Purpose/Background: The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) recommend against both typical and atypical antipsychotic use for delirium in critically ill patients. This recommendation is based on evidence showing that these medications are not associated with shorter durations of delirium, mechanical ventilation, intensive care unit (ICU) length of stay, or reduced mortality. There are many long term complications associated with the use of antipsychotics including QTc prolongation, extrapyramidal symptoms, metabolic abnormalities, and anticholinergic effects. Regardless, antipsychotics remain the most common medication used to treat ICU related delirium. Unspecified treatment durations lead to inappropriate continuation of anti-psychotics post-ICU admission. This project was designed to evaluate antipsychotic continuation across the continuum of care at a community hospital.
Methods: This project was a single-center, retrospective chart review of all patients who were initiated on a new-start antipsychotic for the treatment of ICU associated delirium. Patients were excluded if the antipsychotic was ordered as a “one-time” or “as needed” dose. Patients were also excluded if they were on an antipsychotic prior to hospital or ICU admission. Pregnant patients as well as those that did not survive to hospital discharge were not included. From the electronic medical record, patient age, sex, and primary diagnosis were all documented. Additional data collected included dose, frequency, and identity of the antipsychotic ordered, the name of the ordering physician, CAM-ICU scores on ICU admission, date of medication initiation, date of ICU discharge, date of antipsychotic discontinuation if applicable, ICU length of stay, and date of antipsychotic initiation. The primary endpoint was the percentage of patients prescribed a new-start, standing antipsychotic in the ICU that was continued post-hospital discharge based on the discharge medication reconciliation and discharge summary.
Results: Seventy-six patients were included in this study, 67 (88%) of which were newly initiated on quetiapine in the ICU. The remaining 9 patients were started on either risperidone or olanzapine. Of the 76 patients initiated on an antipsychotic agent in the ICU setting, 62 (82%) were continued post-ICU discharge. A large portion of these patients, 37 (49%), were continued on an antipsychotic at hospital discharge. Confusion Assessment Method for the ICU (CAM-ICU) scores were documented for 63 (83%) of patients however 0 (0%) had a positive result.
Discussion: Antipsychotic-naïve patients who are initiated on an antipsychotic in the ICU are continued on this agent at a rate of 49% at hospital discharge. Patients started on these medications are commonly on prolonged courses of sedation. Antipsychotic initiation and discontinuation did not correlate with CAM-ICU scores. Pharmacists can play a role in following patients across the continuum of care to ensure unnecessary medications are discontinued prior to discharge.
2019 ASHP Midyear Clinical Meeting
Michael Pasqualicchio - Pharmacy Resident PGY2
Pasqualicchio, Michael and Clarke, Heidi, "Evaluating Antipsychotic Prescribing in the Intensive Care Unit and Across the Continuum of Care" (2019). All Publications. 3536.
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