title: Impact of an Antipsychotic Discontinuation Bundle During Transitions of Care in Critically Ill Patients.
abstract: Delirium affects a large proportion of patients admitted to the intensive care unit (ICU) and is associated with increased morbidity and mortality. Antipsychotics have become frequently used agents for the treatment of delirium; however, they are often continued at transitions of care. This has potential negative short- and long-term health consequences that are preventable. We investigated the antipsychotic tapering bundle's impact on the rate of antipsychotic continuation at transitions from the medical intensive care unit (MICU).
  This was a preretrospective and postretrospective chart review that included adult patients in the MICU initiated on antipsychotic therapy for ICU delirium. A bundled multidisciplinary education program and antipsychotic discontinuation algorithm were implemented in the MICU to provide recommendations for safe and effective use of antipsychotics for ICU delirium and minimize continuation of therapy at transitions of care. Rates of antipsychotic continuation at transition from the MICU were compared between the preintervention and postintervention groups with the χ2test.
  A total of 140 patients in the prebundle group and 141 patients in the postbundle group were enrolled. Overall, baseline characteristics were similar. After implementation of the discontinuation bundle, antipsychotic continuation at MICU discharge decreased (27.9% in the prebundle group vs 17.7% in the postbundle group; P < .05). In the multivariate analysis, patients were less likely to be continued on antipsychotic therapy at MICU discharge after implementation of the bundle (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.26-0.86). There were also lower rates of overall antipsychotic continuation at hospital discharge (OR: 0.4; 95% CI: 0.18-0.89).
  This is the first study to demonstrate a reduction in antipsychotic continuation at transition from the MICU after implementation of an antipsychotic discontinuation bundle in ICU patients. We believe this bundle allows for safer transitions of care from the MICU and decreases unnecessary antipsychotic therapy.
authors.affiliation: 1 Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.|2 Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA.
authors.forename: Ryan G
authors.initials: RG
authors.lastname: D'Angelo
authors.affiliation: 1 Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.
authors.forename: Molly
authors.initials: M
authors.lastname: Rincavage
authors.affiliation: 2 Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA.
authors.forename: Asha L
authors.initials: AL
authors.lastname: Tata
authors.affiliation: 3 Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
authors.forename: Leah S
authors.initials: LS
authors.lastname: Millstein
authors.affiliation: 3 Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
authors.forename: Mangla S
authors.initials: MS
authors.lastname: Gulati
authors.affiliation: 4 Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA, USA.
authors.forename: Rachel W
authors.initials: RW
authors.lastname: Flurie
authors.affiliation: 1 Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.|2 Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA.
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Gonzales
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D014150:Antipsychotic Agents / Q000008:administration & dosage*; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D003422:Critical Care; D016638:Critical Illness / Q000523:psychology* / Q000628:therapy; D003693:Delirium / Q000188:drug therapy*; D005260:Female; D006801:Humans; D008297:Male; D059065:Medication Reconciliation; D008875:Middle Aged; D010351:Patient Discharge; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies
chemical_list: D014150:Antipsychotic Agents
keywords: antipsychotic agents; critical care; delirium; intensive care units; patient harm; patient transfer