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Diseroad ER, Minnick S, Hutson TK. Assessment of intensive care unit delirium in developmentally delayed children. Pediatr Res 2024:10.1038/s41390-024-03529-1. [PMID: 39210052 DOI: 10.1038/s41390-024-03529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 08/14/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
Pediatric intensive care unit (ICU) delirium is an increasingly common diagnosis with negative impacts on morbidity and mortality. Patients with developmental delay are particularly susceptible to developing ICU delirium due to possible cerebral disease, sensory loss, unfamiliar environment, or use of deliriogenic medications. Of the existing scoring tools to assess for ICU delirium, few have been evaluated for patients with developmental delay. This review highlights the literature investigating measures of accuracy of ICU delirium scoring tools in pediatric patients, potential impact of developmental delay on successfully diagnosing delirium, and future directions for this area of care. IMPACT: This article summarizes pediatric intensive care unit (ICU) delirium, delirium screening tools, and developmental delay. This article highlights the limitations to current ICU delirium screening tools in patients with developmental delay and highlights future directions for the field.
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Affiliation(s)
- Emily R Diseroad
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Samantha Minnick
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tamara Kay Hutson
- Department of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Harrison S, Capers K, Chen G, Liu JT, Pannu A, Goodspeed V, Leibowitz A, Bose S. New initiation of opioids, benzodiazepines and antipsychotics following hospitalization for COVID-19. J Hosp Med 2024. [PMID: 38742528 DOI: 10.1002/jhm.13408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Patients newly initiated on opioids (OP), benzodiazepines (BZD), and antipsychotics (AP) during hospitalization are often prescribed these on discharge. Implications of this practice on outcomes remains unexplored. OBJECTIVE To explore the prevalence and risk factors of new initiation of select OP, BZD and AP among patients requiring in-patient stays. Test the hypothesis that new prescriptions are associated with higher odds of readmission or death within 28 days of discharge. DESIGN Single center retrospective cohort study. SETTING AND PARTICIPANTS Patients admitted to a tertiary-level medical center with either a primary diagnosis of RT-PCR positive for COVID-19 or high index of clinical suspicion thereof. INTERVENTION None. MAIN OUTCOME AND MEASURES Exposure was the new initiation of select common OP, BZD, and AP which were continued on hospital discharge. Outcome was a composite of 28-day readmission or death following index admission. Multivariable logistic regression was used to assess patient mortality or readmission within 28 days of discharge associated with new prescriptions at discharge. RESULTS One thousand three hundred and nineteen patients were included in the analysis. 11.3% (149/1319) were discharged with a new prescription of select OP, BZD, or AP either alone or in combination. OP (110/149) were most prescribed followed by BZD (41/149) and AP (22/149). After adjusting for unbalanced confounders, new prescriptions (adjusted odds ratio: 2.44, 95% confidence interval: 1.42-4.12; p = .001) were associated with readmission or death within 28 days of discharge. One in nine patients admitted with a diagnosis of COVID-19 or high clinical suspicion thereof were discharged with a new prescription of either OP, BZD or AP. New prescriptions were associated with higher odds of 28-day readmission or death. Strengthening medication reconciliation processes focused on these classes may reduce avoidable harm.
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Affiliation(s)
- Samantha Harrison
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Krystal Capers
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Guanqing Chen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Ji T Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Valerie Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
| | - Akiva Leibowitz
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Center for Anesthesia Research Excellence (CARE), Boston, Massachusetts, USA
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Short A, McPeake J, Andonovic M, McFee S, Quasim T, Leyland A, Shaw M, Iwashyna T, MacTavish P. Medication-related problems in critical care survivors: a systematic review. Eur J Hosp Pharm 2023; 30:250-256. [PMID: 37142386 PMCID: PMC10447966 DOI: 10.1136/ejhpharm-2023-003715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES There are numerous, often single centre discussions of assorted medication-related problems after hospital discharge in patients who survive critical illness. However, there has been little synthesis of the incidence of medication-related problems, the classes of medications most often studied, the factors that are associated with greater patient risk of such problems or interventions that can prevent them. METHODS We undertook a systematic review to understand medication management and medication problems in critical care survivors in the hospital discharge period. We searched OVID Medline, Embase, PsychINFO, CINAHL and the Cochrane database (2001-2022). Two reviewers independently screened publications to identify studies that examined medication management at hospital discharge or thereafter in critical care survivors. We included randomised and non-randomised studies. We extracted data independently and in duplicate. Data extracted included medication type, medication-related problems and frequency of medication issues, alongside demographics such as study setting. Cohort study quality was assessed using the Newcastle Ottowa Score checklist. Data were analysed across medication categories. RESULTS The database search initially retrieved 1180 studies; following the removal of duplicates and studies which did not fit the inclusion criteria, 47 papers were included. The quality of studies included varied. The outcomes measured and the timepoints at which data were captured also varied, which impacted the quality of data synthesis. Across the studies included, we found that as many as 80% of critically ill patients experienced medication-related problems in the posthospital discharge period. These issues included inappropriate continuation of newly prescribed drugs such as antipsychotics, gastrointestinal prophylaxis and analgesic medications, as well as inappropriate discontinuation of chronic disease medications, such as secondary prevention cardiac drugs. CONCLUSIONS Following critical illness, a high proportion of patients experience problems with their medications. These changes were present across multiple health systems. Further research is required to understand optimal medicine management across the full recovery trajectory of critical illness. PROSPERO REGISTRATION NUMBER CRD42021255975.
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Affiliation(s)
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Mark Andonovic
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Tozer T, MacKenzie M, Burgess S, Loubani O, Neville H. Opioid and Sedative Coprescription: Prescribing Patterns after an ICU Admission. Can J Hosp Pharm 2023; 76:29-39. [PMID: 36683658 PMCID: PMC9817220 DOI: 10.4212/cjhp.3245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Opioid misuse constitutes a health care crisis in Canada, and coprescription of opioids with sedatives has been associated with adverse events. Opioids and sedatives are frequently administered in the intensive care unit (ICU). The rate of continuation of opioid-sedative combinations after an ICU admission at the study institution was unknown. Objectives To determine the rates of opioid and sedative coprescriptions following an ICU admission and to identify factors associated with continuation of hospital-initiated opioid-sedative coprescriptions at ICU transfer and hospital discharge. Methods This retrospective chart review involved patients admitted to ICUs at a tertiary care centre between April 1, 2018, and March 31, 2019. Baseline characteristics were obtained from a clinical database and medication information from medication reconciliation forms. An opioid coprescription was defined as prescription of an opioid in combination with a sedative (benzodiazepine, z-drug, gabapentinoid, tricyclic antidepressant, or antipsychotic), and hospital-initiated coprescriptions encompassed various predefined scenarios of therapy started or modified before ICU transfer. Factors associated with hospital-initiated opioid coprescription were analyzed by multivariable logistic regression. Results A total of 735 patients met the inclusion criteria. At ICU transfer, 23.0% (169/735) of the patients had an opioid coprescription, and 87.0% (147/169) of these coprescriptions were hospital-initiated. At hospital discharge, 8.6% (44/514) of the patients had an opioid coprescription, and 56.8% (25/44) of these coprescriptions were hospital-initiated. Male sex, home opioid coprescription, surgical patient, prolonged hospital stay, and in-hospital death were significantly associated with hospital-initiated opioid coprescription at the time of ICU transfer. Home opioid coprescription was significantly associated with opioid coprescription at the time of hospital discharge. Conclusions Hospital-initiated opioid coprescriptions accounted for the majority of opioid coprescriptions at ICU transfer and hospital discharge. Pharmacists should assess all opioid coprescriptions to determine whether discontinuation and/or dose reduction is appropriate.
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Tollinche LE, Seier KP, Yang G, Tan KS, Tayban YD, Pastores SM, Yeoh CB, Karamchandani K. Discharge prescribing of enteral opioids in opioid naïve patients following non-surgical intensive care: A retrospective cohort study. J Crit Care 2021; 68:16-21. [PMID: 34856489 DOI: 10.1016/j.jcrc.2021.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/13/2021] [Accepted: 10/23/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To estimate the incidence of new prescription of enteral opioids on hospital discharge in opioid naïve, non-surgical, critically ill patients and evaluate the risk factors associated with such occurrence. METHODS Using hospital-wide and ICU databases, we retrospectively identified all patients (≥ 18 years old) who were admitted to the 20-bed adult ICU of Memorial Sloan Kettering Cancer Center (MSKCC) between July 1, 2015 and April 20, 2020. Patients' electronic medical records (EMR) were retrieved and patient demographics, peri-ICU admission data were captured and analyzed. RESULTS During the study period, a total of 3755 opioid naïve patients were admitted to the ICU and 848 patients met the inclusion criteria. Among these, 346 (40.8%) patients were discharged with a new opioid prescription. Age at ICU admission, preadmission use of benzodiazepine, and antidepressants, a diagnosis of sepsis, and use of mechanical ventilation, antidepressants or, opioid infusion for greater than 4 h during the ICU stay, hospital length of stay (LOS), and days between ICU discharge and hospital discharge were independently associated with increased odds of a new opioid prescription. CONCLUSIONS A significant proportion of opioid naïve non-surgical ICU survivors receive a new opioid prescription on hospital discharge.
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Affiliation(s)
| | - Kenneth P Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, USA.
| | - Gloria Yang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, USA.
| | - Yekaterina D Tayban
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Cindy B Yeoh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, USA.
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, UT Southwestern Medical Center, USA.
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Schmidt LE, Patel S, Stollings JL. The pharmacist's role in implementation of the ABCDEF bundle into clinical practice. Am J Health Syst Pharm 2021; 77:1751-1762. [PMID: 32789461 DOI: 10.1093/ajhp/zxaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. SUMMARY Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. CONCLUSIONS Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.
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Affiliation(s)
- Lauren E Schmidt
- Department of Pharmacy, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Sneha Patel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.,Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
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Dixit D, Barbarello Andrews L, Radparvar S, Adams C, Kumar ST, Cardinale M. Descriptive analysis of the unwarranted continuation of antipsychotics for the management of ICU delirium during transitions of care: A multicenter evaluation across New Jersey. Am J Health Syst Pharm 2021; 78:1385-1394. [PMID: 33895793 DOI: 10.1093/ajhp/zxab180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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.
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Affiliation(s)
- Deepali Dixit
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | - Liza Barbarello Andrews
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | | | - Christopher Adams
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
| | | | - Maria Cardinale
- Ernest Mario School of Pharmacy, Rutgers,The State University of New Jersey, Piscataway, NJ,USA
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Lambert J, Vermassen J, Fierens J, Peperstraete H, Petrovic M, Colpaert K. Discharge from hospital with newly administered antipsychotics after intensive care unit delirium - Incidence and contributing factors. J Crit Care 2020; 61:162-167. [PMID: 33171333 DOI: 10.1016/j.jcrc.2020.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Delirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium. METHODS This retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation. RESULTS A total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37-6.41]) and quetiapine treatment (5.81 [1.63-20.83]) were independently associated with antipsychotic continuation at hospital discharge. CONCLUSIONS Approximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.
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Affiliation(s)
- Johannes Lambert
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B9000 Ghent, Belgium.
| | - Joris Vermassen
- Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Jan Fierens
- Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Harlinde Peperstraete
- Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
| | - Kirsten Colpaert
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B9000 Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium
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Mohammad RA, Betthauser KD, Korona RB, Coe AB, Kolpek JH, Fritschle AC, Jagow B, Kenes M, MacTavish P, Slampak‐Cindric AA, Whitten JA, Jones C, Simonelli R, Rowlands I, Stollings JL. Clinical pharmacist services within intensive care unit recovery clinics: An opinion of the critical care practice and research network of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Rima A. Mohammad
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Kevin D. Betthauser
- Department of Pharmacy Services Barnes‐Jewish Hospital Saint Louis Missouri USA
| | | | - Antoinette B. Coe
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | | | | | - Benjamin Jagow
- Department of Pharmacy MercyOne Des Moines Medical Center Des Moines Iowa USA
| | - Michael Kenes
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | | | | | | | - Carol Jones
- Department of Pharmacy Guy's and St. Thomas' NHS Foundation Trust London UK
| | | | - Ian Rowlands
- Department of Pharmacy Barts Health NHS Trust London UK
| | - Joanna L. Stollings
- Department of Pharmacy and Critical Illness Brain Dysfunction, Survivorship (CIBS) Center, Vanderbilt University Medical Center Nashville Tennessee USA
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