2025 Southeastern Residency Conference

Title: Implementation of a Glucagon Discharge Prescription Protocol at a Large Community Hospital


Authors: Grace Rooks, Sophia Carter, Lauren Butler, Anna Cross


Background: According to the American Diabetes Association (ADA) and the Endocrine Society, patients at risk for emergent hypoglycemia, including those treated with insulin, should have access to glucagon to help prevent prolonged severe hypoglycemia and its complications. Severe hypoglycemia is a frequent cause of expensive emergency department visits and the use of emergency medical services. Hypoglycemia events result in more than 100,000 emergency department visits annually, with a cost of roughly $120 million. Clinicians should readily assess patients’ access to glucagon, and the ADA guidelines recognize that glucagon prescribing practices are very low. The purpose of this project is to increase at home access to glucagon for emergent hypoglycemia events in at risk patients. 


Methods: This is a single-center analysis of pre-implementation data from May to August 2024 and post-implementation data from November 2024 to February 2025. Patients included in this study were 19 years of age or older who have been diagnosed with Type 1 or Type 2 Diabetes or Latent autoimmune diabetes in adults (LADA). Due to the majority of insulin prescribers at Huntsville Hospital being the hospitalists, endocrinologists, University of Alabama at Birmingham (UAB) physicians, a glucagon discharge prescription protocol was created by clinical pharmacists and approved by these providers for insulin prescriptions sent to Huntsville Hospital retail pharmacies. The protocol allows transitions of care (TOC) pharmacists to add glucagon for patients with a new insulin prescription at discharge who did not already have a glucagon prescription. The primary endpoint of this study is the number of glucagon prescriptions that were dispensed for adult patients who received a new insulin prescription at discharge. Additionally, rates of glucagon initiation, initiating service, different dispensing barriers, and cost margins will be evaluated.  


Results: In the pre-implementation group, 2 glucagon prescriptions were sent and 1 was dispensed. In the post-implementation group, 35 glucagon prescriptions were sent and 17 (49%) were dispensed. 94% of glucagon prescriptions from the post-implementation group were sent by a TOC pharmacist. Of the 18 glucagon prescriptions that were not dispensed, majority of them were due to the patient requesting a prescription transfer (77.7%). Of the 25 uninsured patients, 12 (48%) received a patient assistance pamphlet.


Conclusion: The implementation of a glucagon discharge prescription protocol increased patient access to glucagon at home for the treatment of emergent hypoglycemia and increased glucagon prescribing rates. Patients’ pharmacy preference had the largest impact on glucagon dispensing rates. Pertinent limitations include sending prescriptions to only Huntsville Hospital retail pharmacies and excluding patients that are discharged outside of TOC pharmacist coverage areas and hours. Educating and involving more providers is needed to increase glucagon access at home in addition to continued protocol practices.

Title: Impact of Pharmacist Discharge Review of Oral Anticoagulation Medications in Hospitalized Patients 


Authors: Courtney Self, PharmD; Jill McHugh, RPh, BCPS; Colin Busbee, PharmD; Rebecca Epperson, PharmD, BCPS 


Objective: To assess the impact of pharmacist discharge medication review on the rate of medication errors in hospitalized patients being discharged on oral anticoagulant therapy.


Self Assessment Question: How do pharmacists' review of discharge medication reconciliations impact transitions of care in current practice?


Background: Anticoagulation therapy is considered a high-risk medication with an increased concern for causing patient harm due to clotting or bleeding if improperly prescribed. Anecdotally, there has been an increase in the number of errors found with patients’ oral anticoagulant therapy on medication reconciliations at the study site. Per protocol, anticoagulants are reviewed daily during admission, but there is no standard review of discharge medication reconciliations. The purpose of this study is to assess the impact of pharmacist discharge medication review on the rate of medication errors in hospitalized patients being discharged on oral anticoagulant therapy.


Methods: This prospective, single-arm study was conducted over a three-month period to evaluate the benefit of clinical pharmacist review of the discharge medication reconciliation at a community hospital.  Patients were included if they were at least 18 years of age, were discharged from either 4 North or Progressive Care units Monday-Friday from 0700-1530 between December 1, 2024-February 28, 2025, and had an oral anticoagulant on their medication reconciliation. If a patient met the inclusion criteria, the pharmacist reviewed the discharge medication reconciliation for errors found and suggested any interventions to the prescriber. The primary endpoint is to identify the total number of oral anticoagulant medication errors found in the discharge medication reconciliation and the number corrected by pharmacist intervention. Secondary endpoints include identifying the total number of other medication errors found in the discharge medication reconciliation and the number corrected by pharmacist intervention, categorizing the types of errors corrected, evaluating the rate of prescriber acceptance of interventions, and estimating the time spent on each discharge reconciliation. 


Results: A total of 52 patients’ discharge medication reconciliations were included in the study and reviewed. For anticoagulation therapy, 7 errors (13.5%) were found, and suggestions to fix the errors were made to the provider for all seven medication errors. Four (57.1%) medication suggestions were accepted before patient discharge. For other medications, 9 errors (1.1%) were found, and suggestions to fix the errors were made for 8 of the errors found. Two (25%) medication suggestions were accepted for the other medication group before discharge. Most errors were categorized as incomplete/inaccurate patient instructions, with 31.3% of errors falling into this category. The average time spent reviewing discharge medication reconciliations was 14 minutes.


Conclusion: Pharmacist review of discharge medication reconciliation led to reduced numbers of medication errors in both anticoagulation therapy and other therapies. 

Title: Evaluation of Hospital Readmission Rates on Patients Who Completed Medication Reconciliation With A Transitions Of Care Clinical Pharmacy Specialist (CPS) Versus Those Who Did Not


Authors: Margaret Stubblefield, Helen T. Bryant, Candace Nichols, Kristina Hazard


Background: Transitions of care from inpatient facilities to outpatient providers can lead to adverse health outcomes and medication errors. Clinical pharmacy specialists are utilized at Kaiser Permanente during transitions of care to prevent these adverse outcomes through a medication reconciliation service. 


Methods: This is a retrospective, observational, IRB-exempt cohort study including Kaiser Permanente of Georgia patients discharged from a hospital to their personal residence. Patients will be excluded from the study if they have already had an office, video, or telephone visit with a medical doctor or were discharged from acute care centers, clinical decisions units, or skilled nursing facilities. The primary outcome of the study is to measure the readmission rates at 30 days after hospital discharge for patients who have a medication reconciliation completed by a transitions of care CPS compared to patients who did not receive a CPS-led medication reconciliation. The secondary outcome is to determine the percentage of patients who do not have a medication reconciliation completed by a transitions of care CPS. Primary outcome data will be analyzed using a Chi-square test of association.


Results: In Progress


Conclusion: In Progress

TITLE: The Impact of Pharmacist Discharge Education in Preventing Acute Heart Failure Rehospitalizations    
   
AUTHORS: Itea Thomallari, Brian Knott, Brian Morini, Anny MacDonald  
   
BACKGROUND: Congestive heart failure remains a significant cause of hospital readmissions, leading to increased morbidity, mortality, and healthcare costs. Pharmacists are uniquely positioned to intervene in the management of heart failure due to their expertise in medication therapy and patient education. Effective pharmacist-led discharge education can enhance patient understanding of their medications, address barriers to adherence, and improve overall health outcomes. This study aims to evaluate the impact of targeted pharmacist discharge education and the feasibility of implementing such a practice to the pharmacist's daily workflow for acute heart failure patients. 
  
METHODS: This was a single-center, prospective pilot study with pre-posttest design taking place at AdventHealth Winter Park from November 25, 2024 through January 22, 2025. Patients were eligible for enrollment if they met the following inclusion criteria: age ≥ 65 years, NT-pro BNP >900 pg/mL, American College of Cardiology/American Heart Association stage C or D heart failure, New York Heart Association class II-IV heart failure, left ventricular ejection fraction 15-70%, admitted for acute congestive heart failure, and had a pharmacist reviewed admission medication reconciliation review and discharge medication reconciliation review. Patients were excluded if they were currently on renal replacement therapy or had a life expectancy of <6 months. The patients in the post-test phase received a pharmacist reviewed admission medication reconciliation, discharge medication reconciliation as well as pharmacist discharge heart failure counseling. The primary endpoint of the trial was the number of barriers to medication adherence resolved at the time of counseling. The barriers included lack of understanding, cost prohibitive, side effects, or other. Secondary endpoints included the duration of the education sessions, 30-day readmission rates, and patient mortality rate.  
  
RESULTS: A total of 41 patients met the above inclusion criteria, with 13 patients receiving pharmacist counseling in the post test phase and the remaining 28 patients who were reviewed in the pre-counseling arm receiving the pharmacist standard of care. The average number of barriers resolved at the time of counseling was one with a median counseling duration of 20 minutes (IQR 12.5-30). 30-day readmission rates and mortality p-values were 0.5696 and 0.7852, respectively.    
  
CONCLUSION: Targeted pharmacist discharge education improved patients’ understanding of their medication regimens. Although this study was not powered to detect differences in 30-day readmission or mortality rates, addressing these barriers has the potential to influence these outcomes. Further research is needed to evaluate the impact on mortality and hospitalizations. However, integrating this counseling into the pharmacist workflow presents challenges due to its time-intensive nature and the need for additional pharmacist support. While the benefits of counseling are evident, its implementation may not be feasible without additional staffing to manage the increased workload. 

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.