Hospital Pharmacy - June 2019 - 182

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Hospital Pharmacy 54(3)

Table 2. Patient Characteristics.
Preintervention
(n = 28)
Gender
Male
Average age, years
Patients ⩾65, years
Age-minimum
Age-maximum
CIWA protocol
Alcohol score
TRISS score

18 (64%)
47
5 (18%)
26
76
6 (21.4%)
3.44
0.89

Table 3. Patient Outcomes.
Intervention
(n = 33)
22 (66%)
54
10 (31%)
19
88
8 (24.2%)
4.65
0.81

0.17
0.19
0.17
NA
NA
0.82
NA
0.15

Note. CIWA = Clinical Institute Withdrawal Assessment for Alcohol;
TRISS = trauma and injury severity score.

Results
During the entire study period, 61 patients met inclusion criteria. Patient characteristics of each group are summarized
in Table 2. Baseline characteristics of the 2 groups were
similar in terms of gender and alcohol withdrawal as determined by the initiation of the Clinical Institute Withdrawal
Assessment for Alcohol (CIWA) protocol. The intervention
group had more elderly patients (⩾65 years of age) than the
preintervention group (10 patients, 31% vs 5 patients, 18%).
The intervention group had a higher predicted mortality
compared with the preintervention group defined from the
baseline TRISS score, but that was not statistically significant (0.81 vs 0.89, P = .15).
There was no difference found in the incidence of delirium
(33.3% vs 24.1%, P = .45), ICU LOS (10.11 vs 7.55 days, P
= .26), ventilator duration (7.11 vs 5.03 days, P = .26), and
mortality (7% vs 24.2%, P = .07) between the preintervention
and intervention group (Table 3). Five patients, 1 in the preintervention group and 4 in the intervention group did not have
documented CAM-ICU scores. Those patients were not
included in the calculated delirium percentage. All of the
deaths in both groups were from nondelirium-related causes
(Table 4). Two patients were not able to be evaluated with the
CAM-ICU assessment due to being unarousable and they
were removed from the final calculation in the incidence of
delirium. Hospital LOS was significantly shorter in the intervention group compared with the preintervention (9.83 vs.
14.75 days, P = .04). There was a significant reduction in the
amount of anticholinergic medications ordered for the intervention group (15.2% vs 42.9%, P = .016). There was no difference found in the use of benzodiazepines (75% vs 63.3%,
P = .34) and antipsychotics (42.9% vs 24.2%, P = .12) in the
preintervention group compared with the intervention group.
Recommendations made by the pharmacists were
recorded in the intervention group (Table 5) as a result of a
CDSS alert. Forty-nine pharmacy interventions were made
for the 33 intervention patients, with 46 (95%) of them
accepted. There were 10 different categories that interventions fell into: (1) discontinuation of continuous sedation, (2)

Intervention
(n = 33, 29a)

Preintervention
(n = 28, 27a)

P value

Delirium present
9 (33.3%)a
(CAM-ICU)
Average ICU LOS,
10.11
days
Average hospital
14.75
LOS, days
Average ventilator
7.11
duration, days
All cause mortality
2 (7%)
No. of delirium-potentiating medications
Benzodiazepines
21 (75%)
Anticholinergics
12 (42.9%)
(patients ⩾65 years)
Antipsychotics
12 (42.9%)

7 (24.1%)a

P value
0.45

7.55

0.26

9.83

0.04

5.03

0.26

8 (24.2%)

0.07

21 (63.6%)
5 (15.2%)

0.34
0.016

8 (24.2%)

0.12

Note. CAM-ICU = Confusion Assessment Method for Intensive Care Unit;
ICU = intensive care unit; LOS = length of stay.
a
Those patients who had no documented CAM-ICU scores were
removed from the incidence of delirium calculation.

Table 4. Causes of Death.
Cause

Preintervention
(n = 2)

Intervention
(n = 9)

1
1
0

0
0
1

0
0
0
0
0
0

1
1
1
1
2
1

Endocarditis
MVC with internal injuries
Hemothorax with acute
multifocal ischemic stroke
Intracranial hemorrhage
Cardiopulmonary failure
Cardiac arrest
Congestive heart failure
Subdural hematoma
Pulmonary embolism
Note. MVC= Motor vehicle collision.

Table 5. Pharmacists Interventions.
Pharmacist intervention

No. (%)

Discontinue continuous sedation
Discontinue sedating agent
Analgesic optimization
Laboratory monitoring
Decreased sedation rate
Changed sedating agent
Restarted home psychiatric meds
Discontinue stimulant
Increase sedation rate
Added sedative agent

13 (27)
12 (24)
9 (18)
6 (12)
4 (8)
4 (8)
3 (6)
2 (4)
1 (2)
1 (2)

discontinuation of sedating medications (benzodiazepines,
opioids, anticholinergics), (3) analgesic optimization, (4)
laboratory monitoring, (5) decreasing the sedation rate, (6)
changing sedating agent, (7) restarting home psychiatric
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