Pharmacist-driven discontinuation of antipsychotics started for ICU delirium
Stuart M, Martz C, Payter K, McDonnell J, Vinay S, Swiderek J, Coba V, To L, Smith Z, and Peters M. Pharmacist-driven discontinuation of antipsychotics started for ICU delirium. Crit Care Med 2019; 47(1).
Crit Care Med
Learning Objectives: The use of antipsychotics reduces the duration of ICU delirium. Studies have identified that up to 72% of antipsychotics prescribed for delirium are continued at hospital discharge. The purpose of this study was to evaluate the impact of a pharmacist-driven antipsychotic discontinuation protocol on the rate of patients with an antipsychotic continued at hospital discharge. Methods: This was an IRB approved, single-center, quasi-experimental study of patients admitted to the medical, surgical, or cardiac ICU started on antipsychotics for delirium. A protocol was developed for pharmacists to discontinue scheduled antipsychotics started for delirium once delirium had resolved based on CAM-ICU scores or electronic medical record (EMR) documentation. The pre- and post-protocol groups included patients between November 2015 to April 2016 and November 2017 to April 2018, respectively. Patients were excluded if they expired, were made hospice, or the antipsychotic was a home medication or initiated by a psychiatrist. The primary outcome was the rate of antipsychotic continuation at hospital discharge. Secondary outcomes were related to antipsychotic use and adverse events. Categorical data were analyzed using Chi-square or Fisher's exact test and continuous data using Mann Whitney U or T-test. Results: The EMR of 296 and 325 patients were screened in the pre- and post-protocol groups, respectively. A total of 79 patients were included in both groups. There were no differences in baseline demographics including age, gender, ICU type, baseline QTc, ICU length of stay (LOS) or hospital LOS (25 [13, 34] vs. 19 [13, 30] days; p>0.05). There was a significant reduction in the rate of antipsychotics continued at hospital discharge with 26 (32.9%) and 6 (7.6%) patients having therapy continued in the pre- and post- protocol groups, respectively (p<0.001). No differences were noted in antipsychotic continuation upon transfer to floor, QTc prolongation, or recurrence of delirium within 7 days of antipsychotic discontinuation. Conclusions: Implementation of a pharmacist-driven antipsychotic discontinuation protocol for delirium was associated with a significant decrease in antipsychotic continuation at hospital discharge. Future studies are needed to assess antipsychotic discontinuation in the ICU setting.