2026 Southeastern Residency Conference

CLASS OF TRADE: AN EXPLORATORY REVIEW THROUGH THE LENS OF A NATIONAL GROUP PURCHASING ORGANIZATION
Benton Zielinski, Laura Crow, Samantha Randlett, Alyssa Huff, Jason Braithwaite
HealthTrust Performance Group/University of Tennessee Health Science Center – Nashville, TN
Background/Purpose: Class of Trade (COT) is a classification of types of healthcare facilities that pharmaceutical suppliers use to determine the price facilities pay for pharmaceutical products. For example, hospitals and retail pharmacies may be classified in different COTs and thus may pay different prices for the same product. No industry standard criteria exist for COT definitions or eligibility determination. Lack of standardization leads to inconsistent COT eligibility determination across pharmaceutical vendors. The purpose of this research was to clarify COT definitions and eligibility criteria as defined by pharmaceutical suppliers to empower healthcare facilities to optimize their pharmaceutical pricing via appropriate COT designation.

Methodology: This was an exploratory review, designed to assess how pharmaceutical suppliers determine COT eligibility. Eligible participants were pharmaceutical suppliers with active contracts with HealthTrust Performance Group (HPG). An anonymous survey was sent to 115 eligible suppliers. Respondents were asked to indicate their supplier type based on their predominant pharmaceutical products (Brands/Reference Biologics, Generics/Biosimilars, or Mixed), whether they use standard definitions for COT, whether an internal or external team determines facility eligibility, and which identifiers are used in this determination. Additionally, respondents were requested to provide their definitions for COTs. The primary endpoint was the frequency distribution of each COT based on total reports across responses. Secondary endpoints were percentage of COT criteria alignment to HPG standard definitions and the number of COTs indicated, both reported by supplier type.

Results: A response rate of 13.0% was achieved, with 15 respondents out of 115 invited to participate. Of these respondents, 8 (53.3%) indicated their supplier type as Brands/Reference Biologics, 5 (33.3%) as Generics/Biosimilars, and 1 (6.7%) as Mixed. The frequency distribution of each COT was reported as follows: 14 (93.3%) Acute Care Hospital; 12 (80.0%) Long Term Care; 11 (73.3%) Ambulatory Care (Hospital-Based); 10 (66.7%) Retail Pharmacy (Specialty); 9 (60.0%) Ambulatory Care (Community-Based); 9 (60.0%) Home Health Care; 9 (60.0%) Retail Pharmacy (Non-Specialty); and 10 (66.7%) use ≥1 additional COT not listed in the survey. Use of standard COT definitions was reported by 14 (93.3%) respondents, with 10 (66.7%) determining COT eligibility internally, 1 (6.7%) externally, and 4 (26.7%) both internally and externally. Average COT criteria alignment between respondents’ definitions and HealthTrust standard definitions were 68.0% for Brands/Reference Biologics, 45.1% for Generics/Biosimilars, and 87.5% for Mixed. The average and range of number of COTs indicated were 9.56 (0-37) for Brands/Reference Biologics, 17.4 (6-31) for Generics/Biosimilars, and 8 (8-8) for Mixed.

Conclusions: Although sample size was limited, this exploratory review identified considerable heterogeneity in COT definitions and facility eligibility criteria across pharmaceutical suppliers, with lower alignment observed among Generics/Biosimilars compared with Brands/Reference Biologics. The lack of standardized, public COT definitions prevents healthcare facilities from optimizing pricing and access to pharmaceutical products, ultimately impacting patient care by constraining financial sustainability.

Background
Autoverification is the process in which a medication is automatically verified after provider order entry, without pharmacist review.  Autoverification of antimicrobials in the emergency department was implemented following health system integration to align with system-wide autoverification practices; however, this was subsequently reverted to reinstate pharmacist verification. Timely administration of antimicrobials has long been recognized as a cornerstone of improving patient outcomes, particularly in those with sepsis. While most autoverification studies focus on quality and process improvement, there is limited data on the impact on clinical outcomes. To address this gap, this study examined if there is a difference in timely administration between autoverified and pharmacist verified antimicrobials. 

Methods
A retrospective chart review of patients bedded in the adult and pediatric emergency departments who received an initial dose of oral or parenteral antimicrobial between November 16th, 2024 and January 16th, 2025, was conducted. Eligible patients were separated into two groups: the control group, during which autoverification of antimicrobials was permitted, and the intervention group, during which autoverification of antimicrobials was not allowed. The primary outcome was administration of antimicrobials within one hour of order entry. Secondary outcomes included pharmacist intervention rates and alerts per 100 orders.   

Results
A total of 300 orders from 235 patients were included in the analysis, 150 orders in the control group; 150 orders in the intervention group. Significant differences in patient demographics were observed for age, race, and infections (abdominal, bloodstream/catheter-related, empiric/unknown). A significant difference was also observed in the order characteristics for the dispense location. One hundred and three (68.7%) orders in the control group and 87 (58%) of orders in the intervention group were administered within one hour (x2 = 3.67, (p = 0.055)).  Compared with the control group, the intervention group observed higher rates of pharmacist intervention (1.33 vs 20 per 100 orders; IRR, 15; 95% CI, 3.58–62.7) and alerts (58 vs 104 per 100 orders; IRR, 1.79; 95% CI, 1.38–2.33). 

Conclusion
This study found no difference in administration of antimicrobials within one hour between the control and intervention groups. The intervention group generated more alerts and required greater pharmacist involvement. Together, these findings suggest that excluding antimicrobials from autoverification does not negatively impact timely administration of antimicrobials and may preserve the safety benefits associated with pharmacist verification. 



Contact: [email protected]

Title: Evaluation of the Medication Discrepancy Rate at Discharge
Purpose: Medication errors during hospital admissions have unfortunately followed patients out of the hospital. Many hospitals aim to resume accurate home medications within 24 hours of admission. However, medication discrepancies at the point of hospital discharge can be overlooked. The prevention of unnecessary or potentially harmful medications at discharge could reduce medication errors as well as provide a potential cost-savings opportunity for the health system. The purpose of this study is to evaluate the rate of medication discrepancies at hospital discharge by comparing prior-to-admission medication lists to discharge medication orders.
Methods: This study is an institutional review board approved, retrospective chart review. Patients discharged from Mobile Infirmary Medical Center between June 1st, 2025 to August 31st, 2025 will be randomized and evaluated by a manual chart review. Medication discrepancies are defined as intentional or unintentional differences between medication lists.  Patients will be excluded if they did not have a home medication list marked as “complete” during the admission, left the hospital admission against medical advice or had more than 2 readmissions during the study period. The primary outcome of this study is to identify the rate of medication discrepancies per medication in patients with a completed prior to admission list. Our secondary outcomes include 30-day readmission rates, types of medication discrepancies, and most common drug classes associated with errors. A subgroup analysis will be completed on patients with at least one unintentional discrepancy, focusing on average number of discrepancies per patient, average length of stay, and average number of home medications. Data that will be collected includes: patient demographics and types of medication discrepancies at the time of hospital discharge.
Results: A chart review was conducted on 350 patients. 137 were excluded, and our final included population was 213. Of the excluded patients, 77 had incomplete prior-to-admission (PTA) lists, 25 did not have any home medications on admission, 24 did not have a discharge medication reconciliation completed, and 11 were readmitted more than twice at the time of review. Baseline characteristics included a mean age of 67 + 14.5, 46% of our population were male, the mean length of stay was 14.3 [5] days, and the mean number of home medications was 6.3 + 4.2. The rate of unintentional medication discrepancies per medication was 6.6%. 87 out of 1345 medications screened had an unintentional discrepancy. The most common type of discrepancy was omission, which accounted for 54% of unintentional discrepancies. Dose was next at 16%, followed by frequency at 13%, other reasons at 9%, duplication at 5%, and route at 3%. Of our total population, 14% were readmitted within 30 days, and 21% of those readmitted had unintentional discrepancies. The top five most common drug classes were analgesics, insulin, statins, beta-blockers, and anticoagulants. 54 (25%) patients from our population had at least one unintentional discrepancy. We found that 85% of these patients had 1-2 discrepancies, 11% had 3-4 discrepancies, and 4% had 5-6 discrepancies. The mean number of discrepancies per patient was 1.6 + 1.1, the mean length of stay in this subgroup was 9.5 [5], and the mean number of home medications was 7.6 + 4.3.
Conclusion: Our study consisted of a thorough chart review of initially 350 patients. Based on exclusion criteria, the included sample size was 213, which is a decently sized sample. Our criteria allows for decent generalizability as it included any adult discharged from mobile infirmary in the span of 3 months, however it did exclude incomplete lists as to focus on discharge medications. We also had to assume that the completed reconciliation was as accurate as possible. This was also a single-center study, though at a large community hospital, and was retrospective, so there was a lack of true control. In conclusion, our study shows that medication discrepancies can still occur at discharge despite a completed prior to admission list, and the medications that have errors are high-risk medications. Future directions include scoring tools, artificial intelligence, and prioritizing the assessment of home medications while on disciplinary rounds. We are hopeful that this study procures a dedicated pharmacist-led reconciliation team and additional medication reconciliation protocols at discharge.

Background: Credentialing and privileging (C&P) formally authorize clinicians to perform defined scopes of practice within a healthcare organization and are widely used for physicians and advanced practice providers. Health‑system pharmacists increasingly deliver protocolized, outcome‑oriented care (dose adjustments, laboratory ordering, device‑data interpretation), yet local processes to recognize this work vary. In South Carolina, pharmacist C&P is not currently implemented, and statewide regulatory guidance for pharmacist‑physician collaborative practice is evolving. To inform the development of a systemwide pharmacist C&P policy and a privilege set that consolidates common, evidence‑based activities currently requiring provider co‑signature, we conducted two surveys: one to characterize internal pharmacist readiness and priorities, and one to benchmark external institutions’ C&P models, barriers, and practical mitigations. 

Methods: A multi‑phase, mixed‑methods approach was used to guide development of the pharmacist credentialing and privileging framework. An internal survey was administered to outpatient and ambulatory pharmacists across the health system to evaluate readiness for a C&P process, identify priority privileges, and assess perceived value and competency evaluation preferences. A national benchmarking survey was then distributed through ASHP listservs to collect information on existing pharmacist C&P programs across diverse health systems, including governance models, eligibility criteria, and implementation challenges. Concurrently, existing institutional policies, guidance documents, and South Carolina pharmacy practice regulations were reviewed to identify requirements for alignment with Medical Staff Affairs processes. Findings from surveys and policy review informed the drafting of a standardized C&P policy, privilege structure, and governance pathway, which were reviewed with pharmacy leadership and Medical Staff Affairs to ensure consistency with established credentialing workflows. Next steps will include finalizing the framework, developing supporting education and operational workflows, piloting the process in select practice areas, and preparing for staged systemwide implementation. 

Results: The internal survey included 53 respondents representing primarily ambulatory, oncology, and specialty practice settings. Respondents rated the anticipated impact of pharmacist C&P highly across all domains including top‑of‑license practice, efficiency, safety/quality, and provider workload reduction, with mean scores of approximately 4.3–4.5 on a 5‑point scale. A majority, 64.4%, reported feeling mostly or fully ready to undergo a C&P process. When asked which activities should be included in a basic privilege set, pharmacists most frequently endorsed medication dose adjustments (including renal, hepatic, and weight‑based), ordering and interpreting laboratory tests, interpreting device‑generated data (e.g., continuous glucose monitoring and blood pressure), therapeutic substitution, initiation and discontinuation of therapy within protocol, vaccination administration, and modifications to medication reconciliation. For assessment, respondents preferred a blended approach comprising continuing education, peer review of clinical documentation, competency examinations, and direct observation.
The external survey captured 22 responses from pharmacists and pharmacy leaders at other organizations. Most reported that pharmacist C&P is integrated with the Medical Staff Office and aligned to the medical staff appointment/reappointment cycle. Common eligibility models combined a PharmD with residency, board certification, or defined years of relevant experience. Frequently cited implementation barriers included infrastructure and process alignment with medical staff governance, scope clarity, and resource bandwidth; respondents mitigated these by engaging MSA early, standardizing privilege delineations, and specifying documentation and quality‑assurance expectations. Short‑term gains centered on autonomy and interprofessional trust, whereas longer‑term benefits included alignment with medical staff processes, expansion of pharmacist services, and maturation of reimbursement pathways in ambulatory settings. 

Conclusions: Internal readiness and externally validated operating models converge on a feasible path to a pharmacist C&P framework in this South Carolina health system. Findings support drafting a broad privilege set covering high‑consensus activities currently requiring provider co‑sign and a aligned policy that specifies eligibility routes and a blended assessment approach. Early engagement with the MSA on format, committee pathway, and reappointment cadence is expected to streamline approval. Results will directly inform policy drafting and selection of an initial ambulatory pilot cohort in the next phase.

Title: Evaluation of an Institutional Inpatient Warfarin Policy Within an Academic Health System

Authors: Conner Correll Cain; Hannah Young; Gabrielle Iliff; Laura Holden

Background: Warfarin is a commonly used anticoagulant with a narrow therapeutic window that requires precise management to avoid complications. Pharmacist involvement has been shown to optimize warfarin therapy and improve patient outcomes; however, many institutions lack dedicated anticoagulation stewardship roles. This study aimed to evaluate compliance with an institutional anticoagulation monitoring policy for inpatient warfarin management to identify opportunities for a pharmacist-driven anticoagulation stewardship program.

Methods: This multicenter, retrospective cohort study evaluated adult patients administered warfarin at a Prisma Health inpatient facility between February 1, 2024 and August 1, 2024. The primary outcome was overall compliance with the institutional anticoagulation monitoring policy, defined as a composite of baseline international normalized ratio (INR) prior to the first scheduled warfarin dose, daily INR levels ordered until two consecutive therapeutic INRs were achieved on a stable dose, and weekly INR monitoring thereafter. Secondary outcomes included compliance with individual policy components, frequency of pharmacy consultation for warfarin management, time to therapeutic INR, incidence of supratherapeutic INR, warfarin reversal, appropriate bridge therapy, direct oral anticoagulant (DOAC) candidacy, prior to admission medication history, and discharge education.

Results: Of the 500 patient encounters reviewed, 418 met inclusion criteria. The vast majority (93.3%) were compliant with INR monitoring per institutional policy. Pharmacy consultation for warfarin management occurred in 49.8% of the encounters. Appropriate bridge therapy was significantly more common when pharmacy was consulted compared to no consultation (91.3% and 75.4%, p=0.01). Pharmacy completion of prior to admission medication histories occurred in fewer than half of the encounters, whereas warfarin discharge education was completed in over half of the encounters (48.9% and 62.9%).

Conclusions: There was widespread compliance with Prisma Health’s inpatient anticoagulation monitoring policy. Secondary outcomes suggest opportunities to improve pharmacy involvement during transitions of care.

Resident Contact: [email protected]

Background:
Burnout is a syndrome resulting from chronic workplace stress. This syndrome usually presents as emotional exhaustion, cynicism and depersonalization from work, and a reduced feeling of achievement. Pharmacy residents are at high risk of burnout due to long hours and increased workload. Due to limited published literature and small sample sizes, current knowledge regarding the presence of pharmacy resident burnout and contributing factors needs further investigation. This study looked at rates of pharmacy resident burnout in both current and recent PGY-1 and PGY-2 residents using the Oldenburg Burnout Inventory (OLBI), as well as baseline demographics and other potential risk factors using additional non-validated survey questions based on prior literature.

Methods:
Surveys were distributed by email to pharmacy school programs and residency program directors requesting that current and past learners complete them. Surveys were also distributed to eligible participants during professional conferences and meetings throughout the fall of 2025. Pharmacy residents enrolled at an accredited institution during the 2024-2025 or 2025-2026 residency year were included. The primary outcome of this study was to determine the percentage of pharmacy residents that experienced burnout during residency. The OLBI was graded for its overall score on a scale of not burned out (<48) and burned out (≥48), and sub-score for exhaustion (<25 not exhausted; ≥25 exhausted) and disengagement (not disengaged <27; disengaged ≥27). Secondary outcomes included the percentage of pharmacy residents experiencing exhaustion, percentage of pharmacy residents experiencing disengagement, and factors contributing to burnout such as relationship status, having children, distance to family, hours spent on residency-related activities, hours of sleep, number of co-residents, and number of consecutive workdays before having at least 24 hours off. Respondents were asked about interventions offered by the residency program, including mental health resources, mental health days, mentorships, and schedule changes to determine if these interventions were helpful, and whether they would recommend completing a residency to students or would choose to complete a residency again.

Results:  
A total of 559 responses collected between September 2025 and February 2026 were included in the analysis. Seventy-seven respondents (13.77%) were considered burned out using a set cut-off of 48 or greater on the OLBI total score. Factors determined to be significantly associated with burnout included hours spent on residency-related activities, hours of sleep, and the number of consecutive workdays. Residents sleeping less than 6 hours per night were associated with higher burnout compared to those sleeping 7–8 hours or more (p <0.001). Exceeding 10 consecutive workdays was associated with higher burnout compared to 10 days or less (p <0.001). There was a positive association between burnout and hospital duty hours, with longer weekly hospital duty hours associated with higher burnout (p < 0.001). Similarly, more hours spent on residency outside of hospital duty hours was associated with higher levels of burnout (p <0.001). According to respondents, mentorships and schedule changes had the highest impact on burnout. Respondents with higher burnout scores were more likely to not recommend completing a residency to students or pursue a residency again themselves (p <0.001).

Conclusion: Based on the study respondents, a majority of pharmacy residents were not burned out during residency. Although the OLBI is a validated scale to assess burnout in adults, the cut-off used to determine burnout in this study has not been validated. Results may also be skewed due to the timing of the survey delivery. Future studies should evaluate burnout at different times throughout the residency year. Hours of sleep, hospital duty hours, outside of hospital duty hours, and the number of consecutive days worked were all factors associated with higher burnout scores.

Background: Auto-verification of medication orders is a critical clinical decision support function intended to improve efficiency while maintaining medication safety. Following a large health system merger, variation in auto-verification protocols may occur, introducing potential safety risks and workflow inefficiencies. This project was initiated prior to the January 1, 2026 update of Joint Commission standards and is therefore based on the previous version, which specified that blanket auto-verification of select medications is not acceptable and required pharmacist review of all medication orders, with limited exceptions as outlined in the “Notes” section of MM.05.01.01.

Objectives: This study aims to describe current auto-verification practices across Prisma Health post-merger, identify discrepancies in clinical appropriateness, and assess potential impacts on medication safety and pharmacist workload, including the potential for increased pharmacist full-time equivalent (FTE) needs if inappropriately auto-verified orders were incorporated into routine verification workload, while ensuring alignment with Joint Commission standards in effect at the time of project initiation.

Methods: A retrospective, descriptive analysis was conducted using Epic SlicerDicer to extract deidentified auto-verified medication orders from December 2025 across Prisma Health. As this project was initiated prior to the January 1, 2026 update to Joint Commission standards, orders were classified as appropriate based on MM.05.01.01. Under these standards, orders were considered appropriate if they fell within specific scenarios in which prospective pharmacy review is not required, as outlined in the “Notes” section. This includes settings such as emergency departments and hospital radiology services, as well as hospital-affiliated ambulatory radiology. Primary outcomes include the proportion of appropriate versus inappropriate auto-verified orders, with subgroup analyses by order type, provider type, and identification of high-alert medications. Secondary outcomes will estimate pharmacist workload impact associated with inappropriate auto-verification.

Results:  A total of 84,310 medication orders were auto-verified across Prisma Health from December 1–31, 2025. Of these, 57,062 orders (68%) were classified as appropriate for auto-verification based on Joint Commission–defined exceptions that were in effect at the time of project initiation. Appropriate orders were most commonly associated with Emergency Medicine (n = 45,743), followed by Radiology (n = 6,510), inpatient diagnostic (n = 2,891), ASC radiology (n = 1,884), and ASC diagnostic services (n = 34).
A total of 27,248 orders (32%) were deemed inappropriate for auto-verification. Among these inappropriate orders, the most frequently represented medication categories were fluids, analgesics, gastrointestinal agents, diagnostic agents, and anesthetics.
High alert medications accounted for approximately 22,000 auto-verified orders during the study period. Of these, an estimated 3,900 occurred in Ambulatory Surgery Center settings and approximately 18,000 occurred in inpatient settings.
Analysis by provider type could not be completed due to limitations in data availability and will be addressed in the study’s limitations.
Sites with meaningful staffing impact included GMH (1.7 FTE), Greer (0.3 FTE), and Patewood (0.2 FTE). The top five sites contributed approximately 77% of total workload associated with inappropriate auto-verification, with GMH accounting for 40% alone.

Conclusions: Post-merger variability in auto-verification practices resulted in a substantial proportion of medication orders being inappropriately auto-verified, including high-alert medications. These findings highlight opportunities to standardize auto-verification protocols to ensure safe medication practices. Targeted interventions at high-impact sites may significantly reduce inappropriate auto-verification, improve medication safety, and optimize pharmacist workload.

Background: Onsite clinical pharmacists balance order verification with a range of concurrent responsibilities. These include consults, multidisciplinary rounds, admission and discharge medication reconciliation, and constant involvement with their respective patient care teams. Increasing demands in any one of these areas can limit availability for higher-value clinical activities. A centralized remote order verification (ROV) pharmacist model was created to alleviate these demands. The intention was to support safe and timely order verification, redistribute workload, and allow onsite clinical pharmacists to prioritize clinical responsibilities while maintaining operational efficiency.

Methods: An ROV pilot was first implemented at a single hospital for a 2-week period. The ROV pharmacist would be allowed to verify medication orders remotely, while multiple order types were excluded from the ROV scope. Exclusions included total parenteral nutrition (TPN) orders, pediatric orders (<18 years old), intensive care unit (ICU) orders, non-formulary medications, medications with a listed health-system defined criteria for use (CFU), and a predefined list of emergency department orders. The ROV pharmacist was also allowed to practice within the health-system’s established clinical scope which included interventions such as dose optimization, intravenous-to-oral, and therapeutic interchanges. This ROV model was later approved to expand via three additional 2-week pilots across seven sites. These pilots were also used as an opportunity to test the capacity of a single ROV pharmacist to support multiple campuses. One pilot involved having the ROV pharmacist cover three sites simultaneously, while the other two pilots involved covering two sites at once. A single ROV pharmacist covered all pilot periods. The general model was implemented at most participating sites. At two larger hospitals, the pilot was modified to align with the sites’ existing workflows, and these sites assigned campus designated verification queues to the ROV pharmacist.

Results: After the initial pilot supported the concept, the second pilot showed the ROV pharmacist verified 29.76% of all orders during the shift time, with a total of 7,562 orders verified. Time in the queue shifted more to the 5 to 10 minute and 10 to 15 minute ranges, but the overall dispensing turnaround time decreased by one minute and 21 seconds. The third pilot saw similar numbers with the ROV pharmacist verifying 32.76% of all orders, 7,072 orders in total, and a similar shift with time in the queue. The dispensing turnaround time remained steady increasing by 12 seconds.

Conclusions: The ROV model was able to effectively absorb a significant verification burden without having any operationally significant slowdown. Overall, the model supports capability of creating additional capacity for onsite pharmacist to focus on other clinical and time intensive tasks.

Factors Associated with Successful Publication of Pharmacy Resident Research Projects
Title: Factors Associated with Successful Publication of Pharmacy Resident Research Projects
Presenters: Victoria Michel-Milian
Author: Victoria Michel-Milian, Eric K. Shaw, Amy Taylor
Contact information: [email protected]
Background:
American Society of Health-System Pharmacists (ASHP) accreditation standards require pharmacy residents to include research components as part of the practice advancement objective. Despite this, publication rates remain as low as 13% per resident submission, with program publication success rates ranging from 1.8% to 36.2%. Multiple barriers to publication have been suggested but there is a paucity of data for characteristics that lead to successful residency publication. The purpose of this study is to identify key factors that promote successful publication of pharmacy resident research projects.
Methodology: 
This study was an observational case-control study of pharmacy residents who presented research projects at pharmacy regional conferences from January 2022 through August 2024. Using ASHP’s list of regional residency conferences, abstracts were identified and assigned a random number to select for inclusion. To identify published vs non-published articles, the included abstracts were cross-referenced with PubMed, Google Scholar, and Web of Science using project titles, author names, and institution affiliations. The primary objective of this study was to determine what factors contribute to successful publications for pharmacy residents. Secondary objectives were to assess potential influencing factors including rates between study characteristics, influence of program characteristics, and commonalities between published studies. In addition to descriptive statistics, chi-square tests and t-tests were performed using SPSS version 28.0.
Results: 
This study included 104 abstracts; 15 (14.4%) of were published as of December 1, 2025. Of the outcomes compared, having any author previously published was significantly associated with publication success (80% vs 67.4%, p<0.001). Programs with a research committee also had statistically higher publication rates (60% vs 28.9%, p=0.015). Of the abstracts published, majority of specialties were infectious diseases (23.1%), ambulatory care (18.3%), and critical care (11.5%). Out of the evaluated studies, primary authors were mainly PGY1 residents (78.8%) with the remainder being PGY2 residents (21.2%). Of the published studies, 40% were from a PGY2 program. The mean number of authors per abstract was 3.7 ±1.75. Secondary and tertiary authors most commonly held a PharmD plus a board certification in a specialty (61.7% for secondary and 56.8% for tertiary authorship), with only a few medical degrees (3.2%). There were no significant associations found for when results were published on the conference abstract, center type, listed mentorship program, research coordinator, dedicated time for research or study type. Notably, when comparing published studies, chart reviews had the highest publication rate (29.4%), while quality improvement and surveys had zero published studies. Limitations include incomplete abstract lists across some conferences, inability to confirm resident status for all abstracts, potential author misidentification due to common or changed names, and dependence on websites for program characteristics.
Conclusions: 
This study successfully identified some key attributes to pharmacy resident publication including prior publication experience among co-authors, presence of a research committee, and increased number of authors. To increase publication rates, residency programs should consider establishing research committees and ensure residents are precepted by experienced, previously published mentors.

Title: Impact of Intravenous Fluid Shortage Mitigation Strategies on Crystalloid Utilization and Clinical Outcomes in Critically Ill Adults 

Authors: CC Gooden, Stuart Pope, Amanda Hammond, Neha Naik 

Objective: To evaluate the impact of IV fluid shortage mitigation strategies on continuous crystalloid utilization and clinical outcomes among adult ICU patients. 

Background: Hurricane Helene damaged a major U.S. IV fluid manufacturing facility in September 2024, triggering nationwide shortages. Emory Healthcare implemented multidisciplinary conservation protocols including prioritizing fluids for resuscitation, minimizing maintenance fluids, and utilizing alternative hydration strategies. 

Methods: This multicenter, retrospective chart review included adult patients (≥18 years) admitted to Emory Healthcare ICUs receiving crystalloid fluids during pre-shortage (November 2023–March 2024) and post-shortage (November 2024–March 2025) periods. Patients who were pregnant, incarcerated, or had diabetic ketoacidosis were excluded. The primary outcome was duration of continuous crystalloid infusions. Secondary outcomes included ICU and hospital length of stay, fluid substitution patterns, diuretic/albumin/vasopressor use, acute kidney injury, mortality, and mechanical ventilation duration. Non-parametric data were analyzed using Mann–Whitney U tests and categorical variables using Fisher's exact tests. 

Results: Among 100 patients (50 per group), baseline diagnoses were similar (p=0.95), with sepsis/infection most common (55%). Median IV fluid duration decreased from 11.5 days (IQR 6.3–20.8) pre-shortage to 2.0 days (IQR 1.0–4.0) post-shortage (p<0.0001; median difference 8.0 days, 95% CI [6.0–12.0]). Bolus-only resuscitation increased from 10% to 38% (OR 5.52, 95% CI [1.86–16.34]; p=0.002). No significant differences were observed in acute kidney injury or in-hospital mortality (p>0.05). 

Conclusions: Implementation of fluid conservation strategies during the national shortage was associated with significant reduction in IV fluid duration and increased use of bolus-only strategies, without observed differences in clinical outcomes. These findings suggest that reduced-duration fluid therapy may warrant further investigation in future studies. 

Self-Assessment Question: True or False: Implementation of IV fluid conservation strategies during a national shortage was associated with a reduction in continuous crystalloid infusion duration without increasing adverse clinical outcomes.

Title:
Transforming Care: Assessing the Role and Impact of Clinical Pharmacist Practitioners through Electronic Consult Services

Authors:
McKinley Corley, Deborah Hobbs, Marci Swanson, Nieka Jackson

Background/Purpose:
The purpose of this project is to evaluate a correlation in e-consults completed by clinical pharmacist practitioners (CPPs) and the impact they have in enhancing Veteran care.

Electronic consults (E-Consults) have been widely used in healthcare systems. An e-consult is initiated by one healthcare provider seeking the opinion of a specialist pertaining to the question at hand. Benefits of e-consults include: engaging specialists earlier in the workup process to minimize unnecessary testing, providing more prompt input from specialists, ensuring more succinct chart documentation, and reducing the need for patient travel. Pharmacists can be one of the specialists that are sought out to respond to the e-consults. E-consults have demonstrated to be an effective method for providers to receive timely pharmacist recommendations. Pharmacists can improve patient outcomes via e-consults by preventing medication-related problems. Research shows that pharmacist recommendations made through e-consults have a positive impact on patient outcomes. The numerous studies conducted within the VA system demonstrate that the Department of Veterans Affairs is at the forefront of using e-consults to improve patient outcomes.

Methodology:
This performance improvement project was approved by the Carl Vinson VA Medical Center Pharmacy and Therapeutics Committee. This project aims to evaluate the implementation rate of clinical pharmacist recommendations and various aspects of the e-consult process. Primary and secondary objectives include characterizing the use and types of clinical pharmacist e-consults, evaluating completion timelines, and assessing the extent of patient management by CPP clinics resulting from e-consults. Data was collected through a retrospective chart review of e-consults using the Integrated Document Manager in VISTA. All clinical pharmacy e-consults completed between 10/01/2024 – 09/30/2025 were evaluated. Exclusion criteria included cancelled e-consults, BHIP Medication Management Consults, and Congestive Heart Failure Re-admission Consults. Collected data encompassed patient demographics (sex, age, race, location), consult details (title, category, requesting provider, and author), reason for e-consult, number of requests per e-consult, time required for completion, the number of accepted recommendations, and referrals to CPP. This comprehensive data collection aims to provide insights into the efficacy and efficiency of clinical pharmacist interventions via e-consults.

Results:
A total of 736 e-consults were completed, leading to 795 recommendations. Out of these recommendations, 688 (86.5%) were accepted by the providers, while 107 (13.5%) were not. The majority of the consults were related to pain management. Impressively, 93.8% of the consults were completed within 72 hours, meeting the established criteria. Additionally, approximately one-third of the patients were referred to CPP clinics as a direct result of the e-consult responses. Overall, this project was highly successful.

Conclusions:
The findings of this project align with published literature supporting pharmacist-led e-consult services. The high acceptance/implementation rate validates the role of the Clinical Pharmacist Practitioners in e-consult services. Opportunities exist to expand and optimize e-consult utilization across the facility, including filling in potential gaps of care and e-consult simplification.

Background/Purpose: Intravenous (IV) therapy is administered to over 90% of hospitalized patients, and medication errors with IV push drugs remain a significant safety concern. Best practice recommendations from the Institute for Safe Medication Practices encourage health institutions to employ ready-to-administer (RTA) formulations to minimize bedside preparation and compounding errors. Hospital pharmacies typically utilize manual preparation, 503B outsourcing, and/or robotic automation for bulk syringe production. Manual compounding can be labor-intensive and prone to human error, while outsourcing introduces variable costs and supply chain risks. Robotic syringe filling technology offers potential improvements in efficiency, compliance, and financial sustainability. This study aims to evaluate the financial and operational implications of implementing robotic syringe filling technology, by comparing cost, efficiency, and quality metrics with those of manual compounding and 503B outsourcing methods for select medications.
Goal: To evaluate the financial and operational impact of implementing an IV syringe filler robot at a large academic medical center.
Purpose Statement: This study aims to evaluate the financial and operational implications of implementing robotic syringe filling technology by comparing cost, efficiency, and quality metrics with those of manual compounding and 503B outsourcing methods for select medications. 
Primary objective: 
Compare cost per syringe before and after the implementation of an IV syringe filler robot
Secondary objectives: 

• Evaluate changes in operational efficiency
• Describe return on investment (ROI) and sterility pass rates following implementation

Methods: A quasi-experimental, pre-test/post-test study will be conducted at a large academic medical center over a ten-month period. The study timeframe incorporates a washout period following robot implementation to accommodate staff training and ensure the technology operates at full capacity. Data sources include inventory management software, purchasing history, syringe filler robot logs, manually completed technician logs, and electronic health record (EHR) systems. Comparator groups consist of pre-implementation (manual compounding and 503B outsourcing) and post-implementation (robotic syringe compounding) periods. The primary endpoint is cost per syringe pre- and post-robot implementation, including supplies, drugs, and IV fluid components. Secondary endpoints include ROI, compounding times during full capacity and downtime events, and sterility pass rates. Continuous data will be analyzed using t-tests, and sterility outcomes and ROI will be summarized with descriptive statistics.
Results: Data collection is currently underway, with preliminary findings expected by June 2026.

Title: Driving Accuracy and Accountability: A Systemwide Inventory Integrity Program

Authors: Veronica Bekheit, PharmD, MSMEd & Heath Jennings, PharmD, MBA, BCPS, FASHP, FACHE

Background:
The Central Florida Division historically relied on a third-party vendor to conduct biannual full inventory audits across pharmacy locations. While these audits provided external validation, they required significant internal labor to verify results and did not support continuous inventory oversight. A prior internal pilot demonstrated that full physical inventory counts could be completed across all campuses within one week using internal resources, supporting the feasibility of an internally managed model. Based on these findings, a Pharmacy Inventory Integrity Analyst Team was established to assume ownership of inventory processes and support a transition to an internal audit model. The goal of this initiative was to improve inventory accuracy to enable adoption of a perpetual inventory system. In June 2025, the team conducted a division-wide internal full inventory count, followed by a comparative validation against a subsequent external audit. These efforts informed the development of a standardized, system-wide inventory integrity program focused on ongoing accuracy, discrepancy reduction, and operational sustainability.

Methods:
A dynamic, risk-based audit framework was developed to prioritize medications with the highest operational and financial impact. To establish the initial audit baseline for January 2026, high-discrepancy medications were identified by averaging variance data from October through December 2025, generating a list of the top 30 discrepancy items per campus. For ongoing audits, this list is updated monthly using a rolling two-month lookback period to ensure prioritization reflects the most recent inventory performance and that previously identified discrepancies are resolved. High-cost medications were identified by estimating average on-hand inventory using PAR level midpoints ((minimum + maximum)/2) and multiplying by blended unit cost to approximate financial exposure. This analysis is also refreshed monthly to account for changes in utilization, pricing, and inventory levels, producing a current list of the top 50 high-cost medications per campus. The Pharmacy Inventory Integrity Analyst Team conducts standardized physical audits during the second week of each month. Physical counts are compared against PLX system inventory, and results are calculated as accuracy percentages and trended month-over-month. Audit findings are reported to campus leadership, and discrepancies undergo further review to identify root causes and support corrective actions.

Results:
A total of 1,248-line items were evaluated during the October 2025 audit. Internal team alignment with the inventory management system (IMS) was higher compared to the external vendor (73.7% vs. 67.0%). Full agreement between the internal team, vendor, and IMS occurred in 63.8% of line items, while complete disagreement was observed in 19.5%. Internal counting accuracy reached 92.0% (1,149/1,248), corresponding to an error rate of 8.0%, with variability observed across campuses. During the February–April 2026 audit period, 2,505 medications were evaluated. Internal team error rates demonstrated progressive improvement from 1.28% in February to 1.02% in March and 0.11% in April, representing a 91% reduction in error rate over the study period.

Conclusion: 
Implementation of a structured internal inventory integrity team and a data-driven audit process was associated with improved inventory accuracy and team performance across campuses. This approach supports scalable, standardized inventory management and progression toward a perpetual inventory system.

Authors: Derek Rhodes, Tim Walker, Doug Furmanek, Laura Holden, Harry Jozefczyk, Deborah Hurley, Ally Nielson, Natalia Valenti
Background: Productivity is measured as a ratio of an input of work hours to an output of a unit of service. Many health systems rely on traditional metrics such as number of billed doses, order processed or patient days to evaluate staffing needs and operational efficiency. Currently, there is no established gold standard for measuring pharmacy productivity that captures all the activities pharmacists perform. This study aimed to evaluate the accuracy of the current productivity metric of 1000 billed doses and determine whether novel pharmacy workload dashboard metrics provide a more accurate representation of pharmacy workload. 
Methods: A study was conducted across Prisma Health hospitals including a retrospective review comparing historical workload data derived from the external productivity report (1000 billed doses) with pharmacy workload dashboard data through the electronic health record (EHR), which captures both operational and clinical actions. In addition, a prospective survey and time study were performed to estimate time spent on routine operational and clinical pharmacy tasks across multiple facilities.The primary endpoint compares the correlation coefficients between these two units of service: 1000 billed doses versus pharmacy dashboard workload actions.  Secondary objectives include evaluating workload trends between hospitals of varying bed size and clinical service scope using time study data and assessing correlations among different workload categories to identify variations in workload patterns across facilities. Data will be analyzed using correlation analysis and simple linear regression, with multivariable regression modeling as appropriate to identify metrics most predictive hours worked.  
Results: In progress
Conclusions: This study will contribute evidence toward improving pharmacy productivity measurement by assessing whether EHR-based workload metrics better reflect real pharmacist workload and support appropriate staffing allocation.

Abstract: 
Background
Musculoskeletal (MSK) pain is a frequent complaint in patients who present to the emergency department (ED) and these patients are often treated with corticosteroids. However, there is mixed and low-level evidence for use of steroids in treatment of MSK pain. The College of Urgent Care Medicine has emphasized steroid stewardship in response to the increasing use of short course steroids in the ED. Steroid stewardship is the systemic effort to prescribe corticosteroids in a rational, evidence-based manner and evaluate the risks associated with short-term use. Steroids with enhanced glucocorticoid selectivity are preferred due to their anti-inflammatory effects but the risks are not benign. Adverse effects such as hyperglycemia, insomnia, dyspepsia, and changes in mood and appetite can occur even with short-term use.  Patients at the Ralph H. Johnson V.A. Medical Center (RHJVAMC) may be at higher risk of these adverse reactions based on age, comorbidities and drug-drug interactions with concomitant medications. Little evidence exists to guide use of steroids; therefore careful evaluation of risks and benefits is necessary. This project aims to evaluate the opportunity for steroid stewardship regarding the treatment of MSK pain.
Methods
This retrospective analysis evaluated Veterans at the RHJVAMC that presented to the ED with a chief complaint of MSK pain based on selected ICD-10 codes from May 1st, 2024 to April 30th, 2025. The population was separated into two groups: patients prescribed steroids and patients that did not receive steroids. The electronic medical record (EMR) was utilized to collect data and determine eligibility for chart review. Patients were excluded if they received steroids for an indication other than MSK pain or were prescribed chronic steroids. The primary outcome was return visit rate within 30 days of index visit for the same MSK chief complaint. Steroid prescribing practices and ED interventions were also observed. The secondary outcome was the rate of steroid-related adverse drug reactions (ADRs) within 30 days of index visit in patients who received steroids in the ED or at ED discharge. A generalized estimating equations (GEE) analysis was performed to investigate associated factors that may impact return visit rates and is reported as adjusted odds ratios (aOR) and 95% confidence intervals (95% CI).
Results
Five hundred eighty-eight patients were included in the analysis; 283 patients received steroids and 305 patients did not receive steroids at the initial ED visit for MSK pain. The primary outcome of return visit for the same MSK pain complaint was significantly higher in patients that received steroids compared to the no steroid group (aOR 1.96, 95% CI 1.05-2.63; p = 0.003) within 30 days of initial ED visit. The GEE model confirmed the administration of steroids was independently associated with rate of return. The majority of patients received intramuscular (IM) dexamethasone in the ED (76.2%) and were discharged on prednisone with a mean 6.4 day (SD ± 3.8) duration of therapy. Pain consultations differed between groups (2.7% vs 0.7%, p=0.022), but were overall seldomly utilized in this patient population. Secondary outcomes data identified 8 patients that experienced steroid-related ADRs. Most of these patients received dexamethasone 10mg (IM) (75%) and all were discharged with multimodal pain control including steroid, NSAID, muscle relaxer, and/or topical pain relief. 
Conclusion
Patients who received steroids in the emergency department for MSK pain were more likely to return for the same chief complaint within 30 days compared to patients who did not. ED interventions for MSK pain, like specialty pain or physical therapy consultations, were found to be under-utilized and warrant further investigation for impact on return rates. Few steroid-related ADRs were observed in this retrospective analysis.

Authors: Tahir Razzaq, Sweta M. Patel, Irene Robb, Naomi Yates

Background:
Direct oral anticoagulants such as rivaroxaban and apixaban are recommended first-line options for the initial treatment of venous thromboembolism (VTE). In patients with unprovoked or recurrent VTEs, extended treatment beyond the initial 3-6 months is recommended. The API-CAT and RENOVE trials evaluated whether dose reduction is appropriate or beneficial in certain patient populations in the extended phase treatment. Both trials concluded that dose reduction had similar VTE recurrence rates with lower bleeding risk compared to full dose treatment. The purpose of this study was to determine if reduced doses of rivaroxaban (10 mg daily) or apixaban (2.5 mg twice daily) offer a safe and effective alternative to the full dose (rivaroxaban 20 mg daily or apixaban 5 mg twice daily) treatment.

Methods: 
This is a retrospective, IRB-exempt cohort study that included adult patients of Kaiser Permanente Georgia treated with rivaroxaban or apixaban for VTE after completion of the initial 6-month duration. The study population consisted of patients treated with full dose treatment between January 1, 2023 to June 30, 2024, with clinical outcomes assessed through June 30, 2025. Patients with mechanical heart valves, atrial fibrillation/flutter, and/or concurrent antiplatelet therapy were excluded. The primary outcome of this study was to evaluate the incidence of VTE recurrence and major bleeding events in patients who took reduced or full doses of rivaroxaban or apixaban after the initial VTE treatment period. The secondary outcome was to analyze patient characteristics among those who received either reduced or full doses of rivaroxaban or apixaban to identify factors associated with dose selection. Descriptive statistics were used to assess differences in clinical outcomes and patient characteristics. Chi-squared tests were used to determine statistical significance with a P-value of < 0.05.

Results: 
A total of 165 patients received either reduced or full dose rivaroxaban or apixaban after the initial VTE treatment period. Of these, 152 patients were included in this analysis. Among this cohort, 14 (9%) patients received dose reduction, including 1 who was on rivaroxaban and 13 on apixaban. A total of 5 patients (3%) experienced a recurrent VTE (2 with rivaroxaban 20 mg daily and 3 with apixaban 5 mg twice daily). Overall, 18 patients (11.8%) experienced either a major or minor bleeding event (10 with rivaroxaban 20 mg daily and 8 with apixaban 5 mg twice daily). Patients who experienced a bleeding event were younger compared to those without bleeding events (mean age 53y vs. 60y; p=0.049). Of the patients who were not dose reduced (n=138), 50 of them (36%) could have benefited from dose reduction. Patients who qualified for dose reduction were significantly older than those who did not (mean age 62y vs 56y; p=0.022). Additionally, the Internal Medicine and Oncology departments were among the prescribing departments that had the highest rates of prescribing both full-dose and reduced-dose regimens.

Conclusion: 
Dose reduction of rivaroxaban and apixaban after the first 6 months of initial VTE treatment demonstrated a lower risk of bleeding. However, full doses of both DOACs were associated with a trend toward higher rates of bleeding and VTE risk. While dose reduction may offer a safer side effect profile, further research may help identify which patient populations would benefit most from dose reduction and its impact on long-term VTE recurrence and bleeding events among those requiring extended VTE treatment. Additionally, pharmacy-led education sessions could help to ensure that dose reductions are performed safely and effectively in clinical practice.  

---

OPIOID UTILIZATION WITH ENHANCED RECOVERY AFTER CESAREAN DELIVERY PROTOCOL VERSUS STANDARD OF CARE
Authors: Trace Easterling, Amanda Williams, Allison Daneault, Catherine Childre, Anna Bulman, Brianna Wheeler, Megan Missanelli, Brittney Bicksler, Francie Ruzic.

Objective: Compare opioid utilization in patients undergoing cesarean delivery with and without use of the enhanced recovery after cesarean delivery protocol.

Background/Purpose –
Cesarean delivery is the most common surgical procedure in the United States and accounts for many women’s first exposure to opioids. The Enhanced Recovery After Surgery (ERAS) Society has published guidelines for many surgical procedures, including cesarean delivery, with the goal of expediting post-surgical recovery, minimizing exposure to opioids, and improving maternal and neonatal outcomes. Until recently, only one facility within Infirmary Health System utilized a standardized Enhanced Recovery and Cesarean (ERAC) protocol. The primary aim of this study is to compare opioid utilization in patients undergoing cesarean delivery with and without use of the ERAC protocol.

Methods –
A retrospective chart review of patients at least 18 years of age undergoing cesarean delivery with ERAC protocol and without ERAC protocol across the three labor and delivery units encompassed in Infirmary Health System was conducted starting July 31, 2025 and working back in time until 150 patients in each category had been reviewed. Data collected through the electronic health record (EHR) included patient demographics, primary or repeat cesarean, scheduled or unscheduled cesarean, intraoperative and post-operative pain management modality, total morphine milligram equivalents (MMEs) post-operatively, length of hospitalization, average daily pain scores for post-operative days 1-3, and post-operative duration epidural and urinary catheterization. Discharge prescriptions were also reviewed and total MMEs of all outpatient prescriptions were recorded. Patient were excluded if they were less then 18 years old, had a complication that may have resulted in increased opioid requirements or length of stay, or had grossly incomplete chart data.

Results –
A total of 303 patients were included in the results of the study. 145 patients received the non-ERAC protocol and 158 received the ERAC protocol. The median total postoperative MMEs were lower in the ERAC arm compared to the non-ERAC study arm (22.5 vs. 86.3 p < 0.01).  Median length of stay and time to first as needed analgesic was also lower in the ERAC group compared to the non-ERAC group (Length of stay (h): 63 vs 75 p < 0.01; Time to first as needed analgesic (h): 15.8 vs. 24.6 p < 0.01). Median postoperative pain scores at day one, two, and three were also decreased in the ERAC arm (Day 1: 1 vs. 2 p < 0.01; Day 2: 2 vs. 3 p < 0.01; Day 3: 2 vs. 3 p < 0.01). For the median MMEs prescribed at discharge, patients in the ERAC group had a lower MME prescribed at discharge compared to those in the non-ERAC group. (MMEs at discharge: 112.5 vs 225 p < 0.01)

Conclusions –
Patient receiving cesarean sections in the ERAC protocol had reduced inpatient opioid requirements, a shorter length of stay, improved pain control and accelerated recovery timelines compared to those in the non-ERAC group. Mothers in the ERAC group also went longer without requesting additional analgesics and received less opioids at discharge on average. These results continue to prove positive outcomes for ERAC protocols mothers receiving cesarean sections. 

Background: Penicillin and sulfonamide allergies are reported by many patients, yet most are not clinically significant. Documented allergies lead to the use of alternative agents such as fluoroquinolones, and this inappropriate use has been linked to increased rates of antimicrobial resistance. While studies have demonstrated the impact antibiotic allergies can have on patient outcomes and healthcare costs, there is minimal literature evaluating the influence documented allergies, whether true or not, may have on antimicrobial susceptibilities. The purpose of this study is to evaluate the relationship between documented antibiotic allergies and antimicrobial susceptibilities for gram-negative bloodstream isolates.

Methods: This is a multicenter, retrospective, cohort study of adult patients admitted to the Prisma Health System with confirmed gram-negative bacteremia from March 1, 2021, to August 1, 2025. The primary outcome is the difference in antibiotic susceptibilities (% susceptible vs % non-susceptible) of isolates between patients with and without documented beta-lactam allergies. Secondary outcomes include the difference in antibiotic susceptibilities among patients with and without fluoroquinolone and sulfonamide allergies and assessing variation in antimicrobial susceptibilities by severity of beta-lactam allergies. Baseline characteristics and outcomes were assessed using descriptive and inferential statistics.

Results: This retrospective cohort study included 500 patients, of which 92 had a beta-lactam allergy present on their chart. The most common bacteria isolated were E. coli (46%), K. pneumoniae (20%), P. mirabilis (10%), and P. aeruginosa (9%). For the primary outcome of rates of non-susceptible isolates in patients with and without a documented beta-lactam allergy, there was no statistically significant difference between the two groups for Enterobacterales or Pseudomonas species for any antimicrobials evaluated. However, patients with a beta-lactam allergy did have numerically higher rates of non-susceptible Enterobacterales isolates for cefazolin, ciprofloxacin,  and sulfamethoxazole-trimethoprim, with a difference of 5%, 5% and 9%, respectively. The secondary outcomes evaluating rates of non-susceptible isolates in patients with and without a fluoroquinolone allergy and with and without a sulfonamide allergy showed no statistically significant difference between groups. Lastly, when stratified by severity of beta-lactam allergy, it was found that patients with a high severity beta-lactam had the highest proportion of non-susceptible Enterobacterales isolates for ampicillin (67%). The medium severity beta-lactam allergy group had the highest proportion of non-susceptible isolates for ceftriaxone (29%), ciprofloxacin (43%), levofloxacin (100%), and sulfamethoxazole-trimethoprim (43%).

Conclusions: Overall, the presence of beta-lactam, fluoroquinolone, or sulfonamide allergies did not impact antibiotic susceptibilities. Almost half of beta-lactam allergies were documented as an “unknown” reaction which emphasizes the improvements that can be made in allergy documentation and reconciliation. This study was limited by the small population of patients with fluoroquinolone or sulfonamide allergies, the subjective manner of allergy assessment, and the process of manual chart review.

• Title: Impact of Sedation Protocol Changes on Restraint Use:   A Pre-Post Analysis of Weight-Based Dosing Adjustment in the Emergency Department
• Authors: Yurim Lee, Carrie Baker
• Practice Site: Wellstar Kennestone Regional Medical Center, Marietta, GA
• Background: Wellstar Kennestone Regional Medical Center (WKRMC) recently implemented a sedation protocol in which initial fentanyl and propofol infusion doses for mechanically ventilated patients are calculated using ideal body weight (IBW), replacing the previous strategy of non-weight-based fentanyl and total body weight-based propofol dosing. Anecdotally, emergency department (ED) staff have observed an increase in the use of physical restraints among mechanically ventilated patients following this change. This study was conducted to assess the impact of protocol change on sedation adequacy by examining physical restraint use in mechanical ventilated (MV) patients.  Physical restraint use was selected as a pragmatic surrogate measure for inadequate sedation in the ED.
• Methods: A single-center retrospective chart review was conducted at WKRMC. Adults ≥18 years who were MV in the ED and received continuous fentanyl or propofol as initial sedation were identified through Epic SlicerDicer and stratified into pre-implementation and post-implementation groups. Protocol adherence was defined as initiation and titration of sedation infusions according to the institutional sedation protocol, including appropriate weight selection and protocol-guided titration intervals. Patients were excluded if they were intubated prior to ED arrival, had restraints applied before intubation, had a Glasgow Coma Scale score of 3 throughout the ED stay, had an ED length of stay ≤1 hour, were pregnant, or arrived in cardiac arrest and expired in the ED. The primary outcome was the frequency of restraint use within 12 hours after intubation or until ICU transfer, whichever occurred first. The secondary outcome was the total dose of adjunctive sedatives administered within the first 12 hours after intubation or until ICU transfer, whichever occurred first, to evaluate the adequacy of initial continuous infusion sedation. Data was collected and analyzed using Microsoft Excel.
• Results: A total of 247 patients were screened, and 50 patients per group were included in the analysis. Baseline demographics, comorbidities, and indications for intubation were similar between the two groups. Restraint use within the first 12 hours after intubation or until ICU transfer occurred in 32% of patients in the pre-implementation group compared with 26% in the post-implementation group. All restraints applied were soft restraints. Protocol adherence occurred in only 54% of pre-implementation patients and 42% of post-implementation patients. When sedation was protocol-adherent, restraint utilization was similar between groups (25.9% vs 23.8%). Among non-protocol-adherent cases, restraint use was higher in the pre-implementation group than in the post-implementation group (39.1% vs 27.6%). Adjunctive sedatives were used in 64% of pre-implementation patients and 58% of post-implementation patients. Benzodiazepines were the most common adjunctive agents used. The mean benzodiazepine-equivalent dose was substantially higher in the pre-implementation group (22.72 mg vs 7.78 mg). Dexmedetomidine and ketamine were also used more frequently in the pre-implementation group. Overall, sedative exposure was higher in the pre-implementation cohort.
• Conclusions: Implementation of an IBW–based sedation protocol in MV ED patients was not associated with increased restraint use or greater adjunctive sedative requirements. Despite lower calculated infusion doses, the new weight-based protocol appeared to provide adequate early sedation and may reduce the need for additional sedative escalation. However, several limitations should be considered. Protocol deviations and inconsistent titration practices were frequently observed and likely contributed to variability in sedation management and restraint utilization. These findings suggest that adherence to standardized sedation protocols, including appropriate weight selection and protocol-guided titration, may play a more important role in achieving adequate sedation than the dosing strategy alone. The results highlight opportunities to improve sedation practices and documentation workflows in the ED, particularly during emergent intubation when medication administration may be documented after the fact. Routine auditing and feedback may help improve protocol adherence and support sustained practice improvement. 

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