Inappropriate Discharge on Bronchodilators and Acid-Blocking Medications After ICU Admission: Importance of Medication Reconciliation

Abstract

BACKGROUND: Previous studies suggest that some medications, including proton pump inhibitors and ␤-agonist inhalers, are administered to hospitalized patients and sometimes continued without indications. Medication reconciliation has been offered as one mechanism to reduce the frequency of such medication errors and is now mandated by the Joint Commission (NPSG.03.06.01). We hypothesized that (1) ␤ agonists and acid-blocking medications are prescribed following critical illness without indications, and (2) medication reconciliation can reduce the frequency of inappropriate continuation of these agents. The study was carried out in a 414-bed community teaching hospital affiliated with the University of Connecticut Medical School. All subjects were admitted to the ICU between February and April 2012 (physician-driven reconciliation) and between July and September 2012, just following implementation of pharmacy technician-driven medication reconciliation. This was a retrospective cohort study. METHODS: Medical records of all subjects were reviewed using a uniform data extraction tool. Demographic information, clinical data, in-patient and out-patient medications (before and following hospital discharge), and outcomes were recorded. RESULTS: Prior to pharmacy technician-administered, physician-confirmed medication reconciliation, 253 ICU subjects were compared to 291 subjects admitted to the ICU after initiation of this process. There were no differences in admission type, stay, history of coronary artery disease, requirements for mechanical ventilation, or length of mechanical ventilation between groups. Rates of discharge on bronchodilators (8.9 vs 4.2%, P ‫؍‬ .09) or acid blockers (19.1 vs 11.2%, P ‫؍‬ .05) without clinical indications were lower with pharmacy technician-driven, physician-confirmed medication reconciliation than with routine physician-driven medication reconciliation. Multiple logistic regression analyses demonstrated a significant association of mechanical ventilation with inappropriate discharge on both bronchodilators and acid blockers. Pharmacy technician-driven medication reconciliation tended to reduce these errors. CONCLUSIONS: In our hospital, acid blockers and bronchodilators were often continued inappropriately following critical illness. The specific pharmacy technician-driven method of medication reconciliation deployed in our hospital reduced by half but did not eliminate this medication error.

Impact of a pharmacist intervention at an intensive care rehabilitation clinic

“…In one study, discontinuation of a statin or antiplatelet medication showed an increased risk of death, hospital admission and emergency department visit up to 1 year after hospital discharge 1. Medications commenced in ICU were also found to have been continued unnecessarily which is also consistent with previous studies 4 5…”

“…When patients are critically ill, their chronic drug therapies are frequently withheld in the ICU but are often, inappropriately, not restarted 2 3. Furthermore, new therapies are often commenced, which may be unnecessary in the long term, such as drugs prescribed for stress ulcer prophylaxis and antipsychotics prescribed for delirium 4 5. The care of the complex and dynamic physiology of these patients is made more challenging by frequent transitions in care across the healthcare system, and poor communication at the time of discharge 6 7…”

Antipsychotic utilization in the intensive care unit and in transitions of care

“…Other classes of medications such as acid suppressive agents (proton pump inhibitors, histamine receptor antagonists) and albuterol are continued after discharge from the Intensive Care Unit 3,4 and up to half of potentially inappropriate medications in the elderly on discharge from the hospital were initiated in the ICU. 10 Pronovost and colleagues identified that the transition of care from the Intensive Care Unit to lower levels of care place patients at increased risk for errors in medication therapy.…”

“…Other classes of medications, including inhaled bronchodilators and proton pump inhibitors, are frequently started during hospitalizations and continued following discharge, many times inappropriately 3,4 . When combined with the multitude of other factors that contribute to medication management in transitions of care, high-risk medications such as antipsychotics may also be continued inappropriately.…”

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

“…There have been several studies evaluating medication‐related interventions during these transitions. These interventions included deprescribing of ICU‐initiated medications such bronchodilators, atypical antipsychotics, and stress ulcer prophylaxis, as well as re‐initiation of home medications 9‐12 . Therefore, it is crucial to review patients' medication lists to ensure they are receiving appropriate medications during each transition of care.…”