institutional Guidelines With or Without EHR-Based Decision Support

Table 1 summarizes institutional guidelines, with or without EHR-based decision support, to reduce inappropriate PPI use. The implementation of institutional guidelines for the appropriate reduction of PPI use has had some success. Coursol and Sanzari evaluated the impact of a treatment algorithm on the appropriateness of prescriptions for SUP in the intensive care unit (ICU).⁸ Risk factors of patients in this study included mechanical ventilation for 48 hours, coagulopathy for 24 hours, postoperative transplant, severe burns, active gastrointestinal (GI) disease, multiple trauma, multiple organ failure, and septicemia. The three treatment options chosen for the algorithm were intravenous (IV) famotidine (if the oral route was unavailable or impractical), omeprazole tablets (if oral access was available), and omeprazole suspension (in cases of dysphagia and presence of nasogastric or orogastric tube). After implementation of the treatment algorithm, the proportion of inappropriate prophylaxis decreased from 95.7% to 88.2% (P = .033), and the cost per patient decreased from $11.11 to $8.49 Canadian dollars (P = .003).

Van Vliet et al implemented a clinical practice guideline listing specific criteria for prescribing a PPI.⁹ Their criteria included the presence of gastric or duodenal ulcer and use of a nonsteroidal anti-inflammatory drug (NSAID) or aspirin, plus at least one additional risk factor (eg, history of gastroduodenal hemorrhage or age >70 years). The proportion of patients started on PPIs during hospitalization decreased from 21% to 13% (odds ratio, 0.56; 95% CI, 0.33-0.97).

Michal et al utilized an institutional pharmacist-driven protocol that stipulated criteria for appropriate PPI use (eg, upper GIB, mechanical ventilation, peptic ulcer disease, gastroesophageal reflux disease, coagulopathy).¹⁰ Pharmacists in the study evaluated patients for PPI appropriateness and recommended changes in medication or discontinuation of use. This institutional intervention decreased PPI use in non-ICU hospitalized adults. Discontinuation of PPIs increased from 41% of patients in the preintervention group to 66% of patients in the postintervention group (P = .001).

In addition to implementing guidelines and intervention strategies, institutions have also adopted changes to the EHR to reduce inappropriate PPI use. Herzig et al utilized a computerized clinical decision support intervention to decrease SUP in non-ICU hospitalized patients.¹¹ Of the available response options for acid-suppressive medication, when SUP was chosen as the only indication for PPI use a prompt alerted the clinician that “[SUP] is not recommended for patients outside the [ICU]”; the alert resulted in a significant reduction in AST for the sole purpose of SUP. With this intervention, the percentage of patients who had any inappropriate acid-suppressive exposure decreased from 4.0% to 0.6% (P < .001).

Table 2 summarizes educational interventions to reduce inappropriate PPI use.

Agee et al employed a pharmacist-led educational seminar that described SUP indications, risks, and costs.¹² Inappropriate SUP prescriptions decreased from 55.5% to 30.5% after the intervention (P < .0001). However, there was no reduction in the percentage of patients discharged on inappropriate AST.

Chui et al performed an intervention with academic detailing wherein a one-on-one visit with a physician took place, providing education to improve physician prescribing behavior.¹³ In this study, academic detailing focused on the most common instances for which PPIs were inappropriately utilized at that hospital (eg, surgical prophylaxis, anemia). Inappropriate use of double-dose PPIs was also targeted. Despite these efforts, no significant difference in inappropriate PPI prescribing was observed post intervention.

Hamzat et al implemented an educational strategy to reduce inappropriate PPI prescribing during hospital stays, which included dissemination of fliers, posters, emails, and presentations over a 4-week period.¹⁴ Educational efforts targeted clinical pharmacists, nurses, physicians, and patients. Appropriate indications for PPI use in this study included peptic ulcer disease (current or previous), H pylori infection, and treatment or prevention of an NSAID-induced ulcer. The primary outcome was a reduction in PPI dose or discontinuation of PPI during the hospital admission, which increased from 9% in the preintervention (pre-education) phase to 43% during the intervention (education) phase and to 46% in the postintervention (posteducation) phase (P = .006).

Liberman and Whelan also implemented an educational intervention among internal medicine residents to reduce inappropriate use of SUP; this intervention was based on practice-based learning and improvement methodology.¹⁵ They noted that the rate of inappropriate prophylaxis with AST decreased from 59% preintervention to 33% post intervention (P < .007).

Table 3 summarizes several multifaceted approaches aimed at reducing inappropriate PPI use. Belfield et al utilized an intervention consisting of an institutional guideline review, education, and monitoring of AST by clinical pharmacists to reduce inappropriate use of PPI for SUP.¹⁶ With this intervention, the primary outcome of total inappropriate days of AST during hospitalization decreased from 279 to 116 (48% relative reduction in risk, P < .01, across 142 patients studied). Furthermore, inappropriate AST prescriptions at discharge decreased from 32% to 8% (P = .006). The one case of GIB noted in this study occurred in the control group.

Del Giorno et al combined audit and feedback with education to reduce new PPI prescriptions at the time of discharge from the hospital.¹⁷ The educational component of this intervention included guidance regarding potentially inappropriate PPI use and associated side effects and targeted multiple departments in the hospital. This intervention led to a sustained reduction in new PPI prescriptions at discharge during the 3-year study period. The annual rate of new PPI prescriptions was 19%, 19%, 18%, and 16% in years 2014, 2015, 2016, and 2017, respectively, in the internal medicine department (postintervention group), compared with rates of 30%, 29%, 36%, 36% (P < .001) for the same years in the surgery department (control group).

Education and the use of medication reconciliation forms on admission and discharge were utilized by Gupta et al to reduce inappropriate AST in hospitalized patients from 51% prior to intervention to 22% post intervention (P < .001).¹⁸ Furthermore, the proportion of patients discharged on inappropriate AST decreased from 69% to 20% (P < .001).

Hatch et al also used educational resources and pharmacist-led medication reconciliation to reduce use of SUP.¹⁹ Before the intervention, 24.4% of patients were continued on SUP after hospital discharge in the absence of a clear indication for use; post intervention, 11% of patients were continued on SUP after hospital discharge (of these patients, 8.7% had no clear indication for use). This represented a 64.4% decrease in inappropriately prescribed SUP after discharge (P < .0001).

Khalili et al combined an educational intervention with an institutional guideline in an infectious disease ward to reduce inappropriate use of SUP.²⁰ This intervention reduced the inappropriate use of AST from 80.9% before the intervention to 47.1% post intervention (P < .001).

Masood et al implemented two interventions wherein pharmacists reviewed SUP indications for each patient during daily team rounds, and ICU residents and fellows received education about indications for SUP and the implemented initiative on a bimonthly basis.²¹ Inappropriate AST decreased from 26.75 to 7.14 prescriptions per 100 patient-days of care (P < .001).

McDonald et al combined education with a web-based quality improvement tool to reduce inappropriate exit prescriptions for PPIs.²² The proportion of PPIs discontinued at hospital discharge increased from 7.7% per month to 18.5% per month (P = .03).

Finally, the initiative implemented by Tasaka et al to reduce overutilization of SUP included an institutional guideline, a pharmacist-led intervention, and an institutional education and awareness campaign.²³ Their initiative led to a reduction in inappropriate SUP both at the time of transfer out of the ICU (8% before intervention, 4% post intervention, P = .54) and at the time of discharge from the hospital (7% before intervention, 0% post intervention, P = .22).

Proton pump inhibitors are often initiated in the hospital setting, with up to half of these new prescriptions continued at discharge.^2,24,25 Inappropriate prescriptions for PPIs expose patients to excess risk of long-term adverse events.²⁶ De-escalating PPIs, however, raises concern among clinicians and patients for potential recurrence of dyspepsia and GIB. There is limited evidence regarding long-term safety outcomes (including GIB) following the discontinuation of PPIs deemed to have been inappropriately initiated in the hospital. In view of this, clinicians should educate and monitor individual patients for symptom relapse to ensure timely and appropriate resumption of AST.

Our literature search for this narrative review and implementation guide has limitations. First, the time frame we included (2000-2018) may have excluded relevant articles published before our starting year. We did not include articles published before 2000 based on concerns these might contain outdated information. Also, there may have been incomplete retrieval of relevant studies/articles due to the labor-intensive nature involved in determining whether PPI prescriptions are appropriate or inappropriate.

We noted that interventional studies aimed at reducing overuse of PPIs were often limited by a low number of participants; these studies were also more likely to be single-center interventions, which limits generalizability. In addition, the studies often had low methodological rigor and lacked randomization or controls. Moreover, to fully evaluate the sustainability of interventions, some of the studies had a limited postimplementation period. For multifaceted interventions, the efficacy of individual components of the interventions was not clearly evaluated. Moreover, there was a high risk of bias in many of the included studies. Some of the larger studies used overall AST prescriptions as a surrogate for more appropriate use. It would be advantageous for a site to perform a pilot study that provides well-defined parameters for appropriate prescribing, and then correlate with the total number of prescriptions (automated and much easier) thereafter. Further, although the evidence regarding appropriate PPI use for SUP and GIB has shifted rapidly in recent years, society guidelines have not been updated to reflect this change. As such, quality improvement interventions have predominantly focused on reducing PPI use for the indications reflected by these guidelines.

The following are our recommendations for successfully implementing an evidence-based, institution-wide initiative to promote the appropriate use of PPIs during hospitalization. These recommendations are informed by the evidence review and reflect the consensus of the combined committees coauthoring this review.

For an initiative to succeed, participation from multiple disciplines is necessary to formulate local guidelines and design and implement interventions. Such an interdisciplinary approach requires advocates to closely monitor and evaluate the program; sustainability will be greatly facilitated by the active engagement of key stakeholders, including the hospital’s executive administration, supply chain, pharmacists, and gastroenterologists. Lack of adequate buy-in on the part of key stakeholders is a barrier to the success of any intervention. Accordingly, before selecting a particular intervention, it is important to understand local factors driving the overuse of PPI.

1. Develop evidence-based institutional guidelines for both SUP and nonvariceal upper GIB through an interdisciplinary workgroup.

• Establish an interdisciplinary group including, but not limited to, pharmacists, hospitalists, gastroenterologists, and intensivists so that changes in practice will be widely adopted as institutional policy.
• Incorporate the best evidence and clearly convey appropriate and inappropriate uses.

2. Integrate changes to the EHR.

• If possible, the EHR should be leveraged to implement changes in PPI ordering practices.
• While integrating changes to the EHR, it is important to consider informatics and implementation science, since the utility of hard stops and best practice alerts has been questioned in the setting of operational inefficiencies and alert fatigue.
• Options for integrating changes to the EHR include the following:
  • Create an ordering pathway that provides clinical decision support for PPI use.
  • Incorporate a best practice alert in the EMR to notify clinicians of institutional guidelines when they initiate an order for PPI outside of the pathway.
  • Consider restricting the authority to order IV PPIs by requiring a code or password or implement another means of using the EHR to limit the supply of PPI.
  • Limit the duration of IV PPI by requiring daily renewal of IV PPI dosing or by altering the period of time that use of IV PPI is permitted (eg, 48 to 72 hours).
  • PPIs should be removed from any current order sets that include medications for SUP.

3. Foster pharmacy-driven interventions.

• Consider requiring pharmacist approval for IV PPIs.
• Pharmacist-led review and feedback to clinicians for discontinuation of inappropriate PPIs can be effective in decreasing inappropriate utilization.

4. Provide education, audit data, and obtain feedback.

• Data auditing is needed to measure the efficacy of interventions. Outcome measures may include the number of non-ICU and ICU patients who are started on a PPI during an admission; the audit should be continued through discharge. A process measure may be the number of pharmacist calls for inappropriate PPIs. A balancing measure would be ulcer-specific upper GIB in patients who do not receive SUP during their admission. (Upper GIB from other etiologies, such as varices, portal hypertensive gastropathy, and Mallory-Weiss tear would not be affected by PPI SUP.)
• Run or control charts should be utilized, and data should be shared with project champions and ordering clinicians—in real time if possible.
• Project champions should provide feedback to colleagues; they should also work with hospital leadership to develop new strategies to improve adherence.
• Provide ongoing education about appropriate indications for PPIs and potential adverse effects associated with their use. Whenever possible, point-of-care or just-in-time teaching is the preferred format.

Excessive use of PPIs during hospitalization is prevalent; however, quality improvement interventions can be effective in achieving sustainable reductions in overuse. There is a need for the American College of Gastroenterology to revisit and update their guidelines for management of patients with ulcer bleeding to include stronger evidence-based recommendations on the proper use of PPIs.²⁷ These updated guidelines could be used to update the implementation blueprint.

Quality improvement teams have an opportunity to use the principles of value-based healthcare to reduce inappropriate PPI use. By following the blueprint outlined in this article, institutions can safely and effectively tailor the use of PPIs to suitable patients in the appropriate settings. Reduction of PPI overuse can be employed as an institutional catalyst to promote implementation of further value-based measures to improve efficiency and quality of patient care.

Respiratory rate (RR) is an essential vital sign that is routinely measured for hospitalized adults. It is a strong predictor of adverse events.^1,2 Therefore, RR is a key component of several widely used risk prediction scores, including the systemic inflammatory response syndrome (SIRS).³

Despite its clinical utility, RR is inaccurately measured.^4-7 One reason for the inaccurate measurement of RR is that RR measurement, in contrast to that of other vital signs, is not automated. The gold-standard technique for measuring RR is the visual assessment of a resting patient. Thus, RR measurement is perceived as time-consuming. Clinical staff instead frequently approximate RR through brief observation.^8-11

Given its clinical importance and widespread inaccuracy, we conducted a quality improvement (QI) initiative to improve RR accuracy.

Design and Setting

We conducted an interdisciplinary QI initiative by using the plan–do–study–act (PDSA) methodology from July 2017 to February 2018. The initiative was set in a single adult 28-bed medical inpatient unit of a large, urban, safety-net hospital consisting of general internal medicine and hematology/oncology patients. Routine vital sign measurements on this unit occur at four- or six-hour intervals per physician orders and are performed by patient-care assistants (PCAs) who are nonregistered nursing support staff. PCAs use a vital signs cart equipped with automated tools to measure vital signs except for RR, which is manually assessed. PCAs are trained on vital sign measurements during a two-day onboarding orientation and four to six weeks of on-the-job training by experienced PCAs. PCAs are directly supervised by nursing operations managers. Formal continuing education programs for PCAs or performance audits of their clinical duties did not exist prior to our QI initiative.

Intervention

Intervention development addressing several important barriers and workflow inefficiencies was based on the direct observation of PCA workflow and information gathering by engaging stakeholders, including PCAs, nursing operations management, nursing leadership, and hospital administration (PDSA cycles 1-7 in Table). Our modified PCA vital sign workflow incorporated RR measurement during the approximate 30 seconds needed to complete automated blood pressure measurement as previously described.¹² Nursing administration purchased three stopwatches (each $5 US) to attach to vital signs carts. One investigator (NK) participated in two monthly one-hour meetings, and three investigators (NK, KB, and SD) participated in 19 daily 15-minute huddles to conduct stakeholder engagement and educate and retrain PCAs on proper technique (total of 6.75 hours).

Evaluation

The primary aim of this QI initiative was to improve RR accuracy, which was evaluated using two distinct but complementary analyses: the prospective comparison of PCA-recorded RRs with gold-standard recorded RRs and the retrospective comparison of RRs recorded in electronic health records (EHR) on the intervention unit versus two control units. The secondary aims were to examine time to complete vital sign measurement and to assess whether the intervention was associated with a reduction in the incidence of SIRS specifically due to tachypnea.

Respiratory Rate Accuracy

PCA-recorded RRs were considered accurate if the RR was within ±2 breaths of a gold-standard RR measurement performed by a trained study member (NK or KB). We conducted gold-standard RR measurements for 100 observations pre- and postintervention within 30 minutes of PCA measurement to avoid Hawthorne bias.

We assessed the variability of recorded RRs in the EHR for all patients in the intervention unit as a proxy for accuracy. We hypothesized on the basis of prior research that improving the accuracy of RR measurement would increase the variability and normality of distribution in RRs.¹³ This is an approach that we have employed previously.⁷ The EHR cohort included consecutive hospitalizations by patients who were admitted to either the intervention unit or to one of two nonintervention general medicine inpatient units that served as concurrent controls. We grouped hospitalizations into a preintervention phase from March 1, 2017-July 22, 2017, a planning phase from July 23, 2017-December 3, 2017, and a postintervention phase from December 21, 2017-February 28, 2018. Hospitalizations during the two-week teaching phase from December 3, 2017-December 21, 2017 were excluded. We excluded vital signs obtained in the emergency department or in a location different from the patient’s admission unit. We qualitatively assessed RR distribution using histograms as we have done previously.⁷

We examined the distributions of RRs recorded in the EHR before and after intervention by individual PCAs on the intervention floor to assess for fidelity and adherence in the PCA uptake of the intervention.

Time

We compared the time to complete vital sign measurement among convenience samples of 50 unique observations pre- and postintervention using the Wilcoxon rank sum test.

SIRS Incidence

Since we hypothesized that improved RR accuracy would reduce falsely elevated RRs but have no impact on the other three SIRS criteria, we assessed changes in tachypnea-specific SIRS incidence, which was defined a priori as the presence of exactly two concurrent SIRS criteria, one of which was an elevated RR.³ We examined changes using a difference-in-differences approach with three different units of analysis (per vital sign measurement, hospital-day, and hospitalization; see footnote for Appendix Table 1 for methodological details. All analyses were conducted using STATA 12.0 (StataCorp, College Station, Texas).

Respiratory Rate Accuracy

Prior to the intervention, the median PCA RR was 18 (IQR 18-20) versus 12 (IQR 12-18) for the gold-standard RR (Appendix Figure 1), with only 36% of PCA measurements considered accurate. After the intervention, the median PCA-recorded RR was 14 (IQR 15-20) versus 14 (IQR 14-20) for the gold-standard RR and a RR accuracy of 58% (P < .001).

For our analyses on RR distribution using EHR data, we included 143,447 unique RRs (Appendix Table 2). After the intervention, the normality of the distribution of RRs on the intervention unit had increased, whereas those of RRs on the control units remained qualitatively similar pre- and postintervention (Appendix Figure 2).

Notable differences existed among the 11 individual PCAs (Figure) despite observing increased variability in PCA-recorded RRs postintervention. Some PCAs (numbers 2, 7, and 10) shifted their narrow RR interquartile range lower by several breaths/minute, whereas most other PCAs had a reduced median RR and widened interquartile range.

Time

Before the intervention, the median time to complete vital sign measurements was 2:36 (IQR 2:04-3:20). After the intervention, the time to complete vital signs decreased to 1:55 (IQR, 1:40-2:22; P < .001), which was 41 less seconds on average per vital sign set.

SIRS Incidence

The intervention was associated with a 3.3% reduction (95% CI, –6.4% to –0.005%) in tachypnea-specific SIRS incidence per hospital-day and a 7.8% reduction (95% CI, –13.5% to –2.2%) per hospitalization (Appendix Table 1). We also observed a modest reduction in overall SIRS incidence after the intervention (2.9% less per vital sign check, 4.6% less per hospital-day, and 3.2% less per hospitalization), although these reductions were not statistically significant.

Our QI initiative improved the absolute RR accuracy by 22%, saved PCAs 41 seconds on average per vital sign measurement, and decreased the absolute proportion of hospitalizations with tachypnea-specific SIRS by 7.8%. Our intervention is a novel, interdisciplinary, low-cost, low-effort, low-tech approach that addressed known challenges to accurate RR measurement,^8,9,11 as well as the key barriers identified in our initial PDSA cycles. Our approach includes adding a time-keeping device to vital sign carts and standardizing a PCA vital sign workflow with increased efficiency. Lastly, this intervention is potentially scalable because stakeholder engagement, education, and retraining of the entire PCA staff for the unit required only 6.75 hours.

While our primary goal was to improve RR accuracy, our QI initiative also improved vital sign efficiency. By extrapolating our findings to an eight-hour PCA shift caring for eight patients who require vital sign checks every four hours, we estimated that our intervention would save approximately 16:24 minutes per PCA shift. This newfound time could be repurposed for other patient-care tasks or could be spent ensuring the accuracy of other vital signs given that accurate monitoring may be neglected because of time constraints.¹¹ Additionally, the improvement in RR accuracy reduced falsely elevated RRs and thus lowered SIRS incidence specifically due to tachypnea. Given that EHR-based sepsis alerts are often based on SIRS criteria, improved RR accuracy may also improve alarm fatigue by reducing the rate of false-positive alerts.¹⁴

This initiative is not without limitations. Generalizability to other hospitals and even other units within the same hospital is uncertain. However, because this initiative was conducted within a safety-net hospital, we anticipate at least similar, if not increased, success in better-resourced hospitals. Second, the long-term durability of our intervention is unclear, although EHR RR variability remained steady for two months after our intervention (data not shown).

To ensure long-term sustainability and further improve RR accuracy, future PDSA cycles could include electing a PCA “vital signs champion” to reiterate the importance of RRs in clinical decision-making and ensure adherence to the modified workflow. Nursing champions act as persuasive change agents that disseminate and implement healthcare change,¹⁵ which may also be true of PCA champions. Additionally, future PDSA cycles can obviate the need for labor-intensive manual audits by leveraging EHR-based auditing to target education and retraining interventions to PCAs with minimal RR variability to optimize workflow adherence.

In conclusion, through a multipronged QI initiative we improved RR accuracy, increased the efficiency of vital sign measurement, and decreased SIRS incidence specifically due to tachypnea by reducing the number of falsely elevated RRs. This novel, low-cost, low-effort, low-tech approach can readily be implemented and disseminated in hospital inpatient settings.

Acknowledgments

The authors would like to acknowledge the meaningful contributions of Mr. Sudarshaan Pathak, RN, Ms. Shirly Koduvathu, RN, and Ms. Judy Herrington MSN, RN in this multidisciplinary initiative. We thank Mr. Christopher McKintosh, RN for his support in data acquisition. Lastly, the authors would like to acknowledge all of the patient-care assistants involved in this QI initiative.

Disclosures

Dr. Makam reports grants from NIA/NIH, during the conduct of the study. All other authors have nothing to disclose.

Funding

This work is supported in part by the Agency for Healthcare Research and Quality-funded UT Southwestern Center for Patient-Centered Outcomes Research (R24HS022418). OKN is funded by the National Heart, Lung, and Blood Institute (K23HL133441), and ANM is funded by the National Institute on Aging (K23AG052603).

Respiratory rate (RR) is an essential vital sign that is routinely measured for hospitalized adults. It is a strong predictor of adverse events.^1,2 Therefore, RR is a key component of several widely used risk prediction scores, including the systemic inflammatory response syndrome (SIRS).³

Despite its clinical utility, RR is inaccurately measured.^4-7 One reason for the inaccurate measurement of RR is that RR measurement, in contrast to that of other vital signs, is not automated. The gold-standard technique for measuring RR is the visual assessment of a resting patient. Thus, RR measurement is perceived as time-consuming. Clinical staff instead frequently approximate RR through brief observation.^8-11

Given its clinical importance and widespread inaccuracy, we conducted a quality improvement (QI) initiative to improve RR accuracy.

Design and Setting

We conducted an interdisciplinary QI initiative by using the plan–do–study–act (PDSA) methodology from July 2017 to February 2018. The initiative was set in a single adult 28-bed medical inpatient unit of a large, urban, safety-net hospital consisting of general internal medicine and hematology/oncology patients. Routine vital sign measurements on this unit occur at four- or six-hour intervals per physician orders and are performed by patient-care assistants (PCAs) who are nonregistered nursing support staff. PCAs use a vital signs cart equipped with automated tools to measure vital signs except for RR, which is manually assessed. PCAs are trained on vital sign measurements during a two-day onboarding orientation and four to six weeks of on-the-job training by experienced PCAs. PCAs are directly supervised by nursing operations managers. Formal continuing education programs for PCAs or performance audits of their clinical duties did not exist prior to our QI initiative.

Intervention

Intervention development addressing several important barriers and workflow inefficiencies was based on the direct observation of PCA workflow and information gathering by engaging stakeholders, including PCAs, nursing operations management, nursing leadership, and hospital administration (PDSA cycles 1-7 in Table). Our modified PCA vital sign workflow incorporated RR measurement during the approximate 30 seconds needed to complete automated blood pressure measurement as previously described.¹² Nursing administration purchased three stopwatches (each $5 US) to attach to vital signs carts. One investigator (NK) participated in two monthly one-hour meetings, and three investigators (NK, KB, and SD) participated in 19 daily 15-minute huddles to conduct stakeholder engagement and educate and retrain PCAs on proper technique (total of 6.75 hours).

Evaluation

The primary aim of this QI initiative was to improve RR accuracy, which was evaluated using two distinct but complementary analyses: the prospective comparison of PCA-recorded RRs with gold-standard recorded RRs and the retrospective comparison of RRs recorded in electronic health records (EHR) on the intervention unit versus two control units. The secondary aims were to examine time to complete vital sign measurement and to assess whether the intervention was associated with a reduction in the incidence of SIRS specifically due to tachypnea.

Respiratory Rate Accuracy

PCA-recorded RRs were considered accurate if the RR was within ±2 breaths of a gold-standard RR measurement performed by a trained study member (NK or KB). We conducted gold-standard RR measurements for 100 observations pre- and postintervention within 30 minutes of PCA measurement to avoid Hawthorne bias.

We assessed the variability of recorded RRs in the EHR for all patients in the intervention unit as a proxy for accuracy. We hypothesized on the basis of prior research that improving the accuracy of RR measurement would increase the variability and normality of distribution in RRs.¹³ This is an approach that we have employed previously.⁷ The EHR cohort included consecutive hospitalizations by patients who were admitted to either the intervention unit or to one of two nonintervention general medicine inpatient units that served as concurrent controls. We grouped hospitalizations into a preintervention phase from March 1, 2017-July 22, 2017, a planning phase from July 23, 2017-December 3, 2017, and a postintervention phase from December 21, 2017-February 28, 2018. Hospitalizations during the two-week teaching phase from December 3, 2017-December 21, 2017 were excluded. We excluded vital signs obtained in the emergency department or in a location different from the patient’s admission unit. We qualitatively assessed RR distribution using histograms as we have done previously.⁷

We examined the distributions of RRs recorded in the EHR before and after intervention by individual PCAs on the intervention floor to assess for fidelity and adherence in the PCA uptake of the intervention.

Time

We compared the time to complete vital sign measurement among convenience samples of 50 unique observations pre- and postintervention using the Wilcoxon rank sum test.

SIRS Incidence

Since we hypothesized that improved RR accuracy would reduce falsely elevated RRs but have no impact on the other three SIRS criteria, we assessed changes in tachypnea-specific SIRS incidence, which was defined a priori as the presence of exactly two concurrent SIRS criteria, one of which was an elevated RR.³ We examined changes using a difference-in-differences approach with three different units of analysis (per vital sign measurement, hospital-day, and hospitalization; see footnote for Appendix Table 1 for methodological details. All analyses were conducted using STATA 12.0 (StataCorp, College Station, Texas).

Respiratory Rate Accuracy

Prior to the intervention, the median PCA RR was 18 (IQR 18-20) versus 12 (IQR 12-18) for the gold-standard RR (Appendix Figure 1), with only 36% of PCA measurements considered accurate. After the intervention, the median PCA-recorded RR was 14 (IQR 15-20) versus 14 (IQR 14-20) for the gold-standard RR and a RR accuracy of 58% (P < .001).

For our analyses on RR distribution using EHR data, we included 143,447 unique RRs (Appendix Table 2). After the intervention, the normality of the distribution of RRs on the intervention unit had increased, whereas those of RRs on the control units remained qualitatively similar pre- and postintervention (Appendix Figure 2).

Notable differences existed among the 11 individual PCAs (Figure) despite observing increased variability in PCA-recorded RRs postintervention. Some PCAs (numbers 2, 7, and 10) shifted their narrow RR interquartile range lower by several breaths/minute, whereas most other PCAs had a reduced median RR and widened interquartile range.

Time

Before the intervention, the median time to complete vital sign measurements was 2:36 (IQR 2:04-3:20). After the intervention, the time to complete vital signs decreased to 1:55 (IQR, 1:40-2:22; P < .001), which was 41 less seconds on average per vital sign set.

SIRS Incidence

The intervention was associated with a 3.3% reduction (95% CI, –6.4% to –0.005%) in tachypnea-specific SIRS incidence per hospital-day and a 7.8% reduction (95% CI, –13.5% to –2.2%) per hospitalization (Appendix Table 1). We also observed a modest reduction in overall SIRS incidence after the intervention (2.9% less per vital sign check, 4.6% less per hospital-day, and 3.2% less per hospitalization), although these reductions were not statistically significant.

Our QI initiative improved the absolute RR accuracy by 22%, saved PCAs 41 seconds on average per vital sign measurement, and decreased the absolute proportion of hospitalizations with tachypnea-specific SIRS by 7.8%. Our intervention is a novel, interdisciplinary, low-cost, low-effort, low-tech approach that addressed known challenges to accurate RR measurement,^8,9,11 as well as the key barriers identified in our initial PDSA cycles. Our approach includes adding a time-keeping device to vital sign carts and standardizing a PCA vital sign workflow with increased efficiency. Lastly, this intervention is potentially scalable because stakeholder engagement, education, and retraining of the entire PCA staff for the unit required only 6.75 hours.

While our primary goal was to improve RR accuracy, our QI initiative also improved vital sign efficiency. By extrapolating our findings to an eight-hour PCA shift caring for eight patients who require vital sign checks every four hours, we estimated that our intervention would save approximately 16:24 minutes per PCA shift. This newfound time could be repurposed for other patient-care tasks or could be spent ensuring the accuracy of other vital signs given that accurate monitoring may be neglected because of time constraints.¹¹ Additionally, the improvement in RR accuracy reduced falsely elevated RRs and thus lowered SIRS incidence specifically due to tachypnea. Given that EHR-based sepsis alerts are often based on SIRS criteria, improved RR accuracy may also improve alarm fatigue by reducing the rate of false-positive alerts.¹⁴

This initiative is not without limitations. Generalizability to other hospitals and even other units within the same hospital is uncertain. However, because this initiative was conducted within a safety-net hospital, we anticipate at least similar, if not increased, success in better-resourced hospitals. Second, the long-term durability of our intervention is unclear, although EHR RR variability remained steady for two months after our intervention (data not shown).

To ensure long-term sustainability and further improve RR accuracy, future PDSA cycles could include electing a PCA “vital signs champion” to reiterate the importance of RRs in clinical decision-making and ensure adherence to the modified workflow. Nursing champions act as persuasive change agents that disseminate and implement healthcare change,¹⁵ which may also be true of PCA champions. Additionally, future PDSA cycles can obviate the need for labor-intensive manual audits by leveraging EHR-based auditing to target education and retraining interventions to PCAs with minimal RR variability to optimize workflow adherence.

In conclusion, through a multipronged QI initiative we improved RR accuracy, increased the efficiency of vital sign measurement, and decreased SIRS incidence specifically due to tachypnea by reducing the number of falsely elevated RRs. This novel, low-cost, low-effort, low-tech approach can readily be implemented and disseminated in hospital inpatient settings.

Acknowledgments

The authors would like to acknowledge the meaningful contributions of Mr. Sudarshaan Pathak, RN, Ms. Shirly Koduvathu, RN, and Ms. Judy Herrington MSN, RN in this multidisciplinary initiative. We thank Mr. Christopher McKintosh, RN for his support in data acquisition. Lastly, the authors would like to acknowledge all of the patient-care assistants involved in this QI initiative.

Disclosures

Dr. Makam reports grants from NIA/NIH, during the conduct of the study. All other authors have nothing to disclose.

Funding

This work is supported in part by the Agency for Healthcare Research and Quality-funded UT Southwestern Center for Patient-Centered Outcomes Research (R24HS022418). OKN is funded by the National Heart, Lung, and Blood Institute (K23HL133441), and ANM is funded by the National Institute on Aging (K23AG052603).

Respiratory rate (RR) is an essential vital sign that is routinely measured for hospitalized adults. It is a strong predictor of adverse events.^1,2 Therefore, RR is a key component of several widely used risk prediction scores, including the systemic inflammatory response syndrome (SIRS).³

Despite its clinical utility, RR is inaccurately measured.^4-7 One reason for the inaccurate measurement of RR is that RR measurement, in contrast to that of other vital signs, is not automated. The gold-standard technique for measuring RR is the visual assessment of a resting patient. Thus, RR measurement is perceived as time-consuming. Clinical staff instead frequently approximate RR through brief observation.^8-11

Given its clinical importance and widespread inaccuracy, we conducted a quality improvement (QI) initiative to improve RR accuracy.

Design and Setting

We conducted an interdisciplinary QI initiative by using the plan–do–study–act (PDSA) methodology from July 2017 to February 2018. The initiative was set in a single adult 28-bed medical inpatient unit of a large, urban, safety-net hospital consisting of general internal medicine and hematology/oncology patients. Routine vital sign measurements on this unit occur at four- or six-hour intervals per physician orders and are performed by patient-care assistants (PCAs) who are nonregistered nursing support staff. PCAs use a vital signs cart equipped with automated tools to measure vital signs except for RR, which is manually assessed. PCAs are trained on vital sign measurements during a two-day onboarding orientation and four to six weeks of on-the-job training by experienced PCAs. PCAs are directly supervised by nursing operations managers. Formal continuing education programs for PCAs or performance audits of their clinical duties did not exist prior to our QI initiative.

Intervention

Intervention development addressing several important barriers and workflow inefficiencies was based on the direct observation of PCA workflow and information gathering by engaging stakeholders, including PCAs, nursing operations management, nursing leadership, and hospital administration (PDSA cycles 1-7 in Table). Our modified PCA vital sign workflow incorporated RR measurement during the approximate 30 seconds needed to complete automated blood pressure measurement as previously described.¹² Nursing administration purchased three stopwatches (each $5 US) to attach to vital signs carts. One investigator (NK) participated in two monthly one-hour meetings, and three investigators (NK, KB, and SD) participated in 19 daily 15-minute huddles to conduct stakeholder engagement and educate and retrain PCAs on proper technique (total of 6.75 hours).

Evaluation

The primary aim of this QI initiative was to improve RR accuracy, which was evaluated using two distinct but complementary analyses: the prospective comparison of PCA-recorded RRs with gold-standard recorded RRs and the retrospective comparison of RRs recorded in electronic health records (EHR) on the intervention unit versus two control units. The secondary aims were to examine time to complete vital sign measurement and to assess whether the intervention was associated with a reduction in the incidence of SIRS specifically due to tachypnea.

Respiratory Rate Accuracy

PCA-recorded RRs were considered accurate if the RR was within ±2 breaths of a gold-standard RR measurement performed by a trained study member (NK or KB). We conducted gold-standard RR measurements for 100 observations pre- and postintervention within 30 minutes of PCA measurement to avoid Hawthorne bias.

We assessed the variability of recorded RRs in the EHR for all patients in the intervention unit as a proxy for accuracy. We hypothesized on the basis of prior research that improving the accuracy of RR measurement would increase the variability and normality of distribution in RRs.¹³ This is an approach that we have employed previously.⁷ The EHR cohort included consecutive hospitalizations by patients who were admitted to either the intervention unit or to one of two nonintervention general medicine inpatient units that served as concurrent controls. We grouped hospitalizations into a preintervention phase from March 1, 2017-July 22, 2017, a planning phase from July 23, 2017-December 3, 2017, and a postintervention phase from December 21, 2017-February 28, 2018. Hospitalizations during the two-week teaching phase from December 3, 2017-December 21, 2017 were excluded. We excluded vital signs obtained in the emergency department or in a location different from the patient’s admission unit. We qualitatively assessed RR distribution using histograms as we have done previously.⁷

We examined the distributions of RRs recorded in the EHR before and after intervention by individual PCAs on the intervention floor to assess for fidelity and adherence in the PCA uptake of the intervention.

Time

We compared the time to complete vital sign measurement among convenience samples of 50 unique observations pre- and postintervention using the Wilcoxon rank sum test.

SIRS Incidence

Since we hypothesized that improved RR accuracy would reduce falsely elevated RRs but have no impact on the other three SIRS criteria, we assessed changes in tachypnea-specific SIRS incidence, which was defined a priori as the presence of exactly two concurrent SIRS criteria, one of which was an elevated RR.³ We examined changes using a difference-in-differences approach with three different units of analysis (per vital sign measurement, hospital-day, and hospitalization; see footnote for Appendix Table 1 for methodological details. All analyses were conducted using STATA 12.0 (StataCorp, College Station, Texas).

Respiratory Rate Accuracy

Prior to the intervention, the median PCA RR was 18 (IQR 18-20) versus 12 (IQR 12-18) for the gold-standard RR (Appendix Figure 1), with only 36% of PCA measurements considered accurate. After the intervention, the median PCA-recorded RR was 14 (IQR 15-20) versus 14 (IQR 14-20) for the gold-standard RR and a RR accuracy of 58% (P < .001).

For our analyses on RR distribution using EHR data, we included 143,447 unique RRs (Appendix Table 2). After the intervention, the normality of the distribution of RRs on the intervention unit had increased, whereas those of RRs on the control units remained qualitatively similar pre- and postintervention (Appendix Figure 2).

Notable differences existed among the 11 individual PCAs (Figure) despite observing increased variability in PCA-recorded RRs postintervention. Some PCAs (numbers 2, 7, and 10) shifted their narrow RR interquartile range lower by several breaths/minute, whereas most other PCAs had a reduced median RR and widened interquartile range.

Time

Before the intervention, the median time to complete vital sign measurements was 2:36 (IQR 2:04-3:20). After the intervention, the time to complete vital signs decreased to 1:55 (IQR, 1:40-2:22; P < .001), which was 41 less seconds on average per vital sign set.

SIRS Incidence

The intervention was associated with a 3.3% reduction (95% CI, –6.4% to –0.005%) in tachypnea-specific SIRS incidence per hospital-day and a 7.8% reduction (95% CI, –13.5% to –2.2%) per hospitalization (Appendix Table 1). We also observed a modest reduction in overall SIRS incidence after the intervention (2.9% less per vital sign check, 4.6% less per hospital-day, and 3.2% less per hospitalization), although these reductions were not statistically significant.

Our QI initiative improved the absolute RR accuracy by 22%, saved PCAs 41 seconds on average per vital sign measurement, and decreased the absolute proportion of hospitalizations with tachypnea-specific SIRS by 7.8%. Our intervention is a novel, interdisciplinary, low-cost, low-effort, low-tech approach that addressed known challenges to accurate RR measurement,^8,9,11 as well as the key barriers identified in our initial PDSA cycles. Our approach includes adding a time-keeping device to vital sign carts and standardizing a PCA vital sign workflow with increased efficiency. Lastly, this intervention is potentially scalable because stakeholder engagement, education, and retraining of the entire PCA staff for the unit required only 6.75 hours.

While our primary goal was to improve RR accuracy, our QI initiative also improved vital sign efficiency. By extrapolating our findings to an eight-hour PCA shift caring for eight patients who require vital sign checks every four hours, we estimated that our intervention would save approximately 16:24 minutes per PCA shift. This newfound time could be repurposed for other patient-care tasks or could be spent ensuring the accuracy of other vital signs given that accurate monitoring may be neglected because of time constraints.¹¹ Additionally, the improvement in RR accuracy reduced falsely elevated RRs and thus lowered SIRS incidence specifically due to tachypnea. Given that EHR-based sepsis alerts are often based on SIRS criteria, improved RR accuracy may also improve alarm fatigue by reducing the rate of false-positive alerts.¹⁴

This initiative is not without limitations. Generalizability to other hospitals and even other units within the same hospital is uncertain. However, because this initiative was conducted within a safety-net hospital, we anticipate at least similar, if not increased, success in better-resourced hospitals. Second, the long-term durability of our intervention is unclear, although EHR RR variability remained steady for two months after our intervention (data not shown).

To ensure long-term sustainability and further improve RR accuracy, future PDSA cycles could include electing a PCA “vital signs champion” to reiterate the importance of RRs in clinical decision-making and ensure adherence to the modified workflow. Nursing champions act as persuasive change agents that disseminate and implement healthcare change,¹⁵ which may also be true of PCA champions. Additionally, future PDSA cycles can obviate the need for labor-intensive manual audits by leveraging EHR-based auditing to target education and retraining interventions to PCAs with minimal RR variability to optimize workflow adherence.

In conclusion, through a multipronged QI initiative we improved RR accuracy, increased the efficiency of vital sign measurement, and decreased SIRS incidence specifically due to tachypnea by reducing the number of falsely elevated RRs. This novel, low-cost, low-effort, low-tech approach can readily be implemented and disseminated in hospital inpatient settings.

Acknowledgments

The authors would like to acknowledge the meaningful contributions of Mr. Sudarshaan Pathak, RN, Ms. Shirly Koduvathu, RN, and Ms. Judy Herrington MSN, RN in this multidisciplinary initiative. We thank Mr. Christopher McKintosh, RN for his support in data acquisition. Lastly, the authors would like to acknowledge all of the patient-care assistants involved in this QI initiative.

Disclosures

Dr. Makam reports grants from NIA/NIH, during the conduct of the study. All other authors have nothing to disclose.

Funding

This work is supported in part by the Agency for Healthcare Research and Quality-funded UT Southwestern Center for Patient-Centered Outcomes Research (R24HS022418). OKN is funded by the National Heart, Lung, and Blood Institute (K23HL133441), and ANM is funded by the National Institute on Aging (K23AG052603).

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A 67-year-old man with acute myeloid leukemia who has recently completed a cycle of consolidation chemotherapy presents to the emergency room with fatigue and bruising. He is found to have pancytopenia due to chemotherapy. His absolute neutrophil count (ANC) is 380/mm³,and he has no symptoms or signs of infection. He is admitted for transfusion support and asks for a dinner tray. The provider reflexively prescribes a neutropenic diet.

Although aggressive chemotherapy regimens have significantly improved survival rates in patients with cancer, these intensive regimens put patients at risk for a number of complications, including severe, prolonged neutropenia. Patients with neutropenia, particularly those with ANC< 500/mm³, are at a significantly increased risk for infection. Common sites of infection include the blood stream, skin, lungs, urinary tract, and, particularly, the gastrointestinal tract.¹ Oncologists and dieticians first designed neutropenic diets, or low-bacteria diets, to limit the introduction of pathogenic microbes to the gastrointestinal system. Neutropenic diets typically limit the intake of fresh fruits, fresh vegetables, raw or undercooked meats and fish, and soft cheese made from unpasteurized milk. Despite the widespread recommendation of the neutropenic diet, no standardized guidelines exist, and the utilization of the diet and its contents vary widely among and within institutions.²

The neutropenic diet is a national phenomenon. A survey of 156 United States members of the Association of Community Cancer Centers revealed that 120 (78%) of the members had placed patients with neutropenia on restricted diets.² The triggers for prescription (neutropenia, or starting chemotherapy), ANC threshold for prescription, and duration of prescription (throughout chemotherapy or just when neutropenic) were not uniform. A majority of centers restricted fresh fruits, fresh vegetables, and raw eggs, while some locations also restricted tap water, herbs and spices, and alcoholic beverages.² Similarly, a study of practices in 29 countries across 6 continents found that 88% of centers have some version of a neutropenic diet guideline with significant heterogeneity in their prescription and content. For example, dried fruits were unrestricted in 23% of centers but were forbidden in 43%.³

The rationale behind the neutropenic diet is to limit the bacterial load delivered to the gut. Studies have shown that organisms such as Enterobacter, Pseudomonas, and Klebsiella have been isolated from food, particularly fruits and vegetables.^4,5 The ingestion of contaminated food products may serve as a source of pathogenic bacteria, which may cause potentially life-threatening infections. Mucositis, a common complication among cancer patients receiving therapy, predisposes patients to infection by disrupting the mucosal barrier, allowing bacteria to translocate from the gut to the bloodstream. Given that neutropenia and mucositis often occur simultaneously, these patients are at an increased risk of infections.⁶ Cooking destroys bacteria if present, rendering cooked foods safe. Thus, the avoidance of fresh fruits and vegetables and other foods considered to have high bacterial loads should theoretically decrease the risk of infections in these patients.

Researchers have investigated the ability of the neutropenic diet to reduce infection in adult and pediatric neutropenic patients. A study involving 153 patients receiving chemotherapy for acute myeloid leukemia or myelodysplastic syndrome randomized 78 patients to a diet that restricted raw fruits and vegetables and 75 patients to a diet that included those foods.⁸ The groups had similar rates of major infection (29% in the cooked group versus 35% in the raw group, P = .60) with no difference in mortality.⁷ In a randomized, multiinstitutional trial of 150 pediatric oncology patients, 77 patients received a neutropenic diet plus a diet based on the food safety guidelines approved by the Food and Drug Administration (FDA), while 73 children received a diet based on FDA-approved food safety guidelines.⁸ Infection rates between the groups were not significantly different (35% vs 33% respectively, P = .78).

Intensive conditioning regimens place hematopoietic stem-cell transplant (HSCT) recipients at an even greater risk of infectious complications than other patients and may increase gastrointestinal toxicity and prolong neutropenia. A study from a single academic US center included 726 HSCT recipients, 363 of whom received a neutropenic diet and 363 of whom received a general diet. Significantly fewer infections were observed in the general diet group than in the neutropenic diet group. Notably, this study was a retrospective trial, and approximately 75% of participants were autologous HSCT recipients, who traditionally have low risks of infection. A survey and analysis of nonpharmacologic anti-infective measures in 339 children with leukemia enrolled in the multicenter Acute Myeloid Leukemia Berlin-Frankfurt-Munster 2004 trial also did not show that the neutropenic diet has protective effects on infection rates.⁹ A metaanalysis that compiled data from the studies mentioned above found the hazard ratio for any infection (major or minor) and fever was actually higher in the neutropenic diet arm (relative risk 1.18, 95% confidence interval: 1.05-1.34, P = .007) relative to that in the unrestricted arm.¹⁰

The inefficacy of the neutropenic diet may be attributed to the fact that many of the organisms found on fresh fruits and vegetables are part of the normal flora in the gastrointestinal tract. A Dutch prospective randomized pilot study of 20 adult patients with acute myeloid leukemia undergoing chemotherapy compared the gut flora in patients on a low-bacteria diet versus that in patients on a normal hospital diet. Gut colonization by potential pathogens or infection rates were not significantly different between the 2 groups.¹¹

In addition to mucositis, the common gastrointestinal complications of chemotherapy include nausea, vomiting, diarrhea, food aversions, and changes in smells and taste, which limit oral intake.¹² Unnecessary dietary restrictions can place patients at further risk of inadequate intake and malnutrition.¹³ In the outpatient setting, compliance with the neutropenic diet is also problematic. In 1 study of 28 patients educated about the neutropenic diet, only 16 (57%) were compliant with the diet as revealed through telephone-based assessments at 6 and 12 weeks, and infection rates were not different between compliant versus noncompliant patients.¹⁴ Patients and family members reported that following the neutropenic diet requires considerably more effort than following a less restrictive diet.⁸ Maintaining nutrition in this patient population is already challenging, and the restriction of a wide variety of food items (fresh fruits, vegetables, dairy, certain meats, eggs) can cause malnutrition, low patient satisfaction, and poor quality of life.^13,14

Evidence shows no benefit of the neutropenic diet in any particular clinical scenario or patient population. However, despite the dearth of evidence to support neutropenic diets, the overall data regarding neutropenic diets are sparse. Randomized control trials to date have been limited by their small size with possible confounding by the type of malignancy and cancer therapy; use of prophylactic antibiotics, growth factors, and air-filtered rooms; variation in contents and adherence to the prescribed diet; and inpatient versus outpatient status. The study that included HSCT recipients was a retrospective trial, and a majority of patients were autologous HSCT recipients.¹⁵ Although no study has specifically investigated the neutropenic diet in preventing infection in patients with noncancer-related neutropenia, no reason exists to suspect that it is helpful. The FDA advises safe food-handling practices for other immunocompromised patients, such as transplant recipients and patients with human immunodeficiency virus/acquired immunodeficiency syndrome, and the same principles can likely be applied to patients with noncancer-related neutropenia.

WHAT WE SHOULD DO INSTEAD

Although the neutropenic diet has not been proven beneficial, the prevention of food-borne infection in this population remains important. FDA-published guidelines, which promote safe food handling to prevent food contamination in patients with cancer, should be followed in inpatient and outpatient settings.¹⁶ These guidelines allow for fresh fruits and vegetables as long as they have been adequately washed. Cleaning (eg, cleaning the lids of canned foods before opening, hand washing), separating raw meats from other foods, cooking to the right temperature (eg, cooking eggs until the yolk and white are firm), and chilling/refrigerating food appropriately are strongly emphasized. These guidelines are also recommended by the American Dietetic Association. Despite additional flexibility, patients following the FDA diet guidelines do not have increased risk of infection.⁸ At our hospitals, the neutropenic diet can no longer be ordered. Neutropenic patients are free to consume all items on the general hospital menu, including eggs, meat, soft cheeses, nuts, and washed raw fruits and vegetables. The National Comprehensive Cancer Network guidelines for the prevention and treatment of cancer-related infections do not specifically address diet.¹⁷ We call upon them to note the lack of benefit and potential harm of the neutropenic diet in the guidelines. Such an action may persuade more institutions to abandon this practice.

RECOMMENDATIONS

• Neutropenic diets, or low-bacteria diets, should not be prescribed to neutropenic patients.
• Properly handled and adequately washed fresh fruits and vegetables can safely be consumed by patients with neutropenia.
• Patients and hospitals should follow FDA-published safe food-handling guidelines to prevent food contamination.

A general diet can be safely ordered for our patient in the presented clinical scenario. Available data from individual studies and pooled data provide no evidence that neutropenic diets prevent infectious complications in patients with neutropenia.

Hospital kitchens must adhere to the food-handling guidelines issued by the FDA, and following these guidelines should provide adequate protection against food-borne infection, even in patients who are immunocompromised. Instead of restricting food groups, the FDA guidelines focus on safe food-handling practices. Less dietary restrictions provide patient’s additional opportunities for balanced nutrition and for food choices based on personal preferences or cultural practices.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason?” Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason” topics by emailing TWDFNR@hospitalmedicine.org.Disclosures: There are no financial or other disclosures for any author.

Disclosures

There are no financial or other disclosures for any author.

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A 67-year-old man with acute myeloid leukemia who has recently completed a cycle of consolidation chemotherapy presents to the emergency room with fatigue and bruising. He is found to have pancytopenia due to chemotherapy. His absolute neutrophil count (ANC) is 380/mm³,and he has no symptoms or signs of infection. He is admitted for transfusion support and asks for a dinner tray. The provider reflexively prescribes a neutropenic diet.

Although aggressive chemotherapy regimens have significantly improved survival rates in patients with cancer, these intensive regimens put patients at risk for a number of complications, including severe, prolonged neutropenia. Patients with neutropenia, particularly those with ANC< 500/mm³, are at a significantly increased risk for infection. Common sites of infection include the blood stream, skin, lungs, urinary tract, and, particularly, the gastrointestinal tract.¹ Oncologists and dieticians first designed neutropenic diets, or low-bacteria diets, to limit the introduction of pathogenic microbes to the gastrointestinal system. Neutropenic diets typically limit the intake of fresh fruits, fresh vegetables, raw or undercooked meats and fish, and soft cheese made from unpasteurized milk. Despite the widespread recommendation of the neutropenic diet, no standardized guidelines exist, and the utilization of the diet and its contents vary widely among and within institutions.²

The neutropenic diet is a national phenomenon. A survey of 156 United States members of the Association of Community Cancer Centers revealed that 120 (78%) of the members had placed patients with neutropenia on restricted diets.² The triggers for prescription (neutropenia, or starting chemotherapy), ANC threshold for prescription, and duration of prescription (throughout chemotherapy or just when neutropenic) were not uniform. A majority of centers restricted fresh fruits, fresh vegetables, and raw eggs, while some locations also restricted tap water, herbs and spices, and alcoholic beverages.² Similarly, a study of practices in 29 countries across 6 continents found that 88% of centers have some version of a neutropenic diet guideline with significant heterogeneity in their prescription and content. For example, dried fruits were unrestricted in 23% of centers but were forbidden in 43%.³

The rationale behind the neutropenic diet is to limit the bacterial load delivered to the gut. Studies have shown that organisms such as Enterobacter, Pseudomonas, and Klebsiella have been isolated from food, particularly fruits and vegetables.^4,5 The ingestion of contaminated food products may serve as a source of pathogenic bacteria, which may cause potentially life-threatening infections. Mucositis, a common complication among cancer patients receiving therapy, predisposes patients to infection by disrupting the mucosal barrier, allowing bacteria to translocate from the gut to the bloodstream. Given that neutropenia and mucositis often occur simultaneously, these patients are at an increased risk of infections.⁶ Cooking destroys bacteria if present, rendering cooked foods safe. Thus, the avoidance of fresh fruits and vegetables and other foods considered to have high bacterial loads should theoretically decrease the risk of infections in these patients.

Researchers have investigated the ability of the neutropenic diet to reduce infection in adult and pediatric neutropenic patients. A study involving 153 patients receiving chemotherapy for acute myeloid leukemia or myelodysplastic syndrome randomized 78 patients to a diet that restricted raw fruits and vegetables and 75 patients to a diet that included those foods.⁸ The groups had similar rates of major infection (29% in the cooked group versus 35% in the raw group, P = .60) with no difference in mortality.⁷ In a randomized, multiinstitutional trial of 150 pediatric oncology patients, 77 patients received a neutropenic diet plus a diet based on the food safety guidelines approved by the Food and Drug Administration (FDA), while 73 children received a diet based on FDA-approved food safety guidelines.⁸ Infection rates between the groups were not significantly different (35% vs 33% respectively, P = .78).

Intensive conditioning regimens place hematopoietic stem-cell transplant (HSCT) recipients at an even greater risk of infectious complications than other patients and may increase gastrointestinal toxicity and prolong neutropenia. A study from a single academic US center included 726 HSCT recipients, 363 of whom received a neutropenic diet and 363 of whom received a general diet. Significantly fewer infections were observed in the general diet group than in the neutropenic diet group. Notably, this study was a retrospective trial, and approximately 75% of participants were autologous HSCT recipients, who traditionally have low risks of infection. A survey and analysis of nonpharmacologic anti-infective measures in 339 children with leukemia enrolled in the multicenter Acute Myeloid Leukemia Berlin-Frankfurt-Munster 2004 trial also did not show that the neutropenic diet has protective effects on infection rates.⁹ A metaanalysis that compiled data from the studies mentioned above found the hazard ratio for any infection (major or minor) and fever was actually higher in the neutropenic diet arm (relative risk 1.18, 95% confidence interval: 1.05-1.34, P = .007) relative to that in the unrestricted arm.¹⁰

The inefficacy of the neutropenic diet may be attributed to the fact that many of the organisms found on fresh fruits and vegetables are part of the normal flora in the gastrointestinal tract. A Dutch prospective randomized pilot study of 20 adult patients with acute myeloid leukemia undergoing chemotherapy compared the gut flora in patients on a low-bacteria diet versus that in patients on a normal hospital diet. Gut colonization by potential pathogens or infection rates were not significantly different between the 2 groups.¹¹

In addition to mucositis, the common gastrointestinal complications of chemotherapy include nausea, vomiting, diarrhea, food aversions, and changes in smells and taste, which limit oral intake.¹² Unnecessary dietary restrictions can place patients at further risk of inadequate intake and malnutrition.¹³ In the outpatient setting, compliance with the neutropenic diet is also problematic. In 1 study of 28 patients educated about the neutropenic diet, only 16 (57%) were compliant with the diet as revealed through telephone-based assessments at 6 and 12 weeks, and infection rates were not different between compliant versus noncompliant patients.¹⁴ Patients and family members reported that following the neutropenic diet requires considerably more effort than following a less restrictive diet.⁸ Maintaining nutrition in this patient population is already challenging, and the restriction of a wide variety of food items (fresh fruits, vegetables, dairy, certain meats, eggs) can cause malnutrition, low patient satisfaction, and poor quality of life.^13,14

Evidence shows no benefit of the neutropenic diet in any particular clinical scenario or patient population. However, despite the dearth of evidence to support neutropenic diets, the overall data regarding neutropenic diets are sparse. Randomized control trials to date have been limited by their small size with possible confounding by the type of malignancy and cancer therapy; use of prophylactic antibiotics, growth factors, and air-filtered rooms; variation in contents and adherence to the prescribed diet; and inpatient versus outpatient status. The study that included HSCT recipients was a retrospective trial, and a majority of patients were autologous HSCT recipients.¹⁵ Although no study has specifically investigated the neutropenic diet in preventing infection in patients with noncancer-related neutropenia, no reason exists to suspect that it is helpful. The FDA advises safe food-handling practices for other immunocompromised patients, such as transplant recipients and patients with human immunodeficiency virus/acquired immunodeficiency syndrome, and the same principles can likely be applied to patients with noncancer-related neutropenia.

WHAT WE SHOULD DO INSTEAD

Although the neutropenic diet has not been proven beneficial, the prevention of food-borne infection in this population remains important. FDA-published guidelines, which promote safe food handling to prevent food contamination in patients with cancer, should be followed in inpatient and outpatient settings.¹⁶ These guidelines allow for fresh fruits and vegetables as long as they have been adequately washed. Cleaning (eg, cleaning the lids of canned foods before opening, hand washing), separating raw meats from other foods, cooking to the right temperature (eg, cooking eggs until the yolk and white are firm), and chilling/refrigerating food appropriately are strongly emphasized. These guidelines are also recommended by the American Dietetic Association. Despite additional flexibility, patients following the FDA diet guidelines do not have increased risk of infection.⁸ At our hospitals, the neutropenic diet can no longer be ordered. Neutropenic patients are free to consume all items on the general hospital menu, including eggs, meat, soft cheeses, nuts, and washed raw fruits and vegetables. The National Comprehensive Cancer Network guidelines for the prevention and treatment of cancer-related infections do not specifically address diet.¹⁷ We call upon them to note the lack of benefit and potential harm of the neutropenic diet in the guidelines. Such an action may persuade more institutions to abandon this practice.

RECOMMENDATIONS

• Neutropenic diets, or low-bacteria diets, should not be prescribed to neutropenic patients.
• Properly handled and adequately washed fresh fruits and vegetables can safely be consumed by patients with neutropenia.
• Patients and hospitals should follow FDA-published safe food-handling guidelines to prevent food contamination.

A general diet can be safely ordered for our patient in the presented clinical scenario. Available data from individual studies and pooled data provide no evidence that neutropenic diets prevent infectious complications in patients with neutropenia.

Hospital kitchens must adhere to the food-handling guidelines issued by the FDA, and following these guidelines should provide adequate protection against food-borne infection, even in patients who are immunocompromised. Instead of restricting food groups, the FDA guidelines focus on safe food-handling practices. Less dietary restrictions provide patient’s additional opportunities for balanced nutrition and for food choices based on personal preferences or cultural practices.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason?” Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason” topics by emailing TWDFNR@hospitalmedicine.org.Disclosures: There are no financial or other disclosures for any author.

Disclosures

There are no financial or other disclosures for any author.

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A 67-year-old man with acute myeloid leukemia who has recently completed a cycle of consolidation chemotherapy presents to the emergency room with fatigue and bruising. He is found to have pancytopenia due to chemotherapy. His absolute neutrophil count (ANC) is 380/mm³,and he has no symptoms or signs of infection. He is admitted for transfusion support and asks for a dinner tray. The provider reflexively prescribes a neutropenic diet.

Although aggressive chemotherapy regimens have significantly improved survival rates in patients with cancer, these intensive regimens put patients at risk for a number of complications, including severe, prolonged neutropenia. Patients with neutropenia, particularly those with ANC< 500/mm³, are at a significantly increased risk for infection. Common sites of infection include the blood stream, skin, lungs, urinary tract, and, particularly, the gastrointestinal tract.¹ Oncologists and dieticians first designed neutropenic diets, or low-bacteria diets, to limit the introduction of pathogenic microbes to the gastrointestinal system. Neutropenic diets typically limit the intake of fresh fruits, fresh vegetables, raw or undercooked meats and fish, and soft cheese made from unpasteurized milk. Despite the widespread recommendation of the neutropenic diet, no standardized guidelines exist, and the utilization of the diet and its contents vary widely among and within institutions.²

The neutropenic diet is a national phenomenon. A survey of 156 United States members of the Association of Community Cancer Centers revealed that 120 (78%) of the members had placed patients with neutropenia on restricted diets.² The triggers for prescription (neutropenia, or starting chemotherapy), ANC threshold for prescription, and duration of prescription (throughout chemotherapy or just when neutropenic) were not uniform. A majority of centers restricted fresh fruits, fresh vegetables, and raw eggs, while some locations also restricted tap water, herbs and spices, and alcoholic beverages.² Similarly, a study of practices in 29 countries across 6 continents found that 88% of centers have some version of a neutropenic diet guideline with significant heterogeneity in their prescription and content. For example, dried fruits were unrestricted in 23% of centers but were forbidden in 43%.³

The rationale behind the neutropenic diet is to limit the bacterial load delivered to the gut. Studies have shown that organisms such as Enterobacter, Pseudomonas, and Klebsiella have been isolated from food, particularly fruits and vegetables.^4,5 The ingestion of contaminated food products may serve as a source of pathogenic bacteria, which may cause potentially life-threatening infections. Mucositis, a common complication among cancer patients receiving therapy, predisposes patients to infection by disrupting the mucosal barrier, allowing bacteria to translocate from the gut to the bloodstream. Given that neutropenia and mucositis often occur simultaneously, these patients are at an increased risk of infections.⁶ Cooking destroys bacteria if present, rendering cooked foods safe. Thus, the avoidance of fresh fruits and vegetables and other foods considered to have high bacterial loads should theoretically decrease the risk of infections in these patients.

Researchers have investigated the ability of the neutropenic diet to reduce infection in adult and pediatric neutropenic patients. A study involving 153 patients receiving chemotherapy for acute myeloid leukemia or myelodysplastic syndrome randomized 78 patients to a diet that restricted raw fruits and vegetables and 75 patients to a diet that included those foods.⁸ The groups had similar rates of major infection (29% in the cooked group versus 35% in the raw group, P = .60) with no difference in mortality.⁷ In a randomized, multiinstitutional trial of 150 pediatric oncology patients, 77 patients received a neutropenic diet plus a diet based on the food safety guidelines approved by the Food and Drug Administration (FDA), while 73 children received a diet based on FDA-approved food safety guidelines.⁸ Infection rates between the groups were not significantly different (35% vs 33% respectively, P = .78).

Intensive conditioning regimens place hematopoietic stem-cell transplant (HSCT) recipients at an even greater risk of infectious complications than other patients and may increase gastrointestinal toxicity and prolong neutropenia. A study from a single academic US center included 726 HSCT recipients, 363 of whom received a neutropenic diet and 363 of whom received a general diet. Significantly fewer infections were observed in the general diet group than in the neutropenic diet group. Notably, this study was a retrospective trial, and approximately 75% of participants were autologous HSCT recipients, who traditionally have low risks of infection. A survey and analysis of nonpharmacologic anti-infective measures in 339 children with leukemia enrolled in the multicenter Acute Myeloid Leukemia Berlin-Frankfurt-Munster 2004 trial also did not show that the neutropenic diet has protective effects on infection rates.⁹ A metaanalysis that compiled data from the studies mentioned above found the hazard ratio for any infection (major or minor) and fever was actually higher in the neutropenic diet arm (relative risk 1.18, 95% confidence interval: 1.05-1.34, P = .007) relative to that in the unrestricted arm.¹⁰

The inefficacy of the neutropenic diet may be attributed to the fact that many of the organisms found on fresh fruits and vegetables are part of the normal flora in the gastrointestinal tract. A Dutch prospective randomized pilot study of 20 adult patients with acute myeloid leukemia undergoing chemotherapy compared the gut flora in patients on a low-bacteria diet versus that in patients on a normal hospital diet. Gut colonization by potential pathogens or infection rates were not significantly different between the 2 groups.¹¹

In addition to mucositis, the common gastrointestinal complications of chemotherapy include nausea, vomiting, diarrhea, food aversions, and changes in smells and taste, which limit oral intake.¹² Unnecessary dietary restrictions can place patients at further risk of inadequate intake and malnutrition.¹³ In the outpatient setting, compliance with the neutropenic diet is also problematic. In 1 study of 28 patients educated about the neutropenic diet, only 16 (57%) were compliant with the diet as revealed through telephone-based assessments at 6 and 12 weeks, and infection rates were not different between compliant versus noncompliant patients.¹⁴ Patients and family members reported that following the neutropenic diet requires considerably more effort than following a less restrictive diet.⁸ Maintaining nutrition in this patient population is already challenging, and the restriction of a wide variety of food items (fresh fruits, vegetables, dairy, certain meats, eggs) can cause malnutrition, low patient satisfaction, and poor quality of life.^13,14

Evidence shows no benefit of the neutropenic diet in any particular clinical scenario or patient population. However, despite the dearth of evidence to support neutropenic diets, the overall data regarding neutropenic diets are sparse. Randomized control trials to date have been limited by their small size with possible confounding by the type of malignancy and cancer therapy; use of prophylactic antibiotics, growth factors, and air-filtered rooms; variation in contents and adherence to the prescribed diet; and inpatient versus outpatient status. The study that included HSCT recipients was a retrospective trial, and a majority of patients were autologous HSCT recipients.¹⁵ Although no study has specifically investigated the neutropenic diet in preventing infection in patients with noncancer-related neutropenia, no reason exists to suspect that it is helpful. The FDA advises safe food-handling practices for other immunocompromised patients, such as transplant recipients and patients with human immunodeficiency virus/acquired immunodeficiency syndrome, and the same principles can likely be applied to patients with noncancer-related neutropenia.

WHAT WE SHOULD DO INSTEAD

Although the neutropenic diet has not been proven beneficial, the prevention of food-borne infection in this population remains important. FDA-published guidelines, which promote safe food handling to prevent food contamination in patients with cancer, should be followed in inpatient and outpatient settings.¹⁶ These guidelines allow for fresh fruits and vegetables as long as they have been adequately washed. Cleaning (eg, cleaning the lids of canned foods before opening, hand washing), separating raw meats from other foods, cooking to the right temperature (eg, cooking eggs until the yolk and white are firm), and chilling/refrigerating food appropriately are strongly emphasized. These guidelines are also recommended by the American Dietetic Association. Despite additional flexibility, patients following the FDA diet guidelines do not have increased risk of infection.⁸ At our hospitals, the neutropenic diet can no longer be ordered. Neutropenic patients are free to consume all items on the general hospital menu, including eggs, meat, soft cheeses, nuts, and washed raw fruits and vegetables. The National Comprehensive Cancer Network guidelines for the prevention and treatment of cancer-related infections do not specifically address diet.¹⁷ We call upon them to note the lack of benefit and potential harm of the neutropenic diet in the guidelines. Such an action may persuade more institutions to abandon this practice.

RECOMMENDATIONS

• Neutropenic diets, or low-bacteria diets, should not be prescribed to neutropenic patients.
• Properly handled and adequately washed fresh fruits and vegetables can safely be consumed by patients with neutropenia.
• Patients and hospitals should follow FDA-published safe food-handling guidelines to prevent food contamination.

A general diet can be safely ordered for our patient in the presented clinical scenario. Available data from individual studies and pooled data provide no evidence that neutropenic diets prevent infectious complications in patients with neutropenia.

Hospital kitchens must adhere to the food-handling guidelines issued by the FDA, and following these guidelines should provide adequate protection against food-borne infection, even in patients who are immunocompromised. Instead of restricting food groups, the FDA guidelines focus on safe food-handling practices. Less dietary restrictions provide patient’s additional opportunities for balanced nutrition and for food choices based on personal preferences or cultural practices.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason?” Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason” topics by emailing TWDFNR@hospitalmedicine.org.Disclosures: There are no financial or other disclosures for any author.

Disclosures

There are no financial or other disclosures for any author.