Evaluating Antipsychotic Prescribing in the Intensive Care Unit and Across the Continuum of Care

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

Evaluation of an elevated VTE thromboprophylaxis guideline for critically ill patients infected with COVID-19

Retrospective studies and systematic-review meta-analysis have shown an association in inducing a prothrombotic state in patients infected with COVID-19. The risk of VTE are compounded in the critically ill. Current practices at Baptist Hospital of Miami (BHM) is to routinely order standard prophylactic dosed chemical thromboprophylaxis for all patients infected with COVID-19. In August 2020 an anticoagulation guidance document was approved to tailor anticoagulation dosing for critically ill COVID-19 patients. At risk patients were based on clinical and laboratory markers such as D-dimer, CRP, and ferritin. Following implementation, our analysis show a statistically significant reduction in the number of treatment dose anticoagulation used within the intensive care units and a statistically significant increase in the number of intermediate intensity anticoagulation ordered. The rate of bleeding was similar before and after implementation, and the rate of venous thromboembolism no statistical difference with a relative risk (RR) of 1.88 (95% CI 0.78 to 4.50). However given the high frequency of VTE further evaluation is underway. Additionally, pending peer review, the REMAP-CAP, ATTACC, and ACTIV-4A is expected to guide clinical practice in the prevention of COVID-19 associated VTE

Evaluation of pharmacist intervention on spontaneous awakening trials (SAT) in ventilated patients

Background: Intensive care unit (ICU) patients regularly require the use of continuous sedation to decrease stress associated with mechanical ventilation, agitation, and overall discomfort. Due to the increased risk of complications associated with prolonged mechanical ventilation & sedation such as oversedation, ventilator-induced lung injury, and extended ICU length of stay, protocols have been developed to ensure spontaneous awakening (SATs) are routinely performed. Despite guideline recommendations, these are often not conducted at the recommended frequency and may not be appropriately conducted across multidisciplinary teams. Literature has demonstrated the clinical benefit of pharmacist involvement in SAT performance including a trend towards shorter weaning times, reduced rates of ventilator-related infections and other medication-related adverse events. The goal of this project is to determine the impact of pharmacist involvement on adherence to a nursing-driven protocol for performance of SATs. Methods: This is a multi-center, IRB-reviewed bi-phasic study of mechanically ventilated patients requiring continuous intravenous (IV) sedation or analgesia with midazolam, propofol, or fentanyl. A random sample of patients on continuous IV sedation was reviewed retrospectively. The prospective phase of this study consisted of ICU pharmacists providing recommendations for performance of SATs on qualifying patients over a 6-month period. The primary outcome was SAT compliance and the number and type of pharmacist interventions. Secondary outcomes included total days of mechanical ventilation and ICU length of stay. Results: A retrospective analysis of 37 patients showed 57% (21/37) of those who met criteria had a SAT conducted. Prospectively, pharmacists provided a total of 86 interventions in a 6-month period. Fifty-nine interventions were recommendations to perform a SAT and 27 interventions focused on providing education on how to properly conduct SATs. The overall acceptance rate of pharmacist interventions was 73.3%. Of the 59 patients who met criteria for a SAT, 69% (41/59) had a SAT conducted following pharmacist intervention (p=0.2). Median duration of ICU length of stay decreased from 11.42 days to 11.1 days (p=0.17) and median duration of mechanical ventilation increased from 8 days to 9 days (p=0.53). Conclusion: Pharmacist intervention through a multidisciplinary approach resulted in a greater percentage of daily spontaneous awakening trials performed in qualifying patients

Evaluating the Association Between Vasopressin Use and In-Hospital Mortality in Patients with Septic Shock

Purpose/Background: The Surviving Sepsis Campaign recommends norepinephrine as the first-line vasopressor in patients with septic shock to maintain a mean arterial pressure (MAP) of at least 65 mmHg. The guideline also makes a weak recommendation (2B) to use vasopressin as an adjuvant therapy to raise MAP to goal or to reduce the norepinephrine rate required to maintain the goal MAP. The recommendation is based on conflicting results of the VASST trial that showed no significant difference in 28-day all-cause mortality between patients managed with norepinephrine alone compared to norepinephrine and vasopressin. However, in subgroup analysis, the VASST trial showed mortality benefit for vasopressin in patients requiring low dose norepinephrine (5-14 mcg/min). This study will evaluate outcomes associated with the use of vasopressin in septic shock in order to validate a future protocol optimizing its utilization. Methods: A retrospective chart review conducted at Baptist Hospital of Miami. Patients admitted from January 2018 to September 2018 with septic shock were divided into two arms based on their maximum norepinephrine equivalent rate or the norepinephrine equivalent rate at the time of vasopressin initiation. Norepinephrine equivalent rates were calculated using the equation from the VASST trial. The threshold for assignment in the severe septic shock arm was a rate greater than 0.2 mcg/kg/minute. Within each arm, patients who were administered vasopressin were compared to those who were not. Pregnant patients as well as those diagnosed with cardiogenic shock or with cardiothoracic surgery during the specific admission were excluded. Patients were also excluded if they were administered vasopressor therapy for less than 12 hours total. The primary outcome was to evaluate the in-hospital mortality in patients with both less severe and severe septic shock who were treated with vasopressin. Secondary outcomes included total time on vasopressors, number of catecholamine agents required, and length of stay. Additional data collected included age, sex, weight, APACHE II score, SOFA score, lactic acid, MAP, norepinephrine equivalent dose at time of inclusion, steroid prescribing rates, midodrine prescribing rates, time to vasopressin initiation, and duration of vasopressin administration. Results: Of the 147 patients included, 53 were included in the low-dose vasopressor or less severe septic shock arm and 94 were included in the high-dose vasopressor or severe septic shock arm. For the patients in the less severe arm, 20 (38%) received vasopressin. Mean SOFA score at the time of inclusion was similar between those receiving vasopressin and those not, 7.9 and 8.1 respectively. Of the patients who received vasopressin on low-dose vasopressors, 7 (35%) expired prior to hospital discharge. This is compared to an in-hospital mortality of 6 (18%) among patients not administered vasopressin (p=0.17). The median time on vasopressors was 75 hours for patients receiving vasopressin compared to 33.4 hours for patients not administered vasopressin. For the patients in the high-dose vasopressor arm, 48 (51%) received vasopressin. Of the patients who received vasopressin with severe septic shock, 34 (70%) expired prior to hospital discharge. This is compared to an in-hospital mortality of 20 (44%) among patients not administered vasopressin (p=0.007). The median duration of vasopressor therapy was similar in each group, 76.5 hours for patients receiving vasopressin versus 74.2 hours for patients not administered vasopressin. Midodrine and steroid use was similar between groups in both arms. Discussion: Vasopressin did not result in in-hospital mortality benefit for patients with less severe or severe septic shock. Vasopressin was not associated with shorter durations of vasopressor therapy. Based on the results of this study, efforts can be made to optimize vasopressin utilization in patients with septic shock in order to maximize cost-effectiveness and clinical benefit. Future studies are required to further evaluate vasopressin use in patients with less severe septic shock

Evaluation of Antiplatelet-Related Bleeding Events in a Community Hospital

Background:Bleeding rate among patients who take high-dose aspirin is approximately 1.92% with an expected 2-3 fold increase after a second antiplatelet is added. Similarly, the addition of an anticoagulant to single or dual antiplatelet therapy results in increased bleeding rates of approximately 13.9% and 15.7% respectively. The concomitant use of antiplatelets and anticoagulants has become a common practice due to the high incidence of clinical conditions for which these agents are used. Hence, reversal of antithrombotic agents is often needed during major bleeding events or invasive procedures. However, the use of antiplatelet reversal is still under-utilized, and its efficacy on patient outcomes remains to be tested. The purpose of this project is to assess the incidence of bleeding, reversal strategies, mortality rates, and thrombotic events in patients with a major bleeding event receiving antiplatelets with or without concomitant anticoagulants. Methods: A retrospective chart review was conducted over a one-year period. Patients 18 years and older taking an antiplatelet excluding low dose aspirin alone at the time of the major bleeding event were included in the study. A major bleeding event was defined as bleeding into a critical area/organ, fall in hemoglobin of ≥ 20 g/L, or transfusion of \u3e 2 units of blood. Subjects were divided into two groups: intracranial and non-intracranial hemorrhage. Patient outcomes will be analyzed based on bleeding severity, causative agents, and reversal strategies utilized. Results: We identified 21 patients with ICH and 38 with Non-ICH. Bleeding rates among patients who had a major bleeding event were as follows: 12.4% of patients on antiplatelet therapy, 2.4% on APT monotherapy, 5.4% on DAPT, and 4% on APT plus an anticoagulant. A reversal strategy was utilized 68% of the time for the reversal of antiplatelets in the setting of an ICH compared to 18% in the Non-ICH group. Our findings suggest that mortality, readmission, and thrombotic events are not affected by bleeding severity or reversal strategy utilized. Discussion: Antiplatelet therapy with or without anticoagulation could increase the risk for a major bleeding event. At Baptist Hospital of Miami, antiplatelet reversal is conducted in accordance with current societal guideline recommendations. However, there is opportunity for improvement in the reversal of antiplatelet agents when utilized concomitantly with an anticoagulant

Optimization of albumin 5% use in a community hospital

Background: The debate surrounding the use of crystalloids versus colloids remains a source of controversy due to limited and conflicting evidence. Emerging data favors the use of crystalloids over colloids in addition to cost benefits. Baptist Hospital of Miami (BHM) has evidence-based guidance for albumin 5%, but it is unclear the degree of appropriate usage. The purpose of this study is to assess the prescribing practices of albumin 5% at BHM and optimize appropriate use through pharmacy driven interventions. Methodology: A single-center, IRB-reviewed, bi-phasic study was conducted within a community hospital. In phase I, a retrospective chart review of patients who received albumin 5% during 2019 was conducted to evaluate prescribing patterns. Phase II was performed after pharmacy driven education was completed to increase appropriate use. A pharmacist was on-call for the prospective chart review to assess appropriateness of albumin 5% orders in patients who met inclusion criteria. The primary outcome is the comparison of appropriate usage of albumin 5% before and after education. Secondary outcomes include pharmacist interventions and the financial impact. Results: After implementation of the albumin 5% stewardship initiative, inappropriate use of albumin 5% was decreased significantly by 54%. Through the 30-day interventional phase, a total of 13 pharmacy interventions were performed with 100% acceptance rate including optimization of crystalloid resuscitation or discontinuation of fluids completely. These interventions along with provider education resulted in at least 72 albumin 5% doses avoided during the phase II study period, which amounts to an extrapolated annual cost savings of ~ $32,400. Conclusion: Introduction of evidence-based guidance in conjugation with prospective pharmacist review and intervention can facilitate the optimization of albumin 5% use. These results demonstrate shifting towards a more evidence-based practice, which ultimately will increase patient’s safety and enhance quality of care