2025 Southeastern Residency Conference

Title: Effect of Antidepressant Continuity on Analgosedation in Mechanically Ventilated Patients

Authors: Isabelle Perling, Sarah Blackwell, Kenda Germain, John Michael Herndon

Objective: Assess the effect of antidepressant continuity or discontinuity on analgosedation in mechanically ventilated patients. 

Self Assessment Question: True or False: Abrupt cessation of antidepressants can cause antidepressant discontinuation syndrome that typically occurs in patients using SSRI or SNRI medications with short half-lives.

Background: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first line treatment options for depression and anxiety and are used for many other psychiatric disorders. In critically ill patients with mental disorders, psychiatric symptoms may be heightened due to a change in environment and physical condition. Despite this, many antidepressants are not continued in the critical care setting for various reasons. Abrupt cessation of antidepressants can cause antidepressant discontinuation syndrome (ADS), with symptoms including agitation, mood changes, insomnia, dizziness, nausea, and vomiting. ADS has a mean onset of two days after discontinuation and is most common in patients using agents with short half-lives. The syndrome can mimic hyperactive intensive care unit (ICU) delirium, which may lead to increased sedative doses to maintain goal sedation, while the underlying cause is left untreated.

Methods: This is a single center, retrospective chart review in patients who were on SSRI or SNRI therapy prior to a hospitalization where they were subsequently intubated. Included patients were 18 years of age or older, receiving outpatient SSRI or SNRI therapy prior to hospitalization, and initiated on mechanical ventilation within 48 hours of admission. Patients with current substance abuse, need for deeper sedation, acute neurological events, chronic invasive mechanical ventilation, pregnancy, or incarceration were excluded. Patients who restarted SSRI or SNRI therapy between 49 and 72 hours were also excluded. Outcomes were compared between patients who resumed their SSRI or SNRI within 48 hours of intubation and patients for whom their SSRI or SNRI was held for more than 72 hours after intubation. The primary endpoint was the dose of IV analgosedation at 72 hours represented by the fraction of IV sedation score (FISS). FISS is a novel scoring system created to compare analgosedation medications and doses for patients on various agents. It is calculated by dividing the dose of each analgosedation agent by the typical maximum dose at the facility. Each of these are then added together to create the numerical FISS. Secondary endpoints included FISS at 24 and 48 hours, RASS at 24, 48, and 72 hours, ICU and hospital lengths of stay, duration of mechanical ventilation, and duration of IV analgosedation. Statistical tests included the student’s t-test and the Wilcoxon rank sum test.

Results: Forty patients were analyzed. FISS was similar between patients who continued their antidepressant and the discontinuity group at 72 hours post intubation, 0.95 ± 1.02 vs. 0.60 ± 0.66 (p = 0.194). There was no difference in FISS at 24 and 48 hours, RASS, ICU and hospital LOS, and duration of mechanical ventilation or analgosedation.

Conclusion: Antidepressant continuity did not result in a difference in analgosedation needs or other outcomes. The novel FISS offers a practical way to compare analgosedation needs across various agents but needs external validation for external use.

Contact information: isabelle.perling@orlandohealth.com

Title: Outcomes Associated with Formal Infectious Diseases Consultation for Positive Blood Cultures with Staphylococci Other Than Staphylococcus aureus 


Authors: Kellee B. Geren, Brandon Hawkins, Mary Joyce Wingler, Jessica Ortwine, Samantha Walker, Helen Ding, Bryan Walker, Cami Andreini 


Objective: This study attempted to determine the impact of infectious diseases consultation on the clinical management, readmission, and mortality of patients with Staphylococcus lugdunensis, Staphylococcus pseudintermedius, or Staphylococcus schleiferi isolated from a blood culture. 


Self Assessment Question: True or False: Infectious diseases consultation in patients with S. lugdunensis, S. pseudintermedius, or S. schleiferi bacteremia resulted in a significant decrease in mortality or 30-day readmission.


Background: There is data suggesting infections caused by S. lugdunensis, S. pseudintermedius, and S. schleiferi may be associated with a higher acuity of illness. However, there is limited data defining the management of these organisms when isolated from a blood culture, as well as the impact of infectious disease consultation on mortality in these patients.


Methods: This was a multi-center, observational, retrospective cohort study that compared the clinical management and disease course of patients with (consult group) and without an infectious diseases consultation (no consult group). Adult patients admitted between January 1, 2014 and March 1, 2024, with blood cultures positive for one of the specified organisms were included. Patients were excluded if S. aureus was isolated at any point during admission or if they discharged, died, or transitioned to hospice prior to blood culture speciation. 


Results: The primary outcome composite of 90-day all-cause mortality from index blood culture or 30-day readmission due to bloodstream infections caused by S. lugdunensis, S. pseudintermedius, or S. schleiferi was 17.9% in the no consult group and 12.2% in the consult group (p = 0.308). Hospital length of stay was a median of 6.82 days in the no consult group compared to a median of 11.69 days in the consult group (p < 0.001). Thirty-day mortality was 12.8% in the no consult group versus 8.5% in the consult group versus (p = 0.379). 


Conclusion: In patients who received an infectious diseases consult, 90-day mortality, 30-day mortality, and 30-day readmission were numerically, but not significantly, lower. A larger study is needed to assess the impact of infectious diseases consultation on mortality for specific staphylococci. 

Title: Description of Clinical Pharmacist Interventions on an Acute Care Unit
Authors: Jamarius Carvin, Kelley Frances Henley, Niaima Geresu, Irene Bemis, Kristina Evans, Stella Ye 
Objective: Evaluate the impact of a dedicated clinical pharmacist on acute care unit interventions 
Self-assessment: How did a dedicated pharmacist affect daily interventions? 
Background: In a clinical setting, pharmacists optimize medication therapy and enhance patient safety. Studies have shown pharmacists identify and prevent errors with potential cost avoidance. Quantifying their impact is crucial for justifying clinical pharmacy services, especially concerning medication errors at hospital discharge, which pose risks and increase costs. Pharmacist-led medication reconciliation at discharge (PMRD) has shown positive impacts on reducing medication errors, preventing adverse drug events and improving patient safety. Pharmacists also provide drug information, optimize therapy, and improve cost-effectiveness. It is important to continue to evaluate the impact of a clinical pharmacist in an evolving healthcare field, so this research investigates the impact of implementing a dedicated clinical pharmacist on an acute care unit by quantifying interventions. 


Methods: This retrospective chart review was conducted at Grady Health System (GHS). The study compared two periods on a 40-bed acute care unit: a baseline period (20 weekdays in April 2024) with usual GHS pharmacy protocol and an intervention period (20 weekdays from May-June 2024) with a dedicated pharmacy resident. The primary outcome was the average number of pharmacist interventions per day. Secondary outcomes included intervention categorization, the number of patients with interventions, the total number of interventions, and high-risk medication interventions. Exclusion criteria were duplicate documented interventions. Descriptive statistics and chi-squared testing were used for analysis. 


Results: The average number of interventions per day increased from 5.7 (± 2.6) in the control period to 16.85 (± 7.8) in the intervention period. The total number of documented interventions in the control period was 99 compared to 337 in the intervention period.  The number of patients with at least one documented pharmacist intervention increased from 61 to 175

Title: 
Evaluation of Quality Measure Outcome Adherence in the Treatment of Spontaneous Bacterial Peritonitis in Patients at a Large Community Hospital

Authors:
Leeann Gowan, Christen Freeman, Doug Carroll

Objective:
Discuss adherence to quality measure outcome set forth by the American Association for the Study of Liver Diseases (AASLD) for the treatment of spontaneous bacterial peritonitis.

Self Assessment Question:
What is the recommended albumin dose patients treated for SBP should receive within 12 hours of the ascitic fluid test result?

Background: 
Spontaneous Bacterial Peritonitis (SBP) is an ascitic fluid infection with an unknown source of origin. This infection is one of many complications resulting from advanced liver cirrhosis and ascites. As recommended by the American Association for the Study of Liver Diseases (AASLD) practice guidance, a diagnostic paracentesis should be performed on all patients with suspected SBP. Management of SBP includes the use of antibiotics and albumin. Empiric IV antibiotics should be initiated in all patients with an ascites polymorphonuclear (PMN) count >250 cells/mm3. 

Furthermore, patients with cirrhosis have an increased risk of worsening liver and renal function from bacterial infections. The appropriateness of treatment of SBP has not been assessed at DCH. Consequently, this is a disease state, that if quality measures are not met, can progress to high rates of mortality and worsening liver and renal function. The purpose of this study was to evaluate percentage adherence to a specific cirrhosis quality measure set forth by the Practice Committee of the AASLD, in the treatment of SBP in patients at DCH Regional Medical Center and Northport Medical Center.

Methods:
This was a retrospective chart review of patients treated for SBP at DCH Regional Medical Center (a large community 583-bed hospital) and Northport Medical Center (a 204-bed community hospital). Patients were included if they were 19 years old or older, had an ICD-10 diagnosis of cirrhosis and ascites and SBP or had an ascitic fluid PMN count >250 cells/mm3. 

A list of patient encounters was generated from the electronic health record (EHR) from May 2021 to July 2024. Patients that were selected for review first, were those with an ICD-10 diagnosis code for SBP, then those with an ascitic fluid white blood cell count (WBC) count. A PMN count was calculated by multiplying the total WBC by the percentage of PMNs in the differential (neutrophils). The primary outcome measure was percentage adherence to meeting all 3 criteria of the guideline recommended quality measure outcome: hospitalized patients with ascites, with an ascitic fluid PMN count of ≥ 250 cells/mm3, should receive: empiric antibiotics and albumin 1.5 g/kg within 12 hours of the ascitic fluid test result and receive albumin 1.0 g/kg on day 3. Secondary outcomes were comparison of results for those with a GI consult, characterization of antibiotic regimen, and patient encounter mortality rate. For the statistical analysis, descriptive statistics were utilized. This study was IRB exempt.

Results:
This study included a total of 40 patients. Overall, there were zero patients that met all 3 criteria of the quality measure outcome. Twenty-eight patients met at least one criteria (70%). Patients with a GI consult overall had improved outcomes. Twelve patients were empirically treated with a 3rd generation cephalosporin (54.5%). Five patients (22.7%) were treated for 5-7 days out of the twenty-two patients only treated for SBP.

Conclusion:
This study observed many ways to improve treatment of SBP at DCH. Areas of improvement include correct albumin dosing, administration of albumin within the 12-hour range, and administration of the second dose of albumin on day 3.

Title: Rates of Gastrointestinal Bleeding (GIB) in Patients Taking Concomitant Dual Antiplatelet Therapy (DAPT) and SSRI/SNRI Therapy Within One Year of Acute Coronary Syndrome (ACS) 
 
Authors: Hannah Holbert, Thaddeus McGiness, A. Shaun Rowe, Travis Fleming


Objective: Evaluate potential gastrointestinal bleeding risk associated with combined SSRI/SNRI and DAPT in patients receiving these medications for twelve months post-ACS.


Self-Assessment Question: Which of the following was associated with increased rates of GIB in patients at 12 months post-ACS?  a. Aspirin + prasugrel + duloxetine; b. Aspirin + prasugrel + sertraline; c. Aspirin + clopidogrel + venlafaxine; d. Aspirin + ticagrelor + fluoxetine; e. None of the above  


Background: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) modulate serotonin, which promotes mood enhancement in the central nervous system (CNS) and hemostasis in the peripheral nervous system (PNS). Inhibition of serotonin reuptake in the CNS increases emotional stability, making SSRIs and SNRIs useful antidepressants. In the PNS, these drugs prevent serotonin-mediated platelet aggregation, increasing bleeding risk. Because depression is common following major adverse cardiovascular events, there is a potential for patients to take concomitant SSRI or SNRI therapy with dual antiplatelet therapy (DAPT) for 12 months post-percutaneous intervention. The purpose of this study was to evaluate if patients receiving this combination were at a greater risk of gastrointestinal bleeding due to multiple antiplatelet mechanisms compared to those receiving DAPT alone. 
 
Methods: This single center retrospective cohort study included adult patients diagnosed with acute coronary syndrome (ACS) and treated with percutaneous intervention, stent implantation, and DAPT between January 1, 2014, to January 1, 2024. Patients were excluded from this study if they received DAPT for any indication other than ACS (e.g., ischemic stroke), if they had a previous diagnosis of cirrhosis, Helicobacter pylori infection, or cancer of the gastrointestinal tract, or if any of the following medications were on their discharge medication list: anticoagulants, systemic steroids, systemic non-steroidal anti-inflammatory drugs (NSAIDs), ginseng, garlic, ginkgo, or vitamin E. The primary outcome of this study was rates of gastrointestinal bleeding within 12 months of ACS diagnosis. Additional secondary outcomes included length of stay, therapy modifications at discharge, and 30-day and 90-day readmission rates.
 
Results: The primary outcome was observed in five patients (3%) in the DAPT group and no patients in the DAPT plus SSRI or SNRI group (P = 0.336). Readmission at 30 days occurred in 23 patients (13.6%) in the DAPT group and 10 patients (17.9%) in the DAPT plus SSRI or SNRI group (P = 0.436). Patients who were readmitted within 90 days of ACS discharge included 37 patients (21.9%) and 19 patients (33.9%) in the DAPT and DAPT plus SSRI or SNRI group, respectively (P = 0.071). There was no statistical difference between median length of stay between the two groups (P = 0.430). One notable baseline characteristic was a documented history of coronary artery disease (CAD). In the DAPT only group, the majority (106 patients; 62.7%) did not have a prior history of CAD, whereas 37 patients (66.1%) in the DAPT plus SSRI or SNRI group did have a documented history of CAD. This finding regarding past medical history of CAD was statistically different between both groups (P < 0.001). 
 
Conclusion: This study found no statistical difference in the rate of GIB in patients who received DAPT compared to those who received DAPT plus an SSRI or SNRI post-ACS. A statistical difference was observed, however, when comparing SSRI or SNRI use in patients based on prior history of CAD. Because patients with a prior history of CAD were more likely to take SSRIs or SNRIs, this study further endorses the use of these agents to treat secondary mental health disorders following ACS. Additionally, none of the patients in this study population who were taking SSRIs or SNRIs experienced a GIB, implying that use of these antidepressants could be considered both effective and safe in this population. More research should be conducted to further evaluate if the use of SSRIs or SNRIs in patients receiving DAPT for one-year post-ACS  impacts rates of bleeding events, especially in women, racial minorities, patients who underwent elective PCIs, and patients who experienced other types of bleeding events.   

Title: Impact of Hyperglycemia Education on Blood Glucose Control
Authors: Maegan Huebner, Kaitlyn Claybrook, Martina Goings, Danna Nelson 
Objective: To evaluate the impact of provider hyperglycemia management education at Baptist Medical Center South through its effect on inpatient glucose control. 
Background: Hyperglycemia in hospitalized patients, defined as a serum blood glucose level greater than 140 mg/dL, is a common occurrence in acutely ill patients. The American Diabetes Association (ADA) currently recommends the use of insulin as the preferred treatment for hyperglycemia in the inpatient setting. Basal or basal plus bolus regimens are preferred, while prolonged sliding scale as sole hyperglycemia treatment is not recommended. Recommendations for maintaining blood glucose less than 180 mg/dL and tailoring insulin regimens around patient enteral intake can improve outcomes, shorten patient length of stay, and reduce readmission rates. To increase adherence to ADA guidelines, physician groups including family medical residents, general medicine residents, and hospitalists from Baptist Medical Center South received a 30 minute interactive presentation on hyperglycemia management.
Methods: This is a retrospective chart review of pre and post physician education for patients who had an order for sliding scale insulin and a serum blood glucose level greater than 200 mg/dL. Patients excluded were those less than 19 years old, prisoners, patients with a singular increased blood glucose level, patients admitted for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), patients with an insulin pump, those requiring a continuous insulin infusion, and pregnancy. Pre-education data was collected and analyzed in June 2024 and post-education data was collected and analyzed in October 2024. Information collected on the selected patients included demographics, length of stay, ordering physician, blood glucose levels, hypoglycemia events, A1c, insulin regimens while hospitalized, and any other oral anti-diabetic medications used. 
Results: After randomization, a total of 40 pre-implementation patients and 75 post-implementation
patients were reviewed and included. For the pre-implementation group, the average length of stay was 14.01 days, 25% experienced a hypoglycemia event, and the average blood glucose was 189.7 mg/dL. The average starting dose for insulin glargine was 10 units per day. The amount of time blood glucose levels were >200 mg/dL was 39.8%. For the post-implementation group, the average length of stay was 17.03 days, 36% experienced a hypoglycemia event, and the average blood glucose was 176.2 mg/dL. The amount of time blood glucose levels were >200 mg/dL was 28.9%. The average starting dose for insulin glargine was 17 units per day. All patients had a sliding scale insulin order besides one patient in the post-implementation group. The most common sliding scale order was written for level 1. 
 
Conclusion: The post-implementation group demonstrated a reduction in the time blood glucose levels were greater than 200 mg/dL, but higher rates of hypoglycemia were also observed. These effects may have been impacted by differences among the study group numbers and patient demographics. The post-implementation group was observed to receive a higher average starting dose of insulin glargine. Providing guideline-based hyperglycemia education to physicians resulted in improved blood glucose control but did not significantly impact hospital length of stay.
 

Title: Safety and Efficacy of Direct-acting Oral Anticoagulants versus Warfarin in the Treatment of Venous Thromboembolism in Severely Obese Patients


Authors: Olukemi Omotola, Madeline Shepherd, Evelyn Grafton


Objective: This study aims to compare the efficacy and safety of DOACs, particularly apixaban and rivaroxaban, versus warfarin in patients with severe obesity diagnosed with VTE.


Background: Venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious and potentially life-threatening condition. Anticoagulation therapy is the cornerstone of treatment for VTE to prevent clot progression, recurrence, and associated complications. Traditionally, warfarin has been the mainstay of treatment; however, direct-acting oral anticoagulants (DOACs), such as apixaban and rivaroxaban, have gained widespread use. In contrast to warfarin, their fixed dosing, fewer drug interactions, and lack of routine laboratory monitoring requirements make DOACs an appealing alternative. In the general population, DOACs have demonstrated non-inferior or superior efficacy and safety profiles compared to warfarin for the treatment of VTE. However, data is limited regarding their use in patients with severe obesity, defined as a body mass index (BMI) ≥ 40 kg/m². Given the growing prevalence of obesity, determining the safest and most effective anticoagulation strategies in this population is critical. 


Methods: This was a retrospective chart review of adult patients with a BMI of > 40 kg/m2 who received either apixaban, rivaroxaban, or warfarin for the treatment of venous thromboembolism from January 1, 2019 to September 30, 2024. Patients were excluded if they were pregnant or breastfeeding, had known hypersensitivity or contraindications to one of the study drugs, experienced active bleeding within 6 months of the start of the study time frame, had a history of a known hypercoagulable state, or if they received a fibrinolytic, mechanical thrombectomy, or underwent EkoSonic endovascular system (EKOS) procedure. The primary endpoint was VTE recurrence within one year. Secondary endpoints included major bleeding occurrence, clinically relevant non-major bleeding (as defined by the International Society of Thrombosis and Hemostasis), and all-cause mortality at one year. 


Results: The study included 76 patients, with 60 in the DOAC group and 16 in the warfarin group. For the primary outcome, 6 patients (10%) in the DOAC group experienced VTE recurrence versus 2 patients (12.5%) in the warfarin group (p=0.3186).  In the DOAC group, 3 patients (5%) experienced a major bleeding event, compared to 1 patient (6.3%) in the warfarin group (p= 0.4268). Two patients (3.3%) in the DOAC group experienced clinically relevant non-major bleeding, while no patients in the warfarin group had this type of bleeding event (p= 0.6211).  Finally, in the DOAC group, there were no reported deaths, while in the warfarin group, 2 patients (12.5%) died (p= 0.0421), making this the only statistically significant finding in the study.


Conclusion: DOACs are a safe and effective alternative to warfarin for treating VTE in severely obese patients. Given their comparable efficacy and lower all-cause mortality, DOACs may be a preferred choice in clinical practice.

Title: Blood Glucose Control in Post-Coronary Artery Bypass Graft (CABG) Patients


Authors: Elise M. Richoux, Leslie A. Hamilton, Heather Wallhauser, Rachael Samples, Taylor Bird, Robert E. Heidel, Travis Fleming


Objective: The objective of this study was to evaluate the median of time within goal blood glucose range following CABG surgery while receiving a continuous insulin infusion in groups before and after an insulin protocol change.


Presentation Objective: Evaluate the impact and incidence of goal blood glucose attainment in patients post-CABG on a continuous insulin infusion before and after an insulin protocol change.


Self Assessment Question: Which statement best describes the impact of hyperglycemia during and after cardiac surgery?
 
Background: Hyperglycemia following cardiac procedures is common. This is likely due to surgical stress triggering catecholamine and cortisol release, along with intraoperative hypothermia induced during cardiopulmonary bypass, which stimulates sympathetic activity. Elevated blood glucose levels during the intra-operative and post-operative period of cardiac surgery is associated with an increased risk of mortality in patients with and without diabetes as well as prolonged ventilator times, atrial fibrillation, and delirium. Controlling blood glucose levels can mitigate consequences such as prolonged ventilation, delayed sternal wound healing, and risk of mortality in patients with and without diabetes. Existing literature has inconsistency in blood glucose targets relative to observed outcomes, prompting consideration of the optimal level of glycemic control for post-CABG patients. More recently, the Society of Thoracic Surgeons (STS) published consensus statements on perioperative cardiac care which included a goal blood glucose range of 140-180mg/dL once an insulin infusion is initated. A protocol change implemented in August 2023 for cardiothoracic surgery patients replaced the previous insulin drip titration method, based on a multiplier and a blood glucose goal of 110-139 mg

Title: Pharmacist Impact on Inpatient Guideline-Directed Medical Therapy Prescribing in Heart Failure with Reduced Ejection Fraction


Authors: Hayley Harrod-Meeks, Kyle Starling, Hunter McDowell 


Objective: This project aimed to evaluate the impact of pharmacist intervention on inpatient prescribing of HFrEF GDMT at Atrium Health Navicent (AHN).


Self Assessment Question: True or False: Pharmacist intervention can increase inpatient prescribing of HFrEF GDMT?


Background: Heart failure with reduced ejection fraction (HFrEF) is a serious condition associated with high morbidity and mortality. The American Heart Association (AHA) guidelines recommend four classes of medications to reduce these risks: renin-angiotensin-aldosterone system (RAAS) inhibitors, beta blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter 2 (SGLT-2) inhibitors. However, hesitancy to initiate or adjust these medications during hospitalization due to transient hypotension or acute kidney injury may worsen patient outcomes. We hypothesize that pharmacists play a key role in improving inpatient guideline-directed medical therapy (GDMT) prescribing. 


Methods: This was a pre-post study that involved physician education and pharmacist intervention. Prior to the intervention period, a brief educational guide on HFrEF GDMT was provided to hospital physicians. During the intervention period, patient chart reviews were conducted to make appropriate recommendations to physicians and to determine outcomes. Patients were included in the analysis if they met all four of the following criteria: were 18 years-old or older, admitted to AHN, had an ejection fraction less than 40%, and had an EPIC-calculated readmission risk score of at least 20%. Key exclusion criteria included patients requiring renal replacement therapy at discharge or those who died during hospital admission. The primary outcome was the percentage of patients discharged on each eligible pillar of GDMT. Secondary outcomes included the percentage of patients discharged on each individual GDMT pillar and the percentage of patients readmitted to AHN within 30 days of discharge. Chi-square analysis was performed to assess differences in outcomes. 


Results: In the intervention group, 24% of patients met the primary outcome while only 12% of baseline patients were discharged on all eligible GDMT pillars of HFrEF (P=0.023). Out of each medication class, the MRAs and SGLT-2 inhibitors were the least commonly prescribed in both groups. However, prescribing of both MRAs and SGLT-2 inhibitors was statistically higher in the intervention group, with a 16.3% increase in MRA prescribing (P=0.014) and a 14.6% increase in SGLT-2 inhibitor prescribing (P=0.031). Thirty-day readmission rates were reduced by 7.7% in the intervention group, though this was not statistically significant (P=0.244). 


Conclusion: In this pre-post study, we found that pharmacist intervention can significantly increase inpatient HFrEF GDMT prescribing, especially by increasing the prescribing of MRAs and SGLT-2 inhibitors. 30-day readmission rates also trended down in the intervention group, though not significantly. Key limitations in this study included physician turnover and hesitancy to change HFrEF regimens when an acute heart failure exacerbation was not the patient’s primary problem. Overall, this study showed that pharmacists play a key role in helping improve inpatient HFreF GDMT prescribing.