Implementation of a partial fill standard operating procedure (SOP) within a Veterans Affairs (VA) outpatient pharmacy Kelsie Welch, Lynsey Neighbors, Britney Willis, Lauren Rass, Phelicia Bush Central Alabama VA Health Care System - Montgomery, AL
Background/Purpose: The VA has a rich history of being at the forefront of pharmacy and has many innovative measures in place to provide efficient pharmaceutical care to the nearly 21,000,000 Veterans served every year. Unlike most state pharmacy laws, the VA allows for most medications to be partial filled for an unspecified number of days, at no cost to the veteran. Currently at the Central Alabama Veterans Healthcare System, there is no SOP in place regarding partial fills. The purpose of this quality improvement project is to implement an SOP that streamlines partial fills and impacts the cost burden of the local pharmacy.
Methodology: The primary objective of this quality improvement project was to evaluate the impact an SOP had on the cost to outpatient pharmacies as it pertains to partial fills. Secondary objectives included the impact an SOP had on the day supply and total number of medications partial filled. Data was obtained from quarters 1 and 2 of fiscal year 2018 for pre-implementation data and included the following: facility partial was filled at, drug, total cost of drug, and day supply. Together with administrative staff and outpatient pharmacists, an SOP was created and implemented. Post-implementation data from quarters 1 and 2 of fiscal year 2019 was evaluated to determine the impact of the SOP.
Presentation Objective: By the end of this presentation the audience should be able to understand the VA_x0019_s partial fill procedure and how it affects the local VA outpatient pharmacy.
Self-Assessment: When a Veteran receives a partial fill from the VA, who is responsible for the cost of the medication?
Evaluation of a population-based management tool in identifying interactions between DOACs and NSAIDs in a health care system Liem Nguyen, Jina Almond, Rebecca Edwards, Jon Folstad, Juan Mobley Salisbury VA Medical Center - Salisbury, NC
Background/Purpose: The overall use of direct oral anticoagulants (DOACs) within the Veterans Health Administration (VHA) continues to steadily increase. Clinically significant drug interactions and changes in laboratory indices can potentially go unnoticed until a patient_x0019_s next encounter with a provider. The Salisbury Veterans Affairs Health Care System (SVAHCS) implemented the DOAC population-based management tool (PMT) in October 2018. The PMT can be used to alert clinical pharmacy specialists (CPSs) of potentially interacting medications, allowing a CPS to quickly and efficiently address any potential concerns without requiring the need for routinely scheduled appointments. The purpose of this evaluation was to identify the potential for CPS intervention based on alerts from the DOAC PMT in patients receiving a DOAC in conjunction with a non-steroidal anti-inflammatory drug (NSAID).
Methodology: This retrospective chart review included patients identified by the DOAC PMT from February to March 2019. The following data was collected from the SVAHCS computer system: baseline demographics, specific DOAC prescribed, renal function, complete blood count, history of NSAID and antiplatelet use, risk factors for bleeding needed for calculating a HAS-BLED score, and if DOAC education was provided for the patient. The data collected was analyzed to determine the potential for CPS intervention based on alerts generated by the DOAC PMT. The data was also used to determine outcomes based on CPS interventions, as well as the potential root cause of the interaction.
Presentation Objective: Assess the impact of using a PMT in identifying potential drug-drug interactions in patients receiving a DOAC in conjunction with an NSAID.
Self-Assessment: Can a population-based management tool be used to identity drug-drug interactions in patients receiving a DOAC and NSAID?
Evaluation of the factors that predict non-participation in a diabetes prevention program Kristine M. Boyle, C. Gamston, M. Schaefer, K. Garza, K. Braxton Lloyd Auburn University Pharmaceutical Care Center - Auburn, AL
Background/Purpose: The CDC_x0019_s Diabetes Prevention Program (DPP) is an evidence-based curriculum that decreases progression to type 2 diabetes from prediabetes by approximately 64%. Seventy-one individuals with prediabetes who recently participated an employer-sponsored wellness program were invited to participate in the DPP. Only 15% participated. This study seeks to identify barriers to participation in a no-cost, worksite offering of the DPP.
Methodology: Wellness program participants with prediabetes who did not participate in the DPP were eligible for this study. Participants were incentivized to complete two self-efficacy surveys and an in-person, semi-structured interview. Quantitative analysis of the surveys assessed participant self-efficacy for diet and physical activity behaviors, the foci of the DPP. The development of the 20-minute interview was guided by the Health Belief Model. The interviews were audio recorded, transcribed, and analyzed via directed content analysis by two independent coders. Common themes were identified.
Results: Quantitative analysis revealed participants_x0019_ willingness to stick to a physical activity regimen but a perceived lack of ability to make time and to reduce calorie intake. Qualitative analysis of the interviews demonstrated several common themes. Perceived barriers included lack of diabetes knowledge and schedule conflicts. Half of participants felt confident in their ability to manage their prediabetes without a program while others stated that learning self-management strategies and gaining support would be benefits of participating in the DPP. Participants also reported the desire for online DPP delivery.
Conclusions: Analysis of the relationship between quantitative and qualitative data is ongoing. Preliminary results demonstrate a series of perceived barriers to participation that are specifically addressed within the DPP curriculum.
Presentation Objective: Identify common barriers to participation in the Diabetes Prevention Program within a work-site pharmacy setting.
Self-Assessment: What are some barriers to diabetes prevention programs offered within the ambulatory care pharmacy setting?
Impact of Clinical Pharmacy Services in the Emergency Department on Analgesia-First Sedation Protocol Utilization J. Luke Britton; H. Rusty Page; Jason Dover; Sarah Cogle; Kristy Williams East Alabama Medical Center - Opelika, AL
Background/Purpose: Use of an analgesia-first sedation (AFS) strategy in mechanically ventilated (MV) patients is associated with shorter duration of MV, shorter intensive care unit (ICU) length of stay (LOS), reduced pain intensity, and reduced need for additional sedatives. This study is designed to evaluate the impact of clinical pharmacy services (CPS) on the provision of AFS in patients intubated in the emergency department (ED).
Methodology: This single center, IRB-approved retrospective study assessed the ICU _x001C_Pain/Agitation/Delirium_x001D_ protocol for MV patients in the ED. Patients were stratified into two groups based on the presence or absence of CPS in the ED from March 1, 2016 through February 28, 2018. Patients 19 years of age or older who were intubated in the ED prior to ICU admission will be included.
The primary endpoint was the change in frequency of AFS in MV patients before and after implementation of CPS in the ED. Secondary endpoints included ICU LOS, total propofol use (mg/kg/day), and frequency of delirium in the ICU.
Results: There was an increased rate of AFS following the initiation of CPS versus prior to such presence (23.4% vs 3.9%, p = 0.006). Additionally, there was a reduction in propofol use for MV patients following initiation of CPS in the ED versus prior (9.14 vs 25.08 [mg/kg/day], P = 0.0001).
Conclusions: Pharmacists in the ED have a beneficial impact on post-intubation patient care. Additionally, the support of AFS by ED pharmacists leads to decreased utilization of other sedatives.
Presentation Objective: Evaluate the impact of daily pharmacist presence in the ED on the provision of guideline-supported care.
Self-Assessment: Which of the following describes an impact of ED pharmacists on post-intubation care?
Implementation of a fixed-dose strategy of 4-factor prothrombin complex concentrate for warfarin reversal Slaughter, William S; Leos, Cara L; Wheeler, Samantha N Baptist Medical Center South - Montgomery, AL
Background/Purpose: Implement a fixed-dose protocol for the use of 4-factor prothrombin complex concentrate (4FPCC) when treating warfarin-related life-threatening bleeding.
Methodology: After January 1st, 2019, all patients ages 19 and older prescribed 4FPCC for the treatment of warfarin-related bleeding were dosed according to a fixed-dose strategy of 2000 units. The pharmacist then ensured a pre-dose INR measurement had been drawn in addition to a follow-up INR measurement timed 60 minutes after order verification. To accompany the 4FPCC, the pharmacist also ensured a one-time order for intravenous Vitamin K 10mg. Data were compared to historical patients to assess INR response, total 4FPCC product use, and time from order to administration.
Presentation Objective: Discuss the benefits of a fixed-dose protocol for the ordering and administration of 4FPCC.
Self-Assessment: What is one potential benefit for using a fixed-dose strategy of 4FPCC for life-threatening bleeding?
Standard vs High Dose Dexmedetomidine for Sedation Maintenance in the ICU Spencer Bolton, Cassie Hamilton, Megan Van Berkel, Jeff Galyon
Background/Purpose: Dexmedetomidine is a commonly used medication for sedation in mechanically ventilated patients. A national drug shortage led our institution to restrict doses to a maximum infusion rate of 1 mcg/kg/hr. Previous randomized controlled trials have analyzed varying doses of dexmedetomidine in sedated ICU patients; however the main comparisons of these studies were of dexmedetomidine to lorazepam, midazolam, or propofol, rather than of varying doses of dexmedetomidine. The purpose of this study is to compare safety and efficacy of high dose (above mcg/kg/hr) and low dose (no greater than 1 mcg/kg/hr) dexmedetomidine.
Methodology: This Institutional Review Board approved, retrospective cohort study was conducted in an academic, level-one trauma center. Chart review was utilized to classify patients as having received dexmedetomidine either before or after maximum dose restriction. Patients were included if they received at least four hours of dexmedetomidine monotherapy for sedation. Patients were excluded if they were intubated at an outside facility prior to transfer, if dexmedetomidine was initiated in the operating room, or if the patient had a Glasgow Coma Score less than 5 at initiation of dexmedetomidine, quadriplegia or simultaneous administration of neuromuscular blocking agent for purposes other than intubation, or history of dementia. The primary outcome was percentage of time on dexmedetomidine spent in goal RASS score range, defined as -2 to 0. The primary outcome was further stratified by percentage of time spent either over or undersedated. Secondary outcomes included occurrence of bradycardia and hypotension, hospital and ICU lengths of stay, and requirement for addition of antipsychotic, vasopressor, or additional sedative.
Presentation Objective: Assess the correlation of dexmedetomidine dose with sedation efficacy as measured by RASS scores.
Self-Assessment: Does high dose dexmedetomidine provide more adequate sedation for adult ICU patients as compared to low dose dexmedetomidine?
Evaluation of supplementation, prescription, and questionnaire utilization following a diagnosis of Alzheimer_x0019_s disease Anna Lyall, Michael Justice, Richard Nicholas, Travis Garrett Appalachian College of Pharmacy - Oakwood, VA
Background/Purpose: To date, FDA-approved medications for the treatment of Alzheimer_x0019_s disease aim to delay the progression of cognitive decline by targeting glutamatergic and cholinergic neurotransmission. In addition, PET imaging studies demonstrate a reduction in cerebral glucose metabolism in patients with Alzheimer_x0019_s disease compared to non-demented, age-matched subjects. Therefore, bypassing glucose sources is a potential treatment strategy for Alzheimer_x0019_s disease. Ketones are a potential fuel source when glucose is not readily available, and thus a mechanism by which to improve cognitive performance in Alzheimer_x0019_s patients. An OTC supplement that can provide a source of ketones are the medium-chain triglycerides provided by Caprylic Acid. Our study seeks to identify the frequency with which and types OTC supplements are incorporated into the treatment plan of patients with Alzheimer_x0019_s disease in southwest Virginia.
Methodology: Eligible subjects for participation include those who are doctors of medicine or osteopathic medicine, nurse practitioners, physician assistants, licensed pharmacists, registered nurses, social workers, and designated caretakers. Ineligible subjects include providers or caretakers who are not primarily involved in health care decisions or who do not complete the survey in its entirety. Additionally, anonymous surveys will be distributed to pre-determined clinics, offices, and pharmacies in rural southwest Virginia. The information requested will include (but not be limited to) which psychological tests are commonly utilized to manage, monitor, and stage cognitive decline, as well as the dosage and frequency of prescribed medications and OTC supplements, focusing on knowledge of sources for medium chain triglycerides. All information collected will be utilized to evaluate the benefits and/or obstacles associated with treating a subset population diagnosed with Alzheimer_x0019_s disease in southwest Virginia.
Presentation Objective: Identify utilization of OTC supplementation in patients with Alzheimer_x0019_s disease in Southwest Virginia.
Self-Assessment: What benefit does Caprylic Acid provide within the Alzheimer_x0019_s population?
Expansion of a Risk Prediction Model for Healthcare Facility-Onset Clostridium difficile Infection Carrie Tilton, Nicole Metzger, Melissa Chesson, Mary Elizabeth Sexton Emory University Hospital/Mercer University College of Pharmacy (Internal Medicine) - Atlanta, GA
Background/Purpose: Clostridium difficile infection (CDI) is a significant challenge in healthcare. The primary objective for the study is to determine if a previously developed CDI risk prediction model accurately identifies patients at high-risk for healthcare facility-onset CDI at Emory Healthcare.
Methodology: This is a multi-center, retrospective, case-control study including adult patients admitted to Emory Healthcare between July 1st, 2016 and July 1st, 2018. Patients diagnosed with healthcare facility-onset CDI who received systemic antibiotics prior to diagnosis will be included cases, and they will be matched 1:1 with controls who received systemic antibiotics by admitting location. The primary outcome is to compare the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of the previously developed model. Secondary endpoints include positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of a new Emory-specific model with the assessment of additional variables, including immunosuppression. Comparison between the baseline demographics from Emory Healthcare and Novant Health will be conducted using Students_x0019_ t-test for continuous variables and chi-square for categorical data. Multivariable logistic regression will be performed to evaluate whether the risk factors assessed are predictors of CDI. A ROC-AUC will be determined to evaluate the degree of discrimination for CDI.
Results: The results of this study will be applied to screen patients who are at high-risk for healthcare facility-onset Clostridium difficile infection to identify opportunities for prospective pharmacist intervention.
Presentation Objective: Describe the application of a risk prediction model in the inpatient setting to identify patients at high risk for healthcare facility-onset Clostridium difficile infection.
Self-Assessment: Which of the following is a factor associated with high-risk of healthcare facility-onset Clostridium difficile infection?
Incidence of acute kidney injury associated with piperacillin/tazobactam extended-infusion compared to standard infusion Emily Bowers, Jason Lin, Eric Clayton Memorial University Medical Center - Savannah, GA
Background/Purpose: The literature for extended-infusion dosing of piperacillin/tazobactam has focused predominately on efficacy rather than safety. Recent studies evaluating the impact of piperacillin/tazobactam infusion strategies on acute kidney injury (AKI) have had inconclusive results. This study will evaluate the incidence of AKI associated with piperacillin/tazobactam extended-infusion dosing compared to standard infusion.
Methodology: This was a single-center, retrospective cohort study. The incidence of AKI in adult patients admitted May 1, 2017 to September 1, 2017 and May 1, 2018 to September 1, 2018 were compared. Patients were included if they were admitted for > 48 hours and received > 3 doses of piperacillin/tazobactam. The primary outcome was AKI and secondary outcomes included length of stay and time to AKI. AKI was defined using both the RIFLE and KDIGO criteria. Patient age, sex, weight, BMI, baseline serum creatinine, serum creatinine values during therapy, concomitant nephrotoxic agents, and comorbid disease states were recorded.
Results: Out of 422 patients, the overall incidence of AKI was 17.9% and was not significantly different between 2018 and 2017. However, the incidence of AKI when using the RIFLE criteria was higher in 2018 compared to 2017 (9.1% vs. 6.8%, p=0.209) but lower when using the KDIGO criteria (15.6% vs 20.2%, p=0.018). There was no difference in length of stay or time to AKI between the two groups.
Conclusions: The dosing strategy of piperacillin/tazobactam does not significantly impact the incidence of AKI in patients receiving piperacillin/tazobactam. However, there was a trend seen towards a decreased incidence of AKI in patients receiving extended-infusion compared to standard infusion.
Presentation Objective: Compare the incidence of AKI in patients receiving standard versus extended-infusion piperacillin/tazobactam
Self-Assessment: Does the criteria used to define AKI influence the number of patients considered to develop AKI while receiving piperacillin/tazobactam?
Safety of therapeutic unfractionated heparin and low molecular weight heparin in patients with liver cirrhosis Kate Summers, Sarah Nisly, Kyle Davis Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Patients with liver cirrhosis are simultaneously at an increased risk of bleeding and thrombosis due to variable synthesis of coagulation factors and anticoagulants. Though parenteral anticoagulants including unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are used in this patient population for the treatment of thrombosis, head-to-head safety studies are lacking. The purpose of this study was to evaluate the safety of therapeutic UFH versus LMWH in patients with cirrhosis.
Methodology: This multi-center, retrospective cohort study included adults with cirrhosis receiving UFH or LMWH for acute deep vein thrombosis (DVT), pulmonary embolism (PE), or portal vein thrombosis (PVT). Patients receiving oral anticoagulation prior to hospitalization were excluded. Patients were stratified based on anticoagulant. The primary endpoint was the incidence of major bleeding during anticoagulant monotherapy or within 48 hours of study agent discontinuation. Secondary endpoints included minor bleeding, bleeding during dual anticoagulant therapy, and transfusion requirements in patients with major bleeding.
Results: Eighty-two patients met inclusion criteria; 52 received UFH and 30 received LMWH. More major bleeding occurred in the UFH versus LMWH arm (19.2% vs. 0%, P=0.010). The most common major bleeding criteria met was bleeding associated with a hemoglobin decrease of at least 2 g/dL (n=9). A stepwise logistic regression identified no baseline characteristics associated with major bleeding. There was no difference in minor bleeding occurrences between groups (5.8% vs. 0%, UFH and LMWH respectively, P=0.180).
Conclusions: Unfractionated heparin was associated with a statistically significant difference in major bleeding over LMWH. Given the safety and practical advantages of LMWH, practitioners should consider utilizing LMWH over UFH for DVT, PE, or PVT treatment in patients with cirrhosis. Further studies to confirm these findings are warranted.
Presentation Objective: Assess safety of therapeutic UFH and LMWH in patients with cirrhosis
Self-Assessment: How does cirrhosis increase bleeding and thrombosis risk?
Early antibiotic de-escalation in febrile neutropenic patients Meredith Long, LeAnn Norris, Mark Twohey, P. Brandon Bookstaver Palmetto Health Richland PGY1 Pharmacy - Columbia, SC
Background/Purpose: Practice guideline recommendations for duration of empirical broad-spectrum antibiotics in patients with febrile neutropenia vary. Prolonged broad-spectrum antimicrobials carry risks of increased antibiotic resistance, adverse drug effects, and Clostridioides difficile infection. Hospitalized patients with febrile neutropenia may be exposed to antibiotics for longer than necessary while awaiting neutrophil recovery. The purpose of this study is to determine antibiotic utilization and patient outcomes before and after the implementation of an updated institutional early antibiotic de-escalation guideline for hospitalized hematology/oncology patients with febrile neutropenia.
Methodology: This is a retrospective, observational, cohort study. Adult patients admitted to Prisma Health Midlands Richland or Baptist hospitals with diagnosis codes of neutropenia and fever were included. Exclusion criteria were neutropenia not due to chemotherapy or patient never meeting diagnosis criteria (fever exceeding 100.4°F and ANC below 500 cells/mm3). Electronic chart data will be retrospectively collected for six-month periods from before and after implementation of the early de-escalation guideline (November 2017 to April 2018 and November 2018 to April 2019, respectively). Key parameters within the de-escalation guideline are culture data, defervescence, and procalcitonin trending. The primary objective is to compare pre- and post-implement cohorts for days of antibiotic therapy per 1000 patient days. Secondary objectives include assessment of patient outcomes including hospital length of stay, fever recurrence, re-escalation of therapy, C. difficile infection, adverse drug effects like acute kidney injury, and mortality. Multivariate logistic regression will be used to assess factors associated with early de-escalation.
Presentation Objective: Assess the impact of early antibiotic de-escalation in hospitalized patients with febrile neutropenia.
Self-Assessment: Does early de-escalation of antibiotics prior to absolute neutrophil count recovery impact patient outcomes?
Improving glycemic control in the patient undergoing orthotopic liver transplantation Emma Chee-How University of Alabama Hospital - Birmingham - Birmingham, AL
Background/Purpose: Hyperglycemia during the immediate post-transplant period, defined as 6 months following transplant, is common in orthotopic liver transplant recipients. Uncontrolled hyperglycemia is associated with decreased patient survival and increased risk of infection, graft rejection, and length of hospital stay, making post-transplant blood glucose management crucial. Insulin is the preferred treatment, with insulin infusions commonly utilized during the first 24 to 48 hours following transplant. Patients with ongoing insulin requirements are then transitioned to subcutaneous insulin therapy to facilitate transitions of care between inpatient and outpatient. While some patients require significant amounts of insulin, including therapy continuation as an outpatient, some patients require minimal to no insulin during the immediate post-transplant period. The primary objective of this study is to identify patient-specific risk factors associated with post-operative liver transplant hyperglycemia that necessitates insulin during the immediate post-transplant period.
Methodology: A retrospective review was performed of all patients 18 years of age or older who received a liver transplant at University of Alabama at Birmingham (UAB) Hospital from January 2017 to December 2017. The primary outcome was patient specific risk factors associated with inpatient insulin use during the immediate post-transplant period. Secondary outcomes included patient specific risk factors associated with insulin use at hospital discharge, length of hospital and ICU stay, insulin regimen at discharge, percentage of patients receiving education from the diabetes educator prior to hospital discharge, duration of outpatient insulin therapy, and percentage of patients with an outpatient hemoglobin A1c during the immediate post-transplant period.
Presentation Objective: Identify patient characteristics associated with insulin use during the immediate post-transplant period following orthotopic liver transplant.
Self-Assessment: What patient characteristics were associated with insulin use during the immediate post-transplant period following orthotopic liver transplant?
EVALUATION OF USP IMPLEMENTATION FOR HAZARDOUS DRUG SPILL MANAGEMENT AT A COMMUNITY HOSPITAL C. Leigh Ellis, Tiffany Bolton, Hind Hamid DCH Regional Healthcare System - Tuscaloosa, AL
Background/Purpose: USP General Chapter Hazardous Drugs _x0013_ Handling in Healthcare Settings was created to address the unique safety requirements that are needed to handle antineoplastics and other hazardous medications. The purpose of this study was to assess the impact of multiple educational interventions on the competency and confidence of pharmacy and nursing staff who handle hazardous drug spills.
Methodology: Pharmacy and nursing staff who frequently handle antineoplastics were included in this study. Employees were assessed in two phases. The pre-implementation assessment consisted of a question-based competency survey and hazardous drug spill drill. The educational interventions included computer-based tutorials and in-person training sessions regarding the implementation of the new hazardous drug spill kit. The post-implementation assessment consisted of a second competency survey and hazardous drug spill drill with an emphasis on the new policy and procedures. Pre- and post-implementation assessment scores will be compared using dependent t-test.
Presentation Objective: Discuss the impact of multimodal educational interventions on pharmacy and nursing staff_x0019_s competency and confidence in hazardous drug spill management.
Self-Assessment: Did the educational interventions increase the employees_x0019_ competency and confidence regarding the handling of hazardous drug spills?
Assessment of the ability of a web-based application with gamification to identify opportunities for healthcare intervention Courtney Gamston; Joshua Hollingsworth; Brent Fox; Kimberly Braxton Lloyd Auburn University Pharmaceutical Care Center - Auburn, AL
Background/Purpose: The aims of this study are (1) to develop an interactive, web-based application that consistently identifies opportunities for intervention in an ambulatory care pharmacy setting and (2) to determine the impact of gamification on the ability of a web-based application to identify intervention opportunities.
Methodology: In this prospective, randomized trial, a web-based application integrating intake paperwork with an algorithm to identify patient-specific intervention opportunities was developed. Patients were included if they were 19 years or older and excluded if they were presenting for an injection only. Patients completed intake forms using the application prior to their appointment. The application prompted patients to answer additional health questions and generated a list of potential interventions. Participants were randomized to one of two groups for the additional questions: (i.) Control: No elements of gamification, and (ii.) Experimental: Enhanced with elements of gamification including trivia questions, fun facts, a progress bar, a health knowledge score, and opportunity for rewards. Participants could opt out at any point. Suggested interventions were discussed, addressed, and documented for all patients that utilized the application during their appointment. This project was approved by the Auburn University IRB.
Results: Recruitment is ongoing. Preliminary data show females are 59.3% of participants, and Caucasians are 74.2%; average age was 42.7 (± 12.4) years. Most participants presented for a wellness screening. An average of 1.56 (± 1.66) interventions per patient (n=194 patients) were identified. The most commonly recommended interventions were need for vaccination, thyroid screening, and diet and exercise counseling.
Conclusions: Results demonstrate that a web-based application can consistently identify need for intervention. The impact of gamification is unknown at this time.
Presentation Objective: To assess the use of an application to identify need for health interventions.
Self-Assessment: What is one obstacle for determining the impact of the application?
Impact of Pharmacist Incorporation in a Transition of Care Team on 30-day Readmission Rates of High Risk Patients Amy Li, Teresa Pounds, Pamela Moye-Dickerson, April Mount WellStar Atlanta Medical Center - Atlanta, GA
Background/Purpose: Hospital readmissions that are medication related can be prevented by performing medication reconciliations and patient counseling prior to discharge. The Joint Commission recognizes that the most vulnerable patient populations are those with complex medication regimens, high-risk treatments, and the elderly. The objective of this study is to evaluate the impact of the incorporation of a pharmacist in a transition of care team on 30-day readmission rates of high risk patients.
Methodology: Patients were included if they were greater than or equal to 65 years old, were discharged on 5 or more medications, had a diagnosis of CHF regardless of age, or had a diagnosis of COPD regardless of age. A pharmacist performed a medication reconciliation of each patient_x0019_s discharge medications to identify and resolve any medication errors. The pharmacist then counseled the patient on all medications, making sure to discuss each medication_x0019_s indication, dose, directions, and pertinent adverse effects. Data collection included: patient demographics, comorbidities, medications counseled, medication errors identified, insurance status, discharge disposition, 30-day readmission status, and whether or not readmission was medication related. Data from the intervention group was compared to a historical group who received standard of care during the same corresponding months of the previous year.
Presentation Objective: List medication errors that may be identified during a medication reconciliation.
Self-Assessment: What are the benefits of pharmacist involvement during transitions of care?
Adult procedural sedation in the emergency department Bethany Patel, P. Blankenship, R. Lazim, K. Allmond, J. Chapman Blount Memorial Hospital - Maryville, TN
Background/Purpose: Orthopedic injuries often require urgent closed reduction that is typically facilitated with sedative/analgesic agents. No standard exists for the selection of procedural sedation agents at BMH and remains highly physician dependent. A 2017 study suggested that having electronic decision support tools improved dosing of medications during procedural sedation. This study will evaluate primary outcomes associated with creating a CPOE procedural sedation orderset for the emergency department (ED) including incidence of adverse effects, compliance with guideline-dosing, documentation of patient monitoring, and improving patient safety. A secondary outcome will be to ensure adequate charge capture.
Methodology: This is a retrospective, single-center, cohort study. Our pre-intervention group will consist of adult patients greater than 18 years old seen in the ED for closed joint reduction with procedural sedation from July 1, 2017 to July 1, 2018. Information collected included: medication and doses used, patient weight, adverse effects noted, pharmacist presence during procedure, need for supportive care, and patient vital signs. A procedural sedation orderset was developed and approved in fall 2018 and activated in December 2018 after provider education. The post-intervention group will consist of patients seen in ED for closed joint reduction from January 1, 2019 to March 31, 2019 after implementation of the new orderset. Patients will be excluded if the procedure was not completed in the ED. Data from both groups will be compared to look for differences in primary outcomes.
Presentation Objective: Discuss the impact of having a CPOE procedural sedation orderset for the ED of a community hospital.
Self-Assessment: Does having a CPOE orderset for procedural sedation improve medication safety in the ED?
Assessment of electrolyte repletion in critically ill patients during a drug shortage L. Freeman, A. Newsome, E. Huang, E. Rowe, B. Croft, C. Forehand Augusta University Medical Center/ University of Georgia College of Pharmacy - Augusta, GA
Background/Purpose: Maintaining normal electrolyte values in critically ill patients prevents excess morbidity and mortality. Protocol use (e.g., ventilator weaning, stress ulcer prophylaxis) within the intensive care unit (ICU) increases survival and promotes efficient resource utilization. Electrolyte replacement protocols (ERP) improve prescribing, optimize timeliness of repletion, and reduce adverse events leading to better rates of electrolyte replacement.
Recently, intravenous electrolyte products have become unavailable due to manufacturing delays and increased demand. The ERP at AU Medical Center was suspended in October 2017 due to these shortages. Our institutional strategy promoted repletion using oral agents during this time.
The study purpose was to determine if electrolyte product shortages negatively impact patient outcomes by increasing the frequency of critically low electrolyte values. The primary objective was to compare the percent of patient days that at least one critically low electrolyte value existed before and after suspension of the general and continuous renal replacement therapy (CRRT) ERP.
Methodology: A retrospective, observational cohort study from April 2017 to August 2018 in individuals admitted to the medical, surgical, and trauma ICU was completed. Adults meeting criteria for the general or CRRT ERP for the first time during the study period were included. Patients were excluded if they met exclusion criteria of either ERP (e.g. serum creatinine > 2 mg/dL, diabetic ketoacidosis). The primary outcome (i.e., percent of patient days that at least one critically low value of potassium, magnesium, and/or phosphorus existed before and after ERP suspension) was examined utilizing a two-sample t-test. Data was censured after a seven day ICU stay.
Presentation Objective: Assess how electrolyte product shortages impact the frequency of critically low electrolyte values in adults during ICU admission
Self-Assessment: Which management strategies are most appropriate for electrolyte replacement in critically ill patients during drug shortages?
Evaluation of Dosing Strategies for Four-Factor Prothrombin Complex Concentrate Administration at Two Community Hospitals Andrea Tse, Elizabeth Barrett, Dora Niculas Emory Decatur Hospital - Decatur, GA
Background/Purpose: Four-factor Prothrombin Complex Concentrate (4FPCC), otherwise known as Kcentra®, is an agent indicated for vitamin K antagonist (VKA) reversal in patients with acute major bleeding, need for urgent surgery, or need for invasive procedures. This agent has also been recommended as a first-line option for reversal in patients taking factor Xa inhibitors. However, the ideal dose for this medication remains controversial. Recently, the 2017 ACC Expert Consensus Decision included recommendations on a fixed-dose option of 1000 units for any major bleed and 1500 units for intracranial hemorrhage in the reversal of VKA. They further recommended a dose of 50 units/kg in reversal of factor Xa inhibitors. Though the expert decision pathway does not address the rationale for these dosing strategies, these recommendations are likely based on studies that have shown efficacy in terms of target INR achievement when using a lower, fixed dose strategy. Given these recommendations and findings, the purpose of this study is to determine if various outcomes are impacted by any lower dosing strategy versus the traditional dosing suggested by the manufacturer.
Methodology: For this retrospective chart review, a computer-generated report from the electronic medical record was used to identify all patients who received 4FPCC during a prespecified time-period. Patients who lacked a post 4FPCC INR value were excluded from analysis. Data points to note included dose of 4FPCC received, pre-4FPCC INR, post-4FPCC INR, administration of vitamin K, and chronic oral anticoagulant used. The primary endpoint was change in INR. Secondary endpoints included hemostatic-related clinical response, thromboembolic events within 7 days, and cost incurred by pharmacy.
Presentation Objective: Compare different dosing strategies of Four-Factor Prothrombin Complex Concentrate that currently exist.
Self-Assessment: What are potential benefits and risks that should be considered when utilizing a lower than recommended or a fixed-dose 4FPCC dosing strategy?
PHARMACIST LED COST EFFECTIVENESS INTERVENTION ANALYSIS OF A LEVEL FUNDED HEALTHCARE PLAN IN T2DM Jessica Phipps, Benjamin Price, and Michael Justice Appalachian College of Pharmacy - Oakwood, VA
Background/Purpose: Over the past four years (2014-2018), a lack of funding resulted in permanent closing of three public schools in Southwest Virginia. As a result, educators in SWVA are faced with a higher student-to-teacher ratio, increased class size, and elevated stress. Previous studies have shown that pharmacist-led-interventions are effective in helping patients manage their chronic disease states, namely diabetes. The main purpose of this study is to effectively reduce the healthcare expenditures collected by an area county school system within SWVA. We proposed to positively impact the health status within the diabetic community of SWVA through pharmacist-led-interventions that include education on disease and prevention.
Methodology: Over a 4-month period, we will recruit employees diagnosed with diabetes in select SWVA school systems. All patients will provide informed consent to participate, and the data will be collected from the school systems Third Party Administration (TPA). A Pharmacist will provide health education focused on diabetes care, management, and supplies (glucometer, test strips, lancets, alcohol pads, and logbook) to measure and monitor daily glucose levels. The objective is to improve accountability and encourage lifestyle changes. As a baseline, recent (
Analysis of Pneumonia Treatment in a Community Hospital Sanjay KC, Heather Gibson, Christina Thurber, Bess Johnson, Drew Kessell FirstHealth Moore Regional Hospital - Pinehurst, NC
Background/Purpose: Pneumonia is the eighth leading cause of mortality among adults in the United States.Despite advances in antimicrobial therapy, community acquired pneumonia (CAP) continues to be a significant cause of morbidity and mortality in adults. CAP is one of the most common causes of severe sepsis and infectious causes of death in adults in the United States, with a mortality rate of 30% to 40%. Annual healthcare expenditures are approximately $ 17 billion and are expected to grow as the population ages. The Centers for Medicare and Medicaid Services (CMS) reports risk standardized 30-days mortality and readmission rates for pneumonia. CMS transitioned to a value based payment model reducing reimbursement to hospitals with readmissions. The purpose of this study is to assess the treatment methods utilized for pneumonia diagnosed patients in a community hospital
Methodology: Retrospective chart review of the patients admitted from Oct 2017 to Nov 2018 with confirmed CAP diagnosis. 100 patients were randomly selected. The following data will be collected: Patient demographics, Empirical antibiotic treatment, total duration of inpatient antibiotic treatment, discharge antibiotics, total duration of discharge antibiotics and overall length of therapy
Results: 50 percent of the patients were older than 70 years old. Most of the patients were treated empirically with Ceftriaxone and Azithromycin. 21 patients were treated between 5-7 days, 39 patients between 8-10 days, 32 patients between 11-15 days and 6 patients were treated for more than 15 days
Conclusions: The initial empiric antibiotic therapy is appropriate. However, the total duration of therapy is longer than recommend 5 to 7 days
Presentation Objective: To determine if initial empiric therapy and duration of treatment were appropriate
Self-Assessment: How do you treat the patient with a past medical history of COPD and Diabetes diagnosed with CAP with calculated CURB-65 score of 2?
Implementation of Enhanced Recovery after Surgery (ERAS) Protocol in Elective Total Joint Surgery Abimbola Agbaere, T. Vivian Liao, Teresa Pounds, Juarez Dulce WellStar Atlanta Medical Center - Atlanta, GA
Background/Purpose: Enhanced Recovery after Surgery (ERAS) is a multidisciplinary, perioperative evidence-based plan of care designed to achieve early recovery after surgical procedures. ERAS protocols focus on a bundled approach to effectively aid patients in recovery. Preoperative patient counseling, nutritional support, standardized anesthesia and postoperative multimodal analgesic regimen, fluid management and early mobilization are the key elements of ERAS with the aim of minimizing and improving the response to stress. Compared to the ERAS protocol, traditional perioperative care includes maintaining a fasted state, provision of general anesthesia without goal-directed fluid management. Traditional perioperative care performed with joint arthroplasty contributes to increased hospital readmissions and higher cost.
Methodology: This was a single-center, IRB _x0013_approved, observational, pre- and post-protocol implementation pilot study from October 2018-January 2019. Patients were included in the study if they were at least 18 years old and underwent elective total hip arthroplasty or total knee arthroplasty identified from ICD 10 procedural codes were included in the study. Patients were excluded from the study for the following reasons: revision elective total joint procedures, receipt of transfusion, emergent/trauma patients, uncontrolled Type 1 and 2 diabetes patients (A1C > 7.5), BMI > 45, condition limiting physical therapy participation, multiple operative procedures, or documented allergy to medications evaluated in this study. The primary objective is postoperative complications such as surgical site on days 1, 14 and 30.
Results: As of January 2019, research is ongoing. To date of the 43 patients admitted, 19 patients qualified for the ERAS pilot study with 2 readmissions.
Presentation Objective: Describe the clinical outcomes of an ERAS comprehensive protocol, when compared to traditional perioperative care, on postoperative complications in adult patients undergoing elective total joint surgery.
Self-Assessment: Does the use of immune boosted nutrition supplementation improve outcomes in patients post elective total joint surgery?
Retrospective Review of Stress Ulcer Prophylaxis Utilization at a Community Teaching Hospital Juan Vargas, Candice Simpson, Gerald Miller Bristol Regional Medical Center - Bristol, TN
Background/Purpose: Stress ulcers are superficial inflammatory lesions that tend to occur in the fundus and body of the stomach. These inflammatory lesions develop during high levels of stress following major trauma or critical illness. Stress ulcers form due to changes in the normal protective mechanism of the gastrointestinal tract, such as changes in epithelial cell turnover or bicarbonate production. Hospitalized patients are often inappropriately prescribed stress ulcer prophylaxis (SUP) agents without an indication. Studies suggest that the inappropriate utilization of proton pump inhibitors and histamine-2 receptor antagonist can be reduced by following the American Society of Health System Pharmacist Therapeutic Guidelines for Stress Ulcer Prophylaxis and East Practice Management Guidelines for Stress Ulcer Prophylaxis. The goal of this study was to examine the frequency of inappropriate SUP usage and associated adverse infectious outcomes.
Methodology: This study was a retrospective, single center, chart review that evaluated the utilization of SUP from January 1, 2018 through June 30, 2018. Using the previously referenced guidelines, SUP was evaluated for appropriateness in patients meeting inclusion criteria of 18 years of age or older, inpatient status and stress ulcer agent started during admission. The incidence of Clostridioides difficile infections and pneumonia, as well as the numbers of discharge prescriptions for proton pump inhibitors and histamine-2 receptor antagonists were also reviewed.
Presentation Objective: Evaluate the appropriate use of stress ulcer prophylaxis in hospitalized patients.
Self-Assessment: Is stress ulcer prophylaxis utilization outside of an intensive care unit setting appropriate?
Incidence of Immune-Mediated Adverse Reactions in Patients Treated with a Checkpoint Inhibitor Samantha Schutte, Beth Butz, Danna Nelson East Alabama Medical Center - Opelika, AL
Background/Purpose: Checkpoint inhibitors (CPI) are a class of antineoplastic agents that interfere with the communication between T-cells and cancer cells to induce T-cell activation. These agents increase the T-cell activity against self-cells as well as cancer cells, which can induce an immune-mediated adverse reaction (imAR). The National Comprehensive Cancer Network and the American Society of Clinical Oncology recently published guidelines on the management of these reactions, however, incidence of these immune-mediated adverse reactions is not widely known.
Methodology: This institutional review board approved, single-center, retrospective chart review included patients greater than or equal to 19 years old prescribed a checkpoint inhibitor (ipilimumab, nivolumab, pembrolizumab, or durvalumab) in an outpatient cancer center. Patients were identified using the electronic medical record system between July 2016 and December 2018. The primary objective of this study was to determine the incidence of immune-mediated adverse reactions. Secondary objectives include: time to onset of immune-mediated adverse reactions, frequency of individual immune-mediated adverse reactions, appropriateness of immune-mediated adverse reaction treatment, and the difference in immune-mediated adverse reactions in patients receiving single-agent immunotherapy versus combination immunotherapy. Statistics were calculated using chi-square and fisher_x0019_s exact analysis.
Results: A total of 70 patients were included in this study. It was found that 29% of patients administered a CPI had an imAR (n=20) 95% CI 0.29 (0.19-0.40). Six patients were administered combination therapy, and four of these patients experienced an imAR. This yielded an association between receiving combination CPI therapy and experiencing an imAR (p=0.0308). When evaluating patients with a pre-existing autoimmune disease (n=19), an association was found between having a pre-existing autoimmune disease and experiencing an imAR (n=9) p=0.0336.
Conclusions: N/A
Presentation Objective: Describe the mechanism of checkpoint inhibitors and their associated immune toxicities.
Self-Assessment: How is the mechanism of a checkpoint inhibitor associated with immune-mediated adverse reactions?
Clinical Outcomes of Using mTOR Inhibitors with Reduced Dose of Calcineurin Inhibitors in Lung Transplant Recipients Morgan Frawley, Juliana Leedy, Alex James, Allison Salter, Victoria Rusanov University of Alabama Hospital - Birmingham - Birmingham, AL
Background/Purpose: The use of mammalian target of rapamycin inhibitors (mTORi) in cardiothoracic transplantation has significantly increased over the past decade. The main indications of mTORi in clinical practice are largely restricted to maintenance therapy in the setting of calcineurin inhibitors (CNI) use and developing malignancy, declining renal function, chronic allograft rejection, and cytomegalovirus (CMV) infection. Several recent clinical trials have demonstrated mTORi efficacy in combination with reduced CNI dosing in heart transplant recipients. Considerably less evidence is available in lung transplant populations and is limited to small retrospective studies. There is a need for more data to support the use of mTORi in this group of patients. The purpose of this study is to analyze clinical outcomes of using mTORi in combination with reduced dose of CNI in lung transplant recipients.
Methodology: Single center, retrospective review including lung transplant recipients > 18 years of age under the care of UAB Lung Transplant between October 1989 and July 2018. Patients with history of multiple transplants or who received mTORi therapy < 3 months were excluded. Variables collected included patient demographics, immunosuppression regimens, indication for mTORi initiation, renal function tests, lung function tests, episodes of acute rejection, squamous cell carcinoma episodes, CMV viremia, and mTORi tolerability.
Presentation Objective: Describe the clinical outcomes of using mTOR inhibitors in lung transplant recipients.
Self-Assessment: Which of the following is true regarding clinical outcomes for lung transplant recipients receiving mTOR inhibitors?
Morgan Frawley, Pharm.D. is a current PGY2 Critical Care Pharmacy Resident at the University of Alabama at Birmingham Hospital. She received her Pharm.D. from Auburn University Harrison School of Pharmacy and completed her PGY1 training at the University of Alabama at Birmingham Hospital... Read More →
Thursday April 25, 2019 9:20am - 9:40am EDT
Parthenon 2
Impact of a community pharmacy-based CDTM program supported by a medication synchronization program Caitlin Prather, C. Gamston, G. Peden, J. Qian, J. Vickers, K.B. Lloyd Auburn University Pharmaceutical Care Center - Auburn, AL
Background/Purpose: Community pharmacists are uniquely positioned to improve health outcomes by providing comprehensive drug therapy management (CDTM). Advances in technology facilitate identification of patients who would benefit from CDTM. An estimated 8% of U.S. pharmacies utilize commercial medication synchronization (medsync) software to improve medication adherence. This software also assesses compliance to national quality indicators for patient care. The objective of this study is to determine the impact CDTM on the drug-related problems of diabetic patients with sub-optimal medication adherence and/or gaps in care identified by PrescribeWellness® medsync software.
Methodology: This quality improvement project was conducted in one closed-door pharmacy. PrescribeWellness® was used to identify patients
Standardization of the immunization process and vaccine education for home based primary care at a VA Health Care System Meghan Mark, Courtney Hines, Mary Caputi Salisbury VA Medical Center - Salisbury, NC
Background/Purpose: Home Based Primary Care (HBPC) is a subset of primary care within the VA where Veterans receive primary care at home. Ensuring Veterans are current on immunizations is a challenge as the process varies across the HBPC teams. Veteran hesitancy or refusal decreases immunization rates. There is substantial morbidity and mortality associated with conditions that can potentially be prevented by vaccines. Research indicates that multicomponent strategies such as increased vaccine knowledge, increased access, targeting of unvaccinated populations, and verbal discussions are the most effective ways to handle vaccine hesitancy. The purpose of this project was to develop a standardized immunization process for all sites within HBPC at the Salisbury VA Health Care System (SVAHCS).
Methodology: This study involved HBPC Veterans and staff (NPs/RNs) within the SVAHCS. Data was collected to gather information regarding the vaccination process, note titles being used to document administration, and common reasons for refusal of vaccines. Education was developed for HBPC staff regarding vaccine resistance, and risks and benefits of common vaccines given within HBPC (influenza, Tdap/Td, PPSV23, PCV13, and zoster series). Before developing standardized education materials, a survey was administered to HBPC staff to assess confidence and comfort regarding providing vaccine education for Veterans, the handling of vaccine resistance, and administering multiple vaccines during one visit. The same survey was re-administered after the development of standardized education to assess the change in HBPC staff_x0019_s confidence and comfort.
Presentation Objective: Evaluate the impact of the development of a standardized immunization process on HBPC staff_x0019_s confidence and comfort with provision of immunization education.
Self-Assessment: How does the development of targeted education for HBPC staff change confidence and comfort with common vaccines given and with addressing Veteran vaccine resistance?
A Review of Appropriate Dosing of Direct Oral Anticoagulants Heather Culler, Abby Singleton, Rebecca Holt, David Stewart Bristol Regional Medical Center - Bristol, TN
Background/Purpose: Direct oral anticoagulants (DOACs) are newer medications used to prevent venous thromboembolism (VTE) and stroke. These medications are often favored by patients due to the lack of laboratory monitoring requirements, as well as the lack of dietary constraints. Despite bleeding being the most common adverse effect, DOACs are often prescribed due to their overall favorable bleeding profiles, compared to warfarin. Studies with DOACs excluded or lacked sufficient representation of special populations, such as overweight and underweight patients, patients with active cancer, and moderate to severe renal insufficiency. Significant questions remain concerning dose appropriates in select patient populations.
Methodology: This Institutional Review Board approved study was a retrospective, single-center, randomized chart review at a community teaching hospital. The electronic medical record system was used to identify patients from September 1, 2017 to September 30, 2018. Eligible participants were inpatients that were 18 years of age or older that reported a DOAC as a home medication, were given a DOAC during their hospital visit, and/or were discharged with an order for a DOAC. Patients were excluded from the study if they were pregnant, had a mechanical heart valve, or were in comfort care or hospice. The primary outcome was incidence of appropriate FDA approved dose of DOAC prescribed for patients. Secondary outcomes included: composite of any major bleed or symptomatic thrombotic event, any hospitalization, hospitalization relative to bleeding or thrombosis, length of stay, and incidence of weight less than 60 kilograms or greater than 100 kilograms.
Presentation Objective: Evaluate event rates associated with appropriately and inappropriately dosed DOACs.
Self-Assessment: Are inappropriately dosed DOACs associated with more strokes, bleeding events, or thromboembolic events?
EFFICACY AND SAFETY OF A STANDARDIZED DIABETIC KETOACIDOSIS MANAGEMENT PROTOCOL IN AN ACADEMIC MEDICAL CENTER Jessica Ringler, Ah Hyun Jun, Christy Forehand, Seth Garner, Clark McDonoug Augusta University Medical Center/ University of Georgia College of Pharmacy - Augusta, GA
Background/Purpose: Studies have shown standardizing the treatment of diabetic ketoacidosis (DKA) results in decreased time to initiation of therapy, faster resolution of DKA, and decreased length of intensive care unit (ICU) stay, while avoiding increases in the incidence of hypoglycemia when comparing nurse-driven protocolized care and physician initiated care. Protocol based treatment is recommended in the American Diabetes Association Hyperglycemic Crisis Guideline; however, the algorithm is unclear in regards to dose titrations after therapy initiation. This requires each institution to develop a protocol. The purpose of this study was to determine if protocolized DKA treatment reduces time to resolution of DKA without increasing risk of hypoglycemia when compared to provider-driven care at an academic medical center.
Methodology: This was an institutional review board-approved, single-center, retrospective chart review. Eligible patients were identified based on treatment for DKA from March 1, 2017 to November 30, 2018. Patients treated for DKA prior to protocol implementation, in February 2018, were identified using discharge ICD-10 codes. Patients treated after protocol implementation were identified using a hospital-specific electronic medical record flag that was associated with the DKA order set. Patients were included if they were greater than or equal to 18 years of age. Patients were excluded if they were pregnant or if basic metabolic panel laboratory result intervals exceeded 8 hours. The primary outcome of this study was time to resolution of DKA. Secondary outcomes included the incidence of anion gap reopening, incidence of hypoglycemia, and ICU length of stay. The primary outcome was assessed using a Kaplan-Meier curve with log-rank testing.
Presentation Objective: Assess an institution-specific, nurse-driven protocol to determine its efficacy and safety in the setting of DKA.
Self-Assessment: In what ways does the use of an institution-specific nurse-driven protocol impact time to resolution of DKA?
Impact of Clinical Pharmacist Practitioners on Urine Culture Stewardship in the Emergency Department Audreanna Williams, Megan Goodale, Evan MacDonald Caromont Regional Medical Center - Gastonia, NC
Background/Purpose: The purpose of this study is to analyze pharmacist-led urine culture follow up after emergency department discharge.
Methodology: Eligible patients were those greater than or equal to 18 years of age who had a urine culture collected in the emergency department and were then discharged. An algorithm was developed based on Infectious Disease Society of America treatment guidelines of acute uncomplicated cystitis and pyelonephritis in addition to FDA approved medication labeling. Patients were then divided into 2 groups; those who had a urine culture obtained prior to implementation of the algorithm and those who had a urine culture obtained after implementation of the algorithm.
Presentation Objective: Describe the common reasons as to why antibiotics are inappropriately prescribed to patients with urinary tract infection.
Self-Assessment: What is one advantage to having clinical pharmacist practitioners involved in urine culture stewardship?
Implementation of a vaccine order set with evidence-based recommendations into a computerized electronic health record system Jeremy Bennett, Kathryn DeSilva, Vian Farino Atlanta Veterans Affairs Medical Center - Atlanta, GA
Background/Purpose: Providing vaccinations and ensuring immunization to preventable diseases can help to reduce preventable hospitalizations and lower healthcare expenditures. The Atlanta Veterans Affairs currently does not have an efficient vaccination ordering system available to healthcare providers. To streamline the vaccine ordering process, a computerized order template with evidence-based recommendations will be created and implemented. Incorporating vaccine order sets with specific vaccine recommendations and dosing schedules may increase provider productivity and ensure proper health maintenance for the patients in various practice settings.
Methodology: The pharmacy resident conducted extensive literature review and incorporated the most relevant vaccine recommendations to implement in the vaccine ordering template based on current data provided through expert opinion, meta-analyses, package inserts, current Centers for Disease Control and Prevention recommendations, and current Advisory Committee on Immunization Practices recommendations. Information included was not be limited to: age recommendations, recommendations based upon co-morbid conditions, dosing schedules, and contraindications for use. The vaccine recommendations and information will be incorporated into the Computerized Patient Record System (CPRS) and provided through an in-clinic order set. To ensure effective incorporation, the pharmacy resident will consult with various physicians, nurses, pharmacists, and information technology specialists. Upon review by several departments, the order template will be submitted to the Pharmacy and Therapeutics committee for final approval. An in-service to the medical center staff will be provided at the completion of this project to increase awareness of its availability and ensure proper use. Once implemented, pharmacy will be responsible for updating the order set periodically based on any new evidence published.
Presentation Objective: To improve the attention given to adult immunizations and streamline the process of ordering the appropriate vaccines.
Self-Assessment: True/False: Implementation of an order set with evidence-based recommendations may assist healthcare providers with ensuring proper health maintenance.
Implementation of Penicillin Skin Testing in Group B Streptococcus-Positive Pregnant Women with Documented Penicillin Allergy Brooke Kopelakis, Heather Gibson, Andrew Kessell FirstHealth Moore Regional Hospital - Pinehurst, NC
Background/Purpose: Current guidelines recommend the use of penicillin G immediately before and during labor for pregnant women who are positive for Group B Streptococcus (GBS) to prevent transmission to the neonate during delivery. Women who have an allergy to penicillin are recommended to receive either cefazolin or vancomycin as an alternative. Per our institution_x0019_s policy, neonates whose mothers receive an alternative antibiotic during delivery must remain in the hospital an additional 24 hours for observation. Penicillin allergies are often self-reported and, when confirmatory allergy testing is performed, many patients are found to not have a true allergy. The purpose of this project was to implement a penicillin skin test in our outpatient women_x0019_s clinic to optimize antibiotic therapy and reduce length of stay in GBS-positive women with a reported penicillin allergy.
Methodology: Literature searches and discussions with the penicillin skin test antigen representatives were performed to determine the safety of penicillin skin testing in the pregnant population. The feasibility of preparing the dilute penicillin G product was reviewed with the inpatient Pharmacy Department, and the stability and storage requirements of the preparation were researched. Discussions with the physicians_x0019_ group of the women_x0019_s clinic were held to determine which patients would be considered eligible for penicillin skin testing. The penicillin skin test policy for the inpatient antimicrobial stewardship program was reviewed and revised for the outpatient obstetrics/gynecology setting. Training and education were scheduled for the nurses and physicians of the outpatient women_x0019_s clinic.
Presentation Objective: List appropriate antibiotics for prevention of Group B Strep transmission during delivery.
Self-Assessment: According to the ACOG Guidelines, which of the following antibiotics is not a recommended first- or second-line agent for prevention of Group B Strep transmission during delivery? (A) Penicillin G (B) Cefazolin (C) Meropenem (D) Vancomycin
Evaluation of a benzodiazepine-sparing alcohol withdrawal treatment protocol Megan Nesbitt, Patrick Ellis, Rachel Kile CHI Memorial - Chattanooga, TN
Background/Purpose: The current standard of care for the treatment of alcohol withdrawal is benzodiazepines. Although effective in reducing withdrawal severity, benzodiazepines are associated with many risks including increased cravings for alcohol, early relapse to drinking, sleep disturbances, and more. The alcohol withdrawal treatment protocol used by our institution consists of scheduled benzodiazepine regimens. With published literature describing the risks of these medications as well as internal issues with this protocol, a decision was made to develop a new, benzodiazepine-sparing alcohol withdrawal protocol, and once developed, assess its efficacy and safety in the patient population treated by our institution. Several studies have demonstrated positive results with a gabapentin taper as an alternative to benzodiazepines in mild to moderate alcohol withdrawal, and this taper became the basis of our institution_x0019_s new alcohol withdrawal protocol.
Methodology: Following development and implementation of a benzodiazepine-sparing alcohol withdrawal protocol utilizing a gabapentin taper, a retrospective analysis was completed to evaluate patients at the Glenwood and Hixson campuses of CHI Memorial Hospital treated for mild to moderate alcohol withdrawal with this protocol. A retrospective comparator group was also evaluated for patients treated with the _x001C_traditional_x001D_ benzodiazepine treatment protocol. Patients excluded from both groups include those that were admitted directly to the intensive care unit (ICU). Data collected from these patients included primary diagnosis, gender, length of stay, occurrence of seizure or transfer to ICU total daily doses of lorazepam, average daily CIWA score, adverse effects, and if a discharge prescription for a benzodiazepine or gabapentin were prescribed.
Presentation Objective: Compare the efficacy and safety of a benzodiazepine-sparing protocol to a traditional benzodiazepine-based protocol in the treatment of mild to moderate alcohol withdrawal.
Self-Assessment: In the treatment of alcohol withdrawal, benzodiazepines have been associated with what risks/effects?
Costs and Clinical Outcomes Associated with AYA 10403 Versus HyperCVAD in Adults with Acute Lymphoblastic Leukemia Pamiz Alibhai, Seyyedeh Saneeymehri, Rebecca Klisovic Emory University Hospital - Atlanta, GA
Background/Purpose: Acute lymphoblastic leukemia (ALL) is a hematological malignancy characterized by proliferation of lymphoid progenitor cells in the bone marrow, blood, and extramedullary sites. Despite improvements in dose intensification that have resulted in improved outcomes for children, the prognosis in elderly patients remains poor. The most commonly utilized regimen for adult ALL patients at Emory University Hospital (EUH) has been _x001C_HyperCVAD_x001D_; however, the use of pediatric-inspired regimens such as AYA 10403 for the adolescent and young adult (AYA) population has shown to improve overall survival (OS). HyperCVAD is typically administered inpatient while AYA10403 is predominately administered outpatient, although toxicities have warranted inpatient admissions for patients on either of these two regimens. The purpose of this study is to compare cost and clinical outcomes associated with treating adult ALL patients with HyperCVAD versus AYA 10403.
Methodology: This IRB-approved single-center, retrospective chart review included patients with newly diagnosed ALL who were least 18 years of age and received primary treatment with either HCVAD or AYA 10403. Patients with Philadelphia chromosome positive disease, refractory disease, or mixed-phenotypic acute leukemia were excluded. Patients were identified based on ICD 9 and ICD 10 codes for the period of July 31st 2017 to July 31st 2018. Data was recorded for 6 months after initiation of treatment, or until the patient switched therapies or expired. The primary endpoint for this study was total costs as generated by the EUH finance department. Secondary endpoints include total inpatient costs, incidence of adverse events and infections, days of treatment delay, and treatment related mortality.
Presentation Objective: Identify regimen specific characteristics that would help determine which regimen would be more ideal for a patient.
Self-Assessment: What are some patient specific factors that decision makers would consider when selecting one regimen over the other?
Medication Discrepancies at Hospital Discharge in Patients with Type 1 and Type 2 Diabetes on Insulin Angela Knight, Autumn Steen, Ryan Tilton Mission Hospitals PGY1 Amb. Care - Asheville, NC
Background/Purpose: In 2017, the Diabetes Education Center at Mission Hospital initiated a program where clinical pharmacists provide post-discharge telephone calls to patients on insulin discharged from Mission Hospital. The outcomes of this program have not yet been evaluated.
Methodology: The electronic medical record was used to identify patients who received a post-discharge call between 1/1/17 and 9/10/18. The following data was collected for each patient: MRN, FIN, age, race, ethnicity, sex, type of insurance, type of diabetes, A1c, comorbidities, discharge date, date of telephone call, number of medications, type of insulin, scheduled and kept appointments, number and type of medication discrepancies, number of appointment discrepancies, and clinical interventions made. Primary objectives for this study included the number and types of medication discrepancies identified, number and types of clinical interventions made by the pharmacists, and the number of appointment discrepancies identified.
Results: A total of 168 telephone calls were evaluated. The clinical pharmacists identified 218 medication discrepancies. The most common discrepancy was not taking a medication that was prescribed at discharge, which represented 27.5% of all medication discrepancies identified. The clinical pharmacists made a total of 169 clinical interventions. The most common clinical intervention was providing education, which accounted for 45% of all interventions. A total of 8 appointment discrepancies were identified. Additionally, 56.8% of patients who received a phone call and had an appointment scheduled at the Diabetes Education Center ended up keeping their appointment, compared to a general no-show rate of 50% at Mission's Diabetes Education Center.
Presentation Objective: To assess the prevalence and characteristics of medication discrepancies, identified through post-discharge telephone calls from clinical pharmacists, among patients with type 1 and type 2 diabetes on insulin therapy.
Self-Assessment: What are some potential benefits of having clinical pharmacists provide post-discharge telephone calls to patients with diabetes on insulin?
Impact of pharmacist intervention on reducing readmission rates and mortality in a community hospital heart failure clinic Stephanie Shuder, Michael Simpson, Holly Gilliam Alamance Regional Medical Center - Burlington, NC
Background/Purpose: Most heart failure patients have co-morbid disease states requiring multiple medications. Patients taking multiple medications are at increased risk of medication-related problems and improper drug selection, which are potential causes of hospital admission. As patients transition from inpatient to the outpatient setting, pharmacists can positively affect medication reconciliation and education. The purpose of this study is to determine if pharmacist intervention can impact 30-day all-cause readmission and mortality of patients in a heart failure clinic. We also hope to determine if pharmacist intervention can impact 90-day all-cause readmission and mortality, 30-day emergency department visits, and time to first all-cause readmission.
Methodology: This study has three intervention groups. The no intervention group is evaluating primary and secondary outcomes in heart failure clinic patients prior to pharmacist interaction. The basic intervention group is evaluating primary and secondary outcomes in patients with two hours of pharmacist medication review. The extended intervention group is evaluating primary and secondary outcomes in patients with pharmacy residents alongside a nurse practitioner. A chart review will be conducted for any qualifying patient to gather baseline demographic data, admission and discharge diagnosis, reason for emergency room visits, medication adherence, treatment parameters, outcomes and time to admission and/or death.
Presentation Objective: Identify if pharmacist intervention has an impact on 30-day all-cause readmission and mortality in a community hospital heart failure clinic.
Self-Assessment: How does pharmacist intervention in a community hospital heart failure clinic impact 30-day all-cause readmission and mortality rates?
Octreotide for Secondary Prevention of Left Ventricular Assist Device-Associated Gastrointestinal Bleeding J Cook, C Carson, M Conway, H Lee, B Liu, C Holley, C Patel, K Campbell Duke University PGY2 Cardiology Residency - Durham, NC
Background/Purpose: Gastrointestinal (GI) bleeding is a significant cause of post-implant morbidity in patients with a continuous-flow left ventricular assist device (CF-LVAD). Clinical application of pharmacologic management strategies has been limited by poor characterization of treatment modalities and a lack of statistical power in existing literature. We conducted a retrospective case-control study to assess the safety and efficacy of octreotide for the secondary prevention of CF-LVAD-associated GI bleeding.
Methodology: Patients 18-89 years of age who received octreotide for secondary prevention of CF-LVAD-associated GI bleeding at Duke University Hospital (Durham, NC) from July 18, 2013 to October 31, 2018 were included. GI bleeding was defined according to the Interagency Registry for Mechanically Assisted Circulatory Support as any clinically suspected or documented bleeding from the GI tract as indicated by a new drop in hemoglobin and/or the appearance of melena, hematochezia, hematemesis, or guaiac-positive stool. Patients treated with octreotide were matched to controls by age ± 5 years, serum creatinine ± < 30%, number of prior CF-LVAD-associated GI bleeds, and device type. Data was collected until the time of cardiac transplantation, device explantation, death, or the conclusion of the study period, whichever occurred first. The primary outcome was the incidence and time to recurrent CF-LVAD-associated GI bleeding. Secondary outcomes included re-hospitalization for recurrent GI bleeding; hospital length of stay; LVAD-associated thrombotic complications; modifications to antithrombotic therapies or device speed; blood product transfusions; and endoscopic procedures and subsequent intervention.
Presentation Objective: Assess the safety and efficacy of octreotide for the secondary prevention of CF-LVAD-associated GI bleeding.
Self-Assessment: Which of the following outcomes is associated with the utilization of octreotide in patients with a CF-LVAD and refractory GI bleeding?
Evaluation of Weight-Based Enoxaparin Dosing and Monitoring for VTE Prophylaxis in Trauma Patients Ashley Taylor, Ellen Huang, Tim Robinson, Cassandra White Augusta University Medical Center/ University of Georgia College of Pharmacy - Augusta, GA
Background/Purpose: Trauma patients are at an increased risk of developing venous thromboembolism (VTE), and enoxaparin is considered the standard of care for VTE prophylaxis in this population. The current standard of practice for VTE prophylaxis in trauma patients at AU Medical Center is weight-based enoxaparin dosed at 0.5 mg/kg subcutaneously every 12 hours that is monitored via anti-factor Xa levels. While there is literature suggesting higher doses of enoxaparin are more effective in achieving goal anti-factor Xa levels, there limited information regarding the use of weight-based dosing across all weights in the trauma population. The purpose of this project is to evaluate the utility of routine anti-factor Xa level monitoring for trauma patients initiated on weight-based enoxaparin for VTE prophylaxis and identify patient populations where monitoring would be necessary.
Methodology: The inclusion criteria were adult patients admitted to the trauma service who received at least 3 consecutive doses of enoxaparin 0.5 mg/kg every 12 hours for VTE prophylaxis prior to an anti-factor Xa peak. Patients were excluded if they had a creatinine clearance of less than 30 mL/min, baseline platelet count of less than 50,000/mm3, allergy to heparin, history of heparin-induced thrombocytopenia, were pregnant or received therapeutic anticoagulation prior to trauma admission. The primary endpoint was the percentage of patients who fell within the goal anti-Xa peak range. The secondary endpoints included the incidence of VTE and clinically significant bleeding. An analysis was completed to determine if a correlation exists between anti-Xa peaks not within the goal range and certain patient characteristics, including critical illness and obesity.
Presentation Objective: Discuss the utility of routine anti-factor Xa monitoring of weight-based enoxaparin dosing for VTE prophylaxis in trauma patients
Self-Assessment: Are anti-factor Xa levels necessary measurements to routinely monitor in trauma patients receiving weight-based enoxaparin dosing for VTE prophylaxis?
Impact of Early, Appropriate Antibiotics in Septic Patients in the Emergency Department Regan Kitchens, Megan Goodale, Evan MacDonald CaroMont Regional Medical Center (Emergency Medicine) - Gastonia, NC
Background/Purpose: Assess the impact of pharmacy-to-nursing education on early antibiotic administration in patients with suspected sepsis in the emergency department (ED)
Methodology: Patients who were 18 years or older, diagnosed with sepsis or septic shock, and received all appropriate antibiotics in the ED according to their suspected source of infection were included in this IRB-approved, prospective study. Nursing in-services were conducted by a pharmacist to educate ED nursing staff on the importance of early time-to-administration of all ordered antibiotics, Centers for Medicare & Medicaid Services (CMS) sepsis core measures, and proper sequence of administration. The primary endpoint was the impact of nursing education on time-to-administration of all ordered antibiotics. Secondary endpoints included appropriate sequence of antibiotic administration, administration of all ordered antibiotics within one hour, 1-3 hours, and three hours after sepsis recognition, and overall mortality.
Presentation Objective: Evaluate the impact of nursing education on time-to-antibiotic administration in septic patients.
Self-Assessment: What is one area in which ED clinical pharmacists can impact time-to-antibiotic administration when caring for septic patients?
Impact of provider education on antibiotic prescribing rate for acute respiratory tract infections in a clinic setting Jessica Some, Brad Crane, Abby Bussey, Emily Duncan, Stephanie Grimes Blount Memorial Hospital - Maryville, TN
Background/Purpose: Antimicrobial stewardship has been well implemented in the inpatient setting; however, the same focus has not been applied in the outpatient setting, where the CDC reports the majority of antibiotic prescribing occurs. Patients are often prescribed antibiotics for acute respiratory conditions, presenting an opportunity to examine antibiotic prescribing rates. The study_x0019_s purpose is to evaluate the impact of pharmacist-led provider education on antibiotic prescribing rates for acute uncomplicated bronchitis, acute sinusitis, and acute pharyngitis in an ambulatory clinic setting.
Methodology: This study is an IRB approved, retrospective cohort analysis comparing all patients who were seen by internal medicine and family medicine providers for acute uncomplicated bronchitis, sinusitis, or pharyngitis as specified by ICD-10 codes during October 1-December 31, 2017 (control group) and October 1-December 31, 2018 (intervention group). Patients were excluded if they had chronic sinusitis or were less than 18 years old. The primary objective was to assess antibiotic prescribing rate before and after a pharmacist-led provider education session focused on best practices for antibiotic prescribing in acute respiratory tract infections. Secondary objectives included assessing differences in antibiotic prescribing between physicians, nurse practitioners, and physician assistants.
Results: A total of 1062 patients (553 control vs. 509 intervention) were included in the study. A reduction in overall antibiotic prescribing rate was observed after the intervention (76.5% vs. 74.7%). The majority of patients were seen by physicians, whose overall antibiotic prescribing rate increased (76.3% vs.77.5%). Antibiotic prescribing rate for nurse practitioners decreased (76.3% vs. 38.5%).
Presentation Objective: To assess whether pharmacist-led provider education had an impact on antibiotic prescribing rates
Self-Assessment: What is one area in which ambulatory care pharmacists can have an impact on outpatient antimicrobial stewardship?
The Financial and Operational Benefits of a PGY-2 Infectious Diseases Residency Program Philip Whitfield, Jonathan Edwards, David Collette, Adam Sawyer Huntsville Hospital - Huntsville, AL
Background/Purpose: A recent study determined that to maintain a robust antimicrobial stewardship program (ASP) at least 1.0 pharmacy specialist per 100 occupied beds should be employed. For most institutions, obtaining additional pharmacist positions is simply not feasible . One proposed strategy to close the gap in antimicrobial stewardship specialists is to invest in a PGY-2 Infectious Diseases (ID) Pharmacy Residency. The purpose of this study was to determine the cost avoidance and operational changes associated with hiring a PGY-2 ID resident.
Methodology: A cost avoidance analysis was performed utilizing known costs of hiring the PGY-2 ID resident and estimated costs of hiring a new ID clinical specialist. Cost items included salary, benefits, recruitment, accreditation fees, travel, and an estimation of residency program director time specifically dedicated to the residency program, that otherwise would not be necessary. Finally, a description of the resident_x0019_s general productivity and the basic operational changes of the ASP during the first year of the program were assessed.
Results: The hiring of a PGY-2 ID resident accounting for cost avoidance alone would save the institution an estimated $82,543. The resident_x0019_s productivity after 2/3 of the residency had been completed was similar with the current clinical specialist employed. Through the resident_x0019_s efforts, a novel protocol of placing ASP recommendations within the appropriate physician_x0019_s electronic EMR inbox was developed leading to an apparent increase in operational efficiency.
Conclusions: The strategy of hiring a PGY-2 ID resident to close the needed gap in antimicrobial stewardship pharmacist positions is justified financially through over $80,000 in cost avoidance and operationally through increased productivity and advances in antimicrobial stewardship practice.
Presentation Objective: The purpose is to review a practical example of the justification for an infectious diseases residency program.
Self-Assessment: In what other pharmacy specialties may a PGY-2 resident show similar benefits?
Prevalence of inpatient hypoglycemia and utilization of basal-bolus for improved glycemic control Karishma Patel Emory Decatur Hospital - Decatur, GA
Background/Purpose: Inpatient hypoglycemia in patients with diabetes leads to longer lengths of stay, higher rates of readmission, and greater likelihood of discharge to skilled nursing facilities. Hypoglycemia is a core measure utilized by Centers of Medicare and Medicaid Services to evaluate quality control of an institution. Currently our institution has a 6% rate of hypoglycemic events over a three month period with a target of less than 1.13%. Therefore, the need to re-evaluate and improve current practice for hyperglycemic control is vital in overall patient outcomes. The American Diabetes Association recommends the use of a basal-bolus regimen and advises against the use of correctional insulin alone. The purpose of this study is to identify the cause of hypoglycemic events, to evaluate insulin prescribing habits to improve management response to hypoglycemic events, and to encourage the use of basal-bolus insulin in applicable patients.
Methodology: This study includes all diabetic adult patients admitted to Emory Decatur Hospital and will be conducted in two phases. The first phase includes a retrospective systematic review of critical hypoglycemic events occurring over a three-month period. The primary outcome is the occurrence of hypoglycemia (BG < 50mg/dL) within 48 hours of admission. Secondary outcomes include: hospital-wide occurrence of hypoglycemia, overall hospital length of stay, and ICU readmission rates. The second phase consists of a prospective approach identifying patients who have experienced a hypoglycemic event, time effectively determining cause of hypoglycemic event, and evaluating the appropriateness of current insulin regimen. Pharmacist intervention includes collaborating with the provider to adjust the insulin regimen per ADA guidelines and initiating basal-bolus insulin for applicable patients.
Presentation Objective: To evaluate the effect of utilization of basal-bolus in appropriate patients and evaluate its impact on the incidence of hypoglycemic events seen at our institution.
Self-Assessment: What are potential causes of hypoglycemia in the inpatient setting?
Peripheral Neuropathy in Non-Hodgkin_x0019_s Lymphoma Patients Receiving Vincristine with and without Aprepitant, Fosaprepitant Jessi K. Edwards, John Bossaer, Paul O. Lewis, Ashley Sant Johnson City Medical Center - Johnson City, TN
Background/Purpose: Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse effect associated with vincristine chemotherapy. In 2014, Naoto Okada and investigators discovered an increased incidence of CIPN onset during the first cycle of chemotherapy when aprepitant, a NK-1 antagonist, was given with vincristine. The purpose of this study was to investigate if there is a clinically significant drug interaction between vincristine and aprepitant/fosaprepitant resulting in early-onset CIPN. Secondarily, this study investigated the cumulative rate of CIPN throughout the entire treatment course.
Methodology: This IRB approved, single-center, retrospective cohort chart review was performed at Johnson City Medical Center and evaluated adults who received R-CHOP or similar chemotherapy for the treatment of Non-Hodgkin_x0019_s Lymphoma between July 1, 2010 through June 30, 2018. Data collected included demographic information, aprepitant/fosaprepitant use, chemotherapy regimen and dose, neuropathy onset time, neuropathy grade, pertinent laboratory values, potential confounding comorbidities, and concurrent use of additional CYP3A4 inhibitors. Early-onset CIPN was defined as neuropathy developing during the first cycle of chemotherapy. Neuropathy rates were analyzed by one-tailed chi-square.
Results: Of the 115 subjects that met inclusion criteria, CIPN rates in the first cycle appeared elevated in subjects with concurrent NK-1 antagonist use as compared to those without (26.7% vs 22.7%; P=0.67). The secondary endpoint of overall neuropathy rates was higher with concurrent NK-1 antagonist use (56% vs 36%; P=0.039). The overall median time to neuropathy onset was 25.5 days.
Conclusions: Concurrent use of aprepitant or fosaprepitant with vincristine-based chemotherapy does not increase the rate of CIPN in the first cycle but appears to increase cumulative rates of CIPN.
Presentation Objective: Identify if there is a clinically significant drug interaction between vincristine and aprepitant or fosaprepitant resulting in early-onset chemotherapy-induced peripheral neuropathy.
Self-Assessment: Does concomitant use of aprepitant or fosaprepitant with vincristine chemotherapy result in early-onset peripheral neuropathy?
Evaluation of Once-Daily vs. Twice-Daily Dosing of Caffeine for Apnea of Prematurity Aubrey Rebentisch, Karen Kovey Mission Hospitals - Asheville, NC
Background/Purpose: Caffeine works to ameliorate apnea in premature infants through stimulation of respiratory neural output and is considered a relatively safe medication with a wide therapeutic index, long half-life, and few associated adverse effects. Standard dosing of caffeine citrate for apnea of prematurity is a 20 mg/kg loading dose given intravenously or enterally, followed by a 5-10 mg/kg once-daily maintenance dose. While no studies have evaluated a twice-daily dosing schedule of caffeine for apnea of prematurity, physicians at Mission Hospital often administer the maintenance dose of caffeine in two divided doses. Evaluation of caffeine citrate dosed twice daily is needed in order to guide best practice in the treatment of apnea of prematurity at Mission Hospital.
Methodology: This is an Institutional Review Board approved, retrospective chart review of infants delivered at < 32 weeks gestation with documented administration of caffeine dosed once daily and twice daily. Exclusion criteria include infants with congenital diaphragmatic hernia, hydrops, genetic abnormalities, or documentation of invasive mechanical ventilation during the study period. The primary objective is to assess the incidence of apnea and bradycardia in infants before and after switching from a once-daily to a twice-daily dosing schedule of caffeine. Secondary objectives include incidence of tachycardia, GERD, NEC, tachypnea, bradycardia, BPD, severe desaturation events, hospital length of stay, growth failure weight on day of life 7/14/21/90, time to reach full enteral feeds, sepsis, anemia, and days on oxygen/positive airway pressure.
Presentation Objective: Describe the outcome of a twice-daily dosing regimen of caffeine for apnea of prematurity.
Self-Assessment: True or False: The maintenance dose of caffeine used for apnea of prematurity is currently labeled for twice-daily administration.
Using a Clinical Order Set to Mitigate Opioid Risk Jack Ledford, Sharon Castle Ralph H. Johnson VA Medical Center - Charleston, SC
Background/Purpose: The misuse of and addiction to opioids, including prescription pain relievers, has developed into a serious national crisis that affects public health as well as social and economic welfare. The Comprehensive Addiction and Recovery Act (CARA), signed into law in 2016, established policy on implementation of Opioid Safety Initiative (OSI) case reviews and requires documentation of opioid-related risks. These documented case reviews are required specifically for: (1) patients identified as being in the _x001C_Very High-Opioid Prescription_x001D_ risk category for an overdose or suicide-related event; and (2) patients with new opioid prescribing, before initiating opioid therapy by the health care provider. The purpose of this project is to evaluate opioid safety metrics (i.e. State Prescription Drug Monitoring, Risk Reviews, Urine Drug Screening) and surrogate markers (i.e. Morphine Equivalents) of patient safety in order to streamline and improve the prescribing of opioids.
Methodology: A clinical order set was created for providers to use when prescribing an opioid. The order set involves completing a PDMP check and assessing the patient_x0019_s risk factors for opioid abuse and adverse effects. This project is a retrospective and prospective medical record review to track the use of opioids pre-and-post implementation of a clinical order set. Any outpatient receiving an opioid during the months of April _x0013_ September 2018 or an opioid using the clinical order set during the months of October 2018 _x0013_ March 2019 were included in this study.
Presentation Objective: To compare outpatient opioid prescribing patterns before and after implementing a clinical order set at a VA Medical Center.
Self-Assessment: Per federal law, how often is the State PDMP required to be reviewed when prescribing a chronic CII substance?
The Impact of Mental Health Clinical Pharmacists in Benzodiazepine Prescribing Hope Syfrett, Rashida Fambro, Jasmine Howell, Eileen Sordo Central Alabama VA Health Care System - Montgomery, AL
Background/Purpose: Long term use of benzodiazepines has been associated with substantial cognitive decline, depression, addiction, diminished physical coordination, and increased hospitalizations. The prevalence of long-term benzodiazepine is high among the military population, and is largely used inappropriately. In response, two programs have been developed. One program, the Psychotropic Drug Safety Initiative (PDSI) will begin in 2019 and is focused on reducing inappropriate use of benzodiazepines. Another, the Academic Detailing sedative-hypnotics in elderly program, focused on increasing education to Veterans and physicians regarding the risk of sedative-hypnotic medications in the elderly, including benzodiazepines, zolpidem, zaleplon, and eszopiclone. The purpose of this project is to identify the pharmacist role in benzodiazepines prescribing.
Methodology: Pharmacist educated psychiatrist within CAVHCS of the purpose of project and reviewed Veterans considered high risk on benzodiazepines via academic detailing dashboards and provided recommendations to the patient_x0019_s provider. Veterans were enrolled in mental health clinical pharmacist specialist clinics per provider consults.
Presentation Objective: Identify various interventions pharmacist can make in benzodiazepine prescribing.
Self-Assessment: What interventions can pharmacists make to help improve patient care with benzodiazepine prescribing?
Pharmacist-led interventions to reduce 30-day readmission rates in patients with COPD Courtney Pearson, Rachel Kile CHI Memorial - Chattanooga, TN
Background/Purpose: Chronic Obstructive Pulmonary Disease (COPD) is the third-leading cause of death in the United States and results in 700,000 hospitalizations annually. Around 20% of these hospitalized patients will be readmitted within 30 days. Quality transitions of care can improve patient outcomes and limit readmission rates and ED visits. Pharmacists are well-equipped to provide transitional care services for patients with COPD.
Methodology: This single-center evaluation includes patients admitted to CHI Memorial with either a primary diagnosis of COPD or related respiratory or cardiovascular conditions with a history of COPD. A pharmacist assesses the level of severity of the patient_x0019_s COPD, home respiratory medications, and insurance status. Interventions are made as needed based on the patient_x0019_s disease severity. Additionally, recommendations to change to more cost-efficient products are made as needed in order to improve medication adherence.
Prior to discharge, a pharmacist provides disease state and respiratory medication education, inhaler technique, a COPD Action Plan, and smoking cessation education if applicable. Written educational documents are provided to patients as applicable. A follow-up phone call is made after discharge. Medication adherence is assessed by a program that tracks prescription fills. A comparable number of patients meeting inclusion criteria will not receive pharmacist intervention in order to compare outcomes.
The following data will be measured: 30-day readmission rate, 60-day readmission rate, and number of pharmacist interventions.
Presentation Objective: Evaluate the impact of a hospital-based, pharmacist-driven transitional care program on 30-day readmission rates in patients with COPD
Self-Assessment: Approximately how many hospitalized patients with COPD will be readmitted within 30 days?
Impact of a Pharmacist-led COPD Clinic on Patient Outcomes in a Rural Healthcare Clinic Sarah Russell, Elizabeth Mills, Steven Johnson Campbell University/Benson Medical Center (Ambulatory Care) - Buies Creek, NC
Background/Purpose: While it is well documented that pharmacists improve disease state outcomes, there are currently no studies evaluating a pharmacist_x0019_s impact on quality of life (QOL), lung function, and adherence in chronic obstructive pulmonary disease (COPD) patients, specifically in a rural healthcare setting. We aimed to compare changes in patient QOL with and without participation in a pharmacist-led COPD clinic in a rural healthcare setting. Secondary objectives included comparison of FEV1 values and adherence to medication before and after implementation of the pharmacist-led COPD clinic.
Methodology: Patients with an established diagnosis of COPD, English-speaking, at least 40 years of age and were receiving care at Benson Area Medical Center were eligible for inclusion. Patients were enrolled to either the case (pharmacist-led clinic) or control arm (standard care). Cases were matched to controls 1:1. Case participants received individualized patient care including pulmonary function test (PFT), quality of life assessment utilizing St. George_x0019_s Respiratory Questionnaire (SGRQ), COPD education, and medication management for a total of 3 appointments during a 6-month evaluation period. Patients were coached on goal setting using SMART (specific, measurable, attainable, relevant, timely) goals and the COPD action plan. Control subjects did not receive the intervention during the appointments and only completed the PFT, SGRQ, and adherence questionnaires. QOL and secondary endpoints were analyzed utilizing a Wilcoxon Signed Rank test.
Presentation Objective: Demonstrate the impact on quality of life in COPD patients when an intensive pharmacist-led education program is implemented.
Self-Assessment: What is the percentage of COPD patients living in rural areas that do not have a primary source of healthcare?
Evaluation of optimal international normalized ratio goals for continuous flow left ventricular assist device patients Alia Reid, Nicholas Barker Emory St. Joseph's Hospital - Atlanta, GA
Background/Purpose: The placement of a left ventricular assist device (LVAD) is an advanced therapy option for patients with worsening end-stage heart failure. The utilization of LVADs has led to a significant improvement in morbidity and mortality of end-stage heart failure patients. However, one of the complications associated with LVADs is device thrombosis. Following LVAD implantation, the device material interacts with the blood and activates the coagulation system, increasing the risk of thromboembolic complications. Therefore, aspirin and anticoagulation with warfarin are recommended in all patients with a LVAD. The international normalized ratio (INR) is the most common way of monitoring anticoagulation with warfarin. An INR between 2-3 is generally considered therapeutic for LVAD patients, based on multiple LVAD clinical trials. However, there are still a significant number of bleeding and thrombotic events that occur in LVAD patients, which has led to alternative INR goals. Several studies evaluating LVAD patients have demonstrated conflicting data on the optimal INR goal to minimize both the bleeding and thrombotic risk, and consequently the optimal INR goal range remains undefined.
The purpose of this study is to compare safety and efficacy outcomes of different INR goals in LVAD patients within Emory Healthcare.
Methodology: This study is a single-system retrospective chart review of all adult LVAD patients implanted at Emory Saint Joseph_x0019_s Hospital (ESJH) and Emory University Hospital (EUH) from January 2015 to December 2017 that were subsequently managed on warfarin at ESJH or EUH. Patients that did not survive to discharge following LVAD implantation, those that underwent repeat LVAD implantation, and those with a major hypercoagulable disorder were excluded from the study.
Presentation Objective: Discuss the safety and efficacy outcomes of the different INR goals in LVAD patients within Emory Healthcare.
Self-Assessment: What is the optimal INR goal to use for LVAD patients?
PGY-2 Solid Organ Transplant Resident, Emory University Hospital
Dr. Alia Reid is the current PGY-2 in Solid Organ Transplant at Emory University Hospital. She was raised in Atlanta, GA and graduated with a BA in Medicine, Health, and Society from Vanderbilt University. She received her Doctor of Pharmacy degree from the University of Georgia College... Read More →
Thursday April 25, 2019 10:20am - 10:40am EDT
Athena D
Evaluation of the appropriateness of parenteral nutrition use in critically-ill adult patients at a community hospital Dwight Burnham, Christen Freeman, Anne Frances Lipscomb DCH Regional Healthcare System - Tuscaloosa, AL
Background/Purpose: Parenteral nutrition involves the provision of nutrients via the intravenous route. In some cases, it is a life-saving therapy in patients who are unable to tolerate oral or tube feedings. The current ASPEN-SCCM consensus guidelines recommend the use of protocols and nutrition support teams to implement strategies that will maximize efficacy and reduce harms of parenteral nutrition. There is evidence to support an association between the use of guideline-driven protocols and nutrition support teams, and a decrease in total costs and complications of parenteral nutrition.
Methodology: This single-center, retrospective cohort study includes adult patients 18 years or older who were initiated on parenteral nutrition while admitted to an intensive care unit from January 2017 through December 2017. Patients who were admitted to the ICU from the floor on parenteral nutrition or from an outpatient setting while on parenteral nutrition were excluded. The primary outcome is a composite endpoint that includes appropriateness of indication, time to initiation of parenteral nutrition, maximum percent daily energy achieved, and maximum percent daily protein achieved. Secondary endpoints included rate of aforementioned appropriateness for each criterion of PN use, rates of hyperglycemia and hypoglycemia, and rate of bloodstream infections.
Results: (preliminary results) 260 patients were screened with 100 patients to be included in the study. Fifty patient charts have been analyzed at this point. Of those patients reviewed, 34 (68%) received appropriate PN therapy, in which all four criteria for appropriateness were met. In regards to the criteria for appropriateness, 44 (88%) had an appropriate indication, 41 (82%) had an appropriate time to initiation, 49 (98%) achieved max goal daily calories, and 49 (98%) achieved max goal daily protein.
Presentation Objective: Identify appropriate use criteria for parenteral nutrition in critically-ill patients.
Self-Assessment: Which risk-assessment tools are used to determine nutrition risk in critically-ill patients?
Time to Blood Culture Positivity as a Predictor of Pathogen in Critically Ill Patients Lindsey Sellers, Christy Forehand, Andrea Newsome Augusta University Medical Center/UGA College of Pharmacy PGY2 Critical Care - Augusta, GA
Background/Purpose: Clinically appropriate de-escalation of empiric antibiotic therapy in patients with septic shock decreases selective pressure for multi-drug resistant organisms and is associated with decreased mortality. Concern for late detection of bacterial pathogens is a barrier to early antibiotic de-escalation efforts. In a previous study conducted in a mixed population, blood stream infection (BSI) culture results at 48 hours had a 97.3% sensitivity and 99.8% negative predictive value for finalized negative cultures. Critically ill patients were underrepresented in this study, so the reliability of these findings in this population is uncertain. For most intensive care unit (ICU) patients, the 72 hour time point is a time at which there is enough clinical data to either support or refute a change or discontinuation in antibiotic therapy. The primary outcome of this study is the sensitivity and negative predictive value of negative blood culture results at 72 hours to predict finalized negative cultures. The results of this study will provide context to assessing BSIs in ICU patients at 72 hours.
Methodology: This study is a retrospective chart review of adult patients admitted to the medical intensive care unit between June 1, 2010 and July 31, 2018. Blood culture isolates were assessed for bacterial species identified and time to positivity for each isolate. The sensitivity, specificity, positive predictive value and negative predictive value of the 72 hour blood culture result for the final culture results were determined using two-way tables.
Presentation Objective: Determine whether 72 hour blood culture results can support the decision to de-escalate antimicrobial therapy in ICU patients meeting clinical criteria for de-escalation.
Self-Assessment: What are potential barriers to antibiotic de-escalation in the ICU?
Pharmacy student comfort with counseling on drug-nutrient interactions, pre-and post interdisciplinary education D. Drummond, C. Gamston, A. Kirby, S. Westrick, K. Braxton Lloyd Auburn University Pharmaceutical Care Center - Auburn, AL
Background/Purpose: Drug-nutrient interactions (DNI) are known to threaten patient outcomes by altering concentrations of medications or interacting nutrients leading to sub- or supratherapeutic levels. Pharmacists should be aware of multiple dietary sources of nutrients to decrease the risk of DNI, but education is lacking in this area.
Methodology: An interdisciplinary team created an educational module about DNI focused on food sources of specific interacting nutrients. Fourth-year pharmacy students completing their first advanced pharmacy practice experience (APPE) in a community pharmacy were incentivized to complete a survey before and after viewing the module to assess knowledge, comfort with counseling, and perceived importance of DNI. Demographic information was used to screen prior experiences and to evaluate baseline knowledge. At the end of the rotation, participants completed a survey to evaluate the use of education provided and anticipated use.
Results: 111 students were invited and 25 eligible students completed the pre- and post-module surveys in this IRB approved study. Baseline knowledge scores were not associated with prior-experience. DNI knowledge scores significantly improved from 65% to 80% (p
Safety and Appropriateness of Outpatient Fluoroquinolone use in the Elderly Paige Wallace, Tiffany Goolsby Atlanta Veterans Affairs Medical Center - Atlanta, GA
Background/Purpose: Fluoroquinolones are one of the most commonly prescribed antibiotics in the adult population. Due to their wide spectrum of antibacterial coverage, they can be used to treat a variety of infections such as respiratory infections, urinary tract infections, and skin and soft tissue infections. However, this drug class has gone through multiple label changes by the Food and Drug administration for various serious side effects.
The elderly population is at increased risk for these serious side effects. Decline in renal function, increased medication use, comorbidities, and increase in hospital stays all lead to increased risk of serious side effects in this population. The specific side effect profile of this class of medication must be considered when choosing them for treatment and should only be used if the benefit outweighs the risk.
This quality improvement project will be conducted to evaluate the appropriateness of fluoroquinolone prescribing to elderly in the outpatient setting and to evaluate the frequency of adverse events occurring in the elderly population.
Methodology: This was a retrospective chart review of Atlanta VAHCS elderly patients prescribed fluoroquinolones outpatient during the year 2018. Adult patients greater than or equal to 65 years of age that have filled a prescription for at least one fluoroquinolone prescription for greater than 3-day supply were included in the study. Patients on fluoroquinolones for chronic prophylaxis, surgical prophylaxis, or initiated on the antibiotic inpatient were excluded from the study. Data was collected and will be analyzed on patient age, gender, medication duration, location of prescribing, and side effects.
Presentation Objective: To determine the appropriateness and safety of fluoroquinolone prescribing for elderly patients in the outpatient setting.
Self-Assessment: Are fluoroquinolones prescribed appropriately in the elderly population at outpatient clinics at this facility?
Effects of Academic Detailing and Institutional-Specific Treatment Guidelines on the Treatment of Urinary Tract Infections John Riles, James Carr, Bridget Roop, Todd McCarty, Joshua Stripling Birmingham VA Medical Center - Birmingham, AL
Background/Purpose: Urinary tract infections are one of the most common bacterial infections among patients, affecting over 150 million people yearly worldwide. With high recurrence rates and increasing antimicrobial resistance that threaten to escalate the economic burden, evidence-based antibiotic therapy is vital for proper treatment and antibacterial stewardship. Patients are often treated inappropriately for asymptomatic bacteriuria and frequently treated for extended durations with broad-spectrum, empiric antibiotics. An institutional treatment guideline was developed, and subsequently, academic detailing was performed for providers to encourage evidence-based decision making. The purpose of this project is to evaluate the effectiveness of provider education and use of an institutional treatment algorithm on UTI diagnosis and treatment.
Methodology: In 2016, a retrospective chart review was conducted by reviewing electronic medical records. Specifically, the review focused on patient_x0019_s symptoms, urine culture data, antibiotic selection and duration of therapy. This retrospective review resulted in the implementation of an institutional-specific guideline-derived treatment algorithm for urinary tract infections, and, subsequently, provider education/academic detailing. The current research project will consist of a retrospective chart review of identified patients to analyze antibiotic drug selection, dose, frequency, and duration through available information in the electronic medical record. The review will be conducted for the time period following implementation of the treatment algorithm and a time period after completion of academic detailing. With these results, treatment success and antibiotic selection will also be evaluated.
Results: Results pending upon completion of research project.
Conclusions: Conclusions pending upon completion of research project.
Presentation Objective: To determine if academic detailing and institutional-specific treatment guidelines improve antibiotic prescribing and treatment outcomes for urinary tract infections (UTIs).
Self-Assessment: What impact does academic detailing and institutional-specific treatment guidelines have on the prescribing of antibiotics for urinary tract infections (UTIs)?
Incorporation and impact of a clinical pharmacist in a hospital-based neurology clinic treating multiple sclerosis patients Alexandria May, Olivia Morgan, Kristi Quairoli Grady Memorial Hospital (Neurology) - Atlanta, GA
Background/Purpose: To describe clinical pharmacy services provided as well as provider satisfaction and perceived impact of incorporating a clinical pharmacist in multiple sclerosis (MS) patient care.
Methodology: This study was conducted in two parts: a retrospective chart review and provider survey conducted in an urban, outpatient neurology clinic at an academic medical center. Between April 2017 and June 2018, electronic medical records (EMRs) of patients seen in clinic with documented interventions by a pharmacist were reviewed to describe clinical pharmacy services provided to MS patients. A voluntary, anonymous survey was distributed to neurology clinic providers to evaluate provider satisfaction and perceived impact of clinical pharmacist involvement in MS patient care.
Results: Sixty-four patients were identified during the study period with 378 documented interventions made by clinical pharmacists. Approximately 58% of pharmacist interventions were made through direct patient care encounters, with an average of 3 to 4 interventions made per patient. The most common interventions involved facilitating medication access (55%), pre-treatment screening (15%), patient counseling (14%) and providing drug information (11%). Overall, neurology providers were satisfied with clinical pharmacist involvement in MS patient care and indicated that pharmacists had the greatest impact in facilitating medication access, providing patient counseling, and managing drug interactions.
Conclusions: Clinical pharmacists play an integral role in MS patient care, particularly with facilitating medication access for patients. Neurology providers reported high satisfaction with pharmacist involvement in MS patient care and perceived that clinical pharmacy services have a positive impact in this setting.
Presentation Objective: Describe the role of a clinical pharmacist in the management of patients with multiple sclerosis (MS) in the ambulatory setting.
Self-Assessment: Where is one area where clinical pharmacists can help to optimize MS patient care?
Incidence of bronchopulmonary dysplasia in neonates receiving parenteral lipid emulsions - Intralipid or SMOFlipid Zauri Bradley, Amy P. Holmes, John B. Harris, Malinda G. Parman Novant Health Forsyth Medical Center - Winston-Salem, NC
Background/Purpose: Despite their widespread use, evidence suggest that the conventional soybean oil based lipid emulsions, e.g. Intralipid, may be far from benign. Due to excessive polyunsaturated fatty acid (PUFA) content adding to oxidative stress, such lipid emulsions may cause harmful outcomes in preterm infants such as bronchopulmonary dysplasia (BPD). This retrospective, multicenter observational study will compare patients before and after the addition of SMOFlipid to Novant Health formulary.
Methodology: Inclusion criteria included preterm infants with a gestational age less than 32 weeks, received parenteral nutrition (PN) as part of their care in the NICU, and were born at Novant Health Forsyth or Presbyterian Medical Center between August 1, 2016 and July 31, 2018. Any infant that received systemic corticosteroids outside the DART protocol, corticosteroids after 36 weeks postmenstrual age, or transferred/expired prior to discharge were excluded. The primary endpoint was the incidence of BPD in relation to Intralipid and SMOFlipid administration. Secondary endpoint was the incidence of BPD in preterm infants who received light protected SMOFlipid.
Presentation Objective: Determine the incidence of BPD of the newer alternative lipid emulsion, SMOFlipid, in comparison to Intralipid in preterm infants receiving parenteral nutrition.
Self-Assessment: What are potential complications associated with the use of lipid emulsions in infants?
Immediate Release Opioid Prescribing Patterns: Effects of Limited Preset Quantities and PDMP Integration Lia Xiong, Erin Himes, Babafunlola A. Davis Kaiser Foundation Health Plan of Georgia - Atlanta, GA
Background/Purpose: More than 350,000 people in the United States have died from an opioid overdose, and 115 Americans die every day. In response to this epidemic, the Centers for Disease Control and Prevention released recommendations to limit initial opioid quantities prescribed and Georgia law now enforces use of the prescription drug monitoring program (PDMP) prior to prescribing certain opioids unless certain conditions are met. The purpose of this study is to evaluate patterns in prescribing of immediate release (IR) schedule II opioids for acute pain after updating preset quantities and integrating PDMP data within the electronic health record (EHR) in an integrated healthcare delivery system.
Methodology: This is a retrospective descriptive study that analyzed claims data to evaluate prescribing patterns of the five most commonly prescribed IR schedule II opioids at Kaiser Permanente Georgia (KPGA) six months pre- and post-implementation of preset quantities in the EHR and PDMP integration. Patients aged 18 years and older who filled hydrocodone/acetaminophen, oxycodone/acetaminophen, oxycodone, morphine sulfate or hydromorphone between January 1, 2016 to December 31, 2018 were included in the study. The primary outcome was the change in mean quantity dispensed per prescription. Secondary outcomes included the mean number of tablets per prescription for each IR schedule II opioid, the mean number of tablets per medical department, and the number of prescriptions written for each preset default quantity during each six-month interval.
Presentation Objective: Describe ways to use electronic health record tools to assist in decreasing opioid prescription quantities.
Self-Assessment: What is one way to assist in decreasing opioid prescription quantities in an integrated healthcare system?
Impact of Direct-to-Consumer Benzodiazepine and Sedative Hypnotic Patient Education at a VAHCS J Liszka, C Goodman, S Cox, G Miller, C Robinette Salisbury VA Medical Center - Salisbury, NC
Background/Purpose: Benzodiazepines and sedative hypnotics are frequently prescribed in the elderly despite recommendations by various organizations to avoid these agents in patients aged 65 years and older. This warrants the need for interventions focused on decreasing the use of benzodiazepines and sedative hypnotics in this population. Sparked by the positive results of the EMPOWER study, two quality improvement projects conducted at the Salisbury VAHCS demonstrated that direct-to-consumer written health education intervention letters enhanced patient-provider conversations regarding benzodiazepine and sedative hypnotic use but results were limited due to reliance on provider response to surveys. This project aims to further evaluate the direct-to-consumer education intervention by comparing the rate of dose reduction or discontinuation of the medications in the education intervention group against usual care.
Methodology: This retrospective chart review evaluates the impact of direct-to-consumer written health education intervention on patients at the Salisbury VAHCS. The intervention group consists of patients aged 75 years and older, who were flagged by the EMPOWER Mail Merge tool and received direct-to-consumer education regarding benzodiazepines and sedative hypnotics from December 2017 to April 2018. The EMPOWER Mail Merge tool was utilized to identify a control group of patients who met the same criteria between November 2016 to October 2017 and did not receive direct-to-consumer education. Medical records will be reviewed to determine if a dose discontinuation or reduction occurred. The data will be analyzed using descriptive chi-square statistics.
Presentation Objective: Evaluate the impact of a direct-to-consumer education intervention measured by the rate of dose reduction and discontinuation of benzodiazepines or sedative hypnotics.
Self-Assessment: Is direct-to-consumer written education associated with a decrease in the use of benzodiazepine and/or sedative hypnotic usage among patients aged 75 years and older?
The Preoperative Use of Intravenous Palonosetron to Prevent Postoperative Nausea and Vomiting Rebecca Scott Caromont Regional Medical Center - Gastonia, NC
Background/Purpose: Assess the impact of a preoperative, prophylactic antiemetic protocol utilizing palonosetron on the incidence of postoperative nausea and vomiting in patients undergoing planned surgical procedures.
Methodology: Eligible participants were American Society of Anesthesiologists Physical Class I, II, and III patients at least 18 years of age undergoing planned hysterectomies, colon resections, and total joint replacement procedures with duration of hospital stay greater than or equal to 18 hours or at least one midnight after surgery. Chart reviews of patients undergoing procedures between November 1, 2017 and February 1, 2018 were compared with chart reviews of procedures between December 1, 2018 and March 31, 2019, after the addition of palonosetron to a preoperative protocol.
Presentation Objective: Identify potential benefits for the use of palonosetron as a preoperative, prophylactic medication.
Self-Assessment: How can pharmacists decrease drug burden for patient benefit through modification of medication protocols?
Assessment of the Prevalence of Burnout in Pharmacy Technicians Jordan T. DeAngelis; Matthew J. Kelm Duke University Hospital - Health System Pharmacy Adm. - Durham, NC
Background/Purpose: The Maslach Burnout Inventory (MBI) was originally developed in 1981 to assess job-related emotional exhaustion, depersonalization, and reduced personal accomplishment. The MBI has been studied and validated in many health-care occupations. Research in nurses and physicians has indicated that burnout exists at an incidence of 25-45%.
While the incidence of burnout has gained national attention and is well-studied in physicians and nurses, a paucity of data in the pharmacy profession indicates a need for additional research. Several professional organizations have made the assessment of burnout and resilience a top priority over the last several years. As research into burnout and resilience gains traction amongst the pharmacy profession, a vital piece in the conversation has often been overlooked: the pharmacy technician. Pharmacy technicians are just as crucial as pharmacists to the operations of pharmacies and pharmacy departments, but their career path is full of unique challenges. Surprisingly, there has been no national attempt to identify the incidence of burnout in pharmacy technicians.
Methodology: This study aims to identify to what extent burnout exists among pharmacy technicians. Data will be collected via an electronic version of the MBI tool on the Qualtrics survey platform. Additionally, this study will assess for risk factors associated with higher incidences of burnout. The risk factors are categorized as pharmacy technician characteristics, institution characteristics, or position characteristics. Working in collaboration with the American Society of Health-System Pharmacists and the Pharmacy Technician Certification Board (PTCB), the tool will be distributed to a sample of PTCB_x0019_s 282,000+ certified pharmacy technician members with a goal of 1,000 responses. Pharmacy students and pharmacists will be excluded from analysis.
Presentation Objective: Describe the prevalence of burnout in certified pharmacy technicians
Self-Assessment: To what extent does burnout exist among certified pharmacy technicians?
Evaluation of a hypoglycemia safety initiative in a Veterans Affairs clinic using a population management tool E Schulz; T Anderson; C Hatley; B Melville; C Robinette Salisbury VA Medical Center - Salisbury, NC
Background/Purpose: Hypoglycemia is a major safety issue in patients with diabetes, which can lead to emergency department visits and other health complications. The Hypoglycemia Screening Tool developed by the Veterans Health Administration identifies Veterans at risk of hypoglycemia by meeting the following criteria: receiving insulin and/or sulfonylurea therapy, AND recent A1c 74 years, diagnosis of cognitive impairment or dementia, or recent SCr >1.7 mg/dL. Within the Salisbury VA Health Care System, most of the Veterans identified by this tool are not followed by a specialist for diabetes management. The purpose of this project is to examine the impact of mailing information about hypoglycemia to Veterans at high risk of hypoglycemia.
Methodology: Information about hypoglycemia and how to directly schedule an appointment with a clinical pharmacy specialist was mailed to Veterans within one patient-aligned care team (PACT) who were identified as high risk for hypoglycemia by the Hypoglycemia Screening Tool. Veterans currently managed by a diabetes specialist were excluded. Data collection was completed through retrospective chart review. The primary objective was the number of Veterans who contacted a provider regarding hypoglycemia within 30 days of mailing the information. Secondary objectives were to observe the number of scheduled visits with a clinical pharmacy specialist and to characterize the interventions made after mailing the hypoglycemia information to Veterans.
Presentation Objective: Evaluate the effects of mailing information on hypoglycemia for Veterans deemed high risk for hypoglycemic episodes.
Self-Assessment: What are risk factors for hypoglycemia among Veterans with diabetes?
Safety and efficacy of apixaban versus warfarin in veterans with end-stage renal disease on dialysis Odirichukwu O. Duru, Vian K. Farino, and Samantha K. Merck Atlanta Veterans Affairs Medical Center - Atlanta, GA
Background/Purpose: Risk of thrombus is heightened in end-stage renal disease (ESRD). Although ESRD is common in clinical practice, it is often underrepresented in clinical trials of warfarin versus direct oral anticoagulants (DOACs). Excluding severe renal impairment makes it difficult to strongly recommend DOACs in this population. Apixaban has been prescribed for patients on dialysis at the Atlanta Veteran Affairs (VA) Health Care System. The VA Pharmacy Benefits Management criteria for use cautions and restricts apixaban in this population. This study aims to review anticoagulant use in the ESRD population by comparing warfarin versus apixaban in dialysis patients.
Methodology: This is an Institutional Review Board approved retrospective study. Actions were taken to ensure patient confidentiality was maintained and patients were assigned generic study letters and numbers. International Classification of Diseases (ICD) 9 and 10 codes were used to recruit patients. This retrospective chart review included adults at least 18-years old on dialysis with a diagnosis of ESRD on either apixaban or warfarin between January 1, 2014 and July 31, 2018. The primary outcome of this study was overall bleeding event rate which was defined as a bleeding event after at least 2 doses of apixaban or 5 doses of warfarin while inpatient or after receiving at least 1 prescription while outpatient. Secondary outcomes included major bleeding events, clinically relevant non-major bleeding events, minor bleeding events, and new or recurrent venous thromboembolism or ischemic stroke. Severity of bleeding was defined using the International Society on Thrombosis and Haemostasis criteria.
Presentation Objective: To determine the safety and efficacy of apixaban compared to warfarin in dialysis patients.
Self-Assessment: Is apixaban as safe and efficacious as warfarin when used in veterans with end-stage renal disease on dialysis?
Evaluation of hypertonic saline in patients with acute liver failure Peter Moran; Ayesha Mukhtar; Zhengjia Chen; Prem Kandiah; Jolie Gallagher Emory University Critical Care - Atlanta, GA
Background/Purpose: Acute liver failure (ALF) is a life-threatening illness characterized by rapid deterioration of liver function without pre-existing liver insult. Cerebral edema is the most serious ALF complication and accounts for 80% of all deaths. Hypertonic saline is recommended for the management of cerebral edema. Additionally, extracorporeal liver support systems (MARS) and/or continuous renal replacement therapies (CRRT) can be utilized to maintain homeostatsis. Unfortunately, the addition of MARS/CRRT may impede attainment of a hypernatremic state because dialysate and replacement fluids have a sodium concentration of 140 mEq/L, which is lower than our goal of 145 to 155 mEq/L. Thus, the purpose of this study is to determine if the addition of a 3% sodium chloride (NaCl) infusion improves target attainment of hypernatremic levels in patients on MARS/CRRT.
Methodology: A retrospective chart review of medical records from January 1, 2014 to September 30, 2018 was performed on patients that received MARS/CRRT and concurrent 23.4% NaCl in the surgical intensive care unit (ICU) at Emory University Hospital. Patients were excluded if they were missing greater than two daily nephrology notes specifying flow rates, received MARS/CRRT for less than 24 hours, received 23.4% NaCl for any non-ALF indication, or died within 24 hours of admission to ICU. The primary endpoint was the percent of time arterial blood gas (ABG) sodium levels were 145 to 155 mEq/L. Secondary endpoints included duration of MARS/CRRT, length of stay in the hospital and ICU, time to first ABG sodium within goal range, percentage of sodium levels >155 mEq/L, and the number of 23.4% NaCl boluses administered.
Presentation Objective: Determine if the addition of a 3% sodium chloride infusion improves target attainment of hypernatremic levels in patients on extracorporeal support
Self-Assessment: How does hypernatremia reduce cerebral edema in ALF patients?
EVALUATION OF ICU SEDATION PRACTICES BEFORE AND AFTER A MULTIDISCIPLINARY EDUCATIONAL INTERVENTION Nesha Patel, Christen Freeman, Doug Carroll DCH Regional Healthcare System - Tuscaloosa, AL
Background/Purpose: To evaluate for performance improvement and compare the prescribing patterns of analgesia-based sedation before and after a multidisciplinary educational intervention and implementation of an analgesia and sedation order set for mechanically ventilated patients.
Methodology: This project was two-phase retrospective chart review. The pre-intervention phase included patients during a 3-month period of June to August 2017. The post-intervention phase included patients admitted during a 3-month period of June to August 2018. A report of patients on continuous infusions of analgesia and sedatives was generated and used to select patients via the use of systemic sampling, where every other patient was selected. Chart reviews were performed using MEDITECH and data was collected using a data collection form.
Results: Fifty patients were included in each retrospective phase. The use of analgesia-based sedation in the pre-intervention phase was 48% compared to 80% in the post-intervention phase. Only 27% used the SAT/SBT protocol and 8% used the analgesia-sedation protocol. The average length of mechanical ventilation was 5.9 days in pre-intervention phase compared to 4.3 days in post-intervention phase. The average length of stay in ICU was 10 days for both phases. Data analysis is ongoing.
Conclusions: The multidisciplinary educational intervention and order set implementation led to an increase in the use of analgesia-based sedation. Process improvements can be made to increase the use of the analgesia-sedation protocol and SAT/SBT protocol.
Presentation Objective: Evaluate the impact of a multidisciplinary educational intervention and order set implementation on ICU sedation practices.
Self-Assessment: Did the multidisciplinary educational intervention increase the use of analgesia-based sedation?
Evaluation of SSRIs and their Impact on the Incidence of Intracranial and Gastrointestinal Bleeding Ashley Beckwith, Drew Kessell, Andrew Krupp, Jennifer Campbell FirstHealth Moore Regional Hospital - Pinehurst, NC
Background/Purpose: Selective serotonin reuptake inhibitors (SSRIs) are used extensively in the treatment of mental health disorders. A review of the literature suggests that SSRI use may increase the risk of bleeding due to inhibition of the sodium/chloride dependent serotonin transporter found on platelets, limiting amplification of platelet aggregation. Through this mechanism, SSRI use may present a clinically significant impact on the risk of life-threatening bleeding. The objective of this study is to determine if SSRI use contributes to the incidence of intracranial (IC) and gastrointestinal (GI) bleeding.
Methodology: A retrospective observational study was conducted to assess the occurrence of intracranial and/or gastrointestinal bleeding in patients presenting to Moore Regional Hospital between November 1, 2017 to September 30, 2018. Patients age 18 and older diagnosed acutely with intracranial hemorrhage (excluding trauma) as well as those diagnosed with gastrointestinal hemorrhage were included. Patients were placed into two groups based upon presence or absence of an SSRI in their home medication history. Data elements evaluated include: SSRI and dose utilized; concomitant anticoagulants, antiplatelets, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs); comorbid conditions; and coagulation laboratory parameters obtained upon presentation. The research methodology to be used in completing this retrospective observational study was approved by the institutional review board.
Results: As of February 2019, data analysis is ongoing. To date, a total of 14 patients (19.4 percent) with intracranial hemorrhage and 30 patients (20 percent) with GI hemorrhage were designated to the SSRI group.
Presentation Objective: To determine if SSRI use contributes to the incidence of intracranial and gastrointestinal bleeding.
Self-Assessment: Of the SSRIs reviewed, which had the strongest correlation with increased bleeding risk at our institution?
Impact of Education and Automatic Refills on Adherence in Patients with a Baseline Proportion of Days Covered of < 80% Melissa Tittinger, Mohamed Aboemeara, Katie Trotta, Charles Herring Campbell University College of Pharmacy & Health Sciences - Buies Creek, NC
Background/Purpose: Over 50% of patients are non-adherent to their medications, leading to poor health outcomes and billions of health care dollars wasted annually. The Center for Medicare and Medicaid Services utilizes adherence to cholesterol, hypertension, and diabetes medications as a measure in determining Star Ratings. Proportion of Days Covered (PDC), a measure of adherence, assesses how many days a patient has medication available to them during a period of time. Higher PDC results in higher Star Ratings, meaning better reimbursements for community pharmacies, and improved health outcomes. The purpose of this study is to determine if adherence counseling and enrollment in an automatic refill (AR) program improves PDC for oral hypertension, diabetes, and cholesterol medications at a chain community pharmacy. Secondary objectives are to determine patient-specific barriers to utilizing AR, to count the number of other maintenance medications added to AR, and to determine the change in return to stock percentages.
Methodology: This pre/post design study included patients with mean PDC of
Ceftriaxone versus Standard of Care for Definitive Treatment of Methicillin-Susceptible Staphylococcus aureus Infections Jessica Snawerdt, Sarah Withers, John Schrank, Jun Wu Greenville Hospital System PGY1 - Greenville, SC
Background/Purpose: Staphylococcus aureus commonly cause skin and soft tissue, bloodstream, bone and joint, and device-related infections. Appropriate treatment of these infections is crucial for positive outcomes. Beta-lactam antibiotics, specifically nafcillin, oxacillin, and cefazolin, have improved outcomes in methicillin-sensitive Staphylococcus aureus (MSSA) infections. These agents, however, have multiple side effects and require several doses per day.
Ceftriaxone is a third generation cephalosporin with a favorable profile for outpatient antibiotic therapy. Limited evidence supporting ceftriaxone therapy for MSSA infections prevents its widespread use. This study seeks to determine if the use of ceftriaxone for definitive treatment of MSSA infections results in similar outcomes compared to standard of care.
Methodology: A multi-center, single institution retrospective chart review was conducted from February 2016 to February 2018. Patients were included if they had a positive MSSA microbiological culture and received treatment with ceftriaxone, nafcillin, or cefazolin. Patients were excluded if they had a polymicrobial infection or did not have adequate clinic follow-up. The following data was collected: demographics, history of intravenous drug use, microbiologic data, site of infection, antimicrobial use data, hospital length of stay, Infectious Diseases consult, discharge disposition, source control defined as incision and drainage or removal of hardware, and adverse reactions. The primary outcome of this study is clinical success, defined as absence of infection-related readmission or recurrent infection within 90 days. Secondary endpoints include frequency of adverse reactions and impact of Infectious Diseases consult.
Presentation Objective: Compare clinical outcomes of ceftriaxone versus standard of care for MSSA infections
Self-Assessment: What are the benefits of using ceftriaxone for the treatment of MSSA infections?
Impact of rapid discontinuation of empiric vancomycin in patients with HAP or HCAP and absence of respiratory tract cultures Alanna H. Rufe, Linda S. Johnson CHI Memorial - Chattanooga, TN
Background/Purpose: Vancomycin is a recommended empiric therapy for patients with hospital-acquired pneumonia (HAP) and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) or who are at high risk for mortality. Although healthcare-associated pneumonia (HCAP) is excluded in the latest Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) pneumonia guidelines, many clinicians still prefer to use empiric anti-MRSA therapy for this process. De-escalation is encouraged in the guidelines, but clinicians often hesitate to do so in the absence of culture data. Few studies have shown that in certain low-risk patients, vancomycin may not be necessary. A clinical criterion document was developed and implemented at CHI Memorial to facilitate rapid de-escalation of vancomycin when appropriate. This study aims to assess the impact of rapid early discontinuation of vancomycin in patients with HAP or HCAP and no respiratory culture.
Methodology: A retrospective cohort analysis was conducted in adult inpatients who presented with HAP or HCAP with no respiratory culture obtained and at most one pre-determined risk factor for MRSA. Patients who were clinically unstable or worsening at 48 to 72 hours, who were receiving antibiotics for a concomitant infection, or who had a pathogen identified from blood or urinary antigen tests were excluded. The primary endpoint was vancomycin days of therapy pre- and post-intervention. Secondary endpoints include vancomycin re-start within 48 hours, respiratory culture growing MRSA after vancomycin discontinuation, ICU and total length of stay, total days of alternate anti-MRSA therapy and in-hospital mortality in de-escalated vs. non-de-escalated patients.
Results: Pending
Conclusions: Pending
Presentation Objective: Evaluate the impact of a rapid vancomycin discontinuation initiative in patients with HAP or HCAP and inadequate respiratory culture data. `
Self-Assessment: Which of the following is not considered to be a risk factor for MRSA per CHI Memorial's Vancomycin Use Criteria?
Magnesium repletion: impact of a national intravenous fluid shortage Jared Cavanaugh, Laurie Cavendish, Kruti Shah, Ted Walton, John Doran Grady Memorial Hospital - Atlanta, GA
Background/Purpose: During the intravenous (IV) fluid shortage, magnesium was targeted as an IV medication that could be converted to an oral formulation. Electronic Medical Record (EMR) alerts and pharmacist interventions were strategies used to encourage use of oral magnesium.
Methodology: This was a single-center, retrospective study with a primary objective of assessing EMR alert adherence. Secondary objectives include evaluating prescribing patterns of magnesium prior to and during the shortage, pharmacist documented interventions, and change in serum magnesium concentration with oral and IV repletion.
Results: A total of 7,476 EMR alerts were reviewed following ordering IV magnesium; 5% resulted in the provider accepting the oral alternative, 89% continued the IV magnesium order, and 6% cancelled the order. During the shortage period, 31% of inpatient magnesium orders were for an oral formulation compared to 19% in the pre-shortage period. One in 73 documented pharmacist interventions switched from IV to oral magnesium. In the 160 medical-surgical patients reviewed, the mean serum magnesium concentration increased by 0.126 mg/dl per gram of IV magnesium sulfate compared to 0.063 mg/dl with 400 mg magnesium oxide.
Conclusions: EMRs can educate providers on the current shortage management strategy by alerting when the targeted product is ordered. Both IV and oral magnesium are viable methods for increasing serum magnesium concentration within 18 hours, however IV magnesium sulfate leads to a greater increase and is not limited by the dose-related gastrointestinal effects of oral magnesium. A better understanding of the efficacy of various medication dosage forms and the role of EMR shortage alerts can be part of a multi-faceted approach to managing drug shortages and minimizing the impact on patient care.
Presentation Objective: Identify the role of electronic medical record alerts in managing medication shortages.
Self-Assessment: What are benefits and limitations of electronic medical record alerts?
RETROSPECTIVE ANALYSIS OF LOCAL ANTIEMETIC USE IN HIGHLY EMETOGENIC CHEMOTHERAPY VERSUS GUIDELINE RECOMMENDATIONS Eric Schumann, Sarah Hand, William Pinkowski, Vicki Penley, Robyn Ward James H. Quillen VA Medical Center PGY1 - Mountain Home, TN
Background/Purpose: Highly emetogenic chemotherapy leads to episodes of emesis in more than 90% of patients in the absence of antiemetic prophylaxis. Patients consistently report chemotherapy-induced nausea and vomiting as one of the most dreaded complications of chemotherapy. Chemotherapy induced-nausea and vomiting may alter chemotherapy regimens by causing delays in treatment or dose reductions. James H. Quillen VA Medical Center uses its own guidance documents for both risks of chemotherapy-induced nausea and vomiting and antiemetic regimens.
Methodology: This study is a single center, retrospective chart review. All patients receiving highly emetogenic chemotherapy _x0013_ defined as regimens containing cisplatin, anthracycline and cyclophosphamide combination, and carboplatin with an area under the curve greater than 4 _x0013_ and a local antiemetic regimen from August 1, 2015 to July 31, 2018 have been included. The primary objective is to evaluate the proportion of patients who experienced nausea. This value will be compared to rates of nausea reported in trials using guideline recommended antiemetic regimens. Secondary endpoints include the use of supportive care, the setting in which the patient reported nausea, if changes to chemotherapy regimen were made due to nausea, and if the patient utilized _x0018_as needed_x0019_ antiemetic medications.
Presentation Objective: Evaluate the efficacy of local antiemetic regimens in highly emetogenic chemotherapy compared to guideline recommended antiemetic regimens.
Self-Assessment: Which antiemetic class of medication is absent from the local antiemetic regimen?
Assessment of Time to Therapeutic Tacrolimus Levels Following Renal Transplantation in a Non-Weight-Based Dosing Model Joshua Banbury; Kristofer Gutierrez; Chee Paul Lin; Adam Dodson University of Alabama Hospital - Birmingham - Birmingham, AL
Background/Purpose: Tacrolimus is a preferred first-line immunosuppressive agent used in maintenance therapy to prevent allograft rejection in patients following solid organ transplantation. Because of its narrow therapeutic index, monitoring trough levels are required to reach goal levels, which are an established surrogate endpoint used to minimize rejection and improve clinical outcomes. At UAB Hospital, tacrolimus is routinely initiated as a standardized dose of 2 mg every 12 hours and then titrated based on trough levels. Utilizing the current practice, patient-specific factors (e.g., weight) that may impact the pharmacokinetic parameters of tacrolimus are excluded from initial dosing considerations. This may contribute to over- or under-dosing patients and may delay discharge until an acceptable trough level is achieved.
Methodology: This is a single-center, retrospective study of primary renal transplant recipients between July 31, 2016 to July 31, 2017 at UAB Hospital. Patients were excluded based on the following criteria: multi-organ or ABO-incompatible transplantation, concurrent use of strong CYP3A4 inducers/inhibitors, HIV, delayed graft function (i.e., requiring dialysis within seven days of transplant), and pre-operative immunosuppressive therapy. To sort patients into quartiles, an initial dose to weight ratio was calculated using the starting tacrolimus dose and the patient_x0019_s weight at the time of transplant. Each quartile was used to assess differences in benchmark serum tacrolimus levels. The primary outcome was time to therapeutic trough level (i.e., 8-12 ng/mL). Secondary objectives include inpatient length of stay and incidence of adverse effects related to allograft function (e.g., serum creatinine, glomerular filtration rate, biopsy-proven acute rejection) within twelve months post-transplantation.
Presentation Objective: Describe the variance in time to therapeutic tacrolimus trough levels among renal transplant recipients based upon the observed dose to weight ratio.
Self-Assessment: Which of the following are sequelae of sub-optimal tacrolimus dosing following renal transplantation?
Implementation of pharmacist-led direct oral anticoagulant candidate screening process within current anticoagulation clinic Jessica Holleman, Emily Jolly, Paul Butts Fayetteville VA Medical Center - Fayetteville, NC
Background/Purpose: At this institution, patients prescribed warfarin for the prevention of stroke in atrial fibrillation are managed by a Clinical Pharmacy Specialist (CPS) in the anticoagulation clinic. Patients prescribed a direct oral anticoagulant (DOAC) for the same indication are followed by a CPS within the Patient Aligned Care Team. A screening tool was developed to identify appropriate candidates to switch from warfarin to DOAC therapy. The purpose of this quality improvement project was to determine the impact of a screening tool on the average number of monthly clinic encounters within the anticoagulation clinic.
Methodology: The number of average monthly clinic encounters for three months prior to and two months after the eight-week screening period, conducted from August _x0013_ September 2018, was compared to determine the impact of the screening tool. The screening tool was developed based on Veterans Affairs Pharmacy Benefits Management Service Criteria for Use. Eligible patients were counseled on DOACs and given the opportunity to switch therapies. The total number of patients who chose to switch and the total number of encounters associated with these patients before and after the screening period were recorded.
Results: On average, seventy additional monthly encounters were observed after screening tool implementation (p= 0.15). Thirty patients chose to switch to DOAC therapy and there was a reduction of seventy-five total encounters after screening (p= 0.01).
Conclusions: The screening tool did not impact the average number of monthly clinic encounters; however, it was clinically and statistically significant in reducing the number of individual encounters associated with patients who elected to switch from warfarin to DOAC therapy.
Presentation Objective: Identify areas where a screening tool to convert patients from warfarin to DOAC therapy may be effective.
Self-Assessment: In what ways can a screening tool for conversion from warfarin to DOAC therapy positively impact an anticoagulation clinic?
EVALUATION OF THE IMPLEMENTATION OF THE GUIDELINES FOR PREVENTION OF GLUCOCORTICOID-INDUCED OSTEOPOROSIS Catrina Hill, Denise Ross Atlanta Veterans Affairs Medical Center - Atlanta, GA
Background/Purpose: Glucocorticoid-induced osteoporosis (GIOP) is one of the most common causes of secondary osteoporosis. Current research shows the proportion of patients being treated with long-term glucocorticoids who are receiving osteoporosis-preventing treatments remains low. The 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis outlines updated recommendations for prevention of osteoporosis and fracture in patients receiving long-term glucocorticoids. The purpose of this study is to evaluate the implementation of these guidelines into practice at the Atlanta VA Health Care System.
Methodology: This study was an IRB-approved, single-center, retrospective chart review of 200 patients aged 18 years or older on long-term prednisone therapy (defined as greater than or equal to three months) between January 1st and December 12th of 2018. Patients who did not meet the definition of long-term prednisone therapy were excluded. Information was obtained on patient demographics, DEXA scans, FRAX score, risk assessment, medication-specific information (medication, dose, length of therapy, contraindications to therapy, therapy discontinuation) for medications of interest, and areas of missing information.
Presentation Objective: Evaluate adherence to guideline recommendations for osteoporosis and fracture prevention in patients receiving long-term prednisone.
Self-Assessment: How frequently should fracture risk be assessed in patients on long-term prednisone therapy?
Impact of a Pharmacist- Led Intervention to Decrease Cardiovascular Risk in Patients with Diabetes in a Primary Care Setting A Bruckelmeyer, N Wilkins, P McLellan, L Sheehan, C Burleson, K McKnight Carolinas HealthCare System - PGY1 AmCare - Charlotte, NC
Background/Purpose: Adult patients with diabetes have 2 to 4 times increased likelihood of dying from atherosclerotic cardiovascular disease (ASCVD) compared to those without diabetes. Cardiovascular risk reduction is not fully attained in most patients with diabetes. Pharmacists can assist primary care providers in providing optimal therapy for ASCVD risk reduction by recommending evidence-based medicine, performing medication reconciliations and assisting in removal of barriers to therapy. The primary objective of this study is to evaluate the effect of pharmacist collaboration in reducing ASCVD risk in patients with Type 2 diabetes by increasing attainment of the quality metric 'Statin Use in Persons with Diabetes' within a primary care setting.
Methodology: Patients with type 2 diabetes aged 40 to 75 years old, not on statin therapy and receiving primary care at Charlotte Medical Clinic-Arboretum and Charlotte Medical Clinic- SouthPark were eligible for selection. Participants were identified through patient registry reports and prospective telephonic interventions were made from October 2018 through March 2019. Patient records were assessed for ASCVD risk lowering recommendations. Patients were then contacted via telephone for risk reduction education and were provided strategies to decrease ASVCD risk including medication recommendations. At 3 weeks, patients who began recommended statin therapy were contacted via telephone to assess adverse events and adherence. Post-pharmacist intervention registry reports will be compared to baseline registry reports to determine improvements in pre-specified outcomes. The primary outcome assessed is use of statin therapy. Secondary outcomes assessed are use of aspirin, use of ACE/ARBs for renal protection, tobacco cessation and medication related problems.
Presentation Objective: To describe the effect of a pharmacist-led intervention on decreasing cardiovascular risk in patients with diabetes in a primary care setting.
Self-Assessment: What recommendations can pharmacists provide to decrease ASCVD risk in adult patients with Type 2 diabetes?
Evaluation of the safety and efficacy of phenobarbital for the management of acute alcohol withdrawal in the ICU D. Malone, D. MacElroy, J. Thompson, M. Al-Hegelan, Y. Bronshteyn Duke Regional Hospital - Durham, NC
Background/Purpose: Duke Regional Hospital has implemented a tapered-dose phenobarbital protocol for use in the emergency department and in the intensive care unit (ICU). Despite the rationale for phenobarbital's utility in alcohol withdrawal syndrome (AWS), there is limited data to support its use for this purpose. This research project analyzed safety and efficacy outcomes of patients diagnosed with AWS pre and post-protocol implementation.
Methodology: This is a retrospective cohort study completed at a community teaching hospital. Patients at least 18 years of age and older and initiated on either the phenobarbital protocol or a benzodiazepine-based treatment regimen for AWS in the emergency department or intensive care unit were included. Subjects were assigned into two cohorts based on the AWS protocol received. The primary outcome analyzed the safety of phenobarbital in patients with AWS by reviewing respiratory support needs. Safety was measured by the occurrence of intubation and/or requirement for at least six liters of oxygen. The secondary objective evaluated the efficacy of phenobarbital compared to a benzodiazepine-based treatment regimen. This was evaluated by hospital and ICU length of stay, incidence of seizure or pneumonia, use of dexmedetomidine, total number of alternative treatments for delirium within the first two weeks of hospitalization, total benzodiazepine dose in lorazepam equivalents, and the Richmond Agitation Sedation Scale (RASS) score with mode and range at 0-9 hours, 9-24 hours, 24-48 hours, and 48-96 hours. Data analysis included the Chi Squared Test for intubation and categorical data, Independent T-Test, Logistic Regression, and descriptive statistics for phenobarbital levels and total phenobarbital administered.
Presentation Objective: Compare safety and clinical outcomes for hospitalized patients receiving a phenobarbital versus a benzodiazepine-based treatment regimen for the treatment of AWS.
Self-Assessment: What impact does the use of phenobarbital have on patients who are at risk for AWS?
Impact of emergency medicine pharmacists on door-to-needle time for intravenous alteplase in acute ischemic stroke patients Courtney Huffman, Matt Bamber, Darla Gonzalez, Rebecca Karner, John Norris FirstHealth Moore Regional Hospital - Pinehurst, NC
Background/Purpose: Current American Heart Association and American Stroke Association guidelines recommend door-to-needle time for intravenous alteplase be within 60 minutes of hospital presentation. Emergency medicine pharmacists can positively influence time to administration through verifying absence of contraindications, assisting with blood pressure management, and preparing alteplase. Rapid administration of alteplase has been shown to result in better neurological outcomes for patients with acute ischemic stroke. We investigated whether door-to-needle time for intravenous alteplase was decreased with the presence of an emergency medicine pharmacist within our institution.
Methodology: A retrospective, observational study was conducted within the FirstHealth community hospital system and included patients diagnosed with an acute ischemic stroke who received alteplase between November 1, 2017 and September 30, 2018. Exclusion criteria included patients less than 18 years of age, alteplase utilization for alternative indication, and administration outside of an emergency department. There were two treatment arms, which included the pharmacist present and pharmacist absent groups. The primary outcome was alteplase door-to-needle time. Secondary outcomes included time from alteplase order to goal blood pressure, 3-hour versus 3-to 4.5-hour administration, NIHSS score 1-hour post-alteplase administration, hemorrhagic conversion, all-cause hospital mortality, and discharge disposition. The research methodology utilized in this study was IRB-approved.
Results: Of the fifty-two patients screened, forty-eight were included in the study. The mean door-to-needle time for intravenous alteplase was 48 minutes for the pharmacist present group and 66 minutes for the pharmacist absent group.
Conclusions: Our study has shown emergency medicine pharmacist presence impacts the efficiency of blood pressure lowering and door-to-needle time of intravenous alteplase in acute ischemic stroke patients.
Presentation Objective: To determine if door-to-needle time is improved in the presence of an emergency medicine pharmacist.
Self-Assessment: What impact can an emergency medicine pharmacist's involvement have on the care of acute ischemic stroke patients?
Seizures in Non-Traumatic Subarachnoid Hemorrhage Patients Based on Presentation and Effect of Prophylactic Levetiracetam Lindsey Little, Bill Asbury, Sadan Ofer, Rhea Battle, Nelson Chen Emory University Hospital - Atlanta, GA
Background/Purpose: The routine use of seizure prophylaxis in patients following non-traumatic subarachnoid hemorrhage (SAH) is controversial. A paucity of data exists regarding the duration of seizure prophylaxis and no randomized trial to show the clear utility of prophylaxis in these patients. For patients presenting to Emory University Hospital (EUH) with no reported seizure activity, levetiracetam is administered for seven days post-SAH. Patients with an unwitnessed event and those that have witnessed seizure-like activity are usually continued on antiepileptic drugs (AEDs) until at least their first clinic appointment. The purpose of this study is to determine the incidence of seizures in patients presenting with non-traumatic SAH to the Emory University Hospital Neuroscience Intensive Care Unit (ICU).
Methodology: Patients were classified in one of the following categories: patients that had a witnessed event with seizure or seizure-like activity at onset, patients that did not have a seizure or seizure-like activity, and patients with unclear seizure activity. Patients are included if they are adult patients with the primary diagnosis of non-traumatic SAH admitted to the neuroscience ICU at EUH. Patients are excluded if they experience early death (
Dr. Lindsey Little is from Hollywood, Florida. She received her Doctorate of Pharmacy from the University of Florida College of Pharmacy and she moved to Atlanta after graduation to complete her PGY-1 Pharmacy Residency at Emory University Hospital. Lindsey has accepted a position... Read More →
Thursday April 25, 2019 11:20am - 11:40am EDT
Athena B
Evaluation of Staff Attitudes Following a Standardized Training Prior to Implementation of Medication Synchronization Laura Dollins, KariLynn Dowling, Vanna Labi, Katelyn Alexander East Tennessee State University - Bill Gatton College of Pharmacy - Johnson City , TN
Background/Purpose: While medication synchronization has far-reaching benefits, the reality of implementing any new service in a community pharmacy can be a trying process for staff. There is limited literature looking at the changing attitudes of pharmacy staff from baseline following a standardized training program. The objectives of this study are: 1) To evaluate staffs_x0019_ perceptions/attitudes, perceived benefits/barriers, and knowledge base about a medication synchronization program; and 2) To determine how perceptions of staff change after a standardized training on medication synchronization.
Methodology: The regional independent pharmacy chain had a goal for each of their locations to offer a successful medication synchronization program in 2019. Some stores had no existing program while others had 5% of their patients med synced. Key stakeholders designed a training program to implement at each location. A pre-survey was administered to assess knowledge, perceptions, and attitudes regarding the medication synchronization program before training took place. An administrative team then conducted live training of one medication synchronization _x001C_champion_x001D_ at each pharmacy. All other staff completed a short online training module. After training was completed, the survey was re-administered to evaluate changes in knowledge, perceptions, and attitudes from baseline. Data collection began at the beginning of December with the pre-survey. The post-survey will occur in February after training has concluded at each pharmacy.
Presentation Objective: Identify core components of a staff training program that may influence staff attitudes related to new service implementation.
Self-Assessment: When implementing a new service, which of the following training components utilized in this study may impact staff attitudes?
a. Pre-survey to gather baseline attitudes
b. Brief, online orientation training overviewing the service for all staff
c. In-depth, live training for select staff implementing the service
Evaluation of a Multifaceted Pharmacist-Led Intervention on Reducing Unnecessary Treatment of Asymptomatic Bacteriuria Hibah Missoum, Tyler Dodd, Doug Carroll, Albert White DCH Regional Healthcare System - Tuscaloosa, AL
Background/Purpose: One of the most common reasons for antimicrobial overuse is the inappropriate treatment of asymptomatic bacteriuria (ASB). ASB is characterized by microbial growth in the urine in the absence of any signs or symptoms suggestive of a urinary tract infection (UTI). While asymptomatic bacteriuria commonly precedes UTI, treatment is not necessary in the majority of patients as it does not prevent the frequency of symptomatic infection nor does it result in better outcomes. The purpose of this project is to evaluate the impact of a multifaceted pharmacist-led intervention aimed towards reducing the unnecessary treatment of asymptomatic bacteriuria.
Methodology: This study is a quasi-experimental study encompassing three phases: a retrospective pre-intervention assessment of current prescribing patterns in regards to ASB, an intervention phase, and a prospective post-intervention phase assessing the efficacy of the interventions implemented. Eligible patients include those who are 19 years and older with positive urine cultures in the absence of UTI symptoms. Interventions include physician education, creation of a UTI/ASB guidance algorithm, prospective audit and feedback, and implementation of selective urine culture reporting. Pre and post-intervention antibiotic use will then be analyzed to assess the efficacy of the interventions implemented.
Results: As of February 2019, research is ongoing. 120 patients were included in the retrospective phase. Prior to implementation of interventions, 73% of patients received unnecessary treatment for asymptomatic bacteriuria. This translates to 632 days of unnecessary antimicrobial therapy per 1000 patient study days and $6,954 in antimicrobial costs.
Presentation Objective: Evaluate the impact of a multifaceted pharmacist-led intervention on reducing unnecessary treatment of asymptomatic bacteriuria.
Self-Assessment: Can pharmacy antimicrobial stewardship efforts decrease unnecessary treatment of asymptomatic bacteriuria?
Risk factors associated with broad spectrum beta-lactam resistance in Gram negative bloodstream infections Caroline Sutton, Carmen Faulkner-Fennell, John Schrank, Joseph Ewing, Li He Greenville Hospital System PGY1 - Greenville, SC
Background/Purpose: The purpose of this study is to identify patient specific risk factors for broad spectrum beta-lactam resistant Gram negative bloodstream infections to facilitate rapid, definitive antimicrobial therapy selection and de-escalation at the time of identification by polymerase chain reaction (PCR) blood culture identification (BCID) panel.
Methodology: In this single-center, retrospective chart review, patients greater than or equal to 18 years old admitted to Greenville Memorial Hospital were included based on the first positive Gram negative blood culture per admission from February 2016 to February 2018. Patients excluded include transfers in from an outside facility after 48 hours, death or transfer to outside facility within 48 hours of admission, positive blood culture result within 48 hours before discharge, or a pediatric unit admission. The primary outcome of this study is the incidence of Gram negative bloodstream infections with broad spectrum beta-lactam resistance defined as resistance to intravenous aminopenicillin, intravenous second generation cephalosporin, and intravenous third generation cephalosporin. The secondary outcome is the identification of risk factors for Gram negative bloodstream infections with broad spectrum beta-lactam resistance. This data will assist appropriate empiric antimicrobial selection and de-escalation at time of Gram negative bloodstream pathogen identification.
Quantifying change in serum magnesium concentration after repletion in hospitalized patients Melissa Sandler, Ted Walton, Laurie Cavendish, Kruti Shah, John Doran Grady Memorial Hospital - Atlanta, GA
Background/Purpose: There is limited data to guide providers regarding magnesium repletion dose. The primary purpose of this study was to quantify the change in serum magnesium concentration after a dose of either intravenous (IV) or oral magnesium. Secondary endpoints included how renal function, route, body mass index, and concomitant medications impact the change in serum magnesium concentration.
Methodology: A retrospective medical record review was conducted of all patients hospitalized between November 1, 2016 and April 30, 2017. Exclusion criteria included intrinsic sources of magnesium release; acute kidney injury or dialysis within 24 hours of the dose; admission to an intensive care, obstetrics or gynecologic unit; pregnancy or incarceration. Patients must have had labs collected within 12 hours before and between 6 and 18 hours after administration. The following data was collected: height, weight, gender, age, chemistry, concomitant medications, magnesium product, dose, and infusion rate of IV magnesium. Descriptive statistics were used to analyze the data.
Results: A total of 1385 patients were identified in the time period, 874 were reviewed, and 151 profiles were included in the analysis. Of the profiles reviewed, 65% were excluded due to lack of baseline or follow-up labs in the designated time. The average change in serum magnesium was 0.141 ± 0.09 mEq/L per gram of IV magnesium sulfate administered (n=131). Twenty-one oral magnesium doses were included.
Conclusions: Intravenous magnesium sulfate increased serum magnesium concentration by 0.141 ± 0.09 mEq/L per gram administered. The number of oral doses included was insufficient to confidently assess the change in serum magnesium associated with these formulations.
Presentation Objective: To quantify the change in serum magnesium concentration after a dose of magnesium is administered and identify variables that impact this change
Self-Assessment: How much does serum magnesium concentration change per gram of IV magnesium sulfate administered?
Retrospective review of chemotherapy induced peripheral neuropathy management Lauren Avery, Sonia Thomas PCOM School of Pharmacy - Suwanee, GA
Background/Purpose: Chemotherapy induced peripheral neuropathy (CIPN) is considered to be one of the most severe adverse effects of treatment, with a significant impact on the quality of life of affected patients. Some of the most common chemotherapy agents causing peripheral neuropathy include platinum derivatives, vinca alkaloids, and taxanes. Effective management depends on early diagnosis and understanding the underlying causes in the individual. Currently, there are no definitive treatments for painful CIPN. CIPN is difficult to manage, and most randomized trials testing a variety of drugs with different mechanisms of action showed no effective treatment.The purpose of this study is to describe the management of chemotherapy induced peripheral neuropathy at Northwest Georgia Oncology Centers (NGOC) North Fulton. Our aim is to see how patients are managed for CIPN and if their symptoms are controlled with treatment.
Methodology: Retrospective electronic health record review of patients with chemotherapy induced peripheral neuropathy at NGOC North Fulton from January 1, 2017 to December 31, 2017. Patients 18 years and older with chemotherapy induced peripheral neuropathy were evaluated for management of symptoms.
Results: A total of 46 patients met the inclusion criteria and were evaluated. 11 patients were receiving treatment for CIPN. The majority of patients were not experiencing symptoms to warrant the need for treatment at the time. 7 patients (64%) receiving treatment were managed with gabapentin. None of these patients demonstrated progression of symptoms while being treated.
Conclusions: We conclude that in the patients being evaluated, gabapentin is an effective treatment option for managing the symptoms of CIPN.
Presentation Objective: Describe effective treatment options for the management of CIPN.
Self-Assessment: What is one potential treatment option for chemotherapy induced peripheral neuropathy?
A Classification of Clinical Questions from an Electronic Drug Information Database Neil Patel, Ashish Advani
Background/Purpose: When making clinical decisions, healthcare practitioners may run into questions they are not able to pursue or find answers to. These unanswered or incompletely answered questions may lead to suboptimal decisions. To facilitate evidence-based medicine, clinicians can consult drug information centers. This investigation aims to classify the types of clinical questions from various healthcare professionals in order to assess the most common inquiry types.
Methodology: A retrospective assessment of inquiries over the course of six months from a drug information database was analyzed. The taxonomy of questions was adapted from previous research to encompass four main categories: diagnosis, treatment, epidemiology, or nonclinical. These individual categories were subdivided to further sort the types of inquiries.
Results: Out of a total 590 inquiries, 502 (85.1%) were related to treatment, 43 (7.3%) were epidemiological, 26 (4.4%) were non-clinical questions, and 19 (3.2%) were diagnostic in nature. Of the treatment-related questions, around 7% were non-pharmacological. Inquiries requesting information regarding drug efficacy or a medication recommendation comprised 42% of the total questions, and queries about drug dosing made up 15% of questions.
Conclusions: Around 80% of clinical inquiries were directly related to drug therapy. Because the incidence of non-drug-related questions is low, pharmacists in drug information centers are equipped to answer the majority of inquiries from healthcare professionals.
Presentation Objective: To classify the types of clinical questions received by an electronic drug information database
Self-Assessment: Are pharmacists equipped to answer the majority of clinical questions from healthcare professionals?
Impact of pharmacist involvement on telehealth Transitional Care Management (TCM) for high medication risk patients Jessica Cole, Linda Xiong,Paige Carson,Danny Fu,Maeghan Moss,Nick Wilkins Carolinas HealthCare System - PGY1 AmCare - Charlotte, NC
Background/Purpose: Transitional care management (TCM) includes services provided to a patient with complex health needs following hospital discharge to prevent hospital readmission and ensure a fluid care transition. At Atrium Health, TCM Nurses contact patients with moderate-to-high risk for rehospitalization following hospital discharge to coordinate medical appointments and address patient questions. The TCM Nurses now have the option to refer patients to a TCM Pharmacist if the patient is identified as having high medication risk. The primary objective of this study is to evaluate the impact of pharmacist involvement in the telehealth TCM program on identifying medication-related problems (MRPs) and improving the quality and safety of the medication discharge process for high medication risk patients.
Methodology: Eligible participants were those >/= 18 years of age with moderate-to-high risk for hospital readmission who were contacted by a TCM Nurse after hospital discharge from an Atrium Health facility, identified as high medication risk patients, and referred to a TCM Pharmacist from September 2018 through February 2019. High medication risk patients were defined as those with polypharmacy, medication nonadherence, low medication literacy, high risk medications, high risk admission diagnoses, or clinical scenarios at the discretion of the TCM Nurse. The TCM Pharmacist then contacted the patient telephonically, completed a comprehensive medication review, identified MRPs, and made interventions or recommendations to primary care providers. Data was collected from the PharmD Clinical Interventions Documentation Ad Hoc form and the patient_x0019_s electronic health record. Primary endpoints included the number and types of MRPs identified, number of MRPs resolved, number of 30-day hospital readmissions, and time of healthcare utilization.
Presentation Objective: Describe the benefits of pharmacist involvement in telehealth Transitional Care Management following hospital discharge
Self-Assessment: What role can ambulatory care pharmacists play in preventing hospital readmissions?
U.S. Ambulatory Prescribing Patterns of Menopausal Hormonal Therapy Following the Women's Health Initiative (2006-2016) A Case, A McLendon, M Jiroutek, D Wilson, S Fuller, M Holland Campbell University College of Pharmacy & Health Sciences (Ambulatory Care) - Buies Creek, NC
Background/Purpose: Hormone Therapy (HT) in postmenopausal women has proved controversial since the results of the Women_x0019_s Health Initiative (WHI) trial in 2002. In 2006, a study was published discussing the drastic decline in HT prescriptions written in 2002 and 2003 due to the findings of the WHI trial. Due at least in part to a more recent analysis of the WHI data showing a more favorable risk-benefit for younger menopausal patients, the 2017 North American Menopause Society (NAMS) Position Statement states that HT remains the gold standard for relief of vasomotor symptoms with menopause. Prescribing patterns of HT for patients suffering menopausal symptoms have not been evaluated in recent years. The objective of this study is to evaluate trends in ambulatory visits with HT prescribed by physicians from 2006-2016 in women aged 40 and older.
Methodology: This is a retrospective, observational, cross-sectional IRB-exempt study utilizing the National Ambulatory Medical Care Survey (NAMCS) population-based survey. Study population includes female visits for those 40 years and older and seen by a provider participating in NAMCS for any of the years studied. A plot for the proportion of visits including HT prescribing (and associated 95% confidence intervals) will be created by year (2006-2016). In addition, a multivariable regression model will be constructed to assess the predictive value of independent variables of interest.
Presentation Objective: Identify trends in population-based proportion of visits with hormone therapy prescribed by physicians who participated in the NAMCS database from 2006-2016 in women aged 40 and older.
Self-Assessment: True/False: Trends in hormone therapy have increased in women 40 years and older in recent years compared to the years directly after the WHI was published.
Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin for the Treatment of Left Ventricular Thrombus Justin Joy, Darshan Patel, Adele Robbins Emory University Hospital - Atlanta, GA
Background/Purpose: There are currently no existing randomized controlled trials evaluating the efficacy and safety of anticoagulation in the treatment of left ventricular thrombus (LVT). Guideline recommendations on the most appropriate anticoagulation regimen and duration are primarily based on case reports, expert opinion, and epidemiologic data due the paucity of available data. The purpose of this retrospective chart review is to assess the efficacy and safety of the use of direct oral anticoagulants (DOACs) in comparison to warfarin for the treatment of LVT.
Methodology: A multi-center, retrospective chart review was conducted among patients with a diagnosis of LVT who were prescribed a DOAC or warfarin and through 7/1/2014 _x0013_ 7/1/2018. Patients were excluded if are obese (BMI>40), have had a prior stroke or an inherited hypercoagulable state (Protein C, S, or antithrombin III deficiency; factor V Leiden). All data was split into two groups depending on the type of anticoagulation treatment received: DOAC or warfarin. The primary endpoint was the resolution of thrombus within 6 months of initial diagnosis as determined by echocardiogram, cardiac magnetic resonance imaging, or computed tomography angiography (CTA). The secondary endpoints were the incidence of ischemic stroke or TIA, and incidence of major bleeding as defined by bleeding from critical site (intracranial, intraspinal, intraocular, retroperitoneal, gastrointestinal, and pericardial).
Results: Data collection is currently ongoing. From an initial list of 385 patients collected via ICD-9 and 10 codes, 111 patients were initially included based on a diagnosis of LVT. Of the remaining 111 patients, 74 of these received warfarin and 37 received a DOAC (22 apixaban, 14 rivaroxaban, 1 dabigatran).
Presentation Objective: Discuss the potential option of DOACs for the treatment of LVT
Self-Assessment: True or False: Current guideline recommendations regarding anticoagulation regimens are primarily based on randomized controlled trials.
4T and HEP scores for heparin-induced thrombocytopenia in patients with mechanical circulatory support devices Arzo Hamidi, S Kram, B Kram, J Schultheis, G Arepally, J Levy, H Lee Duke University Hospital PGY2 - Critical Care - Durham, NC
Background/Purpose: Thrombocytopenia occurs in 20-50% of the critically ill patient population and may be due to sepsis, consumption by devices, dilutional changes or medications. Heparin-induced thrombocytopenia (HIT) is an IgG-mediated formation to the platelet factor 4 (PF4)/heparin complex that forms on the surface of platelets due to exposure with heparin. Several methods have been evaluated to determine pre-test probability until laboratory data are available to confirm HIT. These scoring tools include the 4T and Heparin Expert Probability (HEP) scores. However, they have not been validated in patients requiring mechanical circulatory support (MCS), which includes extracorporeal membrane oxygenation, ventricular assist devices, and intra-aortic balloon pumps. MCS routinely causes thrombocytopenia through platelet activation and release of PF4 or consumption. MCS devices also require anticoagulation, further complicating the diagnosis of HIT.
Methodology: The purpose of this study is to determine the predictive value of the 4T and HEP scores in patients requiring MCS. The primary objective is to determine pretest probability scores of HIT diagnosis by PF4 assay utilizing the 4T score or HEP score. The secondary objectives are to compare the pretest probability of the 4T score to HEP score in PF4-confirmed HIT; and to compare the pretest probability of 4T score to HEP score in SRA-confirmed HIT.
Adult patients who required MCS for greater than 24 hours and had a PF4 assay sent while they required MCS and heparin will be included. Patients will be excluded if the PF4 assay was ordered when not requiring MCS or if they did not have exposure to heparin within the previous 14 days.
Presentation Objective: Discuss the limitations of the pretest tools that are used to determine the risk of HIT.
Self-Assessment: What are some of the contributing factors of thrombocytopenia in patients requiring MCS?
Evaluation of phenylephrine as a second-line vasopressor in septic shock refractory to norepinephrine Lisa Gibbs, Jaime Foushee, Lyndsay Gormley, Anand Pariyadath, Jun Wu Greenville Hospital System PGY1 - Greenville, SC
Background/Purpose: The Surviving Sepsis guidelines recommend vasopressin or epinephrine as second-line agents for septic shock refractory to norepinephrine. Although not guideline recommended, phenylephrine may be selected as a second-line vasopressor in clinical practice in patients with tachyarrhythmias. The objective of this study is to determine if differences exist in the safety and efficacy of phenylephrine as a second-line agent for patients with septic shock refractory to norepinephrine compared to current guideline-recommended second-line therapies.
Methodology: This single center retrospective cohort study will compare patients with septic shock refractory to norepinephrine who received phenylephrine as a second-line vasopressor to those who received vasopressin or epinephrine as a second-line vasopressor. Adult patients over 18 years of age admitted to the medical-surgical intensive care unit (ICU) or coronary care unit (CCU), who required at least two vasoactive agents within 48 hours of septic shock diagnosis were included. Patients who received vasopressors for an indication other than septic shock were excluded. The primary outcome of this study is the percentage of patients achieving a goal mean arterial pressure of 65 mmHg or greater following implementation of a second vasopressor. Secondary outcomes include duration of vasopressor use, percentage of ICU vasopressor free days, new onset tachyarrhythmia within 24 hours of second vasopressor addition, in-hospital mortality, as well as ICU and hospital lengths of stay. Results of this study will be used to determine if any patients or subset of patients with septic shock refractory to norepinephrine benefit from the use of phenylephrine in place of vasopressin or epinephrine.
Presentation Objective: To define the role of phenylephrine for use in septic shock refractory to norepinpehrine.
Self-Assessment: What is phenylephrine's mechanism of action that may guide its role in therapy in the management of septic shock?
Implementation and Evaluation of Comprehensive Diabetes Education to Improve Initiation of Statin Therapy in Diabetes Patient Annie Lee, Joshua Kinsey, Erin Aviles Mercer University School of Pharmacy - Atlanta, GA
Background/Purpose: Patients with type 2 diabetes have an increased risk of developing cardiovascular disease. Based on this evidence, the Standards of Medical Care in Diabetes published by the American Diabetes Association recommends all patients with diabetes at the age of 40 and above to be treated with moderate to high intensity statin therapy. A statin has been the gold standard of treatment in reducing the risk of developing atherosclerotic cardiovascular disease for decades. However, despite this recommendation, 33 to 49% of diabetes patients are not on statin therapy. Since diabetes is a complex disorder, it requires patient engagement and self-management support. The purpose of this study is to provide education about diabetes management, review potential related long-term complications, and evaluate the patients' willingness to initiate statin therapy.
Methodology: Eligible participants are those with type 2 diabetes between the age of 40 and 75 currently taking medications for diabetes and are not on statin therapy. Participants were given brief structured diabetes education regarding long-term complications using models and follow-up surveys to assess their understanding of long-term complications of diabetes and their acceptance in initiating statin therapy.
Presentation Objective: Evaluate the impact of patient_x0019_s understanding of diabetes management and related long-term complications to improve initiation of statin therapy.
Self-Assessment: What challenges must be addressed when trying to improve initiation of statin therapy in diabetes patients?
Evaluation of Antibiotic Prescribing Practices Associated with FilmArray Respiratory Panel Results at a VA Medical Center Ngoc-Tram Huynh, Bailey Guest, Kelly Sugarman, David Rudd Salisbury VA Medical Center - Salisbury, NC
Background/Purpose: Acute respiratory infections (ARIs) have been reported as some of the most frequent indications for antibiotic prescriptions. Multiple clinical studies have shown that the majority of antibiotics prescribed for treatment of ARIs have been inappropriate. Overuse of antibiotics may lead to increased risk for allergic reactions and other serious antibiotic-related adverse events. Advances in laboratory testing, such as the FilmArray® respiratory panel, have the potential to impact antibiotic prescribing patterns by identifying patients with viral positivity who may not receive benefit from antibiotic treatment. However, few studies have been performed to assess the utility of these tests in the Veteran population. The purpose of this project is to evaluate antibiotic prescribing practices and clinical outcomes in patients with ARIs who have undergone respiratory panel testing at the Salisbury VA Health Care System (VAHCS).
Methodology: This was a retrospective chart review. A patient list was generated through TheraDoc® to identify patients for whom a FilmArray® respiratory panel was ordered between October and December 2018. The primary objective is to evaluate antibiotic prescribing practices regardless of respiratory panel results. Secondary objectives are to assess rates of admission, readmission, or emergency department visits within 30 days of diagnosis, length of hospitalization, and incidence of antibiotic-related adverse events. Patients were excluded if they had a concomitant infection other than a respiratory source, bronchiectasis, pulmonary fibrosis, interstitial lung disease or if they were immunocompromised or immunosuppressed at the time the respiratory panel was ordered. Results will be presented as descriptive statistics.
Presentation Objective: Evaluate the impact of respiratory screening results on antibiotic prescribing practices and clinical outcomes in patients with acute respiratory infections at a VA Medical Center.
Self-Assessment: What strategies can be devised through antimicrobial stewardship to optimize appropriate ordering of both FilmArray® respiratory panels and antibiotic prescriptions?
Influence of piperacillin/tazobactam infusion strategies on the incidence of acute kidney injury Renésha Henderson, Julie Thompson, Manali Patel, John Boreyko Duke Regional Hospital - Durham, NC
Background/Purpose: Current literature on the extended-infusion beta-lactams primarily focuses on their clinical efficacy, when the free drug plasma concentration remains above the minimum inhibitory concentration (MIC) (fT _ MIC) for at least 50% of the dosing interval. There is limited data assessing the impact of nephrotoxicity with extended-infusion beta-lactams. Thus, the objective of this study is to investigate the incidence of acute kidney injury (AKI) in hospitalized patients receiving intermittent-infusion versus extended-infusion piperacillin/tazobactam without the concomitant use of vancomycin.
Methodology: In this retrospective match-cohort study, we examined the electronic medical records of patients who received piperacillin/tazobactam for at least 48 hours at a community teaching hospital and at an academic medical center between November 1, 2014 to March 31, 2015 and November 1, 2017 to March 31, 2018. Patients were matched based on baseline characteristics. The primary outcome was the incidence of AKI defined by the RIFLE (risk, injury, failure, loss, and end-stage) criteria. The secondary outcome evaluated the difference in the total length of hospitalization between treatment groups.
Results: A total of 187 patients were included in the matched analysis, with 65 in the intermittent-infusion group and 122 in the extended-infusion group of piperacillin/tazobactam. The incidence of AKI was similar between groups, occurring in 16.9% of patients who received the intermittent-infusion and 16.4% in those who received the extended-infusion (p = 0.799). The length of hospitalization between the intermittent and extended infusion groups was 7.1 days versus 8.9 days (p = 0.010).
Conclusions: There was no significant difference in the incidence of AKI between piperacillin/tazobactam infusion groups. However, a statistically significant difference was apparent in the average length of hospitalization between groups.
Presentation Objective: To determine the incidence of AKI based on piperacillin/tazobactam infusion strategies.
Self-Assessment: Is the extended-infusion of piperacillin/tazobactam associated with greater nephrotoxicity than the intermittent-infusion?
Pharmacy Facilitated Education of Appropriate Procalcitonin Assays and Physician Response Haley Ethredge and Maura Hall John D. Archbold Memorial Hospital - Thomasville, GA
Background/Purpose: Procalcitonin (PCT) is a biomarker that can serve as a diagnostic tool to aid in the identification of bacterial infection in sepsis, pneumonia, and bacteremia. The goal of this review is to evaluate the impact of pharmacy led physician education on the utilization of PCT assays in determining appropriate patient populations and response to levels.
Methodology: All PCT assays drawn from July 11th to August 9th 2018 were collected for analysis. Inclusion criteria were patients over 18 years old with PCT assays ordered for diagnosis or clinical signs and symptoms of sepsis or pneumonia. Education was provided to the ED physicians and hospitalists about appropriate usage and response with PCT in order to maximize antimicrobial stewardship with PCT assays and to minimize inappropriate labs. After completion of education, data from December 22nd to January 20th 2019 was compared to historical baseline data to evaluate changes in number of inappropriate PCT assays drawn and response to PCT levels.
Results: Before physician education, 59.5% of PCT draws were appropriate. After physician education, 67% of PCT draws were appropriate. After education, there was not an increase in appropriate physician response to PCT levels in pneumonia or sepsis patients.
Conclusions: Pharmacist led physician education resulted in increased use of PCT assays in patients with presumed sepsis or pneumonia and increased appropriateness of PCT draws. Several patients with low PCT levels were continued on antibiotics without physician documentation. Focus will be placed on physician documentation for PCT assays to help assess utility and effectiveness. Continuous pharmacist driven provider education on response to PCT levels will be necessary to effectively use PCTs to influence antimicrobial stewardship.
Presentation Objective: Explain how pharmacy can impact Procalcitonin draws and responses to levels.
Self-Assessment: True or False: Procalcitonin assays on hemodialysis patients are clinically appropriate.
A PRE- AND POST-IMPLEMENTATION EVALUATION OF TRANSITIONING R-EPOCH TO THE OUTPATIENT SETTING Tina D. Nguyen, Tushar K. Patel, Ryan R. Crossman Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) is a chemotherapy regimen used to treat specific subtypes of B-cell and T-cell non-Hodgkin_x0019_s lymphomas and may be administered to patients in an inpatient or outpatient setting. Outpatient administration of R-EPOCH has demonstrated similar efficacy and tolerability compared to inpatient administration. However, outpatient management allows for a decreased inpatient length of stay, which ultimately reduces health care costs for patients and institutions. R-EPOCH has traditionally been administered at our institution on an inpatient basis. On October 8, 2018, we implemented a protocol for the outpatient administration of R-EPOCH at our institution. The purpose of this study is to determine if transitioning R-EPOCH to the outpatient setting will reduce costs.
Methodology: A retrospective chart review was conducted to evaluate patients who received R-EPOCH from October 2014 to April 2019. Records of R-EPOCH chemotherapy orders were utilized to identify patients. Patients 18 years and older who have completed a course of R-EPOCH were included. Exclusion criteria include lack of data or documentation. Patients who received inpatient R-EPOCH were compared to patients who received outpatient R-EPOCH after the implementation of an outpatient transition protocol. The primary objective was the difference in cost between inpatient R-EPOCH administration during the pre-implementation period and outpatient R-EPOCH administration during the post-implementation period. The secondary objectives were median number of inpatient days, percentage of inpatient admissions within 20 days of a completed regimen, percentage of hospital-acquired infections, and percentage of deviations from the protocol.
Presentation Objective: Describe how transitioning R-EPOCH administration from the inpatient setting to the outpatient setting can impact economic and clinical outcomes.
Self-Assessment: What are the potential benefits of transitioning R-EPOCH chemotherapy administration to the outpatient setting?
Evaluation of Using a Patient Specific Readmission Prediction Score to Target Transitions of Care Services Benjamin Coles, Aubrie Rafferty Mission Hospitals (Administration and Leadership with Masters) - Asheville, NC
Background/Purpose: Pharmacy provided transitions of care services have been shown to improve patient outcomes at hospital discharge, but many hospitals lack sufficient resources to provide this service to all discharging patients. The purpose of this study was to evaluate the use of a patient specific readmission prediction score to improve the targeting of high risk patients for discharge review.
Methodology: This Institutional Review Board approved, prospective study evaluated transitional services provided to adult patients (18 years and older) who were discharged from Mission Hospital from October 2018 to December 2018 with a readmission prediction score of 0.3 or greater. These patients received a discharge medication reconciliation review by a pharmacist in addition to completed interventions as identified through the review. Study outcomes were compared to transitional services provided to patents based on the hospital_x0019_s current stratification score. Primary outcome: intervention rate associated with discharge medication reconciliation review. Secondary outcomes: pharmacy service return on investment, change in readmission prediction score, healthcare cost avoidance, impact on readmissions, and prescriber contact rate.
Results: 1459 patients were in the standard group and 357 in the study group. The intervention rate for the study group was 20.2% compared to 18.6% for the standard group (p=0.25). The prescriber contact rate for the study group was 17.4% compared to 14.3% for the standard group (p=0.3).
Conclusions: Intervention rate for patients identified for transitional services using the patient specific readmission prediction score was greater, although not significantly, than the rate for the patients who were targeted for pharmacy review through standard methods.
Presentation Objective: Describe the potential utilization of a patient specific readmission prediction score in targeting high risk patients for pharmacy discharge review.
Self-Assessment: What risk factors are useful in targeting a high risk patient for discharge review?
Weight-based dosing strategy to improve transition from IR to XR tacrolimus in kidney transplant recipients Mackenzie Magid, Scott Sanoff, Hui-Jee Lee, Zidanyue Yang, Jennifer Byrns Duke University Hospital - PGY1 - Durham, NC
Background/Purpose: At Duke University Hospital, kidney transplant patients are initially started on a standard weight-based dose of tacrolimus. The potential for increased compliance and reduced side effects of Envarsus XR®, the extended-release formulation of tacrolimus, has interested many providers in transitioning patients. Current clinical practice at Duke follows the manufacturer_x0019_s recommendations for Envarsus XR® dose conversion as 80% of the total daily dose of the immediate release formulation. During the time of transition to Envarsus XR®, a patient is at risk for rejection of the transplanted kidney due to subtherapeutic levels or nephrotoxicity due to supratherapeutic levels. To establish a safe protocol to guide transition from immediate-release tacrolimus to Envarsus XR®, we examined tacrolimus levels achieved at the time of the initial transition to Envarsus XR®, as well as dose adjustments required to reach the therapeutic target. The primary endpoint was the initial weight-based dose of Envarsus XR® required to achieve therapeutic levels.
Methodology: This is a retrospective, single center study that included adults at least 18 years of age who have received a kidney transplant at Duke and were managed on a tacrolimus-based immunosuppression regimen between July 2015 and December 2018. Excluded patients received dual organs or non-kidney transplants, lacked appropriately drawn tacrolimus levels, and those taking moderate-strong inducers or inhibitors of CYP3A4 during the transition period. Patients were identified by querying prescriptions for Envarsus XR®, and manual chart review was performed to exclude any patients without sufficient follow-up after the initiation of Envarsus XR®.
Presentation Objective: To describe the relationship between weight and Envarsus XR® dose that may guide transition from immediate-release to extended-release tacrolimus in kidney transplant recipients.
Self-Assessment: What risks and adverse effects are associated with the transition period from immediate-release tacrolimus to Envarsus XR® in the renal transplant population?
PGY2 Solid Organ Transplant Resident, Duke University Hospital
Mackenzie Magid is the current PGY2 Solid Organ Transplant Resident at Duke University Hospital in Durham, North Carolina. She received her Doctor of Pharmacy and Bachelors of Science in Pharmaceutical Studies from the University of Kansas School of Pharmacy. After pharmacy school... Read More →
Thursday April 25, 2019 11:40am - 12:00pm EDT
Parthenon 2
Impact of a Physician-Pharmacist co-visit model on access, revenue, and quality of care Tanya Devine, Kristie Clark, Kayla Morgan, Nick Wilkins, Paige Carson Carolinas HealthCare System - PGY1 AmCare - Charlotte, NC
Background/Purpose: Pharmacists have become an important member of the healthcare team, as their role is expanding beyond dispensing. Not only has the pharmacist_x0019_s role in patient care increased one_x0019_s access to care, but also has shown to improve patient outcomes through medication therapy management. A traditional embedded pharmacist model involves the pharmacist having a separate schedule from providers and independently seeing patients for disease state management. Pharmacists generate revenue for their respective practices through incident-to-billing, labs ordered, immunizations given, and other services. Unfortunately, revenue from incident-to-billing is limited as Medicare does not yet recognize pharmacists as providers. Many practices have been unable to justify the salary of a pharmacist based on billing and reimbursement for encounters with a pharmacist alone. The primary objective of this study is to evaluate revenue, access, and quality of care provided through a physician-pharmacist co-visit model compared to a physician-only model.
Methodology: One-half day per week will be used to pilot the co-visit model. The pharmacist will see patients on the provider_x0019_s schedule with one or more chronic disease states, fifteen or more prescription medications, or any high-risk medication. The pharmacist will review and update the medication list, identify medication-related problems, provide medication therapy management, answer medication-related questions, and identify items needing physician attention. Data will be collected and compared to a physician-only control group to evaluate the difference in revenue as the primary endpoint. Secondary endpoints include time spent with a patient, additional patients seen on a provider_x0019_s schedule, and the number and type of medication related problems identified.
Presentation Objective: Describe the benefits of a physician-pharmacist co-visit model.
Self-Assessment: What are barriers to the physician-pharmacist co-visit model and how can these barriers be overcome?
Oral Thiazide Diuretic Comparison in Acute Decompensated Heart Failure Julia Pendexter, Elizabeth Nguyen, Derek Polly, Kathy Tang Emory University Hospital Midtown - Atlanta, GA
Background/Purpose: Acute decompensated heart failure (ADHF) accounts for a large percentage of annual hospitalizations in the United States and patients are faced with high levels of morbidity and mortality. Intravenous (IV) loop diuretics are recommended as the therapy of choice in ADHF patients with significant volume overload. However, loop diuretic resistance occurs frequently in ADHF patients and minimal data exists to guide the management of refractory volume overload in loop diuretic resistance. Sequential nephron blockade using thiazide-type diuretics has been a proposed strategy to overcome diuretic resistance in ADHF. The primary objective of this study is to evaluate the efficacy and safety of oral chlorothiazide versus oral metolazone, which to our knowledge, is not currently addressed by existing literature.
Methodology: A single center, retrospective chart review was performed on ADHF patients with loop diuretic resistance who received oral metolazone or oral chlorothiazide from July 1st, 2016 to July 31st, 2018. Loop diuretic resistance was defined as administration of IV furosemide at a dose of greater than or equal to 160 mg/day or equivalent dose of IV bumetanide. The primary efficacy endpoint was net urine output at 24 hour after initiation of the thiazide-like diuretic. Secondary endpoints included change in body weight, serum creatinine, electrolyte abnormalities, length of stay, need for ICU transfer, and 30-day readmission.
Results: To be presented
Presentation Objective: Compare the efficacy and safety between oral metolazone and oral chlorothiazide in ADHF with loop diuretic resistance.
Self-Assessment: What is the difference in efficacy and/or safety between thiazide-type diuretics for loop diuretic resistance in ADHF patients?
Effectiveness of Atypical Antipsychotics as Sedative Adjuncts in Mechanically-Ventilated Adults Kelsey Ohman, Jennifer Schultheis, Shawn Kram, Bridgette Kram Duke University Hospital - PGY1 - Durham, NC
Background/Purpose: Sedation may be clinically indicated for mechanically-ventilated patients to alleviate anxiety, reduce ventilator dyssynchrony, and prevent agitation-related injury. Strategies to manage the adverse effects associated with commonly used sedatives includes analgesia-first sedation and maintaining light levels of sedation. Unfortunately, these strategies may be ineffective for certain patients, specifically for patients requiring deep sedation. At our institution, atypical antipsychotics (AAPs) have been utilized as sedative adjuncts to reduce sedative requirements in patients who experience dose-limiting adverse effects of traditional sedatives. The aim of this study is to determine if AAPs are effective at reducing sedative dosage requirements when utilized as sedative adjuncts.
Methodology: This retrospective case-control study included mechanically-ventilated adult patients (>18 years of age) admitted to the Medical ICU who received an AAP between July 1, 2013 and July 1, 2018. The specific AAP agents evaluated in this study included quetiapine and risperidone. Patients were excluded if they received fewer than two consecutive doses of AAPs, had an indication for AAPs other than as a sedative adjunct, had an AAP documented as a home medication, were initiated on AAPs prior to ICU arrival, or received concomitant neuromuscular blockers. Patients were also excluded if they underwent tracheostomy, extubation, or operating room (OR) procedures during the study period. The primary endpoint of this study is total daily sedative dosage requirements over 24 hours pre- and post-initiation of an AAP. Secondary endpoints of the study include RASS score, total daily sedative dosage requirements over 48 hours pre- and post-initiation of AAP, and total daily opioid dosage requirements. Safety endpoints include QTc pre- and post-initiation of AAP.
Presentation Objective: To determine whether atypical antipsychotics affect total daily sedative dosage requirements in mechanically-ventilated adults.
Self-Assessment: Which of the following scenarios represent an appropriate use of antipsychotics in the ICU?
Evaluation of prophylactic antibiotic therapy in civilian penetrating brain injury Brian Norman; Michael Wagner; Kimberly Clark; Alex Ewing Greenville Hospital System PGY1 - Greenville, SC
Background/Purpose: Penetrating brain injury (PBI) is classified as a form of traumatic brain injury with high mortality. The development of an infection following PBI can further increase morbidity and mortality, as well as increase healthcare costs. Due to the high risk of infection and negative outcomes, there could be a role for administering routine prophylactic antibiotics in PBI patients. A variety of antibiotics are found in the medical literature with cephalosporins being preferred, but no specific regimen or duration has been specified.
While previously published studies investigated the impact of prophylactic antibiotics, these studies lacked the use of a standardized guideline. Our institution implemented a standardized prophylactic antibiotic guideline of vancomycin and ceftriaxone for 10 days in patients suffering from a PBI.
The purpose of this retrospective study is to determine if a pre-specified prophylactic antibiotic regimen would lead to a reduction in post PBI infection rates.
Methodology: This retrospective cohort study compared adult patients admitted with a PBI who received guideline based prophylactic antibiotics to a historical cohort of patients who received no prophylactic antibiotics. The primary outcome of this study was intracranial infection within 30 days of PBI. Secondary outcomes include length of hospital stay, mortality, guideline compliance, documented Clostridium difficile infection, and adverse drug events.
Presentation Objective: Determine the effect of an institution_x0019_s PBI prophylactic antibiotic guideline on the incidence of intracranial infections.
Self-Assessment: When providing prophylactic antibiotics for a PBI, which organism must be covered?
Impact of routine education and data feedback on the durability of antimicrobial stewardship for outpatient UTIs Funaro JR; Moehring RW; Lu B, Lee H-J; Sarubbi CB; Anderson DJ; Wrenn RH Duke University Hospital- PGY2 Amb. Care - Durham, NC
Background/Purpose: National organizations recommend implementing outpatient antimicrobial stewardship (AS) programs to reduce inappropriate antibiotic prescriptions. While outpatient AS has an immediate beneficial impact, prescribing patterns trend back towards baseline once the active AS intervention is removed. This study aims to evaluate the impact of routine education and data feedback on the durability of an outpatient AS intervention for urinary tract infections (UTIs).
Methodology: We conducted a prospective quasi-experimental study at one primary care (PC) and one urgent care (UC) clinic to evaluate the durability of an outpatient AS intervention. We developed clinic-specific antibiograms and UTI diagnosis and treatment guidelines. Education materials, along with clinic- and provider-specific feedback reports, were then routinely emailed to clinicians. Clinicians who treated adult patients with a diagnosis of acute UTI at either clinic participated in the study. The primary outcome was percent of encounters in which first- or second-line antibiotics were prescribed, according to clinic-specific guidelines. Pre- and post-intervention phase and trend changes were assessed using an interrupted time series approach.
Results: To date, 763 and 3,523 UTIs have been treated at PC and UC, respectively. Preliminary data suggest that the percent of visits with guideline-concordant antibiotics increased at PC from 66% at baseline to 72% seventeen months after the intervention and at UC from 36% at baseline to 58% fourteen months after the intervention. Over the same period, there was a sustained reduction in the number of treated UTIs at PC by 40% and at UC by 14%.
Conclusions: Routine education and data feedback is effective at maintaining the durability of an AS intervention for outpatient UTIs.
Presentation Objective: Identify potential strategies for maintaining the durability of outpatient AS.
Self-Assessment: Is routine education and data feedback effective at maintaining the initial benefit of an outpatient AS intervention?
Analysis of the etiologies and medications in hospital-acquired acute kidney injury Geren Thomas, Maura Hall John D. Archbold Memorial Hospital - Thomasville, GA
Background/Purpose: Acute kidney injury (AKI) is associated with increased mortality and healthcare costs. Identification of causes and risk factors is fundamental to reversing the trend of prolonged hospitalization.
Methodology: This retrospective, cross-sectional study of patients at John D. Archbold Memorial Hospital assessed causes of acute kidney injury during hospitalization. Patients were included if they were found to have a diagnosis code of N17.9, acute kidney failure unspecified, and were inpatients sometime during the 2017 calendar year. Patients were excluded if acute kidney injury was diagnosed during or prior to admission.
Results: Two-thirds of AKI cases could be attributed to pre-renal etiology. Surgical and contrast-induced nephropathy each played a role in about 25% of cases. About one-quarter of patients had multifactorial injuries. Over half of patients received a beta-lactam or cephalosporin, a loop diuretic, or a proton pump inhibitor prior to documented renal injury. Other commonly observed nephrotoxic drugs included statins, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and vancomycin.
Conclusions: The majority of AKI events not present on admission can be attributed to pre-renal causes. The high numbers of patients on loop diuretics with heart failure as a comorbidity may indicate a common cause of acute injury is over-diuresis in exacerbation of heart failure.
Presentation Objective: Communicate demographics of hospitalized patients who developed AKI and the etiologies and medications most likely associated with their renal decline.
Self-Assessment: Which of the following medications requires close surveillance of renal function due to the high number of AKI events identified in this study?
Evaluation of Prophylactic Prescribing Adherence to NCCN Guidelines for High & Moderate Emetogenic Risk IV Chemotherapy Chelsea Parry, Mhandy Gerard, Laura Hallman, Hayley Klein, NaaDede Plange Piedmont Atlanta Hospital - Atlanta, GA
Background/Purpose: Chemotherapy-induced nausea and vomiting (CINV) is a significant concern in patients receiving chemotherapy. CINV can lead to altered treatment regimens, increased treatment cost, and reduced quality-of-life due to dehydration, malnutrition, or death. The National Comprehensive Cancer Network® (NCCN) provides guidelines to offer effective CINV prophylaxis. Appropriate utilization of CINV prophylaxis can greatly reduce and potentially eliminate CINV. The objective of this study is to evaluate provider adherence to NCCN guidelines for CINV prophylaxis.
Methodology: The study was a retrospective chart review of patients >17, who received moderate or high emetic risk intravenous chemotherapy from July 2017 to November 2018 at Piedmont Atlanta Hospital or at Piedmont West Infusion Center. The primary endpoint was to determine adherence to NCCN guidelines for CINV prophylaxis. Secondary endpoints included length of stay, readmission rate due to CINV, alteration in regimens, and implementation of antiemetic rescue.
Results: A total of 122 patients were included in the study. There were 476 chemotherapy orders associated with these patients. Eighty patients (65.5%) received high emetic risk regimens and forty-two (34.5%) received moderate emetic risk regimens. Of the 122 patients, appropriate CINV prophylaxis was ordered for fifteen (12.3%). Average length of stay was three days (range 1-56). There were 43 readmissions including four (9.3%) related to CINV. None of the chemotherapy regimens were altered due to CINV. Rescue antiemetics were prescribed for thirteen (10.7%) patients.
Conclusions: CINV prophylaxis differed from the NCCN guideline recommendations for the majority of patients. Education will be developed and provided to oncologists and pharmacists to ensure improvement in adherence to guidelines and patient outcomes.
Presentation Objective: Assess prescribing patterns for CINV prophylaxis in high and moderate emetic risk chemotherapy regimens.
Self-Assessment: What are the potential sequelae that may develop in poorly managed CINV?
Comparison of Neonatal Outcomes from Utilizing SMOFlipid vs. INTRAlipid Dalton Hudgins, Amy P. Holmes, Malinda G. Parman, J. Brock Harris Novant Health Forsyth Medical Center - Winston-Salem, NC
Background/Purpose: SMOFlipid is a four-oil lipid injectable emulsion. The four oils that make up the emulsion are soybean oil (30%), fish oil (15%), medium-chain triglycerides (30%), and olive oil (25%). A unique characteristic of SMOFlipid_x0019_s composition when compared to INTRAlipid_x0019_s composition is the ration of omega-6: omega-3 fatty acids. SMOFlipid has a ratio of 2.5:1, whereas INTRAlipid's ratio is 7:1. The American Society for Parenteral and Enteral Nutrition and the European Society of Pediatric Gastroenterology Hepatology and Nutrition agree that SMOFlipid has the potential to reduce the inflammatory response seen with soybean oil-based lipid emulsions as well as have a beneficial effect on cholestasis and parenteral nutrition-associated liver disease. This study seeks to provide evidence-based answers to the SMOFlipid vs. INTRAlipid debate through assessing efficacy and safety outcomes in neonatal patients while utilizing the aforementioned products.
Methodology: The institutional review board approved this multi-center, retrospective chart review of patients from August 2016 _x0013_ August 2018. Patients were included if they had a gestational age of less than or equal to 34 weeks, required at least 7 days of parenteral nutrition with either SMOFlipid or INTRAlipid, and had a birth weight between 500g and 2000g. Patients were excluded if they had other diagnosed causes of neonatal cholestasis, such as biliary atresia, choledochal cysts, congenital infections, viral hepatitis, and congenital hypothyroidism, or who were discharged or transferred outside of our health system prior to being on SMOFlipid or INTRAlipid for a minimum of 7 days. The primary outcome of this study is a composite of development of cholestasis or development of hypertriglyceridemia.
Presentation Objective: To identify differences in neonatal outcomes when using SMOFlipid vs. INTRAlipid.
Self-Assessment: Is SMOFlipid effective for reducing the incidence of cholestasis or hypertriglyceridemia in a neonatal population when compared to INTRAlipid?
IMPLEMENTATION OF A POST-SURGICAL PAIN MANAGEMENT ORDER SET IN OPIOID NAÏVE PATIENTS Faith Brown, Maggie Guinta, Jenna Swindler McLeod Regional Medical Center - Florence, SC
Background/Purpose: Perioperative pain management guidelines recommend the use of multimodal analgesia (MMA) to improve pain control and reduce the quantity of opioids administered perioperatively. The use of MMA is routine practice for many surgical specialties at McLeod Regional Medical Center, but has not been adopted hospital wide. The primary objective of this study is to assess whether a revision to the post-operative pain management order set for general surgery patients that implements MMA as well as equianalgesic opioid doses will reduce the quantity of opioids required postoperatively.
Methodology: The study utilizes a retrospective and prospective cohort. Patients are included if undergoing non-emergent or scheduled general surgery procedures and are classified as opioid naïve, determined through self-reported home medication lists and the Prescription Drug Monitoring Program. The primary outcome is the total quantity of inpatient opioids administered in opioid naïve patients. The secondary outcomes analyze the safety and efficacy of the protocol through review of inpatient naloxone administration, patient reported pain scores, and quantity of opioids prescribed at discharge. Concomitantly, an extensive nurse and physician education initiative will be implemented to inform of the benefits of MMA as well as current recommendations for opioid prescribing at discharge. The pre and post-operative order sets include scheduled acetaminophen and gabapentin, with options for scheduled celecoxib, scheduled or as needed ketorolac, as needed oxycodone, and as needed morphine. The following data will be collected for each patient: pre-operative medications, intra-operative medications, total quantity of inpatient opioids administered (in oral morphine equivalents), standard demographics, comorbidities, history of drug/alcohol abuse, benzodiazepine and gabapentin use in the previous year, type of surgery, post-surgical pain scores, inpatient naloxone administration, and opioid quantity prescribed at discharge.
Presentation Objective: Describe the effects of multimodal analgesia on opioid requirements postoperatively.
Self-Assessment: What are non-opioid analgesic options for post-operative pain?
Evaluation of antipsychotics use in the intensive care unit for delirium Dieuhong T. Nguyen, Laura R Frantz, Allison Gaddy, Sanaa Belrhiti Novant Health Presbyterian Medical Center - Charlotte, NC
Background/Purpose: Antipsychotics are used for the treatment of delirium in the intensive care unit (ICU). Studies have shown that delirium in the ICU is associated with longer ICU and hospital length of stay (LOS), increased mortality, and increased hospital costs. The primary objective of this study is to evaluate ICU and hospital LOS in patients receiving antipsychotics for acute delirium. The secondary objectives include duration of positive confusion assessment method (CAM) status/delirium, percent of patients with delirium who received antipsychotics without CAM assessment, number of days patient received antipsychotics, percent of patients without provider order for non-pharmacologic measures to prevent delirium, rate of adverse drug reactions, percent of antipsychotic(s) discontinuation prior to ICU and hospital discharge, and number of pharmacist interventions related to drug-drug interactions associated with antipsychotic(s) use.
Methodology: This retrospective, multi-center, electronic chart review may include up to 120 patients. Inclusion criteria comprised age greater than or equal to 18 years, admission to the ICU between July 2017 and June 2018, administration of two or more doses of either injectable and/or oral antipsychotics during ICU stay, and delirium diagnosis during ICU admission. Data collection included demographics, diagnosis of delirium during ICU stay, hospital LOS, ICU LOS, antipsychotic(s) discontinuation after ICU discharge, readmission to ICU with antipsychotic(s) initiated during initial ICU stay, home medications, inpatient medications, discharge medications, laboratory values, pharmacist intervention documentation, QTc, documentation of fall occurrence within 24 hours following antipsychotic administration, interacting medications, adverse drug reactions, CAM assessments, and non-pharmacologic orders. Subsequently, these data will be utilized to evaluate the appropriateness of antipsychotic use for ICU delirium.
Presentation Objective: Assess the appropriateness of antipsychotic use for ICU delirium.
Self-Assessment: What are the benefits/limitations of antipsychotics in ICU delirium?
Categorizing causes of heart failure readmissions in a Veterans Affairs Medical Center Karen Quach, Veldana Nuhi Ralph H. Johnson VA Medical Center - Charleston, SC
Background/Purpose: Heart failure (HF) is a major healthcare problem, not only due to wide prevalence, affecting over 6.5 million adults in the U.S., but also high healthcare cost of $30.7 billion per year. This cost is largely attributed to by hospitalizations and high readmission rates for patients with HF. Currently at the Ralph H. Johnson VA Medical Center (RHJVAMC), there are multiple practices in place to safely discharge HF patients and coordinate care to outside providers, however, HF remains the leading cause hospitalizations as well as readmissions. The purpose of this project to learn more about the factors leading to HF readmissions and determine a trend that will help improve the transitions of care process for patients with HF.
Methodology: A data query identified patients with a hospital admission for HF at the RHJVAMC between September 2017 and August 2018. A retrospective chart review was performed to identify patient-specific factors including demographics, medications, medical history, and laboratory results. Descriptive statistics will be the primary statistical method used to analyze the collected data.
Presentation Objective: Explain patient-specific factors that play a role in the risk for heart failure readmissions.
Self-Assessment: What are important patient-level assessments required to individualize and assess risk of heart failure readmission?
Cardioprotective effects of pre-operative cyclosporine in patients undergoing heart transplantation Yoko Hirase, Matt Harris, Mara Watson, Hui-Jie Lee, Chetan Patel Duke University Hospital (Transplant) - Duurham, NC
Background/Purpose: Heart transplantation is one of the treatment options for patients with end-stage heart failure. Ischemia-reperfusion injury is a major issue associated with heart transplantation and is attributed to increased rates of graft dysfunction and risk for rejection. Cyclosporine is reported to reduce tissue injury by blocking the release of apoptotic factors. The purpose of this study is to determine if pre-operative cyclosporine decreases the rate of primary graft dysfunction (PGD) in patients undergoing orthotopic heart transplant (OHT).
Methodology: Retrospective, single center study of 172 OHT recipients between July 2013 and June 2018. Primary endpoint was incidence of PGD within 24 hours post-OHT in patients who did and did not receive pre-operative cyclosporine. Secondary endpoints were PGD subcategories used at our institution (right ventricular PGD, moderate left ventricular PGD, and severe left ventricular PGD), which were categorized based on left ventricular ejection fraction and use of circulatory support devices. Other endpoints include patient and graft survival at 30 and 90 days, intensive care unit and hospital lengths of stay, duration on inotropic and/or vasopressor support, and renal function within 7 days post-OHT. To account for selection bias of cyclosporine treatment, 1:1 propensity score matching was performed.
Results: Total of 172 patients were matched with no significant differences in baseline characteristics. PGD occurred in 20.9% of cyclosporine and in 20.9% of non-cyclosporine patients (p=1). No significant differences were seen in all secondary endpoints.
Conclusions: In this study, pre-operative cyclosporine did not affect the rate of PGD suggesting that its use may not be beneficial in OHT recipients.
Presentation Objective: To assess the effects of pre-operative cyclosporine on the rates of primary graft dysfunction post-heart transplant
Self-Assessment: Is pre-operative cyclosporine use associated with decreased rates of primary graft dysfunction in heart transplant recipients?
Evaluation of a pharmacy-led overactive bladder management service in a women_x0019_s health center: a prospective pilot study Catherine Helms, Lydia Wang, Michael Kennelly, Amber Herr Carolinas HealthCare System - PGY1 AmCare - Charlotte, NC
Background/Purpose: Overactive bladder is an increasingly common syndrome, particularly in females, characterized by urinary urgency, frequency, nocturia, and incontinence. This syndrome can have a significant negative impact on the quality of patients_x0019_ lives. Pharmacists are in a unique position to care for these patients given their education, training, and presence in outpatient clinics. The primary objective of this study is to evaluate the impact of clinical pharmacist intervention on overactive bladder outcomes through behavioral therapy education, pharmaceutical optimization utilizing AUA/SUFU guidelines, side effect management, and in-depth pharmacological and non-pharmacological counseling.
Methodology: Patients were eligible for inclusion if they were at least 18 years old, had female reproductive organs, received care for overactive bladder at Women_x0019_s Center for Pelvic Health, required overactive bladder medication or were currently receiving overactive bladder medication, and had symptoms of overactive bladder lasting at least 3 months. Participants were identified via Cerner electronic medical record by pharmacists or directly referred from providers at the Women_x0019_s Center for Pelvic Health. Patients were then randomized into control or intervention arms and required to complete voiding diaries prior to each visit. During four consecutive clinic visits with pharmacist, patients filled out questionnaires assessing symptom severity, health-related quality of life, cognition and satisfaction with services and providers. At each visit, the pharmacist provided disease state education, counseled on lifestyle intervention, monitored adherence, optimized medication lists, and initiated overactive bladder medication(s) based upon study protocol. Primary endpoints assessed were disease/symptomatic control, health-related quality of life, and value of pharmacist involvement.
Presentation Objective: Describe the benefits of a pharmacist-led overactive bladder service in an outpatient women_x0019_s pelvic health clinic.
Self-Assessment: What outpatient services can pharmacists offer to benefit patients with overactive bladder?
Genetic Testing for Familial Hypercholesterolemia in minority patients with an LDL-C >190 mg/dL Allison Hester, Mary Katherine Cheeley, Terry Jacobson Grady Memorial Hospital (Ambulatory Care) - Atlanta, GA
Background/Purpose: Diagnosis of Familial Hypercholesterolemia (FH) includes use of clinical tools that rely heavily on family history of ASCVD or elevated LDL-C. In our indigent patient population, few patients know their family history, making it challenging to diagnose FH. The prevalence of FH in minority populations is not well studied.
Methodology: All patients received a 7-gene genetic test and an Lp(a) measurement. Patients were prospectively included from lipid clinic or from a list of patients with an LDL-C >190 mg/dL. Patients were excluded if they had a secondary cause for elevated LDL-C or were pregnant, incarcerated, or less than 18 years old.
Results: Of 100 patients, 97 were black, 2 hispanic, and 1 caucasian. Median baseline LDL-C was 229mg/dL (IQR 214-250). Forty-three percent of patients had ASCVD. The baseline Dutch Lipid Score was 5 (IQR 3-5). Overall, 12 patients had a positive genetic test. Nine percent of patients had an LDL-C raising mutation. There were 8 LDLR mutations, 1 apoB mutation, and 3 apoE mutations. LDL-C in genetically positive patients was higher (median (IQR) 272 (238-289) vs 227 (211-245), p190 mg/dL.
Self-Assessment: True or False: It can be challenging to reach a clinical diagnosis of FH in a patient who cannot report family history.
Assessment of provider/nurse perceptions of naloxone prescribing and opioid misuse treatment from the emergency department Marcus Kaplan, J. Mando-Vandrick, H. Glover, M. Funke, S. Eucker Duke University Hospital - PGY2 Emergency Medicin - Durham, NC
Background/Purpose: Emergency department (ED) visits for opioid overdose continue to rise nationwide. A crucial ED-based harm reduction strategy that can demonstrably save lives is the routine prescription of naloxone at discharge to patients at risk for opioid overdose. This study sought to characterize knowledge and perceptions of opioid misuse and naloxone prescribing among ED staff at our institution.
Methodology: All physicians (MDs), physician assistants (PAs), and registered nurses (RNs) working in our ED were invited to complete the survey, with results then used to guide the content of in-service educational interventions to address survey findings.
Results: Completed responses were received from 53/69 MDs (77% response rate), 8/13 PAs (62%), and 98/118 RNs (83%). Regarding perceptions of addiction, 11% of providers (MD/PA) and 27% of nurses did not agree that addiction is a chronic medical illness, while 25% of providers and 21% of nurses felt that there is little they could do to help drug users. In assessing barriers to naloxone prescribing, 41% of providers and 43% of nurses felt that their limited knowledge of the evidence supporting naloxone was at least moderately prohibitive. However, 62% of providers felt ED-based naloxone prescribing was very important and 77% were very or completely willing to do so. Among nurses, 43% felt ED-based naloxone prescribing was very important and 53% were very or completely willing to recommend this intervention.
Conclusions: Key areas of focus for education were identified from the results of this initial survey, while a willingness to support the practice of ED-based naloxone prescribing was also evident. A repeat survey is planned following educational interventions to assess changes in perceptions or knowledge of these topics.
Presentation Objective: Discuss barriers to implementation of ED-based naloxone prescribing.
Self-Assessment: What is one barrier to the implementation of routine ED-based naloxone prescribing?
Evaluating the effects of corticosteroids in patients with non-septic shock following cardiothoracic surgery Daniel Anderson, Ceressa Ward, Amit Prabhakar, Brent Keeling, Vanessa Moll Emory University Hospital Midtown - Atlanta, GA
Background/Purpose: Recent evidence favors utilizing corticosteroids in septic shock patients. However, there remains a paucity of evidence for use in other types of shock. Thus, the purpose of this study is to analyze the effects of corticosteroids on morbidity and mortality in non-septic shock patients following cardiothoracic (CT) surgery.
Methodology: A retrospective chart review was conducted on patients diagnosed with non-septic shock following CT surgery admitted to the CT surgery intensive care unit (ICU) at Emory University Hospital Midtown between May 1, 2012 and July 31, 2018.
Eligible patients were at least 18 years of age, status post coronary artery bypass graft (CABG) and/or valve replacement surgery, and on vasopressor therapy for at least 24 hours. Patients were excluded if they received antibiotics (excluding perioperative prophylaxis) before steroids or within 72 hours of surgery, or received a dose of steroids in the 24 hours prior to surgery.
Data was abstracted from the Society of Thoracic Surgery (STS) Adult Cardiac Surgery Database. Of the 3,911 patients admitted to the CTS ICU status post CABG and/or valve replacement surgery, during the defined study period, 400 patients will be included for final analysis.
The primary outcome is 30-day mortality. Secondary outcomes include: 30-day mortality for adrenal sufficient and insufficient patients (adrenal insufficient defined as random cortisol < 18 mcg/dL), ICU and hospital length of stay, ICU mortality, number of vasopressor free days out of 30, number of ventilator free days out of 30, rates of acute kidney injury, incidence of surgical site infections, and incidence of sepsis.
Presentation Objective: List potential risks and benefits of initiating corticosteroid therapy in patients with non-septic shock following cardiothoracic surgery.
Self-Assessment: What is one scenario in which corticosteroids may be an effective agent in patients with non-septic shock following cardiothoracic surgery?
Impact of a Pharmacist-Driven Methicillin-resistant Staphylococcus aureus Surveillance Protocol on Vancomycin Exposure Will Evans, Ron Trible, Kristen Paciullo Emory St. Joseph's Hospital - Atlanta, GA
Background/Purpose: Although methicillin-resistant Staphylococcus aureus (MRSA) is a rarely identified pathogen of pneumonia, providers are often compelled to use anti-MRSA agents empirically. As a result, patients may be exposed to unnecessary anti-MRSA antibiotic therapy. Polymerase chain reaction (PCR) nares screening for MRSA colonization has repeatedly shown a negative predictive value of >95% for MRSA pneumonia. Therefore, nares screenings have the potential to serve as a valuable tool to de-escalate anti-MRSA antibiotics for patients with pneumonia. Recently, our institution implemented a protocol whereby pharmacists order a MRSA PCR screen for patients with suspected MRSA pneumonia at the time of vancomycin initiation. For negative MRSA PCR results, pharmacists contact the provider and recommend discontinuation of vancomycin.
Methodology: A retrospective chart review of patients with suspected MRSA pneumonia pre- and post-protocol implementation was conducted September 1, 2017 through November 30, 2017 (control) and September 1, 2018 through November 30, 2018 (intervention). Patients were excluded for the following: concomitant non-pulmonary MRSA infection, septic shock requiring vasopressors, confirmed MRSA infection within the last 30 days, cystic fibrosis or bronchiectasis. The primary outcome was reduction in duration of vancomycin therapy.
Results: Our IRB-approved study included 196 patients (n=81 pre-protocol, n=115 post-protocol). For the primary outcome, we saw a significant reduction in median hours of vancomycin in the post-protocol group (37.97 pre-protocol, 23.5 post protocol, p=0.002). We did not see a significant difference in clinical outcomes such as length of stay, acute kidney injury, or readmission at 30 days.
Conclusions: Implementation of a pharmacist-driven MRSA nares screen significantly and safely reduces unnecessary vancomycin exposure in patients with suspected pneumonia.
Presentation Objective: Discuss the efficacy of pharmacist-driven MRSA nares screen protocol for de-escalation of vancomycin therapy.
Self-Assessment: What patient population may benefit from using MRSA nares screens for vancomycin de-escalation?
Impact of a pharmacist-run neurology clinic in managing migraine headaches at a Veterans Affairs Medical Center Emily Hailstone, Alison Martin Ralph H. Johnson VA Medical Center (Administration and Leadership) - Charleston, SC
Background/Purpose: Migraine headache disorders are one of the most prevalent conditions for which patients are referred to neurology service. Migraine headaches can be extremely debilitating for patients and lead to increased healthcare utilization. Extended treatment trials and duration are often needed for adequate efficacy. Patient concerns may include treatment efficacy, medication safety and tolerance, and complexities of medication administration including route of administration and complex dose titrations or taper schedules. Studies have shown that adverse drug reactions may result with neurological medications when poorly managed, however, interventions by a pharmacist have shown to decrease these drug-related problems within neurological care. Current literature is lacking on the impact of pharmacist interventions within an ambulatory neurology clinic setting. The purpose of this project was to assess the impact of pharmacist interventions on migraine headache outcomes including headache frequency, intensity, duration and emergency department visits, for patients consulted to a pharmacist-run neurology clinic at a Veterans Affairs Medical Center.
Methodology: The electronic medical record was reviewed to identify patients consulted to the neurology pharmacotherapy clinic from November 1, 2017 to October 31, 2018 with a minimum 3-month follow-up after the last enrollment date of October 31, 2018. Baseline demographic data was collected, including medication(s) prescribed for migraine headaches. Migraine headache frequency, intensity, and duration was assessed at baseline and at specified follow-up intervals up to 12 weeks. The number of neurology pharmacotherapy visits, migraine headache medication changes, and non-pharmacologic interventions were also determined. Adverse drug reactions managed or prevented during pharmacist visits were described and classified by the Medication Therapy Program categories framework classification system.
Presentation Objective: Identify potential pharmacist interventions for migraine headache patients through a pharmacist-run neurology clinic.
Self-Assessment: Which medication below was excluded from this project?
Evaluating the tolerability of pembrolizumab in patients with an FDA-approved indication within the UNC REX Healthcare system R. Nickell, R. Jones, J. Lipetzky, B. Ramsey, S. Baumhover Rex Hospital - Raleigh, NC
Background/Purpose: The purpose of this study is to develop a tolerability profile for patients receiving pembrolizumab for an FDA-approved indication from UNC REX Healthcare.
Methodology: Patients included in this study were at least 18 years old who had received pembrolizumab from UNC REX Healthcare for an FDA-approved indication between October 2015 to June 2018. The selected patient charts were reviewed from first administration of pembrolizumab through 90 days from the last administration for physician documentation of the most common immune-related reactions related to checkpoint inhibitors, including the following: pneumonitis, hepatitis, new onset diabetes, hypothyroidism, colitis, dermatitis and infusion related reactions.
Results: A total of 91 patients were included in this study. The most common indication for receiving pembrolizumab was non-small cell lung cancer, and the average age of first administration was 66.9 years. In total, 17 of 91 patients (18.7%) experienced at least one immune-related reaction attributed to pembrolizumab per provider documentation. Hypothyroidism was the most commonly experienced immune-related reaction overall. The results of a secondary analysis demonstrated that of the 17 patients that reacted, 14 patients (82.4%) had a smoking history, and 3 patients (17.6%) had no smoking history. Of the 17 patients who experienced an immune-related reaction, 11 patients (64.7%) were male and 6 patients (35.3%) were female; 7 patients (41.2%) were 65 years or older and 10 patients (58.8%) were under the age of 65.
Conclusions: There were not enough documented immune-related reaction events recorded to draw any definitive conclusions regarding a tolerability profile for pembrolizumab.
Presentation Objective: Develop a tolerability profile for pembrolizumab for patients in the UNC REX Healthcare system.
Self-Assessment: What was most common immune-related reaction associated with pembrolizumab in this study?
TREATMENT OF NEONATAL HYPOGLYCEMIA WITH DEXTROSE GEL Rachel Horne, Laura Hagan, Corinne Murphy, Tushar Patel Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: Neonatal hypoglycemia is a common problem that can often be corrected with feeding, but may require transfer to a neonatal intensive care unit (NICU) to receive treatment with intravenous (IV) dextrose if the feeding attempt is not successful at correcting the hypoglycemia. These transfers are associated with higher cost, mother-baby separation, and lower breastfeeding rates. Recently, literature has shown that treating neonatal hypoglycemia with oral dextrose gel has positive outcomes. On December 17, 2019, a neonatal dextrose gel protocol was implemented at our institution, which includes treating hypoglycemia with breastmilk and/or formula initially, and if this is unsuccessful, utilizing the dextrose gel for treatment prior to transferring the patient to the NICU for IV dextrose. The purpose of this study is to determine the effectiveness of dextrose gel in preventing transfers to the NICU for hypoglycemia management.
Methodology: All patients transferred to the NICU for hypoglycemia management or given oral dextrose gel from August 1, 2017 through February 28, 2019 were evaluated pre- and post-implementation of a dextrose gel protocol to determine its effects on NICU admission rates for hypoglycemia. As a secondary analysis, patients who received the dextrose gel were evaluated to determine the failure rate of the dextrose gel by assessing necessity of transfer to the NICU for IV dextrose despite initial treatment with oral dextrose gel. Patients were excluded if they had a serious congenital malformation or terminal conditions. The primary objective is to determine the impact of an oral dextrose gel protocol on the rate of NICU admissions for hypoglycemia management.
Presentation Objective: Discuss the outcomes associated with use of dextrose gel for neonatal hypoglycemia.
Self-Assessment: What is one positive outcome for using dextrose gel to treat neonatal hypoglycemia?
Facility based reduction strategy to limit opioid exposure Ryan Faulconer, Michael Saavedra Parkridge Health System Residency Program - Chattanooga, TN
Background/Purpose: Overutilization of opioids inpatient may increase opioid tolerance, cause respiratory depression and lead to long-term opioid use outside of the hospital. The goal of this project is to reduce opioids used at Parkridge Health System by utilizing more alternative analgesic medications and updating hospital policies.
Methodology: The total amount of opioid analgesics administered in oral morphine milligram equivalents (MME) were screened for all patients at Parkridge Medical Center between December 15th 2017 and March 15th 2018 and analyzed in 100 patients chosen at random. An acute pain order-set is being implemented in the hospital_x0019_s computer based order entry (CPOE) system to provide guidance for the treatment of acute pain in opioid tolerant and naïve patients as well as neuropathic and nociceptive pain. Post-intervention data will be collected after the order-set implementation and compared with pre-intervention data.
Presentation Objective: Compare acute pain treatment between opioid tolerant and opioid naïve patients.
Self-Assessment: What conditions place patients at higher risk for adverse events from opioids?
IMPLEMENTATION OF A PHARMACIST-LED MEDICATION-ASSISTED TREATMENT (MAT) CLINIC AT A VETERANS AFFAIRS MEDICAL CENTER Jade Abudia Carl Vinson VA Medical Center (Psychiatric) - Dublin, GA
Background/Purpose: Prior to project implementation, there was no formal process for veterans with substance use disorder (SUD) to receive medication-assisted treatment (MAT) at the Carl Vinson Veteran Affairs Medical Center (VAMC). Veterans with SUD may be referred to the mental health residential rehabilitation treatment program (MH-RRTP) for intensive inpatient treatment where they have access to group and individual therapy to treat active SUD. However, these veterans were not typically offered MAT while admitted. To increase access to MAT, a psychiatric pharmacist-led clinic was created for veterans completing the MH-RRTP. The purpose of this study is to increase access to MAT for alcohol (AUD), opioid (OUD), and cocaine (CUD) use disorders by at least 20% through utilization of a psychiatric pharmacist's clinic within the MH-RRTP.
Methodology: An initial chart review was conducted for patients residing in MH-RRTP to gather baseline data to include the SUD diagnosis and any active MAT. A pharmacist-led MAT clinic consult template was devised and made available to providers. When consulted, the pharmacist will meet with the veteran individually for assessment and possible initiation of MAT in a once weekly, afternoon clinic. After 16 weeks, the lead investigator will conduct a final chart review of MH-RRTP veterans to determine if those patients with a diagnosis of OUD, AUD, or CUD are on active MAT.
Results: To date, 26 veterans have been referred to the MAT clinic for treatment; of those, 20 accepted MAT and had a diagnosis of OUD, AUD, and/or CUD. 2 of the veterans accepted MAT but had a diagnosis of methamphetamine dependence. 4 of the veterans declined to start MAT and received education only.
Presentation Objective: List potential MAT options for alcohol, opioid, and cocaine use disorders.
Self-Assessment: What is one medication that has been shown to reduce total number of heavy drinking days in alcohol use disorder?
Training and Schedule Restructuring of Clinical Pharmacy Specialist Clinics in a Veterans Affairs Health Care Center Carrie J. Sartin, Taylor S. Clements, Erin L. Amadon Fayetteville VA Medical Center - Fayetteville, NC
Background/Purpose: Clinical Pharmacy Specialists (CPS) are scoped practitioners who are members of the Patient Aligned Care Team (PACT) within the Veterans Affairs health care system. Collaborative care agreements were recently created that allow PACT CPS to identify patients who may benefit from pharmacist-led disease state management (DSM). PACT CPS schedules were redesigned to allow for an increase from 100 to a minimum of 120 potential encounters each month. This quality improvement project seeks to discover the effects of educational training and schedule optimization on monthly disease state encounters.
Methodology: Educational training sessions were provided to PACT CPS on the use of available reporting tools to identify and recruit patients who may benefit from pharmacist intervention. Monthly reports were generated to determine the total number of DSM encounters 6 months surrounding training and restructuring. Clinics performing below the 75th percentile prior to training and restructuring were further analyzed regarding overall change in DSM encounters.
Results: This project resulted in an 18.2% (p= 0.46) increase in total DSM encounters during the post-training and redesign period. Results of this analysis showed an average of 81 monthly encounters prior to clinic redesign and an average of 97 monthly encounters following redesign. Six of ten PACT CPS clinics were identified as performing below the 75th percentile prior to educational training and redesign. These clinics resulted in a 2.6% (p= 0.94) overall increase in DSM encounters.
Conclusions: This quality improvement project resulted with a clinically significant increase in the total number of DSM encounters following educational training and clinic redesign. Results may have been limited by clinic closures, weather restrictions, and inconsistent appointment encountering among CPS.
Presentation Objective: Discuss outcomes associated with educational training and clinic restructuring.
Self-Assessment: How has educational training and clinic grid restructuring impacted Veteran access to care?
IMPACT OF TRANSITIONING FROM A TRADITIONAL ANTICOAGULANT CLINIC TO A CENTRALIZED ANTICOAGULANT CLINIC: A QUALITY IMPROVEMENT Morgan Tolley, Tiffany Jagel, Vanessa Herrington, Mary Ford, Frances Hofman Gulf Coast Veterans Health Care System - Biloxi, MS
Background/Purpose: Long-term treatment/prophylaxis of vascular thromboembolisms and strokes with warfarin in anticoagulation clinics using the traditional office visit model has been the primary method for anticoagulation management. Recent evidence suggests that transitioning to a centralized model yields similar therapeutic outcomes. This study will compare therapeutic outcomes and continuity of documentation before and after centralization.
Methodology: Retrospective review of patients prescribed warfarin over 13 month period. Therapeutic outcomes will be assessed using anticoagulation reports performed at the Veterans Integrated Service Network (VISN) 16 level, while continuity of documentation will be assessed by physical review of approximately 10% of all anticoagulation electronic health records. Clinical pharmacy specialists will be provided continuous feedback on therapeutic outcomes and chart documentation using monthly scorecards to allow for continuous quality improvement throughout this study.
Results: Overall, number of overall unique warfarin patients decreased and number of therapeutic warfarin patients remained consistent over time. Patients lost to follow-up during initial transition months trended upward, followed briefly by a period of stabilization with a downward trend. Notably, lost to follow-up in January 2019 sharply increased which is similar to what was seen in January 2018.
Conclusions: This project has revealed that transitioning to centralized clinic for warfarin therapy generates similar outcomes as seen in a traditional setting. A unique pattern appears to center around the holiday season resulting in sharp increase in lost to follow-up. Current theory being that the holidays are predominant driver of these results and may negatively impact on warfarin therapy. Further investigations are warranted.
Presentation Objective: Examine therapeutic outcomes and continuity of documentation within the GCVHCSs region before and after the implementation of a centralized anticoagulation clinic model.
Self-Assessment: Examine therapeutic outcomes and continuity of documentation within the GCVHCSs region before and after the implementation of a centralized anticoagulation clinic model.
Initiation of a PCSK-9 Inhibitor For The Management of Complex Hyperlipidemia Through The Use of a Risk Assessment Tool Nieka Jackson, Chad Potts, Nathaniel Swanson Carl Vinson VA Medical Center - Dublin, GA
Background/Purpose: Atherosclerotic cardiovascular disease (ASCVD) can lead to clinically significant outcomes such as myocardial infarction, ischemic stroke, and revascularization procedures. Many Veterans with multiple comorbidities have experienced an acute cardiovascular event and require secondary prevention.
Clinical practice guidelines recommend the lowering of plasma low-density lipoprotein cholesterol (LDL-C) for the secondary prevention of ASCVD. Proprotein convertase substilin/kexin type 9 (PCSK-9) inhibitors have proved to lower LDL-C up to 60% and can prevent secondary cardiovascular events. The purpose of this project is to identify patients with ASCVD who require additional LDL-C lowering and recommend the initiation of a PCSK-9 inhibitor.
Methodology: A risk assessment tool was created to determine if Veterans were eligible to receive a PCSK-9 inhibitor for secondary prevention. The computerized patient record system (CPRS) was used to identify high risk Veterans via ICD-9 and ICD-10 diagnosis codes. Identified patients were then evaluated utilizing the assessment tool for the potential initiation of a PCSK-9 inhibitor. If a patient did not qualify for therapy, other recommendations were provided in order to improve lipid control and patient outcomes.
Results: As of February 2019, research is ongoing. A total of 108 Veterans met the inclusion criteria and the mean LDL-C was 129 mg/dl (range 100 -245mg/dl). Sixty-seven patients were completely evaluated utilizing the risk assessment tool and 41 patients were excluded.
Conclusions: Pending final results
Presentation Objective: Identify potential barriers to prescribing PCSK-9 inhibitors in the Veterans population.
Self-Assessment: What is the primary limitation to prescribing PCSK-9 inhibitors in the Veterans Affairs healthcare system?
Fluid overload and de-resuscitation efforts in patients treated for sepsis and septic shock Christina Crawley, Jeremy Ray Huntsville Hospital - Huntsville, AL
Background/Purpose: Sepsis and septic shock are associated with significant morbidity and mortality in critically ill patients. Sepsis is characterized by endothelial injury and capillary permeability resulting in hypotension. For patients with septic shock, aggressive fluid resuscitation is often required to maintain venous return and stroke volume. However, the large volumes of fluid required may increase the risk of fluid overload, especially in patients with significant comorbidities. Research shows that fluid overload and positive fluid balance can be associated with poor outcomes. These complicated patient cases require a delicate balance of fluid resuscitation and de-escalation. The goal of this project is to review the association between fluid overload and outcomes in critically ill adult patients in order to identify appropriate management strategies to improve patient care.
Methodology: Adult patients presenting to the emergency department with a diagnosis of sepsis from February 2018 through July 2018 were evaluated. Only patients that were admitted to an intensive care unit (ICU) were included in the study. Retrospective chart review was performed to determine length of hospital stay, length of ICU stay, 28-day readmission, inpatient mortality, comorbid conditions, vasopressor use, shock resolution time, fluid balance throughout ICU stay, weight changes, and diuretic use. This information was assessed to discern current fluid de-escalation efforts and implement methods of improvement.
Presentation Objective: To determine the association between fluid overload and outcomes in critically ill patients diagnosed with sepsis or septic shock and implement strategies to manage fluid volume in these patients.
Self-Assessment: Patients are at increased risk of what negative outcomes when exposed to a prolonged positive fluid balance during ICU stay?
Full Dose Versus Reduced Dose Alteplase for Cardiac Arrest Secondary to Pulmonary Embolism Perry Carrington, Lyndsay Gormley, Alyson Ghizzoni-Burns, John Howard Greenville Hospital System PGY2 Critical Care - Greenville, SC
Background/Purpose: Per CHEST guidelines, those presenting with pulmonary embolism experiencing hypotension should be treated with alteplase 100 mg intravenously over two hours. For patients with pulmonary embolism associated with cardiopulmonary arrest, known as a fulminant pulmonary embolism, the use of thrombolytic therapy is not clearly defined. The objective of this study was to determine the difference in survival rates for patients presenting with suspected fulminant pulmonary embolism who received full dose (100 mg) or reduced dose (< 100 mg) alteplase. The use of tenecteplase at our institution was also examined.
Methodology: A single center, retrospective cohort study was conducted on all patients admitted to Prisma Health Upstate that were greater than 18 years of age and received either alteplase or tenecteplase for suspected or confirmed pulmonary embolism from June 1, 2016 to June 3, 2018. Patients were excluded if thrombolytic therapy was not administered during cardiopulmonary resuscitation or if pulmonary embolism was ruled out. The primary outcome was the percentage of patients surviving to discharge. Secondary outcomes included survival at 24 hours post-thrombolytic therapy, the percentage of patients receiving tenecteplase surviving to discharge, initiation of therapeutic heparin infusion after thrombolytic therapy, percentage of patients who experienced life-threatening bleeding post thrombolytic administration, and percentage of patients who experienced an ischemic or hemorrhagic stroke. The following data were collected: demographics, risk factors for pulmonary embolism, details of the patient_x0019_s cardiac arrest, thrombolytic type, dose, and infusion rate, utilization of therapeutic heparin infusions, and bleeding within 24 hours of thrombolytic administration as defined by the GUSTO criteria.
Presentation Objective: Identify the thrombolytic dosing strategy associated with the highest rate of survival to discharge for patients experiencing fulminant pulmonary embolism.
Self-Assessment: According to our results, what thrombolytic dosing strategy was associated with the greatest survival to discharge?
Nephrotoxicity of Piperacillin-Tazobactam and Vancomycin in comparison to other empiric antimicrobial therapy in ICU Masaad Almutairi, Josh Chestnutt, Omar Almohammed, Mathew McAllister Piedmont Columbus Regional Midtown (Critical Care) - Columbus, GA
Background/Purpose: Several studies have shown an increased risk of nephrotoxicity associated with piperacillin-tazobactam (PT) and vancomycin though there is a lack of data regarding this combination in critical care population. Acute kidney injury (AKI) was defined according to Acute Kidney Injury Network (AKIN).
Methodology: A retrospective chart review was conducted to investigate the incidence of AKI in critically ill patients who receive piperacillin-tazobactam (PT) and vancomycin as compared with other empiric combination antimicrobials in a community teaching hospital. Secondary outcomes included duration of AKI, length of stay, and evaluation of the association between occurrence of AKI and other covariates using a logistic regression analysis.
Results: A total of 79 patients (50 vancomycin with PT and 29 vancomycin with other empiric antibiotics) were included. Twenty-six patients in vancomycin with PT group (52%) and 11 patients in vancomycin with other empiric antibiotic group (37.9 %) developed AKI (p=0.22). Duration of AKI and length of ICU stay were not statistically significant between the 2 groups (p= 0.56 and p=0.18 respectively). A logistic regression analysis found that vancomycin concentration greater than or equal 20, concomitant use of nephrotoxic medications or African American race were associated with an increased risk of developing AKI (OR 7.1, 95% CI 1.96_x0013_ 25.84, p=0.003; OR 3.94, 95% CI 1.27-12.2, p=0.017; OR 3.53, 95% CI 1.1-11.27, p=0.034, respectively.
Conclusions: This study was not able to find a statistically significance differences in AKI between piperacillin-tazobactam with vancomycin and vancomycin with other empiric antibiotics. However, our small sample size could affect this conclusion. More research is needed to clarify the risk factors for AKI.
Presentation Objective: Discuss the incidence of nephrotoxicity in patients receiving a combination of PT and vancomycin in comparison to other empiric combination antimicrobials.
Self-Assessment: What are the covariates that are associated with the occurrence of AKI?
Evaluation of acute kidney injury using a vancomycin area under the curve guided protocol in a community hospital Michael T. Dailey, Nancy E. Bailey, Fernando J. Diggs, Terry W. Harris Jackson Hospital - PGY1 Residency - Montgomery, AL
Background/Purpose: Literature has emerged showing increased occurrences of acute kidney injury (AKI) from aggressive vancomycin dosing targeting serum levels of 15_x0013_20 mg/L. These trends have prompted clinicians to evaluate area under the curve/ minimum inhibitory concentration (AUC/MIC)_x0013_based dosing with a target of 400 to 600 mg*h/L. Previously, Jackson Hospital utilized a nomogram_x0013_based dosing protocol. Based on data regarding improved safety with AUC/MIC_x0013_based vancomycin dosing, Jackson Hospital proactively implemented a new dosing protocol for vancomycin. The objective of this study was to compare the safety of a nomogram_x0013_based dosing protocol to an AUC/MIC_x0013_guided dosing protocol for patients being treated with vancomycin.
Methodology: This single_x0013_center, retrospective, observational Institutional Review Board (IRB) approved study included patients aged 18 years or older who had a suspected or documented methicillin_x0013_resistant Staphylococcus aureus (MRSA) infection, had received vancomycin for a minimum of 72 hours, and had vancomycin dosed according to either the institution_x0013_specific dosing protocol or the AUC/MIC_x0013_guided dosing protocol. The electronic medical record was utilized to identify eligible patients who developed AKI using the Risk, Injury, Failure, Loss of kidney function, and End_x0013_stage kidney disease (RIFLE) classification system. The primary outcome assessed the incidence of AKI for patients dosed with the institution_x0013_specific nomogram_x0013_based protocol compared to the AUC/MIC_x0013_guided dosing protocol.
Results: Pending
Conclusions: Pending
Presentation Objective: Compare rates of acute kidney injury with an institution_x0013_specific nomogram_x0013_based dosing protocol versus an area under the curve/minimum inhibitory concentration_x0013_guided dosing protocol for vancomycin in adult, hospitalized patients.
Self-Assessment: Based on recent literature, what dosing method can pharmacists utilize to optimize vancomycin dosing in adult, hospitalized patients to achieve effective serum concentrations while minimizing AKI risk in moderate to severe infections?
Evaluation of antibiotic prophylaxis for urological surgical procedures at a large academic medi Emily N. Drwiega, Saira Rab, Sheena Kandiah, Emily Durr, Jordan R. Wong Grady Memorial Hospital - Atlanta, GA
Background/Purpose: The purpose of this study is to evaluate antibiotic use in patients undergoing urological procedures.
Methodology: This is a single-center, IRB-approved, retrospective, observational study at Grady Health System. Patients were included if undergoing their first inpatient urologic procedures between April 1, 2016 and April 1, 2018. Patients were excluded if < 18 years old, pregnant, or a prisoner. The primary outcome was percentage of overall adherence to our institutional guidelines for surgical prophylaxis as a composite of antibiotic selection, dose, pre-operative timing, and post-operative duration. Secondary outcomes include individual components of the composite outcome, nephrotoxicity, Clostridium difficile infection, and discharge antibiotic prescriptions. Descriptive statistics were used.
Results: Of the 100 patients evaluated, 11 met institutional guideline adherence. Of the 89 patients who did not achieve composite outcome, only 8 utilized the appropriate perioperative antibiotic regimen. Nineteen patients received no antibiotics. In the 70 patients who received perioperative antibiotics, 39% were dose appropriately, 60% were administered at the appropriate time with respect to time of incision, and 59% received perioperative antibiotics for no more than 24 hours. All nine patients whom developed nephrotoxicity received non-compliant perioperative prophylaxis. No patient developed Clostridium difficile infection within 30 days of surgery. Fifty-eight patients were discharged with a prescription for at least one antibiotic.
Conclusions: The majority of perioperative antibiotic prophylaxis for genitourinary surgeries are not compliant with institution guideline recommendations. All of the patients identified as having an evaluated antibiotic-related adverse effect, did not receive appropriate perioperative antibiotic prophylaxis. Over half of the patients received a prescription at discharge for at least one antibiotic.
Presentation Objective: Understand the importance of appropriate perioperative antibiotic prophylaxis in genitourinary procedures.
Self-Assessment: What is a potential risk of inappropriate perioperative antibiotic prophylaxis?
PGY-2 Infectious Diseases Pharmacy Resident, Grady Health System
Emily Drwiega, PharmD is the PGY2-Infectious Diseases Pharmacy Resident at Grady Health System. She also completed her PGY1 residency at Grady Health System after attending pharmacy school at Butler University in Indianapolis, IN. Emily is looking forward to starting as a fellow at... Read More →
Thursday April 25, 2019 1:50pm - 2:10pm EDT
Olympia 1
Evaluation of Warfarin versus Direct Oral Anticoagulants in Patients with Inherited Thrombophilia Megan Bereda,Lydia Newsom,Kathryn Momary,Jonathan Masor,Mary Bailey Jones Emory University Hospital - Atlanta, GA
Background/Purpose: Patients with inherited thrombophilia are at increased risk of venous thromboembolism (VTE). The most common inherited thrombophilia include Factor V Leiden and Prothrombin Gene 20210A (Factor II) mutation. With over half of VTE cases found to be in patients with thrombophilia, these conditions pose a clinical challenge in terms of treatment. The 2016 American College of Chest Physicians (ACCP) Antithrombic Therapy guidelines favor the use of direct oral anticoagulants (DOACs) for the acute treatment of VTE but only mention thrombophilia as a risk factor. The 2012 CHEST Antithrombotic Guidelines fail to recommend DOACs due to lack of clinical use and availability at the time. Historically, patients with thrombophilia have been treated with warfarin, but in comparison DOACs offer many advantages including less potential for food and drug interactions, shorter half-life, and no routine laboratory monitoring. The primary outcome of this study is to assess the treatment and secondary prevention of VTE by analyzing VTE recurrence within a one-year period in patients with minor thrombophilia.
Methodology: A retrospective chart review was performed for patients with Factor V Leiden and/or Prothrombin 20210A mutation initiated on anticoagulation within the Emory Healthcare Clinics for venous thromboembolism from January 1, 2014 to September 1, 2018. Data collected includes patient demographics, mutation zygosity, VTE recurrence, bleeding events, and healthcare utilization during the one year follow up period. VTE recurrence and bleeding events in patients receiving warfarin versus DOACs were compared using descriptive statistics.
Presentation Objective: Compare the safety and efficacy of DOACs to warfarin in patients with minor thrombophilia.
Self-Assessment: Are DOACs as safe and efficacious as warfarin for patients with minor thrombophilia?
Evaluation of bleeding incidence of DOACs versus enoxaparin in the treatment of VTE in cancer patients with thrombocytopenia Justin Wilson, Rebecca Jones, David Blanchard, Walter Laundon, Jared Peak Rex Hospital - Raleigh, NC
Background/Purpose: Cancer patients are at a high risk of developing a venous thromboembolism (VTE) requiring the need for anticoagulant treatment. Anticoagulation therapy becomes complicated for this patient population when chemotherapy induced thrombocytopenia is present leading to increased risk of life-threatening or fatal bleeding events. This is a retrospective cohort study comparing the incidence of major bleeding events between direct oral anticoagulants and enoxaparin used in this setting.
Methodology: This retrospective cohort study includes 146 patients with a platelet count less than 50,000, with an active cancer diagnosis seen at a UNC health system hospital or clinic with a VTE between 08/01/2017 and 08/01/2018. Patients were grouped into two arms: one group who received a direct oral anticoagulant for the treatment of the VTE and other group who were treated with enoxaparin. The primary outcome is the evaluation of the incidence of major bleeding events between patients who received direct oral anticoagulants and patients who received enoxaparin.
Results: Currently in progress.
Conclusions: Currently in progress.
Presentation Objective: By the end of the presentation, the learner should be able to explain the relative bleeding risk associated with DOACs when compared to enoxaparin for treating a VTE in cancer patients with thrombocytopenia.
Self-Assessment: What is the relative risk of bleeding in patients treated with DOACs when compared to enoxaparin in the treatment of VTE in cancer patients with thrombocytopenia?
Designing Opioid Provider Scorecards Jared Gabbert, Amanda Mixon, Heather Limper, Erin Neal Vanderbilt University Medical Center (Administration and Leadership with Masters) - Nashville, TN
Background/Purpose: Deaths due to opioid use have drastically increased over the last decade and continue to be a national health crisis. Providing opioid data to promote changes in prescribing behavior is one of many potential solutions proposed to address this crisis, though the most appropriate content and usability of such report cards has not been well documented. The aim of this work is to design and evaluate the usability of individual prescriber opioid scorecards.
Methodology: An opioid prescriber scorecard was created by the Tennessee Department of Health and the MidSouth Practice Transformation Network. Opioid prescribers participating in the Transforming Clinical Practice Initiative (TCPI) were recruited to participate in a one-on-one interview to provide structured feedback regarding the usability of a scorecard populated with mock data. The interview was structured to obtain usability data based on the System Usability Scale (SUS) as well as responses to predetermined open-ended questions. The responses to the open-ended questions were then categorized using an affinity exercise. The results of the interviews were used to improve the scorecard until an acceptable level of usability was achieved.
Cost evaluation comparing Remicade to biosimilar agent (Renflexis) for use in an outpatient infusion clinic Linh Tong, Jonathan Spry, Chris Pamperin Huntsville Hospital - Huntsville, AL
Background/Purpose: The purpose of this project is to evaluate opportunities for cost savings by assessing the use of Remicade versus Renflexis in the hospital_x0019_s outpatient infusion clinic. The goal is to determine optimal insurance reimbursement of infliximab by evaluating current reimbursement trends. Previously, the hospital used Remicade for all patients, but recently there was a switch to Renflexis. Using a single agent for all patients may not be the best option. This project financially evaluates the use Remicade versus Renflexis in order to provide reimbursement information that may lead to the development of individualized therapy.
Methodology: This study qualified for exemption from the Institution Review Committee. Patients that received Remicade from the hospital_x0019_s outpatient infusion clinic from June through October 2018 and patients that received Renflexis from December 2018 through January 2019 were evaluated for inclusion. Exclusion criteria included all patients with an outstanding payment balance. Data collected included date of service, insurance plan descriptions, total charges, total insurance adjustments and payments, drug charges, and drug amount. The financial information was used to calculate the reimbursement percentage for each patient. This percentage was extrapolated to determine the amount the hospital was reimbursed for each product. The drug cost was compared to the reimbursement amount to determine the overall margin for each patient encounter. The data for Remicade patients was used to determine the reimbursement and margin/loss if that same patient was administered Renflexis. This information was used to calculate the apparent margin if individualized therapy was provided for all patients.
Presentation Objective: Explain what considerations need to be evaluated in determining the best infliximab agent to maximize reimbursement and optimize patient care.
Self-Assessment: What are factors that should be considered when choosing an infliximab agent for a patient in an outpatient infusion clinic?
Evaluation of a Pharmacist-Led Chronic Obstructive Pulmonary Disease (COPD) Clinic R. Reid Allison, Amy Kyle James H. Quillen VA Medical Center PGY1 - Mountain Home, TN
Background/Purpose: COPD is one of the most burdensome disease states in the United States, both from a cost and morbidity/mortality standpoint. The James H. Quillen VA Medical Center admitted 206 patients for COPD exacerbations in fiscal year 2017, with an all-cause, 30-day readmission rate of 18% during quarter 4. The purpose of this project is to evaluate the impact of a pharmacist-led COPD clinic in the primary care setting, with a particular focus on 30-day readmission rates.
Methodology: An appointment with a clinical pharmacist is scheduled within 7 days of discharge from a COPD related hospitalization. COPD pharmacotherapy clinic visits include an assessment of COPD medication regimen, smoking and vaccination status, symptomology (CAT score), and if a patient has a spirometry confirmed diagnosis. Medication optimizations are made based on GOLD guideline classification and recommendations. Disease state and medication counseling and education, including a COPD action plan, are provided. PharmD clinic appointments are coupled with respiratory therapy visits to assess and educate on inhaler technique. The primary endpoint being evaluated is all-cause 30-day readmission rate following a hospitalization for a COPD exacerbation. Secondary endpoints being evaluated include medication optimizations, CAT scores, smoking status, immunization status, and rate of confirmed diagnosis by spirometry.
Results: A total of 65 patients have been seen in clinic following hospitalizations for COPD between 3/1/2018 and 12/15/2018. Of those, 4 patients were readmitted within 30 days representing an all-cause 30-day readmission rate of 6.2%. Data collection is still ongoing.
Conclusions: There is promising preliminary data to support the effectiveness of a pharmacist-led COPD clinic in helping to reduce all-cause 30-day readmission rates in a VA facility.
Presentation Objective: To discuss the impact of a pharmacist-led COPD clinic in a VA primary care setting.
Self-Assessment: What interventions can a primary care pharmacist make to improve COPD outcomes?
Medication Adherence Barriers: An Opportunity to Improve Population Health Iliana Morataya, Benjamin Smith, Patrick Gregory, Beiyu Liu Duke University Hospital - Health System Pharmacy Adm. - Durham, NC
Background/Purpose: The Centers for Medicare and Medicaid Services (CMS) developed the Five-Star Quality Rating System to measure the quality of Medicare Advantage Plans. Medicare Advantage Plans with Part D coverage (MAPD) include three medication adherence measures targeting adherence to renin- angiotensin system antagonists, statins, and non-insulin diabetes medications. Duke Health supports value-based contracts with three MAPDs. The purpose of this study is to identify and describe medication adherence metric barriers in a Medicare Advantage Plan population.
Methodology: This is a retrospective observational study evaluating the barriers to medication adherence metrics. The primary endpoint is to identify the percentage of recognized medication adherence metric barriers for each of nine pre-specified categories. Secondary endpoints are to identify the percentage of (1) patients for whom Duke Health is incorrectly reported as an attributed provider of their care, (2) patients who see an external provider as the primary prescriber of designated medication, (3) medication adherence metric barriers for patients enrolled in the different participating Plans, and (4) total patients evaluated by county of residence and age. Patients included were enrolled in one of three specified MAPD plans for 2016-2017 and were attributed to a value-based agreement with Duke Health, met the criteria for at least one of the three Medicare medication adherence Star Measures and failed to meet the adherence goals of at least one of these Star Measures in both 2016 and 2017. Patients deceased at the time of data collection were excluded. Patients were identified by MAPD star-rating reports sent directly to Duke Health. Adherence barriers have been through chart review and telephone interview.
Presentation Objective: Determine the major reasons Medicare patients fail medication adherence Star Rating measures.
Self-Assessment: What are the most common reasons patients fail medication adherence Star Rating measures?
Iliana Morataya is the PGY2 Health-System Pharmacy Administration and Leadership Resident at Duke University Hospital. She received her Bachelor of Science in Chemistry and Bachelor of Science in Biology from Kennesaw State University. She earned her Doctorate of Pharmacy and is currently... Read More →
Thursday April 25, 2019 2:10pm - 2:30pm EDT
Athena A
Identification of patients at risk for drug-induced acute kidney injury guided by a novel biomarker in the ICU Alexandria Hall, Marina Rabinovich, Emily Durr, Michael J Connor Grady Memorial Hospital - Atlanta, GA
Background/Purpose: Acute kidney injury (AKI) occurs in >50% of critically ill patients. There is significant morbidity associated with nephrotoxicity, contributing to 18-50% of in-hospital mortality. Nephrocheck® is a urinary biomarker that predicts the risk of AKI and adverse kidney events 12 hours sooner than serum creatinine. The purpose of this retrospective chart review was to evaluate the progression of AKI in patients with moderate to high risk Nephrocheck® results.
Methodology: This was a single-center retrospective chart review of ICU patients in whom Nephrocheck® was ordered between June 1, 2017 and June 1, 2018. Patients met inclusion criteria if they were 18+ years of age, admitted to the medical, surgical, burn or neuro ICU at Grady Health system, experienced cardiovascular or respiratory compromise and were exposed to 3+ nephrotoxins. Patients were excluded if they had stage 2 or 3 AKI or CKD (SCr >1.8mg/dL or eGFR
PGY-2 Critical Care Pharmacy Resident, Grady Health System
Alexandria (Andie) Hall, PharmD is the PGY-2 critical care pharmacy resident at Grady Health System. She completed her PGY-1 residency at Grady as well and obtained her PharmD from the Medical University of South Carolina in 2018. She is an active member of the Society of Critical... Read More →
Thursday April 25, 2019 2:10pm - 2:30pm EDT
Athena H
PREVENTION OF DELIRIUM IN THE INTENSIVE CARE UNIT AT A COMMUNITY TEACHING HOSPITAL Gina Mirza, Josh Chestnutt, Ryan Crossman, Lauren Duty Piedmont Columbus Regional Midtown (Critical Care) - Columbus, GA
Background/Purpose: Pain, anxiety, agitation, and agents utilized to treat them contribute to delirium development in patients in the intensive care unit (ICU). This preventable delirium is associated with increased mortality, post-ICU cognitive impairment, and prolonged ICU and overall hospital length of stay. The proper utilization of evidence-based pain and sedation protocols, a vital component of the ABCDEF bundle, has been shown to reduce the incidence of delirium in critically ill patients. Effective education of physicians and nurses, therefore, is instrumental in reducing variability in practice habits and ensuring adherence to _x001C_analgesia-first_x001D_ and light sedation targets per guideline recommendations. The purpose of this study is to determine if a pharmacist-designed delirium-minimization algorithm with education improves prescribing practices and helps prevent delirium in the ICU.
Methodology: A single-center, IRB-approved, retrospective chart review of approximately 150 adult patients on sedative/analgesic drips in the ICU from April to June 2018 and January to March 2019 is being conducted at Piedmont Columbus Regional Midtown. Patients with a pre-sedation Richmond Agitation Sedation Scale (RASS) of -4 to -5, patients who require deep sedation or the preferred use of benzodiazepines (i.e. alcohol withdrawal, traumatic brain injury), or those who had withdrawal of life support were excluded. Patient outcomes pre- and post-education will be compared to determine if pharmacist-led delirium-minimization efforts will result in an increased percentage of delirium-free assessments as measured by the Confusion Assessment Method in the Intensive Care Unit (CAM-ICU). Secondary endpoints including ICU length of stay; selection of, starting rate, and duration of sedative/analgesic agents; compliance with CAM-ICU assessments and sedation vacations; and duration of Foley catheterization will be assessed.
Presentation Objective: Identify prescribing, administration, monitoring, and documentation practices that contribute to the development of delirium in the ICU.
Self-Assessment: What clinical benefits were associated with a pharmacist-driven delirium minimization process?
Retrospective Analysis of Pharmacologic Hyperkalemia Management Strategies at a Large Community Hospital R. Monroe Crawley, PharmD, BCPS; Mickala M. Thompson, PharmD, BCPS, BCNSP Huntsville Hospital (Critical Care) - Huntsville, AL
Background/Purpose: Hyperkalemia is among the most urgent and life-threatening electrolyte disturbances that critically ill patients often manifest. Moderate to severe hyperkalemia can contribute to electrocardiogram disturbances and, in turn, progress to fatal arrhythmias. Treatment guidelines for the management of acute hyperkalemia are well established, yet no institutional treatment protocol exists. Thus, pharmacologic treatment selections, and timing of such modalities, vary widely between providers. The purpose of this investigation is to characterize the pharmacologic hyperkalemia management strategies at our hospital system and to develop an evidence-based house-wide treatment algorithm.
Methodology: An Investigational Review Board- approved retrospective review and analysis was conducted in patients at least 18 years of age with a serum potassium level of 5.5 mEq/L or greater, from January 2018 to December 2018. Exclusion criteria included end-stage renal disease requiring hemodialysis, diabetic ketoacidosis, and post-operative cardiac surgery requiring cardioplegia solution. Instances of potassium-lowering treatment modality use and removal of hyperkalemia-intensifying drugs were identified. Regimen appropriateness and time to initiation were evaluated. The results will be used to guide the development of a new hyperkalemia treatment protocol.
Presentation Objective: Determine the severity of and develop evidence-based therapeutic strategies for hyperkalemia management in adult patients.
Self-Assessment: What patient-specific factors should be taken into consideration when formulating a hyperkalemia treatment approach?
Evaluation of factors associated with inappropriate antibiotic selection in patients with sepsis in the emergency department Meshell Maxam, Jordan Wong, Jane Kriengkauykiat, Sheetal Kandiah,Saira Rab Grady Memorial Hospital (Infectious Diseases) - Atlanta, GA
Background/Purpose: Previous studies have observed up to 39% of antibiotics are inappropriately prescribed in the emergency department (ED). The purpose of this study was to evaluate factors that drive inappropriate antibiotic selection in the ED.
Methodology: This is a single-center, retrospective, IRB-approved, cohort study performed at Grady Health System (GHS). Patients were identified using the sepsis database in the ED between January 1, 2017 and April 30, 2018. Twenty-five patients per month were selected using a random number generator to include a total of 400 patients for analysis. Patients were excluded if they were pregnant, incarcerated, or did not receive their first dose of antibiotics in the ED. The primary outcome was to determine the percent of patients with suspected sepsis that had inappropriate antibiotics selected in the ED based on GHS empiric treatment guidelines. Secondary outcomes include identifying factors associated with inappropriate antibiotic selection. Categorical variables were analyzed using chi-square tests and continuous variables were analyzed using Mann-Whitney U test.
Results: Out of the 400 patients evaluated, 254 (64%) had inappropriate antibiotic selection. No difference in adherence to guidelines was observed when comparing community-acquired to healthcare-associated suspected sepsis. Order set usage was 38% in the adherent group and 62% in the non-adherent group. Additional secondary outcomes are pending analysis.
Conclusions: The majority of antibiotics selected for suspected sepsis in the ED are inappropriate based on GHS guidelines.
Presentation Objective: Discuss the importance of appropriate antibiotic selection in sepsis
Self-Assessment: Appropriate antibiotic selection in sepsis is associated with an improvement in which clinical outcome?
Evaluation of Readmission Rates of Outpatient Parenteral Antimicrobial Therapy Colleen Lau, PharmD, Paul O. Lewis, BCPS, AQ-ID Johnson City Medical Center - Johnson City, TN
Background/Purpose: Home health and outpatient infusion centers (OPIC) are two commonly utilized models for the administration of outpatient parenteral antimicrobial therapy (OPAT). The purpose of this study is to compare the 30-day readmission rates of home health versus OPIC.
Methodology: This retrospective cohort study was conducted at Johnson City Medical Center. Patients were included if they received OPAT via home health or OPIC from March 2016 to November 2018. The primary endpoint was readmission within 30 days of hospital discharge. Pertinent data collected include comorbidities, history of intravenous drug use (IDU), infectious process, organism, antimicrobials, and infusion-related adverse events.
Results: There were 75 OPIC patients and 90 home health patients included in this study. For the primary outcome, there was no significant difference in 30-days readmission rates between OPIC and home health [15/75 (20%) versus 18/90 (20%), p>0.99]. The most common infections were cellulitis, osteomyelitis, and endocarditis. The most common organisms treated were Staphylococcus aureus and Escherichia coli. Daptomycin, ceftriaxone, and vancomycin were the most commonly administered medications. Home health patients tended to be older with an average age of 45 years for OPIC and 54 years for home health (p=0.0006). History of IDU was higher in OPIC compared to home health [26/75 (34.7%) versus 11/90 (12.2%), p=0.0007].
Conclusions: Readmission rates were similar between OPIC and home health, despite high rates of IDU and the younger age of OPIC patients. Outpatient infusion center appears to be a viable alternative to home health.
Presentation Objective: To compare the readmission rates of home health to OPIC.
Self-Assessment: How do readmission rates of OPIC compare to home health?
A Retrospective Evaluation of SMOF Lipids on Liver Function for Home Parenteral Nutrition Patients Adrian Lawrence, Vivian Zhao, Daniel Griffith, Nisha Dave, Thomas Ziegler Emory University Nutrition Support - Atlanta, GA
Background/Purpose: Commercially available lipid emulsions in the United States differ in fatty acid content and composition. Potential complications following the use of soybean oil (SO) sole based emulsions have led to the investigation of other alternatives such as soybean/MCT/olive/fish oil (SMOF) emulsion. The purpose is to assess the safety and tolerance of SMOF emulsion in adult patients requiring home parenteral nutrition (HPN).
Methodology: A retrospective, case-controlled chart review of adult patients requiring HPN and followed by the Metabolic Nutrition Support Service from May 1, 2016 to November 30, 2018. The primary objective is to compare the effects on total bilirubin before and after the patient switches from SO emulsion to SMOF emulsion. The secondary objectives compare the effects on C-reactive protein (CRP) and on liver function tests before and after the switches. Inclusion criteria include adults > 18 years old who were on SO-containing HPN for > 8 weeks followed by a switch to SMOF-containing HPN for at least eight weeks with at least two liver function test (LFT) panels on each formulation. Lastly, the patient must be at home for at least 2 months post discharge. Exclusion criteria include patients that received either lipid formulation less than three times weekly or for less than eight weeks during the study period. The data collection includes demographics, dose of lipids, intravenous access, adverse drug reactions, allergies, days on HPN, CRP, and liver function test panels. A multivariate regression analysis will be performed to assess the effects of conjugated bilirubin on liver function and secondary outcome variables.
Presentation Objective: Assist prescribers in the optimal choice of lipid emulsion by determining the risk and benefits associated with each formulation in patients receiving HPN.
Self-Assessment: Are SMOF emulsions more safe and tolerable in adult patients requiring home parenteral nutrition?
Beta-Blocker Therapy for the Prevention of Doxorubicin-Induced Cardiotoxicity: A Retrospective Cohort Olivia Witt, David Blanchard, Oksana Kamneva, Rebecca Jones, Stephanie Baum Rex Hospital - Raleigh, NC
Background/Purpose: The use of beta-blockers for cardioprotection in patients treated with anthracyclines remains controversial. This retrospective, multi-center, cohort study sought to evaluate the effectiveness of beta-blocker therapy in the prevention of doxorubicin-induced cardiotoxicity.
Methodology: This study included 114 adults with normal left ventricular ejection fraction (LVEF) that received conventional doxorubicin therapy within UNC Health System hospitals or clinics between January 1, 2014 and December 31, 2016. Patients were grouped into two arms: those that received concomitant therapy with select beta-blockers (metoprolol, carvedilol, and propranolol) and those that did not receive beta-blocker therapy. The primary endpoint was the incidence of cardiotoxicity, defined as LVEF less than 50% measured within 12 months of completion of doxorubicin therapy. Key secondary endpoints included the absolute change in LVEF from baseline and an absolute decrease in LVEF greater than or equal to 10% from baseline.
Results: 57 patients received concomitant beta-blocker therapy and 57 patients received doxorubicin therapy alone. Cardiotoxicity occurred in 11 patients (19.3%) in the beta-blocker group and 4 patients (7.0%) in the control group (p = 0.0524). In secondary analyses, the overall decline in LVEF was 6.04 percentage points in the beta-blocker group and 1.93 percentage points in the control group (p = 0.2059). Significantly more patients in the beta-blocker group experienced a decline in LVEF greater than or equal to 10% compared to the control group (21.1% vs. 7.0%; p = 0.031).
Conclusions: In this study, patients treated with conventional doxorubicin therapy and concomitant select beta-blockers did not experience additional protection against development of cardiotoxicity.
Presentation Objective: Discuss the proposed mechanism behind the use of beta-blockers for prevention of anthracycline-induced cardiotoxicity.
Self-Assessment: Which patients with cancer are at increased risk for developing cardiac dysfunction?
Impact of ketamine on opioid usage after bariatric or colorectal surgery Zachary J. Haffler, Jon Wanderer, Matt McEvoy, Bob Lobo, Jennifer Jayaram, Vanderbilt University Medical Center - Nashville, TN
Background/Purpose: Opioids are often the first-line therapy utilized for post-operative pain. Adverse effects associated with opioid administration promote the use of adjunctive therapy to reduce pain. Ketamine has been suggested as an option for reducing post-operative opioid consumption. The purpose of this study is to determine if low-dose ketamine infusions administered post-operatively reduce morphine milligram equivalents required by colorectal and bariatric surgery patients without subsequent increases in pain scores.
Methodology: We conducted a single-center, retrospective cohort study in a colorectal and bariatric surgical population to assess the impact of low-dose ketamine infusions on post-operative inpatient morphine milligram equivalent requirements. Our primary outcome is morphine milligram equivalents administered 24 hours post-operatively for bariatric surgery patients and 48 hours post-operatively for colorectal surgery patients. Secondary outcomes include morphine milligram equivalents administered 48 hours post-operatively for bariatric surgery patients and 96 hours post-operatively for colorectal surgery patients, length of stay, and pain scales.
Presentation Objective: Evaluate the implementation of a low-dose ketamine infusion protocol following bariatric or colorectal surgeries to reduce morphine milligram equivalents (MMEs) required to control postoperative pain.
Self-Assessment: What impact did the addition of low-dose ketamine infusions have on MME requirements necessary to control postoperative pain in patients undergoing bariatric and colorectal surgery?
An Interprofessional Approach to Achieving Opioid Guideline Recommendations at a Primary Care Clinic Wade Tugman, David Stewart, Brooklyn Nelson, Emily Russell ETSU - Bill Gatton College of Pharmacy - PGY2 Amb. Care - Johnson City, TN
Background/Purpose: Determine if a pharmacist integrated into a primary care clinic as part of an inter-professional team affects the clinic_x0019_s success in adhering to the Center for Disease Control_x0019_s 2016 Guideline for Prescribing Opioids for Chronic Pain.
Methodology: The study population will include primary care patients who were on high dose (MME >90 mg) chronic opioid therapy (defined as > 3 months) as of February 1, 2017. MMEs will be assessed for each study subject at index date (February 1, 2017) and at exit date (February 1, 2018) for both the intervention group (pharmacist integrated into the practice) and the control group (clinics that currently do not have pharmacist at the clinic). Other outcomes to be assessed are: change in naloxone prescriptions, change in compliance to urine drug screening per CDC guideline recommendations (yearly), and change in the number of concurrently prescribed benzodiazepines
Presentation Objective: Review the impact that a pharmacist as part of an inter-professional team in a primary care clinic can have on clinic compliance to the Center for Disease Control_x0019_s 2016 Guideline for Prescribing Opioids for Chronic Pain.
Self-Assessment: Which of the following are measures that an embedded pharmacist in a primary care clinic can have a positive impact on in regard to opioid stewardship?
Evaluation of Diuretic Dose Modification at Discharge and 30-Day Readmission Rate in HFpEF Meredith Welty, PharmD; Patrick Baldwin, PharmD; Bethany M. Brock, PharmD Mobile Infirmary Medical Center - Mobile, AL
Background/Purpose: To evaluate the relationship between discharge loop diuretic dose modification and 30-day hospital readmission rates in patients with heart failure with preserved ejection fraction
Methodology: This is an institutional review board-approved, single-center, retrospective study. Included patients are those admitted to inpatient care for acute decompensated heart failure, age greater than or equal to 18 years, pre-existing heart failure with preserved ejection fraction (LVEF greater than or equal to 50%), evidence of volume overload, loop diuretic (furosemide, bumetanide, torsemide) prescribed pre-admission and at discharge. All diuretic doses will be converted to oral furosemide equivalents using established conversion ratios. The primary endpoint for this study will be 30-day all-cause readmission. A post-hoc analysis will examine the impact of the magnitude of the change in diuretic dose at discharge on hospital readmission.
Results: Ten patients were included in a preliminary data analysis. Seven patients were readmitted during the 30 days after discharge; the prior to admission diuretic dose was increased in 2 patients (29%), not changed in 4 patients (57%), and decreased in 1 patient (14%). Three patients were not readmitted within this same period; the prior to admission diuretic dose was increased in 1 patient (33%), not changed in 1 patient (33%), and decreased in 1 patient (33%).
Conclusions: Preliminary results indicate that increasing or not changing the prior to admission diuretic dose at discharge is favorably correlated with a decreased readmission rate at 30 days post-discharge. It is notable that 70% of included patients were readmitted within 30 days of initial discharge. Additional data collection and analysis is necessary to assess the correlation between diuretic dose modification and readmission rate.
Presentation Objective: Explain etiologies of acute decompensated heart failure
Self-Assessment: Which of the following is NOT a risk factor for the development of acute decompensated heart failure?
Evaluation of burn resuscitation practices at a large ABA-verified burn center Tu-Trinh Tran, Ansley Tidwell, Rita Gayed Grady Memorial Hospital (Critical Care) - Atlanta, GA
Background/Purpose: Burn injuries of 20% total body surface area (TBSA) or greater lead to a systemic inflammatory response titled burn shock. Adequate fluid resuscitation in the first 24-48 hours is essential to improve outcomes. Although many formulas have been evaluated for fluid resuscitation in burn shock, there is currently no gold standard. The objective of this study was to assess burn resuscitation practices at Grady Health System (GHS) and associated outcomes.
Methodology: This was a single-center retrospective chart review of all patients with large burns between January 2011 and June 2018 who survived the first 48 hours of admission. The primary endpoint was the percentage of patients receiving fluid based on resuscitation formulas. Secondary endpoints included type and volume of crystalloid administered, use of colloids and high dose ascorbic acid (HDAA) as resuscitation adjuncts, adverse events related to over-resuscitation, utilization of monitoring parameters, intensive care and hospital length of stay, and in-hospital mortality.
Results: Patients received a mean of 3.9ml per kg per %TBSA of crystalloids within the first 24 hours. Most patients received colloids (59%) and HDAA (44%) as resuscitative adjuncts. The most common complication of over-resuscitation included pulmonary edema (32%); however, the incidence of compartment syndrome was low at 9%. Despite optimal fluid management, 38% of patients required vasopressors for hemodynamic support. Base deficits and urine output were monitored and met goals in ~80% of patients while lactate levels were not regularly obtained.
Conclusions: GHS burn resuscitation practices are consistent with current literature. Formalizing a resuscitation protocol can encourage the use of goal-directed resuscitation markers to assist with fluid titration and monitoring during acute burn resuscitation phase.
Presentation Objective: Assess the appropriate management of burn resuscitation in patients with greater than 20% TBSA burns
Self-Assessment: What are the complications of over-resuscitation?
Evaluation of vasopressor titration in coronary critical care units Stephanie Proctor, Jonathan Spry, Sharon Baty, Kate Adcock Huntsville Hospital (Critical Care) - Huntsville, AL
Background/Purpose: Vasopressors are commonly used medications in the coronary care units to treat hypotension and shock. Prescribers generally order a vasopressor with a stated systolic blood pressure (SBP) or mean arterial pressure (MAP) goal but do not always specify how to titrate the medication. The Joint Commission (TJC) Medication Management Standard 04.01.01 requires that all medication orders be clear and accurate. With a recent transition from paper charting to a new electronic medical record (EMR) with computerized prescriber order entry (CPOE) and smart pump technology, real time data on how vasopressor agents are being titrated is now available. Based on the results of this project, compliance to TJC Medication Management Standard MM.04.01.01 and the institution specific taper and titration guidelines can be evaluated. The purpose of this project is to determine compliance to and efficacy of institution specific taper and titration guidelines for vasopressors in Coronary Critical Care Units.
Methodology: This study is an IRB exempt single-center retrospective chart review and prospective observational analysis. The electronic medical record system will be used to identify patients who received a titratable vasopressor (phenylephrine, norepinephrine, epinephrine, or dopamine) while in the Huntsville Hospital Coronary Care Units from September 2018 _x0013_ March 2019. The following data will be collected: patient age, gender, weight, primary diagnosis, reported adverse medication events, vasopressor(s) used, blood pressure, and information on vasopressor titration (frequency of titration/amount of titration). All data will be recorded without patient identifiers and maintained confidentially. This information will be analyzed to determine TJC medication ordering compliance and how often nurses are correctly utilizing the Huntsville Hospital taper and titration guidelines for vasopressor titration.
Presentation Objective: Identify the required elements for medication titration orders to meet The Joint Commission Medication Management Standard MM.04.01.01
Self-Assessment: What are the required elements for medication titration orders?
EVALUATION OF THE EFFECTIVENESS OF A VANCOMYCIN DOSING NOMOGRAM USING A SIMPLIFED 24 HOUR AREA UNDER THE CURVE EQUATION Brad Bright, Kirsten Hawbaker Holston Valley Medical Center - Kingsport, TN
Background/Purpose: An update to the vancomycin guidelines is under review and re-emphasizes the necessity of AUC-guided dosing for more accurate therapeutic vancomycin levels. A simplified equation has been developed utilizing one steady-state trough value to estimate an AUC. The objective of this study is to evaluate the effectiveness of the vancomycin dosing nomogram currently used at Holston Valley Medical Center at predicting and calculating initial vancomycin dosing regimens yielding therapeutic 24-hour area under the curve (AUC) to minimum inhibitory concentration (MIC) ratios using this simplified equation.
Methodology: Patient information was collected through retrospective chart review of patients receiving intravenous vancomycin therapy between April 1, 2018 and December 1, 2018. Patients were included in the study if they were 18 years or older of age, were given intravenous vancomycin therapy per the dosing nomogram at Holston Valley Medical Center, had an estimated creatinine clearance of 30 or greater, and had an appropriately drawn trough (within one hour before the fourth, fifth, or sixth dose). Patients were excluded if they had baseline impaired renal function (CrCl
Impact of Procalcitonin Levels on Antibiotic Days of Therapy in Medical-ICU Patients with Sepsis Kerry Ward,Kathy Pollitzer,Chelsea Searels,Donley Galloway,Jennafer Pennell Medical Center of Central Georgia PGY1 - Macon, GA
Background/Purpose: Procalcitonin has emerged as a useful diagnostic marker for invasive bacterial disease. Normalization of procalcitonin levels can be used to guide antibiotic discontinuation in septic patients without a negative impact on morbidity and mortality. This study will attempt to identify differences in antibiotic days of therapy in patients who have sepsis with measured procalcitonin levels versus patients with sepsis who do not have measured procalcitonin levels.
Methodology: Eligible patients are those greater than or equal to 18 years of age being treated in the medical intensive care unit for sepsis. ICD-10 codes were used to generate a report of all patients treated for sepsis and retrospective chart review was completed to gather data. Patients were divided into two groups based on whether or not procalcitonin levels were measured. Antibiotic days of therapy was determined in each patient and a comparison of those days of therapy between groups was completed.
Presentation Objective: Determine how the presence, or lack of, procalcitonin levels impacted antibiotic days of therapy in medical intensive care unit patients with sepsis.
Self-Assessment: How can procalcitonin levels be used to aid in antimicrobial stewardship efforts?
Impact of pharmacist job aid on the incidence of hypoglycemia and hyperglycemia Danielle Carroll, Chelsea Ehalt, Eric Clayton Memorial University Medical Center - Savannah, GA
Background/Purpose: An important goal of inpatient care is managing glucose levels to avoid adverse events associated with hypoglycemia and hyperglycemia. Memorial Health University Medical Center uses a clinical surveillance platform, VigiLanz, which alerts pharmacists to patients with glucose levels outside of goal range. Providing a job aid detailing how to address these alerts may increase pharmacist interventions and improve patient care.
Methodology: This IRB-approved study included all adult patients with at least one alert for hypoglycemia or hyperglycemia between October 8, 2018 and December 31, 2018. The principal investigator developed a job aid including recommended interventions such as nursing education and physician discussion. This document was distributed to all pharmacists on November 19, 2018. Patients were divided into a pre-aid and post-aid group. Pharmacist interventions and patient characteristics were recorded and compared.
Results: A total of 564 alerts were included. The physician had already adjusted the patient_x0019_s antidiabetic regimen prior to the pharmacist addressing the alert in 45.9% of the pre-aid period and 54.1% of the post-aid period. These alerts were excluded from the following analyses. Pharmacists intervened on a significantly higher proportion of alerts in the post-aid period than in the pre-aid period (45.9% vs. 22.2%, p < .0005). The proportion of patients with repeat alerts was lower in the post-aid group compared to the pre-aid group (23.0% vs. 25.0%, p = 0.748), although this was not statistically significant.
Conclusions: The use of a standardized job aid can significantly increase the amount of clinical interventions that pharmacists make for patients with hypoglycemia or hyperglycemia.
Presentation Objective: To determine if the addition of a pharmacist job aid correlates to an increased number of interventions on patients with hypoglycemia and hyperglycemia.
Self-Assessment: Is a pharmacist job aid an effective means of improving patient care in conjunction with pharmacy monitoring software?
MANAGEMENT OF ANTICOAGULATION IN HEMATOPOIETIC CELL TRANSPLANT PATIENTS WITH NEW OR RECENT VENOUS THROMBOEMBOLISM Catherine Gawronski, Kathryn Culos, Bipin Savani, Katie Gatwood Vanderbilt University Medical Center - Nashville, TN
Background/Purpose: The association between venous thromboembolism (VTE) and cancer is well-established and the incidence of VTE in patients with hematologic malignancies ranges from a 4.1 to 6.5 fold increase from the general population. Many of these patients proceed to hematopoietic cell transplantation (HCT); however, there is limited information available on the incidence, risk factors, and optimal approach for management of VTE in this population. The majority of data regarding VTE and malignancy derives from patients with active cancer, not cancer in remission during stem cell transplantation, making extrapolation difficult. A high risk of bleeding due to thrombocytopenia and other transplant-associated factors also present an additional challenge for managing HCT patients with VTE. This purpose of this study was to evaluate current therapeutic anticoagulation practices in HCT patients at our institution in order to identify the optimal management strategy for treatment of VTE in the early post-transplant period.
Methodology: We performed a retrospective study of patients greater than or equal to 18 years of age who received therapeutic anticoagulation for new or recent VTE (within 30 days prior to HCT) during the first 100 days post-stem cell transplant. Transplant patients with ICD-9 and ICD-10 codes relating to pulmonary embolism and deep vein thrombosis were identified for inclusion. Exclusion criteria included patients not treated with standard therapeutic anticoagulation. The primary outcome was incidence of VTE recurrence. Key secondary outcomes include incidence of major and minor bleeding, incidence of acute graft-versus-host disease, and non-relapse mortality at day +100.
Results: Fifty patients met the criteria for inclusion.
Presentation Objective: Describe a factor that adds complexity to the choice of anticoagulation in the HCT population.
Self-Assessment: What is one reference available to guide decision making for anticoagulation in patients with cancer?
Evaluation of initial antidepressant failure rates to establish opportunities for pharmacogenomic testing Elyse Prather, Ann McGee, Adam Root, Deepak Voora, Zidanyue Yang Duke University Hospital Drug Information - Durham, NC
Background/Purpose: Major Depressive Disorder (MDD) is a common mental illness in the United States that is initially treated with cognitive therapy and antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs). For treatment failure, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study recommends optimizing the antidepressant dose, augmenting therapy, or switching medications. Each change in treatment can take weeks before subsequent evaluations. As a result, the patient experiences prolonged suffering and possibly adverse effects. Pharmacogenomic testing is a potential biomarker to guide the selection of appropriate antidepressant therapy with the goal to minimize treatment failure or adverse effects due to SSRI polymorphisms.
Methodology: A retrospective chart review was conducted for patients within the Duke Health System, non-psychiatric, ambulatory care setting between January 1, 2016 and December 31, 2016. The investigators identified a random sample of 200 patients who met the inclusion criteria. Patients included were adults age 18 years and older who were started on SSRIs for initial MDD treatment. Patients were excluded if they received prior pharmacogenomic testing, care from a psychiatric specialist, or were pregnant. The primary objective was to evaluate the initial treatment failure rates of SSRIs prescribed for MDD in the non-psychiatric ambulatory care setting. For purposes of this study, antidepressant treatment failure was defined as one of the following: augmentation of MDD therapy with additional medications, change in therapy to another antidepressant, or discontinuation of SSRI therapy due to lack of response or adverse effects. The data from this study will be used to evaluate the opportunity for pharmacogenomic testing based on the treatment failure rates.
Presentation Objective: To assess the opportunity to incorporate pharmacogenomic testing in MDD to decrease initial antidepressant failure rates.
Self-Assessment: What are some of the potential benefits of utilizing pharmacogenomic testing for guiding SSRI prescribing?
Impact of a pharmacist-led antiarrhythmic drug monitoring outpatient clinic within a Veterans Affairs Medical Center (VAMC) Elizabeth Jacobs Fayetteville VA Medical Center (Ambulatory Care) - Fayetteville, NC
Background/Purpose: Amiodarone and sotalol are antiarrhythmics commonly used in the management of atrial fibrillation, atrial flutter, and ventricular tachycardia in the outpatient setting. Studies have shown a very low adherence rate to the recommended monitoring of these medications. However, the implementation of pharmacist-led clinics has positively impacted adherence rates to recommended monitoring. The purpose of this project is to determine adherence to medication monitoring of amiodarone and sotalol in a pharmacist-led clinic compared to standard care.
Methodology: A pharmacist-led antiarrhythmic monitoring clinic was established under the purview of the cardiology pharmacist at the Fayetteville Veterans Affairs Healthcare Center (VA HCC), an outpatient branch of the Fayetteville Veterans Affairs Medical Center (VAMC). The cardiologists at the Fayetteville VA HCC were informed of the establishment of the clinic. Patients were identified for enrollment in the clinic through direct referrals from providers and through chart review. All patients with an active prescription for amiodarone or sotalol from the Fayetteville VAMC were screened. Patients with medication initiation between December 1st, 2014 and March 1st, 2018 at a VAMC were included in the project. Patients meeting these criteria were contacted via telephone and scheduled for an initial meeting with the clinical pharmacist. Data collected included demographics, adherence to medication therapy and adherence to recommend monitoring parameters before and after enrollment in the pharmacist-led clinic. The number and nature of pharmacist interventions were also collected.
Presentation Objective: Describe the impact of a pharmacist-led clinic on adherence to recommended medication monitoring of amiodarone and sotalol compared to standard care.
Self-Assessment: In a patient receiving amiodarone, which labs are recommended for monitoring every 6 months?
Evaluation of Fixed-dose Four-factor Prothrombin Complex Concentrate within a Community Health System Ester Lee, Sherri Merritt, Kunal Patel Northeast Georgia Health Systems - Gainesville, GA
Background/Purpose: Four-factor prothrombin complex concentrate (PCC) is a combination of blood coagulation factors that is FDA-approved for urgent warfarin reversal. Weight-based dosing per package insert is a commonly used dosing strategy. Alternative dosing strategies using fixed-dose regimens have also been studied. Our institution implemented a fixed-dose PCC protocol utilizing either 1500 or 2500 units. The purpose of this study is to determine the efficacy and safety of fixed dosing strategy implemented at a community health system.
Methodology: This was an IRB-approved retrospective chart review of patients that received fixed-dose PCC from time of protocol implementation until six months afterwards. The primary endpoint was International Normalized Ratio (INR) less than 1.5 post fixed-dose PCC administration. Secondary endpoints included change in INR pre and post fixed-dose PCC, concurrent phytonadione administration, and any additional doses of PCC or fresh frozen plasma administration. The safety endpoint was incidence of thromboembolic events within 30 days of fixed-dose PCC administration.
Results: A total of 49 subjects were included in the study. The most common indication for fixed-dose PCC treatment for any subject was hemorrhage (63.3%) followed by urgent surgery/procedure (34.7%). The median baseline INR was 2.90 (1.53 to 16.34) and the median INR post fixed-dose PCC was 1.41 (1.01 to 4.31; p < 0.00001). A total of 24 (64.9%) subjects with baseline warfarin achieved INR < 1.5 and 31 (83.8%) subjects achieved INR < 2. Two (4.1%) subjects developed a thrombus within 30 days of PCC administration and no subjects required a supplemental dose of PCC.
Conclusions: Fixed-dose PCC administration leads to adequate warfarin reversal. Minimal thromboembolic risk and reduced dosing errors were observed for all subjects. This evaluation suggests good efficacy and safety of a fixed-dose PCC protocol.
Presentation Objective: Demonstrate efficacy and safety of fixed-dose PCC protocol
Self-Assessment: What is/are potential benefit(s) of fixed-dose PCC?
Evaluating a new tool to optimize the medication history process Colleen Riley, Rylee Rankin, William Bell, Lindsay Harris Mission Hospitals PGY2 Emergency Medicine - Asheville, NC
Background/Purpose: A previous study showed that the use of a risk stratification algorithm led to medication histories completed in less time compared to the historical method. A triage dashboard was developed from this algorithm and was implemented in the emergency department. The objective of this study is to evaluate a tool as a way to optimize the medication history process in the emergency department at a tertiary care community hospital.
Methodology: After Institutional Review Board approval, a comparison of medication histories pre- and post-implementation of a triage dashboard was performed. Patients who presented to the emergency department at Mission Hospital and had a medication history completed by a pharmacy technician or pharmacy student were included. The primary outcome is number of medication histories completed on patients who were admitted. Secondary outcomes include average number of medication histories completed per hour, time to complete a medication history, and percentage of medication histories completed on patients deemed complex.
Results: A total of 1,582 patients were included. The percent of admitted patients was 81 % (n = 557)in the pre-implementation group and 59% (n = 523)in the post-implementation group. The average number of medication histories completed per hour were 1.9 in the pre-implementation group and 2.5 in the post-implementation group. The average time from arrival to completion of a medication history in the pre-implementation group was 3.7 hours and 4.9 hours in the post-implementation group. Patients deemed to be complex were 70% (n = 481) in the pre-implementation group and 81% (n=721) in the post-implementation group. Data analysis is ongoing.
Conclusions: N/A
Presentation Objective: Identify possible advantages of utilizing a triage tool to complete medication histories.
Self-Assessment: What are some patient characteristics that can be utilized to triage patients in the Emergency department prior to obtaining a medication history?
Treatment of Hyperkalemia in the Emergency Department Jimmy L. Pruitt III, John Patka, Timothy Moran, Anwar Osborne, Dan Wu Grady Memorial Hospital (Emergency Medicine) - Atlanta, GA
Background/Purpose: Hyperkalemia is a potentially life-threatening condition and may be a cause of cardiac arrest. The incidence of hyperkalemia in the emergency department (ED) is low however this number may be underreported. Treatments for hyperkalemia include calcium, insulin and dextrose, beta-agonists, and alkalinizing agents such as sodium bicarbonate. These agents have a temporary effect on the serum potassium and removal of potassium from the body may require diuretics, ion exchange agents, or hemodialysis. There is no guideline currently available to determine the order or inclusion of agents to treat hyperkalemia. This investigation will examine the initial treatment of hyperkalemia in the ED.
Methodology: A retrospective chart review will be performed to evaluate initial treatment(s) for hyperkalemia in the emergency department over a three month period between May 1, 2018, and July 31, 2018. Electronic medical records will be identified based medications prescribed in the ED and initial potassium levels. Charts will be reviewed from the time period of January through July 2018. Patients were included if a non-hemolyzed serum potassium concentration >5.1 mEq/L and treatment with one or more of the following: calcium chloride, calcium gluconate, insulin and dextrose, albuterol, injectable sodium bicarbonate. Patients were excluded if age less than 18 years old, pregnancy, or incarcerated. Sample size analysis demonstrated a need to review 150 patients.
Presentation Objective: To evaluate the initial treatment for hyperkalemia in the ED at a large academic teaching hospital
Self-Assessment: What is the most commonly pharmacologic agent used to stabilize the cardiac membrane in the setting of hyperkalemia?
Impact of a Community Pharmacist_x0019_s Intervention on Converting Patients to 90-Day Prescriptions in a Value-Based Population Kirklin Bowles, Beth Williams, Daniel Watson, A. Luebchow, R. Schomberg Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Evaluate the impact of a community pharmacist_x0019_s intervention on the total percentage of qualifying medications filled as 90-day prescriptions for Medicare Advantage patients attributed to an academic medical center.
Methodology: The target population was Medicare Advantage patients receiving qualifying medications for quantities
Assessing acute kidney injury in elderly patients based on vancomycin administration frequency Zachary DeGrave, Ryan Tilton, Lindsay Harris Mission Hospital PGY1 Inpatient Care - Asheville, NC
Background/Purpose: Elderly patients face an increased risk of vancomycin toxicity in the form of acute kidney injury (AKI) due to their low muscle mass, which may lead to overestimation of renal function and more aggressive dosing regimens. The purpose of this study is to analyze rates of AKI in elderly patients based on frequency of vancomycin administration to assess if every eight hour administration contributes to this complication compared to every twelve hour administration.
Methodology: The Institutional Review Board approved this retrospective, matched cohort study. Patients age 60 years and older who received at least 48 hours of vancomycin therapy with an 8-hour or 12-hour frequency were included. Patients were excluded if any of the following criteria were met: admitted from an outside hospital, baseline serum creatinine greater than 1 mg/dL or no baseline serum creatinine prior to initiation of vancomycin therapy, or AKI prior to or during the first 24 hours of vancomycin initiation. Patients will be matched based on age, intensive-care unit status at initiation of vancomycin therapy, and systolic blood pressure. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines will be used to classify AKI. The primary outcome is difference in incidence of AKI between patients who received vancomycin every 8 hours versus every 12 hours.
Results: 453 patients met inclusion criteria for the study. Before the patients were matched, 15 of the 118 (12.7%) patients who received vancomycin every 8 hours had AKI compared to 38 of the 355 (10.7%) patients who received vancomycin every 12 hours. Matching and additional analysis is underway.
Presentation Objective: Explain how vancomycin dosing frequency can affect the rates of acute kidney injury in elderly patients.
Self-Assessment: When dosing vancomycin, what factors should be assessed prior to determining the dosing frequency?
SAFETY AND EFFICACY OF APIXABAN IN PATIENTS WITH VENOUS THROMBOEMBOLISM AND END-STAGE RENAL DISEASE Kimberly Knight, Bethany Marshall, Ann Maxwell McLeod Regional Medical Center - Florence, SC
Background/Purpose: Direct-oral anticoagulants (DOACs) have been demonstrated to be noninferior to warfarin for the treatment of venous thromboembolism (VTE) with the benefit of lower rates of major bleeding. Large, randomized trials have excluded patients with estimated glomerular filtration rate (eGFR) < 30 mL/min and/or patients on hemodialysis (HD) or peritoneal dialysis (PD), likely because patients with end-stage renal disease (ESRD) have a higher baseline bleeding risk due to uremia-induced platelet dysfunction. The purpose of this study is to evaluate the safety of apixaban compared to warfarin in patients with acute VTE and ESRD on hemodialysis or peritoneal dialysis.
Methodology: This retrospective cohort will screen all adults admitted between August 2014 and November 2018 with ESRD who received apixaban or warfarin. Patients with newly diagnosed deep-venous thromboembolism (DVT), confirmed by compression ultrasound or venography, or pulmonary embolism (PE), confirmed by CT angiography or V/Q scan, will be included. The primary outcome is the composite incidence of any clinically-relevant bleeding. Secondary outcomes include incidence of VTE-related death, recurrent VTE at 3, 6, and 12 months, fatal bleeding, non-fatal major bleeding, and non-major, clinically relevant bleeding. Nominal data will be analyzed using Chi-squared or Fisher_x0019_s exact test. Continuous data will be analyzed using a student_x0019_s t-test. A priori subgroup analyses will include patients receiving concomitant heparin with HD, days of initial anticoagulation, warfarin TTR, maintenance apixaban dose, and obesity.
Presentation Objective: Compare the risk of bleeding in patients with ESRD taking apixaban vs. warfarin for the treatment of VTE.
Self-Assessment: Based on the available evidence, is the standard apixaban dose of 5 mg BID safe to use in patients with ESRD?
Incidence of vancomycin nephrotoxicity: area under the curve dosing versus traditional dosing Macy Mullins Redmond Regional Medical Center - Rome, GA
Background/Purpose: It is thought that traditional vancomycin dosing results in higher trough levels than necessary for adequate treatment and subsequently increased incidence of nephrotoxicity. The purpose of this review is to determine incidence of nephrotoxicity at our facility now that the transition to area under the curve (AUC) dosing is complete. The outcomes of this review may provide support for improved safety outcomes that are associated with AUC dosing versus traditional dosing.
Methodology: We will conduct a retrospective chart review at Redmond Regional Medical Center, using patients_x0019_ electronic medical records to gather data related to vancomycin from the third quarter of 2017 and 2018. The data from 2017 will reflect traditional vancomycin dosing and the 2018 data will reflect area under the curve (AUC) dosing. We will randomly select/assign a minimum of 100 patients per dosing group. Data collection will include: dosing type, vancomycin levels, demographics, use of other nephrotoxic agents, other factors that could affect the ability to clear vancomycin, and incidence of nephrotoxicity. Patients with baseline acute kidney injury and end stage renal disease will be excluded. Primary endpoint: nephrotoxicity- patients with an increase serum creatinine concentration of 0.5 mg/dL or >50% increase from baseline with absence of an alternative explanation. Secondary endpoint: appropriateness of dosing. Following data collection we will evaluate nephrotoxicity in each group and draw a conclusion based on comparison of each group.
Conclusions: No significant difference in the incidence of nephrotoxicity in patients that were traditionally dosed versus those that were dosed based on a goal AUC of 400-600 found.
Presentation Objective: 1. Explain AUC dosing
2. Describe the use of AUC based dosing at RRMC
3. Compare outcomes of each dosing method
4. List future guidelines that will recommend AUC based vancomycin dosing
Self-Assessment: Is dosing vancomycin based on AUC safer than traditional trough based dosing?
Incidence of Post-Transplantation Diabetes Mellitus (PTDM) in Haploidentical Hematopoietic Cell Transplant Patients Brendan Mangan; Dilan Patel; Kathryn Culos; Katie Gatwood; Brian Engelhardt Vanderbilt University Medical Center - Nashville, TN
Background/Purpose: New-onset post-transplantation diabetes mellitus (PTDM) occurs in approximately 60% of patients undergoing allogeneic hematopoietic cell transplantation (alloHCT). A 2012 study of matched related/unrelated alloHCT patients without preexisting diabetes reported a PTDM incidence of 66.7% by post-HCT day 100. Due to a lack of evidence in the haploidentical HCT population, we examined the incidence, outcomes, and risk factors for PTDM in patients undergoing haploidentical HCT.
Methodology: This study was a single-center, retrospective review of haploidentical HCT patients at the Vanderbilt-Ingram Cancer Center (VICC). Patients were excluded if undergoing a non-haploidentical HCT or having a prior diagnosis of diabetes. PTDM was defined as a random blood glucose > 200 mg/dL. The primary outcome was the incidence and time to PTDM by post-HCT day 100. Secondary outcomes included the use of metabolic medications prior to and on post-HCT day 100, the incidence of graft-versus-host disease (GVHD), maximum dose of steroids, and relapsed/non-relapsed mortality.
Results: Since 2013, 81 patients have received a haploidentical HCT at VICC, with 65 patients meeting inclusion criteria. Of the 65 patients, 14 patients (21.5%) have met the primary outcome of developing PTDM in the first 100 days post-HCT.
Presentation Objective: Discuss the risk factors associated with PTDM in haploidentical HCT patients.
Self-Assessment: (T/F) Haploidentical HCT patients have a higher incidence of PTDM compared to matched alloHCT patients.
Implementation of a neonatal sepsis risk calculator to reduce the exposure to antibiotics in term neonates Bianca Rivera-Ramirez, Laura Hagan, Matthew McAllister, Corinne Murphy Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: Neonatal sepsis is one of the leading causes of morbidity and mortality in preterm and term infants. Furthermore, broad-spectrum antibiotics and prolonged empiric treatment are associated with adverse outcomes, including invasive candidiasis, increased antimicrobial resistance, necrotizing enterocolitis (NEC), late-onset sepsis, and death. The Kaiser Permanente Neonatal Early-Onset Sepsis Calculator is a screening tool that produces the probability of early-onset sepsis per 1,000 newborns, taking into consideration maternal and newborn risk factors. Several institutions have opted to implement the use of the sepsis risk calculator to decrease unnecessary antibiotic exposure when EOS is suspected. The purpose of this study was to determine if use of the Kaiser Permanente Neonatal Early-Onset Sepsis Calculator during clinical assessment of term neonates decreases the percent of neonates transferred from newborn nursery to the NICU for antimicrobial treatment.
Methodology: A pre-post study was conducted of patients admitted to newborn nursery. Patients were divided into two groups: those born before use of the sepsis risk calculator and those born after implementation of the calculator. Data was compared pre- and post-implementation of the sepsis risk calculator, including percentage of newborns transferred to the NICU for antibiotics for rule out sepsis, number of CBC and CRP laboratory evaluations done per 1000 patient days, length of stay, and cost.
Presentation Objective: Identify the potential benefits of the use of a neonatal sepsis risk calculator in term neonates.
Self-Assessment: How can pharmacist have an impact in antimicrobial stewardship in the neonatal intensive care unit?
Comparison of two antithymocyte globulin (rabbit) dosing regimens in kidney transplant recipients Maggie A. Klingensmith, Kwame Asare, Caroline Barone, Jordan Brooke Tullos St. Thomas West Hospital - Nashville, TN
Background/Purpose: Antithymocyte globulin (rabbit) is FDA approved for induction therapy in renal transplant recipients at a dose of 1.5mg/kg/dose for 4-7 days. The primary objective is to compare the rates of rejection between two antithymocyte globulin induction dosing regimens in kidney transplant recipient. The secondary objectives are to compare length of stay, incidence of malignancy, and incidence of adverse effects between study groups.
Methodology: This was a single-center retrospective chart review comparing antithymocyte globulin, 1.5mg/kg/dose for 4 doses versus 2mg/kg/dose for 3 doses.
Results: The 2mg/kg study group was predominantly Caucasian (n=31, 65%) and the 1.5mg/kg study group was predominantly African American (n=28, 65%). The average cold ischemic time was lower for the 1.5mg/kg group. Other baseline characteristics were similar. Acute rejection occurred in 1 participant from the 2mg/kg study group and 2 participants from the 1.5mg/kg study group. Average length of stay was shorter in the 2mg/kg group (97 hours) compared to the 1.5mg/kg group (184 hours). No incidence of malignancy occurred. Adverse effects were similar between groups. More participants in the 1.5mg/kg study group received a decrease in antithymocyte globulin dosing as a result of adverse effects (n=10) compared to the 2mg/kg study group (n=4).
Conclusions: There was no statistically significant difference in incidence of acute rejection between study groups. The only secondary objective that was found to be statistically significant was length of stay (p = 0.0195).
Presentation Objective: Asses the rates of acute rejection, length of stay, incidence of malignancy, and incidence of adverse events in kidney transplant patients receiving different dosing regimens of antithymocyte globulin (rabbit) for induction therapy.
Self-Assessment: Is thymoglobulin 2mg/kg for three days associated with a decreased rate of acute rejection, shorter length of stay, and more adverse effects when compared to thymoglobulin 1.5mg/kg for four days?
THE PATIENT ALIGNED CARE TEAM (PACT) MODEL: A COMPARATIVE ANALYSIS OF NATIONAL STANDARD PATIENT CENTERED MEASURES FOLLOWING R Morgan Tolley, Tiffany Jagel, Vanessa Herrington, Frances Hoffman Gulf Coast Veterans Health Care System - Biloxi, MS
Background/Purpose: Within the VA primary care setting, a patient aligned care team (PACT) functions to provide an interdisciplinary health care delivery system which integrates the skills of the clinical pharmacy specialist (CPS), who has prescriptive authority specific to a scope of practice. This integration has proven to expand overall appointment availability and improve patient outcomes and safety.
Methodology: National standards of performance measures, Strategic Analytics for Improvement and Learning (SAIL) and Healthcare Effectiveness Data and Information Set (HEDIS), for Veterans Integrated Service Network (VISN) 16 will be used for primary data analysis. Eligible veterans identified through the Primary Care Almanac will be recruited and scheduled into CPS clinics hemoglobin a1c > 9% and BP > 140/90 mmHg. To target access, a measure of SAIL, CPS capacity scorecards, source of patient referrals, and conversion of primary care physician (PCP) appointments will be measured.
Results: A total of 459 patients were seen by PACT CPSs from September 2018 to January 2019. Of the 459, 239 were recruited during PACT expansion (CPS 50.2%, primary care 47.7%, and other 2.1%). Overall capacity versus patients scheduled has remained stable with average capacity score of 62.6% from 10/22/18 through 1/18/19. Core HEDIS measure a1c poorly controlled (a1c > 9%) remained stable with a decrease in performance for blood pressure control (BP > 140/90 mmHg).
Conclusions: CPS integration into PACT helped maintain HEDIS measure performance. Increasing access for veterans in primary care was supported by the indirect measurement of appointment conversions and clinic capacity measurements. On average, CPS clinics dedicated at minimum 60 hours a week serving veterans.
Presentation Objective: This project will use national standards of performance measures to assess the expansion of the PACT model within the GCVHS.
Self-Assessment: In what ways can CPSs improve patient outcomes within the primary care setting?
Efficacy and Safety of Tranexamic Acid versus Aminocaproic Acid in Cardiac Surgery Hannah Lineberry, Evan Tatum, Allison Gaddy Novant Health Forsyth Medical Center - Winston-Salem, NC
Background/Purpose: A major complication of cardiac surgery is bleeding which increases the need for blood products, can lead to additional exploratory surgeries and potentially result in increased morbidity and mortality. The use of lysine analog antifibrinolytics are guideline recommended to reduce total blood loss and decrease the number of patients who require blood transfusions during cardiac procedures. However, little evidence exists for guidance on use of one agent over the other. The purpose of the study is to assess the safety and efficacy of the dosing regimen implemented for tranexamic acid (TXA), as compared to aminocaproic acid (ACA), in patients undergoing cardiac surgery utilizing cardiopulmonary bypass (CPB).
Methodology: This was an observational, retrospective, multi-center cohort study. Patients were included if they were 18 years or older, underwent cardiac surgery on cardiopulmonary bypass at Novant Health Forsyth Medical Center or Novant Health Presbyterian Medical Center and received either TXA or ACA between May 1st, 2017 to May 31st, 2018. Patients were excluded if they had a documented bleeding disorder, refused blood products or the Novant Health TXA or ACA dosing strategy was not used. The primary efficacy endpoint was total perioperative and post-operative blood products required within the first 24 hours. The primary safety endpoint was incidence of venous thromboembolism (VTE). Secondary endpoints included incidence of seizures and exploratory surgery for bleeding.
Presentation Objective: Assess the efficacy and safety of the implemented TXA dosing regimen as compared to ACA in cardiac surgery.
Self-Assessment: Which agent, TXA or ACA, has a higher incidence of venous thromboembolism?
Evaluation of 4-factor prothrombin complex concentrate administered at high infusion rates on patient safety, effectiveness a Brittny Medenwald, Nicholas Barker, Molly Trent , Katleen Chester Grady Memorial Hospital (Neurology) - Atlanta, GA
Background/Purpose: Reversal of vitamin K antagonists in the setting of life-threatening bleeding or urgent procedures should occur with 4-factor prothrombin complex concentrate (4F-PCC) as soon as possible. The labeled maximum infusion rate of 4F-PCC is 8.4 mL/min, although rapid administration is reported in real-world practice. Limited information is available on the safety, efficacy, and time to administration of 4F-PCC when administered at high infusion rates.
Methodology: In 2017 Grady Health System implemented rapid 4F-PCC administration to reduce times from order entry to administration. Doses of 4F-PCC were prepared in up to four, 60-mL syringes. Each syringe was administered IV push over 2 minutes. This IRB-approved study is a retrospective evaluation of 4F-PCC administrations using usual infusion rates compared to a rapid administration protocol. The primary objective is to evaluate turn-around times for 4F-PCC. Secondary objectives include safety and effectiveness of INR reversal in patients previously on warfarin. All PCC administrations were included in the evaluation regardless of indication.
Results: One hundred and ninety nine patients were included in the study between January 3rd, 2016 and April 26th, 2018. No significant difference was seen between the order-to-administration times. No significant differences in hemodynamic effects or thrombolytic evens were noted. One injection site reaction was reported with rapid 4F-PCC administration. No difference was seen in patients who achieved an INR < 1.4, however, the median INR after the administration of 4F-PCC was significantly lower in the rapid administration cohort.
Conclusions: Administration of 4F-PCC as an IV push appears to be safe and effective. Turn-around times were not significantly different with rapid 4F-PCC administration. These results support further evaluation of 4F-PCC rapid administration protocols.
Presentation Objective: Recall the safety and efficacy of IV push 4F-PCC.
Self-Assessment: True or False: Administering IV push 4F-PCC decreases turn-around times without significant adverse effects.
Expansion of pharmacist-driven centralized antimicrobial culture follow up in a six hospital regional health system Jimmy Godwin, Erika Herman, Trey Wingerson, Lindsay Harris Mission Hospitals - Asheville, NC
Background/Purpose: Microbial samples drawn in the emergency department (ED) are frequently not finalized until after patient discharge and the absence of a structured follow-up process may lead to failure of appropriate therapy. Pharmacist led microbial follow-up in the ED, compared to physician or nurse led follow-up results in increased appropriateness of antibiotic therapy. At Mission Hospital, pharmacists are responsible for microbial follow-up in the ED, compared to a shared responsibility between physicians and nurses at Mission Health affiliate EDs. The purpose of this project is to determine feasibility of centralizing the microbial follow up process to a single location.
Methodology: After obtaining IRB approval, culture reports for all six of the Mission Health EDs were sent to a centralized location, from November 1, 2018 to November 30, 2018. Exclusion criteria was admission to any Mission inpatient facility or hospice. The primary objective is to quantify the number of necessary interventions during microbial follow-up for all of the Mission Health system EDs compared to the usual volume of microbial follow-ups done at Mission alone.
Results: 1574 culture reports were reviewed, of which 1420 were included. Of the 374 positive results, 53% (n=200) were from Mission Hospital and the remaining 47% (n=174) were from the five affiliate hospitals. An intervention was necessary for 44% (n=88) of the positive results at Mission compared to 35% (n=61) at the five affiliate hospitals.
Presentation Objective: Identify opportunities of improvement in the current microbial follow-up process in the six hospital Mission Health system.
Self-Assessment: What is the potential benefit to the centralization and standardization of microbial follow-up process for the Mission Health system?
Pharmacists_x0019_ Contribution in a Value-Based Care Model at a Large Regional Health System Tiffany Sherod-Harris, Beth Williams, Molly Hinely, Tacorya Adewodu, et al. Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Describe the impact pharmacist participation has in a value-based care model.
Methodology: This single-center retrospective study evaluated data from the electronic medical records of Medicare beneficiaries served by eighteen outpatient clinics. Eligible patients were those enrolled in a value-based care contract who had a completed medication review by a pharmacist from April 1, 2018 to December 31, 2018. The total number of completed medication reviews, total number of pharmacist recommendations flagged for the provider, and overall provider acceptance rate were identified. In addition, provider acceptance rate per recommendation category were documented.
Results: A total of 2,921 comprehensive medication reviews (CMRs) were completed over the nine-month study period by pharmacists. Among that total, 963 (33%) CMRs with 1, 385 recommendations were flagged with recommendations communicated to providers. The overall provider acceptance rate was 317.5 of 1, 385 (23%). The most common recommendations accepted by providers included antihypertensive management 61 of 294 (21%), preventative health screenings 77 of 375 (21%), and general dosing recommendations 133.5 of 482 (28%).
Conclusions: As healthcare shifts to value-based care, it is critical to understand the impact pharmacists can make to improve the quality of care. Value-based care models are limited in data surrounding pharmacist participation and warrant future research. Description of how pharmacists can contribute to value-based care on a patient level will inform the overall impact on value-based care. Using the provider acceptance rate per category in this study will allow pharmacists to focus on targeted areas in which providers are more likely to accept recommendations.
Presentation Objective: Identify a standardized approach for pharmacists to target medication-related quality measures.
Self-Assessment: What are some interventions that pharmacists can make to improve medication-related quality measures in a value-based care population?
Clinical and Economic Outcomes of Inpatient Standard of Care versus Outpatient Oritavancin Therapy for Patients with ABSSSI Brandy Williams, Jonathan Edwards, April Williams Huntsville Hospital - Huntsville, AL
Background/Purpose: Oritavancin is a long-acting lipoglycopolysaccharide indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI). Oritavancin provides a complete treatment course in a single 1200 mg IV dose which ensures patient compliance with antimicrobial therapy. Due to its expense, oritavancin is not the preferred agent for inpatient treatment with ABSSSI; however, oritavancin is an attractive option for the management of ABSSSI in the outpatient setting. The purpose of this evaluation is to compare inpatient standard of care management of ABSSSI to outpatient oritavancin therapy.
Methodology: This is an Institutional Review Board approved retrospective chart review of patients who are >18 years of age admitted to the hospital between February 2015-December 2018 with a diagnosis related grouping code of 603 (cellulitis without major co-morbidities). Data collection includes patient demographics, 30-day inpatient readmission rates for those who received standard of care, 30-day outpatient admission rates of those who received oritavancin, length of stay, and insurance reimbursement rates. The primary endpoint of this evaluation is to compare clinical outcomes of patients treated as an inpatient with standard of care management versus outpatient management utilizing oritavancin in patients with ABSSSI. The secondary endpoint of this evaluation is to compare reimbursement outcomes in both groups to determine if the administration of oritavancin in the outpatient setting is more economical compared to inpatient management.
Presentation Objective: To determine if outpatient administration of oritavancin is clinically and economically more advantageous for the facility compared to inpatient management of ABSSSI utilizing current standard of care treatment.
Self-Assessment: Does oritavancin provide a clinically and financially feasible alternative for the treatment of ABSSSI compared to inpatient standard of care management?
Effect of targeted prescriber education on comfort and knowledge in the treatment of attention deficit/hyperactivity disorder Perrine, JA; Chamberlin, SM; Jeter, JW; Eudaley, ST. University of Tennessee Medical Center (Pharmacotherapy) - Knoxville, TN
Background/Purpose: Despite the relatively high incidence of AD/HD in children between the ages of 4 _x0013_ 18 in the United States, research has shown physicians find providing optimal care to these patients challenging. Assessment of current prescribing patterns and implementation of interventions to improve prescriber comfort and knowledge, as well as, guide appropriate guideline-based therapy for AD/HD are imperative to optimize treatment success, patient safety, and cost-effectiveness. The objective of this study is to evaluate prescriber comfort and knowledge of AD/HD treatment in patients between the ages of 4 - 18 within a Family Medicine resident clinic.
Methodology: This was a survey study of Family Medicine residents and faculty aimed at assessing baseline comfort and knowledge of diagnosis and treatment of AD/HD prior to a targeted education session by a multidisciplinary team (physician, clinical pharmacist, and clinical psychologist). The survey was composed of three different sections: demographics, comfort, and knowledge. This is part of a longitudinal pre/post survey study with the primary outcome evaluating change in prescriber comfort and knowledge in diagnosis and treatment of AD/HD. Data from the initial survey was used to tailor prescriber education to areas for improvement. Education included a review of evidence-based diagnosis and treatment of AD/HD, in addition to a clinic-specific flow diagram for diagnosis/treatment and medication formulary. An application exercise using patient cases was also included.
Presentation Objective: Identify areas of improvement in prescriber comfort and knowledge of AD/HD treatment in patients between the ages of 4 - 18 within a Family Medicine resident clinic.
Self-Assessment: What is one method in which pharmacists may contribute to prescriber targeted education sessions?
Enhancing Clinical Pharmacy Specialist Involvement In Transitions of Care Focusing On Ambulatory Care Sensitive Conditions Fisher M, Elam A, Gordon A, Howard M, Neighbors L, Ragan A Central Alabama VA Health Care System - Montgomery, AL
Background/Purpose: Ineffective care transitions can lead to adverse events and higher hospital readmission rates, and therefore have detrimental effects on quality of life, morbidity, and mortality for the patient. The purpose of this project was to evaluate the impact of clinical pharmacy specialist (CPS) involvement in the post-discharge period on 30-day readmission rates for patients hospitalized for heart failure (HF) or chronic obstructive pulmonary disease (COPD).
Methodology: A new transitions of care process consisting of two contacts with an ambulatory care CPS within 30 days of hospital discharge was implemented for patients with a principle or secondary discharge diagnosis of HF or COPD for a 3-month time frame. Index and all-cause 30-day readmission rates for the included patients were compared to the rate for comparable patients during the same time period of the previous year.
Results: Through implementation of 7-day and 21-day post-discharge contacts with an ambulatory care CPS, there was an observed 5.68% and 8.82% decrease in the 30-day index readmission rates for patients discharged with COPD and HF, respectively. Additionally, there was an observed 5.19% decrease in the 30-day all-cause readmission rate for patients discharged with COPD and HF combined.
Conclusions: Involving ambulatory care CPS in the post-discharge period may reduce index and all-cause readmission rates for patients discharged with ambulatory-care sensitive conditions.
Presentation Objective: To discuss various interventions the CPS could make in a Veterans Affairs Healthcare Center during the 30-day post-discharge period for patients hospitalized for ambulatory-care sensitive conditions.
Self-Assessment: Identify nonpharmacological interventions that could be made by a CPS in a Veterans Affairs Healthcare Center during the 30-day post-discharge period for patients recently hospitalized for an ambulatory-care sensitive condition.
Incidence of rejection in heart transplant patients who received induction therapy versus those who did not Madison Como, Caroline Barone Gatzke, Kwame Asare St. Thomas West Hospital - Nashville, TN
Background/Purpose: The purpose of this study was to determine if induction therapy in heart transplant patients is beneficial in reducing the risk of rejection within 3 months post-transplant without increasing the risk of infection, and if induction therapy can reduce the risk of nephrotoxicity by delaying calcineurin inhibitor initiation.
Methodology: This was an institutional review board approved, retrospective electronic chart review of patients who underwent cardiac transplant at Ascension Saint Thomas West Hospital between April 1, 2016 and July 31, 2018. Patients were categorized based on if they did or did not receive induction therapy. Data was analyzed to determine incidence of rejection requiring treatment and infection requiring hospitalization within the first three months post-transplant. Timing of calcineurin inhibitor initiation and incidence of nephrotoxicity were also assessed.
Results: Forty-six patients were included in the study. Rejection did not occur in any patients who received induction and in 21 percent of patients who did not. Infection occurred in 15 percent of patients in both groups. Nephrotoxicity occurred in 36 percent of patients in both groups. The mean timing of calcineurin inhibitor initiation was 3 days in patients who received induction and 1 day in patients who did not.
Conclusions: There was no statistically significant difference in rejection or infection between groups. Although not statistically significant, the study showed a trend of less incidence of rejection in patients who received induction therapy. There was a statistically significant difference in timing of calcineurin inhibitor initiation, however incidence of nephrotoxicity was similar between groups.
Presentation Objective: Determine the incidence of rejection within the first three months post heart transplant in patients who received induction therapy versus those who did not.
Self-Assessment: Is there an effect on the rates of rejection and serious infection within three months post-heart transplant in patients who received induction therapy?
Evaluation of the cost differences between non-treatment and treatment of asymptomatic bacteriuria in a community hospital Kelly G. Gandy, William R. Johnson, Leborah C. Lee Jackson Hospital - PGY1 Residency - Montgomery, AL
Background/Purpose: The 2005 Infectious Diseases Society of America (IDSA) Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults suggest not screening for or treating asymptomatic bacteriuria in community-dwelling, nonpregnant adults. Studies have indicated treating asymptomatic bacteriuria with antibiotics may not prevent progression to urinary tract infections, may lead to the development of multidrug resistant organisms, and may result in unnecessary adverse drug reactions. To our knowledge, a financial analysis has not been published regarding inappropriate treatment of asymptomatic bacteriuria. The purpose of this study is to determine the cost per hospital stay difference associated with non-treatment or treatment of asymptomatic bacteriuria in patients whom therapy was not indicated.
Methodology: This study is a single-center, retrospective cohort chart review and was approved as exempt by the Institutional Review Board. Patients were identified by positive urinalysis (UA) based on LabCorp® reflex culture standards adapted to our reporting values and positive urine cultures (UC) for patients admitted between January 1, 2018 and February 28, 2018. Patients were excluded if they had a urinary catheter present on admission, symptoms of cystitis or pyelonephritis, documented antibiotic use in the two weeks prior to admission, admitted for another possible infectious disease, positive blood cultures during admission, met SIRS criteria, were immunocompromised, or were pregnant.
Results: Preliminary data analyses reveal a numerical difference between the average length of stay in the non-treatment group (3.4 days, n=65) compared to the treatment group (4.8 days, n=55).
Presentation Objective: Apply the IDSA guidelines to identify patients who should be screened and treated for asymptomatic bacteriuria.
Self-Assessment: What is the appropriate treatment for a 43-year-old female patient who presents with a STEMI, has no urinary related complaints or flank pain, a urinalysis positive for nitrites and bacteria, and a negative HCG?
DISCONTINUATION OF BUPRENORPHINE/NALOXONE POST A LONG-TERM MAINTENANCE PERIOD IN VETERANS WITH OPIOID USE DISORDER Anesa E. Hughes, Rebecca M. Spivey, and Robyn Ward James H. Quillen VA Medical Center PGY1 - Mountain Home, TN
Background/Purpose: According to the NIH National Institute on Drug Abuse, more than 115 individuals in the United States experience a fatal opioid overdose every day. An estimated 517,000 individuals are addicted to heroin and 1.9 million are addicted to prescription opioids. The VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders recommends medication assisted therapy (MAT) with buprenorphine/naloxone or methadone for patients with opioid use disorder (OUD). James H. Quillen VA Medical Center (JHQVAMC) has one of the lowest percentages within its network in prescribing MAT to patients diagnosed with OUD. Some reluctance in prescribing has been attributed to the fact that current literature supports indefinite treatment. The purpose of this project is to provide insight on the discontinuation of buprenorphine/naloxone and successful abstinence of opioids and ultimately encourage the use of buprenorphine/naloxone as a treatment option for OUD.
Methodology: Retrospective review of the buprenorphine clinic, mental health, and primary care notes in the electronic medical record is taking place. Patients who received buprenorphine/naloxone from the JHQVAMC pharmacy from January 2011 - January 2015 are included. Long-term treatment is defined as at least 330 days of MAT in a 425-day timeframe. Chart reviews are being used to determine if patients are still enrolled in the clinic or if they were discharged post a maintenance period. Status following discharge may be successful remission, currently receiving non-VA MAT, still abusing opioids, or unable to determine. Successful OUD remission is considered abstinence from opioids 6 months from the last buprenorphine fill date based on patient report and urine drug screen results if available.
Presentation Objective: To determine the likelihood of successful abstinence of opioids following a maintenance period of buprenorphine/naloxone with subsequent discontinuation.
Self-Assessment: What is the recommended duration for medication-assisted therapy?
Improving Efficiency through Optimizing Workflow in a Pharmacist-Run Diabetes Clinic Leva Jaberizadeh, Jasmine Peterson, Stephanie Thrall Kaiser Foundation Health Plan of Georgia - Atlanta, GA
Background/Purpose: Patients with uncontrolled diabetes are associated with higher overall healthcare expenditure and poorer health outcomes. Pharmacists may collaborate with physicians to manage patients with uncontrolled diabetes through a variety of methods including telephonic pharmacist appointments. A common barrier that pharmacists may encounter is a low response rate from patients. In efforts to improve clinical outcomes and reduce cost, Kaiser Permanente Georgia (KPGA) hired non-clinical support staff to assist ambulatory care clinical pharmacists by scheduling and preparing patients for telephone visits. This study aims to evaluate the impact of hiring non-clinical support staff on improving pharmacist productivity and regionwide diabetes control.
Methodology: In this retrospective cohort study, an electronic medical record was used to evaluate KPGA adult members with Type 2 diabetes. Patients were included if they were contacted via telephone for a diabetes consult with a clinical pharmacist between July 1, 2015 to June 30, 2017. Patients were excluded if they had gestational diabetes, were followed regularly by Endocrine (three or more visits during the study period), prescribed insulin U-500, or using an insulin pump. The primary outcome was to evaluate the average rate of completed telephone encounters per month before and after hiring non-clinical support staff. The secondary outcome was to assess hemoglobin A1c (HbA1c) change in patients who had a HbA1c completed within 90 days after clinical pharmacist outreach. The tertiary outcome was call completion rate for scheduled appointments versus cold calls.
Presentation Objective: Describe the impact of hiring non-clinical support staff in scheduling telephone appointments for a team of ambulatory care clinical pharmacists.
Self-Assessment: What is a possible benefit of utilizing non-clinical support staff in scheduling telephone appointments with a clinical pharmacist in an ambulatory care setting?
AN EVALUATION OF INSULIN INFUSION MANAGEMENT IN DIABETIC KETOACIDOSIS Nerea Irusta, Matthew McAllister, Katie Fulks Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: Diabetic ketoacidosis (DKA) is an acute, life-threatening emergency with an increased prevalence despite advances in the diagnosis and treatment of diabetes. Although the clinical presentation of DKA can range from mild to severe, many of the current treatment strategies utilized require an advanced level of care and result in the consumption of a large variety of healthcare resources. The goal of this study was to identify trends in patient presentation, management of disease state, and resolution of DKA at our institution.
Methodology: A retrospective chart review was conducted on a convenience sample of 250 patients admitted with a diagnosis of DKA between July 1st 2017-June 30th 2018 at Piedmont Columbus Regional Midtown. Charts were reviewed for patients over the age of 18 with a primary diagnosis of DKA that were treated with an insulin infusion. Patients receiving chronic high dose systemic steroids; an insulin infusion for indications other than DKA; and those transferred to another facility, discharged, or expired prior to resolution of DKA were excluded. Patients were grouped based on initial presentation as mild, moderate or severe DKA which was classified by initial pH, bicarbonate level, anion gap and alterations in mental status. The primary endpoint of time to resolution of DKA was then assessed between these groups. Data collection allowed for the evaluation of several secondary endpoints including ICU length of stay, hospital length of stay and incidence of hypokalemia and hypoglycemia.
Presentation Objective: Identify patient characteristics and clinical factors that influence time to resolution of diabetic ketoacidosis and overall length of hospital stay.
Self-Assessment: What are the clinical characteristics that influence time to resolution of diabetic ketoacidosis?
Effect of hyperglycemia resolution on intracranial hemorrhage risk in patients receiving alteplase for acute ischemic stroke Katherine Greenhill, Eric Clayton, Joseph Morris Memorial University Medical Center - Savannah, GA
Background/Purpose: Hyperglycemia on admission has previously been associated with increased risk of intracranial hemorrhage (ICH) in patients receiving intravenous (IV) alteplase for acute ischemic stroke (AIS). The purpose of this study was to assess the effect of hyperglycemia resolution on incidence of ICH for patients who have received IV alteplase for AIS.
Methodology: All patients within HCA_x0019_s South Atlantic division admitted for AIS who received IV alteplase from October 1, 2015 to September 1, 2018 were included in this IRB-approved study. Blood glucose values for each patient were collected out to 72 hours from the initial recorded value. Patients admitted with hyperglycemia (blood glucose > 180 mg/dL) were separated into two groups, those with resolved hyperglycemia and those with unresolved hyperglycemia. Incidence of ICH was compared between the two groups.
Results: Out of the 973 total patients assessed, 66 (6.8%) experienced an ICH. Of the total patients, 140 (16.7%) were admitted with a blood glucose > 180 mg/dL. For the patients with multiple glucose values able to trend, 42 remained hyperglycemic throughout the 72-hour period compared to 98 patients who had resolution of hyperglycemia. Of the patients from this group, 15/98 (15.3%) of the patients from the resolved groups vs 1/42 (2.4%) patient in the non-resolution group experienced an ICH (OR 7.410, 95% CI 0.946 to 58.050; p = 0.057).
Conclusions: Although the primary endpoint was not significant, there was a trend toward significance for resolution of hyperglycemia being associated with increased ICH. A larger chart review is required in order to assess effect of hyperglycemia resolution on incidence of ICH following IV alteplase administration for AIS.
Presentation Objective: Describe the correlation between blood glucose and incidence of ICH following IV alteplase administration for AIS.
Self-Assessment: Was hyperglycemia demonstrated to be a modifiable risk factor?
Effect of Using a Standardized Iron Regimen on Blood Transfusions in Critically-Ill, Trauma and Acute Care Surgical Patients Michelle Vu PharmD, Leslie Roebuck PharmD, Jason VanLandingham PharmD, BCPS Northeast Georgia Health Systems - Gainesville, GA
Background/Purpose: Determine the effect that using non-standardized versus standardized intravenous (IV) iron affects the number of blood transfusions in critically-ill trauma and acute care surgical patients and quantify the projected cost avoidance in using a standardized iron regimen.
Methodology: The study included subjects who were at least 18 years of age, admitted to the surgical trauma intensive care unit, and received at least one dose of IV iron dextran or iron sucrose. Data was collected via retrospective chart review and included iron administration, number of blood transfusions, and relevant labs.
Results: Twenty-six patients were included in the IRB-approved study. The non-standardized IV iron group required an average of 2.7 blood transfusions per patient (range 0 _x0013_ 12), and the standardized IV iron group required an average of 0.73 blood transfusions per patient (range 0 _x0013_ 5). All of the patients in the pre-standardized group received all doses of iron ordered, while 34% of the patients in the standardized iron group received all doses of iron ordered. The projected cost saved in blood products alone was more with the use of standardized IV iron sucrose.
Conclusions: Using the standardized IV iron supplementation resulted in less blood transfusions. Continuing to trend the blood product usage with either iron dextran or iron sucrose and optimizing doses could result in improved blood product stewardship.
Presentation Objective: Propose a possible patient blood management tool in using a standardized iron regimen that may reduce the number of blood transfusions required in trauma/surgery patients.
Self-Assessment: What is one possible pharmacy-driven patient blood management tool?
Evaluation of empiric IV vancomycin and risk factors for methicillin-resistant Staphylococcus aureus in a large community hos Courtney Bradley, PharmD; Britney Cothren, PharmD, BCPS; Rachel Simons, Pha Mobile Infirmary Medical Center - Mobile, AL
Background/Purpose: The purpose of this retrospective chart review is to evaluate the use of empiric intravenous (IV) vancomycin in hospitalized patients at Mobile Infirmary (MI).
Methodology: Patients that received IV vancomycin therapy at MI from December 1, 2017 to May 31, 2018 were reviewed retrospectively. Inclusion criteria were as follows: MI inpatient adults greater than or equal to 18 years old admitted to MI who received at least one dose of IV vancomycin empirically for any indication. For those patient charts that met inclusion criteria, 150 charts were randomly selected to be reviewed using an online number generator. Indication for use, culture results, length of therapy, risk factors present for methicillin-resistant Staphylococcus aureus, appropriate de-escalation, including intravenous to oral therapy when applicable, length of stay and number of vancomycin trough levels or random levels were collected. Each chart was systematically reviewed using a standardized data collection tool and the data collected was analyzed to determine appropriate empiric use, de-escalation rates, and length of therapy.
Results: One hundred fifty patients were reviewed. Appropriate use of empiric IV vancomycin was noted in 60 percent of patients. Culture and sensitivity reports were available for 78 percent of the patients reviewed, with only 45 percent of patients having empiric therapy de-escalated when culture and sensitivity reports resulted. Confirmed MRSA infections were seen in 12 percent of patients who presented with MRSA risk factors. Of the 150 patients reviewed, only 82 patients had guidelines-directed MRSA risk factor(s).
Conclusions: There is opportunity to improve empiric IV vancomycin prescribing and to capitalize on de-escalation opportunities at MI. In this study, traditional MRSA risk factors were not necessarily predictive of MRSA infection.
Linezolid for terminal therapy for Gram-positive bacteremia James Terenyi, Sarah Green, Adwait Silwal Novant Health Forsyth Medical Center (Administration and Leadership with Masters) - w\Winston-Salem, NC
Background/Purpose: Current clinical guidance recommends intravenous antibiotic therapy for the treatment of Gram-positive bacteremia and endocarditis. Recent trials have demonstrated the potential for oral antibiotic therapy as an alternative to intravenous therapy. The purpose of this study was to examine outcomes associated with oral linezolid therapy as an alternative to intravenous antibiotics for the treatment of Gram-positive bloodstream infections.
Methodology: This single center retrospective study evaluated outcomes associated with oral linezolid treatment for Gram-positive bloodstream infections. Data was collected for all patients treated with linezolid at Novant Health Forsyth Medical Center between June 1, 2015 and June 1, 2018. Patients were included based on the presence of documented Gram-positive bacteremia or endocarditis transitioned to oral linezolid for completion of antibiotic therapy. Documented infection was defined as the presence of positive blood cultures. Patients were excluded based on presence of any of the following: CNS infection, implanted prostheses, or plan for surgical management. The primary outcome was the composite of readmission within 30 days, 30-day all-cause mortality, and documented infection relapse or treatment failure within 30 days post-treatment. Treatment failure was defined as the presence of positive blood cultures or new antibiotic use to treat the previously documented infection.
Presentation Objective: Describe the benefits and limitations of oral linezolid as an alternative treatment for Gram-positive bloodstream infections.
Self-Assessment: Which factors make oral linezolid a reasonable alternative to IV therapy for Gram-positive bacteremia?
Evaluation of maintenance inhaler regimens impact on systemic corticosteroid exposure for the treatment of COPD exacerbations Brittany Williams Spartanburg Regional Medical Center - PGY1 - Spartanburg, SC
Background/Purpose: Determine if patients receiving maintenance inhaled corticosteroids (ICS) have decreased systemic corticosteroid exposure during a chronic obstructive pulmonary disease (COPD) exacerbation compared to those not taking an ICS.
Methodology: Patients greater than or equal to 18 years old receiving maintenance inhaled therapy at home and admitted between September 1, 2017 and September 30, 2018 with the primary diagnosis of a COPD exacerbation were eligible for inclusion in this study. Patients were stratified into 2 cohorts: those using home ICS and those not using home ICS. The primary outcome was daily systemic corticosteroid exposure, which was measured in prednisone equivalents. Secondary outcomes included the rate of transfer to the intensive care unit, the rate of 30-day readmission for a COPD exacerbation or pneumonia, hospital length of stay, exposure to as needed short-acting bronchodilators, blood glucose control, discharge maintenance inhaler regimens, and cumulative systemic corticosteroid exposure in prednisone equivalents.
Presentation Objective: Describe the relationship between maintenance inhaled corticosteroids and systemic corticosteroid exposure during a COPD exacerbation.
Self-Assessment: Does maintenance inhaled corticosteroid use decrease systemic corticosteroid exposure during a COPD exacerbation?
Retrospective review of daratumumab/bortezomib/dexamethasone (DVd) with weekly administration of bortezomib M Abousaud, J Duda, L Kennedy, E Dressler, C Rodriguez Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Based on the CASTOR trial, the combination of daratumumab, twice weekly subcutaneous (SC) bortezomib, and dexamethasone was given a category 1 designation for patients with relapsed and/or refractory multiple myeloma (MM). A common, notable non-hematologic adverse effect that leads to dose modification or discontinuation of bortezomib is peripheral sensory neuropathy. At Wake Forest Baptist Health (WFBH), patients with MM are treated with weekly SC bortezomib and daratumumab plus dexamethasone in order to reduce rates of peripheral neuropathy. The purpose of this study is to evaluate response rates, progression free survival rates (PFS), and incidence of neuropathy of weekly SC bortezomib, daratumumab, and dexamethasone.
Methodology: An observational, single-center, non-randomized, retrospective chart review was conducted between December 1, 2015 to July 1, 2018. Patients were included if they were 18 years of age or older with MM who received weekly DVd, if they received all of their chemotherapy doses at a WFBH Hematology/Oncology infusion clinic, and if they received at least 2 doses of weekly DVd within 7 days of each dose. Patients were excluded if they received twice weekly SC bortezomib or intravenous (IV) bortezomib either weekly or twice weekly. The primary objective is to evaluate response rates among MM patients on weekly DVd. The secondary objectives are to evaluate PFS rates, rates and severity of peripheral neuropathy.
Presentation Objective: Assess the potential risks and benefits of weekly versus twice weekly SC bortezomib administration
Self-Assessment: What is one of the benefits of weekly SC bortezomib in comparison to twice weekly SC bortezomib in the DVd regimen?
Evaluation of an Enhanced Recovery Pathway in Colorectal Surgery Kelley Trent, John Eibl, Valerie Van Vickle, Allan Lopez, Deborah Armstrong Williamson Medical Center - Franklin, TN
Background/Purpose: Enhanced Recovery After Surgery (ERAS®) protocols are multimodal perioperative pathways that have demonstrated quicker recovery after surgery by maintaining preoperative organ function and reducing the stress response after surgery. Key elements in these protocols include preoperative counseling, preoperative nutrition, standardized analgesic/anesthetic regimens, and early mobilization. An Enhanced Recovery Pathway for colorectal surgery patients was implemented at Williamson Medical Center in 2017. The objective of this study is to determine if implementation of an Enhanced Recovery Pathway improved outcomes in patients undergoing colorectal surgery versus those treated with traditional perioperative treatment pathways.
Methodology: This was a retrospective chart review of 260 patients who were identified via DRG codes for major colorectal surgery. This included 130 patients prior to implementation and 130 patients after implementation of the Enhanced Recovery Pathway. The primary objective was to determine whether or not the Enhanced Recovery Pathway led to a decreased length of hospital stay. Secondary objectives included evaluating the effect of the Enhanced Recovery Pathway on other patient outcomes including cumulative opioid and non-opioid analgesic usage, incidence of post-operative nausea and vomiting, decreased pain scores, readmission rates, cost savings, incidence of renal dysfunction, and incidence of postoperative infections.
Presentation Objective: Identify specific patient outcomes that demonstrated improvement with the implementation of an Enhanced Recovery Pathway at Williamson Medical Center.
Self-Assessment: How many days did length of hospital stay decrease with the implementation of the Enhanced Recovery Pathway in colorectal surgery at Williamson Medical Center?
Assessing postgraduate year one pharmacy residency candidate areas for improvement relative to letters of recommendation Katherine Bradley, Daniel Chastain, Henry Young, Rod Gilmore, Sharmon Osae Phoebe Putney Memorial Hospital - Albany, GA
Background/Purpose: Postgraduate year one (PGY1) pharmacy residency positions are becoming increasingly competitive to attain. Letters of recommendation (LORs) are instrumental for evaluating candidates_x0019_ strengths and areas for improvement. Personal areas for improvement should be thoroughly addressed throughout residency training and sufficient feedback should be provided to residents to foster lifelong learning. Despite widespread knowledge of the importance of feedback in medical education, studies suggest feedback is often low-quality and/or infrequent. The aim of this study is to assess the congruency between candidate reported areas for improvement with LORs.
Methodology: This IRB-approved single-center retrospective qualitative study examined residency candidate materials submitted to a PGY1 pharmacy residency program at a community teaching hospital. ASHP Match Phase I applicants between 2015-18 with a complete PhORCAS application and self-evaluation submitted to the study site_x0019_s residency program were included. Recommender and applicant reported areas for improvement were assessed by comparing LORs to pre-interview candidate self-evaluations and letters of intent (LOIs). The frequency of congruency of candidate and LOR areas for improvement were assessed. Other data points collected included candidate gender, recommender characteristics, candidate and recommender-reported strengths, and the study site_x0019_s evaluation of the candidate for the ASHP Match.
Presentation Objective: Evaluate consistency of reported areas for improvement between applicants and recommenders in PGY1 PhORCAS applications.
Self-Assessment: Are areas for improvement reported in residency applications consistent between learners and their mentors?
Evaluation of Medication Therapy Management (MTM) Interventions by Clinical Pharmacists in the Ambulatory Care Setting Alyssa E. Utz, Mackenzie L. Mullenix, and Babafunlola A. Davis Kaiser Foundation Health Plan of Georgia (Ambulatory) - Kennesaw, GA
Background/Purpose: Medication therapy management (MTM) programs are designed to address medication use and adherence. Pharmacists often provide MTM services based on their extensive medication knowledge and training focused on patient education. The Centers for Medicare and Medicaid Services (CMS) further classifies MTM reviews as either a comprehensive medication review (CMR), which is required annually, or a targeted medication review (TMR). CMRs are comprised of a thorough medication review, identification of any medication-related problems, and the development of a patient-centered care plan. The purpose of this study is to qualitatively and quantitatively describe pharmacist interventions following CMRs at an integrated healthcare delivery system.
Methodology: This cross-sectional study determined the number and method of implemented CMR interventions when pharmacists practice in centralized and decentralized settings. This study also described the categories of implemented CMR pharmacist interventions. Medicare Part D members eligible for a CMR between January 1, 2017 to December 31, 2017 were included in the study. Members who only received a TMR during the study period were excluded. Data collected included encounter type, pharmacist location, intervention implementation type (per protocol or recommendation to physician), and intervention category. Descriptive statistics were utilized for data analysis.
Presentation Objective: Describe pharmacist interventions identified during MTM CMRs.
Self-Assessment: Which of the following would be an example of an unnecessary drug therapy intervention made by a pharmacist during a CMR?
Thiazide diuretic management post-bariatric surgery Taylor Vanderpool, Natalie Kurtkaya Ralph H. Johnson VA Medical Center (Ambulatory Care) - Charleston, SC
Background/Purpose: Bariatric surgery has been found to have significant impacts on morbidity and mortality with evidence that it may improve or resolve more than 40 obesity-related diseases and conditions including type 2 diabetes, heart disease, and hypertension. Per the Ralph H. Johnson VA Medical Center _x001C_Weight Loss Surgery Guide,_x001D_ patients are advised that a thiazide diuretic may be discontinued immediately following surgery due to increased risk of dehydration and low blood pressure. At the Ralph H. Johnson VA Medical Center pharmacists serve an integral member of the bariatric surgery team and have noted that thiazide diuretics are often discontinued relatively soon after bariatric surgery and may even be related to adverse drug events in some cases. However, based on a review of the literature, there is no published evidence for the continuation or discontinuation of thiazide diuretics following bariatric surgery.
Methodology: A data query identified patients who underwent bariatric surgery between January 1, 2011 and September 1, 2018 and had filled a thiazide diuretic within 180 days of the surgery date. Retrospective chart review was performed to identify the rate of continuation following bariatric surgery, baseline characteristics, comorbidities, concomitant blood pressure medications, and blood pressure during the follow-up period.
Presentation Objective: To estimate clinical necessity and to evaluate safety considerations of the use of thiazide diuretics following bariatric surgery to provide guidance for clinical management of these agents during the pharmacy pre-operative review.
Self-Assessment: Which of the following is a potential adverse drug event related to a thiazide diuretic?
Evaluation of the Effectiveness of a Revised Critical Care Continuous Insulin Infusion Protocol Hallie Dankewich, Megan Freeman, Sarah Murphy Northside Hospital - Atlanta, GA
Background/Purpose: Currently, Northside Hospital utilizes a protocol with a tighter blood glucose (BG) goal in the ICU (120-150 mg/dL) and a standard control protocol for DKA and non-ICU units (150-180 mg/dL). Historically, it was recommended that critically ill patients achieve tighter glucose control. However, American Diabetes Association (ADA) guidelines now recommend a target BG of 140-180 mg/dL in most critically and non-critically ill patients. The purpose of this study is to evaluate an updated insulin infusion protocol with a common goal blood glucose.
Methodology: Retrospective review was conducted analyzing median blood glucose before insulin infusion, time within glycemic targets, and rates of hypoglycemia prior to implementation of the updated protocol. In the next study phase, similar outcomes will be analyzed post-implementation of an updated insulin infusion protocol.
Results: 100 patients were included in the retrospective review. Median pre-infusion BG for the tight control group was 303 mg/dL and was 438 mg/dL for the standard control group. While receiving the insulin infusion, the median BG for the tight control group was 158 mg/dL and median BG for the standard control group was 183 mg/dL. Hypoglycemia occurred in 7 patients (14%) in the tight control group and 4 patients (8%) in the standard group. Additionally, 46% of the drips were in compliance with the protocol used.
Conclusions: Preliminary data demonstrates a median BG above the goal range for both the tight control and standard control groups. Hypoglycemia was more common in the tight control group. There is opportunity for improvement in protocol compliance which will be evaluated following the next study phase.
Presentation Objective: Explain how implementation of a new insulin infusion protocol effects compliance, efficacy, and hypoglycemia.
Self-Assessment: Does implementing a revised insulin infusion protocol to target a blood glucose of 140-180 mg/dL improve protocol compliance and reduce hypoglycemia?
Impact of Intravenous N-Acetylcysteine in Non-Acetaminophen Acute Liver Failure in the Intensive Care Unit Sofiya Sovalska, Stephanie Lesslie, Eric Clayton Memorial Health University Medical Center PGY2 Critical Care - Savannah, GA
Background/Purpose: The 2011 American Association for the Study of Liver Diseases Acute Liver Failure Guidelines briefly discuss the utility of N-acetylcysteine as a potential therapy for non-acetaminophen acute liver failure. Currently, there is a paucity of data regarding the potential benefit of N-acetylcysteine in critically-ill patients. The aim of this observational study is to evaluate the efficacy of intravenous N-acetylcysteine in critically-ill patients with non-acetaminophen acute liver failure compared to patients that did not receive N-acetylcysteine.
Methodology: This retrospective study utilized electronic medical records to identify patients with non-acetaminophen acute liver failure between May 2015 and October 2018.
Results: Of 722 patients screened, 29 patients did not receive N-acetylcysteine and 46 patients did. The change in AST (no N-acetylcysteine -618.6 ± 1488.6 vs. N-acetylcysteine -4001.7 ± 3837.9, p = 0.185) and ALT (no N-acetylcysteine -395.9 ± 720.3 vs. N-acetylcysteine -1057.9 ± 1372.4, p = 0.608) from baseline was not statistically significant when controlled for baseline AST and ALT values. Length of stay, intensive care unit length of stay, and ventilator days were significantly higher in the N-acetylcysteine group. No differences in mortality or safety were observed.
Conclusions: N-acetylcysteine was not associated with a significant reduction in liver function tests in non-acetaminophen acute liver failure, however, this may be due to a small sample size. N-acetylcysteine may continue to be a viable option for patients with non-acetaminophen acute liver failure until more data becomes available.
Presentation Objective: Evaluate the efficacy of N-acetylcysteine in intensive care unit patients with non-acetaminophen acute liver failure.
Self-Assessment: N-acetylcysteine may be hepatoprotective in that it helps restore hepatic stores of what substance?
IMPLEMENTATION OF INTRAVENOUS PUSH ADMINISTRATION OF ANTIBIOTICS IN THE EMERGENCY DEPARTMENT Aayush Patel, Matthew McAllister, Katie Fulks Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: While traditionally administered as intermittent infusions lasting upwards of 30 minutes per dose, numerous antibiotics can actually be administered as a _x001C_slow push_x001D_ over three to five minutes. Intravenous (IV) push antibiotics can provide a multitude of clinical advantages such as a reduction in time to antibiotic administration and potential cost savings. On February 5, 2019, our institution implemented an IV push antibiotics protocol for several antibiotics including aztreonam, cefazolin, cefoxitin, ceftazidime, ceftriaxone and meropenem. The purpose of this study was to evaluate the impact of the protocol on time to initial antibiotic administration as well as financial implications of the protocol.
Methodology: An Institutional Review Board approved, pre_x0013_post study was undertaken during two independent three-month time periods, before and after the implementation of an IV push antibiotics protocol in the emergency department at the Piedmont Columbus Regional Midtown. Patients were included if they received intravenous antibiotics (aztreonam, cefazolin, cefoxitin, ceftazidime, ceftriaxone and meropenem) in the emergency department during the pre-implementation phase and post-implementation phase. The primary objective was to evaluate effect on time to antibiotic administration while secondary objectives evaluated adverse drug reactions and cost associated with treatment. An online survey was also sent to the nursing staff after the implementation of the protocol to assess nurse satisfaction.
Presentation Objective: Discuss the outcomes associated with the implementation of intravenous push administration of antibiotics in the emergency department.
Self-Assessment: Did the implementation of intravenous slow push administration of antibiotics in the emergency department reduce the time to antibiotics administration compared to a longer infusion method?
Effect of a remote antimicrobial stewardship program on antimicrobial use in a regional hospital system Joshua Mark Knight, Jessica Michal, Jenna Swindler, Stephanie Weisberg McLeod Regional Medical Center - Florence, SC
Background/Purpose: While antimicrobial stewardship programs (ASPs) are well established at most large medical centers, small or rural facilities frequently do not have access to the same resources; thus, new methods must be developed to expand ASPs to all healthcare centers. This study was conducted at a regional health system comprised of seven facilities with a total of 939 beds. While our central facility has had an ASP established for 10 years, outlying hospitals had no formal program in place prior to October 2018. The purpose of this study was to describe the implementation of a remote ASP and assess that program_x0019_s effect on antimicrobial use.
Methodology: Baseline antimicrobial use for individual facilities and the entire system was established using data from the six months prior to the study start date. Starting October 1, 2018, data was collected monthly until March 31, 2019. Metrics for antimicrobial use were collected through clinical decision support software. The primary metric assessed was system-wide total antimicrobial days of therapy per 1000 patient days (DOT/1000 patient days). Secondary outcomes included DOT/1000 patient days for carbapenems, agents active against methicillin resistant Staphylococcus aureus, empiric anti-pseudomonal agents, and total antimicrobial use for each of the individual facilities. Number of interventions, percentage of interventions accepted, and number of interventions requiring ID physician assistance was assessed. Descriptive statistics were used for monthly values.
Presentation Objective: Understand the impact of a remote antimicrobial stewardship program
Self-Assessment: Which of the following is a potential pitfall of using DOT/1000 patient days to track antimicrobial use for a hospital system?
a. DOT/1000 patient days may underestimate use at smaller facilities
b. DOT/1000 patient days may overestimate use at smaller facilities
c. DOT/1000 patient days may underestimate use at larger facilities
d. DOT/1000 patient days may overestimate use at larger facilities
USE OF INVASIVE, QUANTITATIVE RESPIRATORY CULTURES TO GUIDE ANTIBIOTIC THERAPY FOR PNEUMONIA IN A TRAUMA POPULATION Lauren Allen, Quentin Minson, Chris Burke TriStar Skyline Medical Center - Nashville, TN
Background/Purpose: Invasive, quantitative respiratory cultures are generally not recommended over noninvasive samples due to a lack of demonstrated benefit. There is insufficient literature regarding the utility of invasive cultures in specific populations, such as trauma. Aspiration, prolonged mechanical ventilation, and multiple operative procedures are some of the factors that may contribute to the increased risk and broader etiology of lower respiratory tract infections in this population. The purpose of this study is to evaluate the impact of invasive quantitative sampling for the management of pneumonia in a trauma population.
Methodology: A retrospective cohort study is being conducted on eligible patients greater than or equal to 18 years old who are admitted to the trauma service from July 2013 to August 2018 and diagnosed with pneumonia based on ICD-9 and ICD-10 codes. Patients are divided into two groups: invasive, quantitative respiratory sampling versus non-invasive respiratory sampling for pneumonia. Invasive, quantitative sampling is defined as bronchoalveolar lavage (BAL), protected specimen brush (PSB), and mini-BAL. Non-invasive sampling is defined as sputum culture and endotracheal aspirate (ETA). The primary endpoint is targeted therapy, which is defined as the discontinuation or modification of antibiotics on the basis of culture results. The secondary endpoints include 28-day mortality, antibiotic days of therapy, and frequency of discontinuation of antibiotics when invasive quantitative culture is below diagnostic threshold (104 cfu/mLs).
Presentation Objective: Evaluate the impact of invasive quantitative sampling as compared to noninvasive sampling for the management of pneumonia in a trauma population.
Self-Assessment: Does invasive quantitative respiratory sampling result in higher rates of targeted therapy and improved outcomes compared to noninvasive sampling for the management of pneumonia in a trauma population?
Comparison of a pharmacist-driven vancomycin dosing nomogram to patient-specific pharmacokinetic calculations Lauren Jacobs, Lakeshea Love, Alexas Polk Southeastern Regional Medical Center - Lumberton, NC
Background/Purpose: Southeastern Regional Medical Center_x0019_s (SRMC) pharmacokinetic consult service allows pharmacists to dose, monitor, and adjust intravenous vancomycin. Pharmacists utilize a standardized dosing nomogram to initiate vancomycin therapy. The nomogram provides initial dosing and interval recommendations based on generalized population pharmacokinetics using patient weight and creatinine clearance. A recent institutional medication use evaluation found 22% of initial vancomycin troughs were in the therapeutic range. Although more time consuming, an alternative method for initiating dosing would be to use patient specific pharmacokinetic calculations, which may more accurately predict the expected trough concentration. The purpose of this study is to compare the efficacy of initial vancomycin dosing regimens calculated from the current SRMC vancomycin nomogram to regimens calculated using patient-specific pharmacokinetics.
Methodology: Eligible patients included those that were admitted to SRMC and initiated on vancomycin between January 1, 2019 and March 31, 2019. Patients were included if they were at least 18 years of age and had one documented vancomycin trough. Exclusion criteria included: end-stage renal disease on dialysis, lack of pharmacy to dose consult, and pregnancy. The primary endpoint of the study will be the percentage of initial therapeutic troughs based on indication. Additionally, the number of therapeutic, sub-therapeutic, and supra-therapeutic troughs will be collected.
Presentation Objective: To compare the efficacy of initial vancomycin dosing regimens from the current SRMC nomogram to dosing calculated using patient-specific pharmacokinetics.
Self-Assessment: Is initial dose selection using the SRMC vancomycin nomogram comparable to pharmacokinetic calculations?
Impact of Pharmacist Intervention on Adherence to NCCN Guidelines for Empiric IV Vancomycin Duration in Febrile Neutropenia Marissa Larkin, Kimm Freeman, Tanea Womack, Yolanda Whitty, Yona Roberts WellStar Cobb Hospital - Austell, GA
Background/Purpose: Febrile neutropenia is a serious clinical condition that places cancer patients at increased infection risk. Due to the prevalence of vancomycin-resistant organisms coupled with insufficient evidence demonstrating all-cause mortality reduction or improvement in patient outcomes, the NCCN strongly discourages empiric intravenous (IV) vancomycin for febrile neutropenia. Empiric IV vancomycin should not exceed three days and if continued per microbiological data, should be discontinued once negative cultures are obtained. The purpose of this study is to assess the impact of pharmacist intervention on adherence to NCCN guidelines for appropriate use and duration of empiric IV vancomycin in febrile neutropenic cancer patients.
Methodology: This is a prospective cohort with a retrospective control evaluating appropriate IV vancomycin use and duration in febrile neutropenic cancer patients admitted to an acute care unit at WellStar Cobb Hospital between October 1, 2018 to April 1, 2019. Appropriate IV vancomycin duration is defined as discontinuation within three days of therapy initiation for patients with negative microbiological cultures for gram-positive (GP) bacteria. Patients with cancer and _x001C_neutropenia, unspecified_x001D_ (ICD-10 D70.9) are identified via the electronic medical record. The retrospective control consists of cancer patients with _x001C_neutropenia, unspecified_x001D_ (ICD-10 D70.9) admitted to an acute care unit at WellStar Cobb Hospital from October 1, 2017 to April 1, 2018.
Presentation Objective: Describe the clinical scenarios for which empiric IV vancomycin should be discontinued within 3 days for management of febrile neutropenia in cancer patients.
Self-Assessment: When is discontinuation of empiric IV vancomycin within three days indicated for the management of febrile neutropenia in cancer patients?
Impact of a Whole Health Approach Utilizing Shared Medical Appointments on Opioid Safety in a Veteran Population Amanda Holloway, Bridget Roop, Joseph Moates, Sherry Cox Birmingham VA Medical Center - Birmingham, AL
Background/Purpose: Throughout the past several decades, opioid prescribing for chronic pain has steadily increased as have the number of overdoses involving opioids. The widespread use and prescribing of opioids has contributed to the current opioid crisis; however, over the last few years there have been several efforts focused on improving opioid safety. The objective of this study is to assess the benefits of a whole health shared medical appointment (SMA) on opioid safety and opioid risk mitigation.
Methodology: This Institutional Review Board approved study consisted of a retrospective review of computerized patient medical records of patients who participated in a whole health and opioid safety SMA. The following data was collected: name, last four of SSN, age, weight, height, substance use disorder, mental health disease, opioid prescribed, tramadol use, length of therapy, PHQ2 and 9 score, concomitant use of a benzodiazepine, morphine equivalent daily dose (MEDD), risk index for overdose or serious opioid induced respiratory depression (RIOSORD) score, stratification tool for opioid risk mitigation (STORM), pain score, naloxone distribution, change in clinic utilization (phone calls, secure messaging, walk-ins, appointments), and addition of non-opioid pharmacotherapy or non-pharmacotherapy modalities for the treatment of pain. All measures, excluding patient demographics, length of therapy, substance use disorder, mental health disease and naloxone distribution, were recorded as prior to SMA, end of SMA, or current. The data will be reviewed through means of descriptive statistics to determine trends in opioid safety and risk mitigation through a whole health SMA.
Results: Results pending upon completion of research project.
Conclusions: Conclusion pending upon completion of research project.
Presentation Objective: Identify the benefits of a whole health shared medical appointment on opioid safety and opioid risk mitigation.
Self-Assessment: What is one risk mitigation strategy which can be utilized to decrease a patient_x0019_s risk of overdose?
Implementing A Population Management Tool For Inflammatory Bowel Disease In A VA Medical Center Cassandra Effken, Cristina Plemmons, Christopher Sedgwick Ralph H. Johnson VA Medical Center - Charleston, SC
Background/Purpose: Inflammatory Bowel Disease is a high cost, high burden disease typically requiring chronic medication therapy and frequent healthcare follow up. Pharmacists can play a significant role in the management of this population in areas such as monitoring, adherence, and education. The purpose of this project was to assess what impact a population management tool has for patients with Inflammatory Bowel Disease.
Methodology: This was a prospective quality improvement project spanning from November to April. Eligible patients included those seeking treatment for an active diagnosis of inflammatory bowel disease at the Ralph H. Johnson VA Medical Center. Excluded were patients that were pregnant, incarcerated, less than 18 years old, or not on a biologic or immunomodulator therapy. An Inflammatory Bowel Disease specific dashboard was created and implemented to identify potential interventions. Interventions were documented in patient charts using a pharmacy high risk drug monitoring note with quantifiable health factors. The primary aim was to describe what role a population management tool serves in monitoring IBD patients. The secondary aim was to track the number of interventions made by a pharmacist.
Presentation Objective: Discuss the use of a population management tool in Inflammatory Bowel Disease patients.
Self-Assessment: What is an area that pharmacists can play a role in medication management in Inflammatory Bowel Disease patients?
Efficacy and safety of non-vitamin K oral anticoagulants following cardiac valve replacement Elizabeth Wood and Mary Katherine Stuart Princeton Baptist Medical Center - Birmingham, AL
Background/Purpose: The 2014 AHA/ACC Valvular Heart Disease Guidelines recommend life-long
anticoagulation with a vitamin K antagonist in patients with mechanical prosthetic
valves, regardless of position. Anticoagulation with vitamin K antagonist therapy is also considered reasonable in bioprosthetic valves for three to six months following replacement. Based on the results of the RE-ALIGN trial, the AHA/ACC Valvular Heart Disease guidelines do not recommend the use of non-vitamin K oral anticoagulants (NOACs) in prosthetic heart valves. Given the paucity of literature regarding the use of NOACs following valve replacement, this study aimed to evaluate the efficacy and safety of NOACs in this population.
Methodology: This retrospective single center chart review included patients 18 years of age or older who underwent cardiac valve replacement and received a NOAC or warfarin between August 2015 and August 2018. Patients were excluded if they experienced a venous thromboembolism (VTE), cerebrovascular accident (CVA), or acute coronary syndrome (ACS) in the month prior to valve replacement, had a transcatheter aortic valve replacement (TAVR), or did not have clinic follow-up notes after discharge. The primary outcome was a composite of thromboembolic events including CVA, transient ischemic attack, ACS, VTE, valve thrombosis, or other vascular occlusion within 90 days of valve replacement. Secondary outcomes included the individual components of the primary outcome, a composite of thromboembolic events within 180 days of valve replacement, and all-cause mortality within 90 and 180 days of valve replacement. The safety endpoints were major and minor bleeding. A predefined subgroup analysis was performed based on valve type and position.
Presentation Objective: Characterize the use of oral anticoagulants following valve replacement at Princeton Baptist Medical Center.
Self-Assessment: What are the associated risks when using non-vitamin K oral anticoagulants following mechanical and bioprosthetic cardiac valve replacement?
EVALUATION OF AN OPIOID-FREE ACUTE PAIN ORDER SET IN THE EMERGENCY DEPARTMENT Shae Tirado, Matthew McAllister, Ryan Crossman Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: One strategy to decrease opioid abuse and misuse is to change prescribing practices in the emergency department (ED). Emerging treatments of pain focus on increasing the use of non-opioid analgesics and using multimodal analgesic therapies. In December 2017, Piedmont Columbus Regional implemented an opioid-free acute pain order set to reduce opioid utilization in the ED. The purpose of this project is to analyze the utilization of an opioid-free acute pain order set and its impact on analgesic prescribing practices in the ED.
Methodology: This study was divided into two parts. Part A consisted of a retrospective chart review of 600 adult patients discharged from the ED with a chief complaint of pain during two independent 3-month time periods, before and after the implementation of an opioid-free acute pain order set. Patients were evaluated to determine the impact the order set had on the selection of initial analgesic (opioid vs non-opioid), as well as the average amount of opioid analgesics administered in the ED. Patients were also evaluated to determine the need for rescue opioid if they were prescribed a non-opioid analgesic initially. Part B assessed trends in prescribing over time based on medication utilization reports. This population included all adult patients presenting to the ED who received an analgesic during the pre- and post-implementation periods. The primary endpoint was change in total doses of analgesics, both opioid and non-opioid, administered per 1000 ED visits.
Presentation Objective: Describe the impact of an opioid-free acute pain order set in the ED.
Self-Assessment: Did the implementation of an opioid-free acute pain order set reduce administration of opioids and increase the administration of non-opioids within the ED?
Fentanyl-induced ventilator non-compliance in critically ill patients Katie Gilbert, Jeremy Hodges, Amanda Teachey, Philip Keith Novant Health Forsyth Medical Center - Winston-Salem, NC
Background/Purpose: Fentanyl-induced ventilator non-compliance, also referred to as fentanyl chest wall rigidity, was first described during procedural sedation, and more commonly in bronchoscopy and in pediatric populations. This phenomenon typically presents as pronounced rigidity and increased upper airway muscle tone and has been infrequently described in the setting of therapeutic analgesia and sedation in critically ill patients. Oftentimes, this reaction is not resolved by traditional interventions including increased analgesia and sedation or changes in ventilator strategy. The use of paralytics may provide a temporary resolution of symptoms, but rigidity may recur. Based on available case reports, reversal of fentanyl resolves this reaction. The purpose of this project is to collect adequate objective information to support the existence of fentanyl-induced ventilator non-compliance and better understand effective management strategies.
Methodology: This IRB-approved case series retrospectively examined patients identified by providers with fentanyl-induced ventilator non-compliance from various critical care units at two facilities from January 1, 2015 to October 22, 2018. Data points collected include: patient demographics, hospital location, ICU type, surgery or procedure within 48 hours, reason for mechanical ventilation, ICU length of stay, fentanyl dose and duration, cumulative dose of fentanyl, other opioids or sedatives used, intervention, ventilator settings, duration of ventilation, arterial blood gas around time of intervention, chest rigidity documentation, documentation of improved ventilator compliance after intervention, APACHE score, and mortality. Data points were used to determine the rate of successful fentanyl reversal with naloxone or other interventions and whether or not documentation of improved ventilator compliance was documented in the medical record.
Presentation Objective: Discuss the hallmarks of fentanyl-induced ventilator non-compliance, risk factors associated with development and effective interventions for this reaction.
Self-Assessment: What are the hallmarks of fentanyl-induced ventilator non-compliance, and what interventions are effective for this reaction?
Effects of a Pharmacist-led Initiative to Reduce Antipsychotic Use in Patients with Dementia Michelle Morales, Crystal A. Wright, and Asia M. Parham Kaiser Foundation Health Plan of Georgia (Ambulatory) - Kennesaw, GA
Background/Purpose: Antipsychotics carry a black box warning for increased mortality in older patients with dementia-related psychosis. The National Committee for Quality Assurance has previously established a Healthcare Effectiveness Data and Information Set (HEDIS) measure in response to expert consensus regarding the limited efficacy and safety concerns with antipsychotic use in patients with dementia. Clinical pharmacists at a managed care organization led a collaborative care initiative to improve performance on this measure. This study will evaluate whether these efforts were successful in reducing antipsychotic utilization in Kaiser Permanente Georgia members with dementia.
Methodology: This retrospective, descriptive chart review will evaluate outcomes from a pharmacist initiative, which occurred between May and December 2017. All initiative patients were eligible for study inclusion and were identified using HEDIS drug-disease interaction specifications and exclusion criteria. Patients were excluded from this study if they expired or dis-enrolled during the initiative period. The primary outcome is to determine the percentage of dementia patients on antipsychotics pre-and post-pharmacist initiative. Secondary objectives will include the persistence of medication changes 12-months post-intervention and the percentage of patients who initiated alternative psychotropic medications during that period.
Presentation Objective: Describe the outcomes and risks associated with antipsychotic use in older adults with dementia
Self-Assessment: Which of the following may be considered an appropriate indication for antipsychotic therapy in older adults?
Drivers of empiric carbapenem use: How important is history of extended-spectrum beta-lactamase (ESBL) infection? Tyler J. Stone, James R. Beardsley, James W. Johnson, John C. Williamson Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: ESBL is a clinically relevant resistance mechanism that is increasing among Enterobacteriaceae in community and healthcare settings. ESBLs are capable of hydrolyzing third generation cephalosporins and aztreonam and are often associated with resistance to other antibiotic classes. In addition, a recent study of piperacillin/tazobactam in the treatment of ESBL infections revealed discouraging outcomes. Carbapenems have emerged as drugs of choice for serious infections caused by ESBL-producing organisms. Once a patient is infected with an ESBL-producing organism, the likelihood of subsequent ESBL infection is unknown. Yet, if a patient has a history of ESBL-positive culture, empiric therapy with a carbapenem has become common practice. The purpose of this study was to evaluate the microbiology of infections among patients with history of ESBL-positive culture and to determine risk factors associated with a second ESBL infection that may justify an empiric carbapenem.
Methodology: This retrospective observational study was conducted at a large academic medical center. Inpatients and outpatients with ESBL-positive cultures for E. coli or K. pneumoniae during calendar year 2017 were identified by computer-generated report. All culture specimen types were included. Patients with an ESBL-positive culture prior to 2017 were excluded. The electronic medical record (EMR) was reviewed up to 1 year after the ESBL-positive culture. Relapsed infection (same site, same bacteria) that occurred within 2 weeks of the original ESBL infection was not considered a second infection. Patient characteristics and information about infections were recorded. The primary outcome was proportion of patients who developed a second ESBL-positive infection. Risk factors associated with a second ESBL infection were determined.
Presentation Objective: Determine when empiric carbapenem therapy is appropriate for patients with history of ESBL infection.
Self-Assessment: What factors are important when choosing empiric antibiotic therapy for patients with history of ESBL infection?
Impact of Procalcitonin Monitoring on Duration of Antimicrobial Therapy in ICU Patients with Pneumonia and Sepsis Richelle Chambliss, Lan Bui St. Vincent's Hospital - Birmingham, AL
Background/Purpose: Monitoring of serum procalcitonin (PCT) levels may be an effective antimicrobial stewardship strategy to guide antibiotic therapy in bacterial infections, specifically lower respiratory tract infections and sepsis. The objective of this study is to evaluate the impact of a procalcitonin monitoring algorithm on antibiotic therapy duration in intensive care unit (ICU) patients with pneumonia and/or sepsis.
Methodology: This pre-post interventional study was approved by the institutional review board. Patients 18 years or older, admitted to one of the two medical ICUs at a community hospital, who received their first dose of antibiotics within 24 hours of admission, and had a diagnosis of presumed sepsis and/or pneumonia were included. Patients were excluded if they had thyroid carcinoma, antibiotic therapy initiation greater than 48 hours prior to ICU admission, positive blood cultures, conditions requiring prolonged therapy, resuscitated cardiac arrest, or severe immunodeficiency (other than corticosteroids). Pre-intervention period was from January 2018 to March 2018; post-intervention period was January 2019 to March 2019. On-site PCT testing was not available during the pre-intervention period. PCT levels were ordered and monitored according to an approved Pharmacy and Therapeutics protocol in the post-intervention period. A clinical pharmacist screened for eligible patients, monitored the PCT level daily, and made suggestions to the medical team to discontinue antibiotic therapy if the PCT level was
Comparison of a fixed-dose 4 factor PCC dosing regimen to a weight based regimen for warfarin associated bleeding Vicente, N; Bennett, M; Hisnanick, D; McFall, R; Thompson, M; Dutton, W Trident Medical Center - Charleston, SC
Background/Purpose: The purpose of this study was to analyze the safety, efficacy and financial implications of a fixed dose 4FPCC dosing protocol in comparison with historical weight based dosing in a community hospital.
Methodology: Eligibility criteria included patients 18 years or older who received 4FPCC for confirmed or suspected warfarin associated bleeding or emergency surgery. Demographic data and warfarin dose, indication, duration of therapy before event, indication for 4FPCC, and site of bleeding was assessed. Efficacy was defined as decrease in INR of less than or equal to 2 or reaching clinical hemostasis as defined by the prescriber. Safety was studied by analyzing thromboembolic events up to 30 days after 4FPCC administration.
Results: Patients in the weight-based 4FPCC group (n=9) who received 4FPCC all achieved INR less than or equal to 2 and received an average of 2,650 units 4FPCC (SD 960.5, IQR 573), or 29 u/kg (SD 9.77, IQR 4.4). Average reduction in INR after 4FPCC was 4.1 (SD 2.8, IQR 1.7) and no patients had thromboembolic events. All the patients in the fixed-dose 4FPCC group (n=4) achieved INR less than or equal to 2, with one patient requiring one additional dose of 4FPCC before surgical intervention. Patients received an average of 1,562 units of 4FPCC (SD 71.2, IQR 120), or 14.7 u/kg (SD 3.1, IQR 5.4). Average INR reduction after 4FPCC was 5.1 (SD 5.1, IQR 5.2), with no thromboembolic events identified.
Conclusions: All the patients that received a fixed-dose 4FPCC reached the efficacy outcome defined in the study of INR less than two and/or clinical hemostasis.
Presentation Objective: Analyze outcomes of fixed-dose 4FPCC dosing protocol.
Self-Assessment: What are the benefits and limitations of using a fixed-dose 4FPCC dosing protocol?
Impact of pharmacists_x0019_ driven pain treatment algorithm in management of cancer patients Hannah Lifsey; Michael Simpson; Adam Peele; Kelly Fuhrmann Alamance Regional Medical Center - Burlington, NC
Background/Purpose: Several studies have demonstrated the impact of pharmacists_x0019_ interventions in the management of adverse events in the cancer patient population related to disease manifestation and anti-neoplastic toxicity. Patients in the cancer population commonly experience episodes of both acute and chronic pain depending on their malignancy, stage, and anti-neoplastic therapy. With an extensive knowledge of pain medication management, pharmacists can play a vital role in managing pain experienced by this population. The objective of this study is to determine the impact of a pharmacists_x0019_ driven pain treatment algorithm on cancer patients admitted in the community hospital setting.
Methodology: The electronic medical record will be utilized to review patient charts to evaluate the impact of a pharmacists_x0019_ driven pain treatment algorithm in cancer patients admitted in the community hospital setting. There will be two cohorts included. The first cohort will consist of cancer patients admitted from September 1, 2017 through February 28, 2018, prior to the initiation of the pharmacists_x0019_ pain management algorithm. The second cohort will consist of patients admitted after the consult is introduced from February 25, 2019 through April 30, 2019. Baseline patient demographic data including but not limited to age, sex, weight, cancer diagnosis, pain type, comorbid conditions, and allergies will be collected. Patient charts will then be reviewed for pain score, amount and duration of opioid use, length of hospital stay, and time to narrowing opioids to alternative pain modalities. To objectively measure patient outcomes, all opioids used will be converted to morphine equivalents.
Results: N/A
Conclusions: N/A
Presentation Objective: The objective of this presentation is to demonstrate the impact that pharmacists' driven interventions can have on the treatment of pain in cancer patients.
Self-Assessment: Can a pharmacist drive pain consult service improve care in the management of pain in cancer patients?
Effectiveness of Corticosteroids as Adjunct Treatment in Pediatric Cystic Fibrosis Pulmonary Exacerbations Taylor Bowick, Anita Gallay, Margaret O. Poisson, Kathleen McKie Augusta University Medical Center/ University of Georgia College of Pharmacy - Augusta, GA
Background/Purpose: Cystic fibrosis (CF) is a genetic disease caused by a mutation in the CF transmembrane conductance regulator (CFTR) gene, which induces aberrant ion transport, decreased mucociliary clearance, and an extensive inflammatory response. At our institution, pulmonologists may augment standard of care cystic fibrosis pulmonary exacerbation (PEx) regimens with corticosteroid bursts in patients who are refractory to systemic antibiotics and increased airway clearance methods. There is currently a paucity of data regarding the role of corticosteroids for this indication. The objective of this study is to characterize the use and assess the efficacy and sustainability of corticosteroids as adjunctive treatment for pediatric CF PEx.
Methodology: This study is a single-center, observational, retrospective chart review of pediatric patients age
Delirium Screening and Management in Orthopedic Surgery Patients as Part of Enhanced Recovery After Surgery Implementation Rachel Anderson, Pharm. D., Jerry Robinson, Pharm.D., BCPS Huntsville Hospital - Huntsville, AL
Background/Purpose: Delirium is a common complication post-operatively in older adults, and is related to adverse outcomes including increased length of stay, morbidity, and mortality. The Enhanced Recovery After Surgery (ERAS) is an initiative with the goal of improving perioperative care for multiple surgery types, with recommendations for delirium screening and management. Currently, delirium is not routinely screened in floor patients. The primary objective is to determine which non-ICU, orthopedic surgery patients are most at risk for delirium and should be screened.
Methodology: This study is a retrospective (pre-implementation) and prospective (post-implementation) chart review. A list of patients with a hip fracture, total knee arthroplasty (TKA), or total hip arthroplasty (THA) from August to November 2018 was obtained. A patient list from medication dispensing cabinets was obtained for delirium treatment medications for cross reference with the aforementioned list. Another list of patients with an ICD-10 code for delirium and an ICD-10 code for hip fracture, TKA, or THA was also obtained. The patients that were identified as having delirium from profile review were compared to the list of patients with an ICD-10 code for delirium. Using this data, the patient population that is most at risk for delirium will be determined. After conducting education for nursing staff on delirium screening and prevention, a validated delirium screening tool and nonpharmacological methods to prevent delirium will be implemented in the identified at-risk patient population. Once this screening tool is implemented, prospective data will be collected to compare the post-implementation delirium rates in the identified at-risk patients.
Presentation Objective: Determine which non-ICU, orthopedic surgical patients are most at risk for delirium and could benefit from routine delirium screening via a validated screening tool.
Self-Assessment: Which patient population was found to be most at risk for delirium in these orthopedic surgery patients?
Impact of Gout Management by Pharmacists in a VA Medical Center Julianne Isaac, Lori Bennett, Holly Mitchell Ralph H. Johnson VA Medical Center - Charleston, SC
Background/Purpose: Gout is the most common inflammatory arthritis in the United States affecting over 8 million people with substantial morbidity and health care associated cost. Prevalence continues to climb likely due to the aging population, poor dietary and lifestyle changes, and the obesity epidemic. Despite established treatment guidelines and effective urate-lowering therapies (ULT), there are currently significant gaps in care for gout patients leading to the doubling of annual hospitalizations in the last decade, the majority of which were preventable, and continuance of poor patient outcomes. Recent literature has demonstrated pharmacists can play a significant role in increasing patient adherence to ULT and increase the likelihood of achieving serum urate targets when compared to standards of care.
Methodology: A data query identified patients with an active ULT prescription prescribed by a pharmacist between December 2017-2018. A retrospective chart review was performed to identify serum urate levels and their appropriateness, gout flares, and patient adherence.
Presentation Objective: Evaluate the impact of pharmacist-managed gout patients by assessing the frequency at which target serum urate levels are achieved, examining the frequency of gout flares after ULT initiation, and evaluating ULT adherence through refill history and patient self-report.
Self-Assessment: The PCP refers a patient to you for management of their first gout flare. Which of the following is the most appropriate action to complete during today_x0019_s visit?
A) Discharge back to PCP as patient has no needs from PharmD clinic as this is his first flare
B) Start allopurinol 100mg daily
C) Start probenecid 250mg BID x 1 week
D) Provide diet and lifestyle education as well as disease state education
IMPACT OF P2Y12 INHIBITOR USE ON REHOSPITALIZATION OF PATIENTS WHO PRESENT WITH NSTEMI Matthew M. Hix, Lynn White, Tina G. Hardison, Jenna F. Cox Palmetto Health Richland PGY1 Pharmacy - Columbia, SC
Background/Purpose: Determine the protective benefit on rehospitalization rates of P2Y12 inhibitor therapy as part of routine, inpatient medical care for patients hospitalized with non-ST elevation myocardial infarction (NSTEMI).
Methodology: Patients listed on the Palmetto Health Heart Hospital ACTION Registry who were admitted with NSTEMI, were at least 18 years of age at time of hospitalization, and were admitted from January 1, 2015 through June 30, 2018 were included in this study. Enrollees were evaluated on their thirty-day rehospitalization rates based on receipt of P2Y12 inhibitor therapy for both ACS- and all-cause readmission. Secondary endpoints included time to rehospitalization, mortality, early-invasive vs ischemia-guided therapeutic strategy, appropriateness of P2Y12 inhibitor prescribing, timing to P2Y12 inhibitor receipt, P2Y12 inhibitor discharge prescribing and use of concierge pharmacy, and disparities in prescribing patterns among local providers/provider groups. Enrollment is estimated to be 1:1 (P2Y12 inhibitor use vs non-use) with a 15% estimated rehospitalization rate in those not receiving P2Y12 inhibitor treatment. Statistics will include logistic regression models using covariates, Kaplan-Meier analyses with log-rank tests, and subgroup analyses.
Presentation Objective: Identify factors which influence rehospitalization rates of patients with NSTEMI.
Self-Assessment: Does P2Y12 inhibitor prescribing present a worthwhile opportunity for pharmacists to have meaningful interventions in the inpatient setting?
EVALUATION OF SHORTAGE-DRIVEN INTERMITTENT VERSUS CONTINUOUS INFUSION OPIOID USAGE IN MEDICALLY CRITICALLY ILL PATIENTS E. Johnston; C. Dodson; L. Norris; D. Schrift; J. Krieg Palmetto Health Richland PGY2 Critical Care - Columbia, SC
Background/Purpose: The Society of Critical Care Medicine recommends intravenous opioids as the first-line therapy for critically ill patients with non-neuropathic pain in the intensive care unit (ICU). These recommendations do not specify a superior method for medication delivery; however continuous administration of opioids has often been utilized as a mechanism for delivery for consistent control of pain. Drug shortages significantly impact health care and have become increasingly prevalent in the management of patient care. As a result of the recent national opioid shortage, alternative methods, like intermittent delivery, have been implemented to preserve resources. Some studies show intermittent opioids are associated with less overall opioid use and may affect patient outcomes positively. The purpose of this study is to determine the total milligram morphine equivalents (MMEs) used per day when comparing administration of continuous and intermittent intravenous opioid dosing. Secondary outcomes will assess the effect of continuous versus intermittent dosing on patient outcomes including length of mechanical ventilation, ICU LOS, and development of ICU delirium.
Methodology: This institutional review board approved single-center, retrospective, chart-review compares the use of continuous versus intermittent opioid use in mechanically ventilated patients in the medical ICU at Prisma Health_x0014_Midlands. Patients were identified and stratified into comparator groups based on the administration of continuous opioids from December 2016 to May 2017 and intermittent opioids December 2017 to May 2018. Linear regression will be used to determine the primary outcome of total MMEs per day used between continuous and intermittent opioid use. Other outcomes assessed include number of ventilator-free days to day 28, ICU LOS, adjunctive non-opioid use, CAM-ICU outcomes, and CPOT scores.
Presentation Objective: To determine the total MME use between continuous and intermittent intravenous opioids and assess secondary outcomes.
Self-Assessment: Which ICU outcomes may be impacted by lower MME use?
The safety and efficacy of fixed dose four-factor prothrombin complex concentrate (Kcentra) for warfarin reversal Jonathan Worley, Hannah Brown, Meghan Bryan Novant Health Presbyterian Medical Center - Charlotte, NC
Background/Purpose: Warfarin is a commonly used anticoagulant that can be associated with life-threatening bleeding events. Kcentra, an inactivated 4-factor prothrombin complex concentrate (4F-PCC) in combination with intravenous (IV) vitamin K, is indicated for the urgent reversal of vitamin K antagonist therapy in patients with acute major bleeding. Traditional dosing algorithms for 4F-PCC utilize an individualized dose determined by a baseline INR value and the patient_x0019_s body weight and can provide delays to treatment. Recently, Novant Health implemented a fixed-dose 4F-PCC strategy across all acute care centers. The purpose of this study was to retrospectively evaluate the safety and efficacy of a fixed-dosed 4F-PCC treatment strategy for warfarin reversal in the setting of life-threatening bleeding events within a multi-site acute care health system.
Methodology: Multi-site, retrospective chart review consisting of all patients presenting to Novant Health acute care facilities from November 1, 2017 _x0013_ April 30, 2018 and June 1, 2018 _x0013_ November 30, 2018 that received 4F-PCC for warfarin reversal due to a life-threatening bleed. The primary endpoint was percentage of patients with INR less than or equal to 1.4 post 4F-PCC dose. Secondary endpoints included time from presentation to initial 4F-PCC dose, time to reversal defined as time from 4F-PCC, administration to INR less than or equal to 1.4, time from presentation to INR less than or equal to 1.4, survival to hospital discharge, discharge disposition, thromboembolic events, financial impact of fixed-dose protocol, and percentage of patients requiring subsequent 4F-PCC doses.
Presentation Objective: To evaluate safety and efficacy, as well as the financial impact, of fixed four-factor prothrombin complex concentrate (4F-PCC) dosing in the reversal of warfarin for life-threatening bleeding events
Self-Assessment: What are the potential benefits of utilizing fixed dose 4F-PCC protocol?
Assessing the impact of compliance packaging on hemoglobin A1c in diabetic patients receiving oral antiglycemic medications. Kandon P. Render, PharmD; Joshua Kinsey, PharmD; Sharon Sherrer, PharmD Mercer University School of Pharmacy - Atlanta, GA
Background/Purpose: An IRB-approved studying evaluating the effect of the use of compliance packaging on hemoglobin A1c in patient's with type 2 diabetes mellitus.
Methodology: The design of the study is a randomized controlled pilot study comprised of diabetic patients receiving oral antiglycemic medications. The study consists of a study group and a control group: patients initiated on compliance packaging and patients receiving no compliance packaging. Patients were excluded if they had any medication changes within three months prior to enrollment. Upon consent and enrollment in the study, a baseline A1c, or an A1c collected within the past three months, was obtained from the patient or their provider. Patients in the compliance packaging group were then initiated on compliance packaging. Patients in the control group continued taking their medications per usual. After 3 months, another A1c was obtained from the patient or their providers. A1c values will also be obtained at 6 months and 9 months, if collected by the patient_x0019_s providers.
Results: Sixteen patients were included in this study. The mean baseline A1c in the control and study groups were 7.35 and 7.56, respectively. The mean number of antiglycemic medications in the control and study groups were 2.4 and 2.67 medications, respectively.
Presentation Objective: Describe the impact that the use of compliance packaging has on hemoglobin A1c in patients with type 2 diabetes.
Self-Assessment: What ways can a community pharmacist positively influence the outcomes of patients with type 2 diabetes?
Effect of implementing a voluntary plan of care protocol in patients with substance use disorders and infective endocarditis Grace Cooksey, Robert Moye, Jerry Epps, Mahmoud Shorman, Michael Veve University of Tennessee Medical Center - Knoxville - Knoxville, TN
Background/Purpose: The national opioid epidemic has resulted in high rates of infections related to substance use disorders (SUD). Infective endocarditis (IE) is associated with increased rates of recurrent infection and high mortality when related to injection drug use. In August 2017, a voluntary protocol focused on safety, pain management, and addiction treatment was implemented for patients hospitalized with drug use associated infections. This study seeks to characterize the burden of illness related to IE secondary to SUD, and to assess the impact of a plan of care protocol for patients with SUD with IE.
Methodology: This single center, quasi experiment included hospitalized adults with active substance use and definite IEs from 1/2013 (pre-implementation) to 1/2019 (post-implementation). Patients with other IE risk factors, such as rheumatic or congenital heart disease, were excluded. Data collection included: patient demographics, substance abuse history, infection characteristics, antimicrobial therapy, disposition status, length of stay, readmission, and mortality. The primary outcome was to evaluate the impact of a plan of care protocol for patients with IE and SUD on all-cause readmission. Secondary outcomes included all-cause mortality and to define the prevalence, characteristics, and current treatment modalities for patients with SUD and IE.
Presentation Objective: Evaluate clinical outcomes after implementing a plan of care protocol for patients with SUD and infective endocarditis.
Self-Assessment: Does the utilization of a voluntary plan of care protocol improve clinical outcomes in patients with SUD and infective endocarditis when compared to those not enrolled in the protocol?
Impact of Pharmacist Intervention on Vancomycin Discharge Dosing and Hospital Readmission Rates. Marisa Pasquale, Amber Rasco, Margaret Pate University of Alabama Hospital - Birmingham - Birmingham, AL
Background/Purpose: While some patients may complete their course of antibiotics inpatient, others may require outpatient parenteral antibiotic therapy (OPAT), depending on the indication and duration of treatment. Currently, the role of the pharmacist as part of the integrated team in the outpatient setting for OPAT does not have much data. Since compliance is a key factor in OPAT, changing a regimen to a more reasonable outpatient interval (i.e., changing a regimen from every eighteen hours to every twelve or twenty-four hours) while still inpatient is ideal. This would allow for a trough to be drawn prior to discharge and allow adequate time for changes to the regimen to be made. This is a crucial part of why the pharmacy notification process was initiated at UAB Hospital and it is essential to analyze the role of the pharmacist in this integration. The purpose of this study is to assess pharmacist interventions and outcomes regarding outpatient vancomycin therapy.
Methodology: The pharmacy notification process was started in 2018, so this study evaluated outcomes both before and after the implementation of this notification. This retrospective, observational chart review included patients from three months in 2017 and three months in 2018. Each patient profile was assessed for inclusion and exclusion criteria and basic demographic data was collected. The primary objective of this study was to determine the percentage of patients with a target trough of 10 _x0013_ 20 mcg/mL with the first outpatient trough. Additional outcomes included incidence of acute kidney injury, 30-day hospital readmission rates, and assessing interventions pharmacists made prior to discharge.
Presentation Objective: List interventions that inpatient pharmacists can make to improve outcomes with outpatient parenteral antibiotic therapy.
Self-Assessment: What interventions can inpatient pharmacists make to improve clinical outcomes with outpatient parenteral antibiotic therapy?
Safety of Prescribing Anticoagulation in Patients with a Recent Intracranial Hemorrhage at a Comprehensive Stroke Center Sarah Fisher; Olivia Morgan; Katleen W. Chester; Kruti Shah Grady Memorial Hospital (Internal Medicine) - Atlanta, GA
Background/Purpose: Anticoagulation is recommended in patients with atrial fibrillation and venous thromboembolism (VTE), however treating patients with anticoagulation has risks. Intracranial hemorrhage (ICH) is a risk of anticoagulation therapy, and if a patient has an ICH, providers are left with the decision when to resume anticoagulation. There is minimal guidance with restarting anticoagulation after an ICH, and most published evidence evaluated vitamin K antagonists. In light of this, the aim of this study was to retrospectively evaluate the safety of anticoagulation prescribing after ICH with a vitamin K antagonist or direct oral anticoagulants (DOACs) at a comprehensive stroke center.
Methodology: This was a retrospective chart review of patients admitted to Grady Health System with an intracranial hemorrhage from 2015 _x0013_ 2018. The primary objective of this study was to evaluate the safety of prescribing anticoagulation in patients admitted for an ICH and an indication for anticoagulation. Secondary objectives were to determine the incidence of recurrence of ICH, major bleeding, and thromboembolic events.
Results: A total of 58 patients were included in the analysis. There was no difference in the primary endpoint of composite of recurrent ICH, major bleeding events, and thromboembolic events. Multiple patients were diagnosed with atrial fibrillation or VTE during the same hospital admission as the ICH. All newly diagnosed VTEs occurred prior to the start of treatment or prophylactic anticoagulation.
Conclusions: Anticoagulation can be restarted in patients with a recent ICH with an indication for anticoagulation as benefits of anticoagulation may outweigh the risks of recurrent ICH and major bleeding.
Presentation Objective: Determine if starting/restarting anticoagulation after a recent intracranial hemorrhage is safe
Self-Assessment: True or False: starting anticoagulation in a patient with a pulmonary embolism who had an ICH 22 days ago is likely safe.
Outcomes for Patients Receiving Ibrutinib With or Without Antifungal Therapy Kori Daniels, Amber Clemmons, Arpita Gandhi Augusta University Medical Center/UGA College of Pharmacy PGY2 Oncology - Augusta, GA
Background/Purpose: Ibrutinib is a Bruton_x0019_s tyrosine kinase (BTK) inhibitor used to treat a variety of lymphoid malignancies and chronic graft-versus-host disease. BTK is involved in B-cell proliferation and survival, as well as macrophage receptor-mediated phagocytosis. Hence, BTK inhibition in patients with chronic lymphocytic leukemia (CLL) is associated with various infections. Overall incidence of fungal infections in patients with CLL has been reported as 1.4% in those not taking ibrutinib as compared to 4% in patients taking ibrutinib. Most fungal infections have been reported to occur in the first six months after initiating ibrutinib. Unfortunately, few reports of CLL patients receiving ibrutinib specified if patients received anti-fungal prophylaxis. Currently, no standard recommendations exist regarding utility of anti-fungal prophylaxis with ibrutinib therapy. Azole anti-fungals are widely utilized for the treatment and prevention of fungal infections. Since azole anti-fungals inhibit cytochrome P4503A, dose adjustment is required when used concomitantly with ibrutinib, a CYP3A substrate. Due to the lack of published data describing safety and efficacy outcomes with concomitant use of ibrutinib and azole anti-fungals, it is unknown if the clinical outcomes for patients receiving prophylactic azole anti-fungals are different than those without prophylaxis.
Methodology: In this retrospective chart review, patients at AU Medical Center at least 18 years old who have received ibrutinib therapy at any time from November 2013 to October 2018 were reviewed. A report of ibrutinib prescriptions filled by the AU Medical Center specialty pharmacy or prior approval paperwork (for Augusta University Health patients using outside pharmacies) was generated.
Results: Sixty-four patients were included in the study.
Presentation Objective: Discuss the role ibrutinib may play in increasing the risk of fungal infections
Self-Assessment: True or false: There are evidence based recommendations supporting the prophylactic use of anti-fungals in patients taking ibrutinib.
Evaluation of Clonidine to Prevent Withdrawal Symptoms in a Pediatric Intensive Care Unit Jillian Mantione, Whitney Moore, Courtney McCracken, Pradip Kamat Children's Healthcare of Atlanta - Atlanta, GA
Background/Purpose: Over 90% of PICU patients requiring sedation receive opioids and benzodiazepines. Data is limited on therapy strategies to prevent withdrawal symptoms upon abrupt cessation of such medications. The Withdrawal Assessment Tool-1 (WAT-1) can identify patients experiencing withdrawal. Clonidine, a central-acting alpha-2 agonist, has sedative and analgesic properties that can facilitate weaning sedation. Literature confirms clonidine_x0019_s efficacy for withdrawal symptoms, but data describing a starting dose is lacking. Our primary objective was to evaluate doses of clonidine that prevented or improved withdrawal symptoms in patients on prolonged sedation.
Methodology: A retrospective chart review was conducted on patients receiving clonidine while in the pediatric or cardiac ICU at Children_x0019_s Healthcare of Atlanta between January 2016 and September 2018. Patients were included if they received 5 or more days of sedation with opioids, benzodiazepines, and/or dexmedetomidine. Demographics, sedation duration, clonidine doses, WAT-1 scores, and adverse effects were collected. Patients were excluded if clonidine and methadone were initiated simultaneously, if clonidine was a home medication, or if clonidine was used for hypertension.
Results: A total of 66 patients (43.9% female) with a median age of 0.4 years (range 0-17.8 years) were reviewed. Patients were commonly sedated with fentanyl (63.6%) and midazolam (36.4%) and placed on a methadone wean. The overall average initial clonidine dose was 7.5 mcg/kg/day. The median baseline WAT-1 score was 3 (range 0-8). Forty-seven patients (71.2%) experienced improved withdrawal symptoms and 20 patients (30%) had complete resolution of symptoms within 5 days of starting clonidine. Lower blood pressures were observed, however, no patient experienced hypotension.
Conclusions: Adding clonidine to facilitate weaning off sedation helped decrease withdrawal symptoms without causing adverse effects.
Presentation Objective: To assess clonidine_x0019_s efficacy at preventing withdrawal symptoms in pediatric patients weaning off sedation
Evaluation of Antiplatelet and Anticoagulant Prescribing in an Ambulatory Care Clinic with a Correlation to Hospital Visits Takesa Toliver, Amanda Stankowitz, Alexander Tunnell Medical Center of Central Georgia PGY1 - Macon, GA
Background/Purpose: For decades, studies have shown that antiplatelet and anticoagulant therapies decrease the risk of primary and secondary thrombotic events. However, the use of these agents may also lead to inherent risks, often related to bleeding. The purpose of this quality improvement initiative is to determine the appropriateness of antiplatelet and anticoagulant prescribing in an ambulatory clinic population. Bleeding or clotting events that resulted in emergency department visits or hospital admissions will be analyzed in an effort to determine if there is a correlation between prescribing habits and visits to the emergency room or hospital.
Methodology: All patients who have filled prescriptions for aspirin, clopidogrel, ticagrelor, dipyridamole, rivaroxaban, apixaban, dabigatran, warfarin, or cilostazol from January 1, 2017 to December 31, 2017 at the ambulatory clinic pharmacy will be identified. A chart review will be conducted. National guidelines detailing indications, dosing, and duration of the study agents will be used to determine appropriateness of antiplatelet and anticoagulant therapies when the first prescription of the study drug(s) are filled within the study period. Following evaluation, patients will be placed into one of two groups, appropriate therapy or inappropriate therapy. Reasons for inappropriate therapy will be recorded. Inpatient medical records will be reviewed to assess for hospital admissions related to episodes of bleeding or clotting between the two groups. Medical records will be assessed for one year following the initial fill of the study drug(s). Hospital visit rates will be compared between groups.
Presentation Objective: To determine the appropriateness of antiplatelet and anticoagulant prescribing in an ambulatory care clinic.
Self-Assessment: Is there a correlation between prescribing habits of antiplatelet and anticoagulant therapies and hospital visit rates in an ambulatory clinic population?
Impact of a pharmacist review service on heart failure patients with reduced ejection fraction between pharmacy residents and Kishan Patel, Ryan Kammer, Zach Klick Novant Health Presbyterian Medical Center - Charlotte, NC
Background/Purpose: Heart failure (HF) is a national epidemic, affecting 5.7 million patients and has a large economic burden, with more than $30 billion in healthcare costs. HF is a condition that results from structural or functional damage of ventricular filling or ejection of blood. In an effort to optimize guideline directed medical therapy, a HF Best Practice computer Alert (BPA) prompting Pharmacist medication review was initiated at Novant Health. The objective of this study is to investigate whether this pharmacy service is beneficial to patient care.
Methodology: This study has been approved by the Institutional Review Board. A multicenter retrospective study will be performed to evaluate overall impact of the heart failure BPA on pharmacists at Novant Health. All acute care Novant Health facilities were included. Patients with a left ventricular ejection fraction (LVEF) less than or equal to 40% hospitalized from April to May and August to September of 2018 were included in the analysis During this time period, pharmacy residents were involved in completing the HF BPA review. This resident data, will be compared to overall review done by staff pharmacists. Data will be collected by reviewing electronic medical records for 200 patients. Descriptive statistics will be used to analyze the data. A complete HF BPA will require documentation of: recent LVEF, assessment of GDMT (ACEI/ARB/ARNI, beta-blocker, aldosterone antagonist therapies), and completed transition of care referral. Pharmacy dosing and monitoring recommendations will be evaluated.
Presentation Objective: Evaluate overall impact of the heart failure triggered alert on patient care for staff pharmacists and pharmacy residents.
Self-Assessment: Is the HF BPA for pharmacists beneficial to optimize patient care?
Alternative to Opioids for Treatment of Acute Headache and Migraine in the Emergency Department Alexandra Komisar, Jessica Chen, Kristin Horton, Disa Patel, Naadede Plange Piedmont Atlanta Hospital - Atlanta, GA
Background/Purpose: Headaches account for more than five million emergency department (ED) visits in the United States, with the most common cause being attributed to migraines. While opioids are often used as first-line therapy, their acceptance has decreased in recent years due to the ongoing opioid epidemic as well as their numerous disadvantages. At Piedmont Atlanta Hospital, no order panel existed for the treatment of acute headache and migraine in the ED. The goal of this study was to decrease the use of opioids by implementing an opioid-free order panel to facilitate a multimodal treatment approach for these indications. With the implementation of an order panel, the expectation was to better manage acute headache and migraine while decreasing morphine equivalents in the ED population.
Methodology: This observational cohort study enrolled patients >/= 18 years of age presenting to Piedmont Atlanta Hospital_x0019_s ED with a diagnosis of headache or migraine during a pre-implementation phase (January/February 2018) and a post-implementation phase (January/February 2019). The primary endpoint was to determine and compare average morphine equivalents between the two cohorts. Secondary endpoints included average pain score, admission rate, and sequential visits or admissions within 30 days for headache or migraine.
Presentation Objective: Evaluate the impact of an opioid-free order panel for the treatment of acute headache and migraine in the ED.
Self-Assessment: Does an opioid-free order panel decrease morphine equivalents for headache and migraine in the emergency department?
Assessing outcomes of a newly initiated multidisciplinary culture-review process in the emergency department Emily Johnson, Kenda Germain, Megan Autrey, Natalie Tapley, Sarah Blackwell Princeton Baptist Medical Center - Birmingham, AL
Background/Purpose: Patients treated for presumed infections in the emergency department (ED) are often sent home with empiric antibiotic therapy; however, culture results are not available until after discharge. If the infective organism is resistant to the prescribed antimicrobial therapy, it may result in negative consequences for the patient and institution. The purpose of this project was to initiate and assess the outcomes of a multidisciplinary ED culture review process.
Methodology: Eligible patients included those greater than 19 years old presenting to the ED with a presumed infection from November 2018 to February 2019 with positive culture results. After implementation of the new process, cultures were reviewed daily to determine if an intervention was required, and recommendations were presented to ED providers. Appropriate follow-up was carried out after this discussion. Subsequently, an IRB-approved retrospective chart review was conducted to assess outcomes of this initiative. Data was compared to historical data obtained pre-implementation in May 2018 to determine the impact of pharmacy involvement in the ED culture review process. The primary outcome was the percent of patients receiving follow-up who required optimization of antibiotic therapy. Secondary outcomes included rate of recommendation acceptance with successful patient follow-up, reason for follow-up, time to follow-up, representation to the ED within 72 hours, and required hospital admission within 30 days.
Presentation Objective: Describe pharmacist-driven interventions that can be made through an ED culture review service.
Self-Assessment: What are the benefits of a pharmacist-driven, multidisciplinary culture-review process?
CLINICAL IMPACT AND PATIENT PERCEPTION OF DIABETES SELF-MANAGEMENT EDUCATION BY COMMUNITY PHARMACISTS Tiffany Park, Maria Yi, Joshua Kinsey Mercer University School of Pharmacy - Atlanta, GA
Background/Purpose: Pharmacists are becoming more involved in patient care in the community setting through protocol-driven medication management, medication therapy reviews, and prescriptive authority on certain medications. There are opportunities to support patients in the community setting by providing education to patients with chronic disease states including diabetes. There are a growing number of patients with diabetes and services like diabetes self-management education (DSME) provides patients with education, support, and accountability to help patients make lifestyle changes. The objective of this study is to assess the effect of diabetes self-management education on patient A1C in diabetes and pre-diabetes patients and to assess patient willingness to invest in DSME services.
Methodology: Patients were offered enrollment in the study based upon the most recent A1C being 5.7% or greater. Patients were scheduled for their first session through physician referral. Patients enrolled were given 3 diabetes self-management education sessions covering diabetes pathophysiology, nutrition and exercise, and complications of diabetes. A pre- and post- survey was given to patients to assess patients_x0019_ attitude toward self-managing diabetes and whether patients would be willing to invest in similar sessions offered at their local community pharmacy.
Presentation Objective: List and describe topics covered in diabetes self-management education sessions and assess preliminary impact on patient A1C and self-evaluation of diabetes management.
Self-Assessment: How does diabetes self-management education help patients with diabetes or pre-diabetes in the community setting?
Risk Factors for Antibiotic Resistance in Stenotrophomonas maltophilia Noah White, PharmD; Jason Lin, PharmD; Eric Clayton MS Memorial University Medical Center - Savannah, GA
Background/Purpose: Stenotrophomonas maltophilia (S. maltophilia) is a multi-drug resistant organism that can cause opportunistic infections. According to recent studies, resistance to the first and second line therapies, sulfamethoxazole/ trimethoprim (STP) and levofloxacin respectively, is increasing. At this time there is limited data regarding patient and treatment factors that may contribute to S. maltophilia resistance. The purpose of this study is to identify risk factors associated with STP and levofloxacin resistance in S. maltophilia infections.
Methodology: This was an Institutional Review Board approved, single-center, retrospective study. The study included inpatients with a positive culture for S. maltophilia from May 2015 to August 2018. Data collected included demographic information (age, sex, race/ethnicity, admission location, discharge location, antibiotic allergies), medical history (comorbidities, medication use, recent ICU/hospital stay, inpatient lines, mechanical ventilation), isolate information (source, polymicrobial, susceptibility) and length of stay. This information was analyzed to determine whether specific patient or treatment characteristics are correlated with resistance.
Results: This study collected data on 120 inpatient isolates. Overall, levofloxacin and STP sensitivity was 82.5 and 95.8 percent respectively. Of all variables studied, those consistent with levofloxacin resistance were: race (other; excluding white, black and Hispanic), intraabdominal lines (colostomy, urostomy, and ileostomy), HIV, and 90 day history of ICU stay or levofloxacin use. Variables consistent with STP resistance were: urine source, allergy to sulfas, and HIV.
Conclusions: S. maltophilia is often considered a hospital acquired infection. This study suggests that patient factors, such as recent antibiotic utilization and site of infection, have a role in resistance.
Presentation Objective: Describe the factors that might lead to Stenotrophomonas maltophilia resistance.
Self-Assessment: A patient presents with both pneumonia and a urine culture growing Stenotrophomonas maltophilia. Which factor would make you concerned about starting levofloxacin empirically?
Development of a computerized prescriber order entry (CPOE) chemotherapy order set in a community hospital Tanner Shields, A Porter, F Pruss, A Knauth, R Lucas, S Roberts Blount Memorial Hospital - Maryville, TN
Background/Purpose: The American Society of Health System Pharmacists (ASHP), American Society of Clinical Oncology (ASCO), and the Institute for Safe Medication Practices (ISMP) recommend the implementation of computerized prescriber order entry (CPOE) in health systems for chemotherapy orders to increase safety and reduce errors. The objective of this project is to describe the development and implementation of a CPOE chemotherapy order set in a community hospital.
Methodology: A retrospective review of paper chemotherapy orders from January 1, 2018 to June 30, 2018 was conducted to assess the number of clarifications and discrepancies. This information was used to guide which types of chemotherapy orders we needed to design and implement first. On the advice of the Oncology Committee the rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was chosen as the first regimen to implement based off of complexity and frequency of use. The order set will be created using current paper order sets, primary literature, ISMP best practices, as well as published articles on similar implementations. From this information a CPOE order set will be created for use by our prescribers for chemotherapy orders. The development of the CPOE order set will involve oncology pharmacists, informatics pharmacists, oncology practitioners, and oncology nurses. Multiple pharmacy and oncology related committees will review and decide whether or not to approve the order set. This project describes the implementation process necessary to switch from paper order sets to CPOE for oncology orders in a community hospital.
Presentation Objective: Describe the creation of a chemotherapy CPOE order set with the help of evidence based practice guidelines, primary literature, and local hospital committees.
Self-Assessment: Self-Assessment Question: Which organizations recommend the use of CPOE for chemotherapy orders?
Outcomes of letermovir prophylaxis in high risk, CMV seropositive hematopoietic stem cell transplantation (HSCT) recipients Eva Karam, Megan Freeman, Sarah Murphy, Justin LaPorte Northside Hospital (Oncology) - Atlanta, GA
Background/Purpose: Cytomegalovirus (CMV) is a double-stranded DNA virus that belongs to the betaherpesvirus subfamily. CMV is an opportunistic pathogen with high seroprevalence that persists in latent states. CMV reactivation after HSCT increases complications and mortality. Use of antiviral prophylaxis in HSCT recipients was limited due to toxicities such as myelosuppression. To minimize exposure, preemptive treatment strategies were used to monitor patients at frequent intervals for CMV viremia and therapeutic doses of antivirals were initiated at predefined thresholds. Recently, the FDA approved letermovir, an antiviral agent indicated for CMV prophylaxis. Letermovir has a favorable adverse effect profile compared to other antiviral agents used for CMV prophylaxis. Northside Hospital implemented letermovir CMV prophylaxis in high risk allogeneic HSCT recipients in January 2018.
Methodology: This is a retrospective, single center chart review of 60 high-risk allogeneic HSCT from 2017 on preemptive therapy alone and 60 high-risk allogeneic HSCT recipients that received letermovir CMV prophylaxis in 2018. Patients were included if 18 years of age or older and high-risk allogeneic HSCT recipients. Primary analysis will compare percentage of CMV infections with letermovir prophylaxis versus preemptive therapy. Secondary endpoints will also be examined: time to onset of virologic failure, percentage of patients developing GVHD, time to engraftment, time to onset and percentage of patients that relapsed, incidence of all-cause mortality, and frequency of CMV treatment.
Results: Preliminary results demonstrated an estimated 50 percent reduction in CMV infection in high risk HSCT recipients receiving letermovir prophylaxis when compared to preemptive therapy alone.
Conclusions: Letermovir appears to decrease percentage of clinically significant CMV infection and decreases need for preemptive treatment.
Presentation Objective: Determine whether CMV prophylaxis with letermovir in high risk allogeneic HSCT recipients improves post-transplant outcomes.
Self-Assessment: True False: Myelosuppression is a common adverse effect associated with letermovir prophylaxis.
Impact of a population health pharmacist within a health system Kailene Perry, Nicole Sims, Christie Dresback, Elizabeth Ramsaur Mission Hospitals PGY1 Amb. Care - Asheville, NC
Background/Purpose: Population health pharmacists can be added to the outpatient healthcare team to improve health outcomes, quality metrics, and cost-savings.
Methodology: Eligible participants are those over 18 years of age within Mission Health System and insured by Humana, Blue Cross Blue Shield (BCBS), or United Healthcare (UHC). We implemented two population health pharmacists at 0.2 full-time equivalents (total of 0.4 full-time equivalents) to oversee this project. Utilizing claims data on four pharmacy-sensitive quality measures, we identified patients within Mission Health System_x0019_s twenty primary care clinics who were not at goal. The population health pharmacists used this data to create individual spreadsheets per clinic. These were uploaded to a secure portal within Mission Health MissionPoint. The portal was accessed and utilized by embedded clinical pharmacists to make interventions on patients in their clinic identified as not meeting a certain metric. If the clinic did not have an embedded pharmacist, the population health pharmacists provided interventions for these patients by phone.
Presentation Objective: Describe the impact of utilizing embedded clinical pharmacists as part of a population health team.
Self-Assessment: Why was it important that we included diabetes-centered measures, such as statin use in people with diabetes?
The feasibility and acceptability of providing pharmacist-led tobacco cessation education to underserved patients Johanna Dresser, Summer Sizemore, Alix Schnibben, Anne Misher St. Joseph's/Candler Health Systems - Savannah, GA
Background/Purpose: Tobacco use is one of the leading causes of preventable death in the United States. Smoking prevalence remains higher among disadvantaged populations, such as those with lower economic status or education attainment. Pharmacists are uniquely positioned to provide tobacco cessation education to patients in the outpatient setting. The primary objective of this study is to evaluate various methods for improving patient recruitment for tobacco cessation classes.
Methodology: This investigation is a prospective feasibility and acceptability study evaluating various approaches to improve recruitment for tobacco cessation classes in underserved populations. Eligible patients were identified according to smoking status via the electronic medical record, and were recruited via clinic schedule and in response to posted advertisements. Patients who consented to participate in the study were asked to attend four tobacco cessation classes provided by an on-site pharmacist. Each class focused on a unique topic, such as coping with triggers and long-term benefits of quitting.
Results: Out of 150 patients eligible for enrollment at the first clinic, 15 patients signed consent and 3 patients attended the first class. Two of these patients also attended the second class. Patient-identified barriers to attending classes included conflict with work schedule, illness, and transportation issues. As of February 2019, 6 patients were enrolled in classes at the second clinic, and all patients were able to attend the first tobacco cessation class.
Conclusions: Due to patient-identified barriers impeding access to tobacco cessation education, further research is ongoing to determine the most effective approach to recruit patients in this underserved population.
Presentation Objective: List potential barriers impeding patient access to tobacco cessation education.
Self-Assessment: What is one approach to overcome barriers that may impede patient access to tobacco cessation education?
IDENTIFYING CANDIDATES FOR ANGIOTENSIN II VASOPRESSOR THERAPY BY TRIAL AND REAL WORLD CRITERIA Spencer Livengood, April Miller Quidley, Lauren Chambers Vidant Medical Center - Greenville, NC
Background/Purpose: Angiotensin II is a new vasopressor with an unclear role in shock treatment, including mortality benefit and risk of thrombosis. The study purpose is to assess the number of patients potentially eligible to receive angiotensin II at an academic medical center and their outcomes relative to ATHOS-3 trial criteria.
Methodology: This is an IRB approved, single center, retrospective cohort study of medical record reports. Patients receiving norepinephrine between 7/1/17 and 6/30/18 were identified for analysis and included if > 18 years of age, with diagnosis codes for septic shock, and catecholamine-resistant hypotension. Excluded patients had acute coronary occlusion; liver failure; ECMO; bleeding; neutropenia; mannitol allergy; received > 500mg hydrocortisone or equivalent/day; or were pregnant. The primary endpoint is the number of patients who were candidates for angiotensin II therapy. The secondary endpoints are mortality, limb ischemia, and patients receiving vasopressin greater than or equal to 0.03U/min.
Results: There were 1666 patients screened as candidates for angiotensin II; 556 patients met specified inclusion criteria; and 156 patients met exclusions. This indicates that 400 patients met the primary outcome of being candidates for angiotensin II therapy. Secondary outcomes showed 7-day mortality of 31%, 28-day mortality of 42%, 3.3% rate of thrombus or limb ischemia, and 289 (72%) patients also receiving vasopressin.
Conclusions: There were a modest number of patients within one year identified as candidates to receive angiotensin II with lower mortality and a higher rate of thrombotic events than evidenced in initial angiotensin II trials. These results suggest the need for close evaluation of potential candidates for angiotensin II therapy and monitoring of patients receiving therapy for thrombotic events.
Presentation Objective: Quantify patients eligible to receive angiotensin II vasopressor therapy in a year_x0019_s time based on trial criteria.
Self-Assessment: How often could angiotensin II be used when incorporated into practice?
Impact of propofol on hemodynamic profile in adults undergoing targeted temperature management Jennifer Kim, Sarah Heck, W. Anthony Hawkins Phoebe Putney Memorial Hospital - Albany, GA
Background/Purpose: Recent guidelines for post-cardiac arrest care strongly recommend targeted temperature management (TTM) for comatose survivors after cardiac arrest. Shivering commonly occurs during TTM and may mitigate clinical benefits of temperature control. Sedative medications are used to control shivering, but there are no established guideline recommendations for specific sedation strategies. Propofol is commonly used due to its short half-life and safety profile over benzodiazepines. Propofol is known to have cardiac depressant effects, but these effects and clinical impact have not been described in patients undergoing TTM. This study aims to investigate hemodynamic changes due to propofol during TTM.
Methodology: This is a single center, retrospective, observational cohort study that was approved by the institutional review board. Patients who received TTM between October 2015 and August 2018 were eligible for inclusion. Patients were excluded if they received TTM for reasons other than non-traumatic cardiac arrest, did not receive continuous infusion of propofol for at least 30 minutes during TTM, or were on propofol infusion before initiation of TTM. The primary outcome of this study is the change in cardiovascular SOFA score 30 minutes after initiation of propofol. Secondary outcomes include change in hemodynamic variables and vasopressor requirements at 30 minute, 1 hour, 2 hour, 3 hour and 4 hour post initiation of propofol. Descriptive statistics will be used for baseline characteristics and dependent t-test will be used to assess outcomes.
Presentation Objective: Describe the effects of propofol on hemodynamics during targeted temperature management.
Self-Assessment: What is the extent of hemodynamic changes due to propofol infusion in patients undergoing targeted temperature management?
PLATELET INHIBITION MEASUREMENT IN TRAUMATIC HEAD INJURY PATIENTS _x0013_ COMPARING CLINICAL OUTCOMES BASED ON P2Y12 MEASURES Kaitlyn Haynes, Christopher Burke, Marshall Hall, Quentin Minson TriStar Skyline Medical Center - Nashville, TN
Background/Purpose: Patients receiving adenosine-diphosphate (ADP) antagonists who experience a traumatic head injury are at an increased risk of intracranial hemorrhage and poor neurological outcomes. Significant response variability can exist in those patients who are taking an ADP antagonist, and cardiac literature has revealed that the VerifyNow P2Y12 assay is a useful tool to assess platelet inhibition and guide platelet transfusion when indicated. The objective of this study is to determine if the VerifyNow P2Y12 assay is a beneficial tool for determining the need for platelet transfusion in patients taking an ADP antagonist who experience a traumatic head injury.
Methodology: A retrospective cohort study is being conducted on eligible patients greater than or equal to 18 years old who experience a traumatic head injury and develop subsequent intracranial hemorrhage on an outpatient ADP antagonist who had a VerifyNow P2Y12 assay performed within 6 hours of presentation to the emergency department from July 2013 to November 2018. Patients on anticoagulation therapy were excluded. Patients were defined as impaired responders, appropriate responders, and heightened responders based on P2Y12 assay results and clinical outcomes were compared between groups. The primary endpoints are Glasgow coma scale (GCS) and death due to any cause. Secondary endpoints include intracerebral hemorrhage growth and the need for platelet transfusion between the groups.
Presentation Objective: Evaluate if the VerifyNow P2Y12 assay is a beneficial tool for predicting clinical outcomes and determining the need for platelet transfusion in patients taking an ADP antagonist who experience a traumatic head injury with subsequent intracranial hemorrhage.
Self-Assessment: Do P2Y12 levels correlate with poor clinical outcomes and the need for platelet transfusion?
Evaluation of a Proton Pump Inhibitor Deprescribing Process in Community-dwelling Older Adults Hien Nguyen; Tasha Woodall Mountain Area Health Education Center PGY2 Geriatrics - Asheville, NC
Background/Purpose: Proton pump inhibitors (PPIs) are frequently suitable targets for deprescribing, since prolonged use is associated with multiple adverse effects. Many individuals remain on chronic PPI therapy despite recommendations to avoid use for greater than 12 weeks for symptoms associated with gastroesophageal reflux disease (GERD). An algorithm for systematic deprescribing of PPIs was previously published and is available online at Deprescibing.org. The purpose of this study is to examine the algorithm_x0019_s validity in community-dwelling older adults in a large family medicine practice, when carried out by a pharmacist either face-to-face or by telephone, to determine whether it should be adopted as a potential standard of care for the practice.
Methodology: Eligible patients were those aged > 65 years on chronic PPI therapy (defined as > 4 months), seen by a provider within the last 12 months, and who qualify for deprescribing of their PPI based on the algorithm from Deprescribing.org. The pharmacist reached the patient via office visit or telephone encounter to provide counseling and education regarding risks and benefits of continued therapy. Subjects who were agreeable to a trial of PPI deprescribing were followed-up at 4 and 12 weeks after taper initiation for further assessment. This study was considered exempt by the organization_x0019_s Institutional Review Board.
Presentation Objective: Identify the acceptance rate of deprescribing PPIs by a pharmacist in community-dwelling older adults via different modalities.
Self-Assessment: What is one way pharmacists can contribute to successful deprescribing of PPIs?
Incidence of acute kidney injury during treatment with vancomycin given on frequencies of every 8 hours versus every 12 hours Irandokht Khaki Najafabadi PCOM School of Pharmacy - Suwanee, GA
Background/Purpose: Currently at WellStar North Fulton Hospital, the empiric vancomycin intravenous (IV) dosing interval is every 12 hours or more. However, several nomograms provide recommendations for regimens that include vancomycin IV dosed at shorter dosing intervals of every 8 hours. The objective of this study is to determine an optimal empiric vancomycin dosing interval for adult patients by assessing the incidence rate of AKI as defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria.
Methodology: A retrospective chart review was conducted at Wellstar North Fulton hospital, a community hospital, on patients who received treatment courses of vancomycin for at least 3 days. Data collected include patient age, gender, weight, laboratory values, intensive care unit (ICU) stay, vancomycin trough level information, vancomycin treatment information, and concurrent nephrotoxic agents. When available, the reported adverse events were also collected.
Presentation Objective: Compare the incidence rate of AKI after vancomycin treatment between the Q8H and Q12H vancomycin groups.
Self-Assessment: Is vancomycin concentration or time dependent in its antimicrobial activity?
Risk Factors for Septic Embolization in Infective Endocarditis Ryan Marshall, Sarah Green, Evan Tatum, Zach Klick Novant Health Forsyth Medical Center - Winston-Salem, NC
Background/Purpose: Patients with infective endocarditis (IE) carry a significant risk of septic embolization. It is not well known whether chronic antithrombotic therapy significantly influences the risk for septic emboli in the setting of IE, and consensus guidelines vary in their stance regarding the management of antithrombotics in the acute phase due to heterogeneous reports and low quality evidence. This study seeks to further characterize the relationship between antithrombotic therapy and septic emboli in the setting of IE.
Methodology: This is an IRB-approved retrospective chart review of adults admitted to Novant Health Forsyth Medical Center or Presbyterian Medical Center between 1/1/15 and 6/30/18. Eligible patients were diagnosed with IE but were manually excluded if they did not meet Modified Duke_x0019_s Criteria for Definite IE. The primary endpoint is the incidence of septic embolization in patients on chronic antithrombotic therapy at baseline compared to those not on antithrombotics. Secondary endpoints include risk factors associated with septic embolization, proportion of patients experiencing two or more septic emboli, and day of antimicrobial therapy at the time of septic embolization. Lastly, the study aims to assess the incidence of ischemic stroke converting to intracranial hemorrhage in patients with a septic cerebral embolus.
Presentation Objective: Characterize patient-specific risk factors associated with septic embolization in the setting of infective endocarditis
Self-Assessment: Does chronic antithrombotic therapy influence patient risk for septic embolization in the setting of infective endocarditis?
Rectal Indomethacin for the Prevention of Post-ERCP Pancreatitis in High-Risk Patients Corey Guidry, John Yates, Daniel Micaletti, Ramanujan Samavedy, Eric Heidel University of Tennessee Medical Center - Knoxville - Knoxville, TN
Background/Purpose: Endoscopic retrograde cholangiopancreatograpy (ERCP) is a complex procedure in which instrumentation is guided into the pancreatic and biliary ducts. The risk of complications is high, with post-ERCP pancreatitis (PEP) occurring most commonly. Several factors have been identified that place patients at a higher risk of developing PEP, and multiple agents have been evaluated as PEP prophylaxis in this patient population. Rectal indomethacin has shown robust data for this indication, but more recent studies provide conflicting evidence. Therefore, in an attempt to determine its utility, this study will investigate the efficacy of rectal indomethacin in reducing PEP in high-risk patients.
Methodology: Eligible patients were those 18 years or older who underwent ERCP and were at high risk for developing post-ERCP pancreatitis (PEP). Patients in the intervention group received 100 mg of rectal indomethacin post ERCP. Those in the control group did not receive this intervention. Demographic data, ERCP procedural information, and pertinent laboratory values were collected for all patients from electronic health records. The primary endpoint was the incidence of PEP, evaluated using a chi-squared test. Secondary endpoints were PEP severity and length of stay, and safety endpoints were rates of bleeding, acute kidney injury, and death.
Presentation Objective: Evaluate the safety and efficacy of rectal indomethacin for the prevention of post-ERCP pancreatitis in high-risk patients.
Self-Assessment: Which statement correctly identifies the efficacy of rectal indomethacin for PEP prevention in high-risk patients?
EVALUATION OF EMERGENCY DEPARTMENT AND HOSPITAL ADMISSIONS IN OUTPATIENT CHEMOTHERAPY PATIENTS FOR PREVENTABLE CONDITIONS Nisha Patel, Nicholas Lockhart CHI Memorial - Chattanooga, TN
Background/Purpose: Cancer is an increasingly prevalent public health condition worldwide and the second leading cause of death in the United States. Approximately 22% of patients with cancer receive chemotherapy each year. Patients receiving chemotherapy on average have two emergency department (ED) visits and one hospital admission annually with certain visits or admissions that could have been potentially prevented. Centers for Medicare and Medicaid Services (CMS) introduced the OP-35 measure that aims to reduce the number of potentially avoidable ED visits and inpatient hospital admissions for cancer patients that receive chemotherapy in a hospital outpatient department (HOPD). The measure looks at ten potentially preventable conditions. This study aimed to evaluate which of the ten preventable conditions are most likely to cause ED visits and hospital admissions and whether appropriate prophylactic treatment was given to these outpatient chemotherapy patients.
Methodology: A single-center retrospective cohort analysis was conducted from January-December 2017. Adult patients who presented to the ED or admitted to the hospital for one or more of the ten preventable conditions and received prior chemotherapy within 30 days at CHI Memorial Infusion Center were included. Patients with leukemia were excluded. Primary endpoint was evaluation of prophylactic medication or supportive care prescribed to outpatient chemotherapy patients that present for medical intervention at the ED or hospital compared to evidence-based guidelines. Secondary endpoints included incidence of preventable conditions and time to ED visit or hospital admission after chemotherapy.
Results: N/A
Conclusions: N/A
Presentation Objective: Evaluate whether appropriate prophylactic treatment is given to outpatient chemotherapy patients for potentially preventable conditions.
Self-Assessment: When does the CMS OP-35 measure take effect?
Polyoma BK Viremia Incidence in Kidney Transplant Patients with Belatacept or Tacrolimus-based Immunosuppression Regimens Geoffrey Zettel, Erika Meredith Emory University Hospital - Atlanta, GA
Background/Purpose: Polyoma virus, BK type, is a ubiquitous, small, double-stranded DNA virus which commonly causes primary infection during childhood and has a sero-prevalence of 80-90% in the human population. Polyoma BK virus reactivation is ordinarily eliminated in immunocompetent individuals. However, with immunosuppressed individuals, such as kidney transplant patients, Polyoma BK virus is particularly burdensome. Immunosuppression induction agents as well as immunosuppression maintenance regimens are known risk factors for Polyoma BK viremia. However, the risk of Polyoma BK viremia in the setting of immunosuppression maintenance with belatacept, a novel co-stimulatory CTLA4-inhibitor, has not been well established. The objective of this study is to evaluate the incidence of Polyoma BK viremia in patients who were administered either a tacrolimus-based immunosuppression regimen or a belatacept-based immunosuppression regimen after kidney transplant. Our primary endpoint is the incidence of BK viremia on either immunosuppression regimens. Secondary endpoints include the following for positive Polyoma BK viremia patients: time until viremia after transplant, rates of biopsy confirmed BK virus associated nephropathy, mean dose of immunosuppression during viremia treatment, time until clearance of viremia, rate of graft loss, rejection rates, and renal function during viremia treatment.
Methodology: This is a single center, retrospective chart review including Emory University Hospital kidney transplant patients who were transplanted between January 1, 2010 to December 1, 2015. Patients were included if they were a kidney recipient at Emory University Hospital, 18 years of age or greater, had induction immunosuppression with basiliximab, and had either Belatacept or tacrolimus immunosuppression maintenance regimens. Exclusion criteria included patients who were HIV positive or had multiple organ transplants.
Presentation Objective: Describe the incidence of BK viremia in kidney transplant patients with either Tacrolimus or Belatacept immunosuppression regimens.
Self-Assessment: How does the incidence of BK viremia in Belatacept-based immunosuppression compare to that of Tacrolimus-based immunosuppression regimens.
Impact of Elective Choice on NAPLEX Performance by Pharmacy Graduates Devin Lavender,Beth Phillips,Catherine Rebitch,Rebecca Stone,Mike Fulford University of Georgia College of Pharmacy - Athens, GA
Background/Purpose: To examine influence of type of elective courses taken on pharmacy graduate NAPLEX performance.
Methodology: Subjects included students who graduated from the University of Georgia College of Pharmacy and took the NAPLEX in 2016 or 2017. Elective courses offered in 2016 or 2017 were classified according to three criteria: 1) Clinical instructor vs. Non-clinical instructor, determined by practicing at a health-care site at least 1 day a week, 2) Drug Therapy vs. Non-drug therapy, determined by the teaching of drug related content within the course, and 3) NAPLEX Area 1 or Area 2 Competency Statements according to the course objectives on each syllabus. Data were analyzed using descriptive statistics, Student T-Tests, and Pearson Correlation where appropriate.
Results: Of the 271 graduates eligible for inclusion, 22 did not report a NAPLEX score and were excluded from the analysis. The average first time NAPLEX pass rates were 92% and 97.1% for the classes of 2016 and 2017 respectively. The average graduating GPA was 3.59 in 2016 and 3.59 in 2017. The average Area 1 scaled score out of 18 was 12.7 for the 2016 class and 12.9 for the 2017 class. A significant correlation was found between higher total scaled scores on the NAPLEX and students who completed an elective which mapped to Area 1 of the NAPLEX (r = 0.124; p value
Optimization of the warfarin management process in a rural primary care clinic Elizabeth Ramsaur, Christie Dresback, Stephanie Kiser Mission Hospitals PGY2 Ambulatory Care - Asheville, NC
Background/Purpose: Blue Ridge Medical Center _x0013_ Yancey Campus (BRMC_x0013_Yancey) is a rural primary care clinic affiliated with the primary care group Mission Medical Associates (MMA). MMA has developed a standard process for warfarin management to promote safe and effective use of this high risk medication. This process was adopted after reviewing practices within Mission Hospitals Anticoagulation Clinic, which has achieved Center of Excellence Status from the Anticoagulation Forum. This quality improvement project aims to align BRMC_x0013_Yancey_x0019_s warfarin management practices with the standards recommended by MMA, promoting safe and effective warfarin management for clinic patients.
Methodology: A process change was implemented at BRMC_x0013_Yancey to align clinic practices with the current MMA standard of practice. Key components of the process change included use of a standard warfarin questionnaire at check-in, documentation using a standard form in the electronic medical record, provision of a written warfarin dosing schedule, and a maximum monitoring interval of 4 weeks. To promote effective implementation, current clinic workflow was considered and education was provided to front office staff, laboratory staff, clinical support staff, and providers regarding process changes and documentation tools existing in the electronic medical record. Pertinent information about clinic patients on warfarin was collected, including demographic data, warfarin indication, desired INR range, and INR results with associated dates. All data was recorded without patient identifiers to maintain confidentiality. To determine the efficacy of standard practice implementation, time in therapeutic range (TTR) was compared before and after the intervention. Clinical staff were surveyed on their perception of the process before and after implementation.
Presentation Objective: Describe key considerations for implementing a change in the warfarin management process in a rural primary care clinic.
Self-Assessment: Which of the following are key considerations for implementing a change in the warfarin management process in a rural primary care clinic?
COMPARISON OF SUSCEPTIBILITY RATES FOR SKIN AND SOFT-TISSUE INFECTIONS ON AN OUTPATIENT AND INPATIENT ANTIBIOGRAM Sara Ludmer, Erica Merritt, Allison Powell, Joey Crosby, Nelly Ayen St. Joseph's/Candler Health Systems - Savannah, GA
Background/Purpose: Outpatient based antibiograms are imperative for reducing inappropriate empiric prescribing and reducing the risk of resistance. An emergency department outpatient specific antibiogram and associated guideline for community-acquired SSTIs caused by Staphylococcus aureus and Streptococcal species was created.
Methodology: Phase one included the creation of a community-acquired SSTI antibiogram. Adult patients that visited the emergency departments who were diagnosed with a SSTI, had a positive Staphylococcus aureus and/or Streptococcal culture, and were discharged with antibiotics were eligible for inclusion. Susceptibility rates from this population were compared to inpatient susceptibility rates. Phase two consisted of creating, educating, and implementing an empiric prescribing guideline. Phase three consisted of retrospectively analyzing data to compare the empiric antibiotic selection and appropriate antimicrobial coverage before and after the creation, education, and implementation of the prescribing guideline.
Results: Out of 202 patients evaluated, 74 patients were included for Staphylococcus aureus and 5 patients were included for Streptococcal species. The outpatient methicillin-resistant Staphylococcus aureus (MRSA) rate for the health system was 68%. The outpatient susceptibility rates were statistically significantly higher than the inpatient rates for all isolates of Staphylococcus aureus for clindamycin (p=0.00012), trimethoprim-sulfamethoxazole (p=0.037), oxacillin (p=0.00073), and doxycycline (p=0.0036).
Conclusions: The data revealed a high MRSA rate from abscesses in this patient population. The comparison of the antibiograms showed a significant difference between the outpatient and inpatient susceptibility rates emphasizing a need for an outpatient prescribing guideline.
Presentation Objective: To compare susceptibility trends for patients presenting to the emergency department with skin and soft-tissue infections.
Self-Assessment: Is there a difference in the susceptibility rates of outpatient versus inpatient antibiograms?
Impact of Chloride Containing Drug Diluents on AKI Incidence in a Surgical/Trauma Patient Population Chris Demitraszek, Lauren Chambers, Natassha Ebert, April Miller Quidley Vidant Medical Center PGY2 Critical Care - Greenville, NC
Background/Purpose: Acute kidney injury (AKI) is common in critically ill patients and is associated with increased morbidity and mortality. The reported incidence of AKI ranges from 20-50%. The effect of hyperchloremia and balanced crystalloid IV fluids has primarily been studied in medical or general ICU patients. The goal of this study is to assess the impact of a change in standard medication diluents, from 5% dextrose to normal saline, on the incidence of AKI in a surgical/trauma ICU population.
Methodology: This single-center, retrospective study performed in surgical/trauma ICU patients included those who received pre-specified medications identified due to high diluent volumes or risk of AKI. Exclusion criteria were history of organ transplant, ESRD, or missing serum creatinine. Prior to a change in practice, patients received medications primarily with dextrose diluents (pre-) and after received primarily normal saline diluents (post-). The primary endpoint was incidence of KDIGO-defined AKI during the first seven days of ICU stay or until ICU discharge compared using Fisher_x0019_s Exact test. Secondary endpoints include cumulative volume and chloride load of pre-specified medication diluents and resuscitative fluids, and hyperchloremia. Multivariable logistic regression models will be developed to evaluate AKI and hyperchloremia.
Results: A total of 562 patients were screened, 447 were included for analysis. The incidence of AKI was not different between groups (pre vs post, 28.7% vs 33.3%; p=0.354). The pre-specified medication diluent chloride load was not different between groups (23.6mEq vs 20.0mEq; p=0.38). Further data analysis is ongoing for secondary endpoints and multivariable logistic regressions.
Conclusions: Preliminary results suggest the change in medication diluents did not change the incidence of AKI in a surgical/trauma ICU population.
Presentation Objective: Identify modifiable and non-modifiable risks factors for AKI in critically ill patients.
Self-Assessment: Does chloride load impact the incidence of AKI in a surgical/trauma population?
Impact of phenobarbital dosing patterns in the management of alcohol withdrawal syndrome on outcomes in critically ill adults Mary Hannah Walters, Alisha Terry, Joeanna Sams, Erin Waldee Phoebe Putney Memorial Hospital - Albany, GA
Background/Purpose: Phenobarbital has commonly been used as an alternative agent to benzodiazepines for symptoms associated with alcohol withdrawal syndrome (AWS). There is currently no preferred dosing regimen established for phenobarbital in these patients. The purpose of this study is to assess the dosing patterns of phenobarbital for AWS with a focus on the first dose given and its effects on patient outcomes.
Methodology: A retrospective chart review was conducted on patients with AWS admitted to the intensive care unit (ICU) from October 1, 2015 through August 31, 2018. Patients were identified using ICD-10 codes for alcohol related disorders. Those identified were included if they were 18 years of age or older and received at least one dose of phenobarbital for AWS. Patients were excluded if they were pregnant, had a Glasgow Coma Scale < 8, had phenobarbital documented as a home medication and/or a positive toxicology screen for barbiturates on arrival or required mechanical ventilation prior to phenobarbital administration. Patients were divided into two groups based on their first dose of phenobarbital; those who received greater than 260 mg and those who received less than or equal to 260 mg. The primary objective was to assess ICU length of stay. The secondary objectives were to evaluate benzodiazepine requirements using lorazepam equivalents and requirement of mechanical ventilation after the initial phenobarbital dose.
Presentation Objective: Identify the impact of the first dose of phenobarbital given to critically ill patients with alcohol withdrawal symptoms.
Self-Assessment: Do patients receiving a higher first dose of phenobarbital have different outcomes compared to those receiving a lower first dose of phenobarbital when used for alcohol withdrawal syndrome?
CLINICAL PERFORMANCE OF T2BACTERIA® PANEL ON WHOLE BLOOD FOR EARLY IDENTIFICATION OF BLOODSTREAM INFECTIONS T.J. Henderson, Deanne Tabb, Matthew McAllister Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: Sepsis is a life-threatening condition representing a frequent cause for patient admission to the intensive care unit. Inappropriate selection of antimicrobial treatment contributes to increased mortality when empiric regimens do not cover isolated pathogens. In contrast to culture-based technology, T2Bacteria® Panel (T2B Panel) allows detection of sepsis-causing pathogens from whole blood samples. The T2B Panel provides detection of Enterococcus faecium, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus in approximately 3-5 hours. The purpose of this study is to evaluate the impact of the T2B Panel in early pathogen identification and antimicrobial optimization in patients with sepsis presenting to the emergency department.
Methodology: A three-month prospective evaluation of patients presenting to the Emergency Department of Piedmont Columbus Regional Midtown in Columbus, GA with sepsis will be conducted. Patients presenting to the emergency department between February to April 2019 who are 18 years and older with a suspicion of severe sepsis identified in the emergency department will be included. Severe sepsis is defined as the presence of two systemic inflammatory response syndrome criteria (Temp 101°F or Fever within 48 hours, RR >20 bpm or PaCO2 10%, HR >90 bpm) and suspected infection along with hypotension (SBP
Vancomycin in combination with beta-lactam versus vancomycin alone in methicillin resistant Staphylococcus aureus bacteremia Juanne Lim, Alyssa Gould, Michael Gooch Novant Health Presbyterian Medical Center - Charlotte, NC
Background/Purpose: Vancomycin is the mainstay of therapy for methicillin resistant Staphylococcus aureus (MRSA) bacteremia. However when compared to beta-lactams, vancomycin has been shown to have slower bactericidal activity and slower time to bloodstream clearance. Synergy between vancomycin and multiple beta-lactams has been shown in vitro, though data evaluating the clinical impact are limited. The purpose of this study was to evaluate the impact of vancomycin with or without a beta-lactam on time to MRSA bacteremia clearance.
Methodology: This multicenter, retrospective chart review assessed adult patients with MRSA bacteremia treated with either vancomycin plus a beta-lactam for at least 24 hours or vancomycin monotherapy. Patients were admitted to one of three Novant Health inpatient facilities from January 1, 2015 to December 31, 2017. Identification of participants were identified by detection of MRSA on blood culture. Patients were excluded if they received one or more dose of other anti-MRSA agents prior to blood culture clearance, receipt of fluoroquinolone or aztreonam prior to blood culture clearance, no documented bacteremia clearance, or admission to onsite long-term care facility. Descriptive statistics were used to assess categorical data. Continuous data were analyzed using student t-test. Logistic regression will also be utilized.
Presentation Objective: Evaluate the clinical impact of combination therapy with vancomycin plus a beta-lactam compared to vancomycin alone on time to bacteremia clearance in patients with MRSA bacteremia.
Self-Assessment: While the mechanism of synergistic activity between vancomycin and beta-lactam agents are not well known, which one of the following is NOT a proposed theory of synergy?
Impact of Pharmacist-led Inhaler Training for Nurses on an Acute Care Pulmonary Unit Blake Johnson, Andrea Franks, Laura Bullock, Danielle Dennis, Timothy Self University of Tennessee Medical Center - Knoxville - Knoxville, TN
Background/Purpose: To determine if a brief, one-on-one inhaler technique educational intervention results in sustained nursing staff skill with Metered Dose Inhaler (MDI) and Dry Powder Inhaler (DPI) administration both immediately post-education and two months later.
Methodology: This study is a prospective, quasi experimental study with a one group pre-test, post-test design. Nurses were provided an inhaler medication in-service with pre-knowledge and post-knowledge test. Demographics, pre-educational confidence, and post-educational confidence were assessed via a written survey and inhaler technique was assessed via checklist. Participants taught inhaler technique to a standardized patient while an investigator evaluated technique. Percent error rates for the steps were calculated and compared pre-education and post-education, as well as post-education to two-month follow-up, to assess for change in inhaler technique education skill and sustained inhaler technique education skill.
Presentation Objective: Evaluate the impact of pharmacist-led inhaler education for nursing staff on technique improvement and confidence in inhaler technique skill.
Self-Assessment: Does inhaler technique education improve nursing staff skill in teaching, identifying, and remediating technique after education provided by a pharmacist?
Efficacy and Safety of High Dose Cyclophosphamide and Etoposide Induction in Patients with Relapsed/Refractory Acute Leukemia Ferrari AM, Moorman MT, Zapolskaya T, Rizzeri DA,and Mackey MC Duke University Hospital - PGY1 - Durham, NC
Background/Purpose: Acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) are characterized by clonal proliferation of abnormally differentiated hematopoietic cells that infiltrate bone marrow, blood, and other tissues. Genetic mutations underlie the pathology of these diseases and despite recent advances in targeted therapeutics, initial treatment with traditional chemotherapeutic agents remains the standard of care. Remission and survival are limited by complications, refractory initial response, and relapsed disease. Due to concerns for cellular resistance, research evaluating alternative induction regimens excluding traditional chemotherapeutics, such as cytarabine, has been ongoing. In 2003, Talbot et al. published a case series summarizing the effects of treating seven relapsed/refractory AML patients with high dose cyclophosphamide with etoposide. Two patients achieved complete remission and three patients progressed to hematopoietic stem cell transplant (HSCT). Results demonstrated that concurrent administration of these agents could be efficacious and safely administered in relapsed/refractory acute leukemia. Since 2003, this combination regimen has been used at Duke University Hospital (DUH) in patients with relapsed/refractory hematologic malignancies.
Methodology: This single-center, retrospective analysis will evaluate the efficacy and safety of this high dose cyclophosphamide and etoposide induction regimen. Patients with relapsed/refractory AML and ALL who received combination treatment between June 1, 2003 and July 31, 2018 at DUH will be included. Pediatric patients and those previously exposed to the combination regimen will be excluded. The primary objective is to determine the complete remission rate of those who received this combination regimen. Secondary objectives include determining rates of 30-day mortality, partial response, and progression to HSCT. Safety profiles of those treated will also be characterized.
Presentation Objective: Describe the benefits and risks associated with high dose cyclophosphamide and etoposide in relapsed/refractory acute leukemia.
Self-Assessment: What is a primary limitation of using high dose cyclophosphamide and etoposide in a relapsed/refractory patient population?
Timing of Direct-Acting Antiviral Therapy for Hepatitis C Virus in Liver Transplant Recipients Kimberly Goehring, Ryan Ford, Sarah Todd, Abigail Moorman Emory University Hospital - Atlanta, GA
Background/Purpose: To compare outcomes in liver transplant recipients with hepatitis C virus (HCV) after early vs. late initiation of direct-acting antivirals (DAAs) post-transplant
Methodology: Single-center retrospective chart review of adults who received DAAs for HCV post-liver transplant from 01/01/2012 to 09/01/2017. Patients were grouped according to timing of DAA initiation. Early initiation (EI) was within six months post-transplant, and late initiation (LI) was beyond six months post-transplant. The primary outcome was a composite of hospitalization, biopsy, or rejection treatment due to elevated liver function tests within the first year post-transplant. Secondary outcomes included graft function at 4, 8 and 12 weeks post-treatment, incidence of acute cellular rejection (ACR), achievement of sustained virologic response (SVR), and one-year graft and patient survival.
Results: Of the 53 patients included in the study, 79.2% were male, with a median age of 58 and median MELD of 25 at time of transplant. Of the sample, 69.8% were Caucasian, 26.4% were African American, 1.9% were Asian, and 1.9% other. Genotypes 1a, 1b, 2 and 3 represented 54.7%, 18.9%, 9.4%, and 17.0% of the sample, respectively. Thirty-one patients were in the EI group and 22 were in the LI group. The primary outcome occurred in 77.4% of patients in the EI group and 63.6% of patients in the LI group. One-year incidence of ACR was 45.2% and 18.2% in the EI and LI group, respectively. SVR was achieved in 83.9% of the EI group and 90.9% of the LI group. Both EI and LI groups experienced 100% one-year graft and patient survival.
Conclusions: Similar studies of greater magnitude are needed to draw definitive conclusions.
Presentation Objective: Compare timing of DAA initiation in patients requiring treatment for HCV after liver transplant.
Self-Assessment: Can SVR be achieved with DAAs when patients with HCV are treated after transplant?
A Proforma to Support Hiring a Team Member for Office-Based Opioid Treatment in Primary Care Mackenzie Farrar, Courtenay Wilson Mountain Area Health Education Center - Ashevill, NC
Background/Purpose: Opioid Use Disorder is a nationwide epidemic, but only 20% of people receive treatment. One barrier to Office-Based Opioid Treatment (OBOT) is the lack of team-based care, a successful care management strategy, due to financial constraints. Since OBOT is primarily medication management with buprenorphine, pharmacists are primed to provide interventions.
Methodology: In 2015, we started OBOT in a rural family medicine practice. Patients established with the practice for at least one year were eligible. In December 2016, we completed a manual chart review to determine the number of medical visits per patient per month in the year prior to OBOT (pre-OBOT) versus since enrollment (post-OBOT). Outcomes included: number of medical visits, payer type, and level of visit billed. Fourteen patients were insured by Medicaid, seven had private insurance, and two were self-pay. OBOT visits were 23.1% Level 3, 69.1% Level 4, and 7.8% Level 5.
Results: 23 patients were enrolled in OBOT. Pre-OBOT, patients were seen an average of 0.32 visits per month (range=0.00-1.17) versus 2.25 visits per month (range=0.75-5.00) post-OBOT, thus a net increase of 1.93 visits per patient per month. When building the proforma, we assumed all visits were reimbursed at the Level 4 NC Medicaid rate ($81.76). We accounted for 20% Cost of Business. If we provided care for 50 OBOT patients for one year, revenue would increase by $75,742.46 (50*1.93*12*81.76*0.80). If we provided care for 100 OBOT patients, we would increase revenue by $151,484.93 (100*1.93*12*81.76*0.80).
Conclusions: Interdisciplinary care is essential to managing OBOT patient_x0019_s complex medical needs. Increased medical billing can offset the cost of hiring team member.
Presentation Objective: Demonstrate the feasibility and necessity of hiring an additional team member to manage an interdisciplinary OBOT clinic.
Self-Assessment: How can you offset the cost of hiring an additional team member for an OBOT program?
Pharmacy Resident Interventions and Contributions in a Student-Run Free Clinic Joshua O Holmes, Erin L Collard, Michelle J Herrmann, Ann M Fugit Vidant Medical Center - Greenville, NC
Background/Purpose: The purpose of this project was to evaluate the growth of post-graduate year one (PGY1) residents through a novel, longitudinal experience in a medical student-run free clinic by assessing interventions made, along with characterizing the clinic practice and patient population.
Methodology: Pre-existing, de-identified databases of pharmacist interventions, clinic demographics, and prescriptions were assessed from July 2016 through August 2018. The primary outcome was the frequency of each intervention type per subject-visit made by PGY1 residents across quarterly segments. Interventions were excluded if provided by a non-PGY1 pharmacist or during the annual training period. Secondary outcomes included the proportion of advanced practice skill interventions and frequency of total interventions across quarterly segments. Primary and secondary outcomes were assessed with repeated measures ANOVA or logistic regression. Clinic demographics and practices were assessed with descriptive statistics.
Results: There were 604 interventions (604/1082; 55.8%) included after applying exclusion criteria. Interventions most commonly performed were medication therapy recommendation (209/604; 34%) and prescription facilitation (201/604; 33%). For the primary outcome, there was no statistically significant difference across the year for any individual intervention type (all p-values >0.05). This held true for total interventions (mean 1.08 interventions/subject-visit; range 0.92-1.27; p-value 0.115). There was no association between time and provision of advanced interventions (p-value 0.061).
Conclusions: There was no change in the types or frequency of interventions found in this analysis, nor was an increased frequency of advanced interventions detected.
Presentation Objective: To assess the change in frequency and type of interventions made by PGY1 pharmacy residents in a free clinic during a longitudinal experience.
Self-Assessment: Which type of interventions were performed most frequently by pharmacists in a free clinic?
Description of lab interference and outcomes for patients on factor Xa inhibitors transitioned to parenteral anticoagulation Justin Harrison, Oksana Kamneva, Debbie Liang, Russel Laundon, Jared Peak Rex Hospital - Raleigh, NC
Background/Purpose: Oral factor Xa inhibitors (fXi), including apixaban and rivaroxaban, directly affect anti-Xa anticoagulation assays used to monitor unfractionated heparin (UFH) and low molecular weight heparin (LMWH). The purpose of this study is to evaluate time off anticoagulation and adverse events in patients exhibiting lab interference from prior oral fXi use transitioned to LMWH or UFH.
Methodology: The institutional review board has approved this observational, retrospective, descriptive study. Patients on apixaban or rivaroxaban with a history of non-valvular Afib or VTE admitted between January 2017 and August 2018 to UNC REX for an ACS event or procedure were included. The primary endpoint was to evaluate time off anticoagulation in patients on titratable UFH (institutional titration nomogram), flat-rate (no anti-Xa adjustment) or LMWH during hospitalization. Secondary outcomes included incidence of safety events for UFH and LMWH groups.
Results: The average time off anticoagulation between oral and parenteral anticoagulation was 23.7, 17.4, and 27 hours for flat-rate UFH, titratable UFH and LMWH, respectively. The average time to UFH anti-Xa normalization was 54.6 hours. Major safety events for UFH within 90 days of admission were 4 (5%) VTEs, 2 (2%) strokes/TIAs, 1 (1%) other clot, 2 (2%) TIMI major bleed events, and 6 (7%) deaths. No major safety events were recorded in the LMWH group within 90 days of admission.
Conclusions: In this study, oral fXi interference on UFH anti-Xa assay was observed to persist on average of 54.6 hours with an mean time off anticoagulation was 17 hours.
Presentation Objective: To describe average time off anticoagulation and adverse events in patients exhibiting UFH anti Xa assay interference from previous oral fXi use.
Self-Assessment: True/False: Patients with acute kidney injury will experience prolonged anti-Xa lab interference while taking an oral factor Xa inhibitor compared to patients with normal renal function.
Diltiazem Versus Metoprolol for Rate Control in Patients Presenting to the Emergency Department in Atrial Fibrillation John Tyrrell, Derrick Clay, Miles Lane, Robert Steed Spartanburg Regional Medical Center - PGY1 - Spartanburg, SC
Background/Purpose: Nondihydropyridine calcium channel blockers (nCCBs) and beta-blockers (BBs) and are both first line options for rate control in patients with atrial fibrillation with rapid ventricular rate (AF RVR). Guidelines suggest both are equally efficacious.
A national shortage of intravenous diltiazem, a nCCB, forced utilization of alternative agents including metoprolol, a BB. This study was conducted to compare outcomes for patients in AF with RVR managed with nCCB versus BB.
Methodology: This is a single-center, retrospective cohort chart review looking at patient encounters between November 1, 2016 _x0013_ July 31, 2018, measuring the success rate of adult patients reaching target heart rate (HR) after administration of either a nCCB or BB in the ED for AF with RVR. Patients were excluded if they had unstable AF or if they received electrical cardioversion or chemical cardioversion with a Class I or III antiarrhythmic prior to administration of the study drugs.
Presentation Objective: Compare effectiveness of rate control agents for patients presenting to the ED in stable AF with RVR.
Self-Assessment: Are calcium channel blockers superior to beta blockers for rate control in stable AF with RVR?
ENTERAL VERSUS INTRAVENOUS PHENOBARBITAL BOLUS DOSING FOR ALCOHOL WITHDRAWAL SYNDROME Jennifer M. Misencik, PharmD, Tonya L. Thomas, PharmD St. Thomas West Hospital - Nashville, TN
Background/Purpose: To determine if a difference in clinical outcomes exists for patients given an enteral bolus dose of phenobarbital versus those given the standard intravenous (IV) bolus dose for the treatment of Alcohol Withdrawal Syndrome (AWS).
Methodology: This study was a retrospective cohort of patients at Ascension-Saint Thomas West Hospital who received IV or enteral phenobarbital bolus doses between April 1, 2017 and October 1, 2018. Patients 18 years of age or older with a diagnosis of AWS were included if they were initiated on the phenobarbital protocol within 24 hours of hospital admission, received either an enteral or IV bolus dose of phenobarbital, and were a medical intensive care unit (MICU) patient during the admission. The primary outcome analyzed was a difference in MICU length of stay between patients who received enteral versus IV phenobarbital as a bolus dose.
Results: After retrospective chart review 32 patients were included in the study. No significant difference existed in MICU length of stay between the enteral (n=16) and IV phenobarbital (n=16) groups. The enteral phenobarbital group was associated with a lower initial bolus dose (194.4 mg vs. 260 mg, p
Impact of BioFire FilmArray Blood Culture Identification on the management of Staphylococcus aureus bacteremia Kiet Nguyen, Lacie McKamey, Sarah Green Novant Health Presbyterian Medical Center - Charlotte, NC
Background/Purpose: Staphylococcus aureus bacteremia (SAB) is a common infection associated with significant 30-day mortality rates that are estimated to be as high as 20 to 40 percent. In order to reduce mortality risk and treatment failures, SAB management should include prompt infectious diseases consultation, repeat blood cultures to ensure clearance, appropriate source control, definitive therapy with a targeted antistaphylococcal agent, intravenous antibiotic utilization for the entirety of treatment, and optimal treatment duration. The objective of this study is to determine the impact of BioFire FilmArray Blood Culture Identification (BCID) on the implementation of these standard of care measures in the management of SAB.
Methodology: This study is a retrospective chart review that evaluates the impact of BCID implementation on the management of SAB by comparing the composite endpoint before and after implementation. The composite endpoint consisted of documented mortality at 30-days, persistent SAB (greater than seven days), and recurrence of SAB within 30-days. Patients were included if they were aged 18 or older and had at least one positive blood culture where S. aureus was isolated.
Presentation Objective: Identify how the management of SAB has changed with the implementation of BioFire FilmArray BCID
Self-Assessment: Which of the following endpoints did BCID not have a statistically significant impact on?
Impact of FDA Drug Safety Alerts on Ambulatory Fluoroquinolone Prescription Rates in South Carolina Jeannette Bouchard, Majdi Al-Hasan, Julie Royer, Julie Justo Palmetto Health Richland/University of South Carolina College of Pharmacy (Infectious Diseases) - Columbia, SC
Background/Purpose: Since 2008 there have been six FDA Drug Safety Alerts regarding fluoroquinolone (FQ) antibiotics. This study aimed to evaluate the impact of the Safety Alerts on ambulatory FQ prescribing rates within the state of South Carolina (SC) between 2012 and 2017.
Methodology: State Medicaid and Employee Health Plan pharmacy claims for outpatient oral antimicrobials among adults aged 18 years or older from January 1, 2012 to December 31, 2017 were utilized. The study period was divided into 3 intervals based on release of FDA alerts. Intervals 1, 2 and 3 were defined as January 2012 - August 2013, September 2013 - May 2016, and June 2016 - December 2017. Linear regression was used to examine the change in FQ prescription rates in relation to the Safety Alerts. Prescription rates of other antimicrobials were also examined.
Results: Over the study period, the mean FQ prescription rate was 11.0 prescriptions per 1,000 person-months. There was a significant decline in mean FQ prescription rates between intervals 1, 2 and 3 (12.8, 11.4 and 8.3 prescriptions per 1,000 person-months, respectively; p
Describing current practices of pharmacist-driven dose adjustment of prophylactic enoxaparin in medically-ill, obese patients Sara Catherine Pearson, Laura Bullock, Jennifer Mendez, Robert Moye University of Tennessee Medical Center - Knoxville - Knoxville, TN
Background/Purpose: Dosing recommendations for enoxaparin do not provide guidance on dose adjustment in patients with a body mass index (BMI) greater than 40 kg/m2. In the absence of clear dosing recommendations, pharmacists must rely on existing data in primary literature on which to base dose adjustments. This study aims to describe the practices of pharmacists at an academic medical center for adjusting doses of prophylactic enoxaparin in this challenging clinical situation.
Methodology: This is a cross-sectional study of medically-ill patients, age 18 years and older with class III obesity who received venous thromboembolism prophylaxis (VTE) with enoxaparin at this institution. Patients are included if they are at least 18 years of age, have a body mass index greater than or equal to 40 kg/m2, and received enoxaparin for venous thromboembolism prophylaxis during their admission. The primary objective is to describe the prevalence of enoxaparin dose adjustment. Secondary outcomes are prevalence of clinically relevant bleeding, prevalence of venous thromboembolism, length of stay, rates of thirty day readmission and average enoxaparin dose adjustment.
Results: To be presented.
Conclusions: To be presented.
Presentation Objective: Describe the risks and benefits associated with enoxaparin dose adjustment in medically-ill patients with BMI greater than 40 kg/m2.
Self-Assessment: What is one benefit of increased enoxaparin dosing for VTE prophylaxis in medically-ill, obese patients?
Incidence of invasive fungal infections in acute leukemia patients with micafungin or second-generation azole prophylaxis Heather Morris, Tanya Zapolskaya, Meredith Moorman, Melissa Mackey Duke University Hospital PGY2 Oncology - Durham, NC
Background/Purpose: Standard therapy for both acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) is myelosuppressive, and patients are expected to be neutropenic for a prolonged period. Due to the high risk of infection, antimicrobial prophylaxis is warranted and should be continued throughout neutropenia. The incidence of documented invasive fungal infections ranges from 12 to 24% in patients with AML and approximately 6.5% in patients with ALL. Guidelines currently recommend posaconazole as a category 1 recommendation for antifungal prophylaxis, with enchinocandins and other azole antifungals, as category 2B. However, posaconazole can be subject to drug-drug interactions and can increase the risk of hepatotoxicity, both of which can be problematic in acute leukemia patients undergoing chemotherapy. For patients unable to receive posaconazole or another second-generation azole antifungal, micafungin is utilized.
To our knowledge, there are no studies comparing second-generation azole antifungals to micafungin as prophylaxis in both AML and ALL during initial or relapsed/refractory induction therapy. The aim of this retrospective study is to compare the incidence of invasive fungal infections in patients with acute leukemia in the setting of micafungin or second-generation azole antifungal prophylaxis during initial and/or relapsed/refractory induction therapy at an academic medical center.
Methodology: Retrospective, single-center study from June 22, 2013 to June 22, 2018.
Presentation Objective: 1. Compare the incidence of invasive fungal infections in patients with acute leukemia in the setting of micafungin or second-generation azole antifungal prophylaxis during initial and/or relapsed/refractory induction therapy
Self-Assessment: 1. What is the recommended first-line antifungal for adult acute leukemia patients during induction chemotherapy?
Pediatric intravenously administered medication concentration standardization and smart pump integration Paul Bauman, Kelley Norris, Stephanie Lively Augusta University Medical Center/UGA College of Pharmacy PGY2 Pediatrics - Augusta, GA
Background/Purpose: There has been an increased emphasis on medication safety in regards to standardized concentrations of intravenously administered medications. Multiple national organizations have issued statements not only highlighting the severity of medication errors in the pediatric population but also providing guidance for improving patient safety, including standardizing available concentrations of IV medications in the pediatric population and using available technology appropriately, efficiently, and judiciously. In response to these concerns, institutions across the nation have begun implementing procedures aimed at standardizing IV concentrations and implementing the full potential of smart pump technology in the care of pediatric patients. The objective of this quality improvement project is to standardize the concentrations available for IV administered medications at an academic children_x0019_s teaching hospital, implement these standardized concentrations into the IV pump libraries, and assess nursing satisfaction before and after concentration standardization.
Methodology: A stepwise approach will be implemented to accomplish this quality improvement project. First, the current library concentrations of the two IV pumps currently being used were evaluated regarding continuous and intermittent IV medications to determine potential opportunities for standardization. Next, appropriate standardized concentrations were established for both continuous and intermittent infusions with oversight and approval from the appropriate institutional committees. Next, an appropriate method for producing and dispensing standardized intermittent IV medications (i.e. bulk bags) will be created and implemented into the pharmacy workflow. Next, the approved standardized concentrations will be implemented into the current software of the Plum 360 IV pump and Medfusion IV syringe pump. A nursing satisfaction survey will be disseminated and collected before and after implementation of the standardized concentrations to assess current and post-implementation satisfaction.
Presentation Objective: Demonstrate how standardizing IV medication concentrations may improve patient safety and nursing satisfaction.
Self-Assessment: What are ways that pharmacy staff may improve patient safety and nursing satisfaction?
Evaluation of a telephone intervention pilot program on antidepressant adherence Audrey Kivlehan, Dana Chiulli, Bonnie Balderose Ralph H. Johnson VA Medical Center - Charleston, SC
Background/Purpose: The Veterans Health Administration utilizes two measures to evaluate antidepressant medication adherence. MDD43h measures the percentage of patients on a new antidepressant medication with possession for at least 84 days out of 114 days of continuous treatment and MDD47h for at least 180 days out of 230 days of treatment. To improve medication adherence, a telephone intervention pilot program by a mental health (MH) nurse and clinical pharmacy specialist (CPS) was implemented. The purpose of this project is to evaluate the impact of the program on MDD43h and MDD47h and describe the outcomes of interventions made by the MH nurse and CPS.
Methodology: Retrospective analysis of all patients at the Ralph H. Johnson VA Medical Center from July 2017 to June 2018 that have telephone encounter notes from the pilot program. Notes were excluded if the encounter was unrelated to the program or if the encounter was for a non-antidepressant medication. The electronic medical record was utilized to collect patient demographics, medication, prescriber clinic and outcome of each encounter. Data analysis was through descriptive statistics.
Results: The analysis included 364 notes from 210 unique patients. There were 19 referrals made to the MH CPS with 12 for medication management, six for dose titrations and one for medication renewal. Over time, MDD43h and MDD47h facility scores improved, however, definitive conclusions about the impact of the pilot program on these measures cannot be determined due to data collinearity.
Conclusions: Although this program has an unclear impact on facility measures, it demonstrated increased patient access and provider follow-up. This program validates the utility of MH CPS in antidepressant management and an opportunity for increased utilization of MH CPS in the future.
Presentation Objective: To examine the impact of a telephone intervention program on antidepressant adherence.
Self-Assessment: What are reasons for antidepressant nonadherence?
Pharmacist-Prescribed Hormonal Contraception: Gauging Pharmacist Interest, Attitudes, and Knowledge in North Carolina Gwen Seamon, Allison Burke, Casey Tak, Macary Marciniak, Mollie Scott Mountain Area Health Education Center - Ashevill, NC
Background/Purpose: The objective of this study is to evaluate the attitudes, interest, and knowledge regarding pharmacist-prescribed hormonal contraception in North Carolina.
Methodology: A web-based survey was distributed via email to all actively licensed pharmacists residing in North Carolina from November 14, 2018 - December 13, 2018. Demographic data and pharmacy practice characteristics were gathered. Respondents in community-based settings were asked their perceptions regarding feasibility of implementation, barriers to implementation, and personal views on prescribing. All respondents were asked regarding support towards pharmacist-prescribed hormonal contraception. Descriptive statistics were used to characterize the responses.
Results: This Institutional Review Board-approved study had a 6% (713/12,001) response rate. Of those, 65% were female, 53% were less than 40 years old, 71% received a PharmD degree, and 16% completed a Postgraduate Year One pharmacy residency. The majority of respondents, 54%, reported their primary practice site as community-based.
Community-based pharmacists reported the most common barriers to impact prescribing ability were added responsibility and liability (81%), time constraints (79%), and need for additional pharmacist training (77%). Perceived benefits of prescribing ability were increased patient contact (91%), increased use and adherence by patients (81.02%), and improved access to hormonal contraception (80%). Overall, 46% of community-based pharmacists felt that pharmacists are well-trained/educated to prescribe versus 51% of non-community pharmacists.
Conclusions: Assuming barriers are removed and sufficient training is provided, most community-based pharmacists in North Carolina are likely to prescribe hormonal contraception. Study limitations include a low response rate and a convenience sample of respondents. This research supports legislation to permit pharmacist-prescribed hormonal contraception.
Presentation Objective: Identify potential benefits and barriers to prescribing hormonal contraception perceived by North Carolina community-based pharmacists
Self-Assessment: What is one potential benefit, identified by community-based pharmacists, of pharmacist-prescribed hormonal contraception in North Carolina?
Evaluation of a pharmacist-driven acute coronary syndrome heparin dosing protocol Suyasha Pradhan, Lakeshea Love, Alexas Polk Southeastern Regional Medical Center - Lumberton, NC
Background/Purpose: Southeastern Regional Medical Center (SRMC) utilizes a consult service that allows pharmacists to dose, monitor, and adjust intravenous heparin. The pharmacist initiates heparin therapy utilizing a standard dosing protocol based on indication. An institutional medication use evaluation reviewed seventy-eight patients initiated on heparin according to the acute coronary syndrome (ACS) dosing protocol and identified that obese patients (BMI > 30 kg/m2) had the greatest difficultly reaching therapeutic anti-Xa levels; requiring an average of two days to attain a therapeutic level. The average heparin rate required to achieve a therapeutic anti-Xa level was 1,471.6 units/hr for obese patients which lead to increasing the maximum initial heparin rate from 1,000 units/hr to 1,300 units/hr. The purpose of this study is to evaluate the efficacy and safety of changing the initial heparin rate for obese patients managed based on the ACS dosing protocol.
Methodology: The study was conducted from January 1, 2019 through March 31, 2019. Patients at least 18 years old, receiving heparin according to the ACS protocol and had at least one documented anti-Xa level were included in the study. Patients previously taking oral anti-Xa inhibitors, on a thrombolytic, or diagnosed with a deep vein thrombosis or pulmonary embolism were excluded from this study. Efficacy endpoints included time to first therapeutic anti-Xa level, number of anti-Xa levels drawn until therapeutic, and pharmacy interventions required to achieve a therapeutic level. Safety endpoints included number of supra-therapeutic anti-Xa levels and signs or symptoms of bleeding.
Presentation Objective: Describe the efficacy and safety of increasing the maximum initial heparin rate for obese patients managed in accordance with SRMC_x0019_s ACS dosing protocol.
Self-Assessment: How has implementation of a higher initial heparin rate impacted time to first therapeutic anti-Xa level in obese patients?
Comparing the Choice of Second Vasopressor in Septic Shock Refractory to Norepinephrine Logan McCall and Kelly Lobdell St. Vincent's Hospital - Birmingham, AL
Background/Purpose: We aim to evaluate the impact of the choice of second vasopressor in septic shock refractory to norepinephrine.
Methodology: In this retrospective observational study over 13 months, adult patients with a diagnosis of septic shock who received norepinephrine followed by a second vasopressor were enrolled. For statistical analysis the second vasopressor used was stratified into 2 groups: preferred agents, vasopressin or epinephrine, and alternative agents, phenylephrine, dobutamine, or dopamine.
Results: Among 369 patients screened, 65 patients were enrolled, aged 67.3 ± 13.8 years. In-hospital mortality was 75.4%. After receiving norepinephrine, 14 patients received vasopressin or epinephrine as the second vasopressor and 51 patients received phenylephrine, dobutamine, or dopamine. Duration of vasopressor therapy was 77.8 ± 77 hours in the preferred agents compared to 88.6 ± 76.3 hours in the alternative agents.
Presentation Objective: Identify recommended vasopressor agents in septic shock.
Self-Assessment: Which of the following agents is currently recommended by the Surviving Sepsis Guidelines to raise mean arterial pressure in patients with septic shock refractory to norepinephrine?
Comparison of the Safety and Efficacy of Heparinoids and Direct Oral Anticoagulants in the Setting of Critical Illness John Carr, Joseph Crosby, Samuel Pavlichek, Wynn Dubuc, Sabrina Croft St. Joseph's/Candler Health System (Critical Care) - Savannah, GA
Background/Purpose: Direct oral anticoagulants (DOACs) are agents used for treatment of or prophylaxis against thromboembolic events. Although numerous studies exist evaluating the safety and efficacy of these agents for a variety of indications in both ambulatory and medically ill patients, no studies are available assessing these medications in the critically ill. In contrast, parenteral heparinoids, including heparin and enoxaparin are frequently used in this population. We sought to compare the safety and efficacy of heparinoids and DOACs by observing the incidence of bleeding events and thromboembolic events in the critically ill population.
Methodology: Patients treated with heparin, enoxaparin, or a DOAC for at least 3 days while in an intensive care unit were included. Patients were excluded if there was an indication for anticoagulation present other than nonvalvular atrial fibrillation, pulmonary embolism, upper extremity venous thromboembolism, or lower extremity venous thromboembolism. Co-primary outcomes were incidence of bleeding events and incidence of thromboembolic events in patients receiving a heparinoid (heparin or enoxaparin) compared with those receiving a DOAC.
Results: Data were collected on 205 patients who received a direct oral anticoagulant and 98 patients who received heparin. Data collection for patients receiving enoxaparin is incomplete. There was no significant difference in the incidence of thromboembolic events in patients receiving heparin compared with DOACs (5.4% vs 4.6%; p=0.39); however, the incidence of bleeding events was significantly greater in the heparin group (24.1% vs. 5.7%; p
Evaluation of targeted pharmacist education on HIV medication adherence rates Whitney Testorf, Joshua Kinsey, Shauna Markes-Wilson, Katina Richmond Mercer University School of Pharmacy - Atlanta, GA
Background/Purpose: Medication adherence is an essential component of treatment for human immunodeficiency virus. Unfortunately, a large number of patients still fail to maintain suitable anti-retroviral therapy adherence. To address these barriers to adherence, we are looking to determine if continuous, targeted education designed for pharmacists impacts patient adherence rates and clinical outcomes associated with HIV in the community setting.
Methodology: Prospective study comparing HIV adherence rates over a 6-month period. Educational handouts will be created on the clinical management of HIV and distributed monthly to select chain community pharmacists. Data from the pharmacy's scorecard will be used to measure patient adherence rates, specifically focusing on patient care metrics including synchronization percentage, late refill percentage, and proactive patient care percentage.
Results: At this time, four educational handouts have been distributed. Following the first month of distribution, patient care metrics were stable at 90% for synchronization, up to 15% for late to refill from 13% the month previously, and down to 75% from 77% for proactive patient care. With the completion of this study, it is anticipated that by continuing to educate pharmacists on the proper clinical management of HIV, patient adherence rates for anti-retroviral therapy will improve.
Conclusions: Specially trained and highly educated pharmacists have the opportunity to improve adherence by providing patient education, maintaining medication inventory, and ensuring patients receive their complete ART regimen. It is my hope to increase pharmacist knowledge on HIV medication management and to improve pharmacist confidence in caring for patients living with HIV.
Presentation Objective: To reinforce the need for pharmacist education to enhance the care of patients living with HIV and to demonstrate the impact it can have on patient adherence rates.
Self-Assessment: True or False: Continuous, targeted education designed for pharmacists improves patient adherence rates for anti-retroviral therapy in the community setting.
The Economic Impact of Early Discharge Using Dalbavancin for the Treatment of Acute Bacterial Skin and Skin Structure Infecti Amanda Lowney, Alyssa Gould, Jamie Warren Novant Health Rowan Medical Center - Salisbury, NC
Background/Purpose: A significant increase in hospitalizations due to ABSSSI necessitates the need for treatment models focused on facilitation of early discharge and admission avoidance. The increasing prevalence of multi-drug resistant pathogens implicated in ABSSSI limits available treatment strategies. Dalbavancin, a long-acting lipoglycopeptide, offers convenient one-time dosing and provides coverage of the most common pathogens while avoiding nephrotoxicity. The purpose of this study is to identify potential cost savings associated with using dalbavancin for early discharge of patients with ABSSSI.
Methodology: Patients admitted to one of four acute care facilities with a diagnosis of ABSSSI were prospectively screened for early discharge with intravenous dalbavancin. Eligible patients were adult patients with an expected length of stay of at least 3 days, at least one systemic sign of infection, and at least two local signs of infection on admission. Further exploratory analysis was performed on patients who did not meet the inclusion criteria based upon the absence of systemic involvement. This subgroup was considered eligible for admission avoidance. A cost minimization analysis was performed in order to determine the potential cost savings associated with reducing length of stay.
Presentation Objective: Assess the estimated financial impact associated with early discharge on dalbavancin in patients with ABSSSI.
Self-Assessment: Which of the following is not applicable when considering dalbavancin for early discharge of patients with ABSSSI?
Impact of a multi-factorial initiative to improve the ordering of thyroid laboratory tests Alyssa Bradshaw, Cynthia Burns, Alex Bonnecaze, James Beardsley Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Published data shows that thyroid laboratory tests are often ordered inappropriately, which leads to unnecessary costs and inappropriate therapy decisions. Pilot data indicates that about two-thirds of the thyroid stimulating hormone (TSH) labs at our institution are unneeded, correlating to a potential cost avoidance of over $300,000 annually. The purpose of this study was to improve the appropriateness of thyroid test ordering through a multi-faceted intervention.
Methodology: This retrospective, single-center, before and after study included patients who were at least 18 years of age, admitted inpatients or emergency department patients of Wake Forest Baptist Medical Center and who had a TSH lab ordered during the study period. Patients were identified using a SlicerDicer report and screened in a random order for study inclusion until 33 patients per study week were reached. Study weeks included the first full week of January, February and March of 2018, which were compared to the first full week of corresponding months the following year. Patients with a history of thyroid cancer were excluded. The initiative included an electronic ordering intervention, which inserted criteria for appropriate test ordering into the order screen, direct education of providers (medical residents, attendings and clinical pharmacists) and distribution of pocket cards. The primary objective was analyzed by comparing the number and percentage of inappropriate TSH labs ordered before and after implementing the initiative. Secondary objectives included measuring cost savings, assessing inappropriate changes in thyroid therapy based on improperly ordered tests and the number of free T4 lab tests ordered on patients with a normal TSH.
Presentation Objective: Describe a multi-factorial initiative to improve ordering of thyroid monitoring tests.
Self-Assessment: When is it appropriate to order a thyroid-stimulating hormone (TSH) test in the acute care setting?
Evaluation of the Treatment Choices, Efficacy and Tolerability of Treatment in Relapsed NSCLC post first line immunotherapy Breanna Taylor PharmD Sally Barbour PharmD BCOP CPP FHOPA Tom Stinchcome MD Duke University Hospital PGY2 Oncology - Durham, NC
Background/Purpose: Inhibitors of programmed death ligand-1 are effective therapies for metastatic NSCLC. The use of these agents either alone or in combination with chemotherapy have changed the standard of care for NSCLC. For patients with a PD-L1 tumor proportion score of greater than or equal to 50% pembrolizumab has replaced chemotherapy as the first-line treatment choice. For those whose score is less than 50%, pembrolizumab in combination with chemotherapy is preferred for both non-squamous and squamous histology. KEYNOTE-189 was a phase III trial that evaluated 616 patients with advanced nonsquamous NSCLC who received chemotherapy with either pembrolizumab or placebo. After a median follow-up of 10.5 months, the estimated rate of overall survival at 12 months was 69.2% in the pembrolizumab-combination group versus 49.4% in the placebo-combination group. The increased survival benefit of patients with NSCLC related to the addition of immune checkpoint inhibitors has substantiated their integration into clinical practice. For those who are refractory to treatment despite the addition of immunotherapy to their regimen it is unclear what their second-line agent should be and how effective it is in improving overall survival and progression free survival.
Methodology: Retrospective review of patients 18 and older with a diagnosis of non-small cell lung cancer who were treated at Duke University Health System. Patients had to have received pembrolizumab or chemotherapy and pembrolizumab as first-line treatment.
Results: In process
Conclusions: In process
Presentation Objective: The primary objective of this study is to determine the receipt and effectiveness of second line chemotherapy treatment in the immunotherapy refractory setting.
Self-Assessment: What second-line treatment options have been used most commonly for immunotherapy refractory patients with non-small cell lung cancer?
Implementation of NINJA program in hospitalized patients with Cystic Fibrosis Shelby Newton, Emily Kurzen, Rachel Linnemann, H. Stella Shin Children's Healthcare of Atlanta - Atlanta, GA
Background/Purpose: NINJA (Nephrotoxic Injury Negated by Just-in-time Action) is a quality improvement initiative aiming to decrease nephrotoxic medication (NTMx)-associated acute kidney injury (AKI) in hospitalized children. Cystic Fibrosis (CF) patients hospitalized with pulmonary exacerbations are exposed to multiple NTMx. The primary objective was to implement and evaluate the NINJA program in hospitalized CF patients at Children's Healthcare of Atlanta.
Methodology: CF patients admitted to the pulmonary service aged 0-21 years were evaluated 4-months pre- and post-NINJA implementation. Patients with high NTMx exposure were identified using an electronic reporting tool that triggered the pharmacist to alert the medical team and recommend Monday/Wednesday/Friday serum creatinine (SCr) monitoring. High NTMx exposure was defined as 3 or more NTMx given concurrently or at least 3 consecutive days of intravenous aminoglycosides or vancomycin. Outcomes assessed were rate of SCr monitoring, NTMx exposure, and incidence of AKI pre- and post-NINJA implementation.
Results: Nineteen patients (25 exposures, median age 16 years) were identified pre-NINJA and 20 patients (26 exposures, median age 13.5 years) were identified post-NINJA. SCr monitoring increased from 13% to 50% of NTMx exposure days in the pre- versus post-NINJA time frame. There were more NTMx exposure days in the post-NINJA time frame, from 250 to 521 exposure days per 1000 patient days. Pre-NINJA data revealed 2 cases of AKI, while post-NINJA data revealed 6 cases (relative increase of 29%).
Conclusions: Increased SCr monitoring for patients with NTMx exposure utilizing NINJA uncovered more episodes of AKI. Increased prevalence of NTMx use was associated with increased rates of AKI. Increased SCr monitoring as a result of NINJA implementation may allow for earlier detection of AKI.
Presentation Objective: Describe the rates of NTMx exposure and NTMx-AKI pre- and post-implementation of NINJA.
Self-Assessment: Name one intervention that can be made in patients at risk for NTMx-AKI?
Pharmacist improvement of opioid safety in patients at risk for opioid-induced respiratory depression Claudia Cooper Caromont Regional Medical Center - Gastonia, NC
Background/Purpose: In 2014, 51% of 1.14 million nonsurgical patients in U.S. hospitals received an opioid during an inpatient admission, where 0.6% of administrations resulted in an opioid-related adverse event. According to the Joint Commission, receiving concomitant benzodiazepines increases patients_x0019_ risk for opioid-induced respiratory depression (OIRD). The aim of this study is to improve opioid safety through pharmacist intervention in admitted patients receiving opioids with concomitant benzodiazepines. In addition, patients with a documented naloxone administration in the inpatient setting are reviewed, as these patients are predicted to be at risk for having a repeat event.
Methodology: All admitted patients during the study period with an active opioid order and a concomitant benzodiazepine order were reviewed to screen for appropriateness. In addition, a daily report was generated of hospital inpatients who received naloxone to determine the need for pharmacist intervention. Interventions outside of the pharmacist scope of practice were recommended to the attending provider. A retrospective review was conducted of patients that met inclusion criteria from January 1, 2018 to March 31, 2018 and compared to the prospective data collected from January 1, 2019 to March 31, 2019. The primary endpoint is the average daily oral milligram morphine equivalents (MME) prescribed per patient. The secondary endpoints are the number of active opioid orders per patient, number of naloxone administrations, and length of stay in the pre- and post-intervention groups.
Results: Pending
Conclusions: Pending
Presentation Objective: Describe the risk factors associated with opioid-induced respiratory depression and identify several interventions pharmacists can make to decrease this risk.
Self-Assessment: What factors may increase a patient_x0019_s risk for respiratory depression while receiving opioid therapy?
Assessing Behavioral Health Patients_x0019_ Comprehension of Medication Knowledge Before and After Pharmacy Led-Education Sessions Lory Calderon Parkridge Health System Residency Program - Chattanooga, TN
Background/Purpose: Medication counseling has shown to be effective in a myriad of chronic illnesses by improving adherence and clinical outcomes. Lack of data exists regarding the effectiveness and feasibility of pharmacy-led education groups.
The impact of pharmacy-led education groups on patients_x0019_ medication knowledge, medication adherence rates, and clinical outcomes in behavioral health patients is unknown.
Methodology: Pharmacists and fourth-year pharmacy students conducted weekly 30 _x0013_ 60-minute pharmacotherapy sessions to a group of five to ten behavioral health patients from October 15 to November 15, 2018. Pharmacy-mediated education sessions focused on improving patient medication knowledge on behavioral health medications. A total of 50 patients voluntarily participated in a one-time pharmacy-mediated education session and completed a pre-and post-education session questionnaire. Wilcoxon rank-signed test was used to determine if a statistical difference existed for individual and cumulative question scores after the intervention.
Results: Differences in patient knowledge of medication names, medication regimens, side effect profile, MOA, and lab monitoring parameters were all statistically significant.
Conclusions: Statistical difference was seen with an improvement of patients_x0019_ overall medication knowledge after a one-time pharmacy-led education session. The smallest difference was seen with changes in patients_x0019_ knowledge of medication regimen after the intervention. The biggest difference was seen with changes in patients_x0019_ knowledge of lab monitoring parameters after the intervention. It is important to note that patients had the lowest average baseline knowledge in lab monitoring parameters.
Presentation Objective: Design an inpatient psychiatric program to assess the impact of pharmacy-led education sessions on patients_x0019_ overall knowledge on behavioral health medications
Self-Assessment: In hospitals where pharmacists may not be able to conduct weekly pharmacotherapy sessions, can pharmacy students be utilized to continue offering services to inpatients?
Can pharmacists_x0019_/students_x0019_ education and training reduce mental health stigma?
Can an increase in medication knowledge correlate with better patient clinical outcomes?
Expansion of Transition of Care Services to Pre-Operative Areas in a Large Community Hospital Rachel Howorth, April Williams, Michele Moseley Huntsville Hospital - Huntsville, AL
Background/Purpose: Inaccurate medication histories are associated with an increase in medication errors and therefore potential harm. At our institution, nursing and our recently-established Transitions of Care (TOC) pharmacy team have shared responsibility for completing the patient_x0019_s admission medication history in various electronic medical record (EMR) applications as patients move throughout the hospital, leading to duplication of work and medication-related discrepancies. A pilot study was initiated utilizing the TOC pharmacy team to complete medication histories for surgery patients with planned hospital admissions. The goal of this project is to improve accuracy of medication histories for these patients and reduce nursing workload by obtaining a correct medication history at pre-admission testing, thereby reducing subsequent medication-related discrepancies and eliminating unnecessary duplication of work when the patient is admitted to the hospital.
Methodology: Data for this project was obtained using retrospective chart review, and Investigational Review Board approval was obtained prior to beginning. The EMR was used to identify surgical patients with documented medication histories completed by nursing from September _x0013_ October 2018. This baseline data was used to evaluate the process of nursing obtaining medication histories versus TOC pharmacy obtaining medication histories, and suggested that expansion of TOC into pre-operative areas would be beneficial. This expansion began with presentations at multidisciplinary committee meetings and staff education. Additionally, TOC pre-admission staffing schedules, training documents, and workflow enhancements were developed and implemented. Follow up data will be collected and evaluated to determine future directives for TOC in pre-operative areas and continued expansion throughout Huntsville Hospital.
Presentation Objective: Describe this hospital_x0019_s approach to implementing a new Transitions of Care pharmacy service in pre-operative areas.
Self-Assessment: List benefits and limitations of this approach to Transitions of Care pharmacy services in pre-operative areas.
Effect of high-stakes pre-graduation NAPLEX® practice exam on first-time NAPLEX® pass rates in graduating PharmD students Melissa A. Johnson; Peter T. Bulatao; Christopher E. Adkins South University School of Pharmacy (Academic) - Savannah, GA
Background/Purpose: The North American Pharmacist Licensure Examination® (NAPLEX®) has experienced a national decline in both overall as well as first-time pass rates over recent years. With a first-time NAPLEX® pass rate historically lower than the national average, South University School of Pharmacy (SUSOP) experienced a steep decrease in its first-time pass rate in 2017. The purpose of this study is to evaluate the impact of a high-stakes NAPLEX® practice exam on first-time NAPLEX® pass rates in graduating PharmD students at an accelerated 3-year pharmacy program.
Methodology: Eligible participants are SUSOP PharmD graduates for the 2015-2016, 2016-2017, and 2017-2018 academic years. The primary objective is to assess the difference in first-time NAPLEX® pass rates in SUSOP students that completed the high-stakes practice exam versus those that did not. The primary outcome is first-time NAPLEX® pass rates. Secondary outcomes include number of attempts to pass the practice exam, completion of mandatory review materials, high-stakes practice exam score, and NAPLEX® score on first attempt. A correlation coefficient will be used to determine the relationship between the high-stakes practice exam and first-time NAPLEX® pass rates. Chi-square analysis will be utilized to test for a difference in dichotomous variables.
Presentation Objective: Identify various review procedures with the potential to positively affect first-time NAPLEX® pass rates.
Self-Assessment: What factors of a NAPLEX® practice exam could have a positive effect on NAPLEX® pass rates?
Sustaining Clinical Pharmacy Services Utilizing North Carolina Medicaid Billing Claire Austin, Courtenay Wilson Mountain Area Health Education Center PGY2 Am Care - Asheville, NC
Background/Purpose: With the shortage of primary care providers, pharmacists are able to help fill a gap in care by increasing access and providing chronic care management especially in rural areas. Financial sustainability has long been the barrier to sustaining pharmacy services. Recent recognition of clinical pharmacist practitioners (CPP), North Carolina_x0019_s (NC) version of a collaborative practice agreement, as providers by NC Medicaid enables billing and provides a possible new way to sustain pharmacy in primary care.
Methodology: A business plan was created to layout how clinical pharmacy services would be started and sustained. NC Medicaid billing practices were reviewed. NC Medicaid credentialing was processed. An Excel tool was created to identify number of visits needed to create sustainable services utilizing Medicaid billing.
Results: Utilizing a previous method of 99211 billing, 6,007 visits would be needed to sustain a CPP position assuming a pharmacist salary + benefits of $125,000. This would require 10 half days of clinic each week with 12-13 encounters each half day. Based on current Medicaid billing percentages in our clinic, 15% 99212 visits, 55% 99213 visits, and 30% 99214 visits, 2115 visits would be needed to sustain a CPP position. This would require 9 half days of clinic per week with 5 encounters per half day.
Conclusions: By utilizing NC Medicaid billing, CPPs are able to bill at the level of service provided as opposed to the traditional billing method of billing only 99211. This allows for a more realistic schedule with less visits needed to break even or sustain an ambulatory care pharmacist position financially. This option depends on having a large enough Medicaid population.
Presentation Objective: Describe a new option for financial sustainability of clinical pharmacy services in North Carolina.
Self-Assessment: What is one limitation to sustaining pharmacy services with NC Medicaid billing?
High-dose methylprednisolone for prevention of postoperative atrial fibrillation in coronary artery bypass grafting Brandon Houseman, Travis Fleming, Sampaguita Wright University of Tennessee Medical Center - Knoxville - Knoxville, TN
Background/Purpose: Postoperative atrial fibrillation (POAF) is a common complication following coronary artery bypass grafting (CABG) in up to 30% of patients. POAF has been associated with increased hospital length of stay (LOS), stroke, and mortality. The 2011 American College of Cardiology Foundation/American Heart Association CABG guidelines recommend a beta-blocker or amiodarone without corticosteroids for prevention of POAF. While beta-blockers and amiodarone are commonly utilized, a consensus approach has not been established. Perioperative steroid use in CABG remains controversial due to conflicting evidence and potential for hyperglycemia, infection, and impaired wound healing. To date, studies of high-dose methylprednisolone have primarily included patients receiving beta-blockers and not amiodarone; its use with amiodarone warrants further study. The purpose of this study is to determine if use of preoperative high-dose methylprednisolone is associated with better outcomes in patients undergoing CABG at a large academic medical center who also received a beta-blocker or amiodarone for prevention of POAF.
Methodology: In this single-center, retrospective cohort study, patients who underwent CABG from October 1, 2016 to October 1, 2018 were assessed for eligibility. Patients who received methylprednisolone preoperatively were compared to those who did not. The primary outcome was incidence of POAF. Secondary outcomes include intensive care unit and hospital LOS, duration of mechanical ventilation, vasopressor requirements, and 30-day readmission rate. Postoperative safety outcomes include hyperglycemia, duration of insulin infusion, surgical site infection, antibiotic use, gastrointestinal bleeding, chest tube output, blood transfusions, and fibrinolytic use. The primary outcome was assessed by logistic regression. Continuous and categorical data were analyzed by independent samples t-test and chi-square test respectively.
Presentation Objective: Describe the use of various medications for prevention of postoperative atrial fibrillation in coronary artery bypass grafting.
Self-Assessment: What potential harms and benefits have been reported with use of corticosteroids for prevention of postoperative atrial fibrillation?
Comparing Medication Histories Obtained by Pharmacy Technicians and Nursing Staff in the Emergency Department Wesley Arrison, Erica Merritt, Allison Powell St. Joseph's/Candler Health System (Emergency Medicine) - Savannah, GA
Background/Purpose: An accurate medication history is crucial for maintaining continuity of care. There are numerous opportunities for discrepancies to occur, such as medication omissions, duplications, incorrect dosing, or incorrect frequencies. Medication discrepancies can prolong hospital length of stay, increase the number of future emergency department (ED) visits, and increase hospital readmissions. Numerous studies have established the advantages of utilizing pharmacy technicians to complete medication histories. We aimed to compare the accuracy of obtaining medication histories through pharmacy technicians compared to nursing staff.
Methodology: This was a single-center, retrospective, observational analysis of patients presenting to the ED between December 2018 through January 2019. A pharmacy technician received on-site training on how to properly obtain a medication history and performed medication histories on the days the pharmacy resident was present between 10:00 and 18:00. Medication histories were obtained by nurses on the days the pharmacy technician was not present. All study medication histories were reviewed for discrepancies by the pharmacy resident.
Results: Medication histories conducted by a pharmacy technician (n=102) resulted in a greater percentage of accurate medication histories (94.1% versus 57.8%; p< 0.01) when compared to those conducted by nurses (n=102). A total of 7 discrepancies were found in the pharmacy technician group compared to 131 in the nursing group (p
Impact of a Pharmacist Managed Protocol on the Inappropriate Usage of Proton Pump Inhibitors in Critically Ill Patients Emily Longaker, Sabrina Croft, Joseph Crosby, St. Joseph's/Candler Health Systems - Savannah, GA
Background/Purpose: Proton Pump Inhibitors (PPIs) are regularly employed to decrease the risk of upper gastrointestinal bleeding in critically ill patients, however these medications have been associated with increased risk of developing of nosocomial infections. Benefits and risks must be assessed when evaluating the appropriateness of stress ulcer prophylaxis. Our health system has several protocols that allow pharmacists to manage inpatient medications, however no protocol that enables pharmacists to discontinue inappropriate PPI therapy exists.
Methodology: A pharmacist-managed protocol was developed and implemented in three intensive care units at St. Joseph_x0019_s Hospital. Pharmacists reviewed PPI usage and discontinued PPIs that did not have an indication based on the criteria outlined in the protocol. A chart review was performed to evaluate patients who received PPIs pre-protocol implementation and post-protocol implementation. The primary outcome was the number of patients in which PPIs without an indication were not discontinued within 24 hours.
Results: This study evaluated 247 eligible patients between the pre-protocol and post-protocol intervention groups. In the pre-protocol arm (n=139), PPIs without an indication were not discontinued in 56.7% of patients. Of the patients receiving inappropriate PPI therapy, 43% were transferred to non-intensive care floors on PPI therapy without an indication. Post-protocol initiation (n=108), 10.7% of PPIs without an indication were not discontinued (p value less than 0.005). No patients were transferred to the non-intensive care floors on PPI therapy without an indication.
Conclusions: The implementation of a pharmacist managed protocol allowing for discontinuation of inappropriate PPI therapy resulted in a decrease in the inappropriate use of PPI therapy in critically ill patients.
Presentation Objective: Report the impact of a pharmacist managed protocol that allows for the discontinuation of inappropriate PPI therapy within a community hospital.
Self-Assessment: What is one potential side effect of proton pump inhibitor therapy?
Impact of a pharmacy resident and pharmacy students on MTM completion rate and reimbursement in a long-term care pharmacy Rachel Cole, Kristi Hawn, Nikki Sowards, Tyler Dougherty, Laura Schalliol South College School of Pharmacy - Knoxville, TN
Background/Purpose: Unlike nursing home facilities, assisted living facilities are not required by federal regulations to complete monthly DRRs (drug regimen reviews) for their residents. Completing Medication Therapy Management (MTM) sessions for these patients provides an opportunity for a vulnerable population to have a licensed pharmacist review their medications and make recommendations. Research is extremely limited regarding MTM services specifically for residents in assisted living facilities, especially in regard to a cost analysis for an independently owned long-term care pharmacy.
Methodology: The pharmacy resident, with assistance from rotational APPE students, will complete medication management services for patients in assisted living facilities who receive their medications from Mac_x0019_s LTC Solutions. The resident and APPE students will provide this service telephonically from Mac_x0019_s LTC Solutions. This research project will involve a record review over 20 weeks of the reimbursement generated from this MTM service and the change in completion rate for MTM. Data will be pulled from OutcomesMTM in the form of a report and completion rates will be recorded weekly. The primary outcome is MTM reimbursement from completed MTM sessions from October 2018 to February 2019. A completed MTM will be defined as a submitted claim for a physician consult or a complete medication review. This research may provide valuable data that may be used by independently owned long-term care pharmacies in implementing and/or expanding this service.
Presentation Objective: Determine the potential reimbursement generated from Medication Therapy Management services in a long-term care pharmacy.
Self-Assessment: What types of Medication Therapy Management services can the pharmacy be reimbursed for when the patient is not managing their own medications?
CHARACTERIZATION OF VANCOMYCIN DOSING REQUIRED TO OBTAIN THERAPEUTIC TROUGH LEVEL IN OBESE PATIENTS Alston Poellnitz;Natalie Tapley;Kenda Germain;Jessica Starr;Nathan Pinner Princeton Baptist Medical Center - Birmingham, AL
Background/Purpose: Vancomycin is the primary antimicrobial agent used to treat methicillin-resistant Staphylococcus aureus infections. Vancomycin is traditionally dosed using both population and patient-specific pharmacokinetic parameters, but these can be significantly affected in obese patients. An increased volume of distribution is expected in obese patients, which commonly leads to supratherapeutic trough levels. Due to limited data regarding vancomycin dosing in obese patients, characterizing the optimal dosing weight required to achieve therapeutic trough levels in these patients is essential to avoid overdosing and the complications associated with supratherapeutic levels. The purpose of this retrospective chart review was to characterize the vancomycin dose required to achieve a therapeutic trough level in obese patients.
Methodology: A retrospective chart review was conducted on a randomized sample of non-pregnant, obese (BMI > 30) patients at least 19 years of age that received vancomycin and had at least one documented serum trough level from January 2014 _x0013_ September 2018. A therapeutic trough level was defined as 10-20 mg/dL for cellulitis and 15-20 mg/dL for more severe infections. Patients were excluded if they had renal dysfunction (CrCl < 30 mL/min) or acute kidney injury, defined as an increase in SCr by 0.5 mg/dL or 50% from baseline on admission, that precluded initiation of a scheduled dosing regimen. Descriptive statistics were used to describe the collected data. The primary outcome was the mean vancomycin dose (mg/kg) required to achieve a therapeutic serum trough level (mg/dL). Secondary outcomes included time to achieve a therapeutic trough (hr), percent of patients achieving a therapeutic trough, incidence of acute kidney injury, and in-hospital mortality.
Presentation Objective: Initiate an appropriate vancomycin dosing regimen for obese patients with stable renal function.
Self-Assessment: What aspect of vancomycin pharmacokinetics is most affected in the obese patient population, and what effect would this have on vancomycin dosing?
Inpatient Hypoglycemia Rate Reduction Utilizing Best Practice Alerts Kaci Foster, Jessica Odom, Rebecca Sawyer, Li Hu, Joseph A. Ewing, et al. Greenville Hospital System PGY1 - Greenville, SC
Background/Purpose: Hypoglycemia has been identified as a contributor to the development of acute cardiovascular, neurologic and inflammatory complications in patients with and without diabetes in the inpatient setting. Risk factors for inpatient hypoglycemia include high dose insulin, acute changes in renal function, inappropriate timing of insulin administration, changes in dietary intake and the use of fluoroquinolones. The purpose of this study is to determine if the implementation of prescriber targeted decision support tools reduces the incidence of inpatient hypoglycemic events.
Methodology: This is a quasi-experimental, nonrandomized, pre-post intervention study. Included patients are those who are >/= 18 years old who experience a hypoglycemic event within 24 hours of insulin administration during hospital admission from October 1st, 2018 to March 31st, 2019. Excluded patients are pregnant women. The interventions consist of two Best Practice Alerts (BPAs) and five hypoglycemia banners that will alert both providers and nurses of patients at high risk for hypoglycemia. Triggers for the BPAs and banners include use of sulfonylureas with reduced renal function, high basal insulin doses based on weight and renal function, a previous episode of hypoglycemia during the admission, or concomitant use of fluoroquinolones and scheduled insulin. The primary outcome of this study is to achieve a 10% reduction of hypoglycemic events across the health system measured as a number of hypoglycemic events per 1000 patient days. Secondary endpoints include length of stay and mortality.
Presentation Objective: Determine if electronic alerts aimed towards prescribers contribute to reduced hypoglycemic events in patients who are receiving insulin during inpatient admission.
Self-Assessment: What are some of the complications caused by inpatient hypoglycemic events?
Dosing of vancomycin and aminoglycosides in pediatric patients on continuous renal replacement therapy Mark L. Vestal, Travis S. Heath Duke University Hospital - PGY1 - Durham, NC
Background/Purpose: In pediatric patients with acute kidney injury (AKI) and/or fluid overload, continuous renal replacement therapy (CRRT) is often the preferred method of renal replacement therapy, due to the ability to provide improved control of hemodynamics. Typically, in pediatric patients, foundational principles of CRRT are similar to adults, as the same CRRT devices are utilized; however, pharmacokinetic (PK) principles may be substantially different. Currently, data regarding the PK principles of pediatric patients receiving CRRT is lacking. In particular, empiric dosing of vancomycin and aminoglycosides, is not well defined in the literature.
Methodology: The primary objective of this retrospective, single-center, observational study was to determine the empiric dosing regimen to achieve therapeutic serum concentrations for vancomycin and aminoglycosides in pediatric patients who are receiving CRRT. Patients
Implementation of a Pharmacy-Driven Transitions-of-Care Post Discharge Pain Management Program Meghan Bresnan, Kim Clarke, Laura Miller, Marci Swanson and Deborah Hobbs Carl Vinson VA Medical Center - Dublin, GA
Background/Purpose: As of January 2018, The Joint Commission has implemented new and revised provisions of care (PC) and elements of performance (EP) to improve the quality and safety of pain assessments and management. A portion of the standards (P.C.01.02.07, EP 8) focus on providing thorough discharge counseling which includes an explanation of the pain management care plan, side effects of medications and the safe use, storage and disposal of opioids. The purpose of this project is to aid the Carl Vinson Veterans Affairs Medical Center in meeting the Joint Commission standards, as well as, improve Veteran_x0019_s confidence in managing their pain by providing focused discharge counseling.
Methodology: Veterans were included if they were admitted to the acute care unit and received two or more doses of analgesics and excluded if they were transferred to another facility or to one of the long term care units at the facility prior to discharge. Patient satisfaction was assessed at the end of discharge counseling. Veterans were contacted two days post discharge to reassess their pain.
Results: Between September 2018 and February 2019, twenty-two Veterans met the inclusion criteria. Thirty-six percent of Veterans contacted met their numerical pain goals post-discharge and 100% of Veterans not meeting their numeric pain goals were appropriately referred to address this concern. All Veterans who completed the survey reported increased confidence and overall satisfaction in managing their pain after counseling.
Conclusions: Focusing on pain management during discharge ensures Veterans are referred back to their providers when their pain is not appropriately controlled during the acute discharge period and increases their confidence and satisfaction with managing their pain.
Presentation Objective: Discuss the importance of focusing on pain management during discharge counseling.
Self-Assessment: What challenges are associated with utilizing a numerical pain scale to assess pain?
Assessment of a health-system pharmacy technician medication history program Danielle Baker, Meredith Hollinger, Kelsey Lirette, Katherine Mieure Wake Forest University Baptist Medical Center - Health System Pharmacy Adm. - Winston Salem, NC
Background/Purpose: Despite efforts to maintain appropriate prior-to-admission (PTA) medication lists in the inpatient setting, medication discrepancies at the time of hospital admission remain an ongoing challenge. Approximately 50% of the medication errors that occur in the hospital are estimated to occur on admission and roughly 30% of these errors have the potential to cause harm. Recent studies recommend using at least two different sources of information in compiling a best possible medication history. However, literature focusing on the value of second source verification is limited.
Methodology: A prospective, randomized controlled intervention was conducted on patients admitted to a large academic medical center with a PTA medication list completed by a pharmacy technician between December 2018 and January 2019. Patients were excluded if admitted as observation status, admitted from a facility, or if discharged prior to the time of second source verification. The following endpoints were collected: patient_x0019_s medical record number, age, admission date and time, service admitted to, date and time of completed PTA medication list, date and time of second source verification, type of second source verification, medication name, dose, route, frequency, formulation, confidence level of pharmacy technician completing the initial PTA medication list, and the type of medication discrepancy. The primary outcome was the percentage of unintentional PTA medication list discrepancies not captured by pharmacy technicians. Secondary outcomes included the percentage of PTA medication lists completed, percentage completed within 24 hours, type of discrepancies, pharmacy technician_x0019_s confidence in completed PTA medication list, time to complete second source verification, and type of second source verification.
Presentation Objective: To determine the percentage of unintentional PTA medication list discrepancies captured by second source verification.
Self-Assessment: What percentage of unintentional PTA medication list discrepancies are captured by second source verification?
A Survey of Residency Graduates to Determine Factors for Sustainability of Clinical Pharmacy Services in Primary Care Erika Hauenstein,Claire Austin,Courtenay Wilson,Mollie Scott,Irene Ulrich Mountain Area Health Education Center PGY2 Am Care - Asheville, NC
Background/Purpose: Aging populations and nationwide shortages of primary care physicians combine for a need for additional healthcare team members. The benefit of the pharmacist is well established, but without provider status, financial models in a fee-for-service model are challenging. There is a need for workforce development around training ambulatory care pharmacists who are adept at creating financially sustainable positions.
A novel approach employed by the Mountain Area Health Education Center for pharmacy residency training in their post-graduate year two (PGY2) program, focuses on starting and sustaining clinical pharmacy services in a primary care practice that does not have a pharmacist. With this comes a need to determine when a primary care practice is ready to implement this innovative model, which is a gap in the literature. A 2018 workgroup surveyed national ambulatory care pharmacy experts and determined what they deemed were essential factors for readiness to implement ambulatory care pharmacy. The next step is to determine whether those essential factors correlate to sustained positions via the residency.
The purpose of this study is to describe factors contributing to sustainability of clinical pharmacy services within primary care practices and to determine the impact of post-graduate pharmacy education on resident_x0019_s future role in academia, leadership, and development of clinical pharmacy services.
Methodology: A survey was emailed via survey monkey to graduates (n=6) of the PGY2 MAHEC/UNC Eshelman School of Pharmacy Ambulatory Care residency.
Presentation Objective: Determine important factors contributing to sustainability of clinical pharmacy services within primary care practices.
Self-Assessment: Which of these is not a key factor contributing to sustainability of clinical pharmacy services within primary care practices?
a. Integration into the clinical team
b. Access to the electronic health record
c. Clinic is currently or is open to practicing team-based care
d. Ability to generate revenue through direct billing
The Implementation of a Warfarin to Direct Oral Anticoagulant Algorithm in Poor Warfarin Responders Asajah Duncan, Andrew Bundeff, Virginia Yoder, Andrew Hwang Wake Forest Baptist Health - Winston-Salem, NC
Background/Purpose: Atrial fibrillation and venous thromboembolism (VTE) are medical conditions that require adequate anticoagulation therapy as poor control increases the risk of thrombotic and hemorrhagic events. The Antithrombotic Therapy for Atrial Fibrillation: The College of Chest Physicians 2018 guidelines recommend considering interventions to improve time in therapeutic range (TTR) or switch to a direct oral anticoagulant (DOAC) when TTR is
Evaluating the dual impact of dose and time to administration of IV loop diuretics in acute heart failure patients Kimberly Keller, Travis Fleming, Sampaguita Wright, Laura Bullock Univeristy of Tennessee Medical Center (Internal Medicine) - Knoxville, TN
Background/Purpose: Current ACCF/AHA guidelines recommend that patients admitted with acute heart failure (AHF) and fluid overload promptly receive IV loop diuretics. For patients who are already receiving maintenance oral loop diuretic therapy prior to admission, the recommended initial IV dose should equal or exceed their daily maintenance dose. The purpose of this study is to evaluate the potential dual impact of dose and time to administration of IV loop diuretic therapy in AHF patients.
Methodology: The study design is a retrospective chart review of patients admitted through the emergency department with a primary diagnosis of AHF. Patients who received IV loop diuretics and had a history of chronic HF on maintenance oral loop diuretics prior to admission will be included. These patients will then be sorted into the following four groups: high dose (IV loop diuretic dose at least double the maintenance oral diuretic dose) or low dose (IV loop diuretic dose less than double the maintenance oral diuretic dose) and early administration (door-to-loop time less than 60 minutes from admission) or delayed administration (door-to-loop time greater than or equal to 60 minutes from admission). The following pertinent data will be collected: demographics, weight, intake and output, concurrent medications, ejection fraction, loop route of administration, and vital signs. The primary endpoint will be the time in hours to conversion from IV loop diuretic to oral loop diuretic therapy. Secondary endpoints will include length of stay, in-hospital mortality, 30-day readmissions, patients requiring supplemental IV loop diuretic doses post-oral conversion, worsening renal function, and rates of severe hypokalemia and hypomagnesemia.
Presentation Objective: To determine the effect of both the dosing and timing of IV loop diuretic therapy in AHF patients.
Self-Assessment: What is the potential benefit of early administration of guideline recommended doses of loop diuretics in AHF patients?
Early Post-Traumatic Seizure Prophylaxis Omission in a Low-Risk Geriatric Trauma Population C. Deri, M. Jaynes, S. Hamblin, B. Dennis, O. Guillamondegui, M. Patel Vanderbilt University Medical Center - Nashville, TN
Background/Purpose: The risk of seizures after traumatic brain injury can be reduced with the use of prophylactic antiepileptic medications. The literature supports the use of seizure prophylaxis in patients with severe traumatic brain injuries; however, studies are lacking to support this practice in mild traumatic brain injury patients. This study aims to compare post-traumatic seizure rates in mild traumatic brain injury patients who received seizure prophylaxis to those who did not.
Methodology: We performed a retrospective cohort study of patients 65 years or older with a mild traumatic brain injury (Glascow Coma Scale (GCS) score of 13-15 and not requiring hourly neuro checks) who were admitted to the trauma service. The trauma registry database (TRACS) was used to identify patients _x0013_ who were excluded if they had a history of epilepsy identified by ICD-9 or ICD-10 codes, prior antiepileptic drug (AED) use, post-traumatic seizure prior to arrival, hourly neuro checks, admission to an intensive care unit (ICU), or received levetiracetam for seizure prophylaxis. The primary outcome of the study was post-traumatic seizure rates within the first 7 days of traumatic brain injury. Secondary outcomes included in-hospital falls, 30-day readmission rates, discharge Ranchos Los Amigos scores, GCS on hospital days 2-3 and days 6-7, hospital length of stay, and disposition at discharge.
Presentation Objective: Explain the potential benefits and risks of seizure prophylaxis in traumatic brain injury patients.
Self-Assessment: What severity of traumatic brain injury patients has the most literature to support the routine use of seizure prophylaxis?
Efficacy associated with the addition of sodium bicarbonate in the treatment of hyperkalemia in the emergency department Shiyi Geng, Jessica Rivera, Emily Vance University of Alabama at Birmingham Hospital (Critical Care) - Birmingham, AL
Background/Purpose: Hyperkalemia is a frequent electrolyte disorder commonly encountered in the emergency department. While sodium bicarbonate is often used for acute lowering of serum potassium, its efficacy is not well established. The purpose of this study is to evaluate the amount of potassium reduction between patients who received intravenous sodium bicarbonate as part of treatment for hyperkalemia and those who did not.
Methodology: A retrospective electronic chart review was conducted on adult patients who presented to the emergency department from August 1, 2010 to August 31, 2018 with initial potassium greater than or equal to 5.4 mMol/L and received insulin as part of hyperkalemia treatment. The primary objective was to compare absolute reduction in first repeat potassium level from initial level between patients who received sodium bicarbonate in addition to insulin and those who did not. The secondary endpoints were to compare absolute reduction in repeat potassium levels at 2 hours, 4 hours, 6 hours, and 8 hours.
Results: (Preliminary)A total of 106 patients were included in this study. Thirty-eight patients received sodium bicarbonate in addition to intravenous insulin therapy and 68 patients only received intravenous insulin. The median initial potassium level was 6.6 mMol/L in the sodium bicarbonate group and 6.1 mMol/L in the insulin only group (p=0.009). Absolute reduction of potassium at first repeat was 1 and 0.9 mMol/L in the sodium bicarbonate group and insulin only group respectively (p=0.976).
Conclusions: (Preliminary) There were no differences detected in absolute potassium reduction at first repeat level between patients who received sodium bicarbonate and those who did not.
Presentation Objective: Evaluate the effects of addition of sodium bicarbonate in the treatment of hyperkalemia in the emergency department
Self-Assessment: Which of the following pharmacologic interventions may be included in the treatment of hyperkalemia?
Development of a Screening Tool to Identify Target Patients for Home-Based Pharmacist Review Amy Stewart, Mia Yang, Rachel Zimmer, Alyssa Stewart, Molly Hinely Wake Forest Baptist Health - Winston-Salem, NC
Background/Purpose: Create a screening tool that identifies patients most likely to benefit from pharmacist medication reviews in the home.
Methodology: Eligible patients were enrolled in Home-Based Primary Care (HBPC) or Transitional and Supportive Care (TSC) programs from July-January 2019. The screening tool included information from the electronic medical record (EMR) calculated prior to pharmacy residents_x0019_ in-home visits: electronic frailty index (eFI) scores, LACE (length of stay, acuity of admission, co-morbidities, emergency department visits) index scores, and number of high-risk medications defined by the 2015 American Geriatric Society Beers Criteria 5th Version. Pharmacy resident/provider pairs visited homebound patients and determined subjective assessments (low, medium, high risk) after considering health literacy, support network, medications, and detection of something unexpected. The EMR-based screening tool was then compared with pharmacy residents_x0019_ subjective risk assessments.
Results: 25 patients received home-based pharmacist medication reviews in this IRB-approved study. 7 (28%) patients were subjectively considered high-risk (would benefit from an in-home pharmacist). The mean number of high-risk medications was 1.9 (median = 2), mean LACE index score was 51 (median = 53 or moderate risk of readmission), and mean eFI score was 0.24 (median = 0.27 or very frail). Screening tool sensitivity and specificity and provider and pharmacy resident satisfaction rates will be available in April 2019.
Conclusions: This novel screening tool allows for targeted in-home pharmacist medication reviews. Further studies could broaden the application of this tool to all patients in need of pharmacist intervention and increase pharmacist involvement for patients at high risk for medication-related adverse outcomes.
Presentation Objective: Identify target patients for home-based pharmacist medication review.
Self-Assessment: What patient-specific factors can be considered for inclusion in a screening tool to identify patients in need of an in-home pharmacist review?
EFFECT OF PHARMACIST LED WEEKEND ANTIMICROBIAL STEWARDSHIP ON VANCOMYCIN UTILIZATION Bria Benson, Julie A. Justo, Joseph Kohn, Hana Rac, P. Brandon Bookstaver Palmetto Health Richland PGY1 Pharmacy - Columbia, SC
Background/Purpose: IDSA and CDC guidelines on implementing an antimicrobial stewardship program emphasize the importance of pharmacist leadership and integration of stewardship into routine pharmacy activities. Therapeutic drug monitoring conducted by pharmacists has been shown to reduce costs and decrease adverse effects. Prior to project initiation at Prisma Health _x0013_ Midlands, pharmacists routinely completed all vancomycin pharmacokinetic dosing and monitoring for the hospital over the weekend, however, antimicrobial stewardship was not an expected duty. The purpose of this study was to expand pharmacist-driven antimicrobial stewardship services to the weekend and analyze the effects on institution wide vancomycin utilization.
Methodology: This is an IRB-approved, retrospective, observational study evaluating the effect of expanded pharmacy rounding and antimicrobial stewardship weekend service at Prisma Health _x0013_ Midlands Richland on vancomycin use. The primary endpoint is the difference in hours of vancomycin use per patient on the weekends among pre-implementation period (December 2017 to March 2018), post-implementation Phase I representing expansion of critical care rounding pharmacist on the weekends (June 2018 to August 2018), and post-implementation Phase II representing additional expansion of antimicrobial stewardship service (December 2018 to March 2019). Secondary endpoints include number of vancomycin concentrations and time to vancomycin discontinuation on the weekends. A descriptive analysis of Phase I and II will include reason for discontinuation (eg rapid diagnostic results, MRSA nasal swab, susceptibility results) and percent of interventions accepted. THERADOC® was used to collect data on number of pharmacist notes, number of attempted interventions, accepted interventions, and rejected interventions.
Presentation Objective: Understand the purpose of expanding antimicrobial stewardship service and the impact that pharmacist-driven antimicrobial stewardship can have on time to optimal therapy.
Self-Assessment: What impact does the addition of weekend expansion of a critical care rounding component and targeted stewardship expansion have on vancomycin utilization?
Penicillin Allergy Assessment and Skin Testing (PAAST) in Outpatient Orthopedic Clinics Brittany S. Morrow, P. Brandon Bookstaver, Hana Rac, Julie Justo, Frank Vos Palmetto Health Richland/University of South Carolina College of Pharmacy (Infectious Diseases) - Columbia, SC
Background/Purpose: Allergic reactions to beta-lactam antibiotics, such as penicillins and cephalosporins, are reported in 10% of the overall population, although as many as 90% may be inappropriately labeled. As a result, patients are prescribed alternative, non-preferred antibiotics leading to increased drug related adverse events, opportunistic infections such as Clostridioides difficile infection and surgical site infections. Use of a penicillin allergy assessment and skin testing (PAAST) program has increased appropriate utility of preferred beta-lactam therapy, primarily in the inpatient setting. Expansion of PAAST to outpatient orthopedic clinics may improve antibiotic prescribing for surgical prophylaxis, mitigate the increased risk associated with alternative perioperative antimicrobial therapy, and optimize operating room workflow.
Methodology: This study is a single-center, observational, concurrent retrospective and prospective cohort study. The medical records of all adult patients scheduled for elective hip or knee surgery at Prisma Health_x0014_Midlands Orthopedic clinics from November 1, 2016 _x0013_ March 31, 2017, pre-implementation period of PAAST protocol, and November 26, 2018 -- March31, 2019 , post-implementation period of PAAST protocol, will be screened for inclusion. Patients are excluded if records with required data points are unavailable. The primary endpoint is percentage of patients prescribed guideline recommended cefazolin for surgical prophylaxis in the pre-implementation period compared to the post-implementation period. Descriptive statistics, will be used to summarize the primary outcome; t-test and chi-squared will be used for comparison as appropriate.
Presentation Objective: To assess the impact of allergy reconciliation and skin testing of self-reported penicillin allergies on preferred, prophylactic antibiotic use in patients undergoing elective outpatient hip or knee orthopedic surgery.
Self-Assessment: How does appropriate allergy reconciliation and skin testing impact the prescribing practice of antibiotic prophylactic options?
Perioperative Management of Anticoagulant and Antiplatelet Therapy in both Planned and Urgent Orthopedic Surgeries Gabriel Hinojosa, Megan Freeman, Sarah Murphy Northside Hospital - Atlanta, GA
Background/Purpose: Therapeutic anticoagulation is often required in patients with atrial fibrillation, mechanical heart valves, deep vein thrombosis, or pulmonary embolism. Management of these medications in the perioperative setting is complex and the frequency of this scenario is expected to increase as our population ages. The purpose of this evaluation is to assess the impact of an evidence-based guideline for the perioperative management of anticoagulant and antiplatelet therapy.
Methodology: A retrospective chart review was performed on patients taking anticoagulant or antiplatelet therapy undergoing orthopedic procedures, prior to implementation of the evidence-based guideline. Data was analyzed for trends in medication hold time prior to procedures, documented thromboembolic or bleeding events, delays in time to OR in urgent scenarios, and re-initiation of anticoagulants after surgical intervention. Data will be compared for similar patients after the implementation of the guideline.
Results: 100 patients meeting study criteria were reviewed retrospectively. Opportunity for optimization of therapy was identified in 26 cases. 15 involved direct oral anticoagulants that were held longer than recommended, and 7 involved antiplatelet therapies that were not held long enough. There were 0 serious bleeding events, and 1 thromboembolic event. 1 patient had an unnecessary delay to OR for urgent hip fracture repair, and re-initiation of therapy was not addressed in 1 patient.
Conclusions: Pre-implementation data suggests the need for a guideline to ensure standard management in these patients. Primary opportunities for improvement involved newer direct oral anticoagulants and antiplatelet medications. Implementation of an evidence-based guideline may improve optimal management of these agents in the perioperative setting.
Presentation Objective: Describe the optimal timing of discontinuation and re-initiation of anticoagulant and antiplatelet therapies in the perioperative setting.
Self-Assessment: What factors must be taken into consideration when deciding how long to withhold anticoagulant or antiplatelet therapy prior to surgical intervention?
Gabe Hinojosa, Pharm.D. is currently a PGY2 Hematology/Oncology Resident Pharmacist at Northside Hospital in Atlanta, GA. After receiving his Doctor of Pharmacy degree from the University of Mississippi in 2016, Gabe returned to his home state of Texas where he worked as a community... Read More →
Friday April 26, 2019 10:30am - 10:50am EDT
Parthenon 1
Adherence patterns to oral anticancer medications u for patients filling at an internal versus external specialty pharmacy C. McCabe, M.S. Barbee, M. Watson, A. Billmeyer, R. Haumschild, B. El-Rayes Emory University Hospital Midtown - Atlanta, GA
Background/Purpose: Pharmacies who dispense specialty medications are rapidly increasing in number across the nation. Now, more than ever, it is imperative for pharmacies to prove their benefit through real life data. Health-system specialty pharmacies (HSSPs) have potential for improved outcomes such as adherence and time-to-treatment (TTT) which is secondary to better visibility, continuity of care, and increased access to providers and electronic medical records.
Methodology: A retrospective chart review was conducted to compare the medication possession ratio (MPR), proportion of days covered (PDC), and TTT for patients who received oral anticancer therapy at Emory Healthcare. The primary outcome was MPR, which is defined as the ratio of days of therapy for each medication for each patient to the days of possession of medication. Secondary outcomes included PDC and TTT. Covariates that may influence adherence were also examined (age, insurance plan, prior authorization requirements, tumor type, gender, race).
Results: A significant difference was seen in MPR and PDC between the internal and external pharmacies (1.01 vs 0.67, p
Why do you do that thing you do? Describing the decision process of postoperative opioid and pain prescribing patterns in ort C Lanier, D Stewart, T Melton, A Salwan, M Jenkins, R Morelock, C Allen ETSU - Bill Gatton College of Pharmacy - PGY2 Internal Medicine - Johnson City, TN
Background/Purpose: The United States is currently embroiled in an opioid epidemic that has resulted in a cost of life and resources that were unimaginable thirty years ago. One of the most at risk groups of patients are surgical patients, notably orthopedic patients, for whom surgeons continually prescribe high quantities of postoperative pain medications. An issue facing surgeons is a lack of guidelines and direction related to individualization of opioid prescribing. The purpose of this study is to identify and categorize themes related to opioid prescribing and screening for risk of opioid abuse, or the lack thereof, and to quantify potential changes in the number of prescriptions written by orthopedic and general surgeons following the passage of opioid prescribing legislation in Tennessee beginning July 1, 2018.
Methodology: This retrospective, cross-sectional, cohort study utilizes both quantitative and qualitative methods. The qualitative component of the study will be a cross-sectional cohort, consisting of semi-structured interviews. Estimated format and length of interviews are one-on-one and roughly 30 minutes, based on questions and information reported. The quantitative section of the study will be a retrospective cohort to measure the impact of the new opioid prescribing laws on practitioner prescribing tendencies from surgeons performing select elective orthopedic and general surgery procedures. Cohorts will be established off of two differing time periods from August _x0013_ November of 2017 and August _x0013_ November 2018.
Presentation Objective: To describe and assess, within a regional hospital system, through use of a behavioral model, the attitudes, reasoning, and quantitative changes in post-operative opioid prescribing and in the approach to abuse risk screening by orthopedic and general surgeons.
Self-Assessment: What component of the theory of planned behavior was most responsible for opioid writing behaviors among surgeons?
Utilization of Gap Analysis to Assess Controlled Substances Management at an Academic Medical Center Eason BE, Vest TA, Mieure KD, Fritz LB, Burrus M, Tryon J Wake Forest University Baptist Medical Center - Health System Pharmacy Adm. - Winston Salem, NC
Background/Purpose: Controlled substances management is a highly regulated process due to risks and abuse potential associated with these medications. Regulations maintain a closed-system of controlled substances and are overseen by federal and state agencies. These regulations contribute to the complexity of management processes.
In recent years, press releases have highlighted difficulties in managing the regulations surrounding controlled substances management such as: record keeping, improper documentation, and instances of failure to report losses to the DEA.
Methodology: Utilizing the Controlled Substances Act (CSA), North Carolina CSA, The Joint Commission Standards and available literature, parameters were identified and defined for use in a gap analysis of the controlled substances management process. Through direct observation, individuals were shadowed and interviewed on current processes. Process maps were drafted to represent the entirety of the current controlled substances management process. The primary objective of this evaluation is to assess the compliance of current controlled substances management processes to a defined desired state.
Results: The medication use process has been mapped out for the areas that interface with controlled substances. These maps will then be analyzed and evaluated utilizing a gap analysis. The results of this analysis will be utilized to validate the current controlled substances medication management program.
Conclusions: Direct observation is an effective modality to evaluate the controlled substance medication use process in an academic medical center. Next steps will include prioritizing the identified areas for optimization and development of strategies for implementation of proposed improvements.
Presentation Objective: To describe the methods utilized in the evaluation of a controlled substances management process at an academic medical center.
Self-Assessment: What are components of controlled substances medication use that make the management more complex?
A Multidisciplinary Diabetes Management Team for Hospital Employees: Clinical and Financial Outcomes Omaima Arab, Emily Brinkman, Lori Hornsby, Ryan Crossman, and Kimberly Brax Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: Workplace-based clinics aim to improve employees_x0019_ health, reduce health-related expenditures, improve job satisfaction, and enhance overall productivity. For employees this service is a convenient and free way to improve their health and possibly lower their out-of-pocket expenses. Diabetes is a particularly important focus due to its growing prevalence and its association with increased morbidity and mortality, as well as reduced productivity at work. For all these reasons, workplace-based clinics may have a significant role to play in diabetes care. The purpose of this study was to evaluate clinical and financial outcomes of a multidisciplinary team-based approach for the management of diabetes offered to hospital employees as a part of a health and wellness program.
Methodology: A retrospective chart review was conducted of patients enrolled in the multidisciplinary chronic disease management program at Piedmont Columbus Regional Midtown Medical Clinic in Columbus, GA. The study explored the impact of utilization of the multidisciplinary disease management program on how effectively the participants_x0019_ diabetes was managed. Patients were included if they were older than 18 years of age with established diabetes mellitus and completed at least two visits in the clinic. This study looked at diabetes control and accompanying cardiovascular management, which were evaluated based on changes in hemoglobin A1c (Hb A1c) from baseline compared to end of study, appropriateness of drug therapy (aspirin, statin, recommended vaccines), and eye examinations. The study also reviewed changes in diabetes related medication costs and changes in adherence rates to medication.
Results: In progress
Conclusions: In progress
Presentation Objective: To describe the benefits of providing free clinic visits to hospital employees for management of chronic diseases.
Self-Assessment: What are the potential benefits from free workplace-based clinics offered to employees for management of chronic diseases?
Impact of Shared Medical Appointments on Diabetes Care in a Rural Internal Medicine Clinic Catie Travis, Candace Dixon, Amanda Carter, Charles Herring, Virginia Yoder Wake Forest Baptist Health - Winston-Salem, NC
Background/Purpose: As of 2017, it was estimated that 30.3 million Americans live with diabetes, totaling approximately $245 billion in direct and indirect costs. Studies have shown that group medical visits are a strategy for improving diabetes outcomes while reducing costs. There is little data regarding the use of group visits in rural populations. Recently, group visits, termed Shared Medical Appointments (SMA), were initiated at an internal medicine practice in North Wilkesboro, North Carolina. This study aims to investigate the impact of group visits on diabetes outcomes in the rural setting.
Methodology: This retrospective chart review included adult Type 2 Diabetes Mellitus patients seen by a provider at Internal Medicine _x0013_ Wilkes from September 1, 2017 to December 15, 2018. Patients had a baseline HbA1c of > 8.0% and were required to have a follow up HbA1c within thirty days of the end of the study period. Patients were excluded if they were followed by Endocrinology for diabetes management. Patients who attended at least one SMA were compared to those who did not attend a SMA during the study period. The primary endpoint was mean change in HbA1c from baseline. Secondary endpoints included the percentage of patients who met goal HbA1c < 8% and the percent of patients who met goal HbA1c < 7%. Exploratory endpoints included the incidence of hypoglycemia and the incidence of emergency department visits and hospital admissions related to diabetes.
Presentation Objective: Describe the impact of Shared Medical Appointments on the management of diabetes in a rural population.
Self-Assessment: What impact do Shared Medical Appointments have on diabetes management in a rural internal medicine clinic?
Process implementation for the management of acute VTE in patients discharged from the emergency department. Maura Jones, Sarah Eudaley, Shauntá Chamblerin, Cassey Peters University of Tennessee Medical Center (Pharmacotherapy) - Knoxville, TN
Background/Purpose: In the emergency department (ED), prescriber guidance to ensure patient access to medication is lacking upon diagnosis of venous thromboembolism (VTE) and immediate discharge home. This process varies between institutions and among providers. Due to lack of standardization, there is potential for patients to be discharged from the ED without access to appropriate duration of therapy or follow-up. The purpose of this study is to evaluate implementation of a standardized process for medication access following diagnosis of an acute VTE. The primary objective is patient satisfaction survey results. Secondary objectives include projected cost avoidance and individual survey components reflecting safety and efficacy outcomes.
Methodology: This is an institutional review board-approved, single-center, observational, quasi-experimental study. Adult patients with confirmed diagnosis of acute VTE and discharged from the ED to the community are included. Patients admitted to the hospital, discharged to a facility, and/or non-English speaking are excluded. Eligible patients are identified through electronic medical records and data is collected for the pre-implementation group between January_x0013_December 2018 and following implementation for the post-group. Components of the implemented process include patient eligibility for direct oral anticoagulant (DOAC), dosing and cost of selected DOACs, medication access options and prescriptions requirements, and patient education and follow-up instructions. Data collected includes patient demographics, VTE diagnosis, insurance and pharmacy type. Patient surveys conducted pre-implementation include select sections of the EDPEC patient satisfaction survey and additional assessment questions. Post-implementation surveys include the pre-implementation surveys and the VEINEs QoL/Sym for DVT only. Surveys are conducted via telephone following a standardized script.
Presentation Objective: Identify barriers to care for patient medication access following diagnosis of acute VTE and discharge from the emergency department.
Self-Assessment: What benefit(s) does a VTE treatment tool offer providers when discharging patients from the emergency department after diagnosis of acute VTE?
Retrospective Review of Treatment Practices for Chlamydia and Gonorrhoeae in a Community Hospital Emergency Department L. Davis; A. Powell; E. Merritt; S. Early; S. Sizemore; J. Crosby St. Joseph's/Candler Health Systems - Savannah, GA
Background/Purpose: Sexually transmitted infections (STIs) are considered an epidemic in the United States, and incidence rates are rising. The two most common infections, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), are frequently tested for, and sometimes empirically treated together in the emergency department (ED) setting. Our intuition_x0019_s ED screening method takes 24-72 hours to result, which leads to empiric coverage of some patients to ensure treatment, as well as follow up for positive results that were not treated with antibiotics appropriately. The aim of this study is to determine the percentage of patients treated inappropriately and the cost incurred to our institution.
Methodology: This investigation was a single-center, retrospective, observational analysis evaluating the occurrence of untreated positive CT and NG test results and empiric treatment for negative test results. Patients who received STI testing in the ED were evaluated for antibiotics prescribed, testing results, and time to appropriate treatment.
Results: Of the 875 patients included in this IRB-approved study, 30 patients were undertreated (3.4%), 304 were overtreated (34.7%), and 3 positive patients were lost to follow up. A chi square analysis determined that the difference between a 2x2 comparison test was statistically significant (p < 0.00001).
Conclusions: Patients who presented to the ED and received STI testing were treated inappropriately 38% of the time. Implementation of rapid diagnostic testing could improve overtreatment rates of negative results and chlamydia, as well as decrease the number of undertreated CT/NG positive results.
Presentation Objective: Determine potential of implementation of a rapid diagnostic testing practice in an emergency department setting
Self-Assessment: What potential benefits could be seen with the use of a point-of-care CT/NG testing practice?
Safety and Efficacy of Direct Oral Anticoagulants in Patients Discharged from the Emergency Department with Venous Thromboemb Lindsey Safley; Matt Felbinger; Chris Champion; Cliff Freeman;Tyler Barrett Vanderbilt University Medical Center - Nashville, TN
Background/Purpose: Venous thromboembolism (VTE) is a common disorder that affects 600,000-900,000 persons in the United States each year. Direct oral anticoagulants (DOAC) are commonly used to treat VTE, and current literature supports DOAC use as an outpatient-management strategy. The adult emergency department at an urban, university-affiliated, tertiary referral center implemented a protocol for low-risk emergency department (ED) patients diagnosed with VTE. Eligible patients were given their first DOAC dose in the ED and discharged with apixaban or rivaroxaban based on insurance, and had close outpatient follow-up scheduled. The study_x0019_s aim is to evaluate the safety and efficacy of using DOACs in low-risk VTE patients in an outpatient setting. We hypothesize the use of apixaban will be a safe and effective alternative therapy to vitamin K antagonists (VKA), low molecular weight heparin (LMWH), and other DOACs for VTE treatment.
Methodology: This is a single-center retrospective analysis of low-risk VTE patients discharged from the ED between July 1, 2016 and June 30, 2018. Eligible patients were identified using ICD-10 code diagnoses from ED discharge data associated with DVT/PE. Patients were excluded if they were hemodynamically unstable, had signs of right heart strain, elevated bleeding risk, active malignancy, pregnancy,or had other contraindications for outpatient oral anticoagulation. The primary outcome was the frequency of repeat visits to the ED or hospitalization due to complications of the VTE or DOAC treatment within 30 days from initial ED discharge. Secondary outcomes include 30-day adverse events such as major bleeding and worsening clot burden.
Presentation Objective: Describe the safety and efficacy of DOACs in the treatment of low risk VTE patients discharged from the ED.
Self-Assessment: Do the use of DOACs in the treatment of low risk VTE patients reduce readmission from secondary sequalae from VTE such as worsening clot burden or bleeding?
Impact of nasal methicillin-resistant Staphylococcus aureus (MRSA) screening on the length of empiric vancomycin therapy for Emily byers, Jarett Worden, Robin Tagatz St. Thomas West Hospital - Nashville, TN
Background/Purpose: The purpose of this study is to determine the extent to which nasal MRSA polymerase chain reaction (PCR) screening impacts length of empiric vancomycin therapy for pneumonia.
Methodology: This study is a retrospective chart review of adult patients treated for pneumonia empirically with vancomycin therapy. Patients were separated into two groups; non-PCR screened patients who were treated from April 1, 2017 to August 31, 2017 and PCR screened patients who were treated from April 1, 2018 to August 31, 2018. Data was analyzed to determine if the implementation of a nasal MRSA PCR screen impacted the length of empiric vancomycin therapy for pneumonia. Secondary outcomes include incidence of acute kidney injury (AKI), time to clinical improvement, and number of vancomycin levels drawn.
Results: The average length of therapy was 30.6 hours (± 34.9) and 60.9 hours (± 64.1) for the PCR group and non-PCR group, respectively (p=0.0045). Additionally, the median length of therapy for each group was 22.3 hours (9.6 _x0013_ 42) and 47.5 hours (27.4 _x0013_ 73.4). The difference between these groups for length of therapy was statistically significant. The secondary outcomes were similar between groups except for the number of levels drawn. The PCR group had 16 (32%) and the non-PCR group had 38 (76%) patients with at least one level drawn (p=0.0001).
Conclusions: The implementation of a nasal MRSA PCR screening significantly decreased the duration of empiric vancomycin therapy for pneumonia. This screening also allows for less monitoring (i.e. vancomycin levels). The incidence of AKI and time to clinical improvement is not significantly impacted by the utilization of this screening.
Presentation Objective: Determine if utilization of nasal MRSA PCR screening decreased duration of empiric vancomycin therapy for pneumonia.
Self-Assessment: Has utilization of the nasal MRSA PCR screening decreased the duration of empiric vancomycin therapy for suspected pneumonia?
Predictors for Early Clinical Response in Patients with Enterococcal Bacteremia Caroline Powers, Celeste Caulder, Abigail Bouknight, P. Brandon Bookstaver Palmetto Health Richland PGY1 Pharmacy - Columbia, SC
Background/Purpose: Early clinical response (ECR) may be a favorable endpoint for predicting long-term clinical outcomes, such as mortality, in patients with bloodstream infections (BSI). The objective of this study is to identify host and treatment factors associated with ECR in hospitalized, adult patients treated for Enterococcal BSI.
Methodology: This IRB-approved, retrospective, observational cohort study included adult patients hospitalized at Prisma Health Midlands from January 1, 2015 to July 31, 2018 with a blood culture positive for Enterococcus spp. Patients with a recurrent episode of Enterococcal BSI within one year of the index culture or polymicrobial infections were excluded. The primary endpoint is to determine host or treatment factors associated with ECR. ECR is defined as the presence of less than two of the following variables at 72 _x0013_ 96 hours from index blood culture: systolic blood pressure < 100 mmHg or vasopressor use, heart rate > 100 beats per minute, respiratory rate >/= 22 breaths per minute or mechanical ventilation, altered mental status, and peripheral white blood cell count > 12,000 cells/mm3. The secondary endpoints include hospital length of stay and BSI recurrence, hospital readmission, and mortality within 180 days of the index culture. T-test or chi square tests will be used to compare clinical outcomes and other factors between those with and without ECR. Logistic regression will be conducted to determine predictors of ECR.
Presentation Objective: List predictors for ECR in adult patients hospitalized for Enterococcal bacteremia.
Self-Assessment: What are predictors for ECR in adult patients with Enterococcal bacteremia?
Comparison of DOAC safety and efficacy in obese patients Mary Pat Bulfin, Zachary Klick, Jamie Warren, Regis Bender Novant Health Forsyth Medical Center - Winston-Salem, NC
Background/Purpose: To compare rates of occurrence of new venous thromboembolism (VTE) and bleeding events among obese patients with a weight or body mass index (BMI) greater than or equal to 120 kg or 40 kg/m2, respectively, receiving direct acting oral anticoagulant (DOAC) therapy.
Methodology: This multicenter, retrospective chart review was approved by the Institutional Review Board for evaluation of male and female patients who were greater than or equal to 18 years of age on DOAC therapy between January 1, 2015 and June 30, 2018. Patients with a weight or BMI greater than or equal to 120 kg or 40 kg/m2, respectively, receiving DOAC therapy with rivaroxaban, dabigatran, apixaban, betrixaban, or edoxaban prior to admission and/or during hospital admission were included. Patients were excluded if they were pregnant, breast feeding, diagnosed with cancer, or had a prosthetic heart valve. Primary efficacy endpoints included rate of new VTE, defined as a composite endpoint of occurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE) within 30 days of hospital admission, and all-cause mortality within 30 days of hospital admission. Primary safety endpoints included occurrence of clinically relevant non-major bleeding and major bleeding (according to the International Society of Thrombosis and Haemostasis definition), and occurrence of thrombotic events within 30 days of hospital admission. Secondary endpoints included rate of hospital readmission, duration of hospital stay, and rate of occurrence of each individual primary efficacy endpoint.
Presentation Objective: Investigate the influence of patient weight and BMI on DOAC dosing, safety, and efficacy by evaluating rates of VTE and bleeding events in obese patients.
Self-Assessment: What is the recommendation from the International Society of Thrombosis and Haemostasis (ISTH) for DOAC therapy in obese patients?
EVALUATION OF EFFICACY, SAFETY, AND COST RELATED TO USE OF RITUXIMAB IN PATIENTS WITH MULIPLE SCLEROSIS Ellen Couchell, Julie Kidd, Meghan Bryan, Matthew Carraro Novant Health Presbyterian Medical Center - Charlotte, NC
Background/Purpose: Rituximab has historically been used for the treatment of patients with multiple sclerosis (MS), however its use remains off-label as rituximab is not FDA approved for the treatment of MS. This study aims to provide an evaluation of outcomes in patients with a diagnosis of MS that have been treated with rituximab throughout the Novant Health Center for Multiple Sclerosis. Efficacy, safety, and cost of rituximab for MS will be evaluated.
Methodology: A single center, retrospective chart review was conducted in patients greater than 18 years of age, with a diagnosis of MS treated with rituximab from August 2016 to July 2018. The primary outcome for efficacy was the number of MS exacerbations during rituximab use, the number of lesions on MRI at baseline compared to number of lesions on MRI while on rituximab, and the expanded disability status scale (EDSS) score at baseline compared to EDSS score while on rituximab (for at least 6 months). The secondary safety outcome was the frequency of adverse drug reactions with use of rituximab. The tertiary outcome was to measure the average cost of therapy with rituximab versus a FDA approved therapy for MS, ocrelizumab.
Presentation Objective: Determine if rituximab is an effective, safe, and affordable option for patients with MS.
Self-Assessment: How does the side effect profile of rituximab compare to ocrelizumab?
Effects on Clinical Outcomes and Safety in Alternative Dosing Intervals of Denosumab in Solid Tumor Malignancies Aseala Abousaud, Meagan Barbee, Christine Davis, Sarah Caulfield Emory University Hospital Oncology - Atlanta, GA
Background/Purpose: Bone metastases with solid tumor malignancies cause bone destruction which leads to increased risk of skeletal-related events (SREs) including spinal cord compression, pathological fracture, and radiotherapy or surgery to the bone. The FDA-approved dose for denosumab is 120mg every 4 weeks, other schedules are used in practice.
Patients were grouped by average denosumab intervals of less than 6 weeks vs. 6-11 weeks vs. greater than 11 weeks. The primary outcome is time to first SRE while on denosumab. The secondary outcomes are overall survival, incidence of hypocalcemia, osteonecrosis of the jaw (ONJ), and hospitalizations. The exploratory endpoint is time to subsequent SREs while on denosumab.
Methodology: This is a retrospective chart review in adults with solid tumor malignancies and bone metastases who received at least two doses of denosumab 120 mg from November 1, 2010 to July 27, 2018. Patients who received denosumab for hypercalcemia of malignancy, osteoporosis, giant cell neoplasm, multiple myeloma were excluded. OS and time to SRE will be analyzed using the Kaplan-Meier method. A two-sided log-rank test will be used to compare time to SRE and OS between groups stratified by cohort and covariates. A Cox proportional hazards model will be used to determine the effects of denosumab dosing schedules after adjustments for covariates with a p-value
Implementation of the overdose education and naloxone distribution (OEND) for at risk patients of national priority providers Athena Vu, Tiffany Jagel, Vanessa Herrington Gulf Coast Veterans Health Care System - Biloxi, MS
Background/Purpose: This quality improvement project was designed to reduce the risk of opioid overdose by providing naloxone distribution and education to at risk patients of the national priority providers at the Gulf Coast Veterans Health Care System that have never been prescribed naloxone.
Methodology: A list of 656 patients of 14 national priority providers was obtained from the overdose education and naloxone distribution (OEND) dashboard for the second quarter of 2018. Patient charts were reviewed to determine if a Veteran was a true candidate for naloxone. If naloxone was needed and once the provider_x0019_s agreement was obtained, pharmacists contacted patients, provided naloxone education by phone, and dispensed naloxone. Additionally, anecdotal evidence suggested that some patients were inappropriately flagged for opioid use and/or opioid dependence diagnosis, even though they were no longer prescribed opioids and had no evidence of abuse, aberrant behavior, or illicit drug use. If it was determined through chart review that a patient was inappropriately flagged, pharmacists ordered the diagnosis removal under the provider_x0019_s name for review and signature if in agreement.
Results: Of the 14 priority providers, one provider declined participation in the project. The total number of patients targeted were 615. Of 361 patients reviewed so far, 30.5% were naloxone candidates. Of those candidates, 92.7% were dispensed naloxone, and 7.3% were not. Amongst the OEND candidates who were not dispensed naloxone, 5 patients declined, 1 patient is no longer followed by this VA medical center, and 1 patient is currently followed by the suboxone clinic. The most common flags in OEND candidates include history of depression, opioid dependence, and history of PTSD.
Presentation Objective: To demonstrate implementation of a model in which pharmacists and pharmacy residents identify candidates for naloxone and provide naloxone education and distribution.
Self-Assessment: Name potential risk factors for opioid overdose
Evaluation of antimicrobial prescribing for uncomplicated urinary tract infections in an urgent care center C Welch, B Becker, S Dobbins, K Kirkpatrick, C Dresback Mission Hospitals - Asheville, NC
Background/Purpose: Inappropriately treated urinary tract infections are a burden to the health care system, resulting in potential re-presentations to outpatient providers or hospital admissions. In June 2018, a process model was created at Mission Health to guide outpatient antibiotic prescribing for acute uncomplicated cystitis. This guide was created using emergency room cultures, which may not accurately represent community antimicrobial resistance patterns. We evaluated prescribing and culturing patterns for urinary tract infections in the urgent care setting, with the eventual end goals of creating a community antibiogram and a pharmacist-led outpatient culture follow up model.
Methodology: This retrospective study approved by an Institutional Review Board reviewed non-pregnant female patients ages 18 years and older who received an electronic prescription for an antimicrobial to treat a urinary tract infection from an urgent care clinic in the Mission network located in Asheville, North Carolina between August 1, 2016 and August 1, 2018. Patients were excluded if they had a diagnosis of a complicated urinary tract infection, but included patients with well controlled diabetes (A1C 7% or less). The primary study objective was to evaluate the appropriateness of antimicrobial prescribing for both uncomplicated cystitis and pyelonephritis compared to current IDSA guidelines (appropriate drug, dose, and duration), culture data, renal function, and patient allergies. Secondary outcomes include re-presentation to urgent care/emergency department/primary care providers in the Mission system within 7 days of initial visit, number of urinalyses collected versus number of cultures collected, and appropriate prescribing in light of prescribing guidance provided by the Mission process model.
Presentation Objective: To evaluate the appropriateness of antimicrobial prescribing for uncomplicated urinary tract infections in an urgent care setting.
Self-Assessment: True or false: Fluoroquinolones are a first-line therapy option for the treatment of acute uncomplicated cystitis.
The Effect of an Antimicrobial Stewardship Program in the Outpatient Setting for Respiratory Infections Amber Keeton, Jennifer Hayes, Jamie Crossman, Deanne Tabb, and Lori Hornsby Piedmont Columbus Regional Midtown - Columbus, GA
Background/Purpose: Antibiotic resistance is a serious public health issue. It is estimated that two million people will acquire an infection that is resistant to antibiotics. Of those, about 23,000 will die of an antibiotic resistant infection. Antimicrobial resistance can amount to $20 billion in direct health care costs annually. Reports show over 50% of all outpatient antibiotics are inappropriate with regards to antibiotic selection, dose, frequency or duration of therapy. In consideration of this information, the purpose of this study is to determine the change in antibiotic prescribing for respiratory infections in the outpatient setting before and after implementation of empiric guidelines as well as the change in appropriate selection of antibiotic, dose, frequency, and duration of therapy.
Methodology: A pre-post study will be conducted to determine the change in antibiotic prescribing for respiratory infections in the outpatient clinics at Piedmont Columbus Regional Midtown in Columbus, GA. This study will look at antibiotic prescribing focused on the following respiratory infections: sinusitis, pharyngitis, upper and lower respiratory tract infections, chronic obstructive pulmonary disease (COPD) and asthma exacerbations, influenza, and community acquired pneumonia (CAP). The study includes the development of empiric treatment guidelines based on recommendations of the Infectious Disease Societies of America (IDSA) and the Center for Disease and Control and Prevention (CDC) as well as patient education, utilizing materials from the CDC regarding the use of antibiotics in respiratory infections, antibiotic resistance, and antibiotic awareness. A retrospective chart review will be conducted to determine antibiotic prescribing per respiratory indication as well as guideline recommended drug selection, dose, frequency, and duration of therapy.
Presentation Objective: Explain the benefit of implementing empiric antibiotic guidelines in the outpatient setting.
Self-Assessment: How can pharmacists impact antibiotic prescribing in the outpatient setting through antimicrobial stewardship?
Identifying risk factors for ventilator associated pneumonia due to Pseudomonas aeruginosa in a trauma population Ashley Condon, James C. McMillen, Jackie Dix, Reagan Bollig, Michael Veve University of Tennessee Medical Center - Knoxville - Knoxville, TN
Background/Purpose: Ventilator associated pneumonia (VAP) remains the most common infection in mechanically ventilated ICU patients; it is associated with increased ICU length of stay, duration of mechanical ventilation, and cost. Due to rise in multidrug resistant pathogens (MDRPs), the 2016 IDSA guidelines recommend empiric coverage against Pseudomonas aeruginosa (PsA) in all patients who develop VAP. Trauma patients tend to have fewer underlying comorbidities and risk factors for MDRP colonization, raising the question of whether empiric anti-pseudomonal coverage is necessary.
Methodology: This IRB approved cross-sectional study with a nested case-control included adult patients admitted to a trauma service between 2011 and 2018 with a diagnosis of VAP based on a positive quantitative culture of bronchoalveolar lavage fluid, along with clinical signs and symptoms. Cases were defined as patients with VAP due to PsA; controls were patients with VAP due to drug-susceptible organisms. Data collection included patient demographics, comorbid conditions, social history, previous healthcare exposure and antibiotic use, Injury Severity Score, mechanism and location of injury, time of pneumonia onset, and microbiology and susceptibilities. The primary exposure of interest for this study was timing of VAP onset. Risk factors for PsA VAP were identified through bivariate analysis, and variables associated with the PsA VAP (P value less than 0.2) in bivariate analysis or deemed clinically relevant were entered into a multivariable logistic regression model to determine independent associations with PsA VAP. Secondary outcomes were the time of onset of PsA VAP, and the incidence of VAP due to MDRPs other than PsA.
Presentation Objective: To identify risk factors for the development of ventilator associated pneumonia caused by Pseudomonas aeruginosa in a trauma population.
Self-Assessment: Which of the following is a known risk factor for colonization with Pseudomonas aeruginosa?
The effect of fluids on mortality and morbidity in septic patients with congestive heart failure or chronic kidney disease Jasleen Bolina, Sabrina Croft, Joseph Crosby St. Joseph's/Candler Health Systems - Savannah, GA
Background/Purpose: The 2018 Surviving Sepsis Campaign Update recommends administration of > 30 ml/kg of intravenous crystalloid fluid in hypotensive patients or those with a lactate > 4 mmol/L within 3 hours of sepsis diagnosis. Concern arises for volume overload in high risk patients such as congestive heart failure (CHF) and chronic kidney disease (CKD) patients. This study aims to determine if these patients are more likely to have worse outcomes when given 30 ml/kg of fluid after sepsis diagnosis compared to a more restricted fluid approach.
Methodology: Patients were identified by having diagnoses for sepsis and either CHF or CKD. They were included if criteria was met for fluid administration and a fluid bolus was ordered. Patients were divided into: (1) those who received > 30 ml/kg of crystalloid fluid and (2) those who received < 30 ml/kg of crystalloid fluid within 12 hours of sepsis diagnosis. Both groups were evaluated based on mortality, incidence of mechanical ventilation, renal replacement therapy (RRT), length of stay, and diuretic use following fluid administration.
Results: Of 89 patients evaluated, 61 received < 30 ml/kg and 28 received > 30 ml/kg. The incidence of the composite outcome of mortality, mechanical ventilation, and RRT, evaluated by chi-square analysis, was 46% in the group receiving > 30 ml/kg of fluid compared to 43% in those who did not (P=0.39).
Conclusions: There was no difference in mortality, mechanical ventilation, and RRT between administering the recommended 30 ml/kg fluid bolus and the more restricted approach with less than 30 ml/kg in CHF and CKD patients.
Presentation Objective: Evaluate the need for fluid boluses in septic patients
Self-Assessment: Current recommendations advise administering 30 ml/kg of fluid to patients with
PGY2 Critical Care Specialty Resident, St. Joseph’s/Candler Hospitals
Jasleen Bolina, PharmD, BCPS is the current PGY2 in critical care at St. Joseph’s/Candler in Savannah, GA. She completed her PGY1 training at the same institution after obtaining her PharmD from the Auburn University Harrison School of Pharmacy. Following completion of residency... Read More →
Friday April 26, 2019 11:10am - 11:30am EDT
Athena A
Time to Analgesia and Sedation Post Rocuronium Administration in the Emergency Department R. Boardman, J. Beardsley, D. Masneri, D. Krebs, B. Dickens, L. Coles Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Previous studies have demonstrated that the use of rocuronium for paralysis is associated with greater delays and lower doses of post-intubation sedation and analgesia care when compared to succinylcholine. Due to the longer duration of action of rocuronium, sedation and analgesia cannot be reliably titrated to patient response once the induction agent has worn off. This can result in patients being paralyzed, awake, and vulnerable to complications of pain and anxiety. Pharmacist presence improves time to post-intubation medications, but specific interventions have not been described. Therefore, the primary objective is to improve time to analgesia and sedation post rocuronium administration in the emergency department, with any post-intubation medication regimen, through the use of targeted education. Secondary objectives are to identify barriers to administration of those medications post-rocuronium administration.
Methodology: This is a retrospective cohort study at a single, large, academic medical center. It will be conducted as a pre and post-intervention study with retrospectively reviewed intubations with rocuronium prior to education (pre-group) compared to patients intubated with rocuronium after pharmacist led education (post-group). The pre-group will be from December 2017 to March 2018 while the post group will be for the same dates in the years 2018 and 2019, respectively. Patients will be identified using a WakeOne report for administrations of rocuronium in the ED during each time periods. Chi-Square tests will be used to assess the number of patients receiving appropriate medications post-intubation. Blood pressure and other continuous variables will be assessed using a student-t test.
Presentation Objective: Recognize pharmacist interventions for how to overcome barriers and improve times to sedation and analgesia medications after the use of rocuronium for intubation.
Self-Assessment: What are potential barriers to timely sedation and analgesia medications after rocuronium is used as a paralytic for intubation?
Incidence and Risk Factors for Multidrug-Resistant Stenotrophomonas maltophilia Hannah Matson, Bruce Jones, Madalyn Motes, Jamie Wagner, Chris Bland St. Joseph's/Candler Health Systems - Savannah, GA
Background/Purpose: Stenotrophomonas maltophilia is a gram-negative bacillus commonly associated with nosocomial respiratory infections. It is intrinsically resistant to multiple antimicrobials, and at our institution has shown increased resistance. The objective of this study is to evaluate the susceptibility patterns of S. maltophilia and identify factors associated with resistance.
Methodology: A retrospective review of respiratory cultures with S. maltophilia was performed from Oct. 2015 to Sept. 2018. The primary outcome was factors associated with resistance among isolates. Secondary outcomes included incidence of resistance to one or more agents, all-cause mortality, and 30-day readmission. Isolates were separated into non-susceptible and susceptible groups and compared. Demographics, antimicrobial, and microbiologic data were collected on each patient. Categorical data was analyzed using Chi-Square or Fisher_x0019_s Exact test and Mann-Whitney U test was used for continuous data.
Results: There were 152 unique isolates of S. maltophilia, of which 23.7% and 23.8% were resistant to sulfamethoxazole/trimethoprim and levofloxacin, respectively. Fifty isolates were in the non-susceptible group and 102 isolates were in the susceptible group. For the primary outcome, the non-susceptible group had a higher percentage of previous positive cultures (16% vs. 4.9%, p=0.03), COPD (69% vs. 55.9%, p=0.152), and other interstitial lung diseases (26% vs. 16.7%, p=0.174). For the secondary outcomes, there was an all-cause mortality of 20.4% and a 15.1% readmission rate.
Conclusions: Our study demonstrated higher resistance rates to first line agents for S. maltophilia compared to published national averages. A previous positive culture was identified as a factor for resistance with higher trends for COPD and other interstitial lung diseases identified as well. Further study at additional facilities is currently ongoing.
Presentation Objective: Identify factors associated with Stenotrophomonas maltophilia resistance.
Self-Assessment: What factor did this study identify as a predictor for Stenotrophomonas maltophilia resistance?
Introduction of a pharmacist-driven culture follow-up program in the emergency department Stephanie Shealy,Christine Alexander,Tina Grof Hardison,Brandon Bookstaver Palmetto Health Richland PGY1 Pharmacy - Columbia, SC
Background/Purpose: Incorporation of pharmacy services into an emergency department culture follow-up program can effectively expand antimicrobial stewardship to the outpatient setting. A pilot pharmacist-driven culture call-back program was implemented at a tertiary teaching hospital in November 2018.
Methodology: This was a single-center, concurrent retrospective and prospective, non-interventional IRB-approved cohort study. Patients at least 18 years discharged from the emergency department with resulting positive cultures and/or microbiologic laboratory data who required outpatient intervention were enrolled. Ninety-day periods pre- and post-introduction of pharmacist were compared. The primary endpoint was time from culture positivity to culture review. Secondary endpoints include time from culture finalization to appropriate prescription of antimicrobial therapy and rate of subsequent emergency department and inpatient encounters. Descriptive statistics will be used to characterize patients and culture types. Paired t-tests and Wilcoxon signed-rank tests will be used to analyze time to event endpoints.
Results: The pre-implementation cohort was mostly female (77.8%) with a mean age of 50 years. Urine cultures predominated (69.4%) followed by sexually transmitted infection panels (24.2%). For patients requiring outpatient intervention, the mean time from culture positivity to culture review was 44.5 hours. Nineteen patients (29.7%) revisited the emergency department and five patients (7.8%) experienced a hospital admission within 90 days. Data collection for the post-implementation cohort is ongoing.
Conclusions: Time from culture positivity to culture review prior to introduction of pharmacist in follow-up process was approximately 2 days.
Presentation Objective: Discuss the impact of a pharmacist-driven culture follow-up program in the emergency department at a tertiary teaching hospital.
Self-Assessment: How did the introduction of a pharmacist to an emergency department culture follow-up process impact time to culture review?
A) Time to culture review was decreased
B) Time to culture review did not significantly change
Impact of a computerized clinical decision subphase on appropriateness of stress ulcer prophylaxis prescribing Paige Eber, ToMy Dinh, Rusty May, Andrea Newsome, Haley Cook Augusta University Medical Center/ University of Georgia College of Pharmacy - Augusta, GA
Background/Purpose: Though the stress ulcer prophylaxis guidelines have not been updated in the past two decades, recently published studies illustrate a low incidence of gastrointestinal bleeding in non-critically ill patients. Risk factors have begun to be identified in these patients, and correlations between prolonged exposure to acid suppressive medications and increased occurrence of pneumonia or C. difficile infections have been shown. Additionally, studies have demonstrated a potential cost-savings for a health system when inappropriate prescribing is controlled. In light of these findings, a subphase orderset was designed to assist physicians assess whether their patient qualifies for stress ulcer prophylaxis.
Methodology: A subphase orderset will be added to admission orders to bring attention to a patient_x0019_s presence or absence of risk factors for stress ulcer prophylaxis. The orderset will be available for new admissions and for patients moving from an ICU, where SUP is normally appropriate, to a medicine floor, where it may no longer be necessary. Data will be collected and analyzed in the same time period of the year prior to and following initiation of the subphase. The purpose of the study is to determine whether the subphase can decrease the amount of inappropriate SUP prescribing.
Presentation Objective: To discuss recent data regarding stress ulcer prophylaxis and the agents utilized for this purpose, and to analyze whether a decision-assisting subphase added to admission order sets would decrease the inappropriate prescribing of stress ulcer prophylaxis to floor status patients.
Self-Assessment: Which of the following patients would require stress-ulcer prophylaxis?
A. A 52 year-old patient requiring treatment with aspirin and Plavix, and an AKI
B. A 45 year-old septic patient
C. A 18 year old requiring high dose steroids for 3 days
D. A 22 year old waiting for rehabilitation following a spinal cord injury
Clinical Utility of Strict Laboratory Monitoring of CDK 4/6 Inhibitors in Metastatic Breast Cancer Patients U Patel, E Sakach, J Young, Z Chen, M Barbee, K Byers, J Meisel Emory University Hospital Oncology - Atlanta, GA
Background/Purpose: Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) are well-tolerated and effective treatment options for hormone receptor positive, metastatic breast cancer (MBC), but can cause neutropenia. FDA mandates assessment of the ANC every 2 weeks for 2 cycles of therapy and monthly thereafter. Strict ANC monitoring is optimal, but is a real world challenge, impacting quality of life and adding financial toxicity. This study evaluates whether strict monitoring of ANC significantly impacts treatment decisions, pt safety, and disease outcomes.
Methodology: A retrospective chart review of 160 MBC pts prescribed CDK4/6is was conducted at the Winship Cancer Institute from Feb 2015 to Jan 2019. ANC at C1D1, C1D14, C2D1, C2D14 were recorded along with various pt outcomes. Pts were divided into strict monitoring (SM) or relaxed monitoring (RM) groups.
Results: 152 patients received palbociclib; 8 received abemaciclib. Average age: 58. Study population: 55% Caucasian, 38% African American, 6% Asian. Average of 3 lines of prior therapy and average of 9 cycles of CDK 4/6i. 71% suffered neutropenia (40%:grade 3, 4%:grade 4, 2.5%:febrile neutropenia). PFS and OS did not statistically differ between groups, but OS data is immature.
Conclusions: This study analyzed a more diverse and heavily pre-treated MBC population than previous CDK4/6i studies. The prevalence of neutropenia aligns with results described in the PALOMA trial. PFS was higher in the RM group than in the SM group, suggesting strict monitoring for neutropenia does not improve PFS. If ANC monitoring parameters could be safely relaxed for CDK4/6i, it could improve quality of life and decrease financial toxicity across the system.
Presentation Objective: Clinical impact of strict laboratory monitoring for patients that are prescribed CDK4/6 inhibitors.
Self-Assessment: Is it clinically necessary to conduct strict monitoring of ANC for patients that are prescribed CDK4/6 inhibitors?
Impact of provider-specified order indication on appropriateness of direct oral anticoagulant dosing Jennifer Rollins, Ruthanne Baird, Neil Wheeless, Jason Moss, Kim Kelly Campbell University College of Pharmacy & Health Sciences - Buies Creek, NC
Background/Purpose: The use of direct oral anticoagulants (DOACs) has increased as studies have shown that they are superior or noninferior to warfarin. This, along with decreased monitoring in comparison to warfarin, has increased their use in patients requiring anticoagulation. Given the varying dosing schemes for labeled indications among DOACs, the indication for anticoagulation is not always clear to pharmacists in medical records. Previous studies have shown that DOACs are often dose-reduced despite package insert recommendations. A provider-specified order indication was added to order entry to clarify the indication for anticoagulation when a patient_x0019_s medical history is unclear in documentation. The provider-specified order indication requires that providers type an indication for anticoagulation whenever an anticoagulant is ordered. The indication is required regardless of whether the anticoagulant is a home medication being continued during an inpatient stay or newly prescribed during the hospitalization. This retrospective review will evaluate whether pharmacist intervention and indication-concordant prescribing of DOAC dosing improved when indication is specified at order entry.
Methodology: The primary objective of this study is to compare the rate of indication-concordant prescribing of DOAC dosing before and after provision of a provider-specified order indication. All patients receiving DOACs over a six-month period will be identified and evaluated for appropriateness of drug therapy and pharmacist intervention based on institution approved practices or recommendation to prescriber. This group will be compared to a retrospective control group prior to the implementation of a provider-specified order indication. Expected results will determine whether the implementation of a provider-specified order indication improved the accuracy of DOACs for respective indication.
Presentation Objective: Evaluate whether an indication specified at order entry improved the accuracy of DOAC prescribing and pharmacist intervention.
Self-Assessment: Does specifying indication for anticoagulation improve the accuracy of DOAC dosing and assist in pharmacist intervention?
IMPLEMENTATION AND IMPACT OF A PHARMACIST-RUN GOUT CLINIC IN THE VETERAN POPULATION Kera Sumner, Kellie Rose, Robyn Ward James H. Quillen VA Medical Center PGY1 - Mountain Home, TN
Background/Purpose: According to the American College of Rheumatology, gout is one of the most common rheumatic diseases in the US adult population and there is a notable gap in quality of care. This gap is thought to be attributable to the lack of patient education and medication compliance which largely increases the burden on the patient_x0019_s quality of life by increasing gout attack frequency and intensity. Currently, James H. Quillen has over 8,000 patients with a diagnosis of gout. The purpose of this project was to develop, implement, and evaluate the impact of a pharmacist-run gout clinic within a VA Medical Center since the nature of gout management has shifted over the years from previously only prescribing colchicine without utilizing or optimizing uric acid lowering therapies.
Methodology: Patients for this study were recruited by referrals from other healthcare providers, by recurrent emergency department visits pertaining to gout, or by having an active colchicine prescription without urate lowering therapy. Patients were then contacted to discuss the new service and enrolled in clinic if interested. The pharmacist had an initial face-to-face visit with labs ordered as appropriate and then follow-up visits were conducted predominantly by telephone. Counseling and education was provided as needed with emphasis on diet and maintenance versus acute gout flare therapies. During the visit, development of a gout attack action plan regarding nonpharmacological and pharmacological interventions as well as preventative therapy were discussed and implemented.
Presentation Objective: To discuss the development, implementation, and interventions made in a pharmacist-run gout clinic.
Self-Assessment: What are the benefits and challenges associated with a pharmacist-run gout clinic?
Evaluation of an Indigent Care Medication Provision Program on 30-day Readmission Rates in a Community Hospital Emily Powell; Jeanna Sewell; Chiahung Chou; Danna Nelson; Wes Wilkerson East Alabama Medical Center - Opelika, AL
Background/Purpose: Socioeconomic status and access to prescription medications pose a significant challenge for community hospitals serving vulnerable populations. Uninsured patients are more likely to forgo prescribed medications due to cost, and disproportionate share hospitals serving these patients are more likely to experience increased readmission rates. Limited evidence exists describing a direct relationship between affordability of medications and hospital readmission rates. This study aimed to evaluate a community hospital indigent care medication provision program to determine if providing a free 30-day supply of medications plays a role in decreasing 30-day readmission rates.
Methodology: This was a single center, institutional review board approved, observational study of a community hospital medication provision program. Patients included were at least 19 years of age and were provided a 30-day supply of medications at no cost from July 2017 to July 2018. The primary endpoint evaluated the rate of readmission at 30-days post discharge. Data collected included: age, gender, insurance coverage, occurrence of 30-day readmission, number and type of medications provided, and dollars spent on medication provision per patient. Additional data collected included the number of patients with a scheduled follow-up appointment upon discharge and evaluation by a transitions of care pharmacist.
Results: Of the 756 included in the study, 45 patients readmitted within 30 days. The readmission rate for patients included in the study was 5.95%, compared to 7.98% of EAMC hospital-wide readmissions.
Conclusions: Providing a free 30-day supply of medications may assist in decreasing readmission rates for community hospitals serving vulnerable populations.
Institution-specific UTI treatment guideline implementation and its effects on outpatient antibiotic prescribing patterns. Laura Jane Straw, Morgan Adams, Jeffery Hall, Martin Durkin Palmetto Health Richland PGY1 Pharmacy - Columbia, SC
Background/Purpose: Historically, urinary tract infections (UTIs) have been underrepresented in studies measuring outpatient antimicrobial stewardship programs. Thus, a more widespread implementation of outpatient stewardship programs is warranted to encourage interprofessional collaborative practice. The purpose of this study is to evaluate the antibiotic prescribing practices of family medicine physicians in an ambulatory setting for the treatment of UTIs before and after implementation of an institution-specific treatment pathway to reduce unnecessary antibiotic use and improve antibiotic selection.
Methodology: This study has been approved by the Institutional Review Board at Prisma Health. This is a single-center, observational, cohort study at an outpatient clinic in Columbia, South Carolina. Adult patients with an encounter from January 2018 through February 2019 with an associated ICD10 code for a UTI were included. Patients with encounters during July or August were excluded due to a new academic year and pathway implementation. Implementation was executed with education of physicians, access to the UTI pathway electronically and hard copies posted at workstations. The primary objective is to evaluate antibiotic utilization pre- and post-implementation of this clinical decision tool on the appropriateness of antibiotic selection, dosing and duration prescribed based on pathway recommendations. Secondary objectives include appropriateness of urine cultures and urinalyses, fluoroquinolone usage, prescribing practices based on physician type, and return office visits or emergency room visits due to adverse events or ineffective therapy. Statistical analysis for primary and secondary endpoints will include a test of 2 proportions for aggregate measures proportions and logistic regression to compare prescribing practices based on physician type.
Presentation Objective: To determine if education on a pathway for the outpatient treatment of UTIs improves adherence to the institution specific guidance for family medicine physicians.
Self-Assessment: What methods are effective in implementing a UTI pathway?
Evaluation of Initial Weight-Based Capping of Continuous Infusion Unfractionated Heparin for the Treatment of Thromboembolism Christopher Gauger, Kacy Whyte, Mark Vance, Mollie Rouse Vidant Medical Center - Greenville, NC
Background/Purpose: Evaluate the effectiveness and safety of initial dose capping of continuous infusion heparin for non-acute-coronary-syndrome indications as compared to traditional, un-capped dosing schema.
Methodology: Eligible subjects include individuals 18 years of age or older, receiving continuous infusion unfractionated heparin (CI UFH) with a target therapeutic activated partial thromboplastin time (aPTT) equivalent to an anti-Xa level of 0.3-0.7, having a weight greater than 111.1 kg at the time of initiation of CI UFH. Patients who are pregnant, have a baseline aPTT within the therapeutic window, and those exhibiting heparin resistance (defined as a 24 hour dose requirement in excess of 25 U/kg/hr) will be excluded. Data collection will occur through targeted electronic health record reports and chart review. The primary outcome of this study is the percentage of patients with a therapeutic aPTT at 24 hours from the initiation of CI UFH. Additional therapeutic endpoints include the time to first therapeutic aPTT; time to first two consecutive therapeutic aPTT values; therapeutic infusion rate at first two consecutive therapeutic aPTT values; and percent subtherapeutic, therapeutic, and supratherapeutic aPTT values during administration of CI UFH. Safety and efficacy will be assessed through the identification of clinically significant bleeding events and progression of thrombotic events requiring fibrinolytic therapy or endovascular intervention.
Presentation Objective: Evaluate the safety and efficacy of initial dose-limiting strategies for continuous infusion unfractionated heparin in overweight and obese patient populations.
Self-Assessment: What is the most appropriate initial dosing strategy for continuous infusion heparin in obese and overweight patients?
Cost Effectiveness of Argatroban versus Heparin Anticoagulation in Adult Extracorporeal Membrane Oxygenation (ECMO) Patients Angelina Cho, Kathleen Jerguson, Joy Peterson, Deepa Patel WellStar Kennestone Hospital - Marietta, GA
Background/Purpose: During ECMO support, patients require therapeutic anticoagulation because of increased risk of thrombosis. Although heparin is most commonly utilized, it is dependent on sufficient antithrombin III (ATIII) levels. However, the high cost of ATIII replacement and its limited availability limits the use of heparin in patients with suboptimal levels. Utilization of argatroban may be more favorable because its effect is not limited by the availability of ATIII. The purpose of this study is to evaluate the cost effectiveness of argatroban compared to heparin during ECMO therapy.
Methodology: This Institutional Review Board approved, retrospective cohort study includes adult patients who received argatroban or heparin infusions with ECMO therapy between January 1, 2017 and June 30, 2018. Adult patients who received heparin or argatroban for at least 48 hours while on ECMO will be included. Patients with temporary mechanical circulatory assist devices will be excluded. Each continuous course of anticoagulant exposure that meets the inclusion criteria will be evaluated. The primary outcome of the study is the total cost of anticoagulant therapy for heparin versus argatroban including all study drugs, associated lab tests and blood products administered. Secondary outcomes include safety and efficacy of anticoagulation with each agent during ECMO. Documentation of bleeding events, circuit clotting and ischemic events will be noted. Partial thromboplastin time (PTT) values will be evaluated for time to therapeutic range and percentage of time therapeutic PTT levels were maintained.
Presentation Objective: To compare the cost effectiveness of argatroban versus heparin during ECMO therapy.
Self-Assessment: What are some potential advantages of argatroban versus heparin in an inpatient setting?
Hydrocortisone and Fludrocortisone versus Hydrocortisone Alone in Critically Ill Medical Patients with Septic Shock Molly Hunt, Jason Frisbee, Shauna Winters, Tina Dudney, Paul Branca University of Tennessee Medical Center (Critical Care) - Knoxville, TN
Background/Purpose: Only two RCTs out of many have shown mortality benefit with use of stress dose steroids and were the only trials to use hydrocortisone/fludrocortisone. To date there has not been a trial comparing the use of hydrocortisone alone versus hydrocortisone/fludrocortisone. The purpose of this study is to determine if the use of hydrocortisone plus fludrocortisone is associated with faster resolution of shock when compared to the use of hydrocortisone alone in medical, critically ill septic shock patients.
Methodology: This study is an IRB approved, single-center, prospective, open-label trial evaluating septic shock patients admitted to the medical critical care unit. Patients received hydrocortisone 50 mg IV Q6h or hydrocortisone with fludrocortisone 50 mcg PO or PFT daily based on their assigned bed number. Patients were included if 18 years or older, required stress dose steroid therapy, and received fludrocortisone within 24 hours of hydrocortisone in the combination group. Exclusion criteria included the following: use of fludrocortisone/hydrocortisone for other reasons, initiation by services other than critical care medicine, prior use of fludrocortisone/hydrocortisone, steroid therapy not in accordance with assigned group, readmission to MCC unit, received more than one dose of hydrocortisone 100 mg, or contraindication to PO/PFT fludrocortisone. The primary outcome is time to resolution of shock (24 hours vasopressor free). Secondary endpoints include ICU and hospital length of stay, all-cause mortality at ICU, hospital discharge, 28, and 90 days, treatment withdrawal in ICU, re-initiation of vasopressor or steroid, mechanical ventilator free days, and steroid therapy duration.
Presentation Objective: Determine if the addition of fludrocortisone to hydrocortisone improves clinical outcomes compared to use of hydrocortisone alone in critically ill medical patients with septic shock.
Self-Assessment: Does use of hydrocortisone/fludrocortisone for critically ill medical patients with septic shock reduce vasopressor requirements compared to hydrocortisone alone?
Rescheduling of gabapentin: effect on prescribing patterns Shivani Patel, Alicia Potter DeFalco, Laura Schalliol, Brian Winbigler South College School of Pharmacy - Knoxville, TN
Background/Purpose: Gabapentin has potential addictive properties that can lead to higher abuse and misuse. The rescheduling of gabapentin as a controlled substance places tighter regulations on dispensing and prescribing. Prescribers may take further steps to determine if the patient is a true candidate of the medication. The purpose of this project is to identify chronic gabapentin patients before July 1, 2018, and compare their gabapentin use after July 1, 2018, when gabapentin became a schedule V medication in the state of Tennessee. This project will look for a decrease in prescribing gabapentin after it became a schedule V medication.
Methodology: This study will be submitted to the Institutional Review Board for approval. Patients with a 90- day fill rate of gabapentin before July 1, 2018 will be evaluated for the study. These patients will be followed until January 2019 to assess if the prescribing pattern of gabapentin will show a decrease in fill rate. Kroger will provide a list of patients who have been receiving gabapentin amongst their stores in Knoxville, TN Division 4 area. The following data will be obtained from Kroger: patient name, age, gender, city, sale date, product name, product strength, quantity dispensed, and store number. All data will be de-identified to further assess for change in prescribing pattern. This data will help to disclose the primary outcome if there is a decrease in prescribing gabapentin after it became a schedule V medication in the state of Tennessee.
Presentation Objective: Describe the changes in prescribing patterns that resulted due to the rescheduling of gabapentin in the state of Tennessee.
Self-Assessment: What effect did the rescheduling of gabapentin products have on prescribing patterns?
Evaluation of the Practical Use of Kinetic GFR for Vancomycin Dosing in Patients with Acutely Changing Renal Function Kendal Miller, N B Plange, J Coluccio, T Parker, R Patel, H Powell, A Ray Piedmont Atlanta Hospital - Atlanta, GA
Background/Purpose: Evaluation of acutely changing kidney function is critical to accurately and safely dose medications. The Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault creatinine clearance (CG) formulas are used to estimate renal function but are unable to account for acute changes in clearance. Nephrologist Dr. Sheldon Chen identified variability in practitioner_x0019_s evaluation of clearance during the acute phase. He developed the kinetic GFR (KeGFR) equation to estimate renal function when serum creatinine is changing acutely; however, no studies have evaluated using KeGFR for dosing medications. The objective of this study is to determine accuracy of calculated trough values using KeGFR and CG when compared to the laboratory-measured trough.
Methodology: This was a retrospective analysis of patients with a steady state vancomycin trough level and a change in serum creatinine of >/= 0.3 mg/dL or 1.5 times baseline within 48 hours. Predicted vancomycin trough levels from CG and KeGFR were compared to actual laboratory vancomycin trough levels. The primary endpoint was to determine the difference in percent error of predicted vancomycin trough levels between KeGFR and CG in patients with acutely changing renal function. The secondary endpoint was a subgroup analysis to determine if chronic kidney disease, diabetes, heart failure, or obesity influenced the accuracy of method used in predicting vancomycin trough levels.
Presentation Objective: Describe the potential role of using the kinetic GFR to predict vancomycin trough levels in patients with acutely changing renal function.
Self-Assessment: What are considerations when evaluating the use of kinetic GFR for predicting vancomycin trough levels?
Impact of FilmArray" Meningitis/Encephalitis Panel on time to optimal therapy for bacterial meningitis Rebecca Moore, Jeannie Watson, Jarett Worden St. Thomas West Hospital - Nashville, TN
Background/Purpose: Meningitis is a severe clinical condition with a high rate of morbidity and mortality. Rapid detection of the causative pathogen is critical to appropriate treatment. The purpose of this study is to determine if the FilmArray" Meningitis/Encephalitis Panel decreases the time to optimal antibiotic therapy versus standard of care for patients with suspected bacterial meningitis.
Methodology: This study is an IRB-approved, retrospective chart review that included patients with suspected bacterial meningitis who were admitted to Ascension Saint Thomas West Hospital during the study time periods of January 1, 2017 _x0013_ August 31, 2017 (CSF control group) and January 1, 2018 _x0013_ August 31, 2018 (MEP study group). The primary endpoint was time to optimal antibiotic therapy in patients with suspected bacterial meningitis. Secondary endpoints include total duration of antibiotics, clinical improvement, length of stay (LOS), and mortality.
Results: Baseline characteristics were similar between groups. Time to optimal therapy was not significantly shorter between the MEP and CSF groups (24 vs. 63 hours; p=0.08). There was no difference in total duration of antibiotics (1.8 vs. 3.0 days; p=0.36), time to defervescence (4 vs. 9 hours; p=0.37), time to WBC count
Antibiotic Therapy in Acute Chronic Obstructive Pulmonary Disease Exacerbations in Patients with a Positive Respiratory Viral Sara Valanejad, Rebecca E. Bookstaver, Julie Dattero Pruitt, Kyle Davis Wake Forest University Baptist Medical Center - PGY1 - Winston-Salem, NC
Background/Purpose: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are commonly triggered by viral, bacterial, or environmental factors. The purpose of this study was to assess the effect of antibiotic use in patients admitted for an AECOPD with a positive respiratory viral panel (RVP).
Methodology: This retrospective cohort study included adult patients admitted to Wake Forest Baptist Health for an AECOPD with a positive RVP between January 1, 2013 and December 31, 2018. The primary endpoint of 30 day hospital readmission secondary to AECOPD was evaluated in those that received antibiotics compared to those that did not. Secondary analyses included total length of hospital stay, ICU length of stay, ventilator dependent days, time to next AECOPD (90 days), development of Clostridium difficile infection within 30 days of discharge and other adverse drug reactions (ADRs).
Results: A total of 217 patients were included for analysis. Of the included patients, 150 received antibiotics and 67 patients did not. Fourteen patients (9.3%) in the antibiotic group and 5 patients (7.5%) in the no antibiotic group experienced a 30 day readmission for a subsequent AECOPD (p = 0.80). Patients who received antibiotics had an increased length of hospital stay (5 days (4-9) vs 4 days (3-6), p = 0.008) with no significant difference in ventilator dependent days (3.5 days (2.3-5) vs 2 days (1.8-3), p = 0.08) or ADRs (6.7% vs. 1.5%, p = 0.18).
Conclusions: There was no difference in 30 day readmission rates between AECOPD patients with a positive RVP and antibiotic use. The appropriateness of antibiotic initiation and continuation should be evaluated to potentially reduce unfavorable outcomes.
Presentation Objective: To assess the effect of antibiotic use in patients admitted for an AECOPD with a positive RVP.
Self-Assessment: What clinical criteria should AECOPD patients meet to receive antimicrobial treatment?
Evaluation of a Pharmacist-Developed Hypersensitivity/Infusion Reaction Protocol for Chemotherapy/Biotherapy Julianna Cebollero; Jennifer LaFollette; Suzanne M. Walton; Marjorie Curry Grady Memorial Hospital (Oncology) - Atlanta, GA
Background/Purpose: Intravenous biologic and cytotoxic anticancer therapy can be associated with hypersensitivity- and/or infusion-related reactions which may result in life-threatening symptoms. In a quality improvement project at Grady Health System (GHS) in 2012, oncology pharmacists developed and implemented a nurse-driven, symptom-based infusion reaction protocol. The initial project evaluated epinephrine administration for the management of reactions due to five anticancer agents. This was expanded to evaluate use of the protocol for all parenteral anticancer agents.
Methodology: 460 patients who received an infusion in the ambulatory infusion center between February 2014-March 2018 were retrospectively evaluated. Patients were included if they received a protocol-specific medication for reaction management. The primary outcome was rate of treatment failure within 72 hours of management for a reaction attributed to parenteral administration of a biologic/cytotoxic agent. Treatment failure was defined as an emergency department (ED) visit, hospital admission or death.
Results: 82 patients experiencing 114 infusion reactions were included in the analysis (rigors only 6%; mild/moderate 58%; severe/anaphylaxis 30%). Treatment failure within 72 hours was observed in 7% of reactions (n=8/114); 4% (n=5) were evaluated in the emergency department and 3% (n=3) were admitted to the hospital. 93% of reactions resolved and patients were discharged to home. No patient deaths were attributed to an infusion reaction.
Conclusions: Treatment failure of a pharmacist-developed, nurse-driven protocol for the management of infusion and/or hypersensitivity reactions due to anticancer treatment was observed in
Long-term safety and efficacy of bumetanide in very low birth weight infants Carson S. Tester, Katelyn Harsh, Jennifer Schriber, Chi Dang Hornik Duke University Hospital Pediatrics PGY2 - Durham, NC
Background/Purpose: Bronchopulmonary dysplasia (BPD) is a chronic lung disease seen in approximately 40% of preterm infants requiring prolonged mechanical ventilation and oxygen therapy for acute respiratory distress. It is the most common pulmonary morbidity in preterm infants and is associated with long term consequences, including neurodevelopmental impairment. Advances in neonatal care have improved survival rates, but there are limited therapeutic options available for management of BPD. While furosemide has been the primary diuretic used for in neonatal intensive care units (NICUs), the development of tachyphylaxis from prolonged use of furosemide may hinder its effectiveness for treatment of a chronic disease. In contrast, bumetanide, a potent loop diuretic, has not been used in most NICUs despite the potential neuroprotective effects seen in neonates. This study examines the use of bumetanide at our institution, in infants at risk of BPD. Risk assessment will be done using The National Institute of Child Health and Human Development BPD Risk Estimator.
Methodology: The primary objective of this study is to determine if bumetanide reduces the risk of BPD in very low birth weight (VLBW) infants. Secondary safety endpoints include proportion of infants diagnosed with nephrocalcinosis prior to NICU discharge, all-cause mortality prior to NICU discharge, and neurodevelopmental impairment scores at 18-24 months of age. This retrospective, single center study includes patients born
Impact of Pharmacist led Smoking Cessation through a Collaborative Practice Agreement and Behavioral Counseling Chelsea Keedy, Joey Crosby, Courtney Reddig, Alix Schnibben St. Joseph's/Candler Health System (Ambulatory) - Savannah, GA
Background/Purpose: The impact on quit rates of pharmacist led tobacco cessation through a Collaborative Practice Agreement (CPA) is not extensively described in the literature. The primary objective of this study was to evaluate if pharmacist involvement in smoking cessation through a CPA and behavioral counseling increased quit rates. Billing codes and reimbursement rates were also assessed.
Methodology: Adults referred for smoking cessation from August 2018 through February 2019 were eligible. Carbon monoxide meters were utilized to assess quit status. Patients participated in one-on-one tobacco cessation visits. All participants were offered medications in combination with the behavioral counseling. Prescriptions were sent through the pre-existing CPA. Patients not interested or not appropriate candidates for medication therapy were assigned to the control group, behavioral counseling only. Patients filled out pre- and post-surveys. Appropriate billing codes were recorded.
Results: Prescriptions were prescribed through the CPA to participants in the treatment group. The percent of individuals in the treatment group who reported cessation was compared to the percent of individuals in the control group who reported cessation. Carbon monoxide readings were used to confirm cessation. Study limitations include not having all participants completed through the program to date.
Conclusions: Data demonstrates the positive impact on tobacco cessation rates of pharmacist led smoking cessation sessions that include prescriptions through a CPA. The data also highlights unique opportunities for pharmacists in regards to billing and reimbursement.
Presentation Objective: To evaluate if pharmacist led smoking cessation through a CPA and behavioral counseling increases patient quit rates
Self-Assessment: What unique skill sets does a pharmacist possess that enables them to contribute to smoking cessation efforts?
Effectiveness of oral metolazone vs. intravenous chlorothiazide in patients receiving IV loop diuretics Kristopher Kindborg, Mark Vance, Erin Cady, Kacy Whyte, Erika Giblin Vidant Medical Center - Greenville, NC
Background/Purpose: Patients with volume overload due to heart failure are often managed with high doses of intravenous loop diuretics, which may lead to diuretic resistance. One strategy employed to overcome loop diuretic resistance is sequential nephron blockade with the thiazide diuretics chlorothiazide and metolazone. Both drugs demonstrated effectiveness when used in combination with loop diuretics but uncertainty remains as to which should be the drug of choice, as recent studies comparing chlorothiazide and metolazone had mixed results and were limited by restrictive eligibility criteria. The purpose of this study is to compare metolazone and chlorothiazide in a manner that reflects real-world practice.
Methodology: This is a single center, retrospective non-inferiority study in which patients with heart failure on intravenous loop diuretics serve as their own control. Patients are included if they received a dose of chlorothiazide followed by a dose of metolazone or vise-versa. The primary endpoint is net urine output in the 24 hours after administration of a study drug. Secondary endpoints include net urine output in the 12 hours after administration of a study drug, change in weight, and percentage of patients with a difference in net urine output of greater than 1000 ml. Safety endpoints include incidence of hypokalemia, hypomagnesaemia, hyponatremia and acute kidney injury. Continuous data will be analyzed using a paired t-test or Wilcoxon signed-rank test. The association between net urine output and baseline variables of interest will be analyzed using multivariable regression.
Results: There are 61 patients who met the eligibility criteria and 130 eligible doses.
Presentation Objective: Compare the effectiveness of chlorothiazide and metolazone when used for sequential nephron blockade.
Self-Assessment: Does the choice of thiazide diuretic have an effect on a patient_x0019_s net urine output?
23.4% sodium chloride versus mannitol for the reduction of intracranial pressure Hayley A. Tatro, James C. McMillen, Leslie A. Hamilton, A. Shaun Rowe University of Tennessee Medical Center (Critical Care) - Knoxville, TN
Background/Purpose: Severe traumatic brain injuries represent one-third of deaths due to trauma in the United States. Intracranial pressure (ICP) monitoring is recommended because elevated ICP is associated with poor outcomes. Mannitol or hypertonic saline (HTS) are recommended to treat elevated ICPs, however current guidelines do not recommend a preferred agent. Previous studies have compared mannitol to HTS with inconclusive results, however no studies have compared 23.4% HTS to mannitol. Therefore, the goal of this study is to determine the difference in reduction of ICP after infusion of 23.4% sodium chloride 30 mL versus 0.5 g/kg 20% mannitol.
Methodology: This study was approved by the University of Tennessee Medical Center Institutional Review Board. The electronic medical record was used to identify patients admitted to the trauma/surgical intensive care unit between August 30, 2016, and August 30, 2018 with a severe traumatic brain injury. Patients were included if they were at least 16 years old, were initiated on the Severe Traumatic Brain Injury Adult Pathway, had an ICP monitor or external ventricular drain (EVD) in place, and if they received 0.5 g/kg mannitol and/or 23.4% sodium chloride 30 mL. The primary objective is absolute reduction in ICP 60 minutes after hyperosmolar therapy.
Presentation Objective: To determine if there is a difference in effectiveness of intracranial pressure reduction between 23.4% sodium chloride and 0.5 g/kg mannitol
Self-Assessment: What is the importance of monitoring and treating an elevated intracranial pressure?
Assessing Risk of Overdose or Serious Opioid-induced Respiratory Depression Amongst Patients Discharged from the ED Meagan Singletary, Danny Basri, Jasmine Jones, Joy Peterson WellStar Kennestone Hospital - Marietta, GA
Background/Purpose: Despite heightened attention on opioid prescribing, overdose remains a major public health concern. In response, assessment tools were developed to aid healthcare providers in identifying patients at risk for opioid induced respiratory depression (OIRD). The purpose of this study is to assess the risk of OIRD in patients discharged from the Emergency Department (ED) with a new or existing opioid prescription.
Methodology: The institutional review board approved this retrospective chart review of patients discharged from the WellStar Kennestone Hospital ED, with a new or existing prescription for an opioid, between July 1st and July 31st, 2018. Risk for OIRD was assessed using the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD) and commercially insured health plan claims database (CIP)-based RIOSORD scoring indexes. The sensitivities of the indexes were compared in identifying risk in our patient population. In addition, naloxone prescribing rates were assessed amongst our high-risk patients. Exclusion criteria are age less than 18 years, pregnancy, discharge to a medical facility, and incomplete demographic information. Patient data was collected and reported using descriptive statistics. The results of this study will be used to heighten clinician awareness of the risk of OIRD in our ED patient population and the opportunities available to mitigate risk by prescribing naloxone emergency kits. Additionally, the study will be used to demonstrate the feasibility of using the RIOSORD methodology for risk assessment in our patient population.
Presentation Objective: Evaluate the feasibility and value of using CIP-based RIOSORD and RIOSORD scoring indexes in identifying OIRD risk in our ED population.
Self-Assessment: What are the benefits of using CIP-based RIOSORD and RIOSORD risk scoring indexes?
Pharmacist Interventions in an Enhanced Vaccine Workflow Samantha Kerr South University School of Pharmacy/Richmond Hill Pharmacy - Savannah, GA
Background/Purpose: As community pharmacists' roles shift to encompass more clinical duties, clinical services such as medication reviews, point of care testing, and drug interaction checking are becoming a standard of practice in most pharmacies across the country. In order to effectively and efficiently deliver these services, it is imperative to integrate them into a more streamlined workflow, decreasing the number of needed visits for the patient and the number of separate touches by the pharmacy. Patients are often required to wait for 10-15 minutes while waiting for vaccine preparation and following administration. Adopting an appointment-based model, centered around a vaccine, allows for streamlining of clinical services and combining multiple services into a single visit.
Methodology: This is an archival data review. Patients ages 18 and older who present to the pharmacy to receive any vaccination during the study time period of mid-October to February will be eligible to receive the enhanced workflow intervention. During the intervention, a team-based approach will be used to allow the pharmacist or student pharmacist to capitalize on the time with the patient. The medication review will be conducted on an electronic tablet that is equipped with a standardized platform. The pharmacist-patient discussion and medication review will be documented through tracking in the same standardized platform, and any relevant, clinical interventions noted will be sent to the patient's provider with patient consent in a secure manner. Descriptive statistics will be used to analyze the data.
Results: IRB approval received August 2018. Research in progress.
Conclusions: In progress.
Presentation Objective: To measure the number of interventions made by community pharmacists during newly-implemented, standardized, pharmacist-initiated medication reviews conducted during routine vaccinations in order to better coordinate care and streamline pharmacy workflow.
Self-Assessment: How do pharmacist interventions in an enhanced vaccine workflow lead to more streamlined clinical services and a better coordination of care?
Assessment of Empiric Antifungal Treatment in Febrile Neutropenia Katherine M. Uyesugi, Allison Sternenberg, Henry Young, Daniel B. Chastain Phoebe Putney Memorial Hospital - Albany, GA
Background/Purpose: Fungal infections can cause significant morbidity and mortality in patients with febrile neutropenia (FN). Available guidelines provide limited detail on empiric antifungal therapy in this patient population. Antifungal resistance has dramatically increased, particularly in Candida and Aspergillus species. Thus, appropriate use of antifungal therapy is critical to ensure necessary empiric coverage of invasive fungal infections, while preventing resistance. The purpose of this study is to evaluate the use of empiric antifungal therapy in patients with FN in actual clinical practice for compliance of the Infectious Diseases Society of America (IDSA) and the National Comprehensive Cancer Network (NCCN) guidelines.
Methodology: This is a single-center retrospective study of patients with FN admitted to a community teaching hospital. Patients were identified using the International Classification of Diseases codes for neutropenia. Patients were eligible for inclusion if they were 18 years of age or older with a fever defined as temperatures greater than or equal to 38.3 degrees Celsius or greater than or equal to 38 for one hour and neutropenia defined as an absolute neutrophil count (ANC) of less than 500 cells per microliter or an ANC expected to decline to less than 500 in 48 hours. Pregnant and human immunodeficiency virus infected patients were excluded. The primary outcome was appropriateness of empiric therapy initiation defined as four days following empiric antibiotic therapy in high-risk patients. Secondary outcomes included appropriateness of empiric antifungal therapy according to guidelines and clinical outcomes including inpatient mortality and breakthrough invasive infections identified through microbiology, serology, and pathology.
Presentation Objective: Evaluate the use of empiric antifungal therapy in patients with febrile neutropenia according to IDSA and NCCN guidelines in a community teaching hospital.
Self-Assessment: What are the current recommendations for the use of empiric antifungal therapy for febrile neutropenia?
Evaluation of High Cost Medication Use in an Outpatient Chemotherapy Infusion Center at a Large Community Hospital C. Squires, A. Ouzts, B. Shippee, P. Thornton, B. Sykes Huntsville Hospital (Oncology) - Huntsville, AL
Background/Purpose: Our outpatient chemotherapy infusion center was established to treat patients that are underserved and underinsured in the North Alabama region, as well as a means of reducing unnecessary admissions for patients receiving chemotherapy. The purpose of this study was to evaluate use of the top 10 high cost medications in our outpatient chemotherapy infusion center, along with identifying partnering oncology practices that may benefit from billing support and aid in patient assistance program (PAP) enrollment. Pending study results may justify the need for personnel designated to managing an increased volume of PAPs, aiding patients in PAP enrollment, and facilitating an optimized billing process for potential hospital cost savings in the future.
Methodology: A retrospective chart review using electronic medical records (EMR) from local oncology practices and outpatient reimbursement data from the top 10 high cost medications utilized in our outpatient chemotherapy infusion center. Data was requested for the top 10 high cost medications used since January 1st, 2018 through September 30th, 2018 in the outpatient infusion center. All patients charged for a top 10 high cost medication at our outpatient chemotherapy infusion center will be included in the review. PAP data was manually retrieved from local oncology practice EMRs.
Presentation Objective: Describe the potential cost savings a large community outpatient infusion center can have through implementing personnel tasked with investigating patient_x0019_s insurance coverage and enrolling patients into PAPs.
Self-Assessment: Explain the potential impact that personnel designated to handling PAP drugs could have financially on an outpatient infusion center?
Evaluating the effects of aromatherapy on neonates with neonatal abstinence syndrome Matthew Brignola Brooke Stayer Melody Fredo Asra Tanveer Holston Valley Medical Center - Kingsport, TN
Background/Purpose: Neonatal abstinence syndrome (NAS) affects newborns due to maternal opioid use during pregnancy. From 1999 to 2013, the United States saw a 300% increase in NAS incidence; coupled with the country_x0019_s rise in opioid addiction, this trend may continue. Current treatment for NAS primarily includes the use of opiates and other adjunct medications to curb withdrawal symptoms. Earlier this year Holston Valley Medical Center (HVMC), a Level III NICU, instituted a protocol to incorporate the use of aromatherapy essential oil patches as a non-pharmacologic way to reduce NAS scores, length of stay, and medication burden.
Methodology: This is a continuation of a study to determine the effect of a recently-instituted aromatherapy patch protocol in the NICU at HVMC. The primary endpoint will be to determine if the use of essential oils decreases NAS scores; secondary endpoints include effects on length of stay, medication use, and NICU admission rates. The information in this two-phase study will be collected retrospectively from the electronic medical record. The initial phase of this study focused on collection of pre-intervention data and protocol implementation including provider education. Neonates evaluated will be those with diagnoses of NAS or fetal exposure to opioids. During the second phase of this study, data was collected on post-intervention neonates to determine whether a significant difference was seen in the primary endpoint. Data for 78 pre-intervention patients and 54 post-intervention patients have been collected. Currently, the information is being analyzed to determine the clinical and statistical efficacy of the newly implemented aromatherapy patch protocol.
Presentation Objective: Identify the possible benefits of aromatherapy in the treatment of Neonatal Abstinence Syndrome.
Self-Assessment: What are new and current treatment approaches for neonatal abstinence syndrome?
