Study Underscores Need to Optimize Pharmacotherapy After Neuro ICU Discharge

Almost 90% of patients discharged from a neurological intensive care unit (ICU) may need an adjustment to their pharmacotherapy to optimize outcomes and minimize the potential for adverse events, according to a new Cleveland Clinic study.

The results are from a retrospective chart review of all patients who had an initial appointment in Cleveland Clinic’s Post Neuro Intensive Care Virtual Clinic (PREVAIL) between December 2020 and January 2022. The review was completed by the neuro ICU clinical pharmacist team — Grace Conroy, PharmD; Danielle Marut, PharmD; and Christine Ahrens, PharmD — and the data were presented at the Neurocritical Care Society’s annual meeting in October.

“Drug therapy is an important consideration in post-neuro ICU patients, and we wanted to assess which pharmacy-related factors influence their outcomes,” says Dr. Ahrens, Manager of Critical Care and Neurology in Cleveland Clinic’s Department of Pharmacy. “Our review showed that a vast number of drug therapy interventions are provided to these patients and that collaboration with long-term acute care hospitals or facilities may be beneficial to effectively manage them.”

How PREVAIL works

Started in December 2020, PREVAIL supports continuity of care for patients with neurologic injuries who have been discharged from a neuro ICU. Its virtual setting makes it one of the first clinics of its kind, as most post-ICU clinics care for medical and surgical ICU patients in a traditional outpatient clinic setting.

Because of the nature of brain injuries sustained by neuro ICU patients, they are more susceptible to post-intensive care syndrome than are general ICU patients. Research shows, for example, that only 15% to 20% of patients admitted to a neuro ICU with a subarachnoid hemorrhage recover to their prior level of functioning.

To be referred to PREVAIL for specialized care, a patient must have been admitted to a neuro ICU for ≥ 72 hours with at least one of the following:

• History of cognitive impairment
• Severe sepsis/septic shock
• Renal replacement therapy
• Acute respiratory distress syndrome
• Mechanical ventilation
• Delirium
• History of psychiatric illness

A patient’s first PREVAIL visit is scheduled within 30 days of their hospital discharge to a long-term acute care facility. Patients are seen by a multidisciplinary team that includes a neurocritical care intensivist, advanced practice nurse practitioners and neurocritical care pharmacists. As part of the PREVAIL model, these professionals use a virtual platform to evaluate patients and counsel patients and their caregivers.

Essentials of the study

The retrospective chart review included 52 PREVAIL patients with a median age of 59 years (interquartile range [IQR], 42-73), 60% of whom were male. The majority (85%) resided in a long-term acute care hospital (LTACH).

Intracranial hemorrhage was the most common primary neurologic diagnosis, seen in 16 patients, followed by seizure and acute ischemic stroke (8 patients each). All patients had received mechanical ventilation in the ICU. The median hospital and ICU stays were 24 days (IQR, 17.3-29.8) and 17 days (IQR, 10-26), respectively.

Key findings

Reconciliation of medications — including antipsychotics, antiseizure agents, antihypertensives, anticoagulants, neuromodulators and antidepressants — was completed by PREVAIL pharmacists for 79% of PREVAIL patients, and recommendations about pharmacotherapy were made for 89%.

Recommendations by the pharmacists for optimizing individual pharmacotherapy plans were made after reviewing patients’ laboratory values and vital signs and after patient examination during a virtual visit. These recommendations included the following (all values are medians):

• 3 medication changes per visit (IQR, 2-5)
• 2 medication discontinuations per patient (IQR, 1-2)
• 1 medication initiation per patient (IQR, 1-2)
• 1 medication adjustment per patient (IQR, 1-2)

More than half of patients (54%) required an addition to their therapeutic drug monitoring plan, most often to monitor or prevent adverse effects.

The medications most often recommended for initiation were antihypertensives, anticoagulants and antidepressants. Adjustments in dosing were most often recommended for antiseizure medications and antihypertensives. The medications most commonly recommended for discontinuation were antihypertensives and H2 receptor antagonists/proton pump inhibitors.

Takeaways and next steps

“As we saw in these patients, some medications prescribed for acute management in the neuro ICU may not be necessary a month or two after discharge,” Dr. Ahrens observes. “Continual re-evaluation of pharmacotherapy, with collaboration among pharmacists, advanced practice nurse practitioners and intensivists, is required to minimize complications from unnecessary drug therapy.”

She says the PREVAIL team plans to publish full results of this study early next year. Meanwhile, the next step in their pharmacotherapy research is to work with their LTACH colleagues to determine the impact of PREVAIL pharmacists’ pharmacotherapy recommendations and assess long-term outcomes among PREVAIL patients. Dr. Ahrens also is mentoring neuro ICU clinical pharmacy specialist Grace Conroy in efforts to secure grant funding to support further research in this area.

“This study highlights the benefits of Cleveland Clinic’s multidisciplinary, collaborative approach to patient care extended beyond the traditional boundaries of our critical care unit,” notes neurointensivist Joao Gomes, MD, who serves as head of the neuro ICU in Cleveland Clinic’s Cerebrovascular Center. “It also shows the importance of approaching medical care as a continuum and demonstrates how strong partnerships between acute care hospitals and LTACHs can positively impact care.”