Current Perceptions and Practices Surrounding the Recognition and Treatment of Delirium in the Intensive Care Unit: A Survey of 250 Critical Care Pharmacists from Eight States

Abstract

Pharmacists are key members of the intensive care unit (ICU) team; however, few data exist regarding their clinical role, perceptions, and current practices in recognizing and managing delirium. To describe current practices and perceptions of ICU pharmacists regarding delirium recognition and treatment relative to current recommendations. A self-administered survey was distributed to 457 pharmacists in 8 states who are members of the Society of Critical Care Medicine or the American College of Clinical Pharmacy and who spend 25% or more of their time providing clinical ICU pharmacy services. A total of 250 (55%) pharmacists responded. A delirium screening tool was routinely used by few (7%) pharmacists. Lack of time (34%) and the belief that screening is a nursing role (24%) were key barriers to pharmacist screenings. Most (85%) said that delirium should be pharmacologically managed; 68% responded that 2 or more medications should be used. The treatments of first choice included haloperidol (76%), an atypical antipsychotic (14%), or a benzodiazepine (10%). Frequently used treatments were haloperidol (87%), quetiapine (59%), and lorazepam (47%). Haloperidol was perceived by many (42%) to have 1 or more randomized trials supporting its use for delirium and Food and Drug Administration approval for this indication (34%). Haloperidol was most often administered on a scheduled basis (62%), intravenously (92%), and at a daily dose of 5-10 mg (58%). While the QTc interval was frequently measured at least once per shift using an electrocardiogram strip (64%), it was not routinely measured in 20% of ICUs, and 60% continued haloperidol when the QTc exceeded 500 msec. Current practices and perceptions surrounding recognition and treatment of delirium in patients in the ICU by the critical care pharmacists surveyed are heterogeneous. Antipsychotics are frequently recommended by pharmacists for delirium treatment, despite a lack of rigorous evidence to support their use. While pharmacists are ideally suited to lead delirium recognition efforts and provide treatment recommendations in this area, these roles need further elucidation. The optimal pedagogical strategy to support these efforts remains unclear, and the potential impact of pharmacists' efforts on patients' outcomes is unknown.