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Beaudrie-Nunn AN, Poyant JO, Groth CM, Rappaport SH, Kruer RM, Miller E, Whitten JA, Mcintire AM, McDaniel CM, Betthauser KD, Mohammad RA, Kenes MT, Bookstavar Korona R, Barber AE, MacTavish P, Dixit D, Yeung SYA, Stollings JL. An international, multicenter post hoc analysis comparing in-person and virtual medication management strategies in post-ICU recovery clinics. Am J Health Syst Pharm 2024:zxae244. [PMID: 39162570 DOI: 10.1093/ajhp/zxae244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Indexed: 08/21/2024] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To compare the incidence of ICU pharmacist interventions in intensive care unit recovery center (ICU-RC) in-person and virtual clinic visits. METHODS This was a post hoc analysis of interventions implemented by ICU pharmacists among adult patients who were referred to 12 ICU-RCs across the United States and the United Kingdom between September 2019 and July 2021, as reported in a previously published study "An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers." That study included patients who received a comprehensive medication review by an ICU pharmacist. Medication-related interventions performed by an ICU pharmacist during ICU-RC in-person clinic visits were compared to those performed during virtual clinic visits. RESULTS There were 507 patients referred to an ICU-RC, of whom 474 patients attended a clinic visit. Of those, 472 received a comprehensive medication review, with 313 patients attending in-person visits and 159 patients attending virtual visits. The incidence of medication-related interventions implemented was higher in the ICU-RC in-person clinic group compared to the virtual clinic group (86.5% vs 79.2%, P = 0.04). There was no difference in the median number of ICU pharmacist interventions per patient between the in-person and virtual clinic groups (2 vs 2, P = 0.13). An ICU admission diagnosis was an independent predictor of medication-related interventions among all patients. CONCLUSION The incidence of ICU pharmacist interventions was higher at ICU-RC in-person clinic visits compared to virtual clinic visits. Pharmacists aid in meeting the complex pharmacologic challenges of post-intensive care syndrome in both settings.
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Affiliation(s)
- Aeryana N Beaudrie-Nunn
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Stephen H Rappaport
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Rachel M Kruer
- Department of Pharmacy, Indiana University Health, Adult Academic Health Center, Indianapolis, IN, USA
| | - Emily Miller
- Department of Pharmacy, Indiana University Health, Adult Academic Health Center, Indianapolis, IN, USA
| | | | | | - Cara M McDaniel
- Department of Pharmacy, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kevin D Betthauser
- Department of Pharmacy Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Rima A Mohammad
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Alexandra E Barber
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | | | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, and Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Siu Yan A Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, and Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
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Nydahl P, Liu K, Bellelli G, Benbenishty J, van den Boogaard M, Caplan G, Chung CR, Elhadi M, Gurjar M, Heras-La Calle G, Hoffmann M, Jeitziner MM, Krewulak K, Mailhot T, Morandi A, Nawa RK, Oh ES, Collet MO, Paulino MC, Lindroth H, von Haken R. A world-wide study on delirium assessments and presence of protocols. Age Ageing 2024; 53:afae129. [PMID: 38952186 DOI: 10.1093/ageing/afae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/26/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
- Institute for Molecular Bioscience (IMB), The University of Queensland, 306 Carmody Rd, St Lucia QLD, 4067, Queensland, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
- Acute Geriatric Unit, IRCCS San Gerardo Foundation, Via Pergolesi 33, 20900 Monza, Italy
| | - Julie Benbenishty
- Hebrew University Faculty of Medicine School of Nursing, PO Box 12272, Jerusalem 91120, Israel
| | - Mark van den Boogaard
- Department Intensive Care, Radboud University Medical Center, 10 Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital Sydney, 320-346 Barker St, Randwick NSW 2031, Sydney, Australia
- University of New South Wales, Gate 9, High St, The Chancellery Kensington, 2052, NSW Sydney, Australia
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro Gangnam-gu. Seoul, Korea 06351, South Korea
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, University Road, Al-Furnaje Tripoli, PO Box 13932, Tripoli, Libya
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow-226014, Uttar Pradesh, India
| | - Gabi Heras-La Calle
- Director of the International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI), Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Magdalena Hoffmann
- Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
- Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 1, Postfach, 4001 Basel, Switzerland
| | - Karla Krewulak
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada
| | - Tanya Mailhot
- Montreal Heart Institute Research Center, Faculty of Nursing, Université de Montréal, 680 Sherbrooke West, Montreal QC, H3A 2M7, Canada
| | - Alessandro Morandi
- Intermediate Care and Rehabilitation, Azienda Speciale Cremona Solidale, Via Brescia 207, 26100 Cremona, Italy
- Parc Sanitari Per Vergili, Val d'Hebron Institute of Research, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ricardo Kenji Nawa
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP 05652-900, Brazil
| | - Esther S Oh
- Departments of Medicine, Psychiatry and Behavioral Sciences, and Pathology, Johns Hopkins University School of Medicine, 733 N. Broadway, MD 21205 Baltimore, ML, USA
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Maria Carolina Paulino
- Department of Intensive Care, Hospital da Luz Lisboa, 1150-082 Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, 1150-199 Lisbon, Portugal
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1500-650 Lisbon, Portugal
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
- Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 W 10th St, Indianapolis, IN 46202, USA
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Harrison S, Capers K, Chen G, Liu JT, Pannu A, Goodspeed V, Leibowitz A, Bose S. New initiation of opioids, benzodiazepines and antipsychotics following hospitalization for COVID-19. J Hosp Med 2024. [PMID: 38742528 DOI: 10.1002/jhm.13408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Patients newly initiated on opioids (OP), benzodiazepines (BZD), and antipsychotics (AP) during hospitalization are often prescribed these on discharge. Implications of this practice on outcomes remains unexplored. OBJECTIVE To explore the prevalence and risk factors of new initiation of select OP, BZD and AP among patients requiring in-patient stays. Test the hypothesis that new prescriptions are associated with higher odds of readmission or death within 28 days of discharge. DESIGN Single center retrospective cohort study. SETTING AND PARTICIPANTS Patients admitted to a tertiary-level medical center with either a primary diagnosis of RT-PCR positive for COVID-19 or high index of clinical suspicion thereof. INTERVENTION None. MAIN OUTCOME AND MEASURES Exposure was the new initiation of select common OP, BZD, and AP which were continued on hospital discharge. Outcome was a composite of 28-day readmission or death following index admission. Multivariable logistic regression was used to assess patient mortality or readmission within 28 days of discharge associated with new prescriptions at discharge. RESULTS One thousand three hundred and nineteen patients were included in the analysis. 11.3% (149/1319) were discharged with a new prescription of select OP, BZD, or AP either alone or in combination. OP (110/149) were most prescribed followed by BZD (41/149) and AP (22/149). After adjusting for unbalanced confounders, new prescriptions (adjusted odds ratio: 2.44, 95% confidence interval: 1.42-4.12; p = .001) were associated with readmission or death within 28 days of discharge. One in nine patients admitted with a diagnosis of COVID-19 or high clinical suspicion thereof were discharged with a new prescription of either OP, BZD or AP. New prescriptions were associated with higher odds of 28-day readmission or death. Strengthening medication reconciliation processes focused on these classes may reduce avoidable harm.
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Affiliation(s)
- Samantha Harrison
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Krystal Capers
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Ji T Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Valerie Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Akiva Leibowitz
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
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Stollings JL, Poyant JO, Groth CM, Rappaport SH, Kruer RM, Miller E, Whitten JA, Mcintire AM, McDaniel CM, Betthauser KD, Mohammad RA, Kenes MT, Korona RB, Barber AE, MacTavish P, Dixit D, Yeung SYA. An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers. J Intensive Care Med 2023; 38:957-965. [PMID: 37198935 DOI: 10.1177/08850666231176194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Post-intensive care syndrome (PICS) is defined as a new or worsening impairment in physical, cognitive, or mental health following critical illness. Intensive care unit recovery centers (ICU-RC) are one means to treat patients who have PICS. The purpose of this study is to describe the role of pharmacists in ICU-RCs. RESEARCH QUESTION What is the number and type of medication interventions made by a pharmacist at an ICU-RC at 12 different centers? STUDY DESIGN AND METHODS This prospective, observational study was conducted in 12 intensive care units (ICUs)/ICU-RCs between September 2019 and July 2021. A full medication review was conducted by a pharmacist on patients seen at the ICU-RC. RESULTS 507 patients were referred to the ICU-RC. Of these patients, 474 attended the ICU-RC and 472 had a full medication review performed by a pharmacist. Baseline demographic and hospital course data were obtained from the electronic health record and at the ICU-RC appointment. Pharmacy interventions were made in 397 (84%) patients. The median number of pharmacy interventions per patient was 2 (interquartile range [IQR] = 1,3). Medications were stopped and started in 124 (26%) and 91 (19%) patients, respectively. The number of patients that had a dose decreased and a dose increased was 51 (11%) and 43 (9%), respectively. There was no difference in the median total number of medications that the patient was prescribed at the start and end of the patient visit (10, IQR = 5, 15). Adverse drug event (ADE) preventive measures were implemented in 115 (24%) patients. ADE events were identified in 69 (15%) patients. Medication interactions were identified in 30 (6%) patients. INTERPRETATION A pharmacist plays an integral role in an ICU-RC resulting in the identification, prevention, and treatment of medication-related problems. This paper should serve as a call to action on the importance of the inclusion of a pharmacist in ICU-RC clinics.
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Affiliation(s)
- Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | | | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Stephen H Rappaport
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA
| | - Rachel M Kruer
- Department of Pharmacy, Indiana University Health, Adult Academic Health Center, Indianapolis, IN, USA
| | - Emily Miller
- Department of Pharmacy, Indiana University Health, Adult Academic Health Center, Indianapolis, IN, USA
| | | | | | - Cara M McDaniel
- Department of Pharmacy, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kevin D Betthauser
- Department of Pharmacy Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Rima A Mohammad
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | | | - Alexandra E Barber
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | | | - Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers University, New Brunswick, NJ, USA
| | - Siu Yan A Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
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Short A, McPeake J, Andonovic M, McFee S, Quasim T, Leyland A, Shaw M, Iwashyna T, MacTavish P. Medication-related problems in critical care survivors: a systematic review. Eur J Hosp Pharm 2023; 30:250-256. [PMID: 37142386 PMCID: PMC10447966 DOI: 10.1136/ejhpharm-2023-003715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES There are numerous, often single centre discussions of assorted medication-related problems after hospital discharge in patients who survive critical illness. However, there has been little synthesis of the incidence of medication-related problems, the classes of medications most often studied, the factors that are associated with greater patient risk of such problems or interventions that can prevent them. METHODS We undertook a systematic review to understand medication management and medication problems in critical care survivors in the hospital discharge period. We searched OVID Medline, Embase, PsychINFO, CINAHL and the Cochrane database (2001-2022). Two reviewers independently screened publications to identify studies that examined medication management at hospital discharge or thereafter in critical care survivors. We included randomised and non-randomised studies. We extracted data independently and in duplicate. Data extracted included medication type, medication-related problems and frequency of medication issues, alongside demographics such as study setting. Cohort study quality was assessed using the Newcastle Ottowa Score checklist. Data were analysed across medication categories. RESULTS The database search initially retrieved 1180 studies; following the removal of duplicates and studies which did not fit the inclusion criteria, 47 papers were included. The quality of studies included varied. The outcomes measured and the timepoints at which data were captured also varied, which impacted the quality of data synthesis. Across the studies included, we found that as many as 80% of critically ill patients experienced medication-related problems in the posthospital discharge period. These issues included inappropriate continuation of newly prescribed drugs such as antipsychotics, gastrointestinal prophylaxis and analgesic medications, as well as inappropriate discontinuation of chronic disease medications, such as secondary prevention cardiac drugs. CONCLUSIONS Following critical illness, a high proportion of patients experience problems with their medications. These changes were present across multiple health systems. Further research is required to understand optimal medicine management across the full recovery trajectory of critical illness. PROSPERO REGISTRATION NUMBER CRD42021255975.
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Affiliation(s)
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Mark Andonovic
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Jaworska N, Krewulak KD, Schalm E, Niven DJ, Ismail Z, Burry LD, Leigh JP, Fiest KM. Facilitators and Barriers Influencing Antipsychotic Medication Prescribing and Deprescribing Practices in Critically Ill Adult Patients: a Qualitative Study. J Gen Intern Med 2023; 38:2262-2271. [PMID: 37072535 PMCID: PMC10112822 DOI: 10.1007/s11606-023-08042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/13/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Antipsychotic medications do not alter the incidence or duration of delirium, but these medications are frequently prescribed and continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. OBJECTIVE The purpose of this study was to identify and describe relevant domains and constructs that influence antipsychotic medication prescribing and deprescribing practices among physicians, nurses, and pharmacists that care for critically ill adult patients during and following critical illness. DESIGN We conducted qualitative semi-structured interviews with critical care and ward healthcare professionals including physicians, nurses, and pharmacists to understand antipsychotic prescribing and deprescribing practices for critically ill adult patients during and following critical illness. PARTICIPANTS Twenty-one interviews were conducted with 11 physicians, five nurses, and five pharmacists from predominantly academic centres in Alberta, Canada, between July 6 and October 29, 2021. MAIN MEASURES We used deductive thematic analysis using the Theoretical Domains Framework (TDF) to identify and describe constructs within relevant domains. KEY RESULTS Seven TDF domains were identified as relevant from the analysis: Social/Professional role and identity; Beliefs about capabilities; Reinforcement; Motivations and goals; Memory, attention, and decision processes; Environmental context and resources; and Beliefs about consequences. Participants reported antipsychotic prescribing for multiple indications beyond delirium and agitation including patient and staff safety, sleep management, and environmental factors such as staff availability and workload. Participants identified potential antipsychotic deprescribing strategies to reduce ongoing antipsychotic medication prescriptions for critically ill patients including direct communication tools between prescribers at transitions of care. CONCLUSIONS Critical care and ward healthcare professionals report several factors influencing established antipsychotic medication prescribing practices. These factors aim to maintain patient and staff safety to facilitate the provision of care to patients with delirium and agitation limiting adherence to current guideline recommendations.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
- Alberta Health Services, Calgary, AB, Canada.
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Emma Schalm
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Abstract
ABSTRACT Delirium is a common neurocognitive disorder among hospitalized older adults, and it can have devastating effects. The purpose of this article is to inform NPs in the hospital setting to recognize, prevent, and manage delirium in older adults. The roles of nonpharmacologic and pharmacologic interventions are described.
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Affiliation(s)
- Thomas J Blodgett
- Thomas J. Blodgett is an assistant professor at Duke University School of Nursing in Durham, N.C
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8
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Post-discharge use of antipsychotics in patients with hospital-acquired delirium and associated risk of mortality - A population-based nested case-control study. Asian J Psychiatr 2023; 83:103533. [PMID: 36863305 DOI: 10.1016/j.ajp.2023.103533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE To evaluate post-discharge use of antipsychotics in patients with incident hospital-acquired delirium and the associated risk of mortality. METHODS We conducted a nested case-control study for patients newly diagnosed with hospital-acquired delirium and subsequently discharged from hospital using Taiwan's National Health Insurance Database (NHID) from 2011 to 2018. RESULTS The use of antipsychotics after discharge did not increase the risk of mortality (adjusted OR: 1·03; 95% CI: 0·98-1·09). CONCLUSIONS The findings suggested that using antipsychotics after discharge in patients with hospital-acquired delirium may not increase the risk of mortality.
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Jaworska N, Moss SJ, Krewulak KD, Stelfox Z, Niven DJ, Ismail Z, Burry LD, Fiest KM. A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings. BMC Health Serv Res 2022; 22:1272. [PMID: 36271347 PMCID: PMC9587627 DOI: 10.1186/s12913-022-08650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 10/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08650-7.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada. .,Alberta Health Services, Calgary, AB, Canada.
| | - Stephana J Moss
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada
| | - Zara Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Leslie Dan Faculty of Pharmacy, Sinai Health System, University of Toronto, Toronto, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.,Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Psychiatry, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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10
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Taylor AD, Chen A, Reddy AJ, Lewandowski A, Torbic H. Retrospective evaluation of a delirium order set utilizing nonpharmacologic and pharmacologic interventions for the treatment of delirium in medical intensive care unit patients. Am J Health Syst Pharm 2022; 79:S33-S42. [PMID: 35136926 DOI: 10.1093/ajhp/zxac042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the use of a medical intensive care unit (MICU) delirium order set pilot and its associated impact on utilization of nonpharmacologic and pharmacologic interventions, pharmacologic continuation at transitions of care, and resolution of ICU delirium. METHODS This was a retrospective cohort analysis of MICU patients who received delirium management using an order set pilot compared to standard care. Patients 18 years of age or older admitted to the MICU between May 2019 and January 2020 who received an antipsychotic or valproic acid for the treatment of delirium were included. RESULTS Pharmacologic treatment continuation past ICU discharge occurred in 30% of patients in the pilot cohort (n = 50) compared to 54% of patients receiving standard care (n = 50; P = 0.027). On treatment days 1 through 7, utilization of deliriogenic medications was significantly lower in the pilot cohort (78% vs 96%, P = 0.007). No differences were observed between the groups in delirium resolution, delirium recurrence, hospital and ICU length of stay, or mortality. CONCLUSION A MICU order set prioritizing nonpharmacologic management and limiting the duration of pharmacologic agents for delirium may aid providers in the management of ICU delirium and reduce exposure to pharmacologic interventions.
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Affiliation(s)
- Alex D Taylor
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Alyssa Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Anita J Reddy
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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11
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Boncyk CS, Farrin E, Stollings JL, Rumbaugh K, Wilson JE, Marshall M, Feng X, Shotwell MS, Pandharipande PP, Hughes CG. Pharmacologic Management of Intensive Care Unit Delirium: Clinical Prescribing Practices and Outcomes in More Than 8500 Patient Encounters. Anesth Analg 2021; 133:713-722. [PMID: 33433117 DOI: 10.1213/ane.0000000000005365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pharmacologic agents are frequently utilized for management of intensive care unit (ICU) delirium, yet prescribing patterns and impact of medication choices on patient outcomes are poorly described. We sought to describe prescribing practices for management of ICU delirium and investigate the independent association of medication choice on key in-hospital outcomes including delirium resolution, in-hospital mortality, and days alive and free of the ICU or hospital. METHODS A retrospective study of delirious adult ICU patients at a tertiary academic medical center. Data were obtained regarding daily mental status (normal, delirious, and comatose), pharmacologic treatment, hospital course, and survival via electronic health record. Daily transition models were constructed to assess the independent association of previous day mental status and medication administration on mental status the following day and in-hospital mortality, after adjusting for prespecified covariates. Linear regression models investigated the association of medication administration on days alive and free of the ICU or the hospital during the first 30 days after ICU admission. RESULTS We identified 8591 encounters of ICU delirium. Half (45.6%) of patients received pharmacologic treatment for delirium, including 45.4% receiving antipsychotics, 2.2% guanfacine, and 0.84% valproic acid. Median highest Richmond Agitation-Sedation Scale (RASS) score was 1 (0, 1) in patients initiated on medications and 0 (-1, 0) for nonrecipients. Haloperidol, olanzapine, and quetiapine comprised >97% of antipsychotics utilized with 48% receiving 2 or more and 20.6% continued on antipsychotic medications at hospital discharge. Haloperidol and olanzapine were associated with greater odds of continued delirium (odds ratio [OR], 1.48; 95% confidence interval [95% CI], 1.30-1.65; P < .001 and OR, 1.37; 95% CI, 1.20-1.56; P = .003, respectively) and increased hazard of in-hospital mortality (hazard ratio [HR], 1.46; 95% CI, 1.10-1.93; P = .01 and HR, 1.67; 95% CI, 1.14-2.45; P = .01, respectively) while quetiapine showed a decreased hazard of in-hospital mortality (HR, 0.58; 95% CI, 0.40-0.84; P = .01). Haloperidol, olanzapine, and quetiapine were associated with fewer days alive and free of hospitalization (all P < .001). There was no significant association of any antipsychotic medication with days alive and free of the ICU. Neither guanfacine nor valproic acid were associated with in-hospital outcomes examined. CONCLUSIONS Pharmacologic interventions for management of ICU delirium are common, most often with antipsychotics, and frequently continued at hospital discharge. These medications may not portend benefit, may introduce additional harm, and should be used with caution for delirium management. Continuation of these medications through hospitalization and discharge draws into question their safety and role in patient recovery.
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Affiliation(s)
- Christina S Boncyk
- From the Department of Anesthesiology.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt
| | | | - Joanna L Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt.,Department of Pharmaceutical Services
| | | | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt.,Department of Psychiatry and Behavioral Science
| | | | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pratik P Pandharipande
- From the Department of Anesthesiology.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt
| | - Christopher G Hughes
- From the Department of Anesthesiology.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt
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12
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Lambert J, Vermassen J, Fierens J, Peperstraete H, Petrovic M, Colpaert K. Discharge from hospital with newly administered antipsychotics after intensive care unit delirium - Incidence and contributing factors. J Crit Care 2020; 61:162-167. [PMID: 33171333 DOI: 10.1016/j.jcrc.2020.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Delirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium. METHODS This retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation. RESULTS A total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37-6.41]) and quetiapine treatment (5.81 [1.63-20.83]) were independently associated with antipsychotic continuation at hospital discharge. CONCLUSIONS Approximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.
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Affiliation(s)
- Johannes Lambert
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B9000 Ghent, Belgium.
| | - Joris Vermassen
- Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Jan Fierens
- Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Harlinde Peperstraete
- Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Kirsten Colpaert
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B9000 Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
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13
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Ohman KL, Schultheis JM, Kram SJ, Cox CE, Gilstrap DL, Yang Z, Kram BL. Effectiveness of Quetiapine as a Sedative Adjunct in Mechanically Ventilated Adults Without Delirium. Ann Pharmacother 2020; 55:149-156. [PMID: 32698609 DOI: 10.1177/1060028020944409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Quetiapine is an atypical antipsychotic that is commonly used in the Intensive Care Unit (ICU). The utility of quetiapine as a sedative adjunct has not yet been evaluated, but has been described previously in studies evaluating quetiapine for delirium or delirium prophylaxis. OBJECTIVE To determine if adjunctive use of quetiapine reduces sedative dosage requirements among mechanically ventilated adults without delirium. METHODS This retrospective intrapatient comparator study included all mechanically ventilated adults admitted to a medical ICU who received quetiapine between July 1, 2013, and July 1, 2018. The primary outcome was the change in sedative dosage requirements over 24 hours following quetiapine initiation. Secondary outcomes included change in sedative dosage requirements 48 hours postquetiapine initiation, opioid dosage requirements 24 hours postquetiapine initiation, percent time at goal for both pain and sedation scores, depth of sedation, and QTc. RESULTS A total of 57 patients were included in the study cohort. There was no significant difference in 24-hour cumulative doses of propofol (P = 0.10), dexmedetomidine (P = 0.14), or benzodiazepines (P = 0.14). During the 48-hour treatment period, there was a significant increase in dexmedetomidine requirements (P = 0.03). There were no differences in 24-hour opioid dosage requirements, percent time at goal pain or sedation scores, depth of sedation, or QTc following quetiapine initiation. CONCLUSION AND RELEVANCE Adjunctive use of quetiapine was not associated with a significant reduction in sedative dosage requirements 24 or 48 hours following initiation among mechanically ventilated adults without delirium.
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14
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Coe AB, Vincent BM, Iwashyna TJ. Statin discontinuation and new antipsychotic use after an acute hospital stay vary by hospital. PLoS One 2020; 15:e0232707. [PMID: 32384108 PMCID: PMC7209203 DOI: 10.1371/journal.pone.0232707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/20/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Patients are at risk for medication problems after hospital admissions, particularly those with critical illness. Medication problems include continuation of acute medications and discontinuation of chronic medications after discharge. Little is known across a national integrated health care system about the extent of these two medication problems. Objective To examine the extent of statin medication discontinuation and new antipsychotic medication use after hospital discharge. Design Retrospective cohort study. Setting Veterans Affairs healthcare system. Participants Veterans with an inpatient hospitalization from January 1, 2014-December 31, 2016, survived at least 180 days post-discharge, and received at least one medication through the VA outpatient pharmacy within one year around admission were included. Hospitalizations were grouped into: 1) direct admission to the intensive care unit (ICU) and a diagnosis of sepsis, 2) direct admission to the ICU without sepsis diagnosis, and 3) no ICU stay during the hospitalization. Main outcome measures Statin medication discontinuation and new antipsychotic use at six months post-hospital discharge. Results A total of 520,187 participants were included in the statin medication and 910,629 in the antipsychotic medication cohorts. Statin discontinuation ranged from 10–15% and new antipsychotic prescription fills from 2–4% across the three hospitalization groups, with highest rates in the ICU admission and sepsis diagnosis group. Statin discontinuation and new antipsychotic use after a hospitalization varied by hospital, with worse performing hospitals having 11% higher odds of discontinuing a statin (median odds ratio at hospital-level, adjusted for patient differences, aMOR: 1.11 (95% CI: 1.09, 1.13)) and 29% higher odds of new antipsychotic use (aMOR, 1.29 (95% CI: 1.24, 1.34)). Risk-adjusted hospital rates of these two medication changes were not correlated (p = 0.49). Conclusions Systemic variation in the rates of statin medication continuation and new antipsychotic use were found.
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Affiliation(s)
- Antoinette B. Coe
- Department of Clinical Pharmacy, College of Pharmacy and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Brenda M. Vincent
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States of America
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
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15
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Stuart MM, Smith ZR, Payter KA, Martz CR, To L, Swiderek JL, Coba VE, Peters MA. Pharmacist‐driven
discontinuation of antipsychotics for
ICU
delirium: A
quasi‐experimental
study. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Misa M. Stuart
- Department of Pharmacy Henry Ford Health System Detroit Michigan USA
| | - Zachary R. Smith
- Department of Pharmacy Henry Ford Health System Detroit Michigan USA
| | - Katelyn A. Payter
- Department of Pharmacy Henry Ford Health System Detroit Michigan USA
| | - Carolyn R. Martz
- Department of Pharmacy Henry Ford Health System Detroit Michigan USA
| | - Long To
- Department of Pharmacy Henry Ford Health System Detroit Michigan USA
| | - Jennifer L. Swiderek
- Pulmonary & Critical Care Medicine Henry Ford Health System Detroit Michigan USA
| | - Victor E. Coba
- Department of Surgery, Division of Trauma and Critical Care Henry Ford Health System Detroit Michigan USA
| | - Michael A. Peters
- Department of Pharmacy Henry Ford Health System Detroit Michigan USA
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16
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Coe AB, Bookstaver RE, Fritschle AC, Kenes MT, MacTavish P, Mohammad RA, Simonelli RJ, Whitten JA, Stollings JL. Pharmacists' Perceptions on Their Role, Activities, Facilitators, and Barriers to Practicing in a Post-Intensive Care Recovery Clinic. Hosp Pharm 2020; 55:119-125. [PMID: 32214446 PMCID: PMC7081480 DOI: 10.1177/0018578718823740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Complex medication regimen changes burden intensive care unit (ICU) survivors and their caregivers during the transition to home. Intensive care unit recovery clinics are a prime setting for pharmacists to address patients' and their caregivers' medication-related needs. The purpose of this study was to describe ICU recovery clinic pharmacists' activities, roles, and perceived barriers and facilitators to practicing in ICU recovery clinics across different institutions. Methods: An expert panel of ICU recovery clinic pharmacists completed a 15-item survey. Survey items addressed the pharmacists' years in practice, education and training, activities performed, their perceptions of facilitators and barriers to practicing in an ICU recovery clinic setting, and general ICU recovery clinic characteristics. Descriptive statistics were used. Results: Nine ICU recovery clinic pharmacists participated. The average number of years in practice was 16.5 years (SD = 13.5, range = 2-38). All pharmacists practiced in an interprofessional ICU recovery clinic affiliated with an academic medical center. Seven (78%) pharmacists always performed medication reconciliation and a comprehensive medication review in each patient visit. Need for medication education was the most prevalent item found in patient comprehensive medication reviews. The main facilitators for pharmacists' successful participation in an ICU recovery clinic were incorporation into clinic workflow, support from other health care providers, and adequate space to see patients. The ICU recovery clinic pharmacists perceived the top barriers to be lack of dedicated time and inadequate billing for services. Conclusions: The ICU recovery clinic pharmacists address ICU survivors' medication needs by providing direct patient care in the clinic. Strategies to mitigate pharmacists' barriers to practicing in ICU recovery clinics, such as lack of dedicated time and adequate billing for pharmacist services, warrant a multifaceted solution, potentially including advocacy and policy work by national pharmacy professional organizations.
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Affiliation(s)
- Antoinette B. Coe
- University of Michigan College of Pharmacy, Ann Arbor MI, USA,Antoinette B. Coe, PharmD, PhD, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, USA.
| | | | | | | | | | - Rima A. Mohammad
- University of Michigan College of Pharmacy, Ann Arbor MI, USA,Michigan Medicine, Ann Arbor, MI, USA
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17
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Barker M, Dixon AA, Camporota L, Barrett NA, Wan RYY. Sedation with alfentanil versus fentanyl in patients receiving extracorporeal membrane oxygenation: outcomes from a single-centre retrospective study. Perfusion 2019; 35:104-109. [PMID: 31296116 DOI: 10.1177/0267659119858037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In November 2016, our institution switched from alfentanil to fentanyl for analgesia and sedation in adult patients receiving extracorporeal membrane oxygenation. There is no published evidence comparing the use of alfentanil with fentanyl for sedation in extracorporeal membrane oxygenation patients. We conducted a retrospective observational study to explore any significant differences in patient outcomes or in the prescribing of adjunct sedatives before and after the switch. METHODS Patients were retrospectively identified from a prospectively recorded database of all patients who received extracorporeal membrane oxygenation at our institution between January 2016 and October 2017. Patients included those sedated with alfentanil or fentanyl. The total daily doses of intravenous opioids (alfentanil or fentanyl) were calculated for each patient, and the prescribing of adjunctive sedative or analgesic agents was recorded. Patient demographics, extracorporeal membrane oxygenation modality, clinical outcomes including mortality and length of intensive care and hospital stay were recorded. RESULTS A total of 174 patients were identified, 69 on alfentanil and 95 on fentanyl. There was no difference found between groups for mode of extracorporeal membrane oxygenation, age, Acute Physiology and Chronic Health Evaluation 2 score (APACHE II) and Charlson score, except for body mass index (p = 0.002). No differences in patient outcomes was observed between groups, although patients in the alfentanil group received a significantly higher median total daily dose of adjuvant sedatives (quetiapine (p = 0.016) and midazolam (p = 0.009)). CONCLUSIONS No differences in patient outcomes were found between extracorporeal membrane oxygenation patients sedated with alfentanil compared with fentanyl. There was a statistically significant reduction in some adjunctive sedatives in patients managed with a fentanyl-based regimen. Prospective studies are required to confirm these results.
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Affiliation(s)
- Mike Barker
- Pharmacy Department, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Alison A Dixon
- Department of Intensive Care, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Intensive Care, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Nick A Barrett
- Department of Intensive Care, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Ruth Y Y Wan
- Pharmacy Department, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
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18
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Kalisch Ellett LM, Pratt NL, Apajee J, Roughead EE. Initiation and continuation of antipsychotic medicines in older people following non-psychiatric hospital admission. Int J Clin Pharm 2019; 41:1341-1347. [PMID: 31240552 DOI: 10.1007/s11096-019-00866-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/17/2019] [Indexed: 11/27/2022]
Abstract
Background Internationally, antipsychotics are frequently initiated during hospital admission for older patients and use often continues post-discharge without indication. We located no Australian studies on this topic. Objective to identify the hospital admissions (excluding psychosis) associated with antipsychotic initiation and continuation in older Australians. Setting Australian Government Department of Veterans' Affairs. Method Retrospective analysis of administrative claims data for people admitted to hospital from 1 January 2014 to 31 December 2014, aged ≥ 65 years, who were antipsychotic naïve. Main outcome measure number of admissions associated with antipsychotic initiation, and the major diagnosis groups for these admissions. Where antipsychotics were initiated, we determined the time to cessation of antipsychotics after discharge. Results There were 142,009 hospital admissions for 66,415 people with a median age of 86 years. 921 (0.65%) admissions were associated with antipsychotic initiation, most commonly where the primary diagnoses were for mental and behavioural disorders excluding psychosis (17.8%) and injuries (16%). Fourteen percent of antipsychotic initiations were for primary diagnoses of delirium or dementia. When secondary diagnoses were considered, 55% of antipsychotic initiations were associated with delirium, dementia or both. The median duration of use among people who used antipsychotics was 132 days, and 40% continued use until death or one year follow-up. Conclusion Initiation of antipsychotics during hospital admissions was not frequent in this Australian population. Amongst those who did initiate antipsychotics, for almost half no diagnosis corresponding with an approved indication for use was recorded and long-term use of up to one year was common.
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Affiliation(s)
- Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia.
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Jemisha Apajee
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA, 5001, Australia
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19
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Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location. Crit Care Med 2019; 47:543-549. [DOI: 10.1097/ccm.0000000000003633] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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20
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Kovacic NL, Gagnon DJ, Riker RR, Wen S, Fraser GL. An Analysis of Psychoactive Medications Initiated in the ICU but Continued Beyond Discharge: A Pilot Study of Stewardship. J Pharm Pract 2019; 33:760-767. [PMID: 30813837 DOI: 10.1177/0897190019830518] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Psychoactive medications (PM) are frequently administered in the intensive care unit (ICU) to provide comfort. Interventions focused on preventing their continuation after the acute phase of illness are needed. OBJECTIVE To determine the frequency that patients with ICU-initiated PM are continued upon ICU and hospital discharge. METHODS This single-center, prospective, observational study assessed consecutive adult ICU patients who received scheduled PM. Frequency of PM continued at ICU and hospital discharge was recorded. The patient's primary treatment team was contacted by the pharmacist within 72 hours of ICU discharge to establish rationale for continued use or to suggest discontinuation. RESULTS Of the 60 patients included, 72% were continued on PM at ICU discharge and 30% at hospital discharge. The pharmacist contacted 40% of treatment teams after ICU discharge and intervention resulted in PM discontinued in 50% of patients. Post ICU discharge, the indication of 41% of patients' PM was unknown by the non-ICU care team or incorrect. Medical ICU patients or those transferred to an outside facility were more likely remain on PM at hospital discharge. CONCLUSION PM are frequently continued during transitions of care and often without knowledge of the initial indication. Future studies should establish effective PM stewardship methods.
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Affiliation(s)
- Nicole Lynn Kovacic
- WVU Medicine, Morgantown, WV, USA.,West Virginia University School of Pharmacy, Morgantown, WV, USA
| | - David J Gagnon
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Richard R Riker
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Sijin Wen
- Health Science Center, 24041West Virginia University, Morgantown, WV, USA
| | - Gilles L Fraser
- 92602Maine Medical Center, Portland, ME, USA.,Tufts University School of Medicine, Boston, MA, USA
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Mulkey MA, Hardin SR, Olson DM, Munro CL, Everhart E. Considering Causes for Hypoactive Delirium. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2019. [DOI: 10.21307/ajon-2017-015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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22
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Shafiekhani M, Mirjalili M, Vazin A. Psychotropic drug therapy in patients in the intensive care unit - usage, adverse effects, and drug interactions: a review. Ther Clin Risk Manag 2018; 14:1799-1812. [PMID: 30319262 PMCID: PMC6168070 DOI: 10.2147/tcrm.s176079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Managing psychological problems in patients admitted to intensive care unit (ICU) is a big challenge, requiring pharmacological interventions. On the other hand, these patients are more prone to side effects and drug interactions associated with psychotropic drugs use. Benzodiazepines (BZDs), antidepressants, and antipsychotics are commonly used in critically ill patients. Therefore, their therapeutic effects and adverse events are discussed in this study. Different studies have shown that non-BZD drugs are preferred to BZDs for agitation and pain management, but antipsychotic agents are not recommended. Also, it is better not to start antidepressants until the patient has fully recovered. However, further investigations are required for the use of psychotropic drugs in ICUs.
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Affiliation(s)
- Mojtaba Shafiekhani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,
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23
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Devlin JW, Smithburger P, Kane JM, Fraser GL, Skrobik Y. Intended and Unintended Consequences of Constraining Clinician Prescribing: The Case of Antipsychotics. Crit Care Med 2018; 44:1805-7. [PMID: 27635480 DOI: 10.1097/ccm.0000000000002103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- John W Devlin
- School of Pharmacy Northeastern University Boston, MASchool of Pharmacy University of Pittsburgh Pittsburgh, PADepartment of Pediatrics University of Chicago Comer Children's Hospital Chicago, ILDepartments of Pharmacy and Critical Care Medicine Maine Medical Center Portland, MEDepartment of Medicine McGill University Montreal, PQ, Canada
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24
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25
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Kram BL, Schultheis JM, Kram SJ, Cox CE. A Pharmacy-Based Electronic Handoff Tool to Reduce Discharge Prescribing of Atypical Antipsychotics Initiated in the Intensive Care Unit: A Quality Improvement Initiative. J Pharm Pract 2018; 32:434-441. [DOI: 10.1177/0897190018761412] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose: To evaluate whether a pharmacist-initiated electronic handoff tool can reduce the overall, and potentially inappropriate, hospital discharge prescribing rate of atypical antipsychotics (AAP) initiated in AAP-naive critically ill adults. Methods: This pre–post quality improvement study was initiated in 5 intensive care units (ICUs) at a large academic medical center. An electronic handoff tool (iVent) was utilized in the post-intervention period to enhance pharmacist communication at inpatient transitions of care. Results: Of the 358 included patients, the proportion of hospital survivors with an AAP initiated in the ICU receiving a hospital discharge prescription was not different between the pre- and post-intervention period (28.6% vs 22.2%, P = .12). The proportion of ICU survivors with an AAP continued at the time of ICU transfer to the floor was reduced post-intervention (78.7% vs 66.7%, P = .012). Additionally, the overall proportion of a patient’s hospitalization receiving an AAP was also reduced (50.4% vs 42.8%, P = .008). A multivariate logistic regression demonstrated thatutilization of the electronic handoff tool was not associated with a reduction in hospital discharge prescribing of an AAP (odds ratio [OR]: 0.97, 95% confidence interval [CI]: 0.57-1.65). Conclusions: A pharmacy-initiated electronic handoff tool may reduce the proportion of AAP-naive ICU survivors with an AAP continued at the time of ICU transfer. The handoff tool was not associated with a significant reduction in the discharge prescribing rates of AAPs for hospital survivors, but a clinically meaningful reduction was possibly achieved due to enhanced communication enabled by this tool.
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Affiliation(s)
| | | | - Shawn J. Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Christopher E. Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University Hospital, Durham, NC, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
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26
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Stollings JL, Bloom SL, Wang L, Ely EW, Jackson JC, Sevin CM. Critical Care Pharmacists and Medication Management in an ICU Recovery Center. Ann Pharmacother 2018; 52:713-723. [PMID: 29457491 DOI: 10.1177/1060028018759343] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Many patients experience complications following critical illness; these are now widely referred to as post-intensive care syndrome (PICS). An interprofessional intensive care unit (ICU) recovery center (ICU-RC), also known as a PICS clinic, is one potential approach to promoting patient and family recovery following critical illness. OBJECTIVES To describe the role of an ICU-RC critical care pharmacist in identifying and treating medication-related problems among ICU survivors. METHODS A prospective, observational cohort study was conducted of all outpatient appointments of a tertiary care hospital's ICU-RC between July 2012 and December 2015. The pharmacist completed a full medication review, including medication reconciliation, interview, counseling, and resultant interventions, during the ICU-RC appointment. RESULTS Data from all completed ICU-RC visits were analyzed (n = 62). A full medication review was performed in 56 (90%) of these patients by the pharmacist. The median number of pharmacy interventions per patient was 4 (interquartile range = 2, 5). All 56 patients had at least 1 pharmacy intervention; 22 (39%) patients had medication(s) stopped at the clinic appointment, and 18 (32%) patients had new medication(s) started. The pharmacist identified 9 (16%) patients who had an adverse drug event (ADE); 18 (32%) patients had ADE preventive measures instituted. An influenza vaccination was administered to 13 (23%) patients despite an inpatient protocol to ensure influenza vaccination prior to discharge. A pneumococcal vaccination was administered to 2 (4%) patients. CONCLUSIONS Use of a critical care pharmacist resulted in the identification and treatment of multiple medication-related problems in an ICU-RC as well as implementation of preventive measures.
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Affiliation(s)
| | - Sarah L Bloom
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA
| | - James C Jackson
- 2 Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA.,3 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Carla M Sevin
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
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Fontaine GV, Mortensen W, Guinto KM, Scott DM, Miller RR. Newly Initiated In-Hospital Antipsychotics Continued at Discharge in Non-psychiatric Patients. Hosp Pharm 2018; 53:308-315. [PMID: 30210148 DOI: 10.1177/0018578717750095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Antipsychotics are commonly initiated in the hospital for agitation and delirium and may be inappropriately continued upon floor transfer and at discharge. We sought to evaluate the magnitude of this issue within our health care system. Methods: We conducted a multicenter, retrospective cohort study within a 22-hospital health care system to evaluate the proportion of patients without identifiable psychiatric illness who received newly initiated inpatient antipsychotics and were then continued on an antipsychotic at hospital discharge. Results: Of 23 049 patients who received at least 1 in-hospital dose of haloperidol, olanzapine, quetiapine, risperidone, or ziprasidone, 8297 patients were included in the final analysis after applying exclusion for identifiable psychiatric illness or previous antipsychotic use. Ultimately, 334 patients (4%) were discharged with a new antipsychotic prescription. Patients receiving antipsychotics at discharge were more likely as an inpatient to receive quetiapine (77.2% vs 35.9%; odds ratio [OR]: 6.1, 95% confidence interval [CI]: 4.7-8.0; P < .001) and less likely to receive haloperidol (15% vs 47%; OR: 0.2, 95% CI: 0.14-0.27; P < .001) or olanzapine (16.2% vs 20.9%; OR: 0.73, 95% CI: 0.53-0.98; P < .04). Conclusions: Antipsychotics may be inappropriately continued in non-psychiatric patients at hospital discharge. Strategies to limit potentially unnecessary antipsychotics upon discharge should be evaluated.
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Affiliation(s)
- Gabriel V Fontaine
- Intermountain Healthcare, Salt Lake City, UT, USA.,The University of Utah, Salt Lake City, USA.,Roseman University of Health Sciences, South Jordan, UT, USA
| | | | | | | | - Russell R Miller
- Intermountain Healthcare, Salt Lake City, UT, USA.,The University of Utah, Salt Lake City, USA
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Garpestad E, Devlin JW. Polypharmacy and Delirium in Critically Ill Older Adults: Recognition and Prevention. Clin Geriatr Med 2017; 33:189-203. [PMID: 28364991 DOI: 10.1016/j.cger.2017.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Among older adults, polypharmacy is a sequelae of admission to the intensive care unit and is associated with increased medication-associated adverse events, drug interactions, and health care costs. Delirium is prevalent in critically ill geriatric patients and medications remain an underappreciated modifiable risk for delirium in this setting. This article reviews the literature on polypharmacy and delirium, with a focus on highlighting the relationships between polypharmacy and delirium in critically ill, older adults. Discussed are clinician strategies on how to recognize and reduce medication-associated delirium and recommendations that help prevent polypharmacy when interventions to reduce the burden of delirium in this vulnerable population are being formulated.
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Affiliation(s)
- Erik Garpestad
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA
| | - John W Devlin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, 200 Washington Street, Boston, MA 02111, USA; School of Pharmacy, Northeastern University, 360 Huntington Avenue 140TF RD218F, Boston, MA 02115, USA.
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29
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Tomichek JE, Stollings JL, Pandharipande PP, Chandrasekhar R, Ely EW, Girard TD. Antipsychotic prescribing patterns during and after critical illness: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:378. [PMID: 27881149 PMCID: PMC5122157 DOI: 10.1186/s13054-016-1557-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 11/04/2016] [Indexed: 12/15/2022]
Abstract
Background Antipsychotics are used to treat delirium in the intensive care unit (ICU) despite unproven efficacy. We hypothesized that atypical antipsychotic treatment in the ICU is a risk factor for antipsychotic prescription at discharge, a practice that might increase risk since long-term use is associated with increased mortality. Methods After excluding patients on antipsychotics prior to admission, we examined antipsychotic use in a prospective cohort of ICU patients with acute respiratory failure and/or shock. We collected data on medication use from medical records and assessed patients for delirium using the Confusion Assessment Method for the ICU. Using multivariable logistic regression, we analyzed whether age, delirium duration, atypical antipsychotic use, and discharge disposition (each selected a priori) were independent risk factors for discharge on an antipsychotic. We also examined admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, haloperidol use, and days of benzodiazepine use in post hoc analyses. Results After excluding 18 patients due to prior antipsychotic use and three who withdrew, we included 500 patients. Among 208 (42%) treated with an antipsychotic, median (interquartile range) age was 59 (49–69) years and APACHE II score was 26 (22–32), characteristics that were similar among antipsychotic nonusers. Antipsychotic users were more likely than nonusers to have had delirium (93% vs. 61%, p < 0.001). Of the 208 antipsychotic users, 172 survived to hospital discharge, and 42 (24%) of these were prescribed an antipsychotic at discharge. Treatment with an atypical antipsychotic was the only independent risk factor for antipsychotic prescription at discharge (odds ratio 17.6, 95% confidence interval 4.9 to 63.3; p < 0.001). Neither age, delirium duration, nor discharge disposition were risk factors (p = 0.11, 0.38, and 0.12, respectively) in the primary regression model, and post hoc analyses found APACHE II (p = 0.07), haloperidol use (p = 0.16), and days of benzodiazepine use (p = 0.31) were also not risk factors for discharge on an antipsychotic. Conclusions In this study, antipsychotics were used to treat nearly half of all antipsychotic-naïve ICU patients and were prescribed at discharge to 24% of antipsychotic-treated patients. Treatment with an atypical antipsychotic greatly increased the odds of discharge with an antipsychotic prescription, a practice that should be examined carefully during medication reconciliation since these drugs carry “black box warnings” regarding long-term use.
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Affiliation(s)
- Jason E Tomichek
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232-7610, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232-7610, USA
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Critical Care, Vanderbilt University School of Medicine, 1211 21st Ave S, Nashville, TN, 37212, USA.,Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Ave S, Nashville, TN, 37212, USA
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN, 37203, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Ave S, Nashville, TN, 37232-2650, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, 1215 21st Ave S, Nashville, TN, 37232-8300, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, 1310 24th Ave S, Nashville, TN, 37212, USA
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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