Ariel L. Clark, PharmD
Increased patient morbidity and mortality as well as costs to the health care system are seen as a direct result of ICU readmissions after discharge. Despite continual efforts to improve in this arena, there remains a significant portion of patients affected by readmissions. According to a 2016 study in Critical Care Medicine, rates for ICU readmissions after discharge were 14.5%.
As researchers have continued to study causation in order to better understand readmission prevention, a recent article published January 25, 2023, in JAPhA by Meckel and colleagues attempts to further narrow causes of ICU readmissions by relating them to medications by class—a previously unstudied connection.
Potentially preventable medication-related readmissions accounted for 25% of total readmissions found in this study, 4 additional days in the ICU, and a price tag of over $1 million.
Authors of the study sought to identify which ICU readmissions were a direct result of a medication error, then further determine which classes of medication were most commonly seen in these cases and if a pharmacist intervening could have resulted in fewer ICU admissions.
Identification techniques
The National Coordinating Council for Medication Error and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”
Similar to in outpatient pharmacies, there are several different types of medication errors that can occur within the hospital setting, including omission, commission, administering, and prescribing.
Nonmodifiable patient risk factors, like sex, weight, severity of illness, and others, have been studied successfully for years. Meckel and colleagues noted that the same scoring systems that use these factors to predict risk for overall morbidity and mortality can also be used to assess patient risk for readmission, including the Badawi and Braslow readmission and mortality tools and the Stability and Workload Index for Transfer.
However, while accurate, these predictive tools do not take into account which medications patients do or do not receive upon discharge, which the investigators noted is an error “given that one medication error occurs for every five doses of medications administered in the ICU.”
Impact of pharmacists
Pharmacists play a critical role in helping prevent medication errors, especially as their roles have expanded.
As far back as 2013, researchers, including Leape and colleagues in their Hospital Pharmacist paper, have noted that pharmacist staffing in the ICU reduced preventable medication errors. Similarly, in this 2023 study, Meckel and colleagues found that of the PPMIRs, 67.4% occurred when there was not a pharmacist rounding with the other unit staff.
Medication culprits
The Institute for Safe Medication Practice (ISMP) categorizes medications as “High Alert” if the consequences of their use in error will cause significant patient harm. Meckel and colleagues found four of the most commonly seen medications in PPMIRs are what ISMP considers “High Alert” medications. These high-alert medications include anti-infectives, opioids, benzodiazepines, and antiarrhythmics as well as diuretics, which might be most surprising to clinicians.
Study investigators noted that fluid balance is a notoriously tricky task in hospitalized, critically ill patients. However, of the 14 cases analyzed in the study period in which a patient was readmitted to the ICU due to a fluid imbalance, authors noted that initiating or continuing a diuretic could have prevented 13 readmissions.
The authors noted that the results of this study showcase how, as roles continue to expand, pharmacist involvement can improve patients’ safety and deter costly ICU readmissions. ■