Intended and Unintended Consequences of Constraining Clinician Prescribing: The Case of Antipsychotics

Facilitators and Barriers Influencing Antipsychotic Medication Prescribing and Deprescribing Practices in Critically Ill Adult Patients: a Qualitative Study

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.

Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions

BACKGROUND

Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown.

RESEARCH QUESTION

What is the burden of health resource utilization and odds of new prescriptions of benzodiazepines and opioids up to 1-year post-hospital discharge in critically ill patients with new antipsychotic prescriptions at hospital discharge?

STUDY DESIGN & METHODS

We completed a multi-center, propensity-score matched retrospective cohort study of critically ill adult patients. The primary exposure was administration of ≥1 dose of an antipsychotic while the patient was admitted in the ICU and ward with continuation at hospital discharge and a filled outpatient prescription within 1-year following hospital discharge. The control group was defined as no doses of antipsychotics administered in the ICU and hospital ward and no filled outpatient prescriptions for antipsychotics within 1-year following hospital discharge. The primary outcome was health resource utilization (72-hour ICU readmission, 30-day hospital readmission, 30-day emergency room visitation, 30-day mortality). Secondary outcomes were administration of benzodiazepines and/or opioids in-hospital and following hospital discharge in patients receiving antipsychotics.

RESULTS

1,388 propensity-score matched patients were included who did and did not receive antipsychotics in ICU and survived to hospital discharge. New antipsychotic prescriptions were not associated with increased health resource utilization or 30-day mortality following hospital discharge. There was increased odds of new prescriptions of benzodiazepines (adjusted odds ratio [aOR] 1.61 [95%CI 1.19-2.19]) and opioids (aOR 1.82 [95%CI 1.38-2.40]) up to 1-year following hospital discharge in patients continuing antipsychotics at hospital discharge.

INTERPRETATION

New antipsychotic prescriptions at hospital discharge are significantly associated with additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge.

A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings

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.

Antipsychotic prescribing practices and patient, family member and healthcare professional perceptions of antipsychotic prescribing in acute care settings: a scoping review protocol

INTRODUCTION

Antipsychotic medications are commonly prescribed off-label in acutely ill patients for non-psychiatric clinical indications such as delirium or insomnia. New prescription initiation of antipsychotics in acute care settings increases the proportion of patients discharged home on antipsychotics without approved clinical indication. Long-term use of antipsychotics is associated with increased risk of sudden cardiac death, falls and cognitive impairment. An understanding of acute care off-label antipsychotic prescribing practices and healthcare professional, patient and family perceptions related to antipsychotic prescribing and deprescribing is necessary to facilitate in-hospital deprescribing initiatives.

METHODS AND ANALYSIS

We present the protocol for a scoping review following the methodology proposed by Arksey and O'Malley and the Scoping Review Methods Manual by the Joanna Briggs Institute. We will search five databases including MEDLINE, EMBASE, CINAHL, PsycINFO and Web of Science from inception to 3 July 2021 (ie, planned search date). We will include both peer-reviewed and non-peer-reviewed qualitative and quantitative studies to identify antipsychotic prescribing practices, and to describe healthcare professional, patient and family perceptions towards antipsychotic prescribing and deprescribing in the acute care setting. Protocols, systematic and scoping reviews will be excluded. Two reviewers will calibrate and perform study screening and data abstraction for quantitative and qualitative outcomes of eligible studies. Quantitative outcomes will include study identifiers, demographics and descriptive statistics of antipsychotic prescribing practices. Qualitative synthesis describing perceptions on antipsychotic prescribing practices will include deductive thematic analysis with mapping of themes to the domains of the Theoretical Domains Framework, a 14-domain behaviour and behaviour change framework.

ETHICS AND DISSEMINATION

No ethical approval will be required for this study as only data from published studies in which informed consent was obtained by primary investigators will be retrieved and analysed. The results of this scoping review will inform integrated knowledge translation initiatives aimed at in-hospital antipsychotic medication deprescribing.

Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative

The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Impact of early home psychotropic medication reinitiation on surrogate measures of intensive care unit delirium

Introduction

Intensive care unit (ICU) delirium is a major contributing factor to increased mortality, length of stay, and cost of care. Psychotropic medications may often require extensive tapering to prevent withdrawal symptoms; during ICU admission, home psychotropics are frequently held which may precipitate acute drug withdrawal and subsequent delirium.

Methods

This is a single-center, observational, retrospective chart review. The primary endpoint was the total number of new-start antipsychotics used to treat ICU delirium. Secondary endpoints included use of restraints, ICU length of stay, and hospital length of stay.

Results

A total of 2334 charts were reviewed for inclusion; 55 patients were categorized into each group. There was no statistically significant difference in the requirement for new-start antipsychotics (P = 1.0), restraint use (P = .057), or ICU length of stay (P = .71). There was a statistically significant decrease in hospital length of stay (P = .048).

Discussion

Early reinitiation was associated with a decrease in hospital length of stay but was not associated with a decrease in the number of new-start antipsychotics, use of restraints, or ICU length of stay.

Prevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines

Delirium is an acute, confusional state characterized by altered consciousness and a reduced ability to focus, sustain, or shift attention. It is associated with a number of complex underlying medical conditions and can be difficult to recognize. Many critically ill patients (e.g., up to 80% of patients in the intensive care unit [ICU]) experience delirium due to underlying medical or surgical health problems, recent surgical or other invasive procedures, medications, or various noxious stimuli (e.g., underlying psychological stressors, mechanical ventilation, noise, light, patient care interactions, and drug-induced sleep disruption or deprivation). Delirium is associated with a longer duration of mechanical ventilation and ICU admittance as well as an increased risk of death, disability, and long-term cognitive dysfunction. Therefore, the early recognition of delirium is important and ICU medical staff should devote careful attention to both watching for the occurrence of delirium and its prevention and management. This review presents a brief overview of delirium and an update of the literature with reference to the 2018 Society of Critical Care Medicine Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.