We’ve written several columns on Beers’ List of potentially inappropriate medications (see our Patient Safety Tips of the Week for January 15, 2008 “ and October 19, 2010 “ ” and September 22, 2009 “Psychotropic Drugs and Falls in the SNF” and our What’s New in the Patient Safety World columns for June 2008 “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” and September 2010 “Beers List and CPOE”).
A new study from Vanderbilt University Medical Center (Morandi 2011) showed that the proportion of patients on potentially inappropriate or actually inappropriate medications increased by 20% after a critical illness and that about half of these were started in the intensive care unit. The most common inappropriate drugs were anticholinergics but the authors also note that antipsychotic agents, often used to treat delirium in the ICU, are also often continued after discharge.
This study highlights the importance of medication reconciliation at all transitions of care. Today most hospital activities on medication reconciliation have focused on admission and discharge. But is it just as important that medication reconciliation take place when patients are transferred from the ICU to the floor (or vice versa) or from one service to another. Physicians are always reluctant to discontinue drugs started by someone else. So it is incumbent upon the transferring physicians to review all drugs and determine which truly need to be continued and, if so, for how long.
The other classic drugs that get started in the ICU and are often continued inappropriately are proton pump inhibitors and H2-blockers. While such acid-suppressing drugs have been demonstrated to reduce the risk of GI bleeding in critically ill ICU patients, they have not been shown to be of similar benefit in other settings and patients not critically ill. A new study (Herzig 2011) confirms that nosocomial bleeding outside the ICU setting is rare and that there is little benefit to use of PPI’s or H2-blockers in the non-ICU population. The number needed to treat (NNT) to prevent one episode of nosocomial GI bleeding was 770 and the NNT to prevent one episode of clinically significant bleeding was 834. There has been increasing evidence that acid-suppressing medications, PPI’s in particular, may increase the likelihood of Clostridiium difficile (C.diff) infections and hospital-acquired pneumonia. So it is critical on both internal transfers and at discharge that PPI’s and H2-blockers be specifically scrutinized. We also recommend that third party payors should use their large drug databases to screen for new starts of such drugs after a hospitalization and then have programs in place to examine the necessity of such drugs.
Morandi A, et al. Society of Critical Care Medicine (SCCM) 40th Critical Care Congress: Abstract 569. Presented January 17, 2011 as reported in Lowry F. Inappropriate Medications Commonly Prescribed to the Elderly in the ICU. Medscape January 2011
Herzig SJ, Vaughn BP, Howell MD, et al. Acid-Suppressive Medication Use and the Risk for Nosocomial Gastrointestinal Tract Bleeding. Arch Intern Med. 2011; published online February 14, 2011