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2021 Winter Meetings | TSHP Poster Abstracts

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Ascension Saint Thomas Hospital West
1Katherine E. Anderson, PharmD


The Incidence of Venous Thromboem­bolism After Heart Transplanta­tion

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Purpose: The purpose of this study is to determine the incidence of venous thromboembolism (VTE) in heart transplant recipients and assess the efficacy of VTE prophylaxis methods used.

Methods: This study is a retrospective chart review of adult patients who underwent heart transplantation at Ascension Saint Thomas Hospital West from May 1st 2016 to September 30th 2020. REDCap (Research Data Capture) will be used to collect data and de-identify patient information. This study will include up to 100 patients total. Patients will be assessed for what type of VTE prophylaxis they received and if they experienced a VTE at 28 days and 90 days post heart transplant. Data will be analyzed to determine the incidence of VTE after heart transplantation and the effectiveness of VTE prophylaxis methods used. Patient characteristics associated with VTE after heart transplant will be reported as secondary outcomes.

Results: Pending

Conclusion: Pending

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VISITPRESENTERFeb. 231p-3p CT

2Racheal L. Bailey, PharmD, MBA


Evaluation of proton-pump inhibitor dosing for gastrointestinal bleed prophylaxis in extracorporeal membrane oxygenation

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Purpose: The purpose of this study is to evaluate the efficacy of proton-pump inhibitors for the prevention of gastrointestinal bleeding in patients undergoing extracorporeal membrane oxygenation.

Methods: This study is a retrospective chart review of adult patients who were on extracorporeal membrane oxygenation between January 1 2019 and July 31, 2020. REDCap (Research Electronic Data Capture) will be used to collect data and de-identify patient information. This study will occur at a single center (Ascension Saint Thomas West Hospital in Nashville, TN) and will include up to 100 patients total. Data will be analyzed to assess differences in proton-pump inhibitor dosing and gastrointestinal bleed. Secondary outcomes include rate of gastrointestinal bleed and mortality.

Results: Pending

Conclusion: Pending

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VISITPRESENTERFeb. 231p-3p CT

3John B. Brannon, PharmD


VTE prophy­laxis strategies in COVID-19 positive ICU patients

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Purpose: Assess the risks and benefits of various venous thrombo­embolism prophylaxis strategies in COVID positive ICU patients

Methods: This study is a retrospective chart review of adult patients who were treated for COVID-19 in the intensive care units at Ascension Saint Thomas West, Midtown, and Rutherford hospitals between March 1, 2020 and December 31, 2020. The objectives of this study are to assess whether there were differences in venous thrombo­embolism incidence as well as bleeding events in patients who received high intensity risk-based venous thrombo­embolism prophylaxis strategies versus patients who received standard prophylaxis. REDCap (Research Electronic Data Capture) will be used to collect data and de-identify patient information. By examining these patients, this study hopes to determine which prophylaxis dosing strategies are associated with less venous thrombo­embolisms, identify which patient characteristics predispose patients to venous thrombo­embolism, and discover which treatments for COVID-19 correlate to lower rates of venous thrombo­embolism.

Results: Pending

Conclusion: Pending

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VISITPRESENTERFeb. 231p-3p CT

4Mary K. Medley, PharmD


Guanfacine to Aid in Weaning Dexmedeto­midine for Sedation in the ICU

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Purpose: Agitation in the intensive care unit (ICU) is a common occurrence associated with adverse clinical outcomes such as prolonged time on the ventilator and increased ICU length of stay (LOS). Current guidelines emphasize the importance of nonpharmacologic strategies in addition to benzodiazepine-sparing regimens to minimize and treat agitation in this population. The latter is supported by evidence demonstrating these medications are associated with a lower incidence of delirium, reduced time on the ventilator and shortened ICU LOS.

Dexmedetomidine, an intravenous alpha-2A adrenergic agonist, is a commonly used sedative with minimal effect on respiratory drive. However, prolonged infusions of dexmedetomidine may lead to withdrawal symptoms upon discontinuation and prohibit transitioning otherwise stable patients to a lower level of care. Transitioning patients from intravenous dexmedetomidine to an enteral alpha-2 adrenergic agonist may provide enough alpha-2 agonism to attenuate the sympathetic hyperactivity and facilitate discontinuation of dexmedetomidine. Clonidine has been utilized to successfully wean patients off of dexmedetomidine, but hypotension and bradycardia are often dose limiting side effects of this strategy. On the other hand, guanfacine, an enteral long-acting alpha-2 agonist with increased affinity to alpha-2A receptors and minimal effect on alpha-2B receptors, may provide the desired level of sedation with less hemodynamic side effects. The purpose of this study is to analyze guanfacine and dexmedetomidine administration practices for agitation and sedation in the adult intensive care setting with a focus on safety and efficacy.

Methods: An IRB-approved, single-center, retrospective chart review will be conducted. Patients 18 years of age and older admitted to Ascension Saint Thomas Hospital West who were treated with dexmedetomidine and guanfacine for sedation in the ICU between January 2017 and September 2020 will be included. Patients will be excluded if they received less than two doses of guanfacine, received guanfacine prior to initiation of dexmedetomidine, were being treated for alcohol withdrawal or were receiving neuromuscular blocking agents.

The primary objective is to evaluate the response to guanfacine at 24 hours after initiation in patients on dexmedetomidine. Patients will be divided into two groups based on response to guanfacine at 24 hours, responders (dexmedetomidine discontinued within 24 hours of initiation of guanfacine without the need for the addition of or dose increase of ancillary psychoactive medications for sedation within 24 hours of initiation of guanfacine) and non-responders. Statistical analysis will be completed using a stepwise multiple logistic regression model to determine predictors of response to guanfacine. Secondary objectives include the safety data (rate of hypotension and bradycardia).

Results: Data collection and evaluation in progress

Conclusion: Pending.

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VISITPRESENTERFeb. 231p-3p CT

5Lindsay M. Oehlkers, PharmD


Remdesivir for 5 vs 10 days of therapy in patients with COVID-19 on invasive mechanical ventilation or extracor­poreal membrane oxygenation

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Purpose: COVID-19, or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in December 2019 and has since caused over 13 million cases in the United States alone, leading to over 266,000 deaths. On May 1, 2020, the FDA granted an Emergency Use Authorization (EUA) for remdesivir in hospitalized patients with severe COVID-19 disease (low oxygen levels or requiring oxygen therapy/ventilatory support). This initial EUA was later expanded and received FDA approval on October 22, 2020 for the treatment of COVID-19 in hospitalized patients 12 years of age or older. A randomized controlled trial published in May of 2020 found five days of remdesivir therapy to be noninferior to ten days of therapy for the treatment of severe COVID-19 in patients who did not require any type of mechanical ventilation. To date, there have not been any published studies looking specifically at shorter courses of remdesivir in patients with COVID-19 who require mechanical ventilation or extracorporeal membrane oxygenation (ECMO). The purpose of this study is to compare 5 versus 10 days of remdesivir therapy specifically in COVID-positive patients who require invasive mechanical ventilation or ECMO.

Methods: This study is an IRB-approved, multicenter, retrospective chart review at four Ascension Saint Thomas Hospitals of patients at least 18 years of age who were treated with remdesivir therapy for SARS-CoV-2 and required mechanical ventilation or ECMO between May 15, 2020 and November 15, 2020. The primary objective of this study is to determine if there is a difference in clinical status, based on an ordinal scale, at day 21 in critically ill patients with COVID-19 on invasive mechanical ventilation or ECMO treated with five versus ten days of remdesivir therapy.

Results: Pending

Conclusion: Pending

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VISITPRESENTERFeb. 231p-3p CT

6Sally A. Sikes, PharmD


INR stabilization after withholding warfarin for colonoscopy

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Purpose: Patients are evaluated peri-procedurally according to their thromboembolic risk stratification in comparison to colonoscopy bleed risk within the Anticoagulation Monitoring Clinic (AMC) at Ascension Saint Thomas Hospital West. Warfarin is held for 3-7 days prior to procedure per the recommendation of the surgeon. In recent years, a variation in the time required for AMC patients to return to stable INR post-colonoscopy has been noticed, as well as a change in their warfarin total weekly dosage regimens. This study seeks to determine the time to INR stabilization among patients who withheld warfarin prior to colonoscopy.

Methods: This study is an IRB-approved, retrospective chart review of adult patients whose warfarin therapy was withheld prior to undergoing colonoscopy from September 1, 2016 to September 30, 2018. REDCap (Research Electronic Data Capture) will be utilized to collect data and de-identify patient information. This study will occur at a single center (Ascension Saint Thomas Hospital West in Nashville, TN) and will include up to 50 patients total. Patients were excluded if they were not monitored by AMC peri-procedurally, underwent additional procedures performed within 4 weeks post-colonoscopy, or were lost to follow-up post-colonoscopy prior to INR stabilization. The primary objective is to determine the time to INR stabilization after withholding warfarin for colonoscopy.

Results: Pending

Conclusion: Pending

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VISITPRESENTERFeb. 231p-3p CT

Ascension Saint Thomas Rutherford 
7Paige N. Gundrum, PharmD


Evaluation of local risk factors for methicillin-resistant Staphylococ­cus aureus and Pseudomonas aeruginosa in community-acquired pneumonia

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In October 2019, community acquired pneumonia (CAP) guidelines were updated to recommend abandoning the use of healthcare associated pneumonia (HCAP). Empiric methicillin-resistant S. aureus (MRSA) and P. aeruginosa coverage should now be based on locally validated risk factors unless prior history of isolation of either organism from the respiratory tract within the last 12 months. The aim of this study is to determine the local risk factors for MRSA and P. aeruginosa CAP at a middle Tennessee healthcare system in order to guide empiric therapy. This multicenter, retrospective cohort study included hospitalized patients that were admitted with a diagnosis of pneumonia less than 48 hours after admission from January 1, 2018, to December 31, 2019. Initial diagnoses in Cerner were used to identify eligible patients, who were then screened for exclusion criteria. The primary outcome was to identify risk factors for CAP due to MRSA and P. aeruginosa by calculating an odds ratio compared to CAP due to other organisms. Risk factors evaluated include previous infection or colonization, prior admission with intravenous antibiotics, chronic kidney disease, end stage renal disease, influenza, prior hospitalization, prior chronic obstructive pulmonary disease (COPD)-related hospitalization, intravenous drug abuse, lung abscess or empyema, admission from a long-term care facility, or outpatient dialysis. Secondary outcomes included all-cause mortality prior to discharge and overall prevalence of MRSA and P. aeruginosa CAP. Results for this study are pending further data collection. It is anticipated that the results of this study will identify risk factors that require empiric coverage for MRSA or P. aeruginosa in patients hospitalized with CAP within the health system.

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VISITPRESENTERFeb. 231p-3p CT

8Rebecca S. Heath, PharmD, MSCR


Safety and efficacy of apixaban and rivaroxaban in obese patients with atrial fibrillation: A multicenter retrospective analysis

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Per the Centers of Disease Control and Prevention, 42.4 percent of the United States adult population is obese. In patients with atrial fibrillation, current guidelines recommend use of direct oral anticoagulants (DOACs) over warfarin. Despite such strong recommendations, uncertainty remains regarding the safety and efficacy of DOAC use in extremes of weight. The purpose of this study is to determine the safety and efficacy of apixaban and rivaroxaban in obese patients with atrial fibrillation.

This is a multicenter, retrospective cohort study of obese adults (BMI greater than 40 kg/m^2 and/or weight greater than 120 kg) with non-valvular atrial fibrillation who were treated with a DOAC (apixaban or rivaroxaban) or warfarin between January 1, 2012 and December 31, 2019 and followed over 12 months. Exclusion criteria include; pregnancy, severe liver disease, and contraindicated concomitant medications while on anticoagulation therapy. The primary efficacy outcome is time to composite rate of thrombosis including stroke, systemic embolism, and myocardial infarction. The primary safety outcome is time to major bleed. Study groups will be analyzed in a 2:1 warfarin to apixaban and warfarin to rivaroxaban ratio. With an alpha level of 0.05, a total of 3524 patients will be needed to meet an 80 percent power with 1762 patients in the warfarin group, 881 patients in the apixaban group, and 881 patients in the rivaroxaban group. A Kaplan-Meier curve or log rank test will be used to assess time to thrombosis or major bleeding event.

Results are pending.

Pending study completion, we anticipate the results to provide insight into whether DOACs are safe and effective therapeutic options for patient who are obese with atrial fibrillation.

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VISITPRESENTERFeb. 231p-3p CT

9Kelsea S. Woolfolk, PharmD


Addition of insulin to parenteral nutrition for patients with type II diabetes mellitus

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Hyperglycemia has been found in as many as 50% of patients receiving total parenteral nutrition (TPN). The risk of hyperglycemia with TPN is greater in patients with impaired glucose utilization at baseline, including patients with type II diabetes mellitus (DM II). The objective of this study is to determine if the addition of insulin to TPN formulations improves glycemic control in patients with DM II as compared to subcutaneously administered insulin alone. This study is a single-center, retrospective study of patients with DM II admitted to our hospital who were receiving TPN between January 1, 2014 and December 31, 2018. Eligible participants were adults aged 18-89 years old with a previous diagnosis of DM II and who had received TPN for at least 72 hours. Major exclusion criteria included type 1 diabetes, pregnancy, or estimated creatinine clearance less than 50 mL/min. The primary outcome was the occurrence of hyperglycemia, defined as point of care (POC) BG greater than 180 mg/dL. Primary outcome variables included POC glucose, insulin type, units of insulin administered, and route of administration. Secondary outcomes included incidence and severity of hypoglycemia, with variables including POC glucose and administration of hypoglycemic rescue medications. It has been determined that 60 subjects would be necessary to appropriately evaluate both the primary and secondary outcomes. Preliminary outcomes were evaluated using a t-test. This analysis includes 34 of the planned 60 patients meeting inclusion criteria for the study. Of the 34 patients enrolled, 22 (65%) patients received insulin as a TPN additive and 12 (35%) received insulin only through sliding scale. Preliminary results revealed 52 (59%) hyperglycemic events in patients who received insulin as a TPN additive and 9 (17%) hyperglycemia events in patients receiving insulin outside of TPN administration (percent difference 42%, p=0.001). The average Total Daily Dose (TDD) was 71 units in patients receiving insulin as a TPN additive vs 13 units in patients receiving insulin outside of TPN administration. Hypoglycemia occurred in 2 (9%) patients receiving insulin as a TPN additive, including 1 incident of severe hypoglycemia (BG less than 54 mg/dl). No patients receiving insulin outside of the TPN experienced a hypoglycemic event. Based on preliminary results, the addition of insulin in TPN for patients with DM II does not improve glycemic control compared to receiving insulin outside of the TPN. Patients receiving insulin in the TPN required a higher TDD of insulin than patients receiving insulin outside of the TPN. Hypoglycemia occurred more often in patients receiving insulin in the TPN.

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VISITPRESENTERFeb. 231p-3p CT

Ascension Saint Thomas – Saint Louise Family Medical Center  
10Courtney L. Baldridge, MBA


Comparison of Sustained Virologic response rate for Hepatitis C patients receiving treatment by interdiscipli­nary Family Medicine team versus Gastroenterol­ogist referral

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Purpose: Direct-acting antivirals (DAA) have improved treatment outcomes in hepatitis C (HCV) through their superior tolerability and efficacy, with cure rates above 95 percent. Though HCV has historically been managed by specialists, the simplicity of DAA regimens has eliminated barriers to care by making treatment by primary care providers (PCPs) possible. The purpose of this study was to assess whether patients treated in a family medicine residency program (FMRP)-affiliated patient centered medical home (PCMH) have superior cure rates in comparison to those referred to a gastroenterologist.

Methods: This was a single-center prospective observational study conducted at an FMRP-affiliated PCMH and included all adult patients with a positive HCV viral load from 01/01/2019 to 12/31/2020. Patients diagnosed with active HCV could either receive treatment by referral to a gastroenterologist or by the patient’s PCP. To support treatment within the PCMH, clinic HCV champions created a quick reference pocket card, electronic health record templates, and order sets. PCPs within the PCMH were encouraged to attend an HCV workshop and to collaborate with an HCV champion in treating their patients. Patients were excluded from the analysis if they expired, declined treatment, could not be reached to offer treatment, had spontaneous clearance, changed PCP, required referral to a subspecialist for complex care, or were deemed not a treatment candidate due to ongoing substance use or poor appointment adherence. The primary outcome was the number of patients with a sustained virologic response at 12 weeks after treatment (SVR12). All patients who received a referral to be treated for their HCV were analyzed in the intention-to-treat population.

Results: A total of 107 patients within the PCMH had a positive viral load between 01/01/2019 and 12/31/2020. Of those patients, 23 were excluded for the reasons listed above. Among 46 patients treated by their PCP at the time of study end date, 19 (41%) patients had completed DAA treatment and SVR12, 16 (35%) patients remained on treatment or were awaiting their SVR12, and 11 (24%) were lost to follow-up. Among 38 patients referred to a gastroenterologist at the time of study end date, 10 (26%) patients completed DAA treatment and SVR12, 3 (8%) patient remained on treatment, and 25 (66%) had become lost to follow-up.

Conclusion: Patients receiving HCV care in an FMRP-affiliated PCMH were less likely to become lost to follow-up and subsequently more likely to achieve a sustained virologic response. Additional studies are needed to determine if this success is replicable in primary care settings.”

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VISITPRESENTERFeb. 231p-3p CT

Blount Memorial Hospital
11Sarah Jesse, PharmD


Improvement of antibiotic prescribing for outpatient community acquired pneumonia in the emergency department

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Purpose: The Infectious Diseases Society of America (IDSA) guideline on treatment of community acquired pneumonia (CAP) was updated in October of 2019, the first update since 2007. In response to this update, two emergency department (ED) interventions were made to facilitate incorporation of the new recommendations into practice. First, an ED discharge order set was created to guide optimal antibiotic selection. Second, ED providers received targeted, physician-led education. This project aims to assess the impact of these interventions on rates of optimal antimicrobial prescribing for outpatient CAP at a 304-bed hospital emergency department.

Methods: This retrospective, observational, single-center, pre-post intervention study was granted approval by the institutional review board prior to its initiation. Adults aged 18 years and older discharged from the ED with an antibiotic prescription for CAP treatment will be included in the study. Those discharged between November 1st, 2019 and December 1st, 2019 will make up the pre-intervention cohort, and those discharged between January 1st, 2020 and February 1st, 2020 will comprise the post-intervention cohort. Immuno­compromised patients well as those admitted to the hospital or transferred to another facility will be excluded from this study. The primary outcome will compare the proportion of patients discharged on optimal antibiotic therapy before and after the intervention period. The rates of optimal therapy based on individual comorbidities will also be compared. Secondary endpoints will look at incidence rates of treatment failure and treatment-related adverse effects before and after intervention.

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VISITPRESENTERFeb. 231p-3p CT

12Erika McDonald, PharmD


Assessment of appropriate guideline-directed A1C goals in elderly diabetic patients who are managed by primary care providers

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Purpose: The goal of this study is to determine the percentage of elderly diabetic patients without guideline directed A1c goal therapy. Per American Diabetes Association guidelines, hemoglobin A1c goals for elderly patients must be determined in a patient-centered fashion, after assessing medical, psychological, functional and social characteristics, since the risk of intensive glycemic control may outweigh the benefits in this population. This information will be compared to national statistics to determine how well local primary care providers are managing. Additionally, this study will perform a financial analysis of medication costs and determine rates of emergency department visits and hospitalizations for hypoglycemia.

Methods: This IRB-approved, retrospective chart review will identify patients from reports collected from Humana, which will be created based on the desired patient population. Charts will be reviewed, and information collected will include chronic disease states, duration of diabetes, A1c measurements, medications prescribed, the number of hospitalizations and ED visits, and indicators of functional status obtained from annual wellness exam questionnaires. Utilizing this information, appropriate A1c goals will be determined, referencing American Diabetes Association’s Standard of Medical Care in Diabetes, which will be compared to reported A1c values. Rates of hypoglycemic episodes resulting in ED visits and hospitalizations will also be determined and compared between patients appropriately aggressively treated and those inappropriately aggressively treated. Data regarding antidiabetic medications prescribed will be used to perform a cost analysis to demonstrate the avoidable cost of inappropriate aggressive therapy.

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VISITPRESENTERFeb. 231p-3p CT

13Elizabeth Pollard, PharmD


Impact of a Clinical Decision Support System (CDSS) Alert on Medication Administration Discrepancies in the Emergency Department

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Purpose: Based on previous analyses, it is estimated 2.5 of every 100 medications removed from the automated dispensing machines (ADM) in the emergency department (ED) at a community hospital do not have documentation of being administered or returned to the ADM. This suggests medications are being administered without documentation or diverted, resulting in potential lost revenue from missed medication charges. The community hospital recently implemented a clinical decision support system (CDSS). The purpose of this project is to determine if a real-time CDSS alert will have an impact on the medication discrepancy rate for medications removed from the ED ADM.

Methods: A custom alert has been built to identify when medications are removed from an ED ADM without documentation of administration or returned to the ADM within 2 hours (discrepancy). Medications that trigger an alert but are administered/returned after two hours, or presumed to be wasted after further investigation, will be excluded from the analysis. Identified discrepancies will be evaluated in a retrospective manner for November 2020 to determine a baseline discrepancy rate (pre-intervention). A process will be developed to notify nurses of discrepancies in real-time with the goal of correcting all discrepancies (intervention). A post-intervention discrepancy rate will be determined in a retrospective manner for January 2021. The overall impact of the alert will be determined by comparing the absolute and relative difference in the pre- and post-intervention discrepancy rates. A chi-square statistical analysis will be performed for the discrepancy rate comparisons. The financial impact of the alert will be determined by comparing the absolute and relative difference in lost revenue from missed medication charges in the pre- and post- intervention periods.

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VISITPRESENTERFeb. 231p-3p CT

Catholic Health Initiatives Memorial Hospital
14Sierra E. Detwiler


Evaluation of the cumulative effect of a pharmacist-led MRSA nasal PCR protocol with anti­micro­bial steward­ship interven­tions on IV vancomycin duration of therapy for suspected pneumonia

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Purpose: The American Thoracic Society and Infectious Disease Society of America recommend the use of a rapid Methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) swabs to help guide the de-escalation of anti-MRSA coverage for pneumonia. Intravenous (IV) vancomycin is commonly used for the empiric treatment of suspected MRSA pneumonia. This study aims to assess the impact of a pharmacist driven protocol for the ordering of rapid MRSA nasal PCR combined with antimicrobial stewardship interventions on IV vancomycin days of therapy for the management of pneumonia.

Methods: This retrospective chart review identified adult, in patients who received IV vancomycin empirically for pneumonia from May 1 – June 30, 2020 (pre-protocol) and August 1 – September 30, 2020 (post-protocol). Patients were excluded if they required IV vancomycin for a concomitant infection or if they only received a one-time dose. The primary outcome was the median duration of IV vancomycin therapy pre- and post-implementation. Secondary outcomes include: pharmacist consistency in obtaining MRSA nasal PCR swabs and making interventions with providers, number of vancomycin levels, time to pharmacist intervention, provider acceptance, incidence of re-escalation to IV vancomycin, and 30-day readmission for pneumonia.

Results: When looking at the primary results, the median vancomycin duration remained the same. There were some possible limitations to this result. For instance, there were 20 missed opportunities, where discontinuation was not recommended, which could have possibly reduced the overall effects on duration seen. Another factor was that each patient is usually reviewed once every 24 hours. There was no difference seen in the number of levels drawn or 30-day readmissions between the pre-and post-data. When looking at the PCR ordering, it increased from about 57 percent to about 92 percent, and of the total PCRs ordered in the post-data pharmacist accounted for 30 of the 57 ordered. When looking at pharmacists’ interventions, there was an increase from 5 total interventions to 26. The five made prior to implementing this protocol were all done by the infectious disease pharmacists who were following respiratory culture results, whereas the 26 in the post data were all based on MRSA PCR results. Of these 26 recommendations to discontinue vancomycin, about 77 percent were accepted by physicians. This review also found the MRSA PCR negative predictive value to be 100 percent, this was based on patients who had both a respiratory culture and MRSA PCR done, therefore further supporting the appropriateness of de-escalation.

Conclusion: There was no difference seen in our primary outcome. However, there was an increase in MRSA PCR swab ordering, available de-escalation opportunities, and pharmacists’ interventions. There were missed opportunities, which indicate room for improvement and a need for additional pharmacist education.

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VISITPRESENTERFeb. 231p-3p CT

15La’Travia S.N. Howard, PharmD, MBA


Medication use evaluation of antibiotic prescribing patterns for patients discharged from the emergency department

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Category: Medication Use Evaluation

Title: Medication use evaluation of antibiotic prescribing patterns for patients discharged from the emergency department

Purpose: Antibiotics are the most commonly prescribed medications in the emergency department (ED) with urinary tract infections being the most common bacterial infections encountered by ED physicians. Antibiotic resistance is a growing concern and resistance to guideline-recommended first-line agents among uropathogens has been increasing, with statistically significant increases in Escherichia coli. Unnecessary or inappropriate antibiotic use can lead to more resistance and result in adverse patient outcomes. The ED is an important setting to address appropriate and inappropriate prescribing habits. The objective of this study is to evaluate antibiotic prescribing patterns for patients discharged from the ED.

Methods: An observational study will be performed by retrospectively reviewing patients’ profiles in the electronic medical record who were prescribed oral antibiotics from January 2020 to July 2020. Prescribing patterns of providers will be evaluated and categorized based on the descriptive statistics. Data collection points will consist of indication, antibiotics prescribed, dose, and duration of therapy. Indications will be identified by utilization of orders, progress notes, and dictation reports.

Results: Of the 244 patients reviewed, 235 had a primary diagnosis of cystitis and 9 had pyelonephritis. At 57%, cefuroxime was the most prescribed oral antibiotic for empiric UTI treatment. CHI’s local antibiogram shows that Escherichia coli is 83% susceptible to cefuroxime. There were similar mean and median durations of therapy for both cystitis and pyelonephritis. Similar durations of therapy were selected across multiple different antibiotic classes with 7 days of treatment being the most selected.

Conclusion: In this study we discovered that our ED providers chose cefuroxime for a duration of 7 days as the preferred empiric treatment for patients discharged from the ED with a diagnosis of urinary tract infection. Though cefuroxime is an effective choice, more education and training is needed with ED providers about local susceptibility patterns and selection of the most optimal duration of therapy.

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VISITPRESENTERFeb. 231p-3p CT

16Kristin A. Liveris, PharmD


Assessment of the time to first antibiotic dose for patients presenting with febrile neutropenia in the emergency department

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Purpose: Fever is often the first sign of an infection in patients undergoing cytotoxic chemotherapy and carries a high mortality rate. Due to increased mortality, various guidelines have endorsed prompt delivery of broad-spectrum antibiotics after presentation. Several factors make prompt initiation of broad-spectrum antibiotics difficult in the Emergency Department (ED). The goal of this study was to determine compliance to guideline directed management of Febrile Neutropenia in regard to time to the time to first antibiotic dose, appropriate empiric antibiotic selection, and blood collection for culture results.

Methods: This was a retrospective cross-sectional study, involving patients at CHI Memorial hospital who received chemotherapy in the thirty days prior to presentation and then presented to the Emergency Department with signs and symptoms of febrile neutropenia. Patients were identified using ICD-10 codes specific to febrile neutropenia. Data was collected through the electronic medical record system. The primary outcome was the time to first dose of antibiotic after presentation with febrile neutropenia. Other outcomes include the incidence of febrile neutropenia in the emergency department and the appropriateness of antibiotic selection.

Results: In regard to antibiotics administered in the Emergency Department, cefepime was the most common antibiotic prescribed. Cefepime was prescribed as monotherapy in 36% of patients, and as dual therapy with Vancomycin in 32% of patients. The average time from triage to administration was 3 hours and 34 minutes. Of the patients included in the study, only 4 patients received antibiotics within 90 minutes. For blood cultures, the elapsed time from admit to blood draw followed a bimodal distribution. A total of 14 patients had cultures taken within one hour, 3 patients had cultures drawn within two hours, and 5 patients did not receive blood draws until greater than two hours from their triage time.

Conclusion: In this study we discovered that our institution utilizes appropriate broad spectrum antibiotic therapy for patients presenting with febrile neutropenia. There was only one deviation from guideline directed therapy during the study period. This situation illuminates the need for further education regarding appropriate empiric antibiotic selection and initiation in the Emergency Department. We hypothesized that collecting cultures prior to the initiation of antibiotics may be the rate limiting step in initiating therapy; however, this did not seem to be the case. It is apparent that other institutional barriers exist that make the initiation of antibiotics difficult and account for the delay in beginning therapy. Our next steps are to question this process further to discover what these barriers are and create a Febrile Neutropenia pathway within the ED to mitigate these difficulties.

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VISITPRESENTERFeb. 231p-3p CT

17Andrea L. Wilkinson, PharmD


Impact of pharmacist-driven 4T score calculation for streamlining heparin-induced thrombo­cyto­penia (HIT) lab tests at a community hospital

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Purpose: Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction characterized by thrombocytopenia and a high risk for venous or arterial thrombosis in patients with heparin exposure. The “4 T’s” are a clinical scoring system that can be used for estimating the probability of HIT based on its characteristic features: Thrombocytopenia, Timing, Thrombosis, and the absence of other explanation(s). The purpose of this evaluation is to determine if pharmacist calculation of the 4T score for patients with suspected HIT will result in decreased heparin antibody tests performed.

Methods: In November 2019, our institution implemented a pharmacist-driven 4T score calculation to streamline heparin antibody testing. When a provider orders a Heparin Antibody Panel, a consult to the pharmacy to calculate a 4T score is required within the electronic health record (EHR). Previous studies suggest low probability (< 5%) for heparin antibodies with a score ≤3. If the pharmacist calculates a score ≤3, the provider is called with the recommendation to cancel the lab test. This retrospective chart review will identify patients from March through August 2020 with orders for a Heparin Antibody Panel. This will be compared to data from March through August 2019, prior to the initiation of the pharmacist-driven 4T score calculation. The main outcome evaluated will be the number of heparin antibody tests performed. Other data evaluated will include calculated 4T score, heparin antibody test results, SRA results, and additional pharmacist interventions made.

Results: Within the 2019 group, there were a total of 79 lab orders. 52 had a low probability of HIT, 25 had an intermediate probability, and 2 had a high probability based on the calculated 4T score. Of the 79 lab tests, 13 resulted in positive heparin antibodies, and 4 of those 13 resulted in a positive SRA test. Within the 2020 group, there were a total of 42 Heparin Antibody Panel orders, 36 of which were included in the study. 4 had a low probability of HIT, 22 had an intermediate probability, 5 had a high probability based on the calculated 4T score, and 5 had pharmacist intervention made to discontinue the lab test prior to a 4T score calculation. 27 orders were sent to lab. 6 resulted in positive heparin antibodies, and 4 of those 6 resulted in a positive SRA test. All of the positive SRA tests from both groups had a 4T score ≥4. Additionally, there were a total of 13 pharmacist interventions made throughout the 2020 group.

Conclusion: 66% (52/79) of the calculated 4T scores from the 2019 data were ≤3 and could have been avoidable lab tests had a 4T score been calculated beforehand. 25% (9/36) of the Heparin Antibody Panel orders did not go on to lab in the 2020 group, indicating pharmacists played a role in decreasing heparin antibody tests in patients unlikely to have HIT.

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VISITPRESENTERFeb. 231p-3p CT

Cookeville Regional Medical Center
18Chloe Kent, PharmD


Early initiation of subcuta­ne­ous long-acting insulin in the acute management of diabetic keto­acidosis

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Diabetic ketoacidosis (DKA) is a life-threatening medical emergency characterized by metabolic acidosis and hyperglycemia. Insulin infusion therapy is part of the standard management for DKA. It requires close monitoring and frequent titration typically done in intensive care units. Recent research suggests that the initiation of long-acting insulin early in the management of DKA leads to quicker recovery times. Due to its pharmacokinetic profile, long-acting insulin may facilitate the transition from insulin infusion therapy while preventing rebound hyperglycemia. The purpose of this study is to evaluate whether long-acting insulin initiated earlier in standard therapy leads to decreased ICU length of stay.

Retrospective data will be collected prior to implementation to determine baseline use of continuous insulin infusion therapy. A protocol for introducing long-acting insulin at either a patient’s current total daily dose or a defined dose for insulin-naive patients will be created and distributed to providers to guide therapy. Providers and nursing staff will be educated regarding the protocol and how dosing and insulin titration decisions will be made. Prospective data after implementation of the protocol will be compared to retrospective data to assess changes in time to anion gap closure, occurrence of rebound hyperglycemia, total daily insulin dose, incidence of adverse effects, and decreased ICU length of stay and/or ICU avoidance.

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VISITPRESENTERFeb. 231p-3p CT

19Loretta Moate, PharmD


Implementa­tion and evaluation of pharmacist-managed vancomycin protocol in adult intermittent hemodialysis and continuous renal replacement therapy patients

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Inconsistent strategies for dosing vancomycin have led to variability in achieving therapeutic troughs in hemodialysis (HD) patients and has been identified by the Antimicrobial Stewardship Committee as an area for improvement at Cookeville Regional Medical Center (CRMC). Current vancomycin dosing and monitoring practices for HD patients at this institution rely on the general adult vancomycin dosing protocol and the clinical pharmacist’s judgment. Th.erefore, a pharmacy-driven quality improvement initiative based on current literature is needed to standardize vancomycin dosing strategies and therapeutic monitoring in this population. The objective of this study is to evaluate our existing vancomycin dosing practices and develop a vancomycin dosing protocol for patients undergoing intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) with the primary aim to increase percentage of initial therapeutic troughs. Secondary aim is to decrease incidence of supratherapeutic troughs. Upon implementation of the new vancomycin dosing protocol, prospective evaluation of the attainment of therapeutic serum troughs in IHD and CRRT patients will be conducted.

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VISITPRESENTERFeb. 231p-3p CT

Lipscomb University College of Pharmacy and Health Sciences
20Anna M. Kirkpatrick, PharmD


Impact of Ambulatory Care Pharmacy on Glycated Hemoglobin

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The role of pharmacists is rapidly expanding within healthcare. Pharmacists play a vital role in the management of diabetes by screening patients at high risk, providing targeted education and cost-effective options, increasing adherence to therapies, recommending monitoring, and increasing quality of life. Various studies have established the benefit of pharmacist involvement in diabetes management; however, few investigate the impact within a collaborative practice agreement compared to a control group. In the current study, patients are referred based on provider discretion, and services are provided under a collaborative practice agreement. A prospective chart review will be conducted on all patients with type two diabetes referred to pharmacy services for diabetes management at a rural primary care clinic. These patients will be followed from February 1, 2020 through December 31, 2020 to quantify the effectiveness of pharmacist interventions. Data retrieved will include each patient’s encounter dates, A1c prior to pharmacy referral, A1c after each encounter, change in A1c, and time from initial encounter to most recent A1c. A matching number of patients from each provider will be included in the control group. Data retrieved from this group will include the provider, nearest A1c before February 2020, and A1c at end of study period. Descriptive statistics will be used to report the median A1c reduction, as well as the percentage of patients with most recent A1c <8% and <7%.

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VISITPRESENTERFeb. 231p-3p CT

21Keith A. Young, PharmD, MS


Effect of Reducing CDS Alert Burden on Alert Override Rates

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Purpose: Medication alerting systems have been implemented within electronic health records (EHRs) to provide alerts and information to prescribers at the time of ordering. These systems have been shown to reduce medication errors and adverse drug events; however, medication-related alerts are significant contributors to the number of interruptive alerts encountered by prescribers. Most alerts are overridden, which calls into question their relevance and impact. Resulting cognitive overload and desensitization to alerts produces alert fatigue, which could lead to burnout and overlooked significant alerts.

Methods: Vanderbilt University Medical Center (VUMC) is an academic, tertiary care medical center in Nashville, TN with a 1000-bed general medical and surgical facility and nearly 2,000,000 patient visits annually. Similar to most other organizations, VUMC has implemented medication alerting (e.g., drug-allergy, drug-drug, and drug-dose alerts) using a 3rd party vendor, many of which are then customized and filtered by severity ratings. In 2018, VUMC created a monthly Medication Alerts Working Group to improve medication safety and reduce alert burden. Concerns about alert fatigue and consequential overriding of clinically relevant medication alerts prompted efforts to reduce the interruptive medication alert burden, with the theory being that fewer alerts might allow for greater impact of the remaining alerts. Therefore, our objective is to 1) evaluate the impact of the Medication Alerts Working Group on the number of alerts seen per 100 orders, and 2) evaluate how those changes have affected alert override rates.

Results (preliminary): To analyze alert burden and concurrent override rates, we retrieved EHR logs of all alerts displayed to users since January of 2018. Extracted data includes alert type, alert date/time, alert triggers, and provider response. Statistical and descriptive analysis is being performed to look for any potential relationship between provider alert burden and the alert override rate. We are evaluating the data using quality control charts for pre- and post-intervention alert rates, as well as a Poisson regression model for statistical significance. To account for increases in clinic volume, ordering, and population growth over time, we are normalizing the number of alerts shown per 100 orders. Preliminary results indicate that the VUMC Medication Alerts Working Group impacted provider alert burden, however, the override rate of interruptive medication alerts remains high.

Conclusion: The key takeaways provided by this study include the impact of the VUMC Medication Alerts Working Group on provider alert burden and, consequently, the override rate of interruptive medication alerts. Lessons learned can be applied to further decrease alert burden and alert fatigue.

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VISITPRESENTERFeb. 231p-3p CT

Methodist Le Bonheur Healthcare
22Jessica G. Tejeda, BS, BSPS


Measuring the impact and feasibility of trigger tools across a health-system

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Background: Trigger tools are a practical method for identifying adverse drug events as they are less resource intensive, sensitive and specific, and provide real-time identification of potential adverse drug events; however, the initial set up can be labor intensive.

Objective: The aim of this study was to measure the feasibility and impact of implementing five trigger tools across a six hospital healthcare system.

Methods: A weekly trigger tool report was generated based on the five trigger tools that were implemented with the following criteria:

  • Administration of naloxone
  • Administration of flumazenil
  • Hyperglycemia secondary to receiving steroids
  • Hypoglycemia secondary to receiving insulin
  • Hypoglycemia secondary to receiving sulfonylureas

A reviewer examined individual patient records to perform a modified chart review within the electronic health record to determine whether an adverse drug event occurred or not.

Results: Preliminary data will be shared to include the following metrics:

  • Average time spent per chart review per trigger tool report
  • Positive predictive value per trigger tool report
  • Total number of potential adverse drug events per trigger tool report

Conclusion: Based on preliminary data, trigger tool reports improved event detection across a health-system and required limited resources for implementing and sustaining results.

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VISITPRESENTERFeb. 231p-3p CT

South College
23Alexander M. Le, PharmD, MBA


Evaluation of direct oral anticoagu­lant (DOAC) utilization in a primary care setting

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Purpose: Direct oral anticoagulants (DOACs) have replaced warfarin as the preferred anticoagulant of choice for patients with nonvalvular atrial fibrillation and venous thromboembolism. However, patient-specific factors and past medical history can dictate the use of a DOAC and appropriate dosing. The purpose of the study to evaluate the utilization of DOACs in a primary care setting to determine whether patients’ regimens follow guidelines-based recommendations and approved FDA labeled dosing. 

Methods: A IRB-approved retrospective cohort chart review will be completed on patients who were prescribed a direct oral anticoagulant from January 1, 2020 to June 30, 2020. Researchers will compare patient’s DOAC dosing and medical history to the treatment plan to determine whether the patient is receiving the medication in accord with evidence-based recommendations. Specific variables of focus include indications for the DOAC, dosing regimen, age, renal function, liver function, weight/BMI, and drug-drug interactions. The primary outcome endpoint will be the proportion of patients who are on a non-evidence-based dose of a DOAC.

Results: Results currently pending.

Conclusion: Results currently pending.

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VISITPRESENTERFeb. 231p-3p CT

TriStar Centennial Medical Center
24Kyle Coutinho


An Evaluation of the Laboratory Monitoring Endpoints to Outcomes in Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) on Anticoagu­lation

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Anticoagulation during extracorporeal membrane oxygenation (ECMO) is considered a standard of care. The most common anticoagulants used are unfractionated heparin or direct thrombin inhibitors. Depending on facility specific protocols these anticoagulants are titrated to a specific therapeutic range using different laboratory values. Unfractionated heparin is considered the gold standard anticoagulant for patients on ECMO. However, titrating heparin can require frequent lab draws and dose modifications which can lead to increase cost. The purpose of this study was to compare heparin and bivalirudin with respect to the number of lab draws, dose modifications and associated costs with each agent.

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VISITPRESENTERFeb. 231p-3p CT

TriStar Skyline Medical Center
25Brianna C. Belsky, PharmD, MBA


Interrupted time series analysis evaluating the short- and long-term impacts of a multifaceted approach to targeting fluoroquin­olone use in a tertiary, non-teaching hospital

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Background: Fluoroquinolone use is a known risk factor for multi-drug resistant organisms, which results in higher hospital costs. Previous studies have shown that restricting fluoroquinolones can lead to reversals in resistance of various bacteria and decrease superinfections. A variety of strategies exist to decrease fluoroquinolone use, but feasibility and efficacy differ depending on the setting and available resources.

Objective: To evaluate the impact of a multifaceted approach to decreasing fluoroquinolone use on consumption of fluoroquinolones and common alternative antibiotics at a smaller, tertiary, non-teaching hospital.

Setting: Single, 288-bed tertiary, non-teaching hospital with 71 ICU beds in Nashville, TN

Results: Pending data analysis.

Conclusions: Pending results.

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VISITPRESENTERFeb. 231p-3p CT

26Caleb C. Hammons, PharmD, MS


Retrospective case series and proposed algorithm for utilization of procalcitonin in a nonacademic medical center

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Background: Studies have demonstrated both strengths and weaknesses regarding procalcitonin’s use in guiding antimicrobial therapies. Certain factors may influence efficacy; including setting, patient population, and additional antimicrobial stewardship strategies in place. While studies have developed and proposed algorithms for interpretation of procalcitonin values based on indication; studies are lacking in development and proposal of an algorithm for initial ordering of a procalcitonin level with a primary objective of optimizing utility. As procalcitonin’s usefulness remains debated, we aim to retrospectively evaluate procalcitonin levels ordered in a single institution to determine which patient populations and clinical scenarios may benefit most and prove cost-effective.

Methods: The study has been submitted to the Institutional Review Board for approval. Retrospective chart review will be performed at a non-academic medical center located in Nashville, TN. Patients greater than or equal to 18 years of age will be evaluated and included in analysis if they had a procalcitonin level ordered and resulted between January and March of 2020. Identification of patients will occur by running reports through a clinical decision support system. An algorithm will be both proposed and applied to patients included in analysis to determine the number of tests potentially saved and overall efficacy of procalcitonin based on new criteria.

Results: Results are pending data analysis

Conclusions: Conclusions are pending data analysis

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VISITPRESENTERFeb. 231p-3p CT

TriStar Summit Medical Center
27Kelly J. Tocki, PharmD


An evaluation of dexmedeto­mi­dine use in an adult intensive care unit

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Purpose: The 2018 Pain, Agitation, Delirium, Immobility, and Sleep Disruption (PADIS) guidelines conditionally recommend that non-benzodiazepine sedatives such as dexmedetomidine or propofol are used over benzodiazepine agents for sedation.  Dexmedetomidine is a selective alpha-2 agonist that carries sedative and analgesic properties and allows for targeting a lighter sedation without significant respiratory effects.  This retrospective evaluation aimed to assess the appropriateness of dexmedetomidine use in an ICU setting.

Methods: A retrospective chart review of all patients that had a medication order for dexmedetomidine admitted to Tristar Summit Medical Center’s medical or surgical intensive care unit between June 1, 2019–December 31, 2019 was performed.  Information obtained from pharmacy surveillance software was utilized to identify potential patients for inclusion which was then confirmed by chart review.  Patients with an order for dexmedetomidine with a documented administration were included in this evaluation.  The data collected included requirement of mechanical ventilation, duration of ventilation, and concomitant sedation medications, as well as dexmedetomidine indication and duration.  The primary endpoint was to determine the percentage of patients receiving multiple sedative infusions at once. Secondary endpoints evaluated were the duration of dexmedetomidine therapy and the indication for which it was used.

Results: A total of 72 patients were reviewed for inclusion in this analysis.  14 patients were excluded due to dexmedetomidine being ordered but never having received a dose. Concomitant sedatives were utilized with dexmedetomidine in 16 patients (28%) with fentanyl as the most common in 10 of those patients (63%). Propofol was given with dexmedetomidine in 9 patients (56%) and midazolam in 3 patients (19%).  Each patient that received a sedative in addition to dexmedetomidine was mechanically ventilated, with a total of 40 patients (69%) in the study requiring mechanical ventilation. Mechanical ventilation averaged 4 days in patients receiving dexmedetomidine only and 5 days in patients receiving a duplicate sedative.  The most frequent indication for dexmedetomidine use was sedation (65%, 38 of 58 patients) followed by alcohol withdrawal (19%, 11 patients) and agitation (16%, 9 patients).  Nine patients (15.5%) used dexmedetomidine as indicated (less than 24 hours) with 21 patients requiring dexmedetomidine for two days and 28 patients for three or more days (36% and 48%, respectively).

Conclusion: The majority of dexmedetomidine was used without additional sedatives but there is still room for improvement.  There needs to be a continued focus on assessing the need for duplicate sedatives, such as propofol and dexmedetomidine together.  As we continue to see more dexmedetomidine use for alcohol withdrawal, it may be useful to create a protocol specific to dexmedetomidine use for these situations in the future.

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VISITPRESENTERFeb. 231p-3p CT

University of Tennessee, Memphis
28Callee M. Brooks, PharmD Candidate


Prescribing Patterns of Dual-Antiplatelet Therapy After Acute Ischemic Stroke or Transient Ischemic Attack at Methodist University Hospital (MUH)

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Purpose: Dual-antiplatelet therapy (DAPT) is currently recommended for 21 days in minor acute ischemic stroke (AIS) or transient ischemic attack (TIA) or for up to 90 days if patients meet criteria for severe intracranial artery (ICA) stenosis defined as greater than 70% occlusion per the AHA/ASA guidelines. Little evidence is available regarding prescribing patterns in clinical practice, rates of proper discontinuation, and impact on bleeding rates. The purpose of this retrospective cohort study was to evaluate duration of DAPT prescribed in patients after AIS/TIA with or without ICA stenosis admitted to MUH.

Methods: A retrospective cohort study of patients receiving DAPT with aspirin and a P2Y12 inhibitor after a documented AIS/TIA admitted to MUH from July 2017 to May 2020 was completed. Adults admitted for AIS/TIA with or without ICA stenosis and aspirin plus clopidogrel or ticagrelor documented on discharge medication reconciliation were included. Patients were excluded if they had a clear indication other than stroke for anticoagulation or DAPT or stroke of cardioembolic origin. Baseline demographics and patient information were collected along with TOAST criteria, and standard of care medications post-stroke. Additionally, number of readmissions during study period, recurrent strokes, and major bleeding events were collected as well as risk factors for stroke and bleeding. The primary objective was to describe DAPT prescribing patterns for patients after stroke and determine if patients who were readmitted to the hospital have remained on DAPT for an inappropriate duration based on the guideline recommendations.

Results: A total of 150 patients, mostly African American males (64% and 53%, respectively) with a mean age of 62 (SD 13) years were included in this analysis. Sixty-eight (45%) patients met criteria for major ICA stenosis. Half of patients (51%) were prescribed the recommended 21- or 90-day duration of DAPT at discharge. Sixty-four patients were readmitted to the Methodist LeBonheur Healthcare system for a total of 119 admissions. Per documented medication histories, patients were still taking DAPT beyond the evidence-based 21- or 90-day duration in half of readmissions (50%). Of those readmissions, there were 19 major bleeding events among 9% of patients and 28 recurrent strokes among 27% of patients.

Discussion: Despite recommendations for the duration of DAPT after stroke in the AHA/ASA guidelines, we found that a considerable amount of patients with a history of AIS or TIA with or without ICA stenosis admitted to MUH, a comprehensive stroke center in the region, remain on DAPT beyond the recommended 21 or 90-day period. Of those patients who were readmitted, 22% experienced a major bleeding event. This reveals an area where pharmacists can impact patient care by assisting with appropriate prescribing post-stroke. We plan to build an order sentence with 21- and 90-day durations to aid providers at time of discharge.

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VISITPRESENTERFeb. 231p-3p CT

QUESTIONS?
Please contact Lindsey Inman at lindsey@tnpharm.org or 615-256-3023.