This is a little assignment that I did for class recently..
Treatment decisions made by healthcare professionals affect the outcomes of patients and the costs to the healthcare system tremendously. It is important for Nurse Practitioners to be up to date with research relating to different admission diagnoses.
Scenario: Pt is admitted with generalized abdominal pain. Pt complains of heartburn, upset stomach and one case of diarrhea. WBC count is slightly elevated and low-grade temperature of 100.0 is present. Stool studies for WBC, C-Diff toxin, occult blood, ova and parasites are sent. This patient has never been diagnosed with GERD prior to admission. Clinical treatment decision issue involves whether or not to place this patient on a proton pump inhibitor to treat for GERD due to request for “something for this horrible heartburn”.
Option 1: Give patient Mylanta PRN for heartburn. Stool studies continue to be negative. GI specialist recommends EGD as outpatient to rule out hiatal hernia and GERD. Pt discharged to home after temperature resolves and is scheduled for EGD.
Option 2: Stool studies negative for C-diff, and O&P. Treat patient with Nexium 40mg PO daily. Heartburn is resolved but with concurrent use of antibiotics, this patient develops diarrhea with a foul odor and is now positive for C-difficile resulting in 5 days of hospital stay and use of private room and contact precaution equipment.
It is estimated that C. difficile infections cost over 1.1 billion healthcare dollars (U.S.) each year and significantly extend the length of hospital stay by an average of three days when compared to patients whose hospital course was not complicated by C. difficile infection. Research as shown that use of proton pump inhibitors on patients with no known reason for heartburn (hiatal hernia, GERD) increases the chances that C-difficile infections will occur due to the reduction of natural acids that may inhibit it’s growth. Furthermore, in the cohort study, patients at greatest risk were those who received multiple antibiotics in addition to a PPI. A case-control study, in which patients were matched based on antibiotic therapy, number of antibiotics and renal dysfunction, also showed a positive association between PPI use and C. difficile infection. (Yam, 2005)
Therefore based on current data, I would not arbitrarily prescribe PPIs to patients in the hospital with no known GERD diagnosis in order to reduce the potential for C-difficile infection. The costs of extended hospital stays which insurance will no longer pay for due to DRGs and the risk of cross contamination to other patients of the C-difficile infection, I would choose Option 1 as a treatment base.