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Brian L Erstad - One of the best experts on this subject based on the ideXlab platform.
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Research Stress Ulcer prophylaxis in trauma patients
2020Co-Authors: Jeffrey F Barletta, Brian L Erstad, John B FortuneAbstract:Introduction A number of issues concerning Stress Ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of Stress Ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding Stress Ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed. Materials and methods A survey was developed that contained questions related to institutional prescribing and evaluation of Stress Ulcer prophylaxis. The survey was intended to delineate these practices at the 188 Level I trauma centers (at the time of the present survey) in the United States. Results One hundred and nineteen surveys were returned, yielding a response rate of 63%. Eighty-six percent stated that medications for Stress Ulcer prophylaxis are used in a vast majority of trauma patients admitted to the intensive care unit. Sixty-five percent stated that there is one preferred medication. For these institutions, histamine-2-blockers were the most popular at 71%. Thirty-nine percent stated that greater than 50% of patients remain on Stress Ulcer prophylaxis following discharge from the intensive care unit. Conclusion The lack of consensus with regards to appropriate Stress Ulcer prophylaxis is apparent in this survey of Level I trauma centers. For those institutions with a preferred agent, histamine-2-blockers were most common.
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pharmacoepidemiology of Stress Ulcer prophylaxis in the united states and canada
Journal of Critical Care, 2014Co-Authors: Jeffrey F Barletta, Robert Maclaren, Salmaan Kanji, Brian L ErstadAbstract:PURPOSE: This study sought to identify the medication class most commonly prescribed for Stress Ulcer prophylaxis (SUP), assess trends in SUP utilization, and report the use of acid suppressive therapy stratified by bleeding risk. MATERIALS AND METHODS: This multicenter, prospective, point prevalence study reviewed adult patients over a 24-hour period for demographics, medications used for SUP, and risk factors for clinically important bleeding. Stress Ulcer prophylaxis was deemed appropriate if acid suppressive therapy was administered to patients at high risk for bleeding or no therapy in patients considered at low bleeding risk. High risk was defined as the presence of mechanical ventilation, coagulopathy, or shock. For patients receiving acid suppression before hospital admission, SUP was considered appropriate if the same drug class was continued regardless of risk factors. A planned subgroup analysis was conducted whereby patients on acid suppressive medications before admission were excluded. RESULTS: There were 584 patients from 58 intensive care units in 27 hospitals. The most common drug class was proton pump inhibitors (70%). Despite receiving other enteral/oral medications, 36% received intravenous acid suppressive therapy. Overall, SUP was considered appropriate in 78% of patients and 68% when patients on acid suppression before admission were excluded. When stratified by risk, acid suppressive medications were used in 92% of high-risk patients and 71% of low-risk patients. CONCLUSION: Stress Ulcer prophylaxis is frequently administered to patients who are not at high risk for clinically important bleeding. Proton pump inhibitors are the overwhelming first choice among practitioners. Several opportunities exist for improvement regarding the provision of SUP.
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Stress Ulcer prophylaxis in the postoperative period
American Journal of Health-system Pharmacy, 2004Co-Authors: Michelle E Allen, Brian J Kopp, Brian L ErstadAbstract:PURPOSE: The implications of recent studies for guidelines that pertain to Stress Ulcer prophylaxis in the postoperative period are discussed. SUMMARY: The therapeutic guidelines on Stress Ulcer prophylaxis published by the American Society of Health-System Pharmacists (ASHP) provided clinicians with recommendations regarding appropriate candidates for Stress Ulcer prophylaxis and selection of a pharmacologic agent. Since these guidelines were published in 1999, additional research has been completed to resolve some of the controversial issues surrounding Stress Ulcer prophylaxis. The frequency of Stress-induced bleeding in recent investigations continues to be highly variable, depending on the definition used to describe bleeding. In general, investigations that evaluate overt bleeding or bleeding without hemodynamic changes or blood transfusion report higher frequencies of bleeding than those that evaluate clinically important bleeding. Similar to that reported in the initial ASHP guidelines, the frequency of clinically important bleeding in recent investigations is low. In addition, the majority of recently published prospective studies and a meta-analysis have been unable to demonstrate a reduction in clinically important bleeding with pharmacologic agents. As a result, some experts have suggested that advances in critical care are more influential in the development of Stress-induced bleeding than the use of pharmacologic agents. Recently published investigations support the effectiveness of institution-specific guidelines to help clinicians identify appropriate candidates for Stress Ulcer prophylaxis. The selection of an optimal pharmacologic agent for Stress Ulcer prophylaxis continues to be debated. The majority of recent studies have involved the administration of proton-pump inhibitors (PPIs). In general, these studies have demonstrated that PPIs are at least as effective as histamine H2-receptor antagonists at increasing gastric pH, but adequately powered studies investigating the endpoint of clinically important bleeding are needed. Similar to the initial ASHP guidelines, the development of institution-specific guidelines is recommended to identify the most appropriate pharmacologic treatment. CONCLUSION: The frequency of clinically important bleeding reported in recent studies is low. The majority of recently published prospective studies and meta-analyses found little significant reduction in bleeding with pharmacologic prophylaxis.
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Stress Ulcer prophylaxis in trauma patients
Critical Care, 2002Co-Authors: Jeffrey F Barletta, Brian L Erstad, John B FortuneAbstract:Introduction A number of issues concerning Stress Ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of Stress Ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding Stress Ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed.
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survey of Stress Ulcer prophylaxis
Critical Care, 1999Co-Authors: Brian L Erstad, Jeffrey F Barletta, Judith Jacobi, Aaron D Killian, Katherine M Kramer, Steven J MartinAbstract:Background No surveys of Stress Ulcer prophylaxis prescribing in the USA havebeen conducted since 1995. Since that time, the most comprehensive meta-analysisand largest randomized study to date concerning Stress Ulcer prophylaxis havebeen published.
Robert Maclaren - One of the best experts on this subject based on the ideXlab platform.
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the sup icu trial does it confirm or condemn the practice of Stress Ulcer prophylaxis
Hospital Pharmacy, 2020Co-Authors: Jeffrey F Barletta, Mitchell S Buckley, Robert MaclarenAbstract:Purpose: Stress Ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of Stress Ulcer–induced, clinically important bleeding (CIB). Recently, the value of ...
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pharmacoepidemiology of Stress Ulcer prophylaxis in the united states and canada
Journal of Critical Care, 2014Co-Authors: Jeffrey F Barletta, Robert Maclaren, Salmaan Kanji, Brian L ErstadAbstract:PURPOSE: This study sought to identify the medication class most commonly prescribed for Stress Ulcer prophylaxis (SUP), assess trends in SUP utilization, and report the use of acid suppressive therapy stratified by bleeding risk. MATERIALS AND METHODS: This multicenter, prospective, point prevalence study reviewed adult patients over a 24-hour period for demographics, medications used for SUP, and risk factors for clinically important bleeding. Stress Ulcer prophylaxis was deemed appropriate if acid suppressive therapy was administered to patients at high risk for bleeding or no therapy in patients considered at low bleeding risk. High risk was defined as the presence of mechanical ventilation, coagulopathy, or shock. For patients receiving acid suppression before hospital admission, SUP was considered appropriate if the same drug class was continued regardless of risk factors. A planned subgroup analysis was conducted whereby patients on acid suppressive medications before admission were excluded. RESULTS: There were 584 patients from 58 intensive care units in 27 hospitals. The most common drug class was proton pump inhibitors (70%). Despite receiving other enteral/oral medications, 36% received intravenous acid suppressive therapy. Overall, SUP was considered appropriate in 78% of patients and 68% when patients on acid suppression before admission were excluded. When stratified by risk, acid suppressive medications were used in 92% of high-risk patients and 71% of low-risk patients. CONCLUSION: Stress Ulcer prophylaxis is frequently administered to patients who are not at high risk for clinically important bleeding. Proton pump inhibitors are the overwhelming first choice among practitioners. Several opportunities exist for improvement regarding the provision of SUP.
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cost effectiveness of histamine receptor 2 antagonist versus proton pump inhibitor for Stress Ulcer prophylaxis in critically ill patients
Critical Care Medicine, 2014Co-Authors: Robert Maclaren, Jon CampbellAbstract:Objective:To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for Stress Ulcer prophylaxis.Design:Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for Stress Ulcer prophylaxis.
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proton pump inhibitors for Stress Ulcer prophylaxis in critically ill patients
Annals of Pharmacotherapy, 2002Co-Authors: Rose Jung, Robert MaclarenAbstract:OBJECTIVE:To evaluate the use of proton-pump inhibitors (PPIs) for Stress Ulcer prophylaxis in critically ill adults.DATA SOURCES:Computerized biomedical literature search of MEDLINE (1966–June 2002) was conducted using the MeSH headings proton-pump inhibitor, Ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts.DATA SYNTHESIS:Traditional medications used for Stress Ulcer prophylaxis include antacids, histamine2 receptor antagonists (H2RAs), and sucralfate. Few studies have evaluated PPIs for Stress Ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH ≥4.0. PPIs are safe and seem to be as efficacious as H2RAs or sucralfate for prevention of bleeding from Stress-related mucosal damage (SRMD) and they may prov...
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use of enteral nutrition for Stress Ulcer prophylaxis
Annals of Pharmacotherapy, 2001Co-Authors: Robert Maclaren, Catherine Jarvis, Douglas N FishAbstract:OBJECTIVE:To review the controversies involving the use of enteral nutrition support for Stress Ulcer prophylaxis and formulate recommendations.DATA SOURCES:A MEDLINE search (1966–December 2000) was conducted using the MeSH of nutrition, Ulcer, critical care, and acid to identify relevant articles. References of selected articles were reviewed, and relevant abstracts from critical care or gastrointestinal journals identified.DATA EXTRACTION:Animal and human data from prospective studies, retrospective studies, and case series were evaluated for the effects of enteral nutrition on gastric pH, intramucosal pH, gastrointestinal blood flow, development of macroscopic mucosal erosions, and hemorrhage.DATA SYNTHESIS:Intragastric administration of enteral nutrition has variable effects on gastric pH, enhances regional distribution of gastrointestinal blood flow, and may lower intramucosal pH. All substrates (carbohydrate, lipid, amino acid), when administered into the stomach, reduce the occurrence of mucosal er...
Jeffrey F Barletta - One of the best experts on this subject based on the ideXlab platform.
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Research Stress Ulcer prophylaxis in trauma patients
2020Co-Authors: Jeffrey F Barletta, Brian L Erstad, John B FortuneAbstract:Introduction A number of issues concerning Stress Ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of Stress Ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding Stress Ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed. Materials and methods A survey was developed that contained questions related to institutional prescribing and evaluation of Stress Ulcer prophylaxis. The survey was intended to delineate these practices at the 188 Level I trauma centers (at the time of the present survey) in the United States. Results One hundred and nineteen surveys were returned, yielding a response rate of 63%. Eighty-six percent stated that medications for Stress Ulcer prophylaxis are used in a vast majority of trauma patients admitted to the intensive care unit. Sixty-five percent stated that there is one preferred medication. For these institutions, histamine-2-blockers were the most popular at 71%. Thirty-nine percent stated that greater than 50% of patients remain on Stress Ulcer prophylaxis following discharge from the intensive care unit. Conclusion The lack of consensus with regards to appropriate Stress Ulcer prophylaxis is apparent in this survey of Level I trauma centers. For those institutions with a preferred agent, histamine-2-blockers were most common.
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the sup icu trial does it confirm or condemn the practice of Stress Ulcer prophylaxis
Hospital Pharmacy, 2020Co-Authors: Jeffrey F Barletta, Mitchell S Buckley, Robert MaclarenAbstract:Purpose: Stress Ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of Stress Ulcer–induced, clinically important bleeding (CIB). Recently, the value of ...
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Stress Ulcer prophylaxis
Critical Care Medicine, 2016Co-Authors: Jeffrey F Barletta, Jeffrey J Bruno, Mitchell S Buckley, Deborah J CookAbstract:Objectives:Stress Ulcer prophylaxis is commonly administered to critically ill patients for the prevention of clinically important Stress-related mucosal bleeding from the upper gastrointestinal tract. Despite widespread incorporation of Stress Ulcer prophylaxis into practice around the world, quest
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impact of a clinical pharmacist Stress Ulcer prophylaxis management program on inappropriate use in hospitalized patients
The American Journal of Medicine, 2015Co-Authors: Mitchell S Buckley, Jeffrey F Barletta, Andrew S Park, Clint S Anderson, Dale S Bikin, Richard Gerkin, Cheryl W Omalley, Laura M Wicks, Roxanne Garciaorr, Sandra L KanegillAbstract:PURPOSE: Appropriate utilization of Stress Ulcer prophylaxis should be limited to high-risk, intensive care unit (ICU) patients. However, inappropriate Stress Ulcer prophylaxis use among all hospitalized patients remains a concern. The purpose of this study was to evaluate the clinical and economic impact of a novel pharmacist-managed Stress Ulcer prophylaxis program in ICU and general ward patients. METHODS: This retrospective, pre- and poststudy design was conducted in adult ICU and general ward patients at a large academic medical center between January 1, 2011 and January 31, 2012 to compare the rates of inappropriate Stress Ulcer prophylaxis before and after the implementation of a pharmacist-led Stress Ulcer prophylaxis management program. RESULTS: A total of 1134 unique patients consisting of 16,415 patient days were evaluated. The relative reduction in the rate of inappropriate Stress Ulcer prophylaxis days after program implementation in ICU and general ward patients was 58.3% and 83.5%, respectively (P $200,000 annually. No differences in clinical outcomes were observed. CONCLUSIONS: The implementation of a pharmacist-managed Stress Ulcer prophylaxis program was associated with a decrease in inappropriate acid suppression rates during hospitalization and upon discharge, as well as significant cost savings.
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pharmacoepidemiology of Stress Ulcer prophylaxis in the united states and canada
Journal of Critical Care, 2014Co-Authors: Jeffrey F Barletta, Robert Maclaren, Salmaan Kanji, Brian L ErstadAbstract:PURPOSE: This study sought to identify the medication class most commonly prescribed for Stress Ulcer prophylaxis (SUP), assess trends in SUP utilization, and report the use of acid suppressive therapy stratified by bleeding risk. MATERIALS AND METHODS: This multicenter, prospective, point prevalence study reviewed adult patients over a 24-hour period for demographics, medications used for SUP, and risk factors for clinically important bleeding. Stress Ulcer prophylaxis was deemed appropriate if acid suppressive therapy was administered to patients at high risk for bleeding or no therapy in patients considered at low bleeding risk. High risk was defined as the presence of mechanical ventilation, coagulopathy, or shock. For patients receiving acid suppression before hospital admission, SUP was considered appropriate if the same drug class was continued regardless of risk factors. A planned subgroup analysis was conducted whereby patients on acid suppressive medications before admission were excluded. RESULTS: There were 584 patients from 58 intensive care units in 27 hospitals. The most common drug class was proton pump inhibitors (70%). Despite receiving other enteral/oral medications, 36% received intravenous acid suppressive therapy. Overall, SUP was considered appropriate in 78% of patients and 68% when patients on acid suppression before admission were excluded. When stratified by risk, acid suppressive medications were used in 92% of high-risk patients and 71% of low-risk patients. CONCLUSION: Stress Ulcer prophylaxis is frequently administered to patients who are not at high risk for clinically important bleeding. Proton pump inhibitors are the overwhelming first choice among practitioners. Several opportunities exist for improvement regarding the provision of SUP.
Mette Krag - One of the best experts on this subject based on the ideXlab platform.
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Stress Ulcer prophylaxis in the intensive care unit trial detailed statistical analysis plan
Acta Anaesthesiologica Scandinavica, 2017Co-Authors: Mette Krag, Anders Perner, Jorn Wetterslev, Theis Lange, Matt P Wise, Mark Borthwick, Stepani Bendel, Paolo Pelosi, Frederik KeusAbstract:Background In this statistical analysis plan, we aim to provide details of the pre-defined statistical analyses of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial. The aim of the SUP-ICU trial is to assess benefits and harms of Stress Ulcer prophylaxis with a proton pump inhibitor in adult patients in the intensive care unit (ICU). Methods The SUP-ICU trial is an investigator-initiated, international, multicentre, randomised, blinded, parallel-group trial of intravenously pantoprazole 40 mg once daily vs. placebo in 3350 acutely ill adult ICU patients at risk of gastrointestinal bleeding. The primary outcome measure is 90-day mortality. Secondary outcomes include the proportion of patients with clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection or myocardial ischaemia, days alive without life support, serious adverse reactions, 1-year mortality, and a health economic analysis. Two formal interim analyses will be performed. The statistical analyses will be conducted according to the outlined pre-defined statistical analysis plan. The primary analysis will be a logistic regression analysis adjusted for stratification variables comparing the two intervention groups in the intention-to-treat population. In a secondary analysis, we will additionally adjust the primary outcome for potential random differences in baseline characteristics. The conclusion will be based on the intention-to-treat population. Conclusion Stress Ulcer prophylaxis is standard of care in ICUs worldwide, but has never been tested in large high-quality randomised placebo-controlled trials. The SUP-ICU trial will provide important high-quality data on the balance between the benefits and harms of Stress Ulcer prophylaxis in adult critically ill patients.
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Stress Ulcer prophylaxis with a proton pump inhibitor versus placebo in critically ill patients sup icu trial study protocol for a randomised controlled trial
Trials, 2016Co-Authors: Mette Krag, Anders Perner, Jorn Wetterslev, Matt P Wise, Mark Borthwick, Stepani Bendel, Paolo Pelosi, Frederik Keus, Anne Berit Guttormsen, Joerg C SchefoldAbstract:Critically ill patients in the intensive care unit (ICU) are at risk of clinically important gastrointestinal bleeding, and acid suppressants are frequently used prophylactically. However, Stress Ulcer prophylaxis may increase the risk of serious adverse events and, additionally, the quantity and quality of evidence supporting the use of Stress Ulcer prophylaxis is low. The aim of the SUP-ICU trial is to assess the benefits and harms of Stress Ulcer prophylaxis with a proton pump inhibitor in adult patients in the ICU. We hypothesise that Stress Ulcer prophylaxis reduces the rate of gastrointestinal bleeding, but increases rates of nosocomial infections and myocardial ischaemia. The overall effect on mortality is unpredictable. The SUP-ICU trial is an investigator-initiated, pragmatic, international, multicentre, randomised, blinded, parallel-group trial of Stress Ulcer prophylaxis with a proton pump inhibitor versus placebo (saline) in 3350 acutely ill ICU patients at risk of gastrointestinal bleeding. The primary outcome measure is 90-day mortality. Secondary outcomes include the proportion of patients with clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection or myocardial ischaemia, days alive without life support in the 90-day period, serious adverse reactions, 1-year mortality, and health economic analyses. The sample size will enable us to detect a 20 % relative risk difference (5 % absolute risk difference) in 90-day mortality assuming a 25 % event rate with a risk of type I error of 5 % and power of 90 %. The trial will be externally monitored according to Good Clinical Practice standards. Interim analyses will be performed after 1650 and 2500 patients. The SUP-ICU trial will provide high-quality data on the benefits and harms of Stress Ulcer prophylaxis with a proton pump inhibitor in critically ill adult patients admitted in the ICU. ClinicalTrials.gov Identifier: NCT02467621 .
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Stress Ulcer prophylaxis versus placebo or no prophylaxis in critically ill patients
Intensive Care Medicine, 2014Co-Authors: Mette Krag, Anders Perner, Jorn Wetterslev, Matt P Wise, Morten Hylander MollerAbstract:Purpose To assess the effects of Stress Ulcer prophylaxis (SUP) versus placebo or no prophylaxis on all-cause mortality, gastrointestinal (GI) bleeding and hospital-acquired pneumonia in adult critically ill patients in the intensive care unit (ICU).
John B Fortune - One of the best experts on this subject based on the ideXlab platform.
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Research Stress Ulcer prophylaxis in trauma patients
2020Co-Authors: Jeffrey F Barletta, Brian L Erstad, John B FortuneAbstract:Introduction A number of issues concerning Stress Ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of Stress Ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding Stress Ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed. Materials and methods A survey was developed that contained questions related to institutional prescribing and evaluation of Stress Ulcer prophylaxis. The survey was intended to delineate these practices at the 188 Level I trauma centers (at the time of the present survey) in the United States. Results One hundred and nineteen surveys were returned, yielding a response rate of 63%. Eighty-six percent stated that medications for Stress Ulcer prophylaxis are used in a vast majority of trauma patients admitted to the intensive care unit. Sixty-five percent stated that there is one preferred medication. For these institutions, histamine-2-blockers were the most popular at 71%. Thirty-nine percent stated that greater than 50% of patients remain on Stress Ulcer prophylaxis following discharge from the intensive care unit. Conclusion The lack of consensus with regards to appropriate Stress Ulcer prophylaxis is apparent in this survey of Level I trauma centers. For those institutions with a preferred agent, histamine-2-blockers were most common.
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Stress Ulcer prophylaxis in trauma patients
Critical Care, 2002Co-Authors: Jeffrey F Barletta, Brian L Erstad, John B FortuneAbstract:Introduction A number of issues concerning Stress Ulcer prophylaxis remain unresolved despite numerous randomized, controlled trials and several meta-analyses. The role of Stress Ulcer prophylaxis, particularly in trauma patients, is further complicated by the lack of trials utilizing clinically important bleeding as an endpoint. Given the lack of consensus regarding Stress Ulcer prophylaxis in trauma patients, prescribing practices at Level I trauma centers in the United States were assessed.
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impacting cost and appropriateness of Stress Ulcer prophylaxis at a university medical center
Critical Care Medicine, 1997Co-Authors: Brian L Erstad, James M Camamo, Michael J Miller, Anthony M Webber, John B FortuneAbstract:OBJECTIVE: To determine the appropriateness and medication cost of Stress Ulcer prophylaxis before and after a targeted educational intervention. DESIGN: In the preintervention cohort (phase 1), 264 patients were evaluated over 2 months, using Stress Ulcer prophylaxis guidelines developed by a comprehensive literature search. Targeted educational programs were subsequently used to inform trauma housestaff on appropriate usage of Stress Ulcer prophylaxis medications with emphasis on using sucralfate. The postintervention cohort (phase 2) involved concurrent evaluation of 279 patients. Length of inappropriate Stress Ulcer prophylaxis (i.e., did not meet approved guidelines) between phases was compared using a Student's t-test for independent samples (alpha = .05). SETTING: A 365-bed university medical center. PATIENTS: Patients admitted to any of the intensive care units and all patients who were placed on histamine-2-antagonists or sucralfate for Stress Ulcer prophylaxis. INTERVENTIONS: Educational intervention regarding appropriate Stress Ulcer prophylaxis directed at the trauma service. MEASUREMENTS AND MAIN RESULTS: Patient demographics in the two phases were similar and there was no difference in the number of patient risk factors for Stress-induced bleeding. The mean length of inappropriate Stress Ulcer prophylaxis was 5.78 +/- 4.36 days in phase 1 and 4.66 +/- 3.10 days in phase 2 (p < .05). Eighty-nine patients in phase 1 received inappropriate Stress Ulcer prophylaxis for a drug cost of $2,272.00 (mean $25.53 +/- 25.52) compared with 90 patients in phase 2 with a drug cost of $1,417.00 (mean $15.75 +/- 13.06). Three patients in each phase had clinically important bleeding (hemodynamic compromise or transfusion); all were receiving ranitidine. The mean total cost (fixed and variable) of hospitalization was $69,288.00 and $74,709.00 for the three patients who bled in each phase compared with $19,850.00 and $15,812.00 for all patients admitted to the intensive care unit in phases 1 and 2, respectively. The mean length of hospital stay was 30.00 days and 29.33 days for the three patients who bled in each phase compared with 11.54 days and 10.27 days for all patients admitted to the intensive care unit in phases 1 and 2, respectively. CONCLUSIONS: Cost savings are associated with more appropriate Stress Ulcer prophylaxis. Clinically important bleeding is uncommon but results in prolonged hospital stays and increased costs.