2025 Southeastern Residency Conference

Title: Evaluation of inappropriate stress ulcer prophylaxis continuation after discharge from the intensive care unit 
Authors:  Abigail McBrayer, Jamarius Carvin, Elaina Etter, Rachele Hollis 
Background/Purpose: Critically ill patients that require admission to the intensive care unit (ICU) are at an increased risk of gastrointestinal (GI) stress ulcers. Stress ulcer prophylaxis (SUP) is achieved through proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) administration. While the optimal duration of SUP therapy is unclear, current literature recommends discontinuing SUP upon resolution of risk factors, most commonly at the time of discharge from the ICU. Inappropriate SUP continuation can negatively affect both the patient and the hospital system. This study evaluates the rate of inappropriate continuation of PPIs or H2RAs for SUP after ICU discharge.  
Methods: This study was a single-center, retrospective chart review from May 1, 2023, to October 31, 2023.  Patients qualified for inclusion if they were greater than 18 years of age, received SUP during their ICU stay, were discharged from the ICU to an intermediate care unit or acute care floor, and had an active SUP order upon transfer to the non-ICU area. Patients were excluded if they had pre-existing conditions requiring acid suppressive therapy (AST) including gastroesophageal reflux disease, peptic ulcer disease, Barrett’s esophagus, and dyspepsia, were discharged directly from ICU to another healthcare facility, or were on appropriately continued AST. The primary outcome was the percentage of patients inappropriately continued PPIs or H2RAs at discharge from the ICU. Inappropriate continuation was defined as patients being continued on SUP after discharge from the ICU, when there are little to no risk factors to warrant the use of SUP. Secondary outcomes included healthcare costs, length of time on inappropriate AST, and the number of patients discharged home with a PPI or H2RA.   
Results: Throughout the study period, 406 patients were assessed for inclusion, with 180 meeting inclusion criteria. The leading reason for exclusion was patient death before ICU discharge, accounting for 55 patients (24%)

Title: Tolerability of Enteral Nutrition in ICU Patients Receiving Vasopressors 

Authors: Micah A. McKinnie, Megan Langley, Jana Mills 

Background/Purpose: Critically ill patients are often faced with malnutrition and are thought to require more high-protein and calorie-dense diets. Due to favorable mortality outcomes, implementation of enteral nutrition within 24-48 hours of ICU admission is recommended for critically ill patients who cannot receive an oral diet. However, studies have shown that patients in the ICU are unlikely to receive the amount of nutrition they were initially prescribed. One contributing factor is the practice of delaying or pausing enteral nutrition for patients on high or increasing doses of vasopressors due to the risk of serious complications, such as ischemic or necrotic bowel. The lack of strong evidence has led to an ongoing debate about whether patients requiring ongoing vasopressors should receive enteral nutrition. As more evidence regarding the safety of initiating early enteral nutrition in patients on vasopressors emerges, there is potential for a professional consensus to be made. This may allow for a greater portion of the nutritional needs to be met in these critically ill patients. This retrospective single-center chart-review study seeks to explore further if patients receiving vasopressors exhibit a decreased tolerance to enteral feedings, resulting in an inability to achieve adequate nutrition.  
 
Methods: A retrospective review was conducted to identify patients admitted to the ICU from January 2024 through August 2024. Patients included in the study were at least 18 years old, on mechanical ventilation for at least 24 hours, admitted to the ICU for greater than 72 hours, and had a consult for enteral nutrition during their ICU stay. Patients were excluded if they were on vasopressors for less than 24 hours, were placed on end-of-life care, underwent GI surgery, or had other contraindications to enteral nutrition. Patients were subdivided into either the treatment group (vasopressors for at least 24 hours) or the control group (no vasopressors) to compare the primary outcome of the average percent of daily caloric goals met. Secondary outcomes included the average daily rate of vasopressors, the median time patients received enteral nutrition, the median time of interruption, and incidences of suspected intolerance to enteral feeding. Data was collected for the total course of the prescribed enteral feeding while in the ICU, or until vasopressors were discontinued (if applicable).  
 
Results: The average percent of caloric goals met while in the ICU was 46.7% for the vasopressor group and 56.9% for the control group. The vasopressor group was found to have both a lower median time receiving enteral nutrition (3 days vs 5 days, p-value 0.002) and a lower median time of enteral nutrition interruption (26 hours vs 45 hours, p-value 0.003). Incidences of suspected intolerance occurred in 28.2% of the vasopressor group and 7.7% of the control group. The median vasopressor rate during the study period was 0.072mcg/kg/min norepinephrine equivalents, and the median vasopressor rate at the time of suspected intolerance was 0.158mcg/kg/min norepinephrine equivalents. 
 
Conclusions: Mechanically ventilated patients requiring vasopressors in the ICU tended to receive a lower percentage of caloric goals through enteral nutrition than those not requiring vasopressors. Regardless of vasopressor use, this patient population was generally underfed while in the ICU. However, the clinical significance of these findings needs further exploration, and prospective research may be beneficial.

Title: Dexamethasone versus dexamethasone and fludrocortisone in patients with septic shock and acute respiratory distress syndrome


Authors: Gabrielle Cromley, PharmD; Audrey Johnson, PharmD, BCCCP; Eric K. Shaw PhD; Stephanie Lesslie, PharmD, BCPS, BCCCP


Objective: The purpose of this study was to compare duration of vasopressors within 30 days in patients with septic shock and ARDS who received either dexamethasone or dexamethasone and fludrocortisone.


Self Assessment Question: By what mechanism does mineralocorticoid activity improve septic shock?


Background:
Corticosteroids are recommended for both septic shock and moderate to severe acute respiratory distress syndrome (ARDS). Hydrocortisone is recommended in septic shock requiring vasopressors and it has both glucocorticoid and mineralocorticoid effects. Its mineralocorticoid effect provides additional benefit in septic shock by increasing fluid retention and peripheral vascular resistance. Dexamethasone is recommended for ARDS given the findings of the DEXA-ARDS trial which showed decreased duration of mechanical ventilation and all-cause mortality. Dexamethasone exhibits pure glucocorticoid activity and does not have mineralocorticoid activity. For patients with septic shock and ARDS, the ideal corticosteroid regimen is not clearly defined. The addition of fludrocortisone to dexamethasone may be beneficial in these patients given its mineralocorticoid effects. The purpose of this study is to determine if the addition of fludrocortisone to dexamethasone reduces vasopressor duration in patients with septic shock and ARDS.
 
Methodology: 
This single-center, retrospective cohort study was conducted at a 711-bed academic medical center. All data was collected from electronic medical records (EMR) by individual chart review. EMR reports of dexamethasone and fludrocortisone administrations between May 2020 through September 2024 were generated. Mechanically ventilated adult patients were included if they met all of the following criteria: PaO₂:FiO₂ < 200; receiving antibiotic therapy; requiring vasopressor support ≥ 10 mcg/min norepinephrine equivalent; administration of dexamethasone for ARDS with or without fludrocortisone for ≥ 48 hours. Patients were excluded if they met any of the following criteria: cardiogenic shock, chronic corticosteroid use, brain death, pregnant, or incarcerated. Patients who received concomitant fludrocortisone and dexamethasone were excluded if fludrocortisone was initiated > 5 days after starting dexamethasone. The primary outcome was the duration of vasopressors within 30 days. Secondary outcomes included all-cause mortality, ICU mortality, duration of mechanical ventilation in ICU survivors, ICU length of stay, and cumulative norepinephrine equivalent (NEE) dose, and fluid balance.
 
Results:
Twenty-nine patients were included in the dexamethasone only group and 15 patients were included in the dexamethasone/fludrocortisone group. Median duration of vasopressors within 30 days was 5 days (IQR 3.5 – 13) in dexamethasone/fludrocortisone group and 5 days (IQR 3 – 10) in the dexamethasone only group (p = 0.81). All-cause mortality was similar with 10 (66.%7) in the dexamethasone/fludrocortisone group and 18 (62.1%) in the dexamethasone only group (p = 0.76). ICU mortality was also similar with 9 (60%) in the dexamethasone/fludrocortisone group and 18 (62.1%) in the dexamethasone only group (p = 0.89). Median ICU length of stay was 11 days (IQR 8.5 – 26.5) for dexamethasone/fludrocortisone versus 12 days (IQR 8 – 21) in the dexamethasone only group (p = 0.84). Median duration of mechanical ventilation was 5 days (IQR 4 – 8) in the dexamethasone/fludrocortisone group compared to 7 days (IQR 6 – 12) in the dexamethasone only group (p = 1.0). The dexamethasone/fludrocortisone group required a median of 55,684 mcg NEE (IQR 36,132 – 86,663) cumulatively compared to 41,651 mcg NEE (IQR 13,686 – 62,784) with dexamethasone only (p = 1.0). Median difference in fluid balance after corticosteroids was +1.9 L (IQR -2.8 – 6.5) in the dexamethasone/fludrocortisone group and +0.54 L (IQR -2.6 – 4.9) in the dexamethasone only group (p = 1.0).
 
Conclusion: 
Patients with septic shock and ARDS had similar duration of vasopressors within 30 days whether they received dexamethasone/fludrocortisone or dexamethasone alone. There were no differences in all-cause mortality, ICU mortality, or ICU length of stay between groups. Patients who received dexamethasone/fludrocortisone had numerically shorter duration of mechanical ventilation and more positive fluid balance but these findings were not statistically significant. This study was underpowered and limited by its small sample size. Larger randomized controlled trials are needed to investigate the effects of fludrocortisone and dexamethasone in patients with ARDS and septic shock.


Resident contact: garbrielle.cromley@hcahealthcare.com

Title: Evaluation of the Efficacy and Safety of Increased Quetiapine Dosing Frequency for Treatment of Delirium and Agitation in Trauma ICU Patients


Authors: Nicole Johnson, Madalyn Kirkwood Brakel


Background: Delirium is a phenomenon characterized by acute onset or fluctuating mental status. Delirium is highly prevalent among patients in intensive care 
units (ICUs) and is a predictor of poor clinical outcomes. Though current guidelines do not recommend routine treatment of delirium, they acknowledge that short-term use of antipsychotics may be beneficial for patients who are agitated or in severe distress. Pre-ICU trauma is a non-modifiable risk factor for the development of delirium, yet trauma patients are often excluded from studies evaluating the management of ICU delirium. Quetiapine has a favorable pharmacokinetic profile 
for the management of delirium given its rapid onset of action, high bioavailability, and a relatively short half-life, however literature evaluating the effect of 
dosing frequency is limited. This study aims to evaluate the efficacy and safety of increased quetiapine dosing frequency (every 6 – 8 hours) compared to historical dosing regimens for the management of ICU delirium and agitation in trauma ICU patients


Methods: This study is a retrospective, single-center chart review evaluating patients admitted to Our Lady of the Lake Regional Medical Center (OLOLRMC) between August 2020 and August 2024. An epic-generated report identified patients admitted to the trauma service who received quetiapine in an ICU. From this list, a subgroup of eligible adult patients who received at least 48 hours of quetiapine therapy after documented ICU delirium, based on Confusion Assessment Method for ICU (CAM-ICU) score, were identified. Patients were excluded based on pre-specified exclusion criteria. The primary endpoint of this study is percentage of delirium free days (DFDs) following dose optimization. Secondary endpoints include the percentage of hyperactive DFDs following dose optimization, percent of Richmond Agitation-Sedation Scale (RASS) scores at goal following dose optimization, time from quetiapine initiation to ICU stepdown, time from dose optimization to ICU
stepdown, and clinically significant QTc prolongation following quetiapine initiation.



Results: Baseline characteristics were similar between groups. The median percentage of DFD was 0 and 0.33 days in the more frequent dosing and historical dosing groups respectively (p=0.026). The median percentage of hyperactive DFD was 0.65 and 0.75 days in the more frequent dosing and historical dosing groups respectively (p=0.027). Percentage of RASS at goal was similar between groups. The median time from dose optimization to ICU stepdown was 4 days in the more frequent dosing group vs 6 days in the historical dosing group (p=0.5). More frequent dosing was not associated with an increased risk of QTc prolongation.


Conclusion: More frequent dosing does not appear to reduce the percentage of DFD but may reduce time to ICU stepdown in trauma patients while maintaining safety

Title: Evaluation of Pharmacists’ Review on Discharge Medication Reconciliation in Transitions of Care 

Authors: Courtney Reliford, Sydney Bowman, Leborah Cole Lee, Randy Hooks, Kayla Brown 

Objective: To evaluate discharge medication reconciliation accuracy in patients with a pharmacist’s review and in patients without a pharmacist’s review.   

Background: Medication reconciliation is a critical component of safe transitions of care. The transition period from the hospital to home or another facility is a vulnerable period for patients and presents various opportunities for pharmacist involvement. Studies have demonstrated the value of pharmacists in transitions of care and medication reconciliation. According to the World Health Organization, more than 40 percent of medication errors may result from inadequate reconciliation in handoffs during hospital admission, transfer, and discharge. Within our institution, pharmacists review 30 to 40 percent of discharge medication reconciliations. This project is designed to evaluate discharge medication reconciliation for accuracy for patients with and without a pharmacist’s review. 

Methods: The Institutional Review Board approved this retrospective chart review of discharge medication reconciliation accuracy in patients with a completed pharmacist’s review and patients without a pharmacist’s review. Study participants were randomly selected for review based on discharges between January 1, 2023, through May 31, 2024. Study participants were randomized to either a control group or a pharmacist reviewed transitions of care group. The primary outcome was the incidence of medication discrepancies at discharge with a pharmacist’s review versus medication discrepancies without a pharmacist’s review. Secondary outcomes included average number of discrepancies per patient, discrepancies by patient location, discrepancies by physician specialty group, length of stay, percentage of patients with a discrepancy related to high-risk medications, type of discrepancies, and 30-day and 90-day hospital re-admission rates. Types of discrepancies included dose, route, frequency, medication, duplication, omission, unnecessary order, and untreated indication. Data were analyzed using Chi-Square, Fisher’s Exact test, Student’s t-test or Mann-Whitney U, depending on data type and distribution. 

Results: A total of 17,675 patients were identified over the study timeframe and randomized. Two hundred and nine patients were screened for inclusion: 99 in the pharmacist intervention group and 110 in the control group to achieve a total of 75 patients in each group.  Baseline characteristics were comparable between the two groups, except for the total number of discrepancies identified (29 discrepancies in the control group (3%) vs. 11 discrepancies in the pharmacist review group (1%), p = 0.005). There were fewer patients with a medication discrepancy in the pharmacist review group compared with the control group (31 % vs. 5%, p < 0.001). The median number of discrepancies also differed between the groups (IQR: 0-1 in the control group vs. 0-0 in the pharmacist review group, p value <0.001). While 30-day readmissions rates were similar between the groups, 90-day readmissions differed with 20 readmissions in the control group (27%) versus 8 readmissions (11%) in the pharmacist review group (p = 0.012). There were no statistically significant differences in discrepancies for high-risk medications between groups, defined as anticoagulants, potassium, narcotics, and insulin.   

Conclusions: This study showed clinically and statistically significant reductions in discrepancies on discharge as well as lower 90-day readmission rates when discharge medications were reviewed by a pharmacist, showing benefit of pharmacists’ participation in transitions of care. Strengths of this study include the inclusion of multiple different pharmacists' review on medication reconciliations, and inclusion of diverse patient populations. Limitations include a small sample size and inclusion of surgery patients who often have little to no changes in home medications. Future studies could provide a more thorough review of discrepancies across the continuum of care.  
 

Title: Characterization of External Ventricular Drain-Associated Ventriculitis
Authors: Jordan Glasgow (Jordan.Glasgow@wellstar.org), Joy Peterson, Karen Barlow 
Objective: Identify risk factors for developing ventriculitis after the placement of an EVD. 
Self-assessment Question: Which of the following may be a risk factor for EVD-associated ventriculitis?  
Background: Hospital-acquired infections (HAI) increase morbidity, mortality, and healthcare costs. However, HAI associated with external ventricular drains (EVDs) are not routinely tracked. Surveillance of these infections can help identify risk factors, causative pathogens, and preventative strategies. The aim of this study is to characterize patients who develop ventriculitis after EVD placement in a large community teaching hospital. We seek to identify practical monitoring parameters and modifiable risk factors to improve patient outcomes in the neurocritical care unit. 
Methods: This is an observational, retrospective chart review of patients admitted to Wellstar Kennestone Regional Medical Center (WKRMC) from December 2021 to August 2024 with a diagnosis of ventriculitis after EVD placement. Additional eligibility criteria are patients ≥ 18 years of age with an EVD in place ≥ 24 hours. Descriptive statistics were performed are the data.   
Results: A total of eighteen EVDs were placed in nine patients with ventriculitis in this IRB-approved study. Each patient had a median of two EVDs installed during their stay and received an average of 15.5 ± 11.12 days of antibiotic therapy. The median length of stay in the neurocritical care unit (neuro ICU) and hospital was 28 days (25-29) and 31 days (25-34), respectively. Two EVDs were placed in the Emergency Department (ED) (11.1%), seven EVDs were placed in the neurocritical care unit (ICU) (38.9%), and nine EVDs were placed in the operating room (50%). Ten of the eighteen EVDs (55.6%) were associated with ventriculitis. Of these ten EVDs, five were linked to culture confirmed ventriculitis, while the other five were associated with a clinical diagnosis of ventriculitis. All EVDs placed in the ED were linked to ventriculitis, while four EVDs placed in both the neuro ICU and OR were also linked to ventriculitis. Among the EVDs associated with culture positive ventriculitis, three were used for intrathecal medication administration. The isolated pathogens in cultured confirmed ventriculitis include Enterobacter cloacae, Neisseria spp, Serratia marcescens, and non-ESBL Klebsiella aerogenes.
Conclusion: Insertion of multiple EVDs and EVD manipulation may be associated with the development of ventriculitis. Additionally, the number of bedside EVDs linked to ventriculitis may be similar to those placed in the operating room. However, further studies including patients who do not develop ventriculitis after EVD placement as a comparator are needed to assess the incidence of ventriculitis following bedside installation.

Title: Incidence and outcomes of positive urine drug screen in neurocritical care 
Authors: Siavash Panahi, Morgan Daniel, Sam Pournezhad, Katleen Chester
Objective: To assess the incidence and clinical outcomes associated with positive UDS results in patients admitted to the neurocritical care unit (NCCU) of a large, urban, academic medical center.
Self Assessment Question: Is the incidence higher or lower than Medical and Surgical ICU?
Background: Substance use disorder (SUD) remains a major public health concern, affecting approximately 20.4 million individuals in the United States. Various substances, including amphetamines (AMP), fentanyl, opiates, cannabinoids (CBD), cocaine, benzodiazepines (BZDs), barbiturates (BAR), and methadone, exert significant effects on the central nervous system. Urine drug screening (UDS) is commonly used in hospitalized patients to detect these substances or their metabolites. While previous studies have evaluated the impact of positive UDS results in medical and surgical intensive care units (ICUs), limited data exist on the influence of positive UDS findings on neurocritical care unit (NCCU) admissions and patient outcomes. The objective of this study is to assess the incidence and clinical outcomes associated with positive UDS results in patients admitted to the NCCU of a large, urban, academic medical center.
Methods: This retrospective review analyzed NCCU admissions at Grady Memorial Hospital from January 2016 to December 2023. The study included all NCCU patients with at least one UDS result, considering only the first UDS per encounter. Patients were excluded if they received any dose of the listed substances after hospital arrival and before UDS sample collection. The primary outcome was the incidence of positive UDS results. Secondary outcomes included hospital length of stay (LOS), ICU LOS, the incidence of positive results for each substance, prevalence of single-substance versus multi-substance use, opioid exposure via morphine milligram equivalents (MME), and mortality rates.
Results: Among the 2,430 NCCU encounters, 46% (n = 1,116) were associated with a positive UDS result. Of these, 70% (n = 779) were positive for a single substance, while 30% (n = 367) indicated multi-substance use. The most frequently detected substances were BZDs (19.5%), fentanyl (13.5%), and cannabinoids (11.9%). Patients with positive UDS results had a significantly higher median hospital LOS (7 days [IQR: 3–16] vs. 6 days [IQR: 3–14], p = 0.003), while ICU LOS was slightly longer but not statistically significant (3.3 days [IQR: 1.6–7.9] vs. 2.9 days [IQR: 1.5–6.9], p = 0.09). Patients with positive UDS results demonstrated significantly higher opioid exposure during admission, with median MME levels of 378.75 (IQR: 59–2250) compared to 120.75 (IQR: 18–1098) in UDS-negative patients (p < 0.001). Substances associated with significantly higher MME included amphetamines, barbiturates, BZDs, cannabinoids, methadone, and opiates (p < 0.05 for all), whereas cocaine and fentanyl did not show statistically significant differences. Overall mortality did not significantly differ between UDS-positive and UDS-negative patients (21.2% vs. 19.9%, p = 0.46). However, subgroup analysis revealed significantly higher mortality rates among patients testing positive for cocaine (26.9%, p = 0.044) and BZDs (28.6%, p = 0.00013), while other substances did not show statistically significant differences.
Conclusion: This study highlights a high prevalence of substance use among NCCU patients, with BZDs, fentanyl, and CBD being the most frequently detected substances. Positive UDS results were associated with prolonged hospital LOS and higher opioid exposure. Additionally, patients testing positive for cocaine and BZDs exhibited significantly higher mortality rates, underscoring the need for targeted interventions in this population. These findings emphasize the impact of substance use on neurocritical care outcomes and the importance of optimizing management strategies for affected patient.

Title: Evaluating the Safety and Efficacy of Bicarbonate Use in Moderate-to-Severe Diabetic Ketoacidosis

Authors: John Ethan Young, Ashley Crisler, Bianca Rivera-Ramirez, McKenzie Hodges

Objective: To evaluate the effects of sodium bicarbonate therapy on the resolution of DKA and its associated outcomes
 
Self-Assessment Question: Which of the following is not characteristic of diabetic ketoacidosis? (A) Hyperglycemia (B) Metabolic alkalosis (C) Ketosis (D) Metabolic acidosis

Background: Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes characterized by hyperglycemia, metabolic acidosis, and elevated ketone levels. While the mainstays of DKA treatment include insulin therapy, fluid resuscitation, and electrolyte correction, the use of sodium bicarbonate to treat acidosis remains controversial. The American Diabetes Association (ADA) 2024 guidelines recommend considering sodium bicarbonate only in cases of severe acidosis (pH <6.9), but its routine use varies widely across institutions. Preliminary evidence from randomized studies has shown no significant improvement in morbidity or mortality with sodium bicarbonate therapy in DKA patients with pH levels between 6.9 and 7.1. However, there remains a gap in the literature regarding its impact on time to DKA resolution, which this study seeks to address. By clarifying the role of sodium bicarbonate in DKA management, this study aims to provide insight into optimizing treatment strategies and minimizing unnecessary interventions in the care of DKA patients.
 
Methods: A retrospective chart review was performed on adult patients treated for diabetic ketoacidosis (DKA) at Piedmont Columbus Regional Midtown between January 1, 2023 and December 31, 2023. Patients had to be 18 years of age or older and have clinical evidence of moderate-to-severe DKA. Patients that met these parameters were divided into two groups based on the administration of a sodium bicarbonate infusion. Patients were excluded if they presented with euglycemic DKA or if their insulin infusion was terminated prior to DKA resolution. The primary objective was time to DKA resolution. Secondary objectives included duration of insulin infusion, recurrence of acidosis, incidence of hypokalemia, hospital length of stay, and ICU length of stay. An independent t-test was used for the primary outcome, as well as the secondary outcomes of insulin infusion duration and length of stay, while a Chi Square Test was used to evaluate the recurrence of acidosis and incidence of hypokalemia.
 
Results: The patients receiving bicarbonate (n=32) had an average time to DKA resolution of 21.9 hours, while the patients receiving the standard of care (n=31) had an average time of 18.4 hours. Additionally, there was no difference seen for the secondary outcomes of insulin infusion duration [23.4 h vs 20.3 h], recurrence of acidosis [15.6% vs 3.2%], incidence of hypokalemia [65.6% vs 51.6%], and ICU length of stay [4.6 d vs 3.3 d]. There was a statistically significant difference for incidence of moderate hypokalemia [28.1% vs 6.5%] and hospital length of stay [10.3 d vs 5.2 d].
 
Conclusion: This study demonstrates that bicarbonate therapy is not efficacious in the management of DKA and may increase the incidence of moderate hypokalemia, risk of fluid overload, and potentially contribute to longer hospital length of stay. In conclusion, bicarbonate therapy should be seldom used for DKA, and the decision should be made by weighing the risks and benefits.

Evaluating the Efficacy of a Standardized Diuretic Order Panel versus Provider-Prescribed Diuretic Dosing in Acute Decompensated Heart Failure (ADHF)
Yanise Hurt, Jarvett Cox
 
 
Background: Acute decompensated heart failure (ADHF) is a leading cause of hospitalization, often driven by fluid overload. Effective diuresis is critical 
to improving clinical outcomes in this population; however, variability in prescribing practices can lead to inconsistent care and suboptimal results. The 
implementation of a standardized Heart Failure Diuresis Panel offers an evidence-based approach to diuretic therapy, promoting consistent and effective fluid removal while potentially reducing hospital length of stay. This study aimed to evaluate the clinical outcomes of ADHF patients treated with diuretics using a standardized panel compared to those managed with individualized provider-prescribed dosing, focusing on its impact on hospital length of stay.
 
Methodology: This retrospective, single-center chart review included 168 adult patients admitted with a primary diagnosis of ADHF at Wellstar Cobb Medical Center between January 1, 2023, and December 31, 2023. Patients were stratified into two groups based on their diuretic management: those who 
received therapy guided by the standardized Heart Failure Diuresis Panel and those managed with provider-prescribed dosing. The primary endpoint of
 the study was hospital length of stay. Secondary endpoints included the mean time to transition from intravenous (IV) to oral diuretics, door-to-diuretic 
time, 30-day heart failure readmission rates, mean changes in urine output and body weight, and diuretic prescriptions at discharge. Data was extracted from electronic medical records through a computer-generated report, and statistical analyses were conducted using t-tests for continuous variables and chi-square tests for categorical variables to evaluate the impact of the standardized panel on clinical outcomes.
 
Results: In the comparison of patients managed with the Heart Failure Diuresis Panel versus provider-prescribed diuretic dosing, there was no significant difference in hospital length of stay (4.79 days vs. 4.75 days; P=0.47) or in the mean time to transition from IV to PO diuretics (68.9 hours vs. 68.4 hours; P=0.23). Similarly, door-to-diuretic time (7.1 hours vs. 7.7 hours; P=0.41), 30-day heart failure readmission rates (8.3% vs. 9.5%; P=0.79), and diuretic 
prescription rates at discharge (85.7% vs. 76.2%; P=0.35) did not differ significantly between groups. However, the panel group demonstrated significantly greater mean urine output at 24 hours (1,584 mL vs. 1,283 mL; P=0.048), indicating enhanced diuretic responsiveness, though no significant differences were observed at 2 or 48 hours. The mean change in body weight was comparable between groups both at 24 hours (0.86 kg vs. 0.50 kg; P=0.29) and at discharge (3.07 kg vs. 2.62 kg; P=0.35). Although the standardized panel did not significantly affect hospital length of stay or most secondary 
measures, it was associated with improved early diuretic efficacy as demonstrated by greater urine output within the first 24 hours.
 
Conclusion: The Heart Failure Diuresis Panel did not demonstrate a significant impact on primary or secondary outcomes, including hospital length of 
stay. However, the consistent administration of appropriate IV diuretic dosing by providers not utilizing the panel suggested that its core principles have been effectively integrated into routine clinical practice. These findings are consistent with the DOSE trial, which underscores the importance of optimized diuretic strategies for symptom relief and fluid management in heart failure. This presents an opportunity to improve provider adherence to these 
protocols, potentially further optimizing patient outcomes.

Title: Evaluating the impact of a pharmacist-driven osteoporosis screening and treatment program in women veterans at the Birmingham VA Health Care System (BVAHCS)



Authors: Sara Chirambo; Lisa Ambrose



Objective: 
The purpose of this quality improvement project is to evaluate the effectiveness of
pharmacist-led interventions using the VA Osteoporosis Screening Dashboard to enhance the
identification of osteoporosis/osteopenia in patients seen in the Women's Health clinic at BVAHCS.


Self Assessment Question: 
What is the impact of pharmacist intervention in osteoporosis screening?


Background:  
Osteoporosis is a common chronic bone disease characterized by low bone mass and
deterioration of bone structure. It predominantly affects women, with higher prevalence
compared to men. Bone mineral density (BMD) peaks in early adulthood and declines with
age, increasing fracture risk. The USPSTF and National Osteoporosis Foundation recommend
routine screening for women aged 65 and older, typically using dual energy x-ray
absorptiometry (DEXA). Despite guideline recommendations, screening rates for osteoporosis
remain low. This project aims to evaluate whether the use of the VA Osteoporosis Screening
Dashboard by pharmacists improves identification of osteoporosis/osteopenia at the Birmingham VA.




Methods:
- Patients without a DEXA scan will be identified via the VA Osteoporosis Screening Dashboard
- Patients identified on dashboard will be reviewed and eligibility will be confirmed via chart review
- Pharmacists will communicate screening recommendations with patient 
- Pharmacists will place order for DEXA scan with patient consent
- DEXA scan will be scheduled through Medical Support Assistants (MSAs) at the Birmingham VA
- Pharmacists will contact patients to discuss DEXA/FRAX results and counsel patients on lifestyle modifications to reduce risk of osteoporosis. If patients are confirmed to have osteoporosis/osteopenia, treatment will be initiated by PharmD provider


Inclusion Criteria:
- Women aged 65 years and older
- No prior history of receiving DEXA scan in Computerized Patient Record System (CPRS)
- Patients followed by a provider in Women’s Health clinic


Exclusion Criteria:
- Patients currently receiving pharmacotherapy for osteoporosis or osteopenia
- Patients previously diagnosed with osteopenia or osteoporosis


Results:
The pharmacist-led osteoporosis screening initiative at the Birmingham VA Women's Clinic demonstrated a positive impact on patient care. 47/80 patients were reached by phone and of those 47, 33 patients were interested in a DXA screening. 57% patients reached who were interested scheduled a DXA scan. The pharmacist's outreach efforts, supported by the use of an osteoporosis dashboard created by the VISN7 VA Academic Detailing team resulted in an increase in screening rates compared to baseline. The intervention achieved a high patient acceptance rate, suggesting that direct pharmacist engagement encouraged participation.


Conclusion:
This quality improvement (QI) project highlights the value of pharmacist intervention in advancing preventative health measures within the VA healthcare system, specifically within women's health. By proactively identifying patients in need of screening and facilitating access to care, pharmacists played a role in increasing osteoporosis screening rates among older female veterans.