2025 Southeastern Residency Conference

Title: Dose-Dependent QTc Prolongation of Methadone in Pediatric Patients


Authors: Kaitlyn Currie, Justin K. Chen, Janae Townsend, Jillian Mantione


Objective: Determine thedose relationshipfor methadone and QTc prolongation in the pediatric population.


Background: Methadone is a synthetic opioid commonly used to wean patients off continuous opioid infusions to prevent withdrawal. Methadone is associated with prolongation of the QTc intervalon electrocardiogram (EKG). In pediatric patients, the dose-dependent relationship of methadone to QTc prolongation has not been established. The primary aim of this study was to investigate the risk of QTc prolongation in pediatric patients maintained on methadone at Children’s Healthcare of Atlanta. 


Methods: A retrospective chart review of patients less than 18 years old initiated on methadone between January 1, 2023 and April 30, 2024, in the intensive care setting. Patients were excluded if they received methadone for <24 hours, did not have EKG results while on methadone, had a history of long QT syndrome, or if they were on methadone for the following indications: chronic pain, palliative care, and/or addiction.

Results: A total of 79 patients met criteria for inclusion, comprised of 266 EKGs. The median age was 0.91 years (IQR 0.36-5.49) with 40 (50.9%) of patients being male. The median baseline QTc was 424 ms (IQR 408-441) for those who had an EKG prior to methadone initiation. There was no correlation between methadone weight-based dose and length of QTc (r=0.07, p=0.23). An analysis comparing low (<0.25 mg/kg/day), moderate (0.25-0.5 mg/kg/day), and high (>0.5 mg/kg/day) dosing of methadone did not show a difference in QTc among the three groups (p=0.71). A secondary analysis comparing patients with a baseline QTc and their QTc on methadone showed no difference (424 ms versus 430 ms, p=0.24).  

Conclusion: This retrospective analysis could not determine a relationship between weight-based methadone dosing and QTc. Patients did not experience a statistically significant difference between their baseline QTc and their QTc on methadone. 

Title: Implementing a Pharmacy Clinical Decision Support Council for a 54Hospital health-system.

Authors: Sabrina Desmond, Pharm.D.; Fei Wang, Pharm.D.; Craig MacDonald, Pharm.D.

Objective: To describe the creation and maintence of a clinical decision support oversight group to manage alerts within a multi-state health system.

Self Assessment Question: True or False: The only purpose of a clinical decision support council is to eliminate as many alerts as possible to reduce alert fatigue.

Background: Pharmacy-driven clinical decision support (CDS) is a critical element for optimizing medication safety and therapeutic outcomes in inpatient hospital systems. Pharmacy teams often manage an extensive array of drug-related alerts that can range from formulary and dosing recommendations to drug interactions and therapeutic duplications. Without focused oversight, these alerts can become overwhelming and lead to alert fatigue which could compromise the quality of patient care. A pharmacy-specific CDS Council can address these challenges by standardizing alert strategies, prioritizing clinically relevant notifications, and driving evidence-based enhancements to medication-related workflows.

Methods: Constructing an advisory group to oversee drug-related alerts required several steps:

• Establishing a workflow for alert review submissions
• Creating specialized workgroups that could provide insight for alert reviews
• Construct a voting structure that allows for diverse assessment and input

Items are entered into the CDS review process by inputting a request into a ticket management platform. After submission, items are reviewed by a workgroup comprised of electronic health record (EHR) analysts and pharmacy informatics experts to evaluate the request and propose solutions for consideration. Following that initial review, solutions are discussed and voted on independently by a medication safety workgroup and a clinical workgroup. Each of these workgroups have at least one representative from each of the eight regions within the hospital system. Finally, solutions and voting results are presented to a final council that includes leaders in clinical, medication safety, EHR, and informatics specialties. All results are discussed, and final actions are determined.

To evaluate the interventions made by this CDS council, requests have been categorized into 4 groups: alert deactivation, alert activation, creation of a custom alert, and no action taken. A secondary analysis was performed to better understand the reasons for taking no action. Therefore, the group "no action taken" was further subcategorized into one of the following: alert is appropriate, alert is not indicated, functionality not available, or exists in current state.

Results: A total of 59 items were tracked from August 1st, 2024 - March 31, 2025.The number of items reviewed were categorized into the 4 groups as follows:

• Alert deactivation: 4 items 
• Alert activation: 11 items
• Creation of custom alert: 12 items
• No action taken: 32 items

Since there were 32 items that were categorized as "no action taken," these items were further subcategorized as follows:

• Alert is appropriate: 18items 
• Alert is not indicated: 5 items
• Functionality not available: 5 items
• Exists in current state: 4 items

Conclusion: A structured workflow is needed in order to perform a systematic review and comprehensive assessment for CDS enhancements within a health system. By gathering insight from diverse specialties and system-wide representatives, balanced adjustments can be made to alert settings. These adjustments potentially lead to management of alert fatigue and other limitations experienced with CDS tools. Further investigation is needed to assess the overall impact that is made when adjusting alert settings. Additionally, further optimization and expansion of the CDS Council process can allow for proactive investigation of potential alert adjustments as well as an assessment of other CDS components beyond alert settings.

Title: Comparative Outcomes of Post-Transplant Cyclophosphamide (PTCy) vs Non-PTCy-Based GVHD Prophylaxis Regimens in Allogeneic Hematopoietic Stem Cell Transplantation


Authors: Gyunash Akibova, Kristen Kilby, Henry Kent Holland, Justin LaPorte, Eva Karam 
 
Objective: This study aims to evaluate the long-term outcomes of PTCy-based GVHD prophylaxis in alloHSCT recipients over a 10-year period at Northside Hospital. The primary objective is to assess chronic GVHD-free relapse-free survival (CGFRFS) in patients receiving PTCy compared to those who did not. Secondary objectives include evaluating overall survival (OS), relapse-free survival (RFS), NRM, and the incidence of acute and chronic GVHD.
 
Background: Graft-versus-host disease (GVHD) is a significant complication following allogeneic hematopoietic stem cell transplantation (alloHSCT), particularly in patients with human leukocyte antigen (HLA)-mismatched or haploidentical donors. Traditional GVHD prophylaxis regimens, such as a calcineurin inhibitor (CI) and methotrexate (MTX), have been effective but are still associated with risks of acute and chronic GVHD, as well as non-relapse mortality (NRM). Post-transplant cyclophosphamide (PTCy) alone or in combination with a CI with or without mycophenolate has emerged as a promising approach for GVHD prophylaxis, showing favorable results in reducing GVHD incidence in alloHSCT recipients. A recent retrospective study at The Blood and Marrow Transplant Program at Northside Hospital suggested the benefits of PTCy beyond haploidentical transplants, prompting further investigation into its long-term outcomes.
 
Methods: This single-center, retrospective chart review will include patients who underwent alloHSCT at Northside Hospital between January 1, 2013, and December 31, 2023. Recipient health records will be identified using a proprietary database to identify patients who received an alloHSCT during the study period. Data will be extracted from electronic health records (Cerner Powerchart®, OncoEMR®) and hospital databases. Patients will be excluded if they are receiving a second alloHSCT. Key data points include patient demographics, HLA disparity, use of PTCy, GVHD incidence, time to GVHD onset, disease relapse, and survival outcomes. 
 
Results: In Progress
 
Conclusion: In Progress

TITLE: Utility of Clonidine Conversion to Prevent Dexmedetomidine Withdrawal Syndrome in Pediatric Patients
 
AUTHORS: Emily Hardy, Andrea Gerwin, Renee Hughes, Paige Klingborg 
 
BACKGROUND: In 2022, the Society of Critical Care Medicine (SCCM) issued a guideline recommending alpha-2 receptor agonists as the preferred class for sedation in critically ill pediatric patients. Amidst emerging concern regarding potential dexmedetomidine withdrawal in this population, recent evidence has supported the use of clonidine, another alpha-2 agonist, as a bridging agent to mitigate or prevent withdrawal. While some institutions may have implemented the use of clonidine in dexmedetomidine weaning, there is no consensus or validated protocol. This study aimed to examine the relationship between cumulative dexmedetomidine exposure and clonidine requirements and will expand upon a previous analysis at the study site that focused on a period prior to the SCCM guideline update.  

METHODS: This IRB-approved, single center, retrospective observational study focused on patients admitted to the PICU from January 2018 to May 2024. Inclusion criteria included receipt of a continuous dexmedetomidine infusion > 24 hours and enteral clonidine for treatment or prevention of dexmedetomidine withdrawal. Patients were excluded if they used clonidine prior to admission or if clonidine was initiated for an alternate indication. Included patients were divided into two groups – a non-escalation and an escalation group – based on whether the patient received an increase in their clonidine dose (at provider discretion). The primary outcome assessed the relationship between cumulative dexmedetomidine exposure and maximum required clonidine dose. Secondary outcomes included dexmedetomidine withdrawal assessment, rate of clonidine failure following initial clonidine dose, hospital and ICU length of stay, ventilator days, central line days, and incidence of tracheostomy placement.
 
RESULTS: Compared to the non-escalation group, the escalation group had a statistically significant increase in duration of dexmedetomidine (346.4 vs 284.3, p-value=0.0114) and increased cumulative dexmedetomidine dose (341.2 vs 230.8, p-value=0.0128). The difference in initial clonidine dose was not significant (5.7 vs 4.9, p-value=0.7928). The escalation group had a statistically significant increase in hospital LOS (36 vs 27.5, p-value=0.0355) and ICU LOS (27 vs 20.5, p-value=0.0426). There was no statistically significant difference in ventilator days, CVL days, or incidence of tracheostomy.  
 
CONCLUSION: Higher cumulative dexmedetomidine exposure is associated with higher clonidine dose requirements. Both hospital and ICU LOS were significantly decreased in patients who did not require an increase in their clonidine dose. Utilizing cumulative dexmedetomidine exposure to determine initial clonidine dose may be beneficial.

Title: Transitioning RFID Medication Tray Solutions: A Nine-Hospital Network Implementation
Authors: Nina Desai, PharmD.; Hiren Shah, PharmD., BCPS; Craig MacDonald, PharmD.
Objective: To address the conversion between RFID systems and the challenges that arise during this process.
Self Assessment Question: True or False. Vendors will always be able to transfer currently tagged products to a new system during a vendor conversion. 
Background:
RFID (radio-frequency identification) in pharmacy enhances the accuracy and efficiency of medication management. By tagging medications with RFID, pharmacies can automate the tracking process and reduce human error. AdventHealth utilizes RFID technology for code trays and anesthesia station trays. Trays and medications are equipped with RFID tags containing unique identifiers for precise tracking and inventory control. The goal of the system is to monitor tray and medication inventory and notify staff when items are nearing expiration or trays need restocking.
AdventHealth is in the process of transitioning vendors for RFID tray solutions. The key benefit of System B is the ability to purchase pre-tagged items directly from AdventHealth’s established wholesaler.
During a brand-new RFID go live a drug library would be built and the items required in the pharmacy would be tagged and entered into the system. With a conversion the existing information and tagged products would ideally be transferable to the new system, removing potential work and redundant inventory. While most published information focuses on implementing new RFID system, this presentation addresses the conversion between RFID systems and the challenges that arise during this process.
Methods: 
AdventHealth’s Central Florida Division is transitioning from System A to System B in a structured three-phase approach. Each phase includes three hospitals and phase three includes sites using mobile solutions for anesthesia-station trays, including the 1,366-bed flagship hospital. The conversion is led by the pharmacy informatics team, vendor representatives and local pharmacy leadership.
System A was not able to transfer existing drug registry information into System B, requiring a conversion process for existing tagged inventory. The preparation of tagged items for the conversion involved commissioning medications previously tagged in System A, purchasing pre-tagged items from the wholesaler, and newly tagging items by the pharmacy.
An action plan was developed for the six weeks preceding the go-live. The first two weeks were spent gathering and preparing tray, NDC, user, and site data. The next week was dedicated to training users, with each site completing buyer, superuser, and general staff training. The following three weeks focused on commissioning to ensure tagged medication was available during go-live. Additionally, sites were encouraged to purchase additional inventory pre-tagged through the wholesaler associated with System B. The existing tagged inventory was separated by lot and commissioned, with daily tracking of commissioned items.
These commissioning weeks provided enough items to reach the project milestones (three-tiered progression):

1. Completed at least one of each tray template.
2. Completed at least three of each tray template.
3. Completed high-priority trays.

Results:
Phase one was completed in December 2024, and phase two will finish by mid-March 2025. The team initially faced a steep learning curve, including commissioning bottlenecks. During some commissioning steps, we are limited to a single System B kiosk, which caused significant bottlenecks. For reference, a smaller site with nearly 200 beds has an inventory of nearly 3,000 tagged items in System A that needed to be commissioned into system B.
The action plan was adjusted after each go-live, leading to significant improvements in preparation and execution. As the flagship hospital transitions to a mobile solution in phase three, the plan will continue to evolve.
Conclusion: In progress