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

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.

New antipsychotic prescription and recurrent infections among adult sepsis survivors: A population‐based cohort study

“…For instance, delirium during ICU admission is independently associated with a higher mortality risk 1 and may prompt haloperidol treatment. 4 Conversely, sleep disorders are other conditions in which providers may consider to initiate antipsychotics, 4 using sedative anticholinergic agents such as quetiapine. 14 Since our study did not capture these initial triggers for antipsychotic use, residual confounding due to imbalanced baseline prognosis may explain the differences observed between groups for the composite outcome.…”

“…We used a composite outcome to account for such differential risk; however, the higher risk of the composite outcome may be explained by a true effect of high‐affinity agents or dissimilar indications and underlying prognosis. For instance, delirium during ICU admission is independently associated with a higher mortality risk 1 and may prompt haloperidol treatment 4 . Conversely, sleep disorders are other conditions in which providers may consider to initiate antipsychotics, 4 using sedative anticholinergic agents such as quetiapine 14 .…”

“…2,3 In Canada, patient and staff safety, management of agitation, sleep disorders and sedation were identified as triggers of antipsychotic treatment in such setting. 4 Antipsychotics have been associated with higher rates of infection (e.g., pneumonia). 5 For example, several studies have reported a higher pneumonia risk with high-D 2 affinity antipsychotics (i.e., haloperidol) in patients with Parkinson's disease 6 and in older patients.…”

“…A fraction of patients are initiated on antipsychotics during critical illness (including sepsis‐ and infection‐related hospitalizations), which are sometimes continued after discharge 2,3 . In Canada, patient and staff safety, management of agitation, sleep disorders and sedation were identified as triggers of antipsychotic treatment in such setting 4 . Antipsychotics have been associated with higher rates of infection (e.g., pneumonia) 5 .…”

Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review

“…Both doctors and nurses reported they chose to use antipsychotics in anticipation that behavioural symptoms could escalate [ 13 ]. In a similar study, interviews with 21 physicians, nurses and pharmacists in an ICU in Canada also found that reasons given for antipsychotic use were to ensure patient and staff safety, promote sleep and settle patients when staffing was inadequate, and workloads were high [ 14 ]. International guidelines allow for antipsychotic use when safety is a concern and non-pharmacological strategies have not been effective.…”