2025 Southeastern Residency Conference

Title: The Implementation of a Passive Bin-Based Perpetual Medication Inventory Model within Ambulatory Clinics at an Academic Medical Center


Authors: Elly Glazier, Jared Gabbert, Grayson Peek


Background: Ambulatory clinics store and dispense high-value medications with little visibility into inventory quantity or product movement. Automated dispensing cabinets are frequently used within inpatient settings to combat this issue but are a large capital investment for the clinic setting. In current state, pharmacies and clinics follow complex workflows to manage the inventory of high-value medications to meet patient demand while minimizing drug waste. This has led  to unrealized opportunities in inventory optimization due to large information gaps. We assessed a passive bin-based inventory model that leverages a system that records every transaction by a clinic team member. The system records these transactions in real time via light sensors and can both register the removal and replacement of medication products. The system then uses artificial intelligence and various algorithms to recommend inventory optimizations via the assessment of the recorded medication transactions and notably requires no electronic health record integration.


Methods: This study was conducted over 10 weeks and included select medications at two ambulatory locations. We assessed if the utilization of a passive bin-based inventory model within ambulatory clinics allowed for a decrease in inventory on-hand valuation. Inventory valuation was assessed prior to implementation and following system recommendations at the conclusion of the pilot. Accuracy of the system was validated via twice weekly manual cycle counts. The primary outcome was the valuation of the inventory on hand change recommended by the system at the conclusion of the evaluation. Secondary outcomes included the accuracy of the system as well as the outcome of a comparison of pre- and post- implementation satisfaction surveys (modified MAS-NAS) offered to nursing staff, as well as the cost of facility modifications required for implementation.


Results: The passive bin-based inventory recorded 3,454 dispenses during the study period. The average days on hand tabulated ranged from 1.5 days to over 30 days. The total inventory valuation decrease across both clinics included 69 product units for a total of $34,000 of average wholesale price. The accuracy of the model was established to be 84.6% at the neurology site and 96.3% at the orthopedics site. Though not extrapolatable due to volume, the results of the modified MAS-NAS nursing satisfaction survey showed a negative change from pre- to post- survey but notably were generally positive regarding the post implementation passive bin-based technology questions.

Conclusions: In this retrospective pre and post implementation study, the utilization of passive bin-based perpetual medication inventory models reduced inventory on hand valuation but was not statistically significant. Additionally, the model offers the opportunity to greatly increase inventory visibility in a difficult to manage care setting. Additional studies that assess benefits of visibility with powered results should be considered as the implementation of this model improves.

Title: Impact of Daily Pharmacist Anticoagulation Review in a Rural Hospital

Authors: Grace Kenley, Lindsey Arthur

Objective: will be included in presentation

Self Assessment Question: will be included in presentation

Background:  Anticoagulants are used for a variety of indications which leads to their frequent administration in hospitalized patients. Whether utilizing anticoagulants for therapeutic indications or for venous thromboembolism (VTE) prophylaxis, dosing is highly individualized to each patient based on factors such as weight and renal function. As patients’ clinical statuses can fluctuate from admission to discharge, it is imperative to review the appropriateness of each anticoagulation regimen on a daily basis. The consequences of inappropriate anticoagulation regimens can be severe, including adverse events such as bleeding or thrombosis. Due to these risks, anticoagulants are included on the Institute for Safe Medication Practices (ISMP) list of high alert medications. The purpose of this study is to determine the impact of daily pharmacist review of anticoagulants within a newly implemented floor-based pharmacist model in a rural hospital.

Methods: A prospective cohort study will be conducted on patients admitted to the medical and telemetry floors at Self Regional Healthcare during the hours of 7:00 AM to 3:30 PM on weekdays between February 24th, 2025 through March 26th, 2025. Anticoagulation regimens, both treatment and prophylaxis, will be reviewed on each patient for appropriateness in terms of indication and patient specific factors such as renal function and weight. Patients not on any type of anticoagulation will be reviewed to determine if therapy is warranted. Patients will also be educated on the importance of anticoagulation if refusals are documented. The primary outcome is the number of anticoagulation recommendations made to ensure appropriate therapy. Secondary outcomes include number of dosage adjustments, number of frequency adjustments, number of anticoagulant initiations, number of anticoagulant discontinuations, number of bleeding events, number of thrombotic events, and number of patient educations performed. 

Results: Between February 24th, 2025 – March 26th, 2025, 1,046 patients were admitted to medical and telemetry-monitored floors. During this period, 67 anticoagulation recommendations were made. Of the 67 recommendations, 60 were accepted by providers, resulting in a 90% acceptance rate.  The most common rejection was the addition of SCDs for patients refusing chemoprophylaxis (4 of the 7 rejections). Results for secondary outcomes are as follows: 29 dosage adjustments, 6 frequency adjustments, 12 initiations, 3 discontinuations, 14 SCDs added on, 2 bleeding events, 1 thrombotic event, and 3 patient educations performed.  

Conclusion: Ultimately, having a pharmacist located on the floor increased the number of therapeutically appropriate anticoagulation recommendations which may lead to decreased adverse bleeding or thrombotic events.

Title: Med-to-Bed Program Expansion to Transplant Services


Authors: Amelia Hornaday, Alyson Ghizzoni-Burns, Heather Kundert, Alexandra Pyatt, Danielle Eskens


Objective: To expand the med-to-bed program to transplant services.


Background: Prisma Health has an established Kidney Transplant Program. It is vital to provide patients with strong continuity of care to support them through life post-transplant. Med-to-Bed programs were developed to decrease readmissions, improve medication adherence, reduce barriers to medication access, improve patient experience, and increase discharge prescription capture. Greenville Memorial Hospital’s med-to-bed program is offered to nearly all inpatient units through Upstate Medical Pharmacy, an internal outpatient pharmacy. Discharge prescriptions for transplant patients are currently being filled and mailed to the hospital by a third-party pharmacy. Given the increasing number of transplants and desire to expand services offered, it is imperative to the patient and organization to develop a process to include solid organ and bone marrow transplant services within the med-to-bed program.


Methods: Current and proposed processes were evaluated and compared to outside institutions to determine best practices. A Medicare Part B billing contract was established at Upstate Medical Pharmacy and test claims were billed for various insurance types. A workgroup was established consisting of both pharmacy and transplant staff to operationalize the workflow. Prior to go-live, education will be provided to transplant nursing and providers, inpatient pharmacy staff, and the outpatient med-to-bed team. Upon program expansion go-live, respective units will be auto-enrolled for med-to-bed in the electronic health record at the point of patient admission. The primary outcome is revenue generation and continued prescription capture rate.


Results: In progress


Conclusion: In progress

IMPACT OF PATIENT PREFERENCE ON INPATIENT ANALGESIA


Lauren Alaine “Lainey” LaMoyne, MaryAnn Birch, Lisa Scott


HCA Florida West Hospital – Pensacola, FL


Background/Purpose: Non-opioid analgesics are often underutilized as part of a multimodal approach. Additionally, patients may prefer non-opioids for moderate to severe pain, but these agents are often only prescribed for mild pain. In response, several changes were implemented to policy and an analgesic order set, and provider and nursing education was provided. The purpose of this study was to see if a pain management intervention consisting of usage of a standardized order set, new policy, and education will increase the usage of non-opioids administered for pain.


Methodology: This is a single center, quasi-experimental study conducted at a 515-bed academic hospital. Adult acute care inpatients were included if they were ordered a PRN (as needed) opioid pain medication and a non-opioid (acetaminophen or ibuprofen). Patients were identified using facility surveillance software reports. Patients were excluded if they had opioid use disorder, active malignancy, requirements of greater than 60 morphine milliequivalents per day before admission, contraindication or allergy to study drug, intravenous acetaminophen administration, incomplete documentation of pain scale, use of a scheduled opioid, and/or opioid reversal prior to inpatient status. Patients were also excluded if admitted to the labor and delivery unit, the intensive care unit, or palliative care. Cohort 1 consists of patients prescribed both opioids and non-opioids (acetaminophen or ibuprofen) without utilization of the revised opioid order set. Cohort 2 includes patients prescribed medications from the revised opioid order set. The primary outcome is the number of times a non-opioid was given for analgesia. The secondary outcomes are patient-reported pain scores and the number of times a non-opioid was given for moderate to severe pain per patient preference.


Results: One hundred and six patients were included in this study. The primary outcome of number of times a non-opioid was given for analgesia per length of days was 0.71 and 1.27 for cohorts 1 and 2, respectively (p=0.0362). The number of times a non-opioid was given for moderate to severe pain per length of days analyzed was 0.03 in cohort 1 and 0.2 in cohort 2 (p=0.0263). The number of times an opioid was given for moderate to sever pain per length of days analyzed was 1.3 in cohort 1 as compared to 1.3 in cohort 2 (p=0.8630). The mean non-opioid change in pain score was 1.4 in cohort 1 and -2.3 in cohort 2 (p=0.0818). The mean opioid change in pain score was -4.0 for cohort 1 as compared to -3.8 in cohort 2 (p=0.4879).
 
Conclusions: There was a statistically significant increase in the number of times non-opioids were administered for analgesia and a statistically significant increase in scheduled APAP utilization. There was also a statistically significant increase in the number of times opioids were given for breakthrough pain. Opioid administrations for moderate to severe pain did not result in a statistically significant difference, and there was no statistical difference in average daily MME between cohortss. Pain Scores could not be accurately assessed due to small sample size. Future studies with a larger sample size are warranted to further investigate the implications of patient preference.


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.

Title: Initiative To Improve Lithium Safety Monitoring at Veterans Affairs Medical Center

Authors: Cydney Smalls, Carrie Sartin, William Erwin

Objective: To evaluate the effectiveness of recommendations provided by a pharmacist via chart review regarding lithium therapeutic drug levels and safety monitoring for Veterans.

Self-Assessment Question:

Background: Lithium is a well-established therapy for mood disorders, known for its effectiveness in mood stabilization and significant reduction in suicide risk. Despite its clinical benefits, lithium therapy is challenging due to its narrow therapeutic index, making patients susceptible to toxicity. Consequently, frequent monitoring of serum lithium levels and organ function (Scr, ECG, TSH, electrolytes, CBC) is critical. This quality improvement initiative aims to evaluate the impact of clinical pharmacist recommendations provided via chart notifications on enhancing lithium monitoring practices.

Methodology: This quality improvement project is designed as a multi-center, prospective cohort analysis, exempt from Institutional Review Board approval. It investigates provider responses to clinical pharmacist recommendations made through a chart-based review for Veterans on lithium therapy at the Fayetteville NC VA Coastal Health Care System (FNCVACHCS). Participants were identified using the Veterans Affairs Lithium Lab Monitoring Dashboard. Recommendations were communicated to providers using a standardized note template embedded within the computerized patient record system (CPRS). The primary outcome measures the percentage of recommendations accepted by prescribers, determined by new orders placed within one week of the note's documentation. Secondary outcomes include evaluating the average duration between note documentation and completion of recommended safety monitoring tests, incidence rates of supra-therapeutic lithium levels along with associated side effects, and the proportion of accepted recommendations not carried out by patients.

Results: Forty-six notes were entered to communicate recommendations to prescribers. Regarding the primary outcome, providers accepted 37% (17) of these recommendations. The average time from note entry to completion of recommended safety monitoring tests was 13 days. Notably, no supratherapeutic lithium levels were reported during the observation period. However, 47.1% (8) of provider-accepted recommendations were not completed by patients, indicating a significant gap between provider acceptance and patient adherence.

Conclusions: Despite the inconsistent laboratory monitoring parameters for Veterans on lithium therapy, the results showed that Veterans for whom lab values were reviewed showed no significant concerns. There were limitations with the initiative which included providers not acknowledging the recommendation within the computerized patient record system (CPRS), resulting in variability in the implementation of recommended monitoring practices. Identified barriers, including time constraints and alert fatigue, likely contributed to this inconsistency. Addressing these challenges through targeted education, streamlined workflows, and supportive feedback is essential to enhancing provider adherence, thereby ensuring consistent patient safety practices. Efforts to mitigate these barriers are crucial to sustaining the initiative without placing undue burden on healthcare providers.

Title: Optimizing Patient Care: The Role of Pharmacy-Driven Nursing Education in Enhancing Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores

Authors: Leah Franks and David Collette

Background: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a national patient satisfaction tool that measures the perception of hospital care. This survey is completed by patients after discharge. Associated scores are directly linked to hospital reimbursement and STAR ratings. A review of recent Huntsville Hospital HCAHPS results revealed that scores were lowest surrounding the Communication about Medicines Domain. This domain addresses whether the indications and side effects of medications were discussed with patients during their hospital stay. Thus, the purpose of this pharmacy pilot project is evaluating if targeted pharmacy education on low-scoring nursing units results in an HCAHPS score improvement.

Methods: A single-center, institutional review committee approved, pre-post analysis was conducted at Huntsville Hospital to assess the impact of pharmacist-driven education as it relates to HCAHPS score improvement. The primary endpoint for this study was HCAHPS Top Box score improvement regarding the “Communication about Medicines” HCAHPS domain.  This study reviewed HCAHPS data (provided by Press-Ganey (PG)) between November 2023 to February 2025. As principal investigator, I worked with the Patient Experience Team to develop education materials for both nurses and patients in an effort to improve the patient experience in regards to the communication surrounding medication administration. Education materials developed included medication tip sheets and nursing education documents. Discussion with nursing unit directors and educators regarding advantages and barriers to success was required before implementation of process change could take place. Analysis was performed by PG and sent to primary investigator for review for pre-data (November 2023 – February 2024) and post-data (November 2024 – February 2025).

Results: A medical unit, two surgical units (A & B), and a neurological unit were included in the study. Pre-implementation Top Box Percentage scores (PG Percentile Rank) were as follows for each unit: Medical Unit – 59.72 (50), Surgical Unit A – 49.28 (5), Surgical Unit B – 57.29 (35), and Neurological Unit – 67.45 (89). Post implementation Top Box scores (PG Percentile Rank) were as follows: Medical Unit – 60.29 (45), Surgical Unit A – 67.43 (85), Surgical Unit B – 54.17 (13), and Neurological Unit – 44.00 (1). Monthly trends of each unit reveal fluctuations in overall data surrounding the primary endpoint.  In addition, at a pilot study debrief with hospital administration and nurse managers for each of the four units, differences in implementation methods for each unit was reported.

Conclusion: Overall, mixed results were seen across the units regarding the primary endpoint. A numerical increase was seen in the Top Box Scores for two out of the four units. Of note, after implementation differences were noted in the debrief, it was concluded that having a higher degree of nurse leadership integration/dissemination of the medication tip sheets correlated with higher HCAHPS Top Box scores.  Limitations included the variations in nursing unit implementation of the pilot project, nurse turnover, inability of primary investigator to participate in repeat educations for nursing units, and small sample size. A clear, general implementation plan would need to be utilized before hospital-wide or system-wide implementation could take place.

Title: Evaluation of Blood Glucose Goal of 110-150 mg/dL in Cardiovascular Intensive Care Patients 
Authors: Joy Dahlen, Jessica Odom, Carly Sisk, Benjamin Gustafson, Alex Ewing, Lyndsay Gormley 
Objective: To determine if a target blood glucose range of 110-150 mg/dL after cardiac surgery resulted in a difference in hypoglycemia incidence compared to previous goal ranges
Background: Hyperglycemia is common in patients, with and without diabetes, who have undergone cardiac surgeries such as coronary artery bypass grafting (CABG) and is associated with many adverse outcomes including increased risk of infection, longer hospital length of stay, and increased risk of mortality. Avoiding hyperglycemia after cardiac surgery mitigates these complications.  However, there is controversy over the ideal goal blood glucose range for patients after cardiac surgery. 
Methods: This multi-center, pre- and post-interventional, retrospective cohort study evaluated patients undergoing cardiac surgery utilizing the new Prisma Health cardiac insulin drip with a goal blood glucose of 110-150 mg/dL (moderate) compared to previous goals of 100-140 mg/dL (low) or 120-160 mg/dL (high). Patients were identified based on a surgical report for all cardiac surgeries and then randomized to include a total of 200 patients, divided into four groups of 50 (two pre-intervention and two post-intervention groups from two institutions. Patients were included in the study if aged 18 years or older, underwent cardiac surgery, and received an insulin drip. Patients were excluded from the study if they were placed on extracorporeal membrane oxygenation (ECMO), died in the operating room, or had an open chest post-surgery. The primary outcome was incidence of hypoglycemic events (<70 mg/dL) per 1000 ICU days. Secondary outcomes included: incidence of severe hypo- and hyperglycemic events per 1000 ICU days, incidence of sternal wound infection and positive blood cultures, and 30-day mortality.  
Results: A total of 200 patients were screened for inclusion, and 182 patients were included in the study. The primary outcome of incidence of hypoglycemia <70 mg/dL was significantly lower between pre- and post- intervention group for Site A, increasing the goal from low 100-140 mg/dL to moderate 110-150 mg/dL (317.46 events per 1000 ICU days in the pre-group vs. 138.25 in the post-group, p=0.0006). There was not a significant difference in hypoglycemic events in the pre- and post-intervention groups for Site B, decreasing the goal from high 120-160 mg/dL to moderate 110-150 mg/dL (13.47 events per 1000 ICU days in the pre-group vs. 20 events per 1000 ICU days in the post-group, p=0.56). There were no significant increases in incidence of sternal wound infection, positive blood cultures, or morality from the moderate goal. 
Conclusions: A blood glucose goal of 110-150 mg/dL resulted in significantly lower incidence of hypoglycemic events (<70 mg/dL) compared to a blood glucose goal of 100-140 mg/dL. A blood glucose goal of 110-150 mg/dL did not significantly increase incidence of hypoglycemic events compared to a goal of 120-160 mg/dL. 

Self-assessment question: Which of the following post-operative goal glucose ranges had the highest incidence of hypoglycemia?