Post-intensive care syndrome (PICS) refers to the development of long-term chronic health and functional status changes after admission to an intensive care unit (ICU).  Approximately 25% to 66% of all patients will develop at least one symptom of PICS following an ICU admission, including but not limited to, physical manifestations such as neuromuscular weakness and increased susceptibility to infection as well as mental health manifestations such as sleep disruptions, anxiety, depression, and post-traumatic stress disorder (PTSD).¹ These manifestations require complex follow up care and transitional services post discharge. Patients discharged from neurocritical care units are at high risk for manifestations of PICS due to neurologic injury and hospital readmission due to infection, cardiovascular events, or recurrent neurologic events.^2,3,4 Clinical pharmacists with expertise in outpatient medication management are in a key position to help reduce hospital readmissions for high-risk populations. Neurocritical care patients were not a focus population for transitions of care services at our institution. Therefore, many patients were discharged without post-discharge services. To help bridge this gap in care, a pharmacist-led PICS clinic was created with the goal of optimizing medication therapy, reducing readmissions, and improving quality of life for neurocritical care patients after discharge.

This clinic was designed for patients with ICU diagnoses including acute ischemic stroke (AIS), spontaneous intracerebral hemorrhage (sICH), and status epilepticus (SE). Patients who were discharged from the ICU with one of the above diagnoses by a physician participating in the collaboration were eligible for a PICS appointment. Pharmacists virtually contacted the patients within 14 days of discharge to complete the PICS appointment. During these appointments, patients were assessed for medication adherence, need for refills, ability to complete activities of daily living, need for aid, mental health screening, and vital sign screening. Through collaboration with neurocritical care physicians, pharmacists were able to assess home blood pressure readings and institute medication adjustments, initiate or adjust medications for cerebral- and cardiovascular benefit, discontinue extraneous prophylaxis medications, and resolve medication discrepancies. Referrals were provided to outpatient services as appropriate and coordination of care was completed as appropriate.  

Our team is passionate about the implementation and importance of this clinic as it has allowed us to decrease medication errors and discrepancies while optimizing care for patients. Not only have we been able to reduce hospital readmissions, but within a population of 33 patients seen, 71 medication discrepancies were identified and resolved. This shows that within the first week of discharge, there were an average of 2.2 medication differences between what patients were taking and their medical records. Furthermore, pharmacist interventions and recommendations were made in 26 out of 33 (79%) patients seen. 

Within a 12-month span, a total of 33 patients completed a visit with a PICS pharmacist. Out of the 33 patients that completed a pharmacist visit, 1 patient was readmitted within 30 days, representing a 3.3% readmission rate. In comparison to 129 patients that did not complete a pharmacist visit, and therefore, received standard post-discharge care, 20 readmissions occurred within 30 days affecting 15 patients, representing an 11.6% readmission rate per patient and a 15.5% readmission rate per index based on Medicare standards. Additionally, 4 readmissions occurred in the intervention group within 60 days affecting 3 patients, representing a 9% readmission rate per patient and a 15.2% readmission rate per index based on Medicare standards. 39 readmissions occurred in the standard care group within 60 days affecting 27 patients, representing a 20.9% readmission rate per patient and a 30.2% readmission rate per index. This translates to an absolute risk reduction of 8.3% for 30-day readmission and 11.9% for 60-day readmission. The results of this study further support existing evidence of the benefits of pharmacist-led PICS clinics on readmission rates.

Table 1: Results

Lower readmission rates were observed in post neurocritical care patients who received care in a pharmacist-led PICS clinic compared to those who received standard post-discharge care. The results of this study suggest a clinically meaningful benefit of pharmacist-led post-discharge care through a decrease in hospital readmissions and optimization of patient care. Additionally, this clinic was selected as the Florida Society of Health-System Pharmacists Best Practices Program. Pharmacists optimized patient medication regimens; identified and resolved potentially harmful medication discrepancies and interactions; and enhanced patient understanding of medication regimens, monitoring, and lifestyle modifications, therefore, optimizing care for our neurocritical care patients.