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Lightfoot et al

Materials and Methods

Table 1. Benzodiazepine Conversion Chart.10,11

This was a single-center, before-and-after study conducted
at Tristar Skyline Medical Center in Nashville, Tennessee.
Using a CDSS, specific medication-related delirium risk
factor rules were created to alert pharmacists to patients who
have increased risk(s) of developing ICU delirium. With
CDSS, clinical pharmacists were alerted to a patient who
met specific risk factors for developing ICU delirium in our
institution in real time. Recommendations were made in
accordance to the standard of care from the 2013 Society of
Critical Care Medicine's Pain, Agitation, and Delirium
guidelines.2 The CDSS rules included patients on continuous sedation, ⩾2 anticholinergic agents for patients 65 years
of age and older, ⩾2 antipsychotics, ⩾2 benzodiazepines,
and administration of ⩾12 mg of lorazepam equivalents of
benzodiazepines in 2 hours (Table 1). The CDSS searches
were completed daily for continuous sedation, using barcode medication administration (BCMA) data to capture
patients to be included in the current study. Continuous
sedation medication included lorazepam, fentanyl, propofol
and dexmedetomidine. Institutional review board (IRB)
approval was obtained and informed consent was waived.
Inclusion criteria were defined as patients ⩾18 years of
age, admitted to the TICU, and a minimum of one deliriumspecific CDSS alert or identification of continuous sedation
from a CDSS search. The study took place over 90 days from
January 1, 2017, through March 31, 2017. Real time alerts
for pharmacist monitoring of the CDSS rules began on
February 15, 2017. Patients who met this criterion prior to
the implementation of CDSS rules (preintervention group)
were compared with those who developed it following delirium-specific CDSS pharmacist monitoring (intervention
group). Patients meeting inclusion criteria between January 1
and February 14, 2017 (45 days) were in the preintervention
group and patients were included in the intervention group
that met inclusion criteria from February 15 to March 31,
2017 (45 days). Patients were included in the intervention
group if they were admitted prior to February 15, but did not
meet inclusion criteria until after the deployment of the
CDSS rules. Patients were excluded from the study if they
qualified to be in the preintervention group and had CDSS
alerts during the intervention phase. In the preintervention
group, a clinical pharmacist accompanied the daily rounds
with the multidisciplinary team, where they would work up
and discuss ICU delirium risk factors during rounds. Whereas
in the intervention group, the clinical pharmacist rounded
and was alerted by the CDSS throughout the entirety of their
shift to potential delirium-potentiating, drug-related issues.
Depth of sedation was assessed using the Richmond
Agitation Sedation Scale (RASS). Nurses were required to
document all RASS scores and infusion rates of sedation medications on the electronic medication record. Delirium was
assessed using the Confusion Assessment Method for Intensive
Care Unit (CAM-ICU) score and was documented by nurses
in the patient's medical record by either stating "delirium" or

Benzodiazepine
Alprazolam
Chlordiazepoxide
Clonazepam
Diazepam
Lorazepam
Midazolam
Oxazepam
Temazepam

Converted lorazepam equivalents (mg)
0.5
25
0.25
5
1
3
15
10

"no delirium." A retrospective data search utilizing the CDSS
was performed for the time frame covering the preintervention
group and determined which patients met inclusion criteria
based on the delirium-specific CDSS alerts that would have
occurred. A daily report was performed utilizing the CDSS to
identify patients admitted to the TICU on continuous sedation
during the intervention phase. Pharmacists involved in the
study participated in daily multidisciplinary trauma rounds
and monitored TICU patients on a daily basis. During the
intervention period, pharmacists were given a standard recommendation algorithm (see the appendix) for the new deliriumspecific CDSS alerts. Clinical pharmacists involved in the
current study utilized CDSS for real-time alerts for delirium
modifiable risk factors and would make recommendations
during multidisciplinary rounds using their clinical judgment.
All recommendations and other pharmaceutical interventions
were documented in the CDSS.
The primary endpoint was occurrence of ICU delirium,
measured by a CAM-ICU score showing the presence of delirium. Secondary endpoints included hospital LOS (days), ICU
LOS (days), ventilator duration (days), and delirium-potentiating medications administered to patients. For all trauma admissions patients, a trauma and injury severity score (TRISS) was
calculated, which determines the probability of survival. On
admission, all TICU patients also received an alcohol score by
the CAGE questionnaire. The CAGE questionnaire is a screening tool to determine whether a patient has a potential alcohol
problem. The CAGE questionnaire asks the following questions: Have you ever felt you should Cut down on your drinking?; Have people Annoyed you by criticizing your drinking?;
Have you ever felt bad or Guilty about your drinking?; Have
you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover (Eye opener)? Responses are
scored 0 or 1, higher the score indicates an alcohol problem.12
The chi-square test was used to compare the preintervention and intervention groups to assess the nominal data,
and the t test was used to assess all continuous variables.
Continuous data, such as the TRISS scores, were transformed by log transformation of the inverse of the values to
remove substantial negative skewness in the data to get it
closer to a normal distribution. The N needed for a twosample t test was 64 in each group for 80% power. For all
statistical tests, P < .05 was considered to be significant.

Hospital Pharmacy - June 2019

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