Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey

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.

Pharmacist‐led intervention to reduce inappropriate continuation of targeted medications initiated in the acute care setting at hospital and ICU discharge

“…The most commonly implicated medications include antipsychotics and acid-suppressive therapies. [1][2][3][4][5] A multicenter, prospective cohort study demonstrated that 24% of patients treated with antipsychotics in the ICU were prescribed one at discharge. 1 Several other studies have demonstrated the inappropriate continuation of antipsychotics initiated in the ICU upon discharge to the floor and ultimately hospital discharge with prescribing rates ranging from approximately 26% to 84% and 29% to 61%, respectively.…”

“…1 Several other studies have demonstrated the inappropriate continuation of antipsychotics initiated in the ICU upon discharge to the floor and ultimately hospital discharge with prescribing rates ranging from approximately 26% to 84% and 29% to 61%, respectively. [2][3][4] Additionally, Wohlt and colleagues demonstrated that 60% of patients were inappropriately continued on an acidsuppressive agent at ICU discharge and 24.4% at hospital discharge. 5 Inappropriate continuation of these medications may lead to an increased risk of adverse effects and greater healthcare-related costs.…”

Medication-related problems in critical care survivors: a systematic review

“…Fourteen studies examined the use of psychotropic medications in survivors of critical care (online supplemental file S3, table 3). 33–46 Drugs included were antipsychotic and anxiolytic agents alongside antidepressants. Twelve studies examined psychotropic medications use in critical care survivors at hospital discharge;34–45 one study examined their use up to 180 days following hospital discharge33 and the final study examined the use of these medications up to 1 year posthospital discharge 46…”

“…Across the studies, in those patients prescribed psychotropic medications during admission, there was wide variation in the continued use of these drugs at hospital discharge (range 10.30–61%), although the appropriateness of this continued use was difficult to assess across the studies 34–45. Four studies gave details on the prescription appropriateness at hospital discharge; one single centre US study found 54 of their cohort of 161 patients (34%) had been continued on antipsychotics or anxiolytics at hospital discharge, with no patient having a documented reason for their use 37.…”

“…Another VA registry study in the US also found that patients with a diagnosis of sepsis were more likely to be continued on antipsychotics in the posthospital discharge phase (up to 180 days) 45. Seven studies found critical illness specific variables, such as ICU length of stay, severity of illness and the type of admission were risk factors for the continuation of psychotropic medications 34 35 38 40–42 44…”