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

Impact of cardiovascular risk factors and cardiac diseases on mortality in patients with moderate to severe ARDS: A retrospective cohort study

Background

History of coronary artery disease (CAD) and/or atrial fibrillation (AF) and/or valvular replacement (VR) are prevalent among patients admitted to intensive care units (ICUs). The impact of these conditions on outcomes in patients with acute respiratory distress syndrome (ARDS) remains insufficiently explored.

Methods

We performed a retrospective study on prospectively collected data from patients with ARDS and a PaO2/FiO2 ratio ≤150 mmHg. Patients were admitted between January 2006 and March 2022. We used multivariable logistic regression analysis. The primary outcome was 1-year mortality from admission to the ICU; secondary outcomes included mortality at 28 days and 90 days.

Results

Among 1.033 patients, 181 (17.5 %) had a history of CAD and/or AF and/or VR. History of CAD and/or AF and/or VR was independently associated with 1-year mortality (Odds-Ratio (OR) = 2.59, 95 % confidence interval (CI) 1.76-3.82, p < 0.001), with mortality at 90 days (OR = 1.87, 95 % CI 1.27-2.76, p = 0.001), but not with mortality at 28 days (OR = 1.40, 95 % CI 0.93-2.11, p = 0.10). In sensitivity analyses, history of CAD and/or AF and/or VR remained independently associated with 1-year mortality in ICU survivors (OR = 3.58, 95 % CI = 2.41-7.82, p < 0.001).

Conclusions

History of CAD and/or AF and/or VR was associated with mortality in ARDS. Prompt referral to cardiologists for comprehensive management post-ICU discharge may be warranted to optimize outcomes in this vulnerable population.

Association between critical care admission and chronic medication discontinuation post-hospital discharge: A retrospective cohort study

Background: Discontinuation of important chronic medication after hospitalisation is common. This study aimed to investigate the association between critical care (vs non-critical care) admission and discontinuation of chronic medications post-hospital discharge, along with factors associated with discontinuation among critical care survivors. Methods: This was a retrospective cohort study in Lothian, Scotland of adults who were admitted to hospital between 01/01/2012 and 31/12/2019 and survived to hospital discharge. Medication classes investigated were statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs), beta-blockers, oral anticoagulants, and thyroid hormones. The risk of medication discontinuation for each class was estimated by odds ratios (OR), with 95% confidence intervals (95%CI), using multivariable logistic regression adjusted for patient demographics, main clinical condition, and index comorbidity. A secondary analysis assessed factors associated with discontinuation in critical care survivors. Results: There were 22,340 critical care and 367,185 non-critical care survivors included. Critical care admission had the highest association with ACEi/ARBs discontinuation (adjusted OR 2.41, 95%CI: 2.26-2.58), followed by oral anticoagulants (adjusted OR 1.33, 95%CI: 1.15-1.53), and beta blockers (adjusted OR 1.18, 95%CI: 1.07-1.29). There was no significant association with thyroid hormones or statin discontinuation. Among critical care survivors, hospital length of stay of 14 days or more was associated with increased discontinuation across all medication classes. Conclusion: Critical care admission was associated with discontinuation of three out of five medication classes studied (ACEi/ARBs, beta-blockers, and oral anticoagulants). Further research is needed to understand the reason for increased medication discontinuation in critical care survivors and how these risks can be mitigated to improve patient outcomes.

Qualitative Insights Into Patients' and Family Members' Experiences of In-Hospital Medication Management After a Critical Care Episode

Background

Patient recovery after a critical illness can be protracted, requiring a care continuum that extends along a patient pathway from the critical care unit, hospital ward, and into the community care setting. High-quality care on patient transfer from critical care, including medication safety, is facilitated by education for patients and families, family engagement, support systems, and health care professional (HCP)-patient communication. Currently, uncertainty exists regarding how HCPs can and should engage with critical care patients and family members about their medication.

Research Question

What are the views and experiences of critical care patients and family members about their involvement in, communication about, understanding of, and decision-making related to their medication after transfer from critical care to the hospital ward?

Study Design and Methods

This qualitative study used semistructured interviews, conducted with critical care patients and family members after transfer from critical care to a hospital ward in a large National Health Service hospital trust. Anonymized transcripts of interviews were analyzed thematically using a coding framework developed from understandings of patient and family engagement in medication administration.

Results

Twenty-seven participants (15 patients and 12 family members of patients) completed the interviews. We identified five themes and 15 subthemes, providing an overview of patients' and family members' views on medication management during acute illness and ongoing recovery. Themes identified were: impact of acute illness and treatment burden on preexisting illness, preexisting knowledge and capability, beliefs about persons roles and expectations, care continuity and individualized information exchange, and engagement in practice.

Interpretation

This study demonstrated that critical care patients and family members want to engage with HCPs about medication administration. HCPs must take an individualized approach to communication and timing, acknowledging the dynamic interplay between patients and family members, using multimodal forms of communication.