2025 Southeastern Residency Conference

Title: Deep vein thrombosis (DVT) prophylaxis agent selection in patients with acute kidney injury
 
Authors: Jacob Powell, Lauren Chambers, Joseph Davis 
 
Objective: To assess differences in bleed risk and clinical outcomes between enoxaparin and unfractionated heparin for the use of DVT prophylaxis in the setting of acute kidney injury 
 
Background: Venous thromboembolisms (VTE) are a significant contributor to morbidity and mortality in hospitalized patients. The American Society of Hematology (ASH) and American College of Chest Physicians recommend pharmacological prophylaxis for acutely or critically ill patients. Reduced kidney function can impair anticoagulant elimination, increasing the risk of bleeding. However, thrombosis and bleeding are both common in patients with acute kidney injury (AKI). Proper dosing is critical to avoid drug accumulation. Enoxaparin is prescribed for DVT prophylaxis at 40 mg daily, while unfractionated heparin (UFH) is given at 5,000 mg 2-3 times daily. In patients with reduced kidney function (creatinine clearance <30 ml/min), enoxaparin is reduced to 30 mg daily. UFH does not require renal dose adjustments. There is insufficient data to lead one to favor enoxaparin over UFH in this patient population. The objective of this research project is to assess differences in bleed risk and clinical outcomes between enoxaparin and UFH for the use of DVT prophylaxis in the setting of AKI. Results from this study will help to guide providers in agent selection for DVT prophylaxis in patients with AKI. 
 
Methods: This study was a single center, retrospective, observational review conducted at ECU Health Medical Center (ECHMC). This study included patients with a creatinine clearance (CrCl) <30 ml/min who had developed an AKI, defined by an increase in serum creatinine (SCr) by ≥0.3 mg/dL, within 48 hours of admission. Patients included received DVT prophylaxis with enoxaparin or UFH for at least 48 hours after admission and during AKI. Patients were excluded if they received both agents, were admitted to a trauma, surgery, or orthopedic service, or had end stage kidney disease (ESKD) receiving dialysis within 30 days of admission. Patients weighing <45kg were likewise excluded from this study. The primary outcome in this study was the incidence of major bleeding between each medication within 30 days of admission. Secondary outcomes included in-hospital mortality, length of stay, daily cost of medications, incidence of minor bleeding, and development of thrombus within 30 days of admission. 
 
Results: A total of 130 patients were included for analysis, with 36 (28%) receiving enoxaparin and 94 (72%) receiving UFH. Baseline characteristics were largely similar between groups, with some notable exceptions. Patients in the UFH group had a significantly higher median weight (77.1 kg vs. 65.6 kg; p=0.0003) and body mass index (27.3 kg/m² vs. 22.2 kg/m²; p=0.0006) compared to those receiving enoxaparin. Additionally, patients receiving UFH had higher median SCr levels on admission (p<0.0001), higher peak SCr during AKI (p<0.0001), and lower median CrCl during AKI (p=0.0005). There was no statistically significant difference in the primary outcome of major bleeding between enoxaparin and UFH groups (5.6% vs. 2.1%; RR 2.611, 95% CI 0.3819–17.854; p=0.3067). Similarly, there were no significant differences in secondary outcomes, including in-hospital mortality, length of stay, incidence of minor bleeding, or thrombus formation within 30 days of admission. However, UFH was associated with a significantly higher median drug cost per day compared to enoxaparin (p<0.001).
 
Conclusion: This study found no increased risk of bleeding with enoxaparin in patients with AKI. While underpowered to detect statistical significance, this study provides additional data on enoxaparin use in this patient population without increased risk of safety concerns. Larger studies are needed to confirm these findings.  
 
Contact Information: Jacob.Powell@ecuhealth.org 

Title: Evaluation of DKA Resolution with a Revised DKA Protocol in a Community Hospital Setting


Authors: Nancy Henin; Vanessa Velazco; Tracey Bastian; Valerie A. Van Vickle


Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that has resulted in an increased hospitalization rate leading to higher healthcare costs. Early and appropriate management of DKA is important to prevent mortality and decrease the risk of complications, such as hypoglycemia, hypokalemia, and  cerebral edema. Implementation of a standardized DKA protocol, including fluid resuscitation, insulin therapy, and electrolyte repletion, is important to ensure optimal treatment outcomes. The objective of this study is to assess the time to DKA resolution after modification to the institution’s DKA protocol in a community hospital setting. 


Methods: This is a single-center, retrospective, Institutional Review Board (IRB)-approved study aimed to evaluate a revised DKA protocol in patients admitted to a 337-bed community hospital. Fluid therapy was adjusted to Lactated Ringers with special considerations for patients with congestive heart failure (CHF)/end-stage renal disease (ESRD). Insulin therapy was modified, including a distinct titration for type 1 vs type 2  diabetic patients. Phosphate supplementation criteria was also included in addition to potassium for electrolyte repletion. Utilizing the order set usage within the electronic health record (EHR), a retrospective chart review was performed to collect relevant data to determine the effectiveness of changes to the DKA protocol comparing data from 2018 (pre-initiation of protocol) and 2023 (post-initiation of protocol) in a 1:1 ratio. The primary outcome is total time on insulin infusion. Secondary outcomes include total time to meeting ADA-based definition of DKA resolution (BG<200 mg/dL and 2 of following: bicarbonate ≥15 mEq/L, venous pH >7.3, and AG≤12 mEq/L) from start of insulin infusion, ICU length of stay, proportion of patients that received appropriate fluid management per protocol, and correlation between beta-hydroxybutyrate (BHB) concentration and DKA  resolution. Secondary safety outcomes are incidence of hypokalemia, hypoglycemia (blood glucose <70 mg/dL  and <40 mg/dL), and rebound DKA. Descriptive statistics were used to analyze data collected for study outcomes. 


Results: A total of 100 patients were included in the study analysis (50 patients in 2018 pre-initiation group and 50 patients in 2023 post-initiation group). Baseline characteristics were comparable between groups, except for a lower percentage of Type 1 diabetic patients in post-initiation compared to pre-initiation group (40% vs 66%, respectively). The primary outcome of total time on insulin infusion was reduced post-initiation of the revised DKA protocol to approximately 18 hours compared to 23 hours pre-initiation of the protocol. Time to meeting ADA definition of DKA resolution from start of insulin infusion was 9.7 hours in post-initiation group and 10.5 hours in pre-initiation group. Total ICU length of stay was 1.8 days for post-initiation group and 2.2 days for pre-initiation group. The proportion of patients that received appropriate fluid management per protocol was 62% in post-initiation group compared to 90% in pre-initiation group. Mean BHB at discontinuation of insulin drip was 0.34 mmol/L in post-initiation group. For safety outcomes, the incidence of hypokalemia was higher in post-initiation vs pre-initiation group (52% vs 36%). Incidence of hypoglycemia (blood glucose <70 mg/dL) was lower in the post-initiation group (52% vs 56%), including the incidence of severe hypoglycemia (blood glucose <40 mg/dL) (6% vs 14%). Incidence of severe hyperglycemia and rebound DKA were comparable between both groups. 


Conclusion: Patients treated using the revised DKA protocol required less total time on insulin infusion and had a reduced ICU length of stay. Opportunities to further improve the protocol include identifying strategies to minimize the incidence of hypoglycemia and hypokalemia.

Impact of Extracorporeal Membrane Oxygenation (ECMO) Circuit Age on Vancomycin Dosing Requirements in Critically Ill Patients 
 
Authors: Hope Elrod, Kathleen Jerguson, Erin Massarello 
Background: 
Extracorporeal Membrane Oxygenation (ECMO) alters drug pharmacokinetics, particularly in the early phase (<96 hours), when drug sequestration onto the circuit can lead to lower circulating concentrations. Over time, the formation of a biofilm may reduce sequestration, potentially altering dosing needs. Understanding how ECMO circuit age affects vancomycin dosing is critical for optimizing therapy in critically ill patients. This study evaluates the impact of ECMO circuit age on vancomycin dosing and therapeutic target attainment. 
Methods: 
This retrospective, observational study included critically ill patients at Wellstar Kennestone Regional Medical Center who received IV vancomycin while on ECMO from January 1, 2016, to July 31, 2024. Patients were categorized into early (<96 hours) and late (≥96 hours) ECMO groups. The primary outcome was the difference in mg/kg/day dosing required to achieve therapeutic vancomycin troughs. Secondary outcomes included the proportion of patients achieving therapeutic troughs and the impact of patient demographics, renal function, and loading dose strategies on dosing requirements. CRRT patients were excluded due to potential for additional drug sequestration. Mg/kg dosing was calculated using actual body weight unless the patient was >120% of ideal body weight, in which case adjusted body weight was used. Descriptive statistics were utilized and statistical analyses included chi-square tests, Fisher’s exact tests, and logistic regression. 
Results: 
Sixty patients were included (30 per group). Patients in the early circuit ECMO group received an actual mg/kg/day vancomycin dose of 42.95 compared to 44.21 in the late circuit group. To achieve an extrapolated therapeutic trough of 15 mcg/mL, the mg/kg/day dose was significantly higher in the early circuit compared to the late circuit group (52.58 mg/kg/day vs. 41.21 mg/kg/day, p = 0.019).  
Among patients who received a loading dose, the mg/kg/day dosing required to reach a therapeutic trough was also significantly higher in the early circuit group compared to the late circuit group (56.6 vs. 36.9 mg/kg/day, p = 0.0168). Patients who did not receive a loading dose had no significant difference in dosing requirements between early and late ECMO phases. Likewise, there were no statistically significant differences in dosing between those who received a loading dose and those who did not. 
Mortality was higher in the late ECMO group (χ² = 7.117, p = 0.0074), while differences in therapeutic trough attainment (p = 0.091) and loading vs. no-loading groups (p = 0.5731) were not significant between groups. Logistic regression found that vancomycin duration (p = 0.016) and early versus late circuit ECMO (p = 0.0019) were statistically significant factors influencing initial vancomycin trough levels. 
Conclusions:
Patients initiated on vancomycin within the first 96 hours of ECMO required significantly higher doses to achieve therapeutic levels compared to those started later. The impact was most pronounced in patients who received a loading dose, suggesting that aggressive initial dosing may be necessary in the early ECMO phase. These findings highlight the importance of close therapeutic drug monitoring and tailored dosing strategies to optimize vancomycin therapy in ECMO patients.

Title: Time-to-Target Mean Arterial Pressure: Weight-Based versus Non-Weight-Based Norepinephrine in Critically Ill Patients with Septic Shock
 
Authors: Kristen Wardell, Pharm.D., Brian Hairston, MBA, Pharm.D., Katie Schipper, Pharm.D., BCCCP, Jamie Wagner, Pharm.D., BCIDP
 
Objective: To determine if there is a difference in time-to-target mean arterial pressure of critically ill patients with septic shock on weight-based norepinephrine dosing or non-weight-based dosing.
 
Background: The optimal norepinephrine dosing strategy, weight-based vs. non-weight-based, in septic shock remains controversial with no clear consensus in current guidelines.  St. Dominic Jackson-Memorial Hospital has historically utilized non-weight-based dosing (non-WBD) but transitioned to weight-based dosing (WBD) in May 2022. However, WBD may lead to excessively high doses in obese patients, which can oversaturate adrenergic receptors. These doses may also cause an increased risk of adverse effects, such as peripheral ischemia and acute kidney injury. The impact of this transition on clinical outcomes remains unclear.
 
Methods: This quasi-experimental study included adult patients admitted to St. Dominic Jackson-Memorial Hospital from January 1, 2019, to December 31, 2019, and from January 1, 2023, to December 31, 2023, who required intravenous norepinephrine for presumed septic shock. Patients were identified via electronic surveillance software. Inclusion criteria were age ≥18 years, hospital admission within the specified study periods, and norepinephrine administration. Exclusion criteria included norepinephrine duration <1 hour, prior administration of another vasopressor, norepinephrine use for non-septic shock indications, or COVID-19 diagnosis during admission. Collected data included baseline demographics, quick Sepsis-Related Organ Failure Assessment (qSOFA) score, Glasgow Coma Scale (GCS) score, initial laboratory parameters (serum lactate, creatinine, bilirubin, platelet count, white blood cell count), ventilator status, oxygenation parameters (partial pressure of oxygen [PaO₂]/fraction of inspired oxygen [FiO₂]), first and last recorded intensive care unit (ICU) mean arterial pressure (MAP), and norepinephrine dose at goal MAP.
The primary outcome of this study was the time (in minutes) to achieve the goal MAP. Secondary outcomes included duration of norepinephrine therapy, ICU length of stay, development of an acute kidney injury (AKI), in-hospital mortality within 30 days of norepinephrine initiation, and norepinephrine dose at the initiation of an additional vasopressor or stress-dose steroids. 
 
Results: In progress.
 
Conclusion: In progress.

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


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


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


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


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


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

Title: Exploring the Analgesic Efficacy of Ketamine in the Management of Traumatic Injuries 
Authors: Aubrey N. Baker, Jordan Spurling, John Patka, Shauntrell Johnson 
Objective: Discuss the use of ketamine in patients with a traumatic injury
Self Assessment Question: What are potential reasons for using ketamine in patients with traumatic injury?
Background: Acute pain is a common complication experienced by trauma patients. Inadequate treatment of acute pain after trauma delays return to work, impairs quality of life and increases the risk of complications such as post-traumatic stress disorder. Although opioids have been the mainstay of treatment, providers have been looking for alternative analgesic agents. Ketamine has analgesic effects and can be beneficial for trauma patients due to its potential beneficial effects on blood pressure and minimal effects on respiratory drive. The purpose of this study is to assess the efficacy of ketamine in patients who have sustained a traumatic injury. 
Methods: This study was a single center retrospective chart review conducted at a level 1 trauma center. Patients were included if they presented between December 2023 through February 2024, ≥ 18 years old, and received an initial ketamine dose ≤ 50 mg. Patients were excluded if they had a Glasgow Coma Score ≤ 8, were on outpatient opioid therapy, or if they were admitted for an acute behavioral emergency.  Patients presenting December through January were included if missing preceding or post ketamine administration pain score. However, patients in the month of February were only included if they had documented pain scores for both a preceding and post ketamine administration. Pain scores prior to ketamine administration was defined as a pain score documented within an hour including a 15-minute leniency period prior to administration. Furthermore, the institutional guidelines require documentation of pain score on arrival to ED and 60-minutes after analgesic administration. The primary outcome of this project is to compare the difference in pain scores from the initial ketamine dose to the next pain score. The secondary outcome is reviewing ketamine dosing for pain based on internal guidelines. Data analysis included the Wilcoxon rank sum test, repeated ANOVA measures 

Title: Evaluating the Safety and Efficacy of Alteplase versus Tenecteplase in the Management of Acute Ischemic Stroke
Authors: Brooke Landry, Matthew McAllister, Shae Tirado, McKenzie Hodges
Background: Acute ischemic stroke (AIS) is a medical emergency caused by a sudden blockage or reduction in blood flow within the brain. Early medical treatment is crucial for reducing morbidity and mortality following AIS. Thrombolytics are the mainstay pharmacologic agent utilized in patients presenting within 4.5 hours of symptom onset. Alteplase and tenecteplase are two thrombytics FDA-approved for the management of AIS. This study aimed to compare outcomes of alteplase versus tenecteplase for AIS, focusing on time to administration, functional outcomes, and incidence of adverse events. The findings of this study may provide additional comparative evidence between these two thrombolytic agents, adding to the growing body of evidence in the treatment of AIS.
Methods: A multi-center, retrospective chart review was performed of individuals who received alteplase from September 1, 2023 to November 30, 2023 and tenecteplase from January 1, 2024 to March 31, 2024 for acute ischemic stroke within Piedmont Health System. We compared door-to-needle times, incidence of symptomatic intracranial hemorrhage, rate of successful reperfusion, mRS at 90-days, and incidence of angioedema between study arms. A subgroup analysis was conducted on patients who underwent mechanical thrombectomy following thrombolytic administration. Door-to-needle times and mRS at discharge/90 days were evaluated utilizing an independent t-test. A chi-squared test was used to assess incidence of symptomatic intracranial hemorrhage, incidence of angioedema, and rate of successful reperfusion.
Results: There were a total of 314 patients included in the study, 159 patients who received alteplase and 155 who received tenecteplase. Baseline characteristics were similar between groups. For the primary outcome of door-to-needle time, average time for the alteplase and tenecteplase arms were 50 minutes and 49 minutes, respectively. This difference was not statistically significant. For secondary outcomes, symptomatic hemorrhagic conversion was identified in 7 alteplase recipients and 5 tenecteplase recipients, average discharge/90-day mRS was 2.6 in the alteplase arm and 2.5 in the tenecteplase arm, and angioedema occurred in 1 alteplase recipient and 2 tenecteplase recipients. None of the secondary outcomes were statistically significant. In the subgroup analysis of patients who underwent mechanical thrombectomy, symptomatic hemorrhagic conversion was identified in 4 alteplase recipients and 1 tenecteplase recipient, average discharge/90-day mRS was 3.3 in the alteplase arm and 4.0 in the tenecteplase arm, and successful reperfusion was achieved in 14 alteplase recipients and 13 tenecteplase recipients. None of the subgroup outcomes were statistically significant.
Conclusion: This study found no difference in door-to-needle times between alteplase and tenecteplase. Additionally, no differences were seen in secondary safety and efficacy outcomes including incidence of angioedema, rate of symptomatic hemorrhagic conversion, mRS at discharge/90 days, or rate of successful reperfusion. These results suggest that tenecteplase is a safe and effective alternative thrombolytic to alteplase for the management of acute ischemic stroke.

Title: A comparison of bivalirudin versus unfractionated heparin for anticoagulation in adult patients requiring venoarterial extracorporeal membrane oxygenation


Authors: Landry Slaughter, PharmD, MMHC; Andrew McRae, PharmD, BCCCP; Lindsey Tolbert, PharmD, BCCP; Aaron Williams, MD; Michelle Miller, PharmD, BCCCP


Background: Extracorporeal membrane oxygenation (ECMO) is a form of life support in patients with cardiac and/or respiratory insufficiency that precludes adequate gas exchange or perfusion. Cannulation onto the ECMO device is an invasive procedure, in which the mechanical design of the circuit allows nonbiologic material to interface with blood creating a highly thrombogenic process. It is imperative to anticoagulate these patients to mitigate thrombosis and manage the leading complication of systemic anticoagulation, bleeding. Despite the recognition of this challenge by the Extracorporeal Life Support Organization (ELSO), minimal high-quality, prospective literature has been published. What exists is retrospective in nature, and anticoagulation is evaluated in mixed ECMO configurations, isolated pediatric, or mixed adult and pediatric populations, or isolates specific ECMO indications, such as cardiogenic shock. This gap in literature leaves uncertainty concerning the most safe and effective anticoagulation strategies in non-cardiogenic shock indications for adult venoarterial ECMO. 


Methods: This retrospective study was performed from May 2021 to September 2024 at an academic medical center that included adult patients supported with venoarterial ECMO (VA-ECMO). The primary outcome was the incidence of in-circuit thrombosis per ECMO day defined as the incidence of oxygenator exchange. Secondary safety outcomes included bleeding per ELSO criteria and thrombotic complications. 


Results: In progress


Conclusion: In progress

Title: Blood Pressure Trajectory Post-Initiation of Eptinezumab Infusions For Migraines


Authors: Ashleigh Neese, Rachel Renwick


Introduction: Calcitonin gene-related peptide (CGRP) is a vasodilatory neuropeptide involved in the pathway responsible for onset of migraines. There are several injectable monoclonal CGRP antagonists approved by the FDA for prevention and treatment of migraines. Post-marketing safety monitoring data for erenumab suggests that CGRP antagonists may place patients at risk for increased blood pressure. Eptinezumab was approved for prevention of migraine in 2020 for the prevention of both episodic as well as chronic migraine. However, it has not undergone evaluation for its effect on blood pressure trajectory post-infusion.


Methods: This retrospective, single-center, multi-site study was performed to determine blood pressure trajectory post-infusion for eptinezumab. Patients selected for inclusion were those who received at least 1 dose of eptinezumab at an infusion center within the VUMC Enterprise. The primary outcome of the study was to assess the incidence of significant blood pressure increases immediately following eptinezumab infusion which was defined as an increase greater than or equal to 20 mmHg or 10 mmHg for systolic or diastolic blood pressure, respectively. The incidence of long-term blood pressure increases at 6 months after eptinezumab infusion and a comparison of increases in blood pressure for the 100 mg versus the 300 mg dose of eptinezumab were investigated.


Results: There were 130 patients who received a total of 512 administrations of eptinezumab during the selected time period. Of these administrations, only 35 (7%), met the criteria for a significant increase in blood pressure immediately following infusion for the primary outcome. The average change in blood pressure was -7.48 mmHg for systolic blood pressure and -4.35 mmHg for diastolic blood pressure immediately following administration. When comparing eptinezumab 100 mg versus 300 mg, 20 (9.1%) and 13 (6.1%) of patients experienced a significant increase in blood pressure, respectively. At six months following infusion, 31 (23.8%) of all patients receiving eptinezumab met the criteria for a significant increase in blood pressure. For patients receiving eptinezumab 100 mg, 28 (25.0%) of patients met criteria for a significant increase in blood pressure at 6 months while 15 (26.3%) of patients receiving eptinezumab 300 mg met criteria.


Conclusions: Many patients were previously on other CGRP agents which may have confounded patients experiencing significant blood pressure increases. Additionally, patients had their blood pressure checked post-infusion which resulted in a more accurate blood pressure reading at rest versus when a patient initially presents for their infusion. There were a limited number of patients with eptinezumab as their original infusion which introduced confounding with the 100 mg patient group. Additionally, there was variability in where the patient's 6-month blood pressure was taken. Overall, it was found that eptinezumab causes low incidences of significant blood pressure increases immediately following infusion but can cause increases over a longer period. Therefore, more research should be performed to compare blood pressure increases in patients undergoing treatment with other CGRP agents to eptinezumab.

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


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


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


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


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


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


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


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

Title 


Evaluation of First Dose Intravenous Push Antibiotics in Emergency Department Sepsis Patients 


Authors 


William Markle, John Norris, Matt Bamber, Caitlin Rousseau


Objective 


Evaluate the effect of intravenous push (IVP) antibiotics on time to antibiotic administration and patient outcomes in emergency department sepsis-patients. 


Self-Assessment Question 


Surviving Sepsis Campaign recommends to administer antibiotics within 1 hour of sepsis recognition. Which of the following antibiotics should only be reconstituted with 0.9% sodium chloride? 


Ceftriaxone 


Cefepime 


Piperacillin/Tazobactam 


Meropenem 


Background 


Current guideline recommendations highlight the importance of timely intravenous (IV) antibiotic administration as an effective intervention in reducing sepsis-related mortality. However, timeliness of IV piggyback administration can be challenging due to preparation of antibiotics and infusion times of multiple medications. IVP antibiotics have been shown to reduce time from order to administration while having similar pharmacodynamic and adverse event profiles, but their effects on patient outcomes are not well known. The purpose of this study is to evaluate the effects of first dose IVP antibiotics on time to administration and patient outcomes in emergency department sepsis-patients. 


Methods 


This study did not require IRB approval. This pre-post study consisted of a retrospective chart review of patients aged ≥18 years who presented to the emergency department of FirstHealth Moore Regional Hospital and received IV piggyback (IVPB) beta-lactam antibiotics for sepsis or septic shock from June 2024 through August 2024. Following implementation of first dose IV push antibiotics in our emergency department, a second retrospective chart review was performed on patients aged ≥18 years who presented to the emergency department of FirstHealth Moore Regional Hospital and received IVP beta-lactam antibiotics for sepsis or septic shock from January 2025 through February 2025. Patients were excluded from both retrospective chart reviews if they were aged <18 years, pregnant, incarcerated, received oral antibiotics in the emergency department, or received potentially effective antibiotics for ≥48 hours within 7 days prior to presentation. The primary outcome is time from physician order entry to receipt of appropriate antibiotics. Secondary outcomes are hospital and ICU length of stay and in hospital mortality. Prior to IVP implementation a new triaging process was implemented in the emergency department that may have led to delays in the administration of antibiotics. To account for the confounder of patients diagnosed with sepsis through this triaging process, a subgroup analysis was performed that included only patients diagnosed with sepsis through our acute care process. 


Results 


There were 104 patients included in the final analysis; 49 patients in the IVPB group and 55 patients in the IVP group. The median time to antibiotic administration in the IVPB group was significantly faster than in the IVP group, 37 minutes versus 54 minutes (p= 0.0373). There were no significant differences in the secondary outcomes. There were 95 patients included in the subgroup analysis; 49 patients in the IVPB group and 46 patients in the IVP group. The median time to antibiotic administration in the IVPB group was not significantly faster than in the IVP group, 37 minutes versus 45.5 minutes (p= 0.4675). There were no significant differences in secondary outcomes. 


Conclusion 


In the overall study population, we observed a significantly faster time to administration in patients who received IVPB antibiotics. We attributed this to the implementation of a new triaging process which rapidly triages patients presenting from the emergency department lobby and potentially leads to delay in medication administration. When comparing IVPB patients to the subgroup of IVP patients that were evaluated through our acute care process, we observed no difference in antibiotic administration time. Future work will seek to evaluate the impact of this new triaging process on delays in patient care. 

Authors: Nathan Doherty, Michael Saavedra
 
Objective: Analyze whether the use of phenobarbital reduced the length of hospital stay vs lorazepam in patients experiencing alcohol withdrawal.
 
Background: Alcohol withdrawal syndrome is a potentially life-threatening condition requiring immediate management. The American Society of Addiction Medicine (ASAM) recommends benzodiazepines, such as lorazepam, as the first-line treatment to prevent the signs and symptoms of alcohol withdrawal including seizures and delirium. Phenobarbital is advised as an alternative to benzodiazepines when benzodiazepines are contraindicated or as an adjunct to benzodiazepines. On June 5th, 2024, our health system added phenobarbital to our alcohol withdrawal order set for ICU patients. The objective of this project is to identify whether phenobarbital decreases the length of hospital stays for patients experiencing alcohol withdrawals when compared to lorazepam.
 
Methods: This single-center, retrospective cohort study included patients diagnosed with alcohol withdrawal syndrome who were treated with either phenobarbital or lorazepam at Parkridge Medical Center (PMC) and Parkridge East Hospital (PEH). Data was collected from electronic medical records to assess total hospital length of stay, incidence of delirium, and safety outcomes. Delirium episodes were identified based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Safety outcomes were evaluated by assessing the incidence of profound respiratory depression requiring respiratory support. Data was collected between June 5, 2024, and January 1, 2025. Statistical significance was determined using a Student's t-test.
 
Results: The average hospital length of stay (LOS) at PMC was 8.2 days for patients who received phenobarbital compared to 4.36 days for those who received lorazepam alone (P = 0.0070). At PEH, the average LOS was similar between the phenobarbital and lorazepam groups (3.79 vs. 3.91 days, P = 0.75). The incidence of delirium at PMC was 1.0 in the phenobarbital group versus 0.70 in the lorazepam group (P = 0.57). At PEH, the incidence of delirium was 0.65 for patients receiving phenobarbital compared to 1.16 for those receiving lorazepam (P = 0.094). Notably, no patients in either group required respiratory support following the initiation of phenobarbital or lorazepam.
 
 
 
Conclusion: A statistically significant difference in hospital length of stay at PMC was observed between patients who received phenobarbital versus those who received lorazepam alone. However, this finding is confounded by the presence of two significant outliers in the phenobarbital group (35 days and 20 days) and the small sample size (n=19). Additionally, a key limitation to phenobarbital use at our facility is the requirement for ICU monitoring, which may serve as a barrier to prescribing it over lorazepam. Notably, most patients at PEH presented with a chief complaint of alcohol withdrawal, whereas patients at PMC were critically ill, with alcohol withdrawal being a secondary diagnosis. This distinction may have contributed to prolonged hospitalization for patients in the PMC group, even after alcohol withdrawal syndrome was managed. Importantly, no patients in either group experienced respiratory depression requiring respiratory support. Given these findings, reconsideration of the ICU restriction for phenobarbital administration should be explored, as it may increase utilization and eliminate the need for inpatient phenobarbital taper completion, potentially expediting discharge. Future studies with larger sample sizes are warranted to further assess the impact of phenobarbital, either as monotherapy or in combination with lorazepam, on hospital LOS.


NTD76@live.com

Title: Implementation of an Opiate Withdrawal Protocol


Authors: Evan Hardbeck, Jeremy Ray


Objective: To assess the impact of standardizing care for patients presenting with opioid withdrawal.


Self Assessment Question: Which medication when paired with frequent patient assessment significantly decreases risk of opiate overdose?


Background: Opioid dependent patients who are experiencing withdrawal symptoms are in a high-risk period due to the risk of opioid overdose as patients attempt to resolve symptoms and cravings. This is an important consideration for patients presenting to the emergency department with withdrawal symptoms as initiating appropriate management has resulted in fewer relapses for patients as well as lower mortality for such patients. Developing standardized treatment options for withdrawal patients also falls in line with the Centers for Disease Control and Prevention calling for increased involvement from emergency departments in managing opioid use disorder.


Methods: This single-center, IRC approved, pre-post implementation study evaluated all patients with confirmed or suspected opioid withdrawal admitted to a large community hospital between November 2023 and August 2024. Data was collected from the electronic medical record (EHR). Data analysis was performed using descriptive statistics, unpaired t-test, or chi-square test as appropriate. Outcomes assessed included duration (days) of detoxification pre- and post- implementation, hospital length of stay (LOS), readmission rate for opiate use disorder, clinical opiate withdrawal scale scores, adjunctive medications utilized, and adverse events. Post intervention data will utilize the same metrics for comparisons. 


Results: A total of 55 patients were included with 54 in the pre-implementation group and 1 in the post-implementation group. The most common detoxification medication in the pre-implementation group was buprenorphine/naloxone (n=45, 83%) with a mean buprenorphine dose of 7.6 ± 4 mg. Additionally, COWS assessments were performed infrequently (n=7, 12.9%) with a mean score of 8 ± 2 in those assessed. The post-implementation patient received routine COWS assessments (n=1, 100%) with a mean score of 5 ± 3 and was determined to not require any detoxification with buprenorphine/naloxone. No safety events occurred in either group.


Conclusion: A larger sample size is needed to fully assess the safety and efficacy of implementing the opiate withdrawal protocol as the one post implementation patient did not require use of buprenorphine/naloxone. However, the scheduling of COWS assessments in the post-implementation patient led to frequent monitoring that was not present in the pre-implementation group which prevented potentially unnecessary use of buprenorphine/naloxone.

Title: Evaluating for racial disparities in intravenous fibrinolytic door-to-needle times at a comprehensive stroke center


Authors: Morgan Daniel, Ashly Lamosek, Olivia Morgan, Katleen Chester


Objective: The purpose of this study was to identify the effect of racial disparities on fibrinolytic door-to-needle (DTN) times.


Self Assessment Question: What factor contributed to the initial racial disparity observed in DTN times for fibrinolytic administration in acute ischemic stroke treatment?


Background: The phrase “time is brain” is a staple in the world of acute ischemic stroke (AIS) as it reflects on the importance of efficient and timely care for patients to preserve neurons and limit the degree of ischemia. In the stroke setting, barriers and negative outcomes are more prevalent in black patients than white patients. Data has shown that non-white patients experiencing signs and symptoms of AIS were less likely to be treated with fibrinolytics, likely due to delay in presentation and not meeting eligibility criteria for administration. Despite this information, there is limited evidence on the relationship between race and fibrinolytic DTN times as most of the literature is focused mainly on the tele-stroke setting or outcomes in mechanical thrombectomies. The patient population that will be evaluated is unique compared to other literature as these patients are presenting to a safety net comprehensive stroke center located in the heart of what is known as the country's stroke belt.


Methods: This was a single-center, retrospective chart review evaluating patients presenting directly to the Grady Memorial Hospital Emergency Care Center receiving intravenous fibrinolytics (alteplase and tenecteplase) for AIS from January 2018 to May 2024.  Patients who received intravenous fibrinolytics via the Mobile Stroke Unit or after hospital admission, were excluded from this study.   Data was obtained from the Institutional Stroke Committee fibrinolytic data reports, which are updated monthly.  The primary outcome was mean DTN time, between whites versus non-white patients.   Secondary outcomes included the percentage of patients who met within 30-, 45-, and 60-minute DTN time goals, means of arrival, presentation time to the Emergency Department (00:01 – 08:00, 08:01 – 16:00, 16:01 – 00:00), and time from last known well to fibrinolytic administration, between white versus non-white patients. 


Results: A total of 893 patients treated with intravenous fibrinolytics were analyzed, including 652 non-white and 241 white patients. Non-white patients were significantly younger (median age 63 years [IQR 54–74] vs. 70 years [IQR 61–80], p = 0.025), with no significant difference in sex distribution (56.2% vs. 60.9%, p = 0.056). Median DTN times were longer for non-white patients (45 vs. 41 minutes, p = 0.014). Non-white patients more often required pre-treatment interventions for blood pressure or glucose control (21% vs. 12%, p = 0.003). When accounting for these interventions, DTN times were similar between groups (59 vs. 55 minutes, p = 0.147). A greater proportion of white patients met DTN time goals at 30, 45, and 60 minutes, though differences were not statistically significant (p = 0.139, p = 0.052, p = 0.108, respectively). Arrival methods and presentation times varied significantly. Non-white patients were more likely to arrive by EMS (85.5% vs. 71.8%, p < 0.001) and less likely by air transport (3.7% vs. 24.9%, p < 0.001). They also presented more frequently between 00:01–08:00 (14.6% vs. 8.7%, p = 0.021). Time from last known well to fibrinolytic administration did not differ significantly between groups (140 vs. 144 minutes, p = 0.160).


Conclusion: Racial disparities in fibrinolytic DTN times were initially observed, but these differences were eliminated after accounting for the higher rates of pre-treatment blood pressure and glucose management in non-white patients. This highlights the need for public health initiatives that address disparities in hypertension and diabetes incidence and management in non-white communities. Further research is essential to promote equitable acute stroke care.

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


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


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


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


Results: In Progress


Conclusion: In Progress

Title: 
Impact of aPTT versus Anti-Xa monitoring of unfractionated heparin during Impella support
 
Authors:
Seneca Williams
Lyndsay Gormley
Logan McCulloh
Bryan Love
Jenna Cox
 
Background:
Receipt of heparin during Impella mechanical circulatory support (MCS) to prevent thromboembolic complications and maintain purge reliability must be balanced with minimizing bleeding risk. Heparin may be administered through the purge solution and intravenously. The device manufacturer recommends the use of heparin via the purge solution and intravenously as needed to attain an activated clotting time (ACT) target of 160 to 180 seconds.  A 2019 survey by Reed et. al found that the majority of high-volume Impella institutions across the United States utilized activated partial thromboplastin time (aPTT) monitoring, followed by ACT and anti-Xa. In 2023, anti-Xa 0.2-0.4 IU/mL became the default heparin dosing strategy for patients receiving Impella support at Prisma Health. An aPTT goal of 50-70 seconds was our default strategy prior to this time and remains an option for providers to choose within our current order sets. Outcomes data comparing anticoagulation targets during Impella support are extremely limited.
 
Methods:
This multicenter, retrospective, cohort study aims to evaluate safety outcomes between aPTT (50-70 seconds) and anti-Xa (0.2-0.4 IU/mL) heparin monitoring strategies in patients receiving Impella support. Adult patients admitted to Prisma Health Richland or Greenville Hospitals between January 1, 2023 to December 31, 2024 who received Impella support for greater than six hours and intravenous heparin were included. Patients were excluded who received non-heparin anticoagulants during Impella support or heparin outside of specified target ranges. The primary outcome is the incidence of bleeding (utilizing major and minor per ISTH criteria). Secondary objectives include comparison of: the incidence of thrombotic events, time to onset of bleeding or thrombotic event, time to therapeutic aPTT or anti-Xa, total heparin exposure, length of Impella support, percentage of laboratory monitoring values (aPTT or anti-Xa, respectively) within target range.
 
Results:
In-Progress
 
Conclusions:
In-Progress

Title: Assessment of medication therapy for patients presenting to a community hospital emergency department with diabetic ketoacidosis or hyperglycemic hyperosmolar state 
 
Authors: Madyson Cruse, Jason Dover, Adrianna T. Reagan, Margaret Williamson, Melissa Bagwell 
 
Learning Objective: Identify areas of improvement in the treatment of patients presenting with diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome 
 
Purpose: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are potentially life-threatening metabolic conditions that require emergent treatment. As a mainstay of therapy, early fluid resuscitation helps restore intravascular volume deficits, end organ perfusion, and insulin sensitivity. The objective of this study was to assess the overall percentage of patients presenting with DKA or HHS who received an appropriate fluid bolus of 1 to 1.5 L within 2 hours of presentation to the emergency department. 
 
Methods: This is a single center, retrospective chart review of patients treated at East Alabama Health emergency department from October 2023 to April 2024. Patients were included if they were ordered an insulin infusion, had a documented admitting diagnosis of DKA or HHS from the emergency department, and were greater than 18 years of age. Outcome variables collected include patient demographics, baseline labs, time to fluid bolus, fluids administered, time to insulin administration, and if an insulin bolus and/or sodium bicarbonate were administered. Statistical tests, run on SPSS, include descriptive statistics, chi-square for categorical variables, and Kolmogorov-Smirnov to determine if data were normally distributed. 
 
Results: One hundred patients with DKA or HHS were reviewed for this study. For the primary outcome, 82 patients (82%) received an appropriate fluid bolus within 2 hours of presentation to the emergency department. The median time from presentation to administration of a fluid bolus was found to be 51 minutes [IQR: 23-95 minutes] with a median of 1 L bolus administered [IQR: 1-2 L]. Forty-two patients (42%) received an insulin bolus via either subcutaneous (2%) or intravenous (40%) routes, and 16 patients (16%) were administered insulin prior to initial laboratory results. Arterial blood gases, collected on 90 patients (90%), revealed that 6 patients (6.7%) met criteria for classi

Title: Evaluating the Safety and Efficacy of Thombolytics in the Setting of Cardiac Arrest
Authors: Elliott Wilch and Derrick Clay


Background: Cardiac arrest refers to circulatory collapse that results in cessation of cardiac function that is either restored by resuscitative efforts or results in cardiac death. Each year there are over 350,000 out of hospital cardiac arrests, which is associated with poor outcomes with only 10.6% of patients surviving to hospital discharge. Cardiac arrest is typically managed with standard resuscitative modalities such as advanced cardiac life support (ACLS). Thrombolytic agents, such as tenecteplase and alteplase can be used in conjunction with ACLS to help restore circulation by initiating fibrinolysis in cardiac arrest due to pulmonary embolism or coronary thrombosis. Data surrounding the use of thrombolytic agents in the setting of cardiac arrest is lacking. Studies have found varying results surrounding outcomes such as survival to hospital discharge and return of spontaneous circulation. Regardless of the lack of definitive data surrounding thrombolytics in cardiac arrest, both the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and the European Resuscitation Council Guidelines for Cardiac Arrest in Special Circumstances recommend their use in this setting. The following study will be conducted to assess the safety and efficacy of thrombolytic agents in the setting of undifferentiated, out of hospital cardiac arrest.  


Methods: This is a single-center, retrospective cohort study assessing the safety and efficacy of thrombolytics in the setting of cardiac arrest. Patients 18 years or older with the primary diagnosis of cardiac arrest who received an IV thrombolytic agent were included in the study. Patients were excluded if they were pregnant or incarcerated. The group of patients who received a thrombolytic agent during cardiac arrest was then. compared to a historical control group of similar demographics. The primary outcome was return of spontaneous circulation. Secondary outcomes included survival to hospital admission, survival at 24-hours, survival to hospital discharge, and neurologically intact survival defined as a Modified Rankin score of less than or equal to two. Safety outcomes included major and minor bleeding complications. 


Results: Among the 144 patients initially reviewed, thirty-two patients did not meet the inclusion criteria for various reasons. Of the 112 patients included in the study, forty-three were assigned to the thrombolytic group and sixty-nine to the no thrombolytic group. The primary outcome, ROSC, for the intervention group versus control group was 32.6% and 53.6% respectively (P=0.029). The results for the thrombolytic group versus no thrombolytic group for secondary outcomes of survival to hospital admission (16.3% vs 31.9%, p=0.067), survival at 24-hours (11.6% vs 15.9%, p=0.526), survival to hospital discharge (4.7% vs 2.9%, p=0.637) and neurologically intact survival (4.7% vs 2.9%, p=0.637) were also calculated.


Conclusion: When examining the use of thrombolytics in the setting of cardiac arrest, the primary outcome was achieved at a higher rate in the group who did not receive a thrombolytic agent. It is important to note that this trial was underpowered due to limited patient enrollment, primarily attributable to the lack of thrombolytic usage during cardiac arrest. While this trial may not have shown a benefit of thrombolytics in the primary and secondary outcomes, the American Heart association and European resuscitation council guidelines for cardiac arrest recommend early administration of thrombolytics as opposed to late. In this study, the average time from presentation to thrombolytic administration was 17.4 minutes indicating that thrombolytics were potentially used as a last line effort in the setting of cardiac arrest, leading to the outcomes seen in this study.

ewilch@srhs.com

Title: Evaluation of Phenobarbital and Benzodiazepine Use for Alcohol Withdrawal Treatment in the Medical Intensive Care Unit 


Authors: Jessica Schuchardt; Mary Massaro; Benjamin Bevill; Micaela Seazzu; Robert Heidel; Madison Booker; Ashtyn Keller; Shauna Winters


Objective: This study aims to compare ICU length of stay for patients receiving phenobarbital and benzodiazepines versus benzodiazepines alone when treating AWS. 


Self Assessment Question: Which of the following is not a reason why phenobarbital is considered a safe and effective alternative for alcohol withdrawal syndrome? 


Background: There is a high prevalence of alcohol use disorder (AUD) leading to a significant risk of alcohol withdrawal syndrome (AWS) in critically ill patients. However, despite existing guidelines, there is limited evidence on the use of phenobarbital for AWS as part of a standardized protocol for medical intensive care unit (ICU) patients.


Methods: This study was a single-center, retrospective, pre-post analysis that compared pre-pathway patients admitted between January 2017 to January 2020 who received benzodiazepines alone to post-pathway patients admitted between August 2022 to September 2024 who received phenobarbital in addition to benzodiazepines for AWS. Patients were included if they were hospitalized with an ICD-10 code for alcohol withdrawal, admitted to the ICU with medical critical care as the primary team, and, for the post-pathway group, must have received phenobarbital from the pathway. The primary outcome was ICU length of stay, while secondary outcomes included hospital length of stay, incidence and length of mechanical ventilation, cumulative benzodiazepines dose, incidence of delirium, and use of adjunctive medications for AWS.


Results: 132 patients were included in analysis (n= 92 pre-pathway; n=40 post-p

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

Title: Evaluation of inappropriate stress ulcer prophylaxis continuation after discharge from the intensive care unit 
Authors:  Abigail McBrayer, Jamarius Carvin, Elaina Etter, Rachele Hollis 
Background/Purpose: Critically ill patients that require admission to the intensive care unit (ICU) are at an increased risk of gastrointestinal (GI) stress ulcers. Stress ulcer prophylaxis (SUP) is achieved through proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) administration. While the optimal duration of SUP therapy is unclear, current literature recommends discontinuing SUP upon resolution of risk factors, most commonly at the time of discharge from the ICU. Inappropriate SUP continuation can negatively affect both the patient and the hospital system. This study evaluates the rate of inappropriate continuation of PPIs or H2RAs for SUP after ICU discharge.  
Methods: This study was a single-center, retrospective chart review from May 1, 2023, to October 31, 2023.  Patients qualified for inclusion if they were greater than 18 years of age, received SUP during their ICU stay, were discharged from the ICU to an intermediate care unit or acute care floor, and had an active SUP order upon transfer to the non-ICU area. Patients were excluded if they had pre-existing conditions requiring acid suppressive therapy (AST) including gastroesophageal reflux disease, peptic ulcer disease, Barrett’s esophagus, and dyspepsia, were discharged directly from ICU to another healthcare facility, or were on appropriately continued AST. The primary outcome was the percentage of patients inappropriately continued PPIs or H2RAs at discharge from the ICU. Inappropriate continuation was defined as patients being continued on SUP after discharge from the ICU, when there are little to no risk factors to warrant the use of SUP. Secondary outcomes included healthcare costs, length of time on inappropriate AST, and the number of patients discharged home with a PPI or H2RA.   
Results: Throughout the study period, 406 patients were assessed for inclusion, with 180 meeting inclusion criteria. The leading reason for exclusion was patient death before ICU discharge, accounting for 55 patients (24%)

Title: Tolerability of Enteral Nutrition in ICU Patients Receiving Vasopressors 

Authors: Micah A. McKinnie, Megan Langley, Jana Mills 

Background/Purpose: Critically ill patients are often faced with malnutrition and are thought to require more high-protein and calorie-dense diets. Due to favorable mortality outcomes, implementation of enteral nutrition within 24-48 hours of ICU admission is recommended for critically ill patients who cannot receive an oral diet. However, studies have shown that patients in the ICU are unlikely to receive the amount of nutrition they were initially prescribed. One contributing factor is the practice of delaying or pausing enteral nutrition for patients on high or increasing doses of vasopressors due to the risk of serious complications, such as ischemic or necrotic bowel. The lack of strong evidence has led to an ongoing debate about whether patients requiring ongoing vasopressors should receive enteral nutrition. As more evidence regarding the safety of initiating early enteral nutrition in patients on vasopressors emerges, there is potential for a professional consensus to be made. This may allow for a greater portion of the nutritional needs to be met in these critically ill patients. This retrospective single-center chart-review study seeks to explore further if patients receiving vasopressors exhibit a decreased tolerance to enteral feedings, resulting in an inability to achieve adequate nutrition.  
 
Methods: A retrospective review was conducted to identify patients admitted to the ICU from January 2024 through August 2024. Patients included in the study were at least 18 years old, on mechanical ventilation for at least 24 hours, admitted to the ICU for greater than 72 hours, and had a consult for enteral nutrition during their ICU stay. Patients were excluded if they were on vasopressors for less than 24 hours, were placed on end-of-life care, underwent GI surgery, or had other contraindications to enteral nutrition. Patients were subdivided into either the treatment group (vasopressors for at least 24 hours) or the control group (no vasopressors) to compare the primary outcome of the average percent of daily caloric goals met. Secondary outcomes included the average daily rate of vasopressors, the median time patients received enteral nutrition, the median time of interruption, and incidences of suspected intolerance to enteral feeding. Data was collected for the total course of the prescribed enteral feeding while in the ICU, or until vasopressors were discontinued (if applicable).  
 
Results: The average percent of caloric goals met while in the ICU was 46.7% for the vasopressor group and 56.9% for the control group. The vasopressor group was found to have both a lower median time receiving enteral nutrition (3 days vs 5 days, p-value 0.002) and a lower median time of enteral nutrition interruption (26 hours vs 45 hours, p-value 0.003). Incidences of suspected intolerance occurred in 28.2% of the vasopressor group and 7.7% of the control group. The median vasopressor rate during the study period was 0.072mcg/kg/min norepinephrine equivalents, and the median vasopressor rate at the time of suspected intolerance was 0.158mcg/kg/min norepinephrine equivalents. 
 
Conclusions: Mechanically ventilated patients requiring vasopressors in the ICU tended to receive a lower percentage of caloric goals through enteral nutrition than those not requiring vasopressors. Regardless of vasopressor use, this patient population was generally underfed while in the ICU. However, the clinical significance of these findings needs further exploration, and prospective research may be beneficial.

Title: Dexamethasone versus dexamethasone and fludrocortisone in patients with septic shock and acute respiratory distress syndrome


Authors: Gabrielle Cromley, PharmD; Audrey Johnson, PharmD, BCCCP; Eric K. Shaw PhD; Stephanie Lesslie, PharmD, BCPS, BCCCP


Objective: The purpose of this study was to compare duration of vasopressors within 30 days in patients with septic shock and ARDS who received either dexamethasone or dexamethasone and fludrocortisone.


Self Assessment Question: By what mechanism does mineralocorticoid activity improve septic shock?


Background:
Corticosteroids are recommended for both septic shock and moderate to severe acute respiratory distress syndrome (ARDS). Hydrocortisone is recommended in septic shock requiring vasopressors and it has both glucocorticoid and mineralocorticoid effects. Its mineralocorticoid effect provides additional benefit in septic shock by increasing fluid retention and peripheral vascular resistance. Dexamethasone is recommended for ARDS given the findings of the DEXA-ARDS trial which showed decreased duration of mechanical ventilation and all-cause mortality. Dexamethasone exhibits pure glucocorticoid activity and does not have mineralocorticoid activity. For patients with septic shock and ARDS, the ideal corticosteroid regimen is not clearly defined. The addition of fludrocortisone to dexamethasone may be beneficial in these patients given its mineralocorticoid effects. The purpose of this study is to determine if the addition of fludrocortisone to dexamethasone reduces vasopressor duration in patients with septic shock and ARDS.
 
Methodology: 
This single-center, retrospective cohort study was conducted at a 711-bed academic medical center. All data was collected from electronic medical records (EMR) by individual chart review. EMR reports of dexamethasone and fludrocortisone administrations between May 2020 through September 2024 were generated. Mechanically ventilated adult patients were included if they met all of the following criteria: PaO₂:FiO₂ < 200; receiving antibiotic therapy; requiring vasopressor support ≥ 10 mcg/min norepinephrine equivalent; administration of dexamethasone for ARDS with or without fludrocortisone for ≥ 48 hours. Patients were excluded if they met any of the following criteria: cardiogenic shock, chronic corticosteroid use, brain death, pregnant, or incarcerated. Patients who received concomitant fludrocortisone and dexamethasone were excluded if fludrocortisone was initiated > 5 days after starting dexamethasone. The primary outcome was the duration of vasopressors within 30 days. Secondary outcomes included all-cause mortality, ICU mortality, duration of mechanical ventilation in ICU survivors, ICU length of stay, and cumulative norepinephrine equivalent (NEE) dose, and fluid balance.
 
Results:
Twenty-nine patients were included in the dexamethasone only group and 15 patients were included in the dexamethasone/fludrocortisone group. Median duration of vasopressors within 30 days was 5 days (IQR 3.5 – 13) in dexamethasone/fludrocortisone group and 5 days (IQR 3 – 10) in the dexamethasone only group (p = 0.81). All-cause mortality was similar with 10 (66.%7) in the dexamethasone/fludrocortisone group and 18 (62.1%) in the dexamethasone only group (p = 0.76). ICU mortality was also similar with 9 (60%) in the dexamethasone/fludrocortisone group and 18 (62.1%) in the dexamethasone only group (p = 0.89). Median ICU length of stay was 11 days (IQR 8.5 – 26.5) for dexamethasone/fludrocortisone versus 12 days (IQR 8 – 21) in the dexamethasone only group (p = 0.84). Median duration of mechanical ventilation was 5 days (IQR 4 – 8) in the dexamethasone/fludrocortisone group compared to 7 days (IQR 6 – 12) in the dexamethasone only group (p = 1.0). The dexamethasone/fludrocortisone group required a median of 55,684 mcg NEE (IQR 36,132 – 86,663) cumulatively compared to 41,651 mcg NEE (IQR 13,686 – 62,784) with dexamethasone only (p = 1.0). Median difference in fluid balance after corticosteroids was +1.9 L (IQR -2.8 – 6.5) in the dexamethasone/fludrocortisone group and +0.54 L (IQR -2.6 – 4.9) in the dexamethasone only group (p = 1.0).
 
Conclusion: 
Patients with septic shock and ARDS had similar duration of vasopressors within 30 days whether they received dexamethasone/fludrocortisone or dexamethasone alone. There were no differences in all-cause mortality, ICU mortality, or ICU length of stay between groups. Patients who received dexamethasone/fludrocortisone had numerically shorter duration of mechanical ventilation and more positive fluid balance but these findings were not statistically significant. This study was underpowered and limited by its small sample size. Larger randomized controlled trials are needed to investigate the effects of fludrocortisone and dexamethasone in patients with ARDS and septic shock.


Resident contact: garbrielle.cromley@hcahealthcare.com

Title: Evaluation of the Efficacy and Safety of Increased Quetiapine Dosing Frequency for Treatment of Delirium and Agitation in Trauma ICU Patients


Authors: Nicole Johnson, Madalyn Kirkwood Brakel


Background: Delirium is a phenomenon characterized by acute onset or fluctuating mental status. Delirium is highly prevalent among patients in intensive care 
units (ICUs) and is a predictor of poor clinical outcomes. Though current guidelines do not recommend routine treatment of delirium, they acknowledge that short-term use of antipsychotics may be beneficial for patients who are agitated or in severe distress. Pre-ICU trauma is a non-modifiable risk factor for the development of delirium, yet trauma patients are often excluded from studies evaluating the management of ICU delirium. Quetiapine has a favorable pharmacokinetic profile 
for the management of delirium given its rapid onset of action, high bioavailability, and a relatively short half-life, however literature evaluating the effect of 
dosing frequency is limited. This study aims to evaluate the efficacy and safety of increased quetiapine dosing frequency (every 6 – 8 hours) compared to historical dosing regimens for the management of ICU delirium and agitation in trauma ICU patients


Methods: This study is a retrospective, single-center chart review evaluating patients admitted to Our Lady of the Lake Regional Medical Center (OLOLRMC) between August 2020 and August 2024. An epic-generated report identified patients admitted to the trauma service who received quetiapine in an ICU. From this list, a subgroup of eligible adult patients who received at least 48 hours of quetiapine therapy after documented ICU delirium, based on Confusion Assessment Method for ICU (CAM-ICU) score, were identified. Patients were excluded based on pre-specified exclusion criteria. The primary endpoint of this study is percentage of delirium free days (DFDs) following dose optimization. Secondary endpoints include the percentage of hyperactive DFDs following dose optimization, percent of Richmond Agitation-Sedation Scale (RASS) scores at goal following dose optimization, time from quetiapine initiation to ICU stepdown, time from dose optimization to ICU
stepdown, and clinically significant QTc prolongation following quetiapine initiation.



Results: Baseline characteristics were similar between groups. The median percentage of DFD was 0 and 0.33 days in the more frequent dosing and historical dosing groups respectively (p=0.026). The median percentage of hyperactive DFD was 0.65 and 0.75 days in the more frequent dosing and historical dosing groups respectively (p=0.027). Percentage of RASS at goal was similar between groups. The median time from dose optimization to ICU stepdown was 4 days in the more frequent dosing group vs 6 days in the historical dosing group (p=0.5). More frequent dosing was not associated with an increased risk of QTc prolongation.


Conclusion: More frequent dosing does not appear to reduce the percentage of DFD but may reduce time to ICU stepdown in trauma patients while maintaining safety

Title: Evaluation of Pharmacists’ Review on Discharge Medication Reconciliation in Transitions of Care 

Authors: Courtney Reliford, Sydney Bowman, Leborah Cole Lee, Randy Hooks, Kayla Brown 

Objective: To evaluate discharge medication reconciliation accuracy in patients with a pharmacist’s review and in patients without a pharmacist’s review.   

Background: Medication reconciliation is a critical component of safe transitions of care. The transition period from the hospital to home or another facility is a vulnerable period for patients and presents various opportunities for pharmacist involvement. Studies have demonstrated the value of pharmacists in transitions of care and medication reconciliation. According to the World Health Organization, more than 40 percent of medication errors may result from inadequate reconciliation in handoffs during hospital admission, transfer, and discharge. Within our institution, pharmacists review 30 to 40 percent of discharge medication reconciliations. This project is designed to evaluate discharge medication reconciliation for accuracy for patients with and without a pharmacist’s review. 

Methods: The Institutional Review Board approved this retrospective chart review of discharge medication reconciliation accuracy in patients with a completed pharmacist’s review and patients without a pharmacist’s review. Study participants were randomly selected for review based on discharges between January 1, 2023, through May 31, 2024. Study participants were randomized to either a control group or a pharmacist reviewed transitions of care group. The primary outcome was the incidence of medication discrepancies at discharge with a pharmacist’s review versus medication discrepancies without a pharmacist’s review. Secondary outcomes included average number of discrepancies per patient, discrepancies by patient location, discrepancies by physician specialty group, length of stay, percentage of patients with a discrepancy related to high-risk medications, type of discrepancies, and 30-day and 90-day hospital re-admission rates. Types of discrepancies included dose, route, frequency, medication, duplication, omission, unnecessary order, and untreated indication. Data were analyzed using Chi-Square, Fisher’s Exact test, Student’s t-test or Mann-Whitney U, depending on data type and distribution. 

Results: A total of 17,675 patients were identified over the study timeframe and randomized. Two hundred and nine patients were screened for inclusion: 99 in the pharmacist intervention group and 110 in the control group to achieve a total of 75 patients in each group.  Baseline characteristics were comparable between the two groups, except for the total number of discrepancies identified (29 discrepancies in the control group (3%) vs. 11 discrepancies in the pharmacist review group (1%), p = 0.005). There were fewer patients with a medication discrepancy in the pharmacist review group compared with the control group (31 % vs. 5%, p < 0.001). The median number of discrepancies also differed between the groups (IQR: 0-1 in the control group vs. 0-0 in the pharmacist review group, p value <0.001). While 30-day readmissions rates were similar between the groups, 90-day readmissions differed with 20 readmissions in the control group (27%) versus 8 readmissions (11%) in the pharmacist review group (p = 0.012). There were no statistically significant differences in discrepancies for high-risk medications between groups, defined as anticoagulants, potassium, narcotics, and insulin.   

Conclusions: This study showed clinically and statistically significant reductions in discrepancies on discharge as well as lower 90-day readmission rates when discharge medications were reviewed by a pharmacist, showing benefit of pharmacists’ participation in transitions of care. Strengths of this study include the inclusion of multiple different pharmacists' review on medication reconciliations, and inclusion of diverse patient populations. Limitations include a small sample size and inclusion of surgery patients who often have little to no changes in home medications. Future studies could provide a more thorough review of discrepancies across the continuum of care.  
 

Title: Characterization of External Ventricular Drain-Associated Ventriculitis
Authors: Jordan Glasgow (Jordan.Glasgow@wellstar.org), Joy Peterson, Karen Barlow 
Objective: Identify risk factors for developing ventriculitis after the placement of an EVD. 
Self-assessment Question: Which of the following may be a risk factor for EVD-associated ventriculitis?  
Background: Hospital-acquired infections (HAI) increase morbidity, mortality, and healthcare costs. However, HAI associated with external ventricular drains (EVDs) are not routinely tracked. Surveillance of these infections can help identify risk factors, causative pathogens, and preventative strategies. The aim of this study is to characterize patients who develop ventriculitis after EVD placement in a large community teaching hospital. We seek to identify practical monitoring parameters and modifiable risk factors to improve patient outcomes in the neurocritical care unit. 
Methods: This is an observational, retrospective chart review of patients admitted to Wellstar Kennestone Regional Medical Center (WKRMC) from December 2021 to August 2024 with a diagnosis of ventriculitis after EVD placement. Additional eligibility criteria are patients ≥ 18 years of age with an EVD in place ≥ 24 hours. Descriptive statistics were performed are the data.   
Results: A total of eighteen EVDs were placed in nine patients with ventriculitis in this IRB-approved study. Each patient had a median of two EVDs installed during their stay and received an average of 15.5 ± 11.12 days of antibiotic therapy. The median length of stay in the neurocritical care unit (neuro ICU) and hospital was 28 days (25-29) and 31 days (25-34), respectively. Two EVDs were placed in the Emergency Department (ED) (11.1%), seven EVDs were placed in the neurocritical care unit (ICU) (38.9%), and nine EVDs were placed in the operating room (50%). Ten of the eighteen EVDs (55.6%) were associated with ventriculitis. Of these ten EVDs, five were linked to culture confirmed ventriculitis, while the other five were associated with a clinical diagnosis of ventriculitis. All EVDs placed in the ED were linked to ventriculitis, while four EVDs placed in both the neuro ICU and OR were also linked to ventriculitis. Among the EVDs associated with culture positive ventriculitis, three were used for intrathecal medication administration. The isolated pathogens in cultured confirmed ventriculitis include Enterobacter cloacae, Neisseria spp, Serratia marcescens, and non-ESBL Klebsiella aerogenes.
Conclusion: Insertion of multiple EVDs and EVD manipulation may be associated with the development of ventriculitis. Additionally, the number of bedside EVDs linked to ventriculitis may be similar to those placed in the operating room. However, further studies including patients who do not develop ventriculitis after EVD placement as a comparator are needed to assess the incidence of ventriculitis following bedside installation.

Title: Incidence and outcomes of positive urine drug screen in neurocritical care 
Authors: Siavash Panahi, Morgan Daniel, Sam Pournezhad, Katleen Chester
Objective: To assess the incidence and clinical outcomes associated with positive UDS results in patients admitted to the neurocritical care unit (NCCU) of a large, urban, academic medical center.
Self Assessment Question: Is the incidence higher or lower than Medical and Surgical ICU?
Background: Substance use disorder (SUD) remains a major public health concern, affecting approximately 20.4 million individuals in the United States. Various substances, including amphetamines (AMP), fentanyl, opiates, cannabinoids (CBD), cocaine, benzodiazepines (BZDs), barbiturates (BAR), and methadone, exert significant effects on the central nervous system. Urine drug screening (UDS) is commonly used in hospitalized patients to detect these substances or their metabolites. While previous studies have evaluated the impact of positive UDS results in medical and surgical intensive care units (ICUs), limited data exist on the influence of positive UDS findings on neurocritical care unit (NCCU) admissions and patient outcomes. The objective of this study is to assess the incidence and clinical outcomes associated with positive UDS results in patients admitted to the NCCU of a large, urban, academic medical center.
Methods: This retrospective review analyzed NCCU admissions at Grady Memorial Hospital from January 2016 to December 2023. The study included all NCCU patients with at least one UDS result, considering only the first UDS per encounter. Patients were excluded if they received any dose of the listed substances after hospital arrival and before UDS sample collection. The primary outcome was the incidence of positive UDS results. Secondary outcomes included hospital length of stay (LOS), ICU LOS, the incidence of positive results for each substance, prevalence of single-substance versus multi-substance use, opioid exposure via morphine milligram equivalents (MME), and mortality rates.
Results: Among the 2,430 NCCU encounters, 46% (n = 1,116) were associated with a positive UDS result. Of these, 70% (n = 779) were positive for a single substance, while 30% (n = 367) indicated multi-substance use. The most frequently detected substances were BZDs (19.5%), fentanyl (13.5%), and cannabinoids (11.9%). Patients with positive UDS results had a significantly higher median hospital LOS (7 days [IQR: 3–16] vs. 6 days [IQR: 3–14], p = 0.003), while ICU LOS was slightly longer but not statistically significant (3.3 days [IQR: 1.6–7.9] vs. 2.9 days [IQR: 1.5–6.9], p = 0.09). Patients with positive UDS results demonstrated significantly higher opioid exposure during admission, with median MME levels of 378.75 (IQR: 59–2250) compared to 120.75 (IQR: 18–1098) in UDS-negative patients (p < 0.001). Substances associated with significantly higher MME included amphetamines, barbiturates, BZDs, cannabinoids, methadone, and opiates (p < 0.05 for all), whereas cocaine and fentanyl did not show statistically significant differences. Overall mortality did not significantly differ between UDS-positive and UDS-negative patients (21.2% vs. 19.9%, p = 0.46). However, subgroup analysis revealed significantly higher mortality rates among patients testing positive for cocaine (26.9%, p = 0.044) and BZDs (28.6%, p = 0.00013), while other substances did not show statistically significant differences.
Conclusion: This study highlights a high prevalence of substance use among NCCU patients, with BZDs, fentanyl, and CBD being the most frequently detected substances. Positive UDS results were associated with prolonged hospital LOS and higher opioid exposure. Additionally, patients testing positive for cocaine and BZDs exhibited significantly higher mortality rates, underscoring the need for targeted interventions in this population. These findings emphasize the impact of substance use on neurocritical care outcomes and the importance of optimizing management strategies for affected patient.

Title: Evaluating the Safety and Efficacy of Bicarbonate Use in Moderate-to-Severe Diabetic Ketoacidosis

Authors: John Ethan Young, Ashley Crisler, Bianca Rivera-Ramirez, McKenzie Hodges

Objective: To evaluate the effects of sodium bicarbonate therapy on the resolution of DKA and its associated outcomes
 
Self-Assessment Question: Which of the following is not characteristic of diabetic ketoacidosis? (A) Hyperglycemia (B) Metabolic alkalosis (C) Ketosis (D) Metabolic acidosis

Background: Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes characterized by hyperglycemia, metabolic acidosis, and elevated ketone levels. While the mainstays of DKA treatment include insulin therapy, fluid resuscitation, and electrolyte correction, the use of sodium bicarbonate to treat acidosis remains controversial. The American Diabetes Association (ADA) 2024 guidelines recommend considering sodium bicarbonate only in cases of severe acidosis (pH <6.9), but its routine use varies widely across institutions. Preliminary evidence from randomized studies has shown no significant improvement in morbidity or mortality with sodium bicarbonate therapy in DKA patients with pH levels between 6.9 and 7.1. However, there remains a gap in the literature regarding its impact on time to DKA resolution, which this study seeks to address. By clarifying the role of sodium bicarbonate in DKA management, this study aims to provide insight into optimizing treatment strategies and minimizing unnecessary interventions in the care of DKA patients.
 
Methods: A retrospective chart review was performed on adult patients treated for diabetic ketoacidosis (DKA) at Piedmont Columbus Regional Midtown between January 1, 2023 and December 31, 2023. Patients had to be 18 years of age or older and have clinical evidence of moderate-to-severe DKA. Patients that met these parameters were divided into two groups based on the administration of a sodium bicarbonate infusion. Patients were excluded if they presented with euglycemic DKA or if their insulin infusion was terminated prior to DKA resolution. The primary objective was time to DKA resolution. Secondary objectives included duration of insulin infusion, recurrence of acidosis, incidence of hypokalemia, hospital length of stay, and ICU length of stay. An independent t-test was used for the primary outcome, as well as the secondary outcomes of insulin infusion duration and length of stay, while a Chi Square Test was used to evaluate the recurrence of acidosis and incidence of hypokalemia.
 
Results: The patients receiving bicarbonate (n=32) had an average time to DKA resolution of 21.9 hours, while the patients receiving the standard of care (n=31) had an average time of 18.4 hours. Additionally, there was no difference seen for the secondary outcomes of insulin infusion duration [23.4 h vs 20.3 h], recurrence of acidosis [15.6% vs 3.2%], incidence of hypokalemia [65.6% vs 51.6%], and ICU length of stay [4.6 d vs 3.3 d]. There was a statistically significant difference for incidence of moderate hypokalemia [28.1% vs 6.5%] and hospital length of stay [10.3 d vs 5.2 d].
 
Conclusion: This study demonstrates that bicarbonate therapy is not efficacious in the management of DKA and may increase the incidence of moderate hypokalemia, risk of fluid overload, and potentially contribute to longer hospital length of stay. In conclusion, bicarbonate therapy should be seldom used for DKA, and the decision should be made by weighing the risks and benefits.

Evaluating the Efficacy of a Standardized Diuretic Order Panel versus Provider-Prescribed Diuretic Dosing in Acute Decompensated Heart Failure (ADHF)
Yanise Hurt, Jarvett Cox
 
 
Background: Acute decompensated heart failure (ADHF) is a leading cause of hospitalization, often driven by fluid overload. Effective diuresis is critical 
to improving clinical outcomes in this population; however, variability in prescribing practices can lead to inconsistent care and suboptimal results. The 
implementation of a standardized Heart Failure Diuresis Panel offers an evidence-based approach to diuretic therapy, promoting consistent and effective fluid removal while potentially reducing hospital length of stay. This study aimed to evaluate the clinical outcomes of ADHF patients treated with diuretics using a standardized panel compared to those managed with individualized provider-prescribed dosing, focusing on its impact on hospital length of stay.
 
Methodology: This retrospective, single-center chart review included 168 adult patients admitted with a primary diagnosis of ADHF at Wellstar Cobb Medical Center between January 1, 2023, and December 31, 2023. Patients were stratified into two groups based on their diuretic management: those who 
received therapy guided by the standardized Heart Failure Diuresis Panel and those managed with provider-prescribed dosing. The primary endpoint of
 the study was hospital length of stay. Secondary endpoints included the mean time to transition from intravenous (IV) to oral diuretics, door-to-diuretic 
time, 30-day heart failure readmission rates, mean changes in urine output and body weight, and diuretic prescriptions at discharge. Data was extracted from electronic medical records through a computer-generated report, and statistical analyses were conducted using t-tests for continuous variables and chi-square tests for categorical variables to evaluate the impact of the standardized panel on clinical outcomes.
 
Results: In the comparison of patients managed with the Heart Failure Diuresis Panel versus provider-prescribed diuretic dosing, there was no significant difference in hospital length of stay (4.79 days vs. 4.75 days; P=0.47) or in the mean time to transition from IV to PO diuretics (68.9 hours vs. 68.4 hours; P=0.23). Similarly, door-to-diuretic time (7.1 hours vs. 7.7 hours; P=0.41), 30-day heart failure readmission rates (8.3% vs. 9.5%; P=0.79), and diuretic 
prescription rates at discharge (85.7% vs. 76.2%; P=0.35) did not differ significantly between groups. However, the panel group demonstrated significantly greater mean urine output at 24 hours (1,584 mL vs. 1,283 mL; P=0.048), indicating enhanced diuretic responsiveness, though no significant differences were observed at 2 or 48 hours. The mean change in body weight was comparable between groups both at 24 hours (0.86 kg vs. 0.50 kg; P=0.29) and at discharge (3.07 kg vs. 2.62 kg; P=0.35). Although the standardized panel did not significantly affect hospital length of stay or most secondary 
measures, it was associated with improved early diuretic efficacy as demonstrated by greater urine output within the first 24 hours.
 
Conclusion: The Heart Failure Diuresis Panel did not demonstrate a significant impact on primary or secondary outcomes, including hospital length of 
stay. However, the consistent administration of appropriate IV diuretic dosing by providers not utilizing the panel suggested that its core principles have been effectively integrated into routine clinical practice. These findings are consistent with the DOSE trial, which underscores the importance of optimized diuretic strategies for symptom relief and fluid management in heart failure. This presents an opportunity to improve provider adherence to these 
protocols, potentially further optimizing patient outcomes.

Title: Evaluating the impact of a pharmacist-driven osteoporosis screening and treatment program in women veterans at the Birmingham VA Health Care System (BVAHCS)



Authors: Sara Chirambo; Lisa Ambrose



Objective: 
The purpose of this quality improvement project is to evaluate the effectiveness of
pharmacist-led interventions using the VA Osteoporosis Screening Dashboard to enhance the
identification of osteoporosis/osteopenia in patients seen in the Women's Health clinic at BVAHCS.


Self Assessment Question: 
What is the impact of pharmacist intervention in osteoporosis screening?


Background:  
Osteoporosis is a common chronic bone disease characterized by low bone mass and
deterioration of bone structure. It predominantly affects women, with higher prevalence
compared to men. Bone mineral density (BMD) peaks in early adulthood and declines with
age, increasing fracture risk. The USPSTF and National Osteoporosis Foundation recommend
routine screening for women aged 65 and older, typically using dual energy x-ray
absorptiometry (DEXA). Despite guideline recommendations, screening rates for osteoporosis
remain low. This project aims to evaluate whether the use of the VA Osteoporosis Screening
Dashboard by pharmacists improves identification of osteoporosis/osteopenia at the Birmingham VA.




Methods:
- Patients without a DEXA scan will be identified via the VA Osteoporosis Screening Dashboard
- Patients identified on dashboard will be reviewed and eligibility will be confirmed via chart review
- Pharmacists will communicate screening recommendations with patient 
- Pharmacists will place order for DEXA scan with patient consent
- DEXA scan will be scheduled through Medical Support Assistants (MSAs) at the Birmingham VA
- Pharmacists will contact patients to discuss DEXA/FRAX results and counsel patients on lifestyle modifications to reduce risk of osteoporosis. If patients are confirmed to have osteoporosis/osteopenia, treatment will be initiated by PharmD provider


Inclusion Criteria:
- Women aged 65 years and older
- No prior history of receiving DEXA scan in Computerized Patient Record System (CPRS)
- Patients followed by a provider in Women’s Health clinic


Exclusion Criteria:
- Patients currently receiving pharmacotherapy for osteoporosis or osteopenia
- Patients previously diagnosed with osteopenia or osteoporosis


Results:
The pharmacist-led osteoporosis screening initiative at the Birmingham VA Women's Clinic demonstrated a positive impact on patient care. 47/80 patients were reached by phone and of those 47, 33 patients were interested in a DXA screening. 57% patients reached who were interested scheduled a DXA scan. The pharmacist's outreach efforts, supported by the use of an osteoporosis dashboard created by the VISN7 VA Academic Detailing team resulted in an increase in screening rates compared to baseline. The intervention achieved a high patient acceptance rate, suggesting that direct pharmacist engagement encouraged participation.


Conclusion:
This quality improvement (QI) project highlights the value of pharmacist intervention in advancing preventative health measures within the VA healthcare system, specifically within women's health. By proactively identifying patients in need of screening and facilitating access to care, pharmacists played a role in increasing osteoporosis screening rates among older female veterans.