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Pavon JM, Sloane RJ, Colón-Emeric CS, Pieper CF, Schmader K, Gallagher D, Hastings SN. Central nervous system medication use around hospitalization. J Am Geriatr Soc 2024. [PMID: 38600620 DOI: 10.1111/jgs.18915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/07/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods. METHODS Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization). RESULTS Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge. CONCLUSIONS CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.
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Affiliation(s)
- Juliessa M Pavon
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - Richard J Sloane
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - Cathleen S Colón-Emeric
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - Carl F Pieper
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Kenneth Schmader
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
| | - David Gallagher
- Department of Medicine/Division of General Internal Medicine/Hospital Medicine, Duke University, Durham, North Carolina, USA
| | - Susan N Hastings
- Department of Medicine/Division of Geriatrics, Duke University, Durham, North Carolina, USA
- Geriatric Research Education Clinical Center, Durham Veteran Affairs Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University, Durham, North Carolina, USA
- Health Services Research & Development, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
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Torbic H, Chen A, Lumpkin M, Yerke J, Mehkri O, Abraham S, Wang X, Duggal A, Scheraga RG. Antipsychotic Use for ICU Delirium and Associated Inflammatory Markers. J Intensive Care Med 2024; 39:313-319. [PMID: 37724016 PMCID: PMC10922065 DOI: 10.1177/08850666231201567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Purpose: We sought to evaluate critically ill patients with delirium to evaluate inflammatory cytokine production and delirium progression and the role of antipsychotics. Materials and Methods: Adult critically ill patients with confirmed delirium according to a positive CAM-ICU score were included and IL-6 and IL-8 levels were trended for 24 h in this single-center, prospective, observational cohort study. Results: A total of 23 patients were consented and had blood samples drawn for inclusion. There was no difference in IL-6 and IL-8 levels at baseline, 4 to 8 h, and 22 to 28 h after enrollment when comparing patients based on antipsychotic exposure. We identified 2 patient clusters based on age, APACHE III, need for mechanical ventilation, and concomitant infection. In cluster 1, 5 (33.3%) patients received antipsychotics versus 5 (62.5%) patients in cluster 2 (P = .18). Patients in cluster 1 had more co-inflammatory conditions (P < .0001), yet numerically lower baseline IL-6 (P = .18) and IL-8 levels (P = .80) compared to cluster 2. Patients in cluster 1 had a greater median number of delirium-free days compared to cluster 2 (17.0 vs 6.0 days; P = .05). Conclusions: In critically ill patients with delirium, IL-6 and IL-8 levels were variable and antipsychotics were not associated with improvements in delirium or inflammatory markers.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Alyssa Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Mollie Lumpkin
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Omar Mehkri
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Susamma Abraham
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel G. Scheraga
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, USA
- Department of Critical Care and Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, 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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Strein M, Holton-Burke JP, Stilianoudakis S, Moses C, Almohaish S, Brophy GM. Levetiracetam-associated behavioral adverse events in neurocritical care patients. Pharmacotherapy 2023; 43:122-128. [PMID: 36606737 DOI: 10.1002/phar.2760] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/14/2022] [Accepted: 12/11/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES The objective of this study was to identify the incidence of levetiracetam-associated BAEs in NCC patients. DESIGN Single-center retrospective cohort analysis. DATA SOURCE Patient charts. PATIENTS 965 adult ICU patients with a neurological injury receiving levetiracetam that were admitted to an intensive care unit. MEASUREMENTS AND MAIN RESULTS There were 965 patients included; 52% males with a median GCS of 13. Injury types included TBI (43.1%), ICH (21.8%), SAH (20.5%), and CI (14.6%). BAEs were identified in 46% of patients. Of these, 60% had documentation of agitation/restlessness, delirium, or anxiety while receiving levetiracetam, only 25% had a positive CAM-ICU, 13% had restraints ordered, and 42% received antipsychotics. Patients with TBI had the highest incidence of BAEs (52.4%). The median time to initiation of levetiracetam after hospital admission was 6.4 hours and BAEs occurred after 1.3 days of levetiracetam initiation. CONCLUSIONS In this study, we found that almost half of our NCC population experienced levetiracetam associated BAEs which were mostly hyperactive in nature. We believe that the incidence of BAEs in our specific patient population cannot solely be attributed to ICU delirium given the lower risk of developing hyperactive delirium in ICU patients as compared to other subtypes. Therefore, monitoring and determination of the benefit versus risk in those experiencing BAEs is highly encouraged.
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Affiliation(s)
- Micheal Strein
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John P Holton-Burke
- Rochester Regional Health, Neuroscience Center & Pain Management, Rochester, New York, USA
| | - Spiro Stilianoudakis
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Sulaiman Almohaish
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
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Atypical Antipsychotic Safety in the CICU. Am J Cardiol 2022; 163:117-123. [PMID: 34794647 DOI: 10.1016/j.amjcard.2021.09.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 11/23/2022]
Abstract
Atypical antipsychotics are used in cardiac intensive care units (CICU) to treat delirium despite limited data on safety in patients with acute cardiovascular conditions. Patients treated with these agents may be at higher risk for adverse events such as QTc prolongation and arrhythmias. We performed a retrospective cohort study of 144 adult patients who were not receiving antipsychotics before admission and received olanzapine (n = 50) or quetiapine (n = 94) in the Michigan Medicine CICU. Data on baseline characteristics, antipsychotic dose and duration, length of stay, and adverse events were collected. Adverse events included ventricular tachycardia (sustained ventricular tachycardia attributed to the medication), hypotension (systolic blood pressure <90 mm Hg attributed to the medication), and QTc prolongation (QTc increase by ≥60 ms or to an interval ≥500 ms). Twenty-six patients (18%) experienced an adverse event. Of those adverse events, 20 patients (14%) experienced QTc prolongation, 3 patients (2%) had ventricular tachycardia, and 3 patients (2%) had hypotension. Patients who received quetiapine had a higher rate of adverse events (25% vs 6%, p = 0.01) including QTc prolongation (18% vs 6%, p = 0.046). Intensive care unit length of stay was shorter in patients who received olanzapine (6.5 vs 9.5 days, p = 0.047). Eighteen patients (13%) had their antipsychotic continued at discharge from the hospital. In conclusion, QTc prolongation was more common in patients treated with quetiapine versus olanzapine although the number of events was relatively low with both agents in a CICU cohort.
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Alaskar MA, Brown JD, Voils SA, Vouri SM. Loop diuretic use following fluid resuscitation in the critically ill. Am J Health Syst Pharm 2021; 79:165-172. [PMID: 34553749 DOI: 10.1093/ajhp/zxab372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] 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 identify the incidence of continuation of newly initiated loop diuretics upon intensive care unit (ICU) and hospital discharge and identify factors associated with continuation. METHODS This was a single-center retrospective study using electronic health records in the setting of adult ICUs at a quaternary care academic medical center. It involved patients with sepsis admitted to the ICU from January 1, 2014, to June 30, 2019, who received intravenous fluid resuscitation. The endpoints of interest were (1) the incidence of loop diuretic use during an ICU stay following fluid resuscitation, (2) continuation of loop diuretics following transition of care, and (3) potential factors associated with loop diuretic continuation after transition from the ICU. RESULTS Of 3,591 patients who received intravenous fluid resuscitation for sepsis, 39.4% (n = 1,415) were newly started on loop diuretics during their ICU stay. Among patients who transitioned to the hospital ward from the ICU, loop diuretics were continued in 33% (388/1,193) of patients. At hospital discharge, 13.4% (52/388) of these patients were prescribed a loop diuretic to be used in the outpatient setting. History of liver disease, development of acute kidney injury, being on vasopressors while in the ICU, receiving blood products, and receiving greater than 90 mL/kg of bolus fluids were significant potential factors associated with loop diuretic continuation after transition from the ICU. CONCLUSION New initiation of loop diuretics following intravenous fluid resuscitation in patients with sepsis during an ICU stay is a common occurrence. Studies are needed to assess the effect of this practice on patient outcomes and resource utilization.
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Affiliation(s)
- Mashael A Alaskar
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida, College of Pharmacy, Gainesville, FL, USA, andKing Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Stacy A Voils
- Department of Pharmacotherapy and Translational Research, University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Scott M Vouri
- Department of Pharmaceutical Outcomes and Policy, Center for Drug Evaluation & Safety, University of Florida, College of Pharmacy, Gainesville, FL, USA
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7
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Dixit D, Barbarello Andrews L, Radparvar S, Adams C, Kumar ST, Cardinale M. Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey. Am J Health Syst Pharm 2021; 78:1385-1394. [PMID: 33895793 DOI: 10.1093/ajhp/zxab180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Nearly half of intensive care unit (ICU) patients will develop delirium. Antipsychotics are used routinely for the management of ICU delirium despite limited reliable data supporting this approach. The unwarranted continuation of antipsychotics initiated for ICU delirium is an emerging transitions of care concern, especially considering the adverse event profile of these agents. We sought to evaluate the magnitude of this issue across 6 centers in New Jersey and describe risk factors for continuation. METHODS This multicenter, retrospective study examined adult ICU patients who developed ICU delirium from June 2016 to June 2018. Patients were included in the study if they received at least 3 doses of antipsychotics while in the ICU with presence of either a clinical diagnosis of delirium or a positive Confusion Assessment Method score. Patients were excluded if they were on an antipsychotic before ICU admission. RESULTS Of the 300 patients included and initiated on antipsychotics for ICU delirium, 157 (52.3%) were continued on therapy upon transfer from the ICU to another level of inpatient care. The number of patients continued on newly initiated antipsychotics further increased to 183 (61%) upon discharge from the hospital. CONCLUSION The continuation of antipsychotics for the management of delirium during transitions of care was a common practice across ICUs in New Jersey. Several risk factors for continuation of antipsychotics were identified. Efforts to reduce unnecessary continuation of antipsychotics at transitions of care are warranted.
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Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | - Liza Barbarello Andrews
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | | | - Christopher Adams
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | | | - Maria Cardinale
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
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Marsh J, Alexander E. Update on the Prevention and Treatment of Intensive Care Unit Delirium. AACN Adv Crit Care 2021; 32:5-10. [PMID: 33725100 DOI: 10.4037/aacnacc2021494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Jennifer Marsh
- Jennifer Marsh is a Critical Care Pharmacist, Department of Pharmacy Services, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33601
| | - Earnest Alexander
- Earnest Alexander is Assistant Director, Clinical Pharmacy Services, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
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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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Levine AR, Lemieux SM, D’Aquino D, Tenney A, Pisani M, Ali S. Risk Factors for Continuation of Atypical Antipsychotics at Hospital Discharge in Two Intensive Care Unit Cohorts. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/1179557319863813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Atypical antipsychotics are frequently initiated in the intensive care unit (ICU) to treat delirium. Many patients continue on these agents at hospital discharge despite a lack of data to support long-term use. Objectives: The primary aim of this study was to determine underlying risk factors for continuation of antipsychotics at hospital discharge in medical intensive care unit (MICU) and surgical intensive care unit (SICU) patients when evaluated as separate cohorts. Methods: A single-center, retrospective study in patients newly initiated on quetiapine, risperidone, or olanzapine in a 22-bed mixed medical-surgical ICU admitted from January 2017 to July 2018. Results: A total of 78 (62.9%) MICU patients and 46 (37.1%) SICU patients met the inclusion criteria during this time frame. A total of 29 MICU patients (37.2%) were prescribed antipsychotics at hospital discharge compared to 25 SICU patients (54.3%), P = .063. The percentage of MICU patients prescribed antipsychotics at hospital discharge was significantly higher in patients ⩾60 years of age (22 [75.9%] vs 26 [53.1%], P = .045), with a history of dementia (5 [17.2%] vs 1 [2%], P = .015), admitted with hemorrhagic stroke (5 [17.2%] vs 2 [4.1%], P = .049), and initiated on risperidone (3 [10.3%] vs 0%, P = .022). The risk of pre-existing dementia remained significant in a multivariate logistic regression that controlled for confounding variables, odds ratio (OR) = 10 (95% confidence interval [CI]: 1.11-90.5, P = .040). The percentage of SICU patients prescribed antipsychotics at discharge was significantly higher in those with severe traumatic brain injury (TBI; 8 [72.7%] vs 0%, P = .004) and initiated on quetiapine (19 [76%] vs 9 [42.9%], P = .022). Conclusion: Antipsychotics were commonly continued at hospital discharge in both MICU and SICU patients. Several risk factors for continuation of antipsychotics were identified in these two cohorts. Future efforts assessing the appropriateness of antipsychotics at transitions of care are warranted.
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Affiliation(s)
- Alexander R Levine
- Department of Pharmacy Practice, School of Pharmacy and Physician Assistant Studies, University of Saint Joseph, Hartford, CT, USA
- Department of Pharmacy, Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - Steven M Lemieux
- Department of Pharmacy Practice, School of Pharmacy and Physician Assistant Studies, University of Saint Joseph, Hartford, CT, USA
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Daniela D’Aquino
- School of Pharmacy, University of Saint Joseph, Hartford, CT, USA
| | - Analise Tenney
- School of Pharmacy, University of Saint Joseph, Hartford, CT, USA
| | - Margaret Pisani
- Department of Pulmonary, Critical Care and Sleep Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Syed Ali
- Department of Medicine, Saint Francis Hospital and Medical Center, Hartford, CT, USA
- School of Medicine, University of Connecticut, Farmington, CT, USA
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11
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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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12
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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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Karamchandani K, Schoaps RS, Bonavia A, Prasad A, Quintili A, Lehman EB, Carr ZJ. Continuation of atypical antipsychotic medications in critically ill patients discharged from the hospital: a single-center retrospective analysis. Ther Adv Drug Saf 2018; 10:2042098618809933. [PMID: 31019677 PMCID: PMC6463330 DOI: 10.1177/2042098618809933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 10/03/2018] [Indexed: 11/28/2022] Open
Abstract
Background: Atypical antipsychotics (AAP) have been associated with reduced duration of
delirium in the intensive care setting. However, long-term use of these
drugs is associated with significant adverse events, including increased
all-cause mortality in the elderly. Inappropriate continuation of AAPs after
discharge from the intensive care unit (ICU) is worrisome and needs to be
addressed. The aim of this work was to assess the prevalence of continuation of AAPs
after hospital discharge and evaluate the associated risk factors. Method: This was a single-center retrospective chart analysis in the setting of adult
ICUs at a tertiary care academic medical center. It involved all adult
patients admitted to the ICU and initiated on AAPs from January 2012 to
December 2014. The measurements were: (1) prevalence of ICU-initiated AAP
continuation following hospital discharge, (2) risk factors associated with
continuation of AAPs following hospital discharge, and (3) risk of
continuation of AAPs in patients ⩾65 years of age. Results: A total of 55% of ICU patients initiated on AAPs were discharged from the
hospital with a prescription for continued AAP therapy. Male sex and
discharge location were highly associated with continuation upon discharge.
Older patients (⩾65 years of age) were not at a higher risk of being
continued on these drugs after discharge. Conclusion: Male sex and discharge to a healthcare facility were associated with a higher
rate of continuation. Research into practical methods to reduce their
continuation upon discharge should be performed to mitigate the long-term
risks of AAP administration.
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Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, H187, Penn State Health Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Robert S Schoaps
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Anthony Bonavia
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amit Prasad
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ashley Quintili
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Zyad J Carr
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Owens RL, Huynh TG, Netzer G. Sleep in the Intensive Care Unit in a Model of Family-Centered Care. AACN Adv Crit Care 2018; 28:171-178. [PMID: 28592477 DOI: 10.4037/aacnacc2017393] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The desire for families to be physically present to support their loved ones in the intensive care unit, and guidelines in favor of this open visitation approach, require that clinicians consider both patient and family sleep. This article reviews the causes of poor sleep for patients and their family members in the intensive care unit as well as the expected changes in cognition and emotion that can result from sleep deprivation. Measures are proposed to improve the intensive care unit environment to promote family sleep. A framework to educate family members and engage them in preservation of their and their loved one's circadian rhythm is also presented. Although further research is needed, the proposed framework has the potential to improve outcomes for patients and their families in the intensive care unit.
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Affiliation(s)
- Robert L Owens
- Robert L. Owens is Assistant Professor of Medicine, University of California San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA 92037 . Truong-Giang Huynh is ICU Assistant Nurse Manager, Jacobs Medical Center, University of California, San Diego Health, La Jolla, California. Giora Netzer is Associate Professor of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Truong-Giang Huynh
- Robert L. Owens is Assistant Professor of Medicine, University of California San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA 92037 . Truong-Giang Huynh is ICU Assistant Nurse Manager, Jacobs Medical Center, University of California, San Diego Health, La Jolla, California. Giora Netzer is Associate Professor of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Giora Netzer
- Robert L. Owens is Assistant Professor of Medicine, University of California San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La Jolla, CA 92037 . Truong-Giang Huynh is ICU Assistant Nurse Manager, Jacobs Medical Center, University of California, San Diego Health, La Jolla, California. Giora Netzer is Associate Professor of Medicine and Epidemiology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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15
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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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16
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Knauert MP, Pisani MA. Dexmedetomidine for hyperactive delirium: worth further study. J Thorac Dis 2016; 8:E999-E1002. [PMID: 27747045 DOI: 10.21037/jtd.2016.08.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Melissa P Knauert
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8057, USA
| | - Margaret A Pisani
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8057, USA
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