Impact of a computer-assisted pharmacy transitions of care process on medication de-prescribing when transferring from the intensive care unit

Introduction: Our hospital instituted a computer-generated intensive care unit (ICU) transitions of care task which prompts pharmacists to evaluate patients with orders to transfer out of the ICU and includes the scope of practice to de-prescribe medications based upon set criteria.Methods: This was a retrospective cohort analysis of adult patients transferred from the ICU to a lower level of care. The primary objective was to describe the number and type of interventions documented after implementation. The secondary objective was to compare, before and after implementation, the percent of inappropriate target medications discontinued within 12 h of ICU transfer order and continued upon hospital discharge.Results: In the 1-year period after implementation, pharmacists identified interventions on 1290 of 3718 patients (34.7%) with transfer orders and documented a total of 1728 interventions. Data for 150 patients in each the pre-implementation group and post-implementation group were compared. Significantly more target acid suppressing medications and quetiapine were discontinued within 12 h of transfer order in the post- versus pre-implementation group (famotidine 46% vs. 10%, p = 0.005; pantoprazole 80% vs. 5.5%, p < 0.001; quetiapine 71.4% vs. 10%, p = 0.005). Acid-suppressing prescriptions started inpatient and continued at hospital discharge without indication were also reduced (famotidine 6.7% vs. 40%, p = 0.022; pantoprazole 6% vs. 41.1%, p < 0.001).Conclusions: Implementation of a pharmacist ICU transitions of care process was simple and resulted in pharmacist-initiated medication reconciliation in one third of patients. The process significantly reduced the amount of inappropriate acid-suppressing medications continued on ICU transfer and hospital discharge, as well as quetiapine continued on ICU transfer.