Pharmacist-led intervention to reduce inappropriate continuation of targeted medications initiated in the acute care setting at hospital and ICU discharge

Pharmacist-led interventions may reduce the inappropriate continuation of acid-suppressive agents and antipsychotics temporarily initiated in the intensive care unit (ICU), but limited data exist for other medications. This study evaluated the impact of a pharmacist-led intervention on the number of medications inappropriately continued upon ICU and hospital discharge. This was a single-center, pre-post intervention analysis conducted in the medical and surgical ICUs at a tertiary academic medical center. The pre- and post-intervention groups included adults who were newly initiated on medications used for stress ulcer prophylaxis, delirium, agitation, wakefulness, sedation, and insomnia from December 1, 2021 to January 31, 2022 and December 12, 2022 to February 13, 2023, respectively. In the post-intervention group, pharmacists identified patients who were newly initiated on a medication of interest and documented in patients' charts via an electronic handoff tool utilizing a standardized template. The appropriateness of those medications was assessed daily, and pharmacists intervened when necessary. The number of medications inappropriately continued at ICU and hospital discharge and ICU and hospital lengths of stay were compared. Overall, 399 encounters were included in the final analysis, and a total of 459 medications were newly initiated in the ICU. There was no significant difference in the number of medications inappropriately continued at hospital discharge [22 (8.4%) vs. 10 (5.1%); p = 0.17]. Significantly fewer medications were inappropriately continued at ICU discharge in the post-intervention group [85 (32.3%) vs. 37 (18.9%); p < 0.01]. The median ICU length of stay was significantly greater in the post-intervention group [4 (2–8) vs. 2 (1–6) days; p < 0.01]. No significant difference was found in the median hospital length of stay [14 (7–26.5) vs. 16 (9–33.75) days; p = 0.08]. Use of an electronic handoff tool was associated with a significant reduction in the number of medications inappropriately continued at ICU discharge.