2025 Southeastern Residency Conference

Title: Monotherapy versus Combination Therapy in the Treatment of Enterococcus faecalis Bloodstream Infections
 
Authors: Amber D. Fraley, Daniel Anderson, Joshua Eudy
 
Objective: To evaluate the safety and efficacy of monotherapy and combination therapy for E. faecalis bloodstream infections.
 
Self Assessment Question: True or False: At this time, there is a need for more outcomes data for both monotherapy and combination therapy for E. faecalis BSI in the absence of IE.
 
Background: Enterococci are gram-positive facultative anaerobic organisms typically found as normal intestinal flora. The two most common species that cause infections in humans are E. faecalis and E. faecium. Historically, combination antibiotic therapy has been the standard of care in treating infective endocarditis (IE) caused by E. faecalis. However,  practice is occasionally extrapolated to E. faecalis bloodstream infections (BSI) without IE. With a lack of outcomes data to support use, combination therapy is a dogmatic practice based on in vitro data from the 1950s involving two antibiotics seldom used for E. faecalis infections, penicillin and streptomycin. 
Therefore, this study seeks to assess the safety and efficacy of monotherapy compared to combination therapy for E. faecalis BSI with or without IE.
 
Methods: This single-center, IRB-approved, propensity-matched, retrospective cohort study, conducted at Wellstar MCG Health, reviewed all adult patients hospitalized between January 1, 2017 and September 30, 2024 with at least one blood culture positive for E. faecalis. Patients were excluded from the study if they expired within 72 hours of index culture, had polymicrobial BSI, did not receive antibiotic treatment, and/or had a prior diagnosis of E. faecalis within the previous 60 days. The primary outcome was a composite of 30-day mortality, 60-day hospital readmission, and/or 60-day recurrence. Secondary outcomes were each individual component of the composite outcome, time to blood culture clearance, duration of bacteremia, length of hospital stay, and adverse events. Outcomes were evaluated using various statistical methods, including chi-squared and Mann-Whitney U, as appropriate. Demographics were evaluated using descriptive statistics. 
 
Results: Of the 139 patients who met the inclusion criteria, there was no statistically significant difference in the primary composite outcome for monotherapy compared to combination therapy (27.1% vs 27.8%; p=0.93), hospital length of stay (12.8 [8.1-24.8] vs​ 15 [8.6-23]; p=0.92), or​ adverse reactions (2.5% vs 5.6%; p=0.96).
 
Conclusion: Both monotherapy and combination therapy yielded similar outcomes for the primary composite and adverse reactions​, however, the study was not adequately powered to detect a difference. Therefore, at this time, larger studies are warranted comparing monotherapy and combination therapy for E. faecalis BSI with or without IE.
 
Contact Information: amber.fraley@wellstar.org

Title: Effect of Steroids on Post Cardiac Surgery Length of Stay 


Authors: Emily-Kate Carter, Krista Riche, and Jamie Wagner


Background: Steroids can be used for patients undergoing surgery to decrease inflammation that arises due to the trauma and stress of surgery, and they can be useful antiemetics in some patients. Additionally, steroids have been proposed to have many benefits in patients just having undergone surgery such as decreased length of stay, decreased pulmonary complications, decreased infection risk, and a decreased risk of post-cardiac surgery new onset atrial fibrillation (AFib). The benefit of steroids, specifically for post-operative AFib risk reduction, seems to be due to the decrease in C-reactive protein, white blood cell count, and inflammatory cytokines following steroid administration. However, using steroids is a known risk factor for hyperglycemia, and therefore increases insulin demand in post-operative patients. Studies show that post-operative hyperglycemia increases the risk of mortality in cardiac surgery patients with and without diabetes. The purpose of our study is to determine if administering steroids after cardiac surgery has an effect on patients’ length of stay.


Methods: This single-center, retrospective group pretest/posttest quasi-experiment included patients admitted to St. Dominic Jackson-Memorial Hospital from June 01, 2023 to December 31, 2023, when steroids were not given to patients post-surgery, and June 01, 2024 to December 31, 2024, when steroids began to be given, who were aged ≥18 years, undergoing major cardiac surgeries, including Coronary artery bypass graft (CABG), Aortic Valve Replacement (AVR), Mitral Valve Replacement (MVR), or Tricuspid Valve Replacement (TVR). Patients were excluded if an Impella device was utilized peri-operatively, if they were treated with antibiotics for known or suspected infection before surgery, or if they died within 48 hours of the surgery. The primary outcome is length of post cardiac surgery ICU stay in hours. Secondary outcomes include total length of post-cardiac surgery hospital stay in hours, prevalence of hyperglycemia within 72-hours post-operation, and prevalence of post-operative-infections within 30 days.


Results: A total of 100 patients were enrolled in this study, with 50 in the steroids group and 50 in the control group. Average length of stay in the ICU was similar in both groups at 88.28 ± 137.30 hours in the control group vs 92.04 ± 137.57 hours in the steroid group (p = 0.89). There was also no statistical difference in total hospital length of stay at 201.08 ± 189.09 hours for the control group vs 193.62 ± 130.84 hours for the steroid group (p= 0.82). The prevalence of hyperglycemia within 72 hours did not differ between the control group with 66% (n=33) and the steroids group with 68% (n=34). No post-operative deep sternal wound infections were observed in either group within 30 days. The only statistically significant finding was a lower rate of post-operative atrial fibrillation (AF) in the steroid group of 14% (n=7) compared to the control group with 48% (n=24) (p= <0.01).


Conclusions: Utilization of post-operative steroids did not impact ICU length of stay or total hospital length of stay. There was not a statistically significant difference in the prevalence of hyperglycemia or deep sternal wound infections between the groups. Post-operative AF occurrence was significantly lower in the steroid group compared to the control group.

Title: Evaluating CPP Impact to Ensure GDMT, Improve Heart Failure Patient Outcomes, and Reduce Readmissions


Authors: Allison D. Johnson; Kathy Davari; Mary K. Pounders


Background: The prevalence of heart failure (HF) is increasing annually with approximately 6.7 million American adults age 20 or older currently affected. The cost of HF in 2012 was estimated to be $30.7 billion. Previous studies have highlighted the role that clinical pharmacists can play in improving hospital readmission rates for patients with HF. The Atlanta VA Health Care System has a procedure in place for clinical pharmacist practitioners (CPP) to assess patients recently discharged from the hospital after a HF exacerbation. Patients are identified using a dashboard that lists any patient recently discharged with an exacerbation. This project aims to evaluate the efficacy of the Atlanta VA CPP interventions related to preventing readmissions for HF patients. A focus will be placed on interventions with Guideline Directed Medical Therapy (GDMT) agents.


Methods: This project is a retrospective quality improvement project comparing readmission rates and prescribing rates of GDMT agents of patients assessed by a CPP within 10 days of a HF exacerbation hospital discharge compared to patients without CPP assessment. For this project, a readmission is defined as a hospitalization within 30 days of initial discharge for a HF exacerbation. Patients that receive care from the Atlanta VA who have a diagnosis of HF during the year 2023 and the year 2024 were identified from the VA electronic health record. Fifty patients with a HF hospitalization in the year 2023 were randomly selected to evaluate their readmission rates and GDMT agents. Fifty patients with HF hospitalization in the year 2024 were randomly selected to evaluate their readmission rates and GDMT agents following CPP intervention. Data collection points will include, but are not limited to, age, gender, time of hospitalization, GDMT medications before and after hospitalization, GDMT agents after CPP assessment, patient readmission, primary care provider or clinic, and CPP who assessed the patient. Data will be recorded without patient identifiers and will be maintained confidentially. Upon review of the data, the impact of CPP’s assessment on patients with a hospitalization for HF exacerbation will be assessed.


Results: In progress


Conclusions: In progress

Authors' names: Katie Williams, Justin Joy, Stuart Pope, Ozlem Bilen, Matthew Gold, Byron Williams III
Background/Purpose: To evaluate the real-world incidence of left ventricular ejection fraction (LVEF) decline to <50% and identify predictors associated with reduced LVEF in patients receiving mavacamten for obstructive hypertrophic cardiomyopathy at an academic medical center.
Methodology: This is a single-center, retrospective chart review of adult patients diagnosed with obstructive hypertrophic cardiomyopathy, who have received mavacamten therapy for at least 3 weeks at the Emory Heart and Vascular Clinic from May 1, 2022, to September 30, 2024. Eligible patients must have a baseline left ventricular outflow tract gradient (LVOT) >30 mmHg and available echocardiogram data at both baseline and post-treatment initiation. Patients with incomplete medical records will be excluded. A univariate logistic regression analysis was performed to identify predictors associated with EF decline.
Results: A total of 54 patients met the inclusion criteria for the IRB-approved study. Among these, five patients (9.3%) discontinued mavacamten therapy[JJ4] . Three patients (5.6%) had an incidence of EF decline <50% during mavacamten therapy; two of them (66.7%) discontinued mavacamten. Patients that discontinued mavacamten had similar EF at baseline than those who continued mavacamten (51.2% vs. 63.6%; P=0.093). Similarly, patients that discontinued mavacamten had similar EF post mavacamten treatment than those who continued mavacamten (52.7% vs. 60.9%; P= 0.127). No factors were associated with EF decline were identified in the initial analysis.
Conclusions: The study revealed that the majority of patients did not have a EF decline <50% while on mavacamten for hypertrophic cardiomyopathy. Given the inconclusive findings, further exploratory analyses will be conducted to identify potential predictors of EF decline.
Presentation Objective: Identify key factors that may contribute to a decrease in ejection fraction in patients taking mavacamten for hypertrophic cardiomyopathy.

Title: Use of Guideline Directed Medical Therapy and Safety in Patients with Cardiogenic Shock


Authors: Thomas Thielbar, Kelly Dunton, Pujan Patel, Laila Handshaw


Background: Heart failure with reduced ejection fraction (HFrEF) clinical practice guidelines currently recommend the use of guideline directed medical therapy (GDMT) to improve survival, decrease hospitalizations, and improve symptoms in patients with HFrEF. Several studies have demonstrated that early initiation of GDMT during hospitalization, once hemodynamically stable, to be safe and clinically beneficial. This study aims to assess the current ordering practices and safety of GDMT in American Heart Association (AHA) stage D / New York Heart Association (NYHA) class IV heart failure (HF) patients hospitalized for acute decompensated heart failure (ADHF).

Methods: This single-site, retrospective, cohort study included patients age ≥18 years, hospitalized at AdventHealth Orlando, admitted with ADHF (defined as having signs and symptoms of congestion, actively receiving inotropes, and/or temporary mechanical circulatory support [MCS]), classified as AHA stage D / NYHA class IV HF, and underwent an advanced HF evaluation. Exclusion criteria include history of durable left-ventricular assist device (LVAD), type 1 diabetes, history of diabetic ketoacidosis (DKA) or euglycemic DKA, history of angioedema associated with GDMT, and pregnant women. The primary endpoint is percentage of patients on GDMT including angiotensin-converting enzyme inhibitor (ACEi) / angiotensin II receptor blocker (ARB) / angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker (BB), mineralocorticoid receptor antagonist (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i) at three points including day of admission, 72 hours post inotrope or MCS initiation, and day of discharge (defined as hospital discharge, in-hospital mortality, left-ventricular assist device implant or heart transplant). Secondary safety endpoints include incidence of genitourinary infections, acute kidney injury or need for renal replacement therapy, hypotension, bradycardia, hyperkalemia, hypoglycemia, DKA, and angioedema assessed at admission, within 72 hours post inotrope or MCS initiation, and discharge. Additional secondary endpoints include number of patients on each individual medication and their doses from primary endpoint, MCS use, inotrope use and dose, vasopressor use, and VIS score at admission, within 72 hours post inotrope or MCS initiation, and discharge.  Exploratory safety endpoints include in-hospital mortality, hospital length of stay, ICU length of stay, implant of LVAD, heart transplant, and actively on heart transplant waitlist. Study endpoints were analyzed utilizing descriptive statistics. 

Results: A total of 129 encounters, encompassing 108 patients were screened for inclusion in which 27 encounters were excluded. The final study population included 102 encounters, encompassing 84 patients with a median age of 57 (IQR 48-65) years old, predominantly white (43.1%) males (72.5%) with past medical history significant for type 2 diabetes (52.9%), chronic kidney disease (52.9%), and arrhythmias (66.7%). The primary cause of HF was non-ischemic cardiomyopathy. Only 20.6% of patients were on all four GDMT medication classes prior to admission. SGLT2i and MRA were the most commonly prescribed GDMT at all three time points. Incidence of SGLT2i was 43.1%, 61.8%, and 78.1% at admission, 72 hours post inotrope or MCS initiation, and discharge respectively. Incidence of MRA was 49%, 80.4%, and 87.5% at admission, 72 hours post inotrope or MCS initiation, and discharge respectively. For secondary endpoints, administration of any GDMT did not increase incidence of any associated adverse effect.

Conclusion: We observed that in this patient population, SGLT2i and MRA were most commonly ordered and did not increase the incidence of any safety outcomes assessed. This study illustrates that it is safe to optimize GDMT in this patient population, however, further studies are needed to assess efficacy on a larger scale.

Title: Evaluation of Thrombophilia Testing in a VHA Healthcare Facility Before and After Implementation of a New Thrombophilia Testing Protocol
Authors: Katherine Medley, Jill Radford, Rebecca Worsham, Shouji Nagata
Background/Purpose: The James H Quillen VA Medical Center (JHQVAMC) does not currently have a standardized process for thrombophilia testing.  Testing for thrombophilia should be used to identify the cause of severe or fatal venous thromboembolism (VTE), aid in decision making on future VTE prevention, and direct family member testing.  Most risk classification guidelines for VTE recurrence do not consider thrombophilia test results.  There is a lack of evidence supporting the clinical benefit of routine testing among patients with VTE.  The accuracy and reliability of thrombophilia testing is dependent on the timing of the tests in association with the initial VTE presentation or the presence of an anticoagulant. Inaccurate testing can lead to false positive or false negative results.  These false results may contribute to patient harm through unnecessary prolonged duration of anticoagulation,  inaccurate diagnosis of thrombophilia, or providing false assurance related to the risk of recurrent VTE.  Studies have shown that thrombophilia testing increases the cost of VTE management without adding meaningful clinical value.  The purpose of this quality improvement project is to develop and implement a thrombophilia testing protocol to reduce unnecessary and inaccurate thrombophilia testing while promoting patient safety and cost savings at the JHQVAMC.
Methodology:  A standardized note template will be created and implemented across the JHQVAMC to guide providers in the appropriate testing for thrombophilia.  Data will be reviewed before and after implementation of the standardized ordering process.  All patients diagnosed with a VTE who had thrombophilia testing completed within the last 5 years will be identified.  Data will be sourced from the corporate data warehouse (CDW), computerized patient record system (CPRS), Joint Legacy View (JLV), and pharmacy benefit management (PBM) services direct oral anticoagulant (DOAC) dashboard.  These data will be evaluated to determine if testing and follow-up were appropriately completed.  Additional endpoints include costs, duration of anticoagulation, anticoagulant choice, and misdiagnosis rate.  Thrombophilia testing practices will be evaluated among inpatient, primary care, and specialty providers.
Results: In progress
Conclusions: In progress

Title: Use of Prophylactic Amiodarone for the Prevention of Atrial Fibrillation After Cardiac Surgery 


Authors: Savannah Salam, Sydney Davis, Michael Bitonti, Lisa Curran, Paul Weldner 


Objective: Discuss the potential benefit of routine oral amiodarone use for atrial fibrillation prophylaxis after cardiovascular surgery


Self Assessment Question: True or False: The use of oral amiodarone for atrial fibrillation prophylaxis should replace prophylactic beta blocker use in patients after cardiac surgery


Background: Amiodarone is a Vaughan-Williams Class III antiarrhythmic agent approved for the management of life-threatening ventricular arrhythmias but is commonly used for treatment of atrial fibrillation (Afib). Approximately 15-40% of patients develop postoperative Afib after cardiac surgery. The PAPABEAR trial found a significant reduction of postoperative Afib with oral amiodarone prophylaxis in patients undergoing nonemergent coronary artery bypass graft (CABG) and/or valve replacement/repair with or without beta blocker use. The 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guidelines added a level IIa recommendation for the use of short-term prophylactic beta blockers or amiodarone in patients undergoing cardiac surgery who are at high risk for developing postoperative Afib. Our institution recently began use of amiodarone prophylaxis in select patients at surgeon discretion. The purpose of this review is to evaluate the impact of oral amiodarone for Afib prophylaxis after cardiac surgery. 

Methods: This review was a single center, IRB reviewed, determined exempt, retrospective comparator evaluation conducted from July 1, 2024 to February 28, 2025. Adult patients who underwent CABG, valve replacement, or valve repair were included in this study. Patients were excluded if they had a history of Afib in the last 12 months, amiodarone use in the last 6 months, were on Vaughan- Williams Class I or III antiarrhythmic medications prior to procedure, required mechanical circulatory support, or if any ventricular or atrial arrhythmia was present before the procedure. Each patient was reviewed for demographic data, type of cardiac procedure, use of prophylactic amiodarone, development of Afib postoperatively, use of prophylactic beta blocker, and development of Afib or Aflutter within 30 days of hospital discharge. Included patients were stratified by use of prophylactic oral amiodarone. The prophylactic amiodarone standard order was 400 mg twice daily for five days. The length of amiodarone treatment and dose were adjusted based on clinical decision-making by the care team. The primary outcome was the incidence of postoperative Afib. Secondary outcomes include time to postoperative Afib, use of intravenous amiodarone, percentage of patients that discontinued prophylactic amiodarone, and readmission for atrial arrhythmias within 30 days of discharge from the index event.  

Results: Of the 126 patients screened, 80 patients were included in this study. There were 30 patients in the amiodarone prophylaxis group and 50 patients in the standard of care group. Baseline patient characteristics were balanced between groups apart from smoking history (16% in amiodarone group vs. 70% in standard of care), history of heart failure (14% vs. 36%), and index event including a valve procedure (70% vs. 32%). Notably all patients received prophylactic beta-blockers per standard practice at our facility. The primary outcome occurred in 23.3% of the amiodarone prophylaxis group vs. 42% in the standard of care group (OR 0.42, 95% CI 0.15-1.14, p=0.09). There were no significant differences in the average time to postoperative Afib (78.8 hrs vs. 70 hrs, p=0.13) and average length of hospital stay (172.1 hrs vs. 154.2 hrs, p=0.39). Rates of post-discharge atrial arrhythmias were 13.3% in amiodarone group vs. 4.0% in standard of care (p=0.13). In the amiodarone prophylaxis group, 3 patients discontinued amiodarone therapy, and 4 patients required a dose-reduction in amiodarone due to reported hypotension, heart block, and nausea.

Conclusions: The use of oral amiodarone prophylaxis may provide a strategy to reduce the incidence of atrial fibrillation after cardiac surgery. This intervention was well tolerated, though it would require further investigation to achieve statistical significance.

Title: Impact of Educational Sources on Patient Knowledge and Confidence with Compounded Medications 
 
Author: Kayla Garris 
 
Objective: The primary objective of this study is to determine how the source of education about compounded medications influences patient confidence and knowledge in compounded medications. 
 
Self-Assessment Question: Do patients feel more confident in their compounded medications after receiving information from their healthcare provider or pharmacist? 
 
Background: Compounded medications account for 1% to 3% of all written prescriptions in the United States. For example, patients with allergies to certain dyes, diluents, binding agents or other inactive ingredients may not be able to tolerate commercially available products. For patients who are unable to take commercially available medications, compounding pharmacies across the United States have been able to fill in the gaps to help provide customized prescriptions. The decision to utilize compounded medication is not solely driven by pharmacists as physicians and patients are essential in the conversation about the use of compounds. Physicians must have a basic understanding of the risks and benefits associated with compounded medications to guide therapeutic decision making and advise their patients. While compounded medications are able to fill in gaps for medically necessary alternatives to commercially available medications, it is important to ensure that patients are knowledgeable about their compounds. The purpose of this study is to assess how the source of education about compounds influences patient confidence and knowledge in compounded medications.  
 

Title: Compounded Medications: Understanding Who Drives the Conversation in Clinical Practice 
 
Author: Katherine Moutis 
 
Practice Site: Innovation Compounding  
 
BACKGROUND: According to Alliance for Pharmacy Compounding, approximately 1-3% of all prescriptions written in the United States are compounded medications. Compounded medications are individualized preparations for patients not achieving therapeutic goals with commercially available FDA-approved medications. The process for obtaining a prescription for a compounded preparation starts in the provider’s office. If a compounded medication is deemed appropriate, the healthcare provider will write a prescription specifying the active ingredients, dose, route of administration, dosage form, and dosing interval. A licensed pharmacist then prepares the medication to these specifications. Through the use of shared decision making, the provider or the patient may initiate the conversation for considering the use of a compounded medication. There is currently no data published on who initiates this conversation. The purpose of this study was to identify if patients or providers are more likely to initiate the conversation for considering the use of a compounded medication and determine if there is a difference in perceptions of who initiates this conversation. 
 
METHODS: Surveys were emailed to providers who had prescribed compounded medications and patients who had obtained compounded medications through one of the  16 pharmacies within the Revelation Pharma network since August of 2023.  The surveys were emailed to 7,907 providers and 55,000 patients via email on October 1, 2024. The survey closed on December 1, 2024. A total of 857 (792 patients and 65 providers) responses were collected. The survey questions concerning who initiates the conversation about compounded medications were open ended. To analyze the data, all responses were examined and categorized as patient, provider, or both. Responses that did not fit into any of these categories were excluded. Responses to the survey were compared and tested using a chi-square test. P values < 0.05 were considered statistically significant. 
 
Results: For both the patient and provider surveys, 75% of responses indicated that the provider initiates the conversation about compounded medications (P = 0.951). One percent of providers and 18% of patients reported that the patient initiated the conversation about compounded medications (P = 0.003). Twenty-four percent of providers and 7% of patients reported that both the patient and the provider initiated the conversation about compounded medications (P < 0.001).  
 
Conclusions: The majority of both patients and providers reported that the providers are most commonly introducing compounded medications as a therapeutic option. This may be important when identifying audiences for education about the appropriate use of compounded medications and the availability of new compounded medications.  
 

Title: Evaluation of the Impact of Medical Billing on Documentation and Patient Outcomes in an Independent Community Pharmacy Chain


Authors: Julissa Gonzalez, Hashan Bhim, Greg Peden, Courtney E. Gamston 


Background  
Community pharmacies play a crucial role in healthcare by offering educational and clinical services in addition to the dispensing of medications. The sustainability of community pharmacies is being jeopardized with 12.8% of community pharmacies closing nationwide from 2009 to 2015. As reimbursement for dispensing medications continues to decline, pharmacies must find additional sources of revenue. As the scope of pharmacists also continues to evolve, opportunities to provide patients with more comprehensive care through clinical pharmacy services in the community setting emerge. Provision of services necessitates consistent and comprehensive documentation which is currently lacking in the community setting. The purpose of this project is to assess the impact of the introduction of medical billing on documentation of care, performed interventions, patient care outcomes and estimated cost of savings within an independent pharmacy chain. 


Methods 
This was a retrospective review analyzing service records from an independent pharmacy chain in North Alabama comparing documentation of patient care activities during the six months before and after the implementation of medical billing (January 2024 through January 2025). Interventions were classified using the Pharmaceutical Care Network Europe Foundation (PCNE) classification of drug-related problems (DRP). Encounters with patients that were cancelled or never completed were excluded. T-test analyses were used to compare the number of interventions documented pre and post introduction of medical billing.


Results
In Progress.


Conclusions
In Progress. 

Title: Impact of a 2,000mg Vancomycin Loading Dose Maximum in Adult Patients


Authors: Tori Parks, Sarah McDaniel, Ashley Lightfoot, Lauren Wright, Josh Settle


Background: Vancomycin is a tricyclic glycopeptide antibiotic that is used to treat gram positive infections including methicillin-resistant Staphylococcus aureus (MRSA) and ampicillin-resistant Enterococcus. Vancomycin has been associated with an increased risk of developing acute kidney injury (AKI). To try to combat this in our patients, the Baptist Health System utilizes both a vancomycin dosing protocol and InsightRx© software to dose and monitor vancomycin for antibiotic area under the curve (AUC) levels and toxicity. InsightRx© is a Bayesian dosing software that utilizes random vancomycin levels to compare individual patients to patients with similar baseline characteristics who have also been entered into the software. This allows InsightRx© to predict how patients will respond to different vancomycin dosing schedules and predict AUC levels, troughs, and toxicity levels. Previously, the Baptist Health System vancomycin dosing protocol allowed for a maximum of a 3000mg vancomycin loading dose.There was thought to be a trend upward in the amount of AKI cases that were being seen in patients who were receiving higher loading doses of vancomycin. For this reason, the protocol was updated in 2023 and went into effect in January of 2024 to reduce the maximum vancomycin loading dose to 2000mg. The objective of this study was to analyze the rates of AKI in patients who received more than a 2000mg vancomycin loading dose before the updated protocol compared to lower loading doses after the implementation of a 2000mg maximum vancomycin loading dose. 
 
 
Methods: This is a investigational review board exempt, retrospective chart review conducted within the Baptist Health system from September to December. All patients admitted to Baptist Medical Center South and Baptist Medical Center East who received vancomycin were identified through an electronic report. After Investigational Review Board (IRB) exemption, a retrospective chart review from September 2023 to December 2023 before the 2000mg loading dose maximum and from January 2024 to July 2024 after the loading dose maximum were evaluated through a chart review and through InsightRx©. Data collected on qualifying patients included demographics, laboratory data, medication administration record data.   


Results: A total of 50 pre-implementation and 50 post-implementation patients were reviewed. Average baseline serum creatinine was 1.36 mg/dL and 1.21 mg/dL respectively. Pre- 2000mg maximum, the rate of AKI was 18%. After the 2000mg maximum the rate of AKI was 10%. Patient receiving loading doses after the 2000mg mg loading dose maximum took longer to reach target AUC (400-600 ug/mL) than patients who received higher loading doses. The implementation of a reduced vancomycin loading dose maximum to 2000mg from 3000mg showed a slight decrease in the rates of AKI, however, these rates cannot be solely attributed to vancomycin loading doses. Reduction of the maximum vancomycin loading dose extended the time to reach therapeutic AUC levels but did not negatively impact clinical outcomes. More research is needed at a larger scale to determine if larger vancomycin loading doses are associated with higher rates of AKI.


Conclusion: The reduction of the vancomycin loading dose maximum to 2000mg decreased the incidence of AKI development by 8% though duration of vancomycin treatment increased by an average of 1.6 days, subsequently increasing the time to reach therapeutic AUC. This change in duration of therapy did not have a negative impact clinical outcomes. The concurrent administration of other nephrotoxic agents could have contributed to the AKI rate. Further research at a larger scale is needed to further analyze the effect of larger vancomycin loading doses on AKI development. Moving forward, the Baptist Health Vancomycin Dosing policy should be evaluated to considered increasing the maximum loading dose of vancomycin to 2500mg from the current 2000mg loading dose maximum.

Title: Correlation of 4T, m4T, and LLL Scores with Positive Heparin-induced Platelet Antibodies and Serotonin Release Assays in Cardiac Surgery ICU Patients
 
Authors: Alese Photiadis, Michelle Dillon, Danielle McPherson
 
Objective: Evaluate the accuracy of diagnostic scoring tools used to predict heparin-induced thrombocytopenia (HIT) in cardiac surgery (CS) and mechanical circulatory support (MCS) patients.
 
Background/Purpose: HIT occurs in up to 5% of patients exposed to heparin. HIT is characterized by a significant fall in platelet count and a hypercoagulable state. Diagnostic scoring tools exist to risk stratify patients prior to ordering laboratory assays, which are limited by either low sensitivity or delayed turnaround times. CS and MCS patients receive large heparin doses and have other significant reasons for thrombocytopenia. This project aims to assess the accuracy of diagnostic scoring tools used to predict HIT in CS and MCS patients.
 
Methodology: This single center, retrospective study included adult CS and MCS patients with a positive heparin-induced platelet antibody result from August 1, 2022, to December 31, 2024. Patients were identified via reporting tools within the Epic Hyperspace platform. Patient demographic information was collected. Patients were allocated based on whether they underwent cardiac surgery only (CS Group), MCS only (MCS Group), or required a combination of CS and MCS (CS-MCS Group). Types of CS and MCS, platelet count, serotonin release assay (SRA) result, duration of heparin therapy, duration of cardiopulmonary bypass (CPB), presence of additional medications implicated in causing thrombocytopenia, time to initiation of bivalirudin, and presence of thrombus were also collected. The primary was the negative predictive values of each of the diagnostic scoring tools (4T, m4T, and LLL scores) in the CS, MCS, and CS-MCS groups. Patients were stratified into risk-categories based upon their score from each of the diagnostic scoring tools. The NPV was then calculated from the true and false negatives.
 
Results: One hundred fifty-eight patients were screened and 92 met inclusion with 28 in the CS Group, 44 in the MCS Group, and 20 in the CS-MCS Group. The most common reasons for exclusion were duplicate patient identifiers, veno-venous extracorporeal membrane oxygenation support, and labs drawn prior to surgery or MCS initiation. The negative predictive value (NPV) for the 4T score in the CS group was 100% for low-risk and 64% for intermediate risk patients. For the m4T score, the NPV was 90% and 80% for the low and intermediate risk groups, respectively. The NPV for the LLL score in the CS group was 100% and 74% for the low and high-risk categories. For low-risk patients in the MCS Group, the NPV of the 4T and m4T scores were 97% and 92%.  For intermediate risk patients, the NPV of the 4T and m4T scores was 80% and 89%. There were no patients in the MCS Group who were classified as high risk by either score. The NPV for the 4T score in the CS-MCS group was 82%, and 63% for the low and intermediate risk categories.  As for the m4T, the NPV in the CS-MCS group was 100%, and 80% for the low and intermediate risk categories. The NPV for the LLL score in the CS-MCS group was 67% and 60% for the low and high-risk categories.
 
Conclusion: In this study, the m4T score had the highest NPV for those undergoing cardiac surgery procedures; however, for low risk stratified patients, all three tests were reliable in ruling out HIT. In the mechanical circulatory support group, both the 4T or m4T score had high NPVs. The m4T was more reliable in the joint cardiac surgery and mechanical circulatory support group.

Presentation Objective: Evaluate the accuracy of diagnostic scoring tools used to predict heparin-induced thrombocytopenia (HIT) in cardiac surgery (CS) and mechanical circulatory support (MCS) patients

Self-Assessment Question: Based on this study, which diagnostic scoring tool(s) is the best in CS, MCS, and CS + MCS patients to rule out HIT?
A. 4T score
B. m4T score
C. LLL score
D. All the above

Safety outcomes with cangrelor versus eptifibatide in patients undergoing periprocedural bridging
Angkear Khorn, Matt Bibb, Kelley Baxter
Ascension Saint Thomas Hospital West, TN


Objective: Evaluate the safety of cangrelor versus eptifibatide for periprocedural IV bridging in cardiac surgery patients focusing on bleeding risk categorized by the  Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria


Self Assessment question: Does the choice of IV bridging agent (cangrelor or eptifibatide) impact bleeding risk in patients undergoing periprocedural cardiac procedures?


Background/purpose:  Periprocedural bridging with intravenous (IV) antiplatelet agents is essential for patients undergoing cardiac surgery to prevent thrombotic events while minimizing bleeding risks. Cangrelor and eptifibatide are commonly used IV bridging agents, but limited data directly compare their safety profiles. This study evaluates the bleeding risk associated with both agents using the GUSTO criteria and assesses secondary outcomes, including transfusion requirements, hospital length of stay, and cost. 


Methodology: This study was a single-center retrospective chart review conducted at Ascension Saint Thomas Hospital West (ASTHW) to evaluate the safety outcomes of cangrelor versus eptifibatide in patients undergoing periprocedural bridging for cardiac procedures. The study included patients who received eptifibatide between July 22, 2018, and July 21, 2021, and those who received cangrelor between July 22, 2021, and July 21, 2024. Patients were included if they required intravenous bridging with either agent for a planned cardiac procedure. Exclusion criteria included patients with a documented allergy to either agent, those receiving the medication for indications other than cardiac bridging, pregnant individuals, and incarcerated patients. The primary outcome assessed was the incidence of bleeding events classified using the GUSTO criteria, while secondary outcomes included transfusion requirements, post-bridge length of stay, bridging duration, and cost analysis.


Results: A total of 268 patients were screened, with 66 meeting the inclusion criteria (31 in the eptifibatide group and 35 in the cangrelor group). Baseline characteristics were similar between groups, with a slightly higher proportion of male patients in the cangrelor group (78%) compared to the eptifibatide group (69%), but no significant differences in age, renal function, comorbidities, or types of cardiac procedures. There was no significant difference in bleeding events between the two groups as assessed by the GUSTO criteria. Secondary outcomes showed that transfusion requirements were higher in the eptifibatide group (42%) compared to the cangrelor group (20%), though this difference did not reach statistical significance (p = 0.053). The median post-bridge hospital length of stay was similar between groups, with cangrelor patients staying a median of 4 days (IQR 5-12) and eptifibatide patients staying 2 days (IQR 1-6, p = 0.884). Bridging duration was also comparable, with a median of 3 days (IQR 2-4) for cangrelor and 2 days (IQR 1-2) for eptifibatide (p = 0.180). However, cost analysis revealed a significant difference, with cangrelor being substantially more expensive per patient (median $3,797, IQR $1,145-$5,727) compared to eptifibatide ($1,847, IQR $938-$2,345, p = 0.0043). 


Conclusions: In this study, we observed that cangrelor and eptifibatide had no significant difference in bleeding outcomes for periprocedural cardiac bridging. Both agents showed similar bridging durations and hospital stays, though cangrelor was significantly more expensive. While eptifibatide had a trend toward higher transfusion requirements, it was not statistically significant. Cost considerations should guide agent selection and further prospective studies are needed to validate these findings.

TITLE: Evaluating the Access Process for Patients Transitioning from Intravenous to Subcutaneous Biologic Administration for Inflammatory Bowel Disease 
 
AUTHORS: Taylor Kissel, Miranda Kozlicki, Bridget Lynch, Josh DeClercq, Autumn Zuckerman
 
OBJECTIVE: Evaluate the medication access process and outcomes for patients with IBD referred to transition to or initiate SC vedolizumab or infliximab. 
 
SELF ASSESSMENT QUESTION:  What is the most common method of approval for patients approved to start subcutaneous vedolizumab or infliximab? A. Benefits investigation only B. PA approval only C. 1^st level appeal D. 2^nd level appeal 
 
BACKGROUND: The U.S. Food and Drug Administration (FDA) recently approved vedolizumab and infliximab for subcutaneous (SC) administration, providing patients with Inflammatory Bowel Disease (IBD) [Crohn’s Disease (CD) and Ulcerative Colitis (UC)] a convenient option to administer medication at home instead of clinic-administered intravenous (IV) infusions. SC formulations are most often covered on pharmacy insurance unlike infusions which are typically covered through medical insurance. Research is needed to evaluate the uptake and challenges associated with vedolizumab and infliximab SC formulations. 
 
METHODS: A single center, ambispective study evaluated patients with IBD with a referral to start or transition to SC vedolizumab or infliximab between September 1, 2023 and December 31, 2024. Patients were excluded if they were prescribed SC vedolizumab or infliximab from a non-Vanderbilt University Medical Center provider, lost to follow-up, or were not referred to Vanderbilt Specialty Pharmacy (VSP). Patients who used a manufacturer quickstart program or whose medication access was still ongoing as of February 18, 2025, were excluded from regression analyses. The primary outcome was time to SC formulation access. Secondary outcomes included whether patients were approved for SC therapy, method of approval for SC formulation, and number of patients not starting SC maintenance therapy after referral. Time to SC formulation access was calculated from the medication access process start date to the medication approval date, either through insurance or manufacturer. Multivariable regression analyses evaluated whether patients were approved to start SC (logistic regression) and time to approval for SC formulation (proportional odds [PO] logistic regression). Covariates of interest included: referral time (from FDA approval date of SC formulation), insurance type, remission status, referral medication, and IV status. 
 
RESULTS: Of the 274 patients referred for SC vedolizumab or infliximab, 262 were included in the study.  Exclusions were for the following reasons: 1 referred by non-VUMC provider, 2 lost to follow-up, and 9 never referred to VSP. Median age was 44 years (Interquartile range [IQR] 34 – 56); approximately half (55%) were female. Most patients were White (89%) and with commercial prescription insurance (84%). Diagnoses included CD (53%) and UC (47%) with a median disease duration of 14 years (IQR 7 – 23). Most referrals were for vedolizumab (81%), and most patients were established on IV therapy (81%). There were 32 patients still in progress or who used a manufacturer quickstart program. Of the remaining 230, most patients (n = 166, 72%) referred to SC were approved, with over half of those approvals occurring via PA (56%). Of the 166 patients approved to start therapy, 21% of patients did not start therapy (n=34/166), largely due to patient decision (47%, n =16/34). The median time to access was 10.5 days (IQR 1 – 42) with a range of 0 to 340 days. Patients with commercial pharmacy insurance were 3.4 times more likely to have a longer approval time (Odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.6 - 7.3, p = 0.001). Patients in remission at baseline and those with an infliximab referral were more likely to be approved (OR: 2.3, 95% CI: 1.04 - 5.1, p=0.041 and OR: 3.3, 95% CI 1.04 - 10.2, p=0.043). Patients with commercial pharmacy insurance were 80% less likely to be approved (OR: 0.2, 95% CI: 0.1 - 0.7, p=0.012).
 
CONCLUSIONS: Strict insurance formulary requirements, particularly in patients with commercial insurance, resulted in lengthy approval times for many patients and prevented a quarter of patients from being approved. Future studies should evaluate clinical and humanistic benefit of SC formulations. 

Title: Pharmacist-Led Interventions to Improve Medication Access to Rifaximin in the Treatment of Hepatic Encephalopathy
Author: Jenny Hollingsworth
Objective: The primary outcome will be the identification of optimal processes specialty pharmacy can utilize for the improvement of workflow to impact the time to rifaximin medication acquisition for patients. Secondary outcomes include patient barriers to starting therapy and the number of patients requiring assistance through manufacturer patient assistance programs.
Self-Assessment Question: What is one method specialty pharmacists can utilize to benefit medication acquisition to patients?
Background: The current standard of practice for monitoring adherence of rifaximin in the treatment of Hepatic Encephalopathy (HE) is lacking. This study’s purpose is to evaluate the effectiveness of community-based specialty pharmacist interventions in enhancing medication adherence and improving patient access. This study aims to identify best practices that pharmacists can employ to optimize therapeutic outcomes and support patient management of rifaximin therapy in a specialty pharmacy setting. 
Methods: Data is anonymous and does not contain patient-specific data points. This is a prospective study utilizing patients who will fill their prescription at a community-based specialty pharmacy located within a health system. Inclusion criteria for patients include those with a confirmed diagnosis of HE, a valid prescription of rifaximin as a new start, and are 18 years of age or older. Exclusion criteria for patients include contraindications to rifaximin or taking rifaximin for treatment other than HE or patients refilling rifaximin. Pharmacist-Led interventions in this study will include coordinated efforts with prescribers to aide in the prior authorization process and utilize patient assistance and copay cards for patients unable to afford rifaximin.
Data collection of these interventions will be conducted over a period of six months from March 1st to April 1st with sample size of 69 patients. Quantitative items in the data will include the number of insurance approval rates, the number of patient applications and approvals or denials for assistance, prescription refills, and the time from prescription receipt to receiving their first fill. The data will be analyzed using descriptive statistics to assess adherence rates with interventions.
Results: The number of prescriptions received throughout the data collection time period was 69. Of the 69, 62 needed prior authorizations which were completed. All 62 prior authorizations received approval with 10 of them needing patient assistance program support. The total number of patients with insurance through Medicare was 27. The total number of patients with insurance through commercial plans was 34. The total numbers of patients with insurance through Medicaid was 7. The total number of uninsured patients was 1. Regarding patient assistance program applications, 16 total applications were submitted and utilized for Medicare patients exclusively. No patient assistance programs were utilized for commercial plan patients.
Regarding time to medication acquisition, the average time from receipt of prescription to medication delivered to patient was 13.7 days. The lowest time was 0 days as represented by receipt of prescription and bedside delivery to patient within the same day upon discharge from the hospital. The longest time was 80 days. The time frame which appeared the most throughout the data collection process was 3 days.
Conclusions: By utilizing the steps outlined in the implemented process of rifaximin acquisition, a quicker medication acquisition time has been demonstrated for patients to begin optimal therapy for treatment with hepatic encephalopathy with a value of 12.5 days, thus demonstrating an improvement in workflow processes. It furthermore displays the avenues in which patients can receive medication by utilizing guided pharmacist support in prior authorizations and patient assistance programs. This study illustrates the importance of pharmacist-led interventions in the community space and showcases pharmacists’ impact on positive patient outcomes in optimization of therapy with rifaximin. 

Title: Use of SGLT2 Inhibitors in Heart Failure Patients Requiring Renal Replacement Therapy 
Authors: Meggie Gilkey, PharmD, Lindsay Reulbach, PharmD, BCPS, Jessica Howington, PharmD, Andi Ray, PharmD, BCCP
Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors, initially studied for type 2 diabetes, were found to reduce heart failure (HF) hospitalizations and cardiovascular death in both heart failure (HF) with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) populations. Additionally, they slow renal disease progression by 35–50%. As SGLT2 inhibitors become central to guideline-directed medical therapy (GDMT), their role in patients with concurrent HF and chronic kidney disease (CKD) has drawn attention. Concerns remain regarding use in severe CKD, especially among those on renal replacement therapy (RRT). To address this gap, we conducted a study evaluating the real-world safety and efficacy of SGLT2 inhibitors in HF patients requiring RRT.
Methods: A single-center, retrospective, observational, cohort study was conducted at Prisma Health Greenville Memorial Hospital. Patients 18 years or older admitted for HF who received an SGLT2 inhibitor and required RRT between October 1, 2023, and June 30, 2024, were included. Patients were monitored for outcomes over six months post-index hospitalization. HF-related admissions were identified using emergency department (ED) diagnoses, and RRT status was determined via nephrologist progress notes. Exclusion criteria included type 1 diabetes, pregnancy, non-HF SGLT2 inhibitor use, recent RRT initiation, RRT nonadherence, or malignancy. The primary outcome was SGLT2 inhibitor related adverse events. The secondary outcome assessed HF-related ED visits or hospitalizations.
Results: A total of 725 patients were screened and 7 were included. All patients received empagliflozin during their hospitalization. RRT was split between hemodialysis (57.1%) and peritoneal dialysis (42.8%). One patient (14.3%) experienced an SGLT2 inhibitor related adverse event, resulting in an ED visit 16 days post-index hospitalization. The adverse event was a urogenital infection in a patient with a known history of frequent urinary tract infections. No episodes of diabetic ketoacidosis, hypoglycemia, or hypotension were observed. No hospitalizations occurred due to SGLT2 inhibitor-related adverse events. Two HF-related hospitalizations occurred during the 6-month follow-up. One patient (14.3%) died during the study period, although the death was not related to SGLT2 inhibitor therapy or HF exacerbation.
 Conclusion: This real-world, observational study provides preliminary insight into the safety and efficacy of SGLT2 inhibitors in HF patients requiring RRT. Although limited by a small sample size, the findings suggest that SGLT2 inhibitors may be well tolerated, with minimal adverse events and potential benefit in reducing HF-related hospitalizations. However, due to the observational nature and limited scope of the study, no definitive conclusions can be drawn. Larger, controlled studies are needed to better understand the role of SGLT2 inhibitors in this high-risk population and to inform clinical decision-making with greater confidence.

Title: Assessment of Intravenous Sotalol Loading Usage in a Veterans Affairs Medical Center


Authors: Justin Barnett, Rebecca Holt, and Cynthia Pohland


Background: Atrial fibrillation (AF) affects up to six million Americans, with approximately 15% of those being veterans. AF can be managed pharmacologically with rate control or rhythm control strategies. Sotalol is a non-selective beta-blocker with potent potassium channel blocking properties and can be used for pharmacological rhythm control.  Sotalol is typically initiated in a health care facility capable of creatine clearance calculation, continuous electrocardiographic monitoring, and cardiac resuscitation to ensure safety during the loading phase. Loading with oral sotalol tablets requires at least 3 days in an appropriate health care facility; however, loading with sotalol intravenous (IV) solution can be achieved in 1 day. The purpose of this quality assurance project is to assess the effects of IV versus oral sotalol loading on hospital length of stay in the James H. Quillen VA Medical Center (JHQVAMC) and to assess the facility’s initiation of sotalol in accordance with monitoring recommendations to identify areas for improvement in the medication use process. 


Methods: This project will identify patients who were initiated on sotalol in the JHQVAMC. Hospital length of stay will be determined as the time from sotalol initiation until the time of discharge. Serum electrolytes (potassium and magnesium), serum creatinine, creatinine clearance, heart rate, QTc interval, and heart rhythm will also be assessed at baseline, during sotalol loading, and after sotalol loading prior to hospital discharge. These electrocardiogram and electrolyte parameters will be evaluated for appropriateness as recommended by manufacturer package labeling, guideline recommendations, and expert opinion for sotalol monitoring. 


Results: In progress


Conclusion: In progress

TITLE: Impact of Prior Beta-Blocker Use on Antihypertensive Escalation in Acute Ischemic Stroke 
 
AUTHORS: Shivani Patel PharmD, Kirbie Wells PharmD
 
OBJECTIVE: To identify the impact of home beta blocker use and its effect on labetalol for achieving blood pressure targets prior to administration of tissue plasminogen activator (tPA) in acute ischemic stroke patients at a rural community hospital. 
 
SELF ASSESSMENT QUESTION: What is the primary clinical concern when managing blood pressure in acute ischemic stroke (AIS) patients who are on beta-blocker therapy at home prior to alteplase (tPA) administration? 
A) Increased risk of hemorrhagic transformation due to excessive blood pressure lowering. 
B) Potential need for escalation to alternative antihypertensive agents after labetalol. 
C) Decreased efficacy of thrombolytic therapy due to beta-blocker-induced vasoconstriction. 
D) Higher likelihood of spontaneous blood pressure normalization without intervention. 
 
BACKGROUND: Stroke is a leading cause of mortality and disability in the U.S., with the highest burden in the Southeastern "stroke belt," where rural areas like Southwest Georgia face barriers to specialized care. In acute ischemic stroke (AIS), timely blood pressure control is crucial before alteplase (tPA) administration to reduce the risk of hemorrhagic transformation. The AHA/ASA recommends lowering systolic BP to <185 mmHg and diastolic BP to <110 mmHg using labetalol, hydralazine, or nicardipine, without specifying a preferred agent. However, prior beta-blocker use may reduce labetalol’s effectiveness due to beta-adrenergic receptor downregulation, necessitating escalation to other agents. This study evaluates whether outpatient beta-blocker use influences the need for additional antihypertensive therapy in AIS patients, potentially guiding personalized stroke management strategies.

METHODOLOGY: This study was a retrospective chart review which included adult patients diagnosed with acute ischemic stroke who had an initial SBP >185 mmHg or DBP >110 mmHg and received labetalol for blood pressure control prior to tPA administration treated at Phoebe Putney Memorial Hospital (PPMH) from January 2019 to December 2023. Patients were excluded if they were pregnant or transferred from another healthcare institution.  
 
RESULTS: A total of 199 patients were included: 65 with prior beta-blocker (BB) use and 134 without. The prior BB group was slightly younger (62 vs. 64.8 years) and heavier (96.6 vs. 83.2 kg). Stroke severity was similar between groups, with the prior BB group having a slightly higher percentage of severe strokes (15.4% vs. 12.7%). More patients with prior BB use required additional antihypertensives (37.5% vs. 19%). The interquartile range for door-to-needle time was 30.5–69 minutes, and for blood pressure control, 19.4–58.3 minutes. Severe hypotension occurred in 4.6% of the prior BB group and 9.7% of the no BB group. Intracerebral bleeding occurred in 6.2% of the prior BB group and 3.7% of the no BB group.
 
CONCLUSIONS: Patients on prior beta-blockers were more likely to require escalation to nicardipine or hydralazine for blood pressure control before Alteplase administration. These findings suggest that prior beta-blocker use may reduce the effectiveness of labetalol, necessitating a more individualized approach to antihypertensive management. Future studies should explore whether alternative first-line strategies could improve blood pressure control efficiency and minimize complications, particularly in resource-limited settings.

Title: Evaluating the Impact of a Community Pharmacist-Led Blood Pressure Service to Improve Hypertension Control
Authors: Tolulope Olajide, Allyson Marsh, Megan Boothby, Catie Harper, Nicole Aldaz, Claire O’Conner
Background: 
Uncontrolled hypertension is associated with increased prevalence of major adverse cardiac events. This health disparity is thought to be largely driven by disparities in Social Drivers of Health (SDOH) in this population. In 2023 Cone Health identified a systemwide disparity between the proportion of patients identifying as Black or African American with hypertension control compared to that of the general population (69.9% vs. 74.8%). A previous cohort study in our health system found pharmacy student-led patient interactions, either in person within a community pharmacy or telephonic, were associated with a significant improvement in hypertension control. As community pharmacists are one of the most accessible healthcare professionals, pharmacist-led blood pressure screenings have the potential to positively impact blood pressure control on a broader scale. The purpose of this study is to assess the impact of community pharmacist-led blood pressure screening and education on hypertension control.
Methods:
This was a single system, multi-site, IRB-exempt, retrospective cohort study. Adults diagnosed with hypertension were included if they had a recent blood pressure reading ≥ 140/90 mmHg recorded in an ambulatory care setting. Patients were outreached via telephone or approached at their Cone Health community pharmacy. Patients that underwent telephonic outreach were recruited from an electronic medical record report that listed recent patient ambulatory blood pressure reading data taken at a Cone Health clinic. A community pharmacist, pharmacy resident, or pharmacy student under the supervision of a pharmacist led the blood pressure monitoring encounter. The pharmacist or pharmacy student led the visit by asking questions related to medication adherence, adverse effects, and at-home blood pressure monitoring. Patients were counseled on the importance of blood pressure control in preventing cardiovascular events, non-pharmacological methods of blood pressure control, and how to properly monitor their blood pressure at home. The primary outcome was a mean change in systolic and diastolic blood pressure in the overall study population. Secondary objectives included percent of African Americans and general population with BP at goal (< 140/90 mmHg), adherence to blood pressure medications (assessed by proportion of days covered), and the number of social drivers of health at risk at time of outreach.
Results: 
Between August 1 and December 31, 2024, 70 patients were included in the study. Of this cohort, 59 patients (84.3%) had a post-encounter blood pressure (BP) reading recorded. Eight patients approached the pharmacy counter for BP screenings but only 2 patients were included in the study. The mean BP was 156/92 mmHg pre-encounter and 142/84 mmHg post-encounter, with a mean within-subject change in systolic blood pressure (SBP) of -12 .4 mmHg (95% CI –19.4 to –5.5; P< 0.001) and diastolic blood pressure (DBP) of –7.4 mmHg (95% CI –11.5 to –3.4; P < 0.001). Overall, achievement of target BP goal of < 140/90 mmHg occurred in 54.2% of patients post-intervention (OR 7.8; 95% CI 2.7-30.2; p<0.001). In a subgroup analysis, BP goal was achieved post-intervention in 26 of the 52 patients identifying as Black or African American and 6 of the 7 Non-Black patients; however, this difference did not reach statistical significance (P=0.11) at this sample size.  Similarly, a trend toward greater mean within-subject reductions was observed in Non-Black compared to Black or African American participants for both SBP (-17.9 vs -11.7; P=0.57 and DBP -8.6 vs 7.3; P =0.84), but these subgroup differences were not statistically significant.
Conclusion: 
Community pharmacist-led blood pressure monitoring encounters resulted in a decrease in average blood pressure. The disparity in achievement of controlled blood pressure persisted in our study, although this difference was not found to be statistically significant. This could be due to limited time and resources to address patients’ social determinants of health.

Title: Utilization of Pharmacist Instructors in Didactic Curricula Across Graduate Healthcare Education Programs


Authors: River Medlin, Carrie Baker, Riley Bowers


Background: Pharmacology and pharmacotherapy courses are part of curricula across health science programs with a variety of strategies utilized to deliver this material including the use of pharmacists. Previous literature has examined the use of pharmacists within physician assistant (PA) programs, but is limited concerning use across graduate healthcare education programs. The purpose of this research was to describe the current utilization of pharmacists in didactic instruction among graduate healthcare education programs along with barriers to utilization.


Methods: This was a cross-sectional, descriptive survey electronically distributed to graduate healthcare education programs within the United States between October 30, 2024 and February 3, 2025. Eligible programs included accredited physician (MD, DO), physician assistant (PA), physical therapy (PT), and occupational therapy (OT) programs. The primary outcome was to compare the utilization of pharmacists as instructors within didactic curricula between accredited health profession education programs. 


Results: Contact information was collected for 903 eligible programs with emails successfully deployed to 823 programs. Of those programs, 129 (15.7%) responded.  Overall responses indicated that 74 (57.4%) programs utilized pharmacists as instructors within their curriculum. When examined by individual program type, 13/18 (72.2%) of MD/DO, 44/51 (86.3%) of PA, and 17/60 (28.3%) of PT/OT programs utilized pharmacists. The most common barrier across all disciplines was availability of qualified pharmacists, and the most influential factor in determining utilization was qualifications of pharmacists.


Conclusion: Current utilization of pharmacist instructors varies across disciplines and regions within the United States. The most influential factors for programs who utilized pharmacists and those who did not was the qualifications of pharmacists and availability of pharmacists with adequate qualifications. This emphasis on qualifications identifies an opportunity for pharmacists to better promote their expertise and capabilities as instructors as the number of pharmacists with post-graduate training, specialization, and board certifications continues to increase.

Title: Optimizing Metronidazole Administration: A Comparative Analysis of Every Twelve Hours Versus Every Eight Hours Dosing for Anaerobic Infections 


Authors: Taylor J. Merritt, Kat Petersen, Benjamin Albrecht, Sujit Suchindran, Sarah B. Green 
Emory University Hospital- Atlanta, GA   


Background: Metronidazole has historically been the drug of choice for anaerobic infections, conventionally dosed every eight hours. Its hydroxy metabolite can exhibit 30-65% activity of the parent drug and has a half-life extending up to 11.65 hours. Serum levels of metronidazole exceed the minimum inhibitory concentration at twelve hours for most anaerobes. Thus, an argument that can be made for dosing every twelve hours for most anaerobic infections. The objective of this study is to determine the probability that patients receiving oral or intravenous metronidazole at a dosing frequency of every twelve hours would have a more or equivalent desirable outcome, measured by desirability of outcome ranking (DOOR), than patients receiving a traditional, every eight hours frequency for the treatment of confirmed anaerobic infections.   


Methods: This was a retrospective, quasi-experimental, multi-center analysis which reviewed adult patients who received metronidazole for the treatment of confirmed anaerobic infections. Included patients received 500 mg doses of intravenous or oral metronidazole at a dosing frequency of eight or twelve hours, for at least 72 hours in duration. Patients were excluded if the indication for metronidazole was hepatic encephalopathy, surgical prophylaxis, or treatment of Clostridioides difficile, central nervous system, parasitic, sexually transmitted, or Helicobacter pylori infections. Those who received metronidazole every eight hours for ≥ 72 hours before transition to every twelve hours, received concomitant antibiotics with anaerobic coverage for ≥ 72 hours, or had an organism with documented resistance to metronidazole were also excluded. The primary outcome was the probability that a patient receiving metronidazole every twelve hours would have a more or equivalent desirable outcome than a patient receiving every eight-hour dosing. Secondary outcomes included an assessment of outcomes specific to the subgroup of immunocompromised patients in the study. 


Results: Baseline demographics were similar between the two groups. The majority of included patients were male (55%), Black (62%), and had an average age of 61 years. The average length of stay was 22 days overall, which was also comparable amongst groups. The overall DOOR distribution between groups was similar and there was no significant difference in the probability of a more desirable outcome for patients who received metronidazole every twelve hours compared to traditional every eight-hour dosing (51.3% [95% CI: 43.5%, 59.0%]; p-value= 0.7417). Of the individual DOOR components, there was a statistically significant difference in treatment failure with a higher probability of desired result (i.e. treatment success) in the every twelve-hour dosing group (p-value= 0.021). Analysis of the immunocompromised subgroup also found no difference in probability of desirable outcomes (45.9% [95% CI: 30.1%, 62.6%]; p-value= 0.6388). 


Conclusion: We found no significant differences in desirable outcomes between the dosing groups for total study patients and the immunocompromised subgroup. The results discussed above included criteria for the DOOR analysis such as treatment failure, unsuccessful discharge, adverse effects, and transition to hospice or death. This provides evidence to support that every twelve hours dosing of metronidazole could be considered over every eight hours for most anaerobic infections, due to the similar DOOR ranking in addition to the time saving component, increased convenience for nursing staff, and expected reduction in cost in contrast to dosing every eight hours. 

Evaluation of VTE Prophylaxis in Trauma Patients at a Large Community Hospital
Authors: Sarah Skaggs Gatewood and Jerry Robinson
Objectives:

1. Identify current recommendations for proper VTE prophylaxis in trauma patients.
2. Explain the implementation of guideline directed VTE prophylaxis management.
3. Compare VTE event rates before and after implementation.

Background/Purpose: In 2022, the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma published a clinical protocol with updated recommendations for inpatient venous thromboembolism (VTE) prophylaxis after trauma.  The dosing of enoxaparin for VTE prophylaxis in trauma patients at Huntsville Hospital did not match these recommendations. Trauma patients are at an increased risk of VTE, including deep vein thrombosis and pulmonary embolism. Pharmacologic and mechanical VTE prophylaxes are often necessary to decrease the risk of thromboembolic events after a trauma occurs. This project seeks to explore previous institution-specific dosing based on age, renal function, and other factors, compared to updated dosing to match 2022 recommendations.
Methods: This single-center, pre-post implementation, quasi-experimental study evaluated adult patients 18 years of age or older admitted to Huntsville Hospital under the care of trauma services from January 1st, 2024, to January 31st, 2025. Data was collected from the electronic health record (EHR) and analyzed using descriptive statistics. The following pre-intervention and post-intervention data were collected: patient demographics, hospital length of stay, renal function, VTE prophylaxis dosing, lab monitoring, and risk factors. Patients were excluded if they had a length of stay less than 72 hours, did not receive any mechanical VTE prophylaxis, or if they transferred to a long-term facility. A classification of patients was made based on current VTE prophylaxis guidelines after the trauma algorithm published by the American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma1. The primary endpoint was appropriate compliance with the 2022 algorithm for VTE prophylaxis post-trauma. Efficacy was assessed via anti-Xa monitoring, targeting a range of 0.2-0.4 units/mL, with 10 mg dosing adjustments for levels outside this range.  Secondary endpoints included composite rates of deep vein thrombosis and pulmonary embolism, patient length of stay, days on VTE prophylaxis, and adverse drug events (ADEs) related to enoxaparin administration. Hospital-specific data and current policies were reviewed to identify areas of improvement, which included adherence to practice guidelines for VTE prophylaxis in trauma patients. Post-intervention data included the same metrics as listed for the pre-implementation data set. An ongoing quality review was performed in the post-intervention phase to identify potential changes and ensure compliance.
Results: A total of 160 patients (mean age, 50 years) were studied, 80 in the pre-implementation group and 80 in the post-implementation group, with similar baseline characteristics, risk scores, overall length of stay, and days on VTE prophylaxis between groups. Adherence to guidelines was noted to be overall 44% in the pre-implementation group and 84% in the post-implementation group for all patients included. No anti-Xa levels were checked in the pre-implementation phase. In the post-implementation phase, target range anti-Xa levels were achieved in 53 out of 80 patients (87%), with 43 patients (70%) having their first level within the target range. The incidence of VTE events was similar between groups but lower in the post-implementation phase, with only 9% of patients experiencing VTE events versus 13% in the pre-implementation phase.
Conclusion: The implemented order set and ongoing feedback integration lead to successful protocol implementation. Overall compliance with the 2022 published algorithm for post-trauma venous thromboembolism prophylaxis was achieved in 84% of patients. Anti-Xa monitoring post implementation occurred in 87% of patients versus zero prior to implementation. VTE events were less in the post implementation phase as well. An ongoing review will be continued to evaluate ordering options as well as opportunities to optimize monitoring and adherence.
Self-Assessment Question:
What is the primary purpose of anti-Xa monitoring in patients?

1. To assess renal function
2. To evaluate anticoagulant effect of current dosing strategy for effectiveness and safety
3. To monitor for potential allergic reactions
4. To check for the development of deep vein thrombosis (DVT)

IMPACT OF A MULTIDISCIPLINARY TEAM IN THE MANAGEMENT OF SUBJECTS WITH HEART FAILURE
Nicole DeLalla, Athena Colon, Richard Lane, Reginald Leandre, Tracey Dobbs
AdventHealth Apopka – AdventHealth Apopka, Florida, FL
Background: In 2024, nearly seven million individuals in the United States were diagnosed with heart failure.1,2 The resulting healthcare-related expenditure for treatment of this disease state has been calculated at over $3 million.1,2 In order to improve clinical outcomes, studies have shown that guideline-directed medical therapy (GDMT) can increase survival rates by 6.3 years. Additionally, GDMT has the potential to alleviate financial burden as a single heart failure-related hospitalization can cost about $15,000. 3,4 A study by Fallon and colleagues found that taking an interdisciplinary approach to heart failure management resulted in a 6% decrease in 30-day recurrent admissions in this patient population.5 However, there are limited studies focusing on how inpatient interventions affect rehospitalizations.
Methods: This was a single-center, retrospective chart review conducted at AdventHealth Apopka between July 1st, 2024 to December 31st, 2024. Included subjects were 18 years of age or older with a diagnosis of heart failure with reduced ejection fraction (HFrEF), defined as ejection fraction (EF) less than 40%. The exclusion criteria were subjects with an EF of 40% or greater, a history of a heart transplant, or planned heart transplant at the time of index visit. The primary objective was to assess the impact of a multidisciplinary heart failure management team on 30-day readmission rates. Secondary objectives included 30-day cardiovascular-related readmission, 30-day all-cause mortality, dose optimization defined as dose titration of GDMT medications or addition of at least one GDMT medication drug class, and inpatient length of stay (LOS). In addition, safety outcomes evaluated were incidence of acute kidney injury (AKI), hypotension, bradycardia, and hyperkalemia. 
Results: A total of 904 subjects were reviewed. Among those patients 146 subjects were included while 758 subjects were excluded. Baseline characteristics showed mainly white/Caucasian males with an average age was 67 years old. The 30-day readmission rates among the included patients were 33%. The 30-day cardiovascular readmission rate was 14%, and the 30-day all-cause mortality rate was 7%. Beta blockers had the highest incidence of dose titration at 17 %. The highest incidence of GDMT initiation was both beta blocks and diuretics with 27%. The average LOS was about 4.92 days.
Conclusion: In conclusion, this study saw a readmission rate of 33% after a multidisciplinary heart failure management team. When compared to national readmission rate of 25%, there is an eight percent difference in readmission rates to this study.6 This would suggest that there are areas of opportunities to further development of this heart management team.
 
References
HF stats 2024: Heart Failure Epidemiology and ... Accessed February 25, 2025. https://onlinejcf.com/article/S1071-9164(24)00232-X/fulltext.

• Centers for Disease Control and Prevention. Heart Failure. CDC. https://www.cdc.gov/heart-disease/about/heart-failure.html. Published October 14, 2022. Accessed September 11th, 2024
• Martin SS, Aday AW, Almarzooq ZI, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association [published correction appears in Circulation. 2024 May 7;149(19):e1164. doi: 10.1161/CIR.0000000000001247]. Circulation. 2024;149(8):e347-e913. doi:10.1161/CIR.0000000000001209   
• Weiss AJ, Jiang HJ. Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); July 20, 2021.
• Fallon JM, Anderson K, McElhaney E, Lewis DA, Williams JB. Pharmacy-led optimization of transitions of care in patients with heart failure. J Am Coll Clin Pharm. 2024;7(6):778-786. doi:10.1002/jac5.1982. 

Foroutan F, Rayner DG, Ross HJ, et al. Global comparison of readmission rates for patients with heart failure. Journal of the American College of Cardiology. 2023;82(5):430-444. doi:10.1016/j.jacc.2023.05.040

Title: Safety Outcomes of Tirofiban Weight Based Dosing Strategy in Overweight Patients
Authors: Merrie Barnett-Brock, Audrey Johnson, Sofiya Paciotti
Background: Tirofiban is a GIIb/GIIIa receptor antagonist therapy used for the treatment of myocardial revascularization in non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). Tirofiban dosing is weight based utilizing actual body weight. There is a hole in the literature regarding studies with information regarding safety outcomes in patients >85kg, including obese patients. Specifically, the previous literature lacks any information regarding safety outcomes in obese patients. Current studies show incidence of bleeding ranging from 0.4% to 5%. This is a major gap in the literature that this study hopes to resolve. 
Methods: This IRB-approved, retrospective, single-center cohort study included patients from a 711-bed academic medical center in Savannah, Georgia. Adult patients treated with tirofiban for cardiac conditions at Memorial Health University Medical Center between January 1, 2015 and September 27, 2024 were utilized as the cohort. Other inclusion criteria included receipt of tirofiban ≥1 hour and patients dosed on actual body weight with renal dose adjustment using a creatinine clearance calculation with actual body weight. Patients were excluded if they were a protected population or if the patients were discharged <48 hours from when infusion started. The aim of this study was to assess the safety outcomes of patients with a weight ≥85 kg with a primary outcome of major bleeding defined by the ISTH criteria and secondary outcomes of minor bleeding, mortality, and rescue agents utilized. These outcomes were further assessed amongst subgroups based on BMI, renal function, and weight. The BMI subgroups included 3 categories, category one being BMI <30 kg/ m², category two being BMI 30-40 kg/m², and category three being BMI >40 kg/m². The weight subgroups included three categories, category one being 85-119.9 kg, category two being 120-149.9 kg, and category three being ≥150 kg. 
Results: Of the 304 patients screened, 47 were included in the final analysis. The majority of patients were white males and no patients were found to have renal dysfunction. The median weight observed in the patient population was 98 kg and the median BMI was 30.7 kg/m². We observed a 29.7% incidence of major of bleeding. For the subgroups defined by BMI, major bleeding was found to be 44.4% in the category 1 patients, 17.3% in the category 2 patients, and 33.3% in the category 3 patients. Major bleeding occurred specifically in the weight subgroups with 30.9% of the category 1 patients, 25% of the category 2 patients, and 0% in category 3 patients. Secondary outcomes in the overall cohort included mortality in 2.1% of the population, minor bleeding in 12.7%, and 2.1% of the patients utilized a rescue agent.
Conclusions: This retrospective study provides descriptive information regarding major bleeding occurrences in patients weighing ≥85 kg where both BMI and weight subgroups were observed. We observed 29.7% of the patient population experienced major bleeding. These findings demonstrate that further research with adequately powered studies are needed to show the incidence of major bleeding amongst higher weight patients receiving tirofiban. 
Disclosures: "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."
Best contact point for follow up of interested participants: merrie.barnettbrock@hcahealthcare.com

Title:
Chlamydia return rates in the ED in a community-based health system following treatment with doxycycline or azithromycin
 
Authors: 
Witney Butler
Devon Burhoe
Erica Merritt
Joseph Crosby


Background:
Sexually transmitted infections (STIs) are a major public health concern, with 1.6 million Chlamydia cases reported in 2022. Emergency Departments (EDs) play a key role in treatment, yet many patients still receive azithromycin despite CDC guidelines favoring doxycycline. Studies show doxycycline is more effective due to its sustained drug levels, while a single dose of azithromycin may be less effective in high bacterial loads or resistance. Comparing return rates between treatments, considering demographics and pharmacist follow-up, could inform hospital protocols. Logistic regression analysis may provide insights to optimize Chlamydia management and reduce ED return visits.


Methods:
This was a retrospective, observational cohort chart review that evaluated adult patients who tested positive and were treated for Chlamydia within a community-based health system and returned within 30 days after their initial visit. Patients were excluded if pregnant or tested negative for Chlamydia. A computer-generated list identified patients with a positive Chlamydia test from December 1, 2021, to August 31, 2024. Subjects were reviewed for study inclusion or exclusion based on the criteria.  Information was gathered from the subjects' electronic health records, including the prescribed antibiotic and whether they returned to the ED within 30 days for a STI complaint. If the patient was seen multiple times within the study period, there must have been at least 6 months between visits to be counted as a new study entry in the data. Patients were evaluated based on demographic characteristics including gender, sexual orientation, age, race, co-infections, insurance type, and if there was follow up by a pharmacist with a documented note in the patient’s chart. Pharmacists only contacted the patient if the test was positive and the patient was not treated correctly for Chlamydia. 


Results:
Of the 1,664 ED encounters with a positive Chlamydia test, 33 patient encounters met inclusion criteria by returning to the ED within 30 days. For comparison, a control group of 33 patients who did not return within 30 days was randomly selected. Logistic regression analysis indicated that antibiotic choice does not significantly impact 30-day return rates for patients treated for Chlamydia (p = 0.067). Logistic regression analysis also showed that ages 18-45 years old, male sex, and African American race were associated with higher odds of 30-day ED return, while having insurance reduced the odds by 46%. Compared to no antibiotics, doxycycline and azithromycin significantly reduced return odds by 76% and 61%, respectively. Co-infection with gonorrhea was also associated with lower return rates which reduced the odds by 44%.

Conclusion: 
Antibiotic selection does not appear to significantly impact 30-day ED return rates for patients with Chlamydia, suggesting it may not be a primary factor in patient return visits. More data in a larger, prospective trial is needed to determine if there is a true relationship between initial antibiotic choice and return visit to the ED. Further research should also explore adherence monitoring strategies or microbiological data to refine STI management protocols in community-based health systems.

Resident follow-up email:
butlerwi@sjchs.org

Title: Clinical and Microbiologic Characteristics of Candida auris Isolates at Grady Health System   
 
Authors: Saira Mirza, PharmD; Joseph Corbino, PharmD, MSc; Shreena Advani, PharmD; Joseph Torrisi, PharmD; Sheetal Kandiah, MD, MPH; Susan M. Ray, MD 
 
Objective: The objective of this study was to identify risk factors associated with increased mortality among admitted individuals with pathogenic cultures for Candida auris and assess sensitivities to currently recommended antifungal agents. 
 
Self-Assessment Question: What was a significant risk factor contributing to mortality in this study? 
 
Background: First isolated in 2009 from the ear canal of Japanese individuals, Candida auris has quickly emerged as an important pathogen of worldwide concern. C. auris, similar to other 

Title: Evaluation of a heparin calculator best practice alert (BPA) implementation at a multi-hospital health system 
Authors: Brittaney-Ann Simpson, Kirsten DiPiro, Ambra Hannah, Jerri Jenkins  
Objective: Describe the use of a heparin infusion calculator dose mismatch Best Practice Alert (BPA) within a health system  
Self Assessment Question:
Background: The electronic heparin calculator has demonstrated benefits in reducing medication errors by minimizing manual calculations in the hospital setting. At Wellstar Health System, heparin infusion initiation and maintenance follow a nurse-driven protocol.  This study evaluated the effectiveness of the heparin infusion calculator dose mismatch Best Practice Alert (BPA) in improving adherence to the heparin calculator and its impact on correct dosing and therapeutic efficacy.  
Methods: A multicenter retrospective chart review was conducted analyzing adult patients who received a heparin infusion 90 days before BPA implementation (May 24, 2023 to August 22, 2023) and 90 days after (October 1, 2023 to December 30, 2023).  Patients were included if they exceeded the maximum starting dose requiring a weight-based heparin infusion adjustment (weight >83.3 kg on low/neuro dose heparin and >125 kg on high dose heparin). Patients were excluded if the heparin infusion was initiated in a procedural area, ordered outside of the heparin order sets, restarted after interruption, or continued on Xa monitoring after receiving a direct oral anticoagulant within 72 hours of heparin initiation. Additionally, patients were excluded from therapeutic efficacy calculations and safety measures if the heparin infusion was less than 24 hours. The primary outcome was to evaluate the impact of the BPA on adherence to heparin calculator weight-based dosing on initiation of a heparin infusion. The secondary outcome evaluated the time to therapeutic heparin levels while safety outcomes assessed major and minor bleeding events. 
Results: A total of 212 patients were included in each study arm. Between both study groups, the majority of patients received low-dose heparin (82%), with acute coronary syndromes being the most common indication (41.7%). The BPA was triggered 33 times in the post-implementation cohort, with an acceptance rate of 84.8% (28 cases). Incorrect initial heparin rates were significantly lower in the post-BPA group at 2.5% (n=5) compared to 6.8% (n=13) in the pre-BPA group (P=0.008). For secondary outcomes, the mean time to achieve the second therapeutic level was similar between groups (27 hours; P=0.53). There was no statistically significant difference in major and minor bleeding events (P=1.0 and P=0.49, respectively).
Conclusions: Implementation of the heparin calculator BPA was associated with improved compliance with starting the correct infusion rate for patients that exceeded the max rate based on weight.  No correlation was observed between heparin calculator compliance and the time to therapeutic levels or bleeding events. Further studies are needed to assess the BPA’s impact on heparin infusion rate adjustments over time.

Title: Injectable Glucagon-Like Peptide-1 Receptor Agonists and Cardiovascular Outcomes in Patients Without Diabetes in Outpatient Cardiology Clinics
 
Authors: Kristina Benbow, Madison Burke, Lauren Schultz, Marina Carter, Deborah Hurley, Benjamin Tabor
 
Background: Glucagon-Like Peptide-1 (GLP-1) receptor agonists have emerged as clinically significant treatment options for type 2 diabetes, obesity, and cardiovascular (CV) risk reduction. To date, Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes (SELECT Trial) is the only trial to comprise of non-diabetic patients with preexisting CV disease defined as myocardial infarction, stroke, or symptomatic peripheral artery disease. In this trial, semaglutide was superior to placebo in reducing a CV composite of death from CV causes, nonfatal myocardial infarction, and nonfatal stroke. This study explores an expansion of the inclusion criteria used in the SELECT Trial, using a large outpatient cardiology population. 
 
Methods: This retrospective cohort study includes adult patients prescribed injectable GLP-1 receptor agonists followed by Prisma Health Cardiology between January 2022 and April 2023. Data was collected through April 2024. Patients were assigned to the control group if they never filled the medication with all other patients considered the intervention group. The primary outcome is a composite of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke. Secondary outcomes include total change in patient health variables (body weight, blood pressure, cholesterol, hemoglobin A1c), hospitalization or urgent medical visit for heart failure, and death from any cause. Descriptive statistics, stratified analyses (control vs intervention group), and multivariable logistic regression will be used to summarize the data and to evaluate the association of GLP-1 use and risk of death and other non-fatal cardiovascular outcomes.
 
Results: 123 patients without diabetes were prescribed a GLP-1 receptor agonist, 83 received the medication (intervention) and 40 did not (control). The primary endpoint did not differ between study arms, with no occurrences of death from CV cause or nonfatal stroke in either group. There was a nonsignificant trend in the control group for nonfatal MI (n=2 control, n=0 intervention; p=0.104). There were no occurrences of death from any cause and hospitalization or urgent medical visit for heart failure between groups. Secondary outcomes reflected a statistically significant reduction for intervention group in body weight (-1.0 kg control, -8.4 kg intervention; p<0.001), BMI (-0.2 kg/m2 control, -3.2 kg/m2 intervention; p<0.001), LDL (+1.4 mg/dL control, -34.1 mg/dL intervention; p<0.001), systolic blood pressure (+1.4 mmHg control; -7.9 mmHg intervention; p<0.001), and diastolic blood pressure (+1.2 mmHg control; -5.4 mmHg intervention; p=0.003). There was no difference in change in A1c between arms (0.0 ± 0.9 control, 0.0 ± 0.3 intervention; p=0.374).

Conclusions: Although unable to find a statistically significant difference in the composite primary endpoint, secondary cardiovascular outcomes favored the use of GLP-1 receptor agonists in patients without diabetes. There was a statistically significant lowering of known cardiovascular risk factors, including body weight, LDL, and blood pressure. Limitations of this study include a small study size which does not allow for true evaluation of primary endpoint, inclusion of patients irrespective of adherence to the GLP-1 receptor agonist or changes to background medications, and lack of available laboratory data points for many patients (notably, A1c and LDL). Unlike the SELECT Trial which looked exclusively at patients with a past medical history of MI, stroke, or symptomatic peripheral artery disease, this study was able to find CV benefit in a population both without CV history and in patients with coronary artery disease, all who were baseline close to having controlled/goal labs and vitals. Ultimately, this data helps advocate for insurance approval of GLP-1 receptor agonist in patients without diabetes secondary to their CV benefit.

EVALUATION OF PROTAMINE DOSING STRATEGIES FOLLOWING CARDIOPULMONARY BYPASS
Justine Bur, Amanda Sowder, Hetal Patel
AdventHealth Orlando-Orlando, FL


OBJECTIVE: Compare the impact of low, medium, or high protamine dosing on bleeding outcomes following cardiopulmonary bypass assisted cardiac surgery.


BACKGROUND: Protamine is used to reverse the anticoagulant effects of heparin after cardiopulmonary bypass (CPB). Improper dosing of protamine may lead to increased postoperative bleeding. Although it is paramount to have an appropriate protamine-to-heparin dosing ratio, evidence remains weak on guiding optimal dosing and inconsistencies exist between guidelines. At our institution, protamine dosing is routinely based off the initial heparin bolus. To our knowledge, no studies have compared protamine-to-heparin dosing ratios in otherwise healthy patients undergoing initial, elective CPB-assisted cardiac surgery. 


METHODS: A single centered, retrospective analysis was performed at a major tertiary referral hospital. Healthy adults aged 18 to 75 years old who underwent CPB-assisted coronary artery bypass graft or valve repair or replacement, with or without concomitant left atrial appendage ligation, MAZE, or myectomy were included. Exclusion criteria included chronic kidney disease or dialysis, liver dysfunction, hematologic disorders, pregnancy, or cancer. Patients were also excluded if they received non-packed red blood cell products in the operating room (OR). Primary endpoints included 24-hour chest tube output and 24-hour postoperative allogeneic transfusion requirements. Secondary endpoints included reintubation within 24 hours and operative re-exploration within 24 hours due to postoperative bleeding. All endpoints were measured after disposition from OR to the intensive care unit. Outcomes were evaluated based on low (<1:1), medium (1:1), and high (>1:1) protamine-to-heparin dosing ratios based on initial heparin and protamine boluses administered.


RESULTS: Seventy of the 267 patients screened between February 2023 and January 2025 were included in the analysis. Patients were median age 60 years, median BMI of 28.6 kg/m2 and 42 (60%) were male. At baseline, median pre-operative labs included: hemoglobin 13.6 g/dL, hematocrit 40.3%, platelets 240,000/μL, ACT 107 seconds, INR 1.0 and aPTT 29.6 seconds. Mitral valve replacement, 37 (53%), and repair, 15 (21%), were the most common cardiac surgeries. Median bypass time was 82 minutes. Median heparin and protamine boluses administered were 36,000 units and 320 mg, respectively. Protamine-to-heparin dosing ratios were characterized as follows: 32 (46%) patients comprised low, 28 (40%) comprised medium, and 10 (14%) comprised high. Twenty-four-hour chest tube output for low, medium, and high dose groups totaled 468, 530, and 850 mL, respectively (p=0.136). Of the 36% of patients who received transfusions, median total volume of transfusions for low, medium, and high dose groups were 506, 349, and 473 mL, respectively (p=0.936). No patients were reintubated due to postoperative bleeding within 24 hours and one patient in the high dose group returned to the OR for re-exploration for postoperative bleeding. Lastly, the median time to extubation of low, medium, and high dose groups was 226, 188, and 351 minutes, respectively (p=0.052).


CONCLUSION: This is the first study evaluating association of protamine-to-heparin dosing ratios with bleeding outcomes in otherwise healthy patients undergoing initial, elective CPB-assisted cardiac surgery. Despite the small sample size, there was a trend in increased post-operative 24-hour chest tube output as the protamine-to-heparin ratio increased. Although time to extubation did not statistically differ between groups, the greater time to extubation experienced by the high dose protamine group presents a clinically interesting finding for further exploration.

Impact of Pharmacist-Led Intervention on Maintenance Inhaler Appropriateness in COPD Exacerbations  
Kaysey Gilchrist, Emily Cooley, Taylor Wells, Danielle McGlynn, Michael Pitt
Background: Chronic Obstructive Pulmonary Disease (COPD) exacerbations are associated with worsening outcomes, including repeat hospital admissions. The Centers for Medicare and Medicaid created a Hospital Readmissions Reductions Program, which financially penalizes hospitals for excessive 30-day readmission rates of certain conditions, including COPD. Previous literature has indicated that pharmacists are uniquely positioned to identify interventions for COPD therapy optimization based on knowledge of clinical guidelines and insurance formularies. However, this study did not describe the implementation of pharmacist led transitions of care initiatives for patients with COPD. The purpose of this study was to identify the impact of pharmacist-led interventions in COPD patients prior to discharge on 30-day hospital readmission rates for COPD by evaluating appropriate maintenance inhaler therapy.
Methods: In July 2024, a new transitions of care service was implemented at Cape Fear Valley Medical Center (CFVMC) which enabled pharmacists to review patients admitted for a COPD exacerbation and send recommendations to the attending provider for optimization of maintenance inhaler regimens before discharge. Adult patients admitted to CFVMC between March 1, 2024 – June 30, 2024 (pre-intervention) and October 1, 2024 – January 31, 2025 (post-intervention) with a primary diagnosis of COPD exacerbation identified by ICD 10 and DRG diagnosis codes were retrospectively reviewed in this single-center study. The primary endpoint was to compare the percentage of patients admitted for COPD exacerbation who are discharged on appropriate maintenance inhaler therapy regimens pre- and post-pharmacist-led intervention. 
Results: A total of 146 hospital encounters were included in the study with 59 hospital encounters in the pre-intervention group and 87 hospital encounters in the post-intervention group. Of the 146 hospital encounters included in the study, 32 regimens (54%) were appropriate at discharged in the pre-intervention phase compared to 67 (77%) in the post-intervention phase (P=0.004). The rate of 30-day hospital readmissions was lower in the post-intervention group compared to the pre-intervention group (19.5% vs 37.3%; P = 0.02).
Conclusions reached to date: This study provides further evidence to confirm the positive impact of pharmacist-led interventions on the provision of guideline-directed maintenance inhaler therapy in patients with COPD prior to discharge from a community teaching hospital.