2026 Southeastern Residency Conference

Title: Impact of a Pharmacist-Led Practice Change in Anti-Xa Monitoring on Bleeding Rates in Burn Injury Patients Receiving Enoxaparin for Venous Thromboembolism Prophylaxis
Authors: Jacob King, Nirali Naik
Background: Burn patients are at an increased risk of venous thromboembolism (VTE) and often receive enoxaparin for VTE prophylaxis. Official guidelines do not exist that outline enoxaparin dosing strategies in burn patients, possibly leading to an increased risk of VTE or bleeding events.  A recent increase in bleeding events has raised concerns regarding whether current dosing and monitoring is appropriate.  The goal of this study was to determine if pharmacist-led monitoring of weight-based enoxaparin compared to current standard practice is associated with less major bleeding events while reducing risk of VTE.
Methods: This study is a single-center retrospective chart review designed to evaluate weight-based enoxaparin dosing and monitoring in burn injury patients in a pharmacist-led protocol (PLP) group compared to current standard practice (SP). Adult patients admitted with a burn injury during two different time periods, who received weight-based enoxaparin for VTE prophylaxis were evaluated. The SP group was reviewed from January 1, 2025, through February 15, 2025 and the PLP group from July 1, 2025 through August 15, 2025. Patients were considered eligible if they received at least 3 consecutive weight-based enoxaparin doses. Patients with renal dysfunction (CrCl < 30 mL/min on admission), coagulation disorders, heparin induced thrombocytopenia, receiving therapeutic anticoagulation or a factor Xa inhibitor within 72 hours of enoxaparin administration, or decompensated cirrhosis were excluded. The primary outcome was to evaluate if a difference exists in major bleeding events when comparing the SP group to the PLP group in regard to anti-Xa monitoring in burn injury patients receiving weight-based enoxaparin for VTE prophylaxis. Secondary outcomes included incidence of patients achieving an anti-Xa within goal range within the first 48 hours, rate of patients who did not achieve goal anti-Xa levels overall, incidence of VTE or minor bleeding events, number of dose adjustments required to achieve goal anti-Xa levels, number of pharmacist interventions and total doses of enoxaparin received during admission. Statistical analysis included descriptive statistics, t-tests for continuous variables, and chi-square or Fisher’s exact tests for categorical variables.
Results: Twenty-five patients were included in the SP group and thirteen patients were in the PLP group. The primary outcome of major bleed events was the same between both groups (p = 1.000). More patients in the PLP group achieved an anti-Xa level within goal range within the first 48 hours (23% vs 0%, p = 0.034).  In the PLP group after 48 hours, 2 patients achieved goal anti-Xa levels at the second level and 1 patient at the third level.   No patients in the SP group achieved an anti-Xa level within goal range throughout their admission compared to 7 patients in the PLP group (100% vs 54%, p=0.001).   
Additional secondary outcomes included the number of pharmacist interventions (n=27), total doses of enoxaparin received during admission (SP group = 332 vs. PLP group n=210), and minor bleed events (p=0.11). There were no reported incidences of VTE events in either group. 
Conclusion: There was no statistically significant difference found when evaluating the primary outcome of major bleeding events between groups. Statistical significance was observed in some secondary outcomes: more patients in the PLP group were able to achieve goal anti-Xa levels within 48 hours, with additional patients being able to achieve goal anti-Xa levels prior to discharge. The difference in the findings of the secondary outcomes in the PLP may be correlated with the pharmacist-led interventions.  Due to a limited sample size and potential confounding variables, all outcomes should be interpreted with caution and within context. Future research should prioritize prospective studies with larger cohorts and rigorous controls for confounding variables to ensure the definitive validation of all outcomes.
Contact: [email protected]

Title: Impact of IV Electrolyte Autoverification Compared to Pharmacist Verification in the Emergency Department   

Authors: Raven Gadson, Brittany Onyeji, Kirsten DiPiro, Ambra Hannah 

Background/Purpose: Autoverification allows medication orders to bypass pharmacist review, which can improve efficiency but also introduces safety concerns. Studies show that removing high‑risk medications from autoverification increases pharmacist involvement and may reduce medication errors. The purpose of this study is to evaluate the safety and efficiency of pharmacist verification to autoverification for intravenous (IV) electrolyte orders in the emergency department setting (ED).  

Methods: A retrospective chart review was conducted from August 1, 2024, to March 1, 2025, to compare pharmacist verification with autoverification. Inclusion criteria were age ≥18 years and received an IV Piggyback (IVPB) in the ED of a Wellstar Health System facility that was stocked in the ED Omnicell. The primary end point was a comparison of error rates related to dosing, indication, duplication, drug interaction, and allergies. Secondary end points included the time to final verification and time to administration that occurred in each study group. 

Results: A total of 150 IVPB electrolyte orders were analyzed. Baseline demographics and order characteristics were similar between groups. No clinically significant ordering errors were identified in either group (P = 1). Time to final verification was significantly shorter with autoverification versus pharmacist verification (0 minutes vs 3 minutes, P < 0.001). However, time to administration did not differ between groups (40 minutes vs 40 minutes, P = 0.997). Provider order-entry alerts were infrequent and comparable. Among pharmacist‑verified orders, pharmacists received an alert for 18.7% of orders and documented a clinical intervention on 2.7%. 

Conclusion: Autoverification of IVPB electrolytes demonstrated no observed increase in ordering errors compared with pharmacist verification and significantly reduced time to final verification, without affecting time to administration. These findings suggest that, within a safeguarded ED workflow, selective autoverification of IVPB electrolyte orders such as those that are pre-mixed, standardized, or placed through an order set may be a safe and efficient strategy. Limitations include retrospective design, modest sample size, reliance on documented interventions, and analysis restricted to medications that were administered. Prospective studies with larger samples are warranted to confirm safety signals and to evaluate operational levers that influence administration time. 

List e-mail of resident (or best contact) for follow-up: [email protected]

Background: 
Automated dispensing cabinet (ADC) overrides are intended for emergent medication access but introduce risk when medications are removed without an associated order. After a medication is pulled on override, a retrospective order should be placed in the electronic health record (EHR) and the override linked to that order.

Overrides unlinked to orders may reflect breakdowns in ordering workflows, verbal order reconciliation, or documentation practices, increasing the risk of inappropriate medication administration or incomplete clinical review. Additionally, medication administration without a documented provider order may carry legal and licensure implications, as it can be interpreted as practice outside established scope and authorization.

Override monitoring is a critical safety and policy component of ADC governance. A company-wide override dashboard was recently updated to pull data from the EHR instead of pulling data from the ADC. This allowed the additional visualization of overrides being linked to orders in the EHR. However, limitations in filtering functionality and data clarity reduced its effectiveness for identifying trends in overrides unlinked to orders.

Objective: 
To evaluate data integrity within a company-wide ADC override dashboard to enhance identification and review of unlinked overrides.

Methods: 
This quality improvement initiative evaluated override data without linked orders from AdventHealth Central Florida Division (CFD), consisting of 10 acute care campuses and 11 off-site emergency departments (OSEDs). An evaluation of dashboard performance was conducted to assess usability and data reliability.

Results: 
Dashboard filters were refined to allow more precise identification of overrides unlinked to medication orders, including improved medication-level and ADC-level stratification. Following implementation of revised filters, medications and ADCs commonly associated with unlinked overrides were more readily identifiable, enabling targeted analysis rather than broad, non-specific review. During detailed data review, a discrepancy was identified between data displayed and data exported. This prompted review of dashboard logic and strengthened confidence in data interpretation.

Medications and ADCs commonly associated with unlinked overrides were systematically identified, and focused analyses were performed to evaluate opportunities to improve override-to-order linking workflows. These finds were brought to the CFD interdisciplinary Medication Safety Committee to facilitate focused discussions on strategies to improve order linking workflows.

Conclusions:
Refinement and validation of a company-wide ADC override dashboard enhanced transparency, usability, and data reliability in monitoring unlinked overrides. Systematic dashboard optimization and multidisciplinary collaboration are essential to strengthening medication safety surveillance across large health systems.
  

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Title: Improving naloxone prescribing rates for Veterans with stimulant use disorder (StUD) through AudioCARE technology at the Atlanta VA Healthcare System
Presenters: Kathryne Spratlin, PharmD
Authors: Lauren Ramshur, MD; Stephanie Oh, PharmD; Kathryne Spratlin, PharmD; Melanie Pafford, NP; Natalie Haslem, NP; Mary K. Pounders, PharmD, BCACP
Background:
StUD is a prevalent diagnosis among the Veteran population. Veterans with StUD are at increased risk of accidental opioid overdose due to contamination of the illicit drug supply. Harm reduction interventions are recommended strategies to reduce stimulant-related overdose deaths.  Using a real-time dashboard, eligible Veterans were identified based on diagnosis of StUD without an active naloxone prescription. This project aimed to evaluate whether AudioCARE technology, an automated Veteran outreach program, can improve naloxone distribution amongst at-risk veterans with StUD in hopes of improving rates of accidental opioid overdoses.
Methodology: 
This prospective quality improvement project utilized automated outreach to identify and engage Veterans at risk for accidental opioid overdose due to StUD. A real-time dashboard identified eligible patients with an active diagnosis of StUD without an active naloxone prescription. Through AudioCARE technology, these Veterans were contacted via an automated phone call and given the options to receive a naloxone kit, decline a naloxone kit, or request additional information. Actions were taken based on each individual Veterans’ response. Those who did not respond were listed as non-responders and were re-contacted using the same process 120 days after the date of initial attempt. The dashboard was reviewed monthly to assess the number of actionable Veterans remaining. Prescribing rates, successful rates of contact, and the impact of secondary outreach were evaluated to assess the impact of the AudioCARE intervention.  
Results: 
AudioCARE outreach successfully identified 1,439 actionable Veterans. After completion of the initial call process, 370 Veterans indicated interest in receiving a naloxone prescription. Prior to implementation of AudioCARE process, 40.1% of Veterans with StUD had an active naloxone prescription; after the first round of outreach, this increased to 47.9%. A second round of calls targeted the 952 Veterans who were unable to be reached during the first round. Of those contacted, 108 additional Veterans requested a naloxone prescription. This further increased the percentage of Veterans with StUD who had active naloxone orders to 48.3%.
Conclusions: 
The AudioCARE process was a feasible strategy to improve naloxone access and support harm reduction efforts for at-risk Veterans with StUD at the VA. Future areas of interest include expansion to other high-risk populations, medication adherence outreach, preventative care initiatives, and chronic disease management support. 
  

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Brady Ratliff, Jessica Brumit

Background/Purpose:
Sotalol is a class III antiarrhythmic requiring inpatient monitoring due to the risk of QT prolongation and proarrhythmias. Obesity may alter pharmacokinetics through changes in volume of distribution and renal clearance estimation. While actual body weight (ABW) is recommended per package insert to calculate creatinine clearance (CrCl), this may overestimate renal function in obese patients, potentially leading to drug accumulation and increased proarrhythmic risk. The purpose of this study was to compare the composite rate of inpatient sotalol discontinuation or dose reduction due to QT/QTc prolongation between obese and non-obese patients during monitored initiation.
Methods:
This retrospective cohort study evaluated adult patients admitted for sotalol initiation at a hospital system in Northeast Tennessee and Southwest Virginia from July 2020–June 2025. Patients were stratified by obesity status (BMI ≥30 kg/m2defined as obese). The primary outcome was the composite of inpatient sotalol discontinuation or dose reduction due to QT/QTc prolongation. Secondary outcomes included all-cause discontinuation, all-cause dose reduction, any dose adjustment, bradycardia (HR <50 bpm), sinus rhythm at discharge, serial QT/QTc trends across up to six doses (QT interval applied when HR <60 bpm; QTc applied when HR ≥60 bpm), and differences in CrCl calculated by ABW versus adjusted body weight (AdjBW). Categorical variables were compared using Fisher’s exact test; continuous variables using Mann-Whitney U test.
Results:
A total of 150 patients were included: 91 obese and 59 non-obese. Obese patients were younger (median 69 [IQR 59.5–75] vs. 74 [67–78] years, p=0.003) with significantly higher ABW-based CrCl (102.6 [85.8–140.4] vs. 73.3 [57.1–88.8] mL/min, p<0.001); the median CrCl overestimation using ABW versus AdjBW was 23.8 mL/min in obese patients compared to 7.7 mL/min in non-obese patients (p<0.001). Baseline serum creatinine, electrolytes, QT/QTc, heart rate, rhythm distribution, and starting sotalol dose were similar between groups. The primary composite outcome of discontinuation or dose reduction due to QT/QTc prolongation occurred in 4 obese patients (4.4%) and 3 non-obese patients (5.1%) (OR 0.86 (95% CI 0.19-3.98); p=1). All composite events were discontinuations; no dose reductions attributable to QT/QTc prolongation occurred in either group. All-cause inpatient discontinuation was similar between groups (14.3% vs. 11.9%, p=0.81). All-cause dose reductions were significantly more frequent in non-obese patients (16.9% vs. 3.3%, p=0.006), driven by bradycardia and hypotension rather than QT prolongation. Any dose adjustment did not differ significantly (23.7% vs. 15.4%, p=0.21). Bradycardia rates (18.6% vs. 13.2%, p=0.37), sinus rhythm at discharge (64.4% vs. 58.2%, p=0.5), and serial QT/QTc values at all time points were comparable between groups.
Conclusions:
Obesity was not associated with an increased composite rate of sotalol discontinuation or dose reduction due to QT/QTc prolongation during monitored inpatient initiation. Despite a clinically meaningful overestimation of CrCl using ABW in obese patients, this did not translate into greater QT-mediated adverse events or higher discontinuation rates. Notably, all-cause dose reductions were more frequent in non-obese patients and were driven by bradycardia and hypotension rather than QT prolongation. These findings suggest that obesity alone may not confer additional proarrhythmic risk during standard inpatient sotalol initiation and support current renal dosing guidance regardless of BMI.

Iron Supplementation in Patients with Heart Failure with Reduced Ejection Fraction Following Pharmacist-Led Review
Lauren Finn, Rachel Kile 
CHI Memorial Hospital, Chattanooga, TN 

Background/Purpose: Heart failure is a leading cause of hospitalization for patients older than 65, requiring proper management during inpatient stays. Iron deficiency is common in heart failure with reduced ejection fraction (HFrEF) and negatively impacts patient outcomes. This project aims to describe the impact of pharmacist intervention on the appropriate initiation of iron supplementation in patients with HFrEF, highlighting the pharmacist's role in optimizing HFrEF management.
 
Methods: This is a single-center, IRB-approved, quasi-experimental study. We conducted a retrospective chart review comparing the proportion of iron-deficient inpatients with an active diagnosis of chronic systolic heart failure who were appropriately initiated on intravenous iron therapy before and after the implementation of a pharmacist-led review process. Appropriate therapy was defined as a course of IV iron of at least 500 mg in iron-deficient patients. Eligible patients were at least 18 years of age with an ejection fraction of forty percent or less and with a ferritin <100 or ferritin between 100 and 300 and TSAT <20%. The primary endpoints analyzed were readmission rates at 30 and 60 days and the number of patients with appropriate iron therapy initiated. Secondary endpoints will include the number of pharmacist-initiated interventions for iron panels, ferritin levels, and iron supplementation. For both study arms, results will be reported with male and female participants combined, as well as sex disaggregated.

Results: There were not statistically significant differences in age, sex, race, or left ventricular ejection fraction between the pre-intervention and post-intervention groups. Additionally, there was not a statistically significant difference in the type of iron administered, and more patients received sodium ferric gluconate compared to iron dextran across both groups. Post-intervention, 39 patients were initiated on appropriate IV iron therapy as opposed to only 7 pre-intervention, This was a statistically significant difference with a p-value of 0.007. Differences in readmission rates at 30 & 60 days were not statistically significant between groups, but a lower percentage of patients was readmitted post-intervention. Of the 39 appropriate IV iron initiations post-intervention, 23 were pharmacist-initiated, with the remaining being provider-led. The number of pharmacist-initiated orders was 18 for iron panels and 21 for ferritin levels. 

Conclusions: Pharmacist-led review significantly improved appropriate IV iron supplementation in patients with HFrEF. Considering that of the 39 patients initiated on appropriate IV iron therapy post-intervention, 23 orders were pharmacist-led, it can be concluded that providers are initiating IV iron therapy as well. Although results for readmission rates were not statistically significant, fewer patients were readmitted post-intervention. Orders for iron panels and ferritin levels were higher in the post-intervention group. Overall, these findings support pharmacist interventions in this patient population to improve adherence to guideline recommendations. 



Contact: [email protected]

Authors: Jada R. Guilford, PharmD; Taylor J. Merritt, PharmD; Sarah B. Green, PharmD, BCIDP, AAHIVP; Sujit Suchindran, MD, MPH; Benjamin Albrecht, PharmD, BCIDP; Emory University Hospital, Atlanta, GA  

Background: For more than 60 years, Vancomycin has been used to treat a variety of infections due to gram-positive organisms. Vancomycin has the potential to be nephrotoxic and ototoxic, subjecting patients to possible adverse events, and requires frequent monitoring to ensure appropriate use, increasing healthcare costs. Clinical guidelines currently recommend utilizing the ratio of 24-hour area under the curve (AUC) to minimum inhibitory concentration (MIC) for as the therapeutic target for dosing and monitoring, as this method improved patient outcomes in methicillin-resistant Staphylococcus aureus (MRSA) infections by ensuring adequate drug exposure while minimizing side effects. Currently, target AUCs range from 400-600 mg*hour/L for MRSA infections, assuming an MIC of ≤1 mg/L; however, there is limited data to support an AUC-based dosing strategy for non-MRSA gram-positive bloodstream infections. The purpose of this study is to assess the differences in select patient outcomes, particularly mortality and adverse events, by comparing time to blood culture clearance in patients with a vancomycin AUC ≥ 400 mg*hour/L and those with AUC <400 mg*hour/L within 5 days of therapy for non-Staphylococcus aureus and non-Staphylococcus lugdunensis gram-positive bloodstream infections.
Methods: This is an Institutional Review Board (IRB)-approved, single center, retrospective observational study. Patients were included if they were 18 years or older with a blood culture positive for a non-Staphylococcus aureus or non-Staphylococcus lugdunensis gram-positive organism and received IV vancomycin between May 1, 2024 and April 22, 2025. Patients were also included if they received ≥120 hours of vancomycin, had at least 1 vancomycin level, and vancomycin was still included in the antimicrobial regimen within 48 hours of culture clearance. Patients were excluded if the vancomycin indication was CNS infection, osteomyelitis, or endocarditis or if they did not meet the criteria for use of the Emory Healthcare AUC dosing protocol: on hemodialysis, peritoneal dialysis, or CRRT, had an acute kidney injury (AKI), weight >250 kg or BMI <20 kg/m2, or a peri-operative indication.
Results: A total of 55 patients met inclusion criteria, including 32 patients with an AUC <400 mg*hour/L and 23 patients with an AUC ≥400 mg*hour/L. There was no difference in the primary outcome of time to blood culture clearance between groups. The average time to blood culture clearance was 34.7 hours for AUC <400 and 37.1 hours for AUC ≥400 (p=0.515). More patients in the AUC ≥400 mg*hour/L group experienced acute kidney injury, but this difference was not statistically significant (17.4% vs 3.1%, respectively). Toxicity is typically seen in AUC > 650 mg*hour/L, and median AUC for each group was 293 mg*hour/L and 519 mg*hour/L respectively. There were no incidences of ototoxicity and one case of inpatient mortality in both groups. Inpatient length of stay was a median of 11 days (IQR 7-21.5) for AUC <400 mg*hour/L and 27 days (IQR 9-43.5) for AUC ≥400 mg*hour/L.
Conclusions: Both AUC groups had similar times to blood culture clearance without significant rates of adverse events or all-cause mortality.  Lower AUCs were associated with decreased length of stay; however, due to low rates of adverse events, and no matching for acuity beyond exclusion, this difference may not be related directly to different AUCs.

Background
Pharmacy technicians are essential members of the healthcare workforce, enabling pharmacists to practice at the top of their license while ensuring safe and efficient medication use systems. In July 2024 Wellstar MCG Health established the Inpatient Pharmacy Technician Practice Council (IPTPC) to facilitate collaboration, communication, and continuous improvement in pharmacy technician practice. However, due to scheduling conflicts and the prioritization of other initiatives it became inactive. The council was designed to empower technicians by giving them a formal platform to contribute to decision-making, standardization efforts, and process improvement initiatives. The purpose of this study is to evaluate whether a pharmacy technician–led council improves technician engagement, operational efficiency and quality metrics within the pharmacy department.

Methods
This is a single-center, pre-post interventional study assessing the impact of a technician-led council using surveys. Surveys were distributed through Qualtrics to all inpatient pharmacy technicians employed at WellStar MCG Health with response reminders employed. Survey items collected information about work experience, training, and work life attitudes generated from literature. The purpose of the surveys is to evaluate the impact of the initiatives implemented by the council and assess overall technician engagement. We excluded any inpatient pharmacy technician supervisors and any pharmacy technician part of the IPTPC. The primary outcome was technician engagement. Secondary outcomes included self and social perceptions of technicians, medication error rates, and turnaround time.

Results 
A total of 14 of 42 eligible pharmacy technicians completed the primary survey, corresponding to a 33% engagement rate. Response rates for medication delivery structure surveys increased from 9% pre-implementation (4/46) to 17% post-implementation (8/46). Most respondents had ≤4 years of experience (71%). Overall satisfaction with training was high, with 79% of respondents reporting being somewhat or extremely satisfied. Experiential learning factors, including prior work experience and mentorship from supervisors and peers, were rated as more valuable than formal training programs. Satisfaction with coworkers and workflow clarity was generally positive, however dissatisfaction regarding workload and opportunities for advancement was prevalent. Following implementation of the medication delivery schedule change, a higher proportion of respondents reported disagreement that the new medication delivery structure supported timely delivery and manageable workload. Medication delivery turnaround time remained unchanged (pre: 1.46 ± 0.52 hours vs post: 1.48 ± 0.56 hours).

Conclusion
Implementation of an inpatient pharmacy technician practice council demonstrated feasibility but did not result in measurable improvements in operational efficiency or technician engagement during the study period. Further research with larger sample sizes and sustained council activity is needed to better evaluate the impact of technician governance models on engagement, efficiency, and quality outcomes.

Objective 
To assess the impact of an inpatient pharmacy technician practice council on self and social perceptions of training and competency of technicians and operational efficiency in a hospital setting. 

Assessment Question
Which of the following statements best reflects the current understanding of inpatient pharmacy technician roles within a hospital setting?
A) Pharmacy technicians are primarily limited to distributive tasks, with minimal involvement in advanced responsibilities or workflow improvement initiatives
B) Decreased pharmacy technician job satisfaction is associated with opportunities for role expansion, professional development, and advanced responsibilities
C) Pharmacy technician involvement in structured governance models such as technician practice councils is well-established with literature demonstrating improvements across healthcare systems
D) While pharmacy technician role expansion is supported, the impact of structured governance models such as pharmacy technician practice councils remains under-explored and requires further evaluation

Title: Impact of an Inpatient Heart Failure Consult Service on Readmission Rates and Guideline-Directed Medical Therapy Prescribing: A Single-Center Pre-Post Intervention Study
Authors: Margaret Matthews, Jessica Yarbrough, Rachel Robinson
Purpose: The 2022 AHA/ACC/HFSA Heart Failure Guideline endorses the initiation, continuation, and reinitiation of guideline-directed medical therapy (GDMT) during hospitalization to improve clinical outcomes for patients with heart failure. GDMT use often varies in the hospital setting based on the patient’s clinical status, individual provider preference, concerns about transitions-of-care, and the dynamic course of acute heart failure. To standardize inpatient management and enhance GDMT optimization, our institution implemented an interdisciplinary inpatient heart failure consult service composed of an advanced heart failure cardiologist, clinical pharmacist, and nurse navigator. This study evaluated the impact of the service on 30-day readmission rates and GDMT prescribing patterns at our rural community hospital.
Methods: This single center, retrospective, pre-post intervention study included patients ≥ 18 years old admitted with a primary diagnosis of heart failure. Exclusion criteria followed the Centers for Medicare & Medicaid Services’ Hospital Readmissions Reduction Program criteria for heart failure readmissions. The pre-implementation period occurred from January 2024 to June 2024, and the post-implementation period occurred from June 2025 to November 2025. The data collected included patient demographics, renal function, heart failure type, discharging provider, GDMT changes during admission, GDMT prescribed at discharge, and documented contraindications. The primary outcome was 30-day-all-cause readmission rate. Secondary outcomes included 30-day heart failure-related readmission rate and change in GDMT from admission to discharge. Primary and secondary outcomes were compared between the pre- and post-implementation groups using descriptive statistics, with continuous data reported as means and categorical data reported as frequencies and percentages.
Results: A total of 447 patients were included in the analysis, with 254 patients in the pre-intervention group and 193 patients in the post-intervention group. Baseline demographics were similar between groups. Thirty-day all-cause readmission rates remained unchanged following implementation of the inpatient heart failure consult service (27% pre-intervention vs 27% post-intervention). Heart failure-related readmissions among readmitted patients decreased numerically from 51% in the pre-intervention group to 45% in the post-intervention group. Appropriate GDMT prescribing improved from admission to discharge in both groups, with a greater absolute improvement observed post-intervention (+38%, 36% to 74%) compared with pre-intervention (+13%, 41% to 54%). The largest post-intervention increases in individual GDMT classes were observed with mineralocorticoid receptor antagonists (+28%) and sodium-glucose cotransporter-2 inhibitors (+20%). Among post-intervention patients, 40% received a heart failure consult, with 27% readmitted within 30 days.
Conclusion: Implementation of an inpatient heart failure consult service was associated with increased use of GDMT at discharge and supported a more standardized approach to care. No difference in 30-day readmission rates was observed; however, not all eligible patients received a consult, which may have limited the overall impact of the intervention. Greater consult utilization and continued acceptance may further improve clinical outcomes, including readmissions.

Title: Impact of Early Resumption of Neuropsychiatric Medications on Sedation Outcomes in Critically Ill Patients 
Authors: Jade Gallahair, Victoria Biaggi, Morgan Turney, Joseph Trang  

Background: Delirium and agitation are common in critically ill adults and are associated with increased mortality, prolonged ventilation, and longer ICU and hospital stays. Withdrawal from chronic neuropsychiatric medications (NPMs), including SSRIs, SNRIs, benzodiazepines, antipsychotics, and gabapentinoids is a potentially modifiable contributor. Abrupt discontinuation may precipitate withdrawal symptoms such as anxiety, restlessness, insomnia, and psychosis, which can manifest as agitation or delirium in the ICU. Although emerging evidence suggests that early reinitiation of home NPMs may improve sedation and delirium outcomes, existing studies show mixed results, and no standardized guideline informs optimal timing. Additional evaluation is needed to clarify the clinical impact of early NPM resumption. The primary objective of this study is to determine whether early resumption of home neuropsychiatric medications reduces the incidence of agitation within the first 72 hours of ICU admission compared with delayed or no resumption. 

Methods: This multicenter retrospective observational cohort study assessed critically ill adults admitted to the ICU who were receiving chronic neuropsychiatric medications prior to hospitalization, focusing on patterns of agitation and timing of medication resumption. Patients were assigned to early initiation (£72 hours) or late initiation (>72 hours or not restarted during ICU stay) groups based on timing of NPM resumption upon ICU admission. The primary endpoint was incidence of agitation, defined as a Richmond Agitation Sedation Scale (RASS) score of +2 to +4 within the first 72 hours of ICU admission. Secondary outcomes included incidence of delirium, duration of mechanical ventilation, new start NPM during ICU admission, hospital length of stay and mortality.  
 
Results: Among the 101 patients initially reviewed, 52 individuals were excluded. A total of 49 patients were included in the final analysis, with 33 patients in the early restart group and 16 patients in the late or no restart group. Differences in baseline home medication classes were also observed, with fewer patients in the early start group prescribed benzodiazepines (21.2% vs 50%; p=0.040). There was no statistically significant difference in the incidence of agitation with 54.5% occurrence in the early start group and 68.8% in the late start (p=0.343). Secondary outcomes were similar between groups for mortality, incidence of delirium, new initiation of neuropsychiatric medications, duration of mechanical ventilation, and hospital length of stay. ICU length of stay was longer in the early start group (14.65 days vs 11.00 days; p=0.023).  

Conclusion: In this retrospective cohort study of critically ill adults with preexisting neuropsychiatric medication use, early resumption of home NPMs within 72 hours of ICU admission did not significantly reduce the incidence of agitation compared with delayed or no resumption. Notably, patients in the early restart group experienced a longer ICU length of stay, and baseline differences in home medication classes specifically benzodiazepines were observed between groups.

Background:
Medication discrepancies during transitions of care, including emergency department (ED) admissions, are prevalent and can lead to medication errors, adverse drug events (ADEs), and increased healthcare costs.1 Medication reconciliation is the formal process of creating the most accurate medication list and comparing it against medication orders.2 Accurate medication reconciliations are often limited by time constraints, incomplete medication history, and a lack of dedicated staff.3 Pharmacist led medication reconciliations increase accuracy and are shown to improve medication safety. On average, about two-thirds of pharmacists’ recommendations are accepted by clinical providers.1 In the two years since the Emergency Department Clinical Pharmacist Practitioners (ED CPPs) began conducting medication reconciliations at the Salisbury VA Medical Center (SBYVAMC), their impact has not been formally evaluated. The purpose of this quality improvement (QI) project is to assess the number and types of medication discrepancies identified through pharmacist-led medication reconciliations.  

Methods:
A retrospective chart review was conducted at the SBYVAMC from January 1, 2025, to April 1, 2025, utilizing the Computerized Patient Record System (CPRS). Veterans were included if they were 18 years and older, admitted to an inpatient service, and a complete medication reconciliation was performed by an ED CPP. Data collection was compiled in a secure, password-protected REDCap database. In CPRS, the ED CPPs enters medication reconciliation notes and document veterans' medication lists, provided by the veteran, guardian, or an external resource. Demographics, admission diagnosis, and prescription/medication information are recorded in the notes, and a pharmacist, provider, or other clinical team member are alerted. The primary outcome of this study is to identify the number and type of discrepancies identified per medication reconciliation. Secondary outcomes include the number of pharmacist interventions and high-risk medication interventions implemented by the clinical team.

Results:
Out of 418 unique veterans, 400 veterans met inclusion criteria. ED CPPs completed a medication reconciliation on 4.6 veterans a day - identifying a total of 1,400 discrepancies, with an average of 3.5 discrepancies per medication reconciliation and 16.1 discrepancies identified per day. Most medication discrepancies were reported by the veteran, caregiver, or both (n = 438). Most veterans identified as white, non-Hispanic males over the age of 65, which is consistent with the broader veteran population. The most common admitted services were general medicine (n = 223) and psychiatry (n = 113). The ED CPPs alerted 607 pharmacists, providers, or advanced practice providers to their medication reconciliation notes. The most common discrepancy was the veteran self-discontinuing their medication (n = 579), of which 66.3% were appropriately restarted during hospitalization. The second most common discrepancy was incorrect dose, frequency, or timing (n = 379), which was resolved upon admission 68.9% of the time. Another common discrepancy was veterans taking expired, discontinued, or completed medications (n = 345). The intervention to not order these medications upon admission occurred 71.9% of the time. Lastly, based on veteran’s renal function, the ED CPPs made 63 recommendations to hold or adjust medication dose. These recommendations were implemented 47.6% of the time. For high-risk medications, 107 medications were involved in discrepancies and 54 interventions were implemented. For veterans on insulin, the dose determined during medication reconciliation was ordered 27.3% of the time at admission.

Conclusion:
The volume of medication reconciliations and clinical recommendations provided by the ED CPPs improve the accuracy of admission medication regimens at SBYVAMC. This data will provide education to the clinical teams to review the medication reconciliation notes and implement ED CPPs’ recommendations as they see clinically appropriate.

Background: Contemporary literature calls for health systems to elevate and structure paid pharmacy internships so they benefit both learners and institutions, moving beyond purely distributive tasks and aligning with patient-care activities and workforce needs. While evidence exists that characterizes the structure and impact of single programs, no publications offer a comparison of program structure or utilize internal stakeholder opinion to influence development. This study is therefore timely and novel in using reported data from existing external programs and internal stakeholder data to inform the design of a comprehensive, hospital-based internship program.  

Methods: This study employed a cross-sectional, survey-based design to help inform the development of a comprehensive hospital-based pharmacy internship program. Electronic surveys were distributed via REDCap to leaders of pharmacy intern programs at external United States health systems and practicing pharmacists at the institution where the project took place. Surveys included quantitative items (e.g., demographics, program characteristics, Likert-scale perceptions of satisfaction and value) and qualitative open-ended questions exploring program strengths, gaps, and factors influencing intern retention. Data wase analyzed descriptively, with thematic analysis applied to qualitative responses. Findings will be used to identify impactful program elements and stakeholder priorities to inform internship program design.

Results: There were six external intern program survey participants. Progressive, multi-year programs made up 50% of the participants. Medication access, medication history, and discharge education were the most common intern activities. The median percent of time dedication to direct patient care was 40 (IQR 10-85). Interns also participated in journal clubs, patient case presentations, and medication use evaluations. Strengths identified by participants included staffing flexibilities, mutual benefit between interns and institutions, and positive mentoring experiences, yet increasing clinical opportunities, funding, and tracking intern errors and activities were identified as areas for improvement. There were 22 internal pharmacist survey participants. Of the 22, 12 were clinical pharmacist while 6 work in the central pharmacy. Pharmacists identified formal mentoring, project participation, clinical shadowing, transitions of care, direct patient care responsibilities, and the training of technicians and/or new interns as beneficial activities to possibly include in the new design. Pharmacists rated their current involvement as a 2 (IWR 1-4) on a scale of 1-10, but this number jumped to 5.5 (IQR 5-8) when asked how involved they are willing to be. Strengths identified by internal pharmacists included exposure to health system practice, strong operational integration, and high potential. Areas of improvement identified included lack of structure and organization, limited visibility and role clarity, insufficient mentorship and professional integration, underutilization, limited clinical exposure, and desire for longitudinal growth and leadership development. 

Conclusion: Institutions have established a need for more formal intern programs with a mutual benefit. There are vast difference in intern programs around the United States, so the development of a new program will more so reflect internal needs. Encouragingly, internal pharmacists are willing to take on a greater role once a formal program is established. The next step is to formalize the design of the program utilizing the survey results. 

Background:
Inflammatory bowel disease (IBD) is a group of chronic inflammatory gastrointestinal conditions characterized by symptoms of diarrhea, abdominal pain, and fatigue. Tumor necrosis factor (TNF)-alpha inhibitors are commonly used to treat these conditions by blocking activation of the pro-inflammatory cytokine TNF-alpha, which mediates inflammation in the gastrointestinal system. TNF-alpha inhibitors have a potential class-wide effect of causing hyperlipidemia; however, there is a paucity of data to show the extent to which hyperlipidemia can occur. To evaluate the prevalence and severity of changes in lipid profiles for patients prescribed TNF-α inhibitors for IBD.
Methods:
This single-center retrospective cohort study examined lipid panels of patients with IBD before and after initiation of TNF-alpha inhibitors. Included patients were age 18 or older, had a documented diagnosis of IBD, were taking a maintenance dose of a TNF-alpha inhibitor, and had lipid panels available within the 2 years before the TNF-alpha inhibitor was started and 2 to 5 years after the TNF-alpha inhibitor was started. Patients were excluded if they were taking TNF-alpha inhibitors for a condition other than IBD. The study period was individualized per patient, spanning from 2 years prior to up to 5 years after the TNF-alpha inhibitor start date. The primary objective of this study was to determine the volume of patients with an increase in either total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), or triglycerides after starting TNF-alpha inhibitor treatment. The secondary objective was to measure the change in lipid panel values after initiation of TNF-alpha inhibitor treatment. Data was collected by both electronic medical record reporting software and manual chart review by the investigator. Descriptive statistics were used for the primary objective, and the Wald Test was used for the secondary objective, controlling for variation within individuals and adjusting for lipid medications, cardiovascular diagnosis, and high or low dose medication status. 
Results:
Overall, 195 patients were included in this analysis. The most used TNF-alpha inhibitors were infliximab and biosimilar (56.4%), and adalimumab and biosimilar (40.6%). Among patients included, 29.2% were taking high-dose maintenance therapy, and 59.5% of patients had a concomitant cardiovascular disease state diagnosis (including hypertension, atherosclerotic vascular disease, hyperlipidemia, history of stroke/cerebrovascular accident or venous thromboembolism). During the study period, 30.7% of patients were taking anti-hyperlipidemic medications. After TNF-alpha inhibitor initiation, 52.3% of patients had an increase in total cholesterol, 20% had an increase in triglycerides, 49.2% had an increase in LDL, and 64.6% had an increase in HDL.  The mean increase in total cholesterol was 5.25 mg/dL (95% CI [0.53, 9.97]; p=0.029). The mean increase in HDL from baseline to follow-up was 4.3 mg/dL (95% CI [2.69, 5.91]; p<0.001). The mean changes in LDL and triglycerides from baseline to follow-up were not statistically significant.
Conclusions:
In this study, a statistically significant increase in total cholesterol and HDL was observed in patients taking maintenance doses of TNF-alpha inhibitors for inflammatory bowel disease. No statistically significant difference in triglyceride or LDL levels was observed. It is possible that the change in total cholesterol was driven by the increase in HDL levels, however, increases in HDL levels are typically advantageous from a cardiovascular disease prevention standpoint. More research is needed to determine if the change in cholesterol levels is clinically significant to cardiovascular risk in patients with inflammatory bowel disease. Limitations of the study include variations in lipid panel lab ordering by providers and an assumption that patients who received maintenance dosing of TNF-alpha inhibitors continued treatment throughout the study period. Additionally, while it was recorded if patients were taking antihyperlipidemic medications, we did not stratify these medications based on degree of lipid-lowering ability.

Title: Analgesic Dose Ketamine Infusion for Pain Control of Trauma Patients in the Critical Care Setting

Authors: Alyssa Sangalang, Brooke Gallman, & Jamie McCarthy

Practice Site: Piedmont Athens Regional Medical Center

Introduction: Adequate pain control is essential in the management of traumatic injuries. Per the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, Sleep Guidelines and the 2024 American College of Surgeons Trauma Quality Improvement Programs Best Practice Guidelines, opioids remain as the standard treatment approach with trauma induced pain. However, because of the deleterious effects of opioids, such as hypotension, hypoxia, decreased gastrointestinal motility, and tolerance, these guidelines recommend a multimodal analgesic approach for sparing opioids and therefore, avoiding unwanted side effects. Ketamine is a N-methyl-D-aspartate receptor antagonist that has analgesic properties at low doses (<0.5 mg/kg/hr) and is a component of the multimodal approach. Ketamine usage at Piedmont Athens Regional (PAR) has previously been utilized for pain as single dose, push orders. Additionally, ketamine use has been ordered at higher, titratable doses for indications such as sedation and agitation. At higher doses, ketamine requires patient monitoring due to the potential risk of cardiovascular, respiratory, and psychiatric events. The analgesic dose ketamine infusion could be a favorable option because it provides analgesia while reducing these potential risks. The primary objective of this study was to determine if the intervention of analgesic dose ketamine infusion would be a safe and effective adjunct therapy to opioids for pain control in trauma patients.

Methods: This single-center, IRB-exempt, pre-post interventional study was completed via a chart review. The intervention investigated was a low, analgesic dose ketamine infusion for pain control in patients admitted due to trauma. The pre-intervention group included patients from October 1st, 2024, to February 28th, 2025, who would have met criteria to receive an adjunct analgesic dose ketamine infusion for pain control if the guidance had been readily available. Patients admitted during this pre-specified period were randomized and data collected on the number of patients necessary to match the post-intervention group.  The inclusion criteria included age greater than 18 years and admission to ICU for a trauma event. The exclusion criteria included pregnancy and contraindications to ketamine. The post-intervention group included patients admitted from October 1st, 2025, to February 28th, 2026. The primary outcome was oral morphine milligram equivalents (MME) per day between the pre- and post-intervention groups. Secondary outcomes were numeric rating pain scores, other multimodal pain modalities received, lengths of stay, oral MME at discharge, and adverse events related to ketamine.   Data between the two groups was analyzed with Microsoft Excel. Chi-square tests were utilized for categorical data and reported as number and percentage. Paired and unpaired t-Test and two-way ANOVA were used for continuous parametric data and reported as mean and standard deviation as appropriate. Outcomes were considered statistically significant if the p-value is ≤ 0.05.

Results: Seven patients were included in the pre- and post-intervention groups. For the primary outcome, the pre-intervention group had an average of 54 oral MME per day compared to 44 oral MME in the post-intervention group (p = 0.26). There was no difference in pain scores between groups over time (p = 0.61) or MME at discharge (p = 0.087). There was a reduction in pain scores prior to and 24 hours after ketamine initiation (p = 0.006). No difference in heart rate or mean arterial pressure was detected between groups (p = 0.22 and p = 0.08). No adverse events were reported in the post-intervention group due to ketamine.

Discussion: A low, analgesic dose ketamine infusion did not detect a difference in oral MME in this small cohort. However, ketamine reduced pain at 24 hours and appeared to be a safe adjunct to opioids.

Authors: Matthew Huebner, Julie Willmon, Kevin Pacheco

Background 
Septic shock is a life-threatening condition characterized by a dysregulated host response to an infection. Hydrocortisone and fludrocortisone are corticosteroids that are proposed to modulate the host response and may improve outcomes in septic shock. In the ADRENAL trial, hydrocortisone did not lower mortality versus placebo1, whereas the APROCCHSS trial demonstrated a mortality benefit with the combination of hydrocortisone plus fludrocortisone2. Evidence from clinical trials is conflicting, and there is a gap in trial data comparing the combination to hydrocortisone monotherapy. However, guidelines suggest the use of both hydrocortisone and fludrocortisone for critically ill patients with septic shock3. The objective of this study is to assess clinical outcomes associated with the current prescribing practices of corticosteroids in septic shock at AdventHealth Central Florida Division hospitals. 

Methods 
A retrospective analysis was conducted in critically ill patients with septic shock to evaluate the effect of hydrocortisone versus hydrocortisone plus fludrocortisone. The primary outcome was the number of vasopressor free days (VFD) out of 28. Secondary outcomes included dose of norepinephrine upon initiation of corticosteroids, number of vasopressors, days of vasopressors, hours of vasopressors, need for mechanical ventilation, duration of mechanical ventilation, recurrence of shock, in hospital mortality, and time to discharge from ICU and hospital. Safety outcomes included new onset infections, number of days with blood glucose >180 g/dL, and number of days with serum sodium out of normal range. 

Results 
From the 140 patients included in this analysis, the median vasopressor free days out of 28 was 0 days (IQR 0-24) in the hydrocortisone group versus 0 days (IQR 0-24) in the hydrocortisone plus fludrocortisone group (P=0.59). When vasopressor free days are adjusted for hospice related deaths, the median VFD was 21.5 days (IQR 0-25) in the hydrocortisone group versus 19 days (IQR 0-24) in the hydrocortisone plus fludrocortisone group (P=0.32). The days of vasopressors were significantly higher in the hydrocortisone plus fludrocortisone group (5 vs 3 days, P=0.005) and hours of norepinephrine (83.0 vs 52.4 hours, P=0.008), vasopressin (51.2 vs 35.6 hours, P=0.04), phenylephrine (83.2 vs 18.3 hours, P=0.03) but not epinephrine (43.8 vs 27.2 hours, P=0.21) compared to the hydrocortisone group. Secondary outcomes for each group were similar, which included the dose of norepinephrine when corticosteroids were initiated in the hydrocortisone plus fludrocortisone group compared to hydrocortisone alone (0.2 vs 0.3 mcg/kg/min, P=0.34), number of vasopressors (2 vs 2 vasopressors, P=0.38), mechanical ventilation (63.9% vs 78.6%, P=0.09), duration of mechanical ventilation (4 vs 3 days, P=0.76), recurrence of shock (15.7% vs 15.7%, P=1.0), in hospital mortality (34.3 vs 37.1%, P=0.72), time to ICU discharge (6 vs 6 days, P=0.19), and time to hospital discharge (11 vs 10 days, P=0.55). The safety outcomes were also similar among both groups, which included new onset infections in the hydrocortisone plus fludrocortisone group compared to hydrocortisone alone (5.7% vs 5.7%, P=1.0), median number of days with BG>180 g/dL (1.5 vs 2 days, P=0.14), and median number of days with sodium out of normal range (1 vs 1 day, P=0.65). 

Conclusion 
Among critically ill patients with septic shock, the number of vasopressor free days did not significantly differ between the hydrocortisone plus fludrocortisone and hydrocortisone monotherapy groups. However, the days of vasopressor use was higher in the group containing fludrocortisone. 

Comparison of cefazolin plus ertapenem to alternative approaches in patients with persistent MSSA bacteremia while on cefazolin
Natalie Harris, PharmD1; Caroline Jozefczyk, PharmD, BCIDP2; Jake Crocker, PharmD, BCIDP2; Sarah Al Mansi, MD1; Brandon Bookstaver, PharmD, BCIDP1,3

• Prisma Health Richland Hospital, Columbia, SC
• Prisma Health Greenville Memorial Hospital, Greenville, SC
• University of South Carolina College of Pharmacy, Columbia, SC

Background: Persistent methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia despite standard cefazolin therapy poses a significant clinical challenge. Historically, salvage approaches have involved anti-staphylococcal penicillins (ASPs), given the growing concern for cefazolin inoculum effect. With ASPs less favorable pharmacokinetic and safety profile, various combination regimens have emerged as potential alternatives. Data directly comparing salvage strategies remains limited. This study compared outcomes of cefazolin plus ertapenem versus alternative salvage therapies in persistent MSSA bacteremia.
Methods: This retrospective cohort study included adults who failed cefazolin and received salvage therapy for persistent MSSA bacteremia from March 1, 2021 to August 31, 2025. Patients were excluded if they transferred from another hospital, had polymicrobial bacteremia, died within 24 hours, or received empiric therapy for > 24 hours after positive blood cultures. The primary objective was to compare the duration of MSSA bacteremia after salvage therapy in patients receiving cefazolin plus ertapenem versus alternative salvage strategies. Secondary objectives included all-cause mortality, infection related re-admission, and adverse effects (ADEs) in both groups.
Results: Fifty-seven patients were included, with 30 in the cefazolin plus ertapenem cohort and 27 in the alternative cohort. The most common source was skin and soft tissue (n=19, 33.3%), and endocarditis was the most common complication (n=17, 29.8%). Most patients in the alternative salvage cohort received nafcillin (n/N=19/30, 70.4%). The average duration of bacteremia after salvage was 1.6 and 2.8 days in the cefazolin plus ertapenem and alternative cohorts, respectively. Patients receiving cefazolin plus ertapenem experienced higher rates of 90-day mortality (23.3% vs 22.2%) and infection-related re-admission (26.7% vs 11.1%), however, patients receiving alternative salvage therapy experienced more ADEs (51.9% vs 36.7%).
Conclusion: Cefazolin plus ertapenem shortened bacteremia duration and led to less ADEs compared with alternative regimens, supporting the use of this combination as a salvage therapy option in persistent MSSA bacteremia.

Title: Ketamine versus Dexmedetomidine for ICU Sedation
Authors: Rebecca Olisa, Anh Nguyen, Jana Mills, Nikulkumar Chaudhari, MD
Background/Purpose:
Critically ill, mechanically ventilated patients often require sedation to manage pain and agitation. Traditional agents like benzodiazepines and propofol can prolong ventilation and increase intensive care unit (ICU) delirium. Ketamine, an N-methyl-D-aspartate (NMDA) antagonist, offers potent analgesia and hemodynamic support but carries a risk of psychomimetic effects. Conversely, dexmedetomidine, an alpha-2 agonist, provides cooperative sedation and reduced delirium without respiratory depression, though its use is often limited by bradycardia and hypotension. Evidence suggests that using these agents, individually or combined, can improve sedation quality, stabilize hemodynamics, and reduce time to extubation when compared to traditional sedatives.
This retrospective chart review evaluated the impact of ketamine or dexmedetomidine on clinical outcomes in mechanically ventilated patients with the primary endpoint being time from initiation of continuous sedation, with ketamine or dexmedetomidine, to successful extubation.
Methods:
This single-center retrospective cohort study was conducted between October 31, 2022, and July 31, 2025. Adult patients were eligible for inclusion if they required mechanical ventilation and received continuous infusions of either ketamine or dexmedetomidine, whether administered alone or were begun as adjuncts to wean traditional sedatives.
Patients were excluded from the analysis if they failed to receive either dexmedetomidine or ketamine, or if they received both agents concurrently or sequentially during a single ICU stay. Further clinical exclusions included patients receiving ketamine at a fixed rate or a dose exceeding 2 mg/kg/hour, those with an overlap of more than 24 hours between primary and adjunctive sedatives, individuals with an ICU stay of less than 24 hours or mortality prior to extubation, and patients who were transitioned to comfort measures, diagnosed with anoxic brain injury, or pregnant.
The primary endpoint was the time from initiation of continuous sedation with ketamine or dexmedetomidine to successful extubation. Secondary assessments included ICU length of stay, total ventilator duration, and the incidences of ICU mortality, hemodynamic instability, and delirium.
Results:
A total of 20 patients met inclusion criteria, 7 in the ketamine group, and 13 in the dexmedetomidine group. The two groups were similar in age (mean 55.6 ± 14.7 vs. 60.8 ± 14.6 years, p = 0.751) and sex distribution (57.1% vs. 53.8% female). Median pre-initiation ventilation times for ketamine and dexmedetomidine were 7.82 vs. 12.30 hours (p=0.699). These comparable durations, alongside similar Richmond Agitation-Sedation Scale scores (RASS), indicate equivalent sedation depth and suggest that pre-sedation ventilation did not confound the primary outcome. For the primary endpoint, ketamine was associated with a shorter median time from sedation initiation to extubation compared to dexmedetomidine (15.5 vs. 23.2 hours), though this difference did not reach statistical significance (p = 0.157). Among secondary endpoints, ketamine patients had numerically shorter total ventilator duration (median 24.3 vs. 39.9 hours, p = 0.097) and ICU length of stay (median 2.0 vs. 3.0 days, p = 0.057). Rates of ICU delirium were lower in the ketamine group (28.6% vs. 46.2%, p = 0.642), as were rates of hemodynamic instability (0% vs. 15.4%, p = 0.521). No deaths occurred in either group during the ICU stay.
Conclusion:
This retrospective pilot study compared ketamine and dexmedetomidine as primary weaning agents for mechanically ventilated patients at two sites within a single healthcare system. Although underpowered for statistical significance, ketamine was associated with shorter times to extubation, reduced ventilator duration, and shorter ICU stays. Furthermore, the ketamine group experienced lower rates of delirium and hemodynamic instability, with no deaths in either cohort. These findings suggest a consistent trend favoring ketamine and support the rationale for a larger, randomized study to definitively evaluate its utility as a weaning sedative in this population. Future research should incorporate illness severity scoring and standardized weaning protocols to build on these promising preliminary trends.

 
Authors: Maria Onusko, Olivia Caron, Marcia Thacher, Carriedelle Fusco, and Nabarun Dasgupta  

Background: Buprenorphine is a life-saving treatment for opioid use disorders (OUD) often co-formulated in a sublingual product with the opioid antagonist naloxone as a diversion prevention measure. While pharmacokinetic studies suggest the amount of naloxone absorbed with proper sublingual administration is negligible, some studies have observed more interpatient variability.1,2,3 Patients can report adverse effects of the combination, buprenorphine-naloxone product, such as headache, nausea, vomiting, dyspepsia, diaphoresis, and fatigue.4  This study sought to assess the levels of naloxone detected in confirmatory urine drug screens (UDS), interpatient variability of naloxone absorption, and any patient specific characteristics (labs, comorbidities, concurrent medications) that may impact absorption of naloxone sublingually. Chart reviews were also conducted to identify any withdrawal symptoms reported at the time of the drug screen.  This study was conducted at the Mountain Area Health Education Center (MAHEC), a federally qualified health center in Asheville, NC. The OBOT clinic is a part of one of MAHEC’s outpatient family medicine clinics.  

Methods: As a qualitative improvement project, the research team requested a registry for all patients on buprenorphine-naloxone products between 5/1/2023 and 9/1/2024. Data points extracted from EHR include patient name, patient identification number, date of birth, age, height in inches, weight in kilograms, primary insurance carrier, concomitant benzodiazepine prescribed, type of buprenorphine-naloxone product, strength of product, duration of medication for OUD treatment at Mountain Area Health Education Center’s OBOT program, serum creatinine, LFTs, and date of last BMP. Two PharmD students manually extracted the following data points between 7/1/24 and 9/30/24: dosing instructions, total daily buprenorphine dose, total daily naloxone dose, quantities of buprenorphine, norbuprenorphine, and naloxone present on UDS, any other positive results on UDS, date of last confirmatory urine drug screen, any withdrawal symptoms reported at time of UDS, and other pertinent comorbidities (Hepatitis C, NASH, cirrhosis).  Due to the high number of patients with reported naloxone, this project was expanded to a research analysis. IRB #2402187 submitted in March 2025 and granted exemption.  Data will be analyzed by a research scientist. Results will be reviewed and themes identified by the research team.  

Results 
In progress 

Conclusions: 
In progress 
 
References:  

1. Heidbreder C, Fudala PJ, Greenwald MK. History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder. Drug and Alcohol Dependence Reports. 2023;6:100133. doi:10.1016/j.dadr.2023.100133  

1. Strickl DM, Burson JK. Sublingual Absorption of Naloxone in a Large Clinical Population. Journal of Drug Metabolism & Toxicology. 2018;9(4):1-4. Accessed March 31, 2026. https://www.longdom.org/open-access/sublingual-absorption-of-naloxone-in-a-large-clinical-population-25281.html 

1. Michel I, Ochal D, Paharia A, Jannetto P, Breitinger S, Oesterle T. Absorption of naloxone in patients prescribed buprenorphine‐naloxone. The American Journal on Addictions. Published online February 2, 2025. doi:https://doi.org/10.1111/ajad.13674 

1. Providers Clinical Support System Medications for Opioid Use Disorders Buprenorphine Prescribing Flexibility: Buprenorphine Prescribing Flexibility: Buprenorphine Monoproduct for Adverse Effects Buprenorphine Monoproduct for Adverse Effects from Buprenorphine/Naloxone from Buprenorphine/Naloxone. https://pcssnow.org/wp-content/uploads/2024/03/Buprenorphine-Prescribing-Flexibility.pdf  

 

Healthcare is undergoing a transformative shift, largely driven by the growing utilization of biologic therapies. While biologics have significantly advanced the treatment of complex and chronic diseases, their high costs have introduced considerable financial strain on both healthcare systems and patients. The creation of biosimilars, agents that are highly similar to their branded reference biologics, have emerged as a promising solution. They offer substantial cost savings and increased patient access without compromising therapeutic efficacy. However, the widespread adoption of biosimilars has been hindered by several challenges, including complex regulatory pathways, evolving reimbursement models, inventory management issues, and payer-imposed restrictions.

Developing and implementing a biosimilar formulary presents unique challenges that Pharmacy and Therapeutics (P&T) Committees have not traditionally encountered. This project was initiated with two primary objectives. The first objective is to establish a systematic process for evaluating both current and future biologic agents in order to develop and maintain a comprehensive formulary for the health system. To achieve this, a structured evaluation framework was created, encompassing key considerations such as drug availability, acquisition cost, site of care, reimbursement pathways, payer policies, and patient access. The data collected through this framework is then analyzed and synthesized into a biologics formulary. Unlike traditional formularies, which often designate a single preferred agent, this biologics formulary ranks the reference product and its biosimilars by site of care, enabling more nuanced and context specific decision making.

The second objective is to implement a standardized workflow that integrates formulary based decision making into clinical practice seamlessly, with no disruption to patient care. To accomplish this, a multidisciplinary team of clinical providers, prior authorization coordinators, and reimbursement specialists collaborates to operationalize the formulary. This integrated approach ensures that the most clinically and economically appropriate agent is selected, balancing the needs of both the health system and the patient.

Looking at biologic invoices for the cancer center with actionable products from September 1, 2025 to March 30, 2026, a total of 963 units were purchased equaling a total of $890,795.56. Reference products accounted for $261,456.22 of the total with only 109 units purchased. Even though the quantity of biosimilars purchased was initially greater than expected, there was a lack of consistency in ordering prior to initiating the formulary, creating missed opportunity for selecting the preferred product with the most reimbursement. Based on the same purchasing data, if all products were switched to the most preferred biologic, it is estimated to have saved a total of $496,625.04. The totals excluded biologics that did not have available biosimilars.

Implementing a biologic formulary has the potential to generate considerable savings and reimbursement. The creation and maintenance of the formulary was without significant challenge. However, the implementation into patient care did have a few setbacks. Most notably there were multiple instances where the most preferred product could not be selected due to insufficient quantities available for purchase, forcing the decision to choose the next best product with reliable stock to not delay patient treatment. There are also instances where patient preference for convenience outweighs the transition to the preferred biosimilar. The majority of implementation of the biosimilar formulary remains at initiation of a new start to therapy, with a few patients transitioning to the preferred biosimilar at the time of insurance authorization renewal. Despite the few setbacks, the initial data are reassuring to confirm the potential of cost savings and maximizing reimbursement to lower financial burden on both the health system and patients.

Outcomes Associated with Implementation of an Electronic Health Record Based Automatic Infectious Disease Consultation for Positive Blood Cultures with Staphylococcus aureus 

Authors: Taylor Bird, Elise Richoux, Brandon Hawkins, Samantha Walker, Miller Hadley, Amber Wolfe 

Background: 
Staphylococcus aureus bacteremia is often associated with high rates of morbidity and mortality if not managed appropriately. Infectious Diseases (ID) involvement in the clinical care of these patients has demonstrated reduced mortality, with early ID consultation also associated with decreased hospital length of stay. This study aims to evaluate the impact of an automatic electronic-health record (EHR) based ID consultation for patients with S. aureus bacteremia. This study will assess whether the automatic ID consultation protocol improves hospital length of stay, time to ID consultation, and time to targeted therapy.  

Methods:
This single-center, retrospective, observational cohort study evaluated the impact of an EHR based automatic infectious disease consultation order for patients with S. aureus bacteremia. This protocol was implemented July 1, 2024. The pre-intervention group was composed of hospital encounters from June 1, 2022 through May 31, 2024, while the post-intervention group contained hospital encounters from July 1, 2024 through April 30, 2025. The primary outcome evaluated overall hospital length of stay. Secondary outcomes included time to ID consultation, time to targeted therapy, and pharmacist interventions recommending ID consultation. Potential subjects were identified via a list generated from clinical surveillance software (TheraDoc). List composition components included patients with at least one positive blood culture for S. aureus. Patients were included in the study, if they were 18 years of age or older and received an ID consultation during the related hospitalization. Exclusion criteria included death or transition to hospice within 48 hours of a positive culture result, patient directed discharge prior to clinical stability, or consult communication to the ID service greater than 24 hours after the EHR automatically ordered an ID consult. Statistical analysis will be performed using SPSS (IBM). Categorical data will be analyzed using Chi-Square or Fisher’s Exact tests. Continuous data will be analyzed using Student’s t-test or Mann-Whitney U test, as appropriate.  

Results:
Hospital length of stay was significantly shorter in the post-intervention groups as compared to the pre-intervention group (15.3 vs 19.1 days p = 0.01). Time to ID consultation was not significantly different, with a mean of 0.38 ± 1.35 days in the pre-intervention group compared to 0.52 ± 0.48 days in the post-intervention groups (p = 0.226). Time to targeted antibiotic therapy was significantly shorter in the post-intervention group with a mean of 2.40 days compared to 2.90 days in the pre-intervention group (p = 0.039). Pharmacy interventions recommending ID consultation were significantly lower in the post-intervention group (5.7% vs 0%; p = 0.001).

Conclusions: 
The implementation of an electronic health record based automatic infectious disease consultation protocol for Staphylococcus aureus bacteremia resulted in significant reductions in overall hospital length of stay and decreased the time to targeted antibiotic therapy.