2025 Southeastern Residency Conference

Evaluation of VTE Prophylaxis in Trauma Patients at a Large Community Hospital
Authors: Sarah Skaggs Gatewood and Jerry Robinson
Objectives:

1. Identify current recommendations for proper VTE prophylaxis in trauma patients.
2. Explain the implementation of guideline directed VTE prophylaxis management.
3. Compare VTE event rates before and after implementation.

Background/Purpose: In 2022, the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma published a clinical protocol with updated recommendations for inpatient venous thromboembolism (VTE) prophylaxis after trauma.  The dosing of enoxaparin for VTE prophylaxis in trauma patients at Huntsville Hospital did not match these recommendations. Trauma patients are at an increased risk of VTE, including deep vein thrombosis and pulmonary embolism. Pharmacologic and mechanical VTE prophylaxes are often necessary to decrease the risk of thromboembolic events after a trauma occurs. This project seeks to explore previous institution-specific dosing based on age, renal function, and other factors, compared to updated dosing to match 2022 recommendations.
Methods: This single-center, pre-post implementation, quasi-experimental study evaluated adult patients 18 years of age or older admitted to Huntsville Hospital under the care of trauma services from January 1st, 2024, to January 31st, 2025. Data was collected from the electronic health record (EHR) and analyzed using descriptive statistics. The following pre-intervention and post-intervention data were collected: patient demographics, hospital length of stay, renal function, VTE prophylaxis dosing, lab monitoring, and risk factors. Patients were excluded if they had a length of stay less than 72 hours, did not receive any mechanical VTE prophylaxis, or if they transferred to a long-term facility. A classification of patients was made based on current VTE prophylaxis guidelines after the trauma algorithm published by the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma1. The primary endpoint was appropriate compliance with the 2022 algorithm for VTE prophylaxis post-trauma. Efficacy was assessed via anti-Xa monitoring, targeting a range of 0.2-0.4 units/mL, with 10 mg dosing adjustments for levels outside this range.  Secondary endpoints included composite rates of deep vein thrombosis and pulmonary embolism, patient length of stay, days on VTE prophylaxis, and adverse drug events (ADEs) related to enoxaparin administration. Hospital-specific data and current policies were reviewed to identify areas of improvement, which included adherence to practice guidelines for VTE prophylaxis in trauma patients. Post-intervention data included the same metrics as listed for the pre-implementation data set. An ongoing quality review was performed in the post-intervention phase to identify potential changes and ensure compliance.
Results: A total of 160 patients (mean age, 50 years) were studied, 80 in the pre-implementation group and 80 in the post-implementation group, with similar baseline characteristics, risk scores, overall length of stay, and days on VTE prophylaxis between groups. Adherence to guidelines was noted to be overall 44% in the pre-implementation group and 84% in the post-implementation group for all patients included. No anti-Xa levels were checked in the pre-implementation phase. In the post-implementation phase, target range anti-Xa levels were achieved in 53 out of 80 patients (87%), with 43 patients (70%) having their first level within the target range. The incidence of VTE events was similar between groups but lower in the post-implementation phase, with only 9% of patients experiencing VTE events versus 13% in the pre-implementation phase.
Conclusion: The implemented order set and ongoing feedback integration lead to successful protocol implementation. Overall compliance with the 2022 published algorithm for post-trauma venous thromboembolism prophylaxis was achieved in 84% of patients. Anti-Xa monitoring post implementation occurred in 87% of patients versus zero prior to implementation. VTE events were less in the post implementation phase as well. An ongoing review will be continued to evaluate ordering options as well as opportunities to optimize monitoring and adherence.
Self-Assessment Question:
What is the primary purpose of anti-Xa monitoring in patients?

1. To assess renal function
2. To evaluate anticoagulant effect of current dosing strategy for effectiveness and safety
3. To monitor for potential allergic reactions
4. To check for the development of deep vein thrombosis (DVT)

IMPACT OF A MULTIDISCIPLINARY TEAM IN THE MANAGEMENT OF SUBJECTS WITH HEART FAILURE
Nicole DeLalla, Athena Colon, Richard Lane, Reginald Leandre, Tracey Dobbs
AdventHealth Apopka – AdventHealth Apopka, Florida, FL
Background: In 2024, nearly seven million individuals in the United States were diagnosed with heart failure.1,2 The resulting healthcare-related expenditure for treatment of this disease state has been calculated at over $3 million.1,2 In order to improve clinical outcomes, studies have shown that guideline-directed medical therapy (GDMT) can increase survival rates by 6.3 years. Additionally, GDMT has the potential to alleviate financial burden as a single heart failure-related hospitalization can cost about $15,000. 3,4 A study by Fallon and colleagues found that taking an interdisciplinary approach to heart failure management resulted in a 6% decrease in 30-day recurrent admissions in this patient population.5 However, there are limited studies focusing on how inpatient interventions affect rehospitalizations.
Methods: This was a single-center, retrospective chart review conducted at AdventHealth Apopka between July 1st, 2024 to December 31st, 2024. Included subjects were 18 years of age or older with a diagnosis of heart failure with reduced ejection fraction (HFrEF), defined as ejection fraction (EF) less than 40%. The exclusion criteria were subjects with an EF of 40% or greater, a history of a heart transplant, or planned heart transplant at the time of index visit. The primary objective was to assess the impact of a multidisciplinary heart failure management team on 30-day readmission rates. Secondary objectives included 30-day cardiovascular-related readmission, 30-day all-cause mortality, dose optimization defined as dose titration of GDMT medications or addition of at least one GDMT medication drug class, and inpatient length of stay (LOS). In addition, safety outcomes evaluated were incidence of acute kidney injury (AKI), hypotension, bradycardia, and hyperkalemia. 
Results: A total of 904 subjects were reviewed. Among those patients 146 subjects were included while 758 subjects were excluded. Baseline characteristics showed mainly white/Caucasian males with an average age was 67 years old. The 30-day readmission rates among the included patients were 33%. The 30-day cardiovascular readmission rate was 14%, and the 30-day all-cause mortality rate was 7%. Beta blockers had the highest incidence of dose titration at 17 %. The highest incidence of GDMT initiation was both beta blocks and diuretics with 27%. The average LOS was about 4.92 days.
Conclusion: In conclusion, this study saw a readmission rate of 33% after a multidisciplinary heart failure management team. When compared to national readmission rate of 25%, there is an eight percent difference in readmission rates to this study.6 This would suggest that there are areas of opportunities to further development of this heart management team.
 
References
HF stats 2024: Heart Failure Epidemiology and ... Accessed February 25, 2025. https://onlinejcf.com/article/S1071-9164(24)00232-X/fulltext.

• Centers for Disease Control and Prevention. Heart Failure. CDC. https://www.cdc.gov/heart-disease/about/heart-failure.html. Published October 14, 2022. Accessed September 11th, 2024
• Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association [published correction appears in Circulation. 2024 May 7;149(19):e1164. doi: 10.1161/CIR.0000000000001247]. Circulation. 2024;149(8):e347-e913. doi:10.1161/CIR.0000000000001209   
• Weiss AJ, Jiang HJ. Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); July 20, 2021.
• Fallon JM, Anderson K, McElhaney E, Lewis DA, Williams JB. Pharmacy-led optimization of transitions of care in patients with heart failure. J Am Coll Clin Pharm. 2024;7(6):778-786. doi:10.1002/jac5.1982. 

Foroutan F, Rayner DG, Ross HJ, et al. Global comparison of readmission rates for patients with heart failure. Journal of the American College of Cardiology. 2023;82(5):430-444. doi:10.1016/j.jacc.2023.05.040

Title: Safety Outcomes of Tirofiban Weight Based Dosing Strategy in Overweight Patients
Authors: Merrie Barnett-Brock, Audrey Johnson, Sofiya Paciotti
Background: Tirofiban is a GIIb/GIIIa receptor antagonist therapy used for the treatment of myocardial revascularization in non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). Tirofiban dosing is weight based utilizing actual body weight. There is a hole in the literature regarding studies with information regarding safety outcomes in patients >85kg, including obese patients. Specifically, the previous literature lacks any information regarding safety outcomes in obese patients. Current studies show incidence of bleeding ranging from 0.4% to 5%. This is a major gap in the literature that this study hopes to resolve. 
Methods: This IRB-approved, retrospective, single-center cohort study included patients from a 711-bed academic medical center in Savannah, Georgia. Adult patients treated with tirofiban for cardiac conditions at Memorial Health University Medical Center between January 1, 2015 and September 27, 2024 were utilized as the cohort. Other inclusion criteria included receipt of tirofiban ≥1 hour and patients dosed on actual body weight with renal dose adjustment using a creatinine clearance calculation with actual body weight. Patients were excluded if they were a protected population or if the patients were discharged <48 hours from when infusion started. The aim of this study was to assess the safety outcomes of patients with a weight ≥85 kg with a primary outcome of major bleeding defined by the ISTH criteria and secondary outcomes of minor bleeding, mortality, and rescue agents utilized. These outcomes were further assessed amongst subgroups based on BMI, renal function, and weight. The BMI subgroups included 3 categories, category one being BMI <30 kg/ m², category two being BMI 30-40 kg/m², and category three being BMI >40 kg/m². The weight subgroups included three categories, category one being 85-119.9 kg, category two being 120-149.9 kg, and category three being ≥150 kg. 
Results: Of the 304 patients screened, 47 were included in the final analysis. The majority of patients were white males and no patients were found to have renal dysfunction. The median weight observed in the patient population was 98 kg and the median BMI was 30.7 kg/m². We observed a 29.7% incidence of major of bleeding. For the subgroups defined by BMI, major bleeding was found to be 44.4% in the category 1 patients, 17.3% in the category 2 patients, and 33.3% in the category 3 patients. Major bleeding occurred specifically in the weight subgroups with 30.9% of the category 1 patients, 25% of the category 2 patients, and 0% in category 3 patients. Secondary outcomes in the overall cohort included mortality in 2.1% of the population, minor bleeding in 12.7%, and 2.1% of the patients utilized a rescue agent.
Conclusions: This retrospective study provides descriptive information regarding major bleeding occurrences in patients weighing ≥85 kg where both BMI and weight subgroups were observed. We observed 29.7% of the patient population experienced major bleeding. These findings demonstrate that further research with adequately powered studies are needed to show the incidence of major bleeding amongst higher weight patients receiving tirofiban. 
Disclosures: "This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities."
Best contact point for follow up of interested participants: merrie.barnettbrock@hcahealthcare.com

Title: Evaluation of a heparin calculator best practice alert (BPA) implementation at a multi-hospital health system 
Authors: Brittaney-Ann Simpson, Kirsten DiPiro, Ambra Hannah, Jerri Jenkins  
Objective: Describe the use of a heparin infusion calculator dose mismatch Best Practice Alert (BPA) within a health system  
Self Assessment Question:
Background: The electronic heparin calculator has demonstrated benefits in reducing medication errors by minimizing manual calculations in the hospital setting. At Wellstar Health System, heparin infusion initiation and maintenance follow a nurse-driven protocol.  This study evaluated the effectiveness of the heparin infusion calculator dose mismatch Best Practice Alert (BPA) in improving adherence to the heparin calculator and its impact on correct dosing and therapeutic efficacy.  
Methods: A multicenter retrospective chart review was conducted analyzing adult patients who received a heparin infusion 90 days before BPA implementation (May 24, 2023 to August 22, 2023) and 90 days after (October 1, 2023 to December 30, 2023).  Patients were included if they exceeded the maximum starting dose requiring a weight-based heparin infusion adjustment (weight >83.3 kg on low/neuro dose heparin and >125 kg on high dose heparin). Patients were excluded if the heparin infusion was initiated in a procedural area, ordered outside of the heparin order sets, restarted after interruption, or continued on Xa monitoring after receiving a direct oral anticoagulant within 72 hours of heparin initiation. Additionally, patients were excluded from therapeutic efficacy calculations and safety measures if the heparin infusion was less than 24 hours. The primary outcome was to evaluate the impact of the BPA on adherence to heparin calculator weight-based dosing on initiation of a heparin infusion. The secondary outcome evaluated the time to therapeutic heparin levels while safety outcomes assessed major and minor bleeding events. 
Results: A total of 212 patients were included in each study arm. Between both study groups, the majority of patients received low-dose heparin (82%), with acute coronary syndromes being the most common indication (41.7%). The BPA was triggered 33 times in the post-implementation cohort, with an acceptance rate of 84.8% (28 cases). Incorrect initial heparin rates were significantly lower in the post-BPA group at 2.5% (n=5) compared to 6.8% (n=13) in the pre-BPA group (P=0.008). For secondary outcomes, the mean time to achieve the second therapeutic level was similar between groups (27 hours; P=0.53). There was no statistically significant difference in major and minor bleeding events (P=1.0 and P=0.49, respectively).
Conclusions: Implementation of the heparin calculator BPA was associated with improved compliance with starting the correct infusion rate for patients that exceeded the max rate based on weight.  No correlation was observed between heparin calculator compliance and the time to therapeutic levels or bleeding events. Further studies are needed to assess the BPA’s impact on heparin infusion rate adjustments over time.

Title: Injectable Glucagon-Like Peptide-1 Receptor Agonists and Cardiovascular Outcomes in Patients Without Diabetes in Outpatient Cardiology Clinics
 
Authors: Kristina Benbow, Madison Burke, Lauren Schultz, Marina Carter, Deborah Hurley, Benjamin Tabor
 
Background: Glucagon-Like Peptide-1 (GLP-1) receptor agonists have emerged as clinically significant treatment options for type 2 diabetes, obesity, and cardiovascular (CV) risk reduction. To date, Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes (SELECT Trial) is the only trial to comprise of non-diabetic patients with preexisting CV disease defined as myocardial infarction, stroke, or symptomatic peripheral artery disease. In this trial, semaglutide was superior to placebo in reducing a CV composite of death from CV causes, nonfatal myocardial infarction, and nonfatal stroke. This study explores an expansion of the inclusion criteria used in the SELECT Trial, using a large outpatient cardiology population. 
 
Methods: This retrospective cohort study includes adult patients prescribed injectable GLP-1 receptor agonists followed by Prisma Health Cardiology between January 2022 and April 2023. Data was collected through April 2024. Patients were assigned to the control group if they never filled the medication with all other patients considered the intervention group. The primary outcome is a composite of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke. Secondary outcomes include total change in patient health variables (body weight, blood pressure, cholesterol, hemoglobin A1c), hospitalization or urgent medical visit for heart failure, and death from any cause. Descriptive statistics, stratified analyses (control vs intervention group), and multivariable logistic regression will be used to summarize the data and to evaluate the association of GLP-1 use and risk of death and other non-fatal cardiovascular outcomes.
 
Results: 123 patients without diabetes were prescribed a GLP-1 receptor agonist, 83 received the medication (intervention) and 40 did not (control). The primary endpoint did not differ between study arms, with no occurrences of death from CV cause or nonfatal stroke in either group. There was a nonsignificant trend in the control group for nonfatal MI (n=2 control, n=0 intervention; p=0.104). There were no occurrences of death from any cause and hospitalization or urgent medical visit for heart failure between groups. Secondary outcomes reflected a statistically significant reduction for intervention group in body weight (-1.0 kg control, -8.4 kg intervention; p<0.001), BMI (-0.2 kg/m2 control, -3.2 kg/m2 intervention; p<0.001), LDL (+1.4 mg/dL control, -34.1 mg/dL intervention; p<0.001), systolic blood pressure (+1.4 mmHg control; -7.9 mmHg intervention; p<0.001), and diastolic blood pressure (+1.2 mmHg control; -5.4 mmHg intervention; p=0.003). There was no difference in change in A1c between arms (0.0 ± 0.9 control, 0.0 ± 0.3 intervention; p=0.374).

Conclusions: Although unable to find a statistically significant difference in the composite primary endpoint, secondary cardiovascular outcomes favored the use of GLP-1 receptor agonists in patients without diabetes. There was a statistically significant lowering of known cardiovascular risk factors, including body weight, LDL, and blood pressure. Limitations of this study include a small study size which does not allow for true evaluation of primary endpoint, inclusion of patients irrespective of adherence to the GLP-1 receptor agonist or changes to background medications, and lack of available laboratory data points for many patients (notably, A1c and LDL). Unlike the SELECT Trial which looked exclusively at patients with a past medical history of MI, stroke, or symptomatic peripheral artery disease, this study was able to find CV benefit in a population both without CV history and in patients with coronary artery disease, all who were baseline close to having controlled/goal labs and vitals. Ultimately, this data helps advocate for insurance approval of GLP-1 receptor agonist in patients without diabetes secondary to their CV benefit.

EVALUATION OF PROTAMINE DOSING STRATEGIES FOLLOWING CARDIOPULMONARY BYPASS
Justine Bur, Amanda Sowder, Hetal Patel
AdventHealth Orlando-Orlando, FL


OBJECTIVE: Compare the impact of low, medium, or high protamine dosing on bleeding outcomes following cardiopulmonary bypass assisted cardiac surgery.


BACKGROUND: Protamine is used to reverse the anticoagulant effects of heparin after cardiopulmonary bypass (CPB). Improper dosing of protamine may lead to increased postoperative bleeding. Although it is paramount to have an appropriate protamine-to-heparin dosing ratio, evidence remains weak on guiding optimal dosing and inconsistencies exist between guidelines. At our institution, protamine dosing is routinely based off the initial heparin bolus. To our knowledge, no studies have compared protamine-to-heparin dosing ratios in otherwise healthy patients undergoing initial, elective CPB-assisted cardiac surgery. 


METHODS: A single centered, retrospective analysis was performed at a major tertiary referral hospital. Healthy adults aged 18 to 75 years old who underwent CPB-assisted coronary artery bypass graft or valve repair or replacement, with or without concomitant left atrial appendage ligation, MAZE, or myectomy were included. Exclusion criteria included chronic kidney disease or dialysis, liver dysfunction, hematologic disorders, pregnancy, or cancer. Patients were also excluded if they received non-packed red blood cell products in the operating room (OR). Primary endpoints included 24-hour chest tube output and 24-hour postoperative allogeneic transfusion requirements. Secondary endpoints included reintubation within 24 hours and operative re-exploration within 24 hours due to postoperative bleeding. All endpoints were measured after disposition from OR to the intensive care unit. Outcomes were evaluated based on low (<1:1), medium (1:1), and high (>1:1) protamine-to-heparin dosing ratios based on initial heparin and protamine boluses administered.


RESULTS: Seventy of the 267 patients screened between February 2023 and January 2025 were included in the analysis. Patients were median age 60 years, median BMI of 28.6 kg/m2 and 42 (60%) were male. At baseline, median pre-operative labs included: hemoglobin 13.6 g/dL, hematocrit 40.3%, platelets 240,000/μL, ACT 107 seconds, INR 1.0 and aPTT 29.6 seconds. Mitral valve replacement, 37 (53%), and repair, 15 (21%), were the most common cardiac surgeries. Median bypass time was 82 minutes. Median heparin and protamine boluses administered were 36,000 units and 320 mg, respectively. Protamine-to-heparin dosing ratios were characterized as follows: 32 (46%) patients comprised low, 28 (40%) comprised medium, and 10 (14%) comprised high. Twenty-four-hour chest tube output for low, medium, and high dose groups totaled 468, 530, and 850 mL, respectively (p=0.136). Of the 36% of patients who received transfusions, median total volume of transfusions for low, medium, and high dose groups were 506, 349, and 473 mL, respectively (p=0.936). No patients were reintubated due to postoperative bleeding within 24 hours and one patient in the high dose group returned to the OR for re-exploration for postoperative bleeding. Lastly, the median time to extubation of low, medium, and high dose groups was 226, 188, and 351 minutes, respectively (p=0.052).


CONCLUSION: This is the first study evaluating association of protamine-to-heparin dosing ratios with bleeding outcomes in otherwise healthy patients undergoing initial, elective CPB-assisted cardiac surgery. Despite the small sample size, there was a trend in increased post-operative 24-hour chest tube output as the protamine-to-heparin ratio increased. Although time to extubation did not statistically differ between groups, the greater time to extubation experienced by the high dose protamine group presents a clinically interesting finding for further exploration.