BackgroundAntipsychotics are used to treat delirium in the intensive care unit (ICU) despite unproven efficacy. We hypothesized that atypical antipsychotic treatment in the ICU is a risk factor for antipsychotic prescription at discharge, a practice that might increase risk since long-term use is associated with increased mortality.MethodsAfter excluding patients on antipsychotics prior to admission, we examined antipsychotic use in a prospective cohort of ICU patients with acute respiratory failure and/or shock. We collected data on medication use from medical records and assessed patients for delirium using the Confusion Assessment Method for the ICU. Using multivariable logistic regression, we analyzed whether age, delirium duration, atypical antipsychotic use, and discharge disposition (each selected a priori) were independent risk factors for discharge on an antipsychotic. We also examined admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, haloperidol use, and days of benzodiazepine use in post hoc analyses.ResultsAfter excluding 18 patients due to prior antipsychotic use and three who withdrew, we included 500 patients. Among 208 (42%) treated with an antipsychotic, median (interquartile range) age was 59 (49–69) years and APACHE II score was 26 (22–32), characteristics that were similar among antipsychotic nonusers. Antipsychotic users were more likely than nonusers to have had delirium (93% vs. 61%, p < 0.001). Of the 208 antipsychotic users, 172 survived to hospital discharge, and 42 (24%) of these were prescribed an antipsychotic at discharge. Treatment with an atypical antipsychotic was the only independent risk factor for antipsychotic prescription at discharge (odds ratio 17.6, 95% confidence interval 4.9 to 63.3; p < 0.001). Neither age, delirium duration, nor discharge disposition were risk factors (p = 0.11, 0.38, and 0.12, respectively) in the primary regression model, and post hoc analyses found APACHE II (p = 0.07), haloperidol use (p = 0.16), and days of benzodiazepine use (p = 0.31) were also not risk factors for discharge on an antipsychotic.ConclusionsIn this study, antipsychotics were used to treat nearly half of all antipsychotic-naïve ICU patients and were prescribed at discharge to 24% of antipsychotic-treated patients. Treatment with an atypical antipsychotic greatly increased the odds of discharge with an antipsychotic prescription, a practice that should be examined carefully during medication reconciliation since these drugs carry “black box warnings” regarding long-term use.
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose This report describes a health-system pharmacy’s response to a natural disaster while staff members simultaneously prepared for the coronavirus disease 2019 (COVID-19) pandemic. By detailing our experience, we hope to help other institutions that are current facing or could encounter similar crises. Summary In early March 2020, a tornado destroyed the health system’s warehouse for storage of most clinical supplies, including personal protective equipment and fluids. The pharmacy purchasing team collaborated with suppliers and manufacturers to recover losses and establish alternative storage areas. Days later, the pharmacy department was forced to address the impending COVID-19 pandemic. Key elements of the COVID-19 response included reducing the potential for patient and staff virus exposure; overcoming challenges in sourcing of staff, personal protective equipment, and medications; and changing care delivery practices to maintain high-quality patient care while maximizing social distancing. The pharmacy department also created distance learning opportunities for 70 pharmacy students on rotations. After an initial plan, ongoing needs include adjustment in patient care activities if significant staff losses occur, when and how to resume clinical activities, and how to best utilize the resources accumulated. Elements of practice changes implemented to reduce COVID-19 threats to patients and pharmacy personnel have proven beneficial and will be further evaluated for potential continuation. Conclusion The pharmacy department’s efforts to respond to a natural disaster and unprecedented pandemic have proven successful to this point and have illuminated several lessons, including the necessity of cohesive department communication, staff flexibility, prioritization of teamwork, and external collaboration.
compare the relative efficacy, safety and cost of iNO versus iEPO in patients with acute PHT following cardiac surgery. Methods: This study was an IRBapproved, single-center, retrospective, observational, comparative trial of adult patients with acute PHT treated with either iNO or iEPO following cardiac surgery. The primary outcome was the normalization of mean pulmonary artery pressure (MPAP) to < 30 mmHg 6 hours after ICU admission. Secondary outcomes, included: ICU and hospital length of stay (LOS), duration of mechanical ventilation, adverse events, in-hospital mortality, and cost. Results: A total of 49 patients who received iEPO between December 2012 and December 2013 met inclusion criteria. These patients were compared to a historical cohort of 49 patients who received iNO following cardiac surgery. A majority of patients in both groups underwent valve surgery (iNO 47% vs. iEPO 59%; p=0.31). Median duration of treatment with iNO was 22 hours versus 18.5 hours in the iEPO group (p=0.2). There was no difference in the primary outcome of normalization of MPAP to < 30 mmHg 6 hours after ICU admission (iNO 67% vs. iEPO 71%; p=0.83) or in the incidence of any adverse event occurring in either group (iNO 20% vs. iEPO 22%; p=1.00). At our institution, the median cost of iEPO per patient was $332.45 versus $2750.00 for iNO (p<0.01). Conclusions: There was no difference in the relative efficacy or incidence of adverse events with iEPO when compared to iNO in patients with acute PHT following cardiac surgery. There was, however, significant cost savings associated with the use of iEPO at our institution.
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