2026 Southeastern Residency Conference

Background: Chemical restraints are parenteral medications used to limit patient movement or behavior rather than treat an underlying condition. Risks include oversedation, respiratory compromise, and loss of patient trust. Regulatory standards require their use only for imminent risk after less restrictive measures have failed, with strict monitoring and timely discontinuation. However, real-world practice patterns remain poorly characterized. This study retrospectively evaluated pharmacologic chemical restraint practices in adult patients, including medication selection, dosing patterns, and ordering services, to identify variability and inform development of a standardized institutional order set aligned with patient safety and regulatory standards.

Methods: A retrospective chart review was performed on patients at least 18 years of age who received at least one dose of a medication classified as a chemical restraint between March 1 and August 31, 2025 at Northside Hospital. Eligible episodes involved injectable haloperidol, ziprasidone, olanzapine, ketamine, lorazepam, diazepam, or midazolam ordered for indications such as aggressive or combative behavior, agitation/anxiety, agitation or severe/refractory agitation, psychosis, hallucinations, or chemical restraint. Patients receiving procedural sedation or anesthesia for non‑restraint purposes were excluded. The primary objective was to evaluate the pharmacological treatments used for chemical restraint. Secondary objectives included average dose used per agent and route, use of multiple restraint agents, ordering service, location of administration, and indication.

Results: The retrospective review included 45 eligible patients with violent agitation (agitation scale 3) who received parenteral chemical restraint medications. Haloperidol was the most frequently administered chemical restraint (N = 32; 37%), followed by lorazepam and ziprasidone (N = 20; 23% each), olanzapine (N = 6; 7%), ketamine (N = 5; 6%), and midazolam (N = 3; 4%). Diazepam was not utilized. Mean doses by agent and route were as follows: haloperidol, 3.99 mg intramuscularly (IM) and 2.41 mg intravenously (IV) (N = 70); ketamine, 0.67 mg/kg mg IM and 1 mg/kg IV (N = 5); lorazepam, 1.32 mg IM and 1.17 mg IV (N = 38); and midazolam, 2 mg IM and 3.67 mg IV (N = 6). Olanzapine and ziprasidone were administered exclusively via the IM route, with mean doses of 6.11mg (N = 9) and 10.66 mg (N = 38). The most frequently documented indications were agitation (N = 24; 56%) and agitation/anxiety (N = 17; 38%), while severe or refractory agitation (N = 2; 4%) and aggressive or threatening behavior (N = 1; 2%) were less common, with no other indications documented.

Most chemical restraints were ordered by Internal Medicine Services (62.2%), followed by the Emergency Department (33.3%) and the Intensive Care Unit (4.4%), with the ordering service corresponding to location of administration. Use of multiple chemical restraint agents per episode occurred in 35 cases (77.8%).

Conclusions: This study identified variability in chemical restraint utilization, dosing, route of administration, episode duration, indications, and documentation among adult hospitalized patients at Northside Hospital. Antipsychotics and benzodiazepines were most commonly used, with haloperidol administered most frequently. 77.8% of patients received multiple agents per episode, suggesting lower initial dosing strategies and the absence of a chemical restraint episode duration. These findings demonstrate the need for a standardized order set and highlight opportunities to enhance consistency in chemical restraint practices and clinical documentation. In response, an Adult Chemical Restraint Order Set was developed that includes four-hour chemical restraint episode, maximum 24-hour dosing recommendations, and age- and obstetric-specific recommendations to support appropriate agent selection and dosing. Required nursing assessments of vital signs and behavioral status were aligned with Joint Commission standards, with additional safety measures including integrated Behavioral Health consultation and electrocardiogram monitoring. This standardized framework aims to improve consistency, safety, monitoring, and documentation of chemical restraint use while promoting patient-centered care across hospital services.

Background: Concomitant administration of carbapenems and valproic acid (VPA) is a well-documented interaction that leads to rapid reductions in serum VPA concentrations with effects observed within 24 hours and persisting up to 7-10 days after discontinuation. This interaction increases the risk of breakthrough seizures, mood destabilization, and is associated with adverse clinical outcomes, including prolonged hospital stays and increased mortality, particularly in critically ill patients. Despite awareness, concomitant prescribing persists in large medical centers. At Grady Health System (GHS), prescribers and pharmacists receive a drug interaction warning when VPA and carbapenems are ordered together. Prior studies report only ~37% compliance with similar alerts, with over 50% of patients developing subtherapeutic VPA levels. Although drug interaction warnings are designed to mitigate this risk, it remains unclear whether these alerts effectively influence healthcare providers' behavior in hospitalized patients. This study aims to evaluate the clinical effectiveness of drug interaction warning targeting the co-administration of carbapenem and VPA and subsequent clinical sequelae at GHS.
Methods: This single-center, retrospective chart review included adults (≥18 years) admitted to GHS between January 1, 2020, and April 1, 2025, who received at least one overlapping dose of VPA and a carbapenem with a triggered drug interaction alert. Patients were excluded if discharged within 48 hours, receiving VPA and carbapenems prior to admission, or if clinical sequelae were documented prior to concomitant exposure. Data collected included demographics, indication for therapy, alert response, and resulting clinical actions (dose adjustment, discontinuation, or substitution). The primary outcome was the proportion of alerts with action versus no action at order entry or verification. Secondary outcomes included the type and frequency of resulting actions, incidence of clinical sequelae, hospital length of stay, duration of antimicrobial therapy, and documented indications for both VPA and carbapenem therapy Descriptive statistics were used, and chi-square and Fisher’s exact analysis evaluated associations between responder type and alert response.
Results: A total of 299 drug interaction alerts across 56 unique patients were analyzed. Clinical action was taken for 65 alerts (22%), while 234 alerts (78%) resulted in no action at order entry or pharmacist verification. Pharmacists were more likely than other providers to override alerts (84.0% vs 71.5%; χ² = 6.73, p = 0.009). Internal Medicine most frequently accounted for the provider responsible for the must-action (45.9%), followed by Infectious Diseases (12.6%). Given that carbapenems are restricted antimicrobials, Infectious Diseases consultation was commonly involved. At the patient level, clinical sequelae occurred in 40% of patients in the action group and 48% in the no-action group (Fisher’s exact p= 0.59). Median hospital length of stay was 22 versus 17 days, and median antibiotic duration was 3 versus 5 days, respectively. Agitation and behavioral changes were the most common sequelae in both groups, while breakthrough seizures and ICU transfer occurred less frequently and at similar rates. When action was taken, the most common interventions were switching the carbapenem, discontinuing valproic acid, or increasing the valproic acid dose.
Conclusions: Among 299 alerts, concomitant VPA and carbapenem use remained common, with alerts most often resulting in no action with no statically significant difference in clinical sequelae. Notably, nearly half of the patients in the no action group experienced adverse clinical outcomes, emphasizing clinical concern. Future research should assess pharmacist education, provider feedback, and alert optimization to improve compliance.

Title: Evaluation of Discharge Process from a High Intensity Psychiatric Unit at a Veteran’s Health Care System

Author’s names: Dalton V. Scott, Lynsey Neighbors, Anisa Britt, Perry Thompson

Background: The Central Alabama Veterans Health Care System (CAVHCS) High Intensity Psychiatric Unit (HIPU) provides mental health (MH) crisis intervention and stabilization to veterans, followed by discharge to the most appropriate level of care, including continued medication management in the outpatient setting. Pharmacy services contribute to this process through discharge medication reconciliation and dispensing the prescribed discharge medications. This project aims to evaluate the timely and appropriate scheduling of follow-up with outpatient MH services as indicated by VHA Directive for veterans discharged from the HIPU to ensure continued medication management in the immediate post-discharge period, and the rates of readmissions related to acute MH within 90 days of discharge.

Methods: This is a retrospective, observational chart review of veterans discharged from the CAVHCS HIPU from 10/01/2024 to 04/22/2025. Exclusion criteria were as follows: veterans with irregular discharge circumstances (e.g., left Against Medical Advice), those transferred to another level of care (e.g., long-term rehabilitation), or those readmitted in the 90-day post-discharge period for non-MH treatment. Primary outcomes included: the rate of veterans who completed outpatient MH prescriber follow-up within ≤ 7 days, 8-30 days, and 31-90 days post-discharge; the rate of readmission for acute MH treatment within 90 days; and the average time to acute MH-related readmission. Secondary outcomes included the rate of pharmacist-entered discharge medication reconciliation notes and the rates of discharge MH medications by class.

Results: Among 166 HIPU discharges, nearly 58% had no outpatient MH follow-up. 15% had scheduled follow-up within ≤ 7 days, followed by 10% within 8-30 days, and 7% within 31-90 days. 3% had walk-in appointments at 8-30 days, and 7%  of walk-in appointments occurred at 31-90 days post-discharge. 34% of discharges resulted in readmission within 90 days. 80% of readmissions had no outpatient MH prescriber follow-up. Of those not readmitted, 46% also lacked outpatient MH prescriber follow-up. Pharmacists provided discharge medication reconciliation to 27% of readmitted veterans while 7% of readmitted veterans did not receive the service. Pharmacists provided discharge medication reconciliation to 56% of non-readmitted veterans while 10% of non-readmitted veterans did not receive the service. The evaluated 536 post-discharge MH medications stratified by medication class were as follows: 28% antidepressants, 18% antipsychotics, 2% benzodiazepines, 2% extrapyramidal symptom agents, 4% mood stabilizers, 16% non-benzodiazepine anxiolytics, 27% sleep agents, 2% substance use disorder agents, and 1% long-acting injectable antipsychotics.

Conclusions: The data indicate that the HIPU discharge process is not aligned with VHA Directive, as over half of the discharges evaluated lacked outpatient MH prescriber follow-up. Alarmingly, 80% of readmissions were comprised of veterans who did not receive outpatient follow-up care within the 90-day post-discharge evaluation period. As HIPU providers only provide outpatient prescriptions for 30-day supplies, a lack of appropriate follow-up increases the risk of acute MH relapse. Establishing effective transition processes, timely scheduling, and ensuring continuity of care are essential to mitigate these risks and improve patient outcomes. Pharmacists play a crucial role in preventing HIPU readmissions, as supported by the finding that over half of patients who received pharmacy discharge medication reconciliation were not readmitted within the 90-day post-discharge period. This highlights the importance of pharmacist involvement in discharge processes to improve patient outcomes and reduce readmission rates. These findings provide compelling evidence for implementing processes to improve transitions of care and to advocate for increased pharmacy involvement for veterans discharged from the HIPU.

Title: Identifying Opportunities to Improve Discharge Prescribing of Newly Initiated Quetiapine During Transitions of Care: A Medication Use Evaluation
Authors: Audra Butler, Bobby Azevedo, Abigayle Campbell

Background: Design a medication use evaluation to assess inappropriate continuation of inpatient-initiated quetiapine at hospital discharge and identify transition-of-care points where pharmacy interventions may reduce unnecessary continuation. 

Methods: This medication use evaluation included a retrospective review of patients discharged between October 1 and December 31, 2025. Data was collected to identify cases in which quetiapine was newly initiated during hospitalization for indications such as agitation, delirium, sedation, or insomnia. Patients were excluded if quetiapine was documented as a home medication or if it was initiated for alternative psychiatric indications, such as schizophrenia and bipolar disorder. Different variables were gathered to evaluate prescribing patterns included initiating and discharging provider, location of prescribing at initiation and discharge, physician specialty group (example: family medicine, hospitalist, intensivist), and documentation of whether a pharmacist was involved with medication reconciliation/review at discharge. Raw data was analyzed to assess correlations in prescribing patterns and factors associated with continuation of quetiapine at discharge. 

Results: A review of prescribing patterns revealed that approximately 25 of the 45 patients started on quetiapine while inpatient for an off label indication were inappropriately continued on therapy at discharge. This indicates that more than half of patients lacked appropriate reassessment or discontinuation of therapy prior to transition of care. Additionally, among the 18 patients with dementia who were newly started on quetiapine during their hospital stay, 9 patients (50%) remained on the medication after discharge for an off label indication.  Additionally, when stratifying the intended short-term inpatient indications among the 25 patients inappropriately continued on quetiapine at discharge, 19 patients were treated for agitation/delirium and 6 patients were treated for insomnia. Regarding pharmacist involvement at the time of discharge for patients that were continued inappropriately on quetiapine at discharge, a pharmacist participated in medication review for 10 patients, while 15 patients had no documented pharmacist involvement.

Conclusions: The high rate of inappropriate continuation of inpatient-initiated quetiapine beyond its intended short-term use at discharge represents a significant patient safety issue and underscores a critical gap in current medication reconciliation practices. This concern is amplified in vulnerable populations, particularly patients with dementia, where continued antipsychotic use carries substantial risk. Given that antipsychotic use in patients with dementia is associated with increased risks, including cerebrovascular events and mortality, this finding is particularly concerning. These findings support the need for targeted interventions, including education to hospitalist and family medicine residents, increased pharmacist involvement in discharge planning, routine reassessment of medications initiated for acute inpatient indications, and improved documentation regarding intended duration of therapy. Implementing these strategies may reduce unnecessary antipsychotic exposure, limit polypharmacy, and decrease the likelihood of adverse drug events and poor clinical outcomes. Strengthening discharge processes is essential to ensure safer transitions of care and promote more appropriate, patient-centered medication management.

Background: Children with sickle cell disease (SCD) are at increased risk for serious bacterial infections due to functional asplenia. Fever in this population is considered a medical emergency requiring rapid evaluation and empiric antibiotics. Guidelines recommend prompt antibiotic administration, while the literature specifically supports delivery within 60 minutes of emergency department (ED) arrival. However, achieving this target is often hindered by ED crowding and limited bed availability. To address this, the Children’s Hospital of Georgia (CHOG) pediatric ED implemented a nurse-driven sickle cell fever triage protocol. This study aims to evaluate whether protocol implementation improved the proportion of patients receiving antibiotics within 60 minutes. 

Methods: This is a single-center, retrospective study conducted in the CHOG pediatric ED evaluating a nurse-first sickle cell fever triage protocol with reiteration on May 21, 2025, which allowed triage nurses to obtain IV access, labs, cultures, and notify a provider prior to room assignment. Patients 0–17 years with sickle cell disease who presented to the ED with fever (≥38°C) from November 2, 2024 to October 31, 2025 were included. Encounters with missing key time points or adult ED admissions were excluded. The primary outcome was the proportion of patients receiving antibiotics within 60 minutes of ED arrival. Secondary outcomes included frequency of protocol use and time from arrival to provider evaluation. Outcomes were compared between pre- and post-implementation periods using descriptive statistics, chi-square tests, and t-tests, as appropriate.  

Results: A total of 52 patients were included in this IRB-approved study, with 31 in the pre-protocol group and 21 in the post-protocol group. Antibiotics were administered within 60 minutes of ED arrival in 3 patients (9.7%) in the pre-protocol group and 2 patients (9.5%) in the post-protocol group (p = 0.9853). The sickle cell with fever triage protocol was utilized in 1 (3.23%) of pre-protocol encounters compared with 4 (19.05%) of post-protocol encounters (p = 0.0576). The mean time from ED arrival to provider evaluation significantly decreased from 55 minutes in the pre-protocol period to 23 minutes in the post-protocol period (p = 0.0031). 

Conclusions: This study found no significant difference in the proportion of patients receiving antibiotics within 60 minutes of ED arrival between the pre- and post-protocol groups at a single institution. There was a significantly faster time to provider evaluation in the post-protocol group, suggesting improved early recognition and prioritization of this high-risk population. While protocol utilization increased in the post-implementation period, it remained relatively low, highlighting the need for further workflow optimization, staff education, and system-level support to enhance adherence. Future efforts should focus on identifying barriers to timely antibiotic administration, particularly challenges with obtaining IV access in this population, and improving consistent protocol activation to better align care with national guidelines and ultimately improve outcomes for children with sickle cell disease presenting with fever. 

Contact: [email protected]

Evaluation of the PRECISE-DAPT Score in Predicting CABG Related Bleeding Readmissions
Inyeong Choi, Danielle McPherson, Davide Ventura
AdventHealth Orlando, FL

Background/Purpose: Dual antiplatelet therapy (DAPT) is recommended for patients after coronary artery bypass graft surgery (CABG) with concomitant acute coronary syndrome (ACS) or recent history of percutaneous coronary intervention (PCI). Large scale analyses have confirmed the external validity of the PRECISE-DAPT score demonstrating that high risk patients (score ≥ 25) have a 3- to 4-fold increased risk of major bleeding. The PRECISE-DAPT score is a five-item bleeding risk score validated in the PCI patient population to assist clinician’s informed decision making on duration of DAPT. This score is determined by age, creatinine clearance (CrCl), white blood cell (WBC) count, hemoglobin (Hgb), and history of bleeding at baseline. However, no validated bleeding risk scores exist for the CABG population. Recently, Society of Thoracic Surgeons (STS) registry data at AdventHealth noted a high rate of re-admissions due to bleeding complications. The benefit of DAPT after CABG remains uncertain as recent trials show no clear ischemic advantage at the expense of more bleeding. This study aims to evaluate the association of the PRECISE-DAPT score and bleeding readmissions in patients discharged from DAPT after CABG.

Methodology: This study was a retrospective cohort study conducted from August 2022 to August 2025. This study included patients who were re-admitted after CABG at AdventHealth Orlando and Celebration campuses due to bleeding complications within 90 days. Bleeding complications included gastrointestinal bleeding (GIB), anticoagulation complications , pleural or pericardial effusion requiring intervention, or hemorrhagic stroke. The PRECISE-DAPT score was retrospectively calculated based on age, CrCl, WBC, Hgb, and history of bleeding. The primary outcome was to evaluate the association of the PRECISE-DAPT score and re-admissions due to bleeding complications. The secondary outcomes included bleeding events defined by the Bleeding Academic Research Consortium (BARC) criteria, time to re-admission, transfusion requirements, and any changes to antiplatelet or anticoagulant regimens. Categorical data were analyzed via a Chi-square test or Fischer’s Exact test. Continuous data were analyzed via a Mann-Whitney U test or Kruskal-Wallist test.

Results: A total of 95 patients with CABG with or without valve replacements were included in the final analysis. Twenty-five patients had a PRECISE-DAPT score < 25 (low bleeding risk) and 70 patients had a PRECISE-DAPT score ≥ 25 (high bleeding risk). The high-risk group had an average score of 43 and accounted for 74% of all bleeding complications. Additionally, high-risk patients experienced numerically more clinically relevant bleeding events (BARC type 2 or greater) than the low-risk group (28 vs. 8, p = 0.342). After readmission, 53% of DAPT patients in the high-risk group were transitioned to single antiplatelet therapy (SAPT) compared with 23% in the low-risk group. Transfusion requirements were comparable between the two groups, with 22.9% in the high-risk group and 28% in the low-risk group.

Conclusion: Elevated PRECISE-DAPT scores are associated with increased risk. Though currently validated for PCI patients only, the PRECISE-DAPT score offers a viable tool for risk stratification in CABG patients. Incorporating the PRECISE-DAPT score in surgical patients may inform tailored antithrombotic regimens as a strategy to minimize bleeding readmissions.

Title: Pharmacogenomic- and Drug-Drug Interaction-Guided Antiplatelet Therapy in Veterans Taking Clopidogrel and Omeprazole
Authors: Sydney Magrath, Julianne Isaac, David Deen
Background:
Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality, with antiplatelet therapy as the foundation for secondary prevention. Clopidogrel, a widely prescribed P2Y12 inhibitor, exhibits variable efficacy due to CYP2C19 genetic polymorphisms and drug-drug interactions, especially with proton-pump inhibitors (PPIs), such as omeprazole. Consensus statements and leading medical journals have begun to recommend utilizing genotype-guided therapy to optimize outcomes in specific indications, such as acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI), to optimize outcomes, yet implementation in clinical practice remains limited. The objective of this project is to reduce category X drug-drug interactions between clopidogrel and omeprazole and assess the feasibility of pharmacogenomic testing in Veterans with ASCVD at high risk for major adverse cardiovascular events (MACE).
Methods:
This prospective, interventional quality improvement project utilized a data query to identify Veterans with ASCVD or post-PCI who were prescribed clopidogrel and omeprazole from September 2022 to December 2025 at the Ralph H Johnson VA Health Care System. Veterans were contacted to discuss pharmacogenomic testing and drug-interaction risks and offered to switch to a non-interacting PPI, de-escalate off PPI or to a histamine-2 receptor antagonist where appropriate. Veteran’s most recent blood pressure, lipid panel, and medication list were reviewed for guideline-recommended interventions. Primary outcome was composite implementation rate, defined as proportion of patients contacted who (1) underwent PPI modification and/or (2) have a final antiplatelet regimen that follows Clinical Pharmacogenetics Implementation Consortium (CPIC) and American College of Cardiology (ACC) recommendations. Secondary outcome was incidence of thrombotic events, bleeding, ticagrelor-associated dyspnea, and worsening dyspepsia following intervention. Tertiary outcome was to assess pharmacist interventions.
Results: 
Of the 82 patients on clopidogrel and omeprazole with an included ICD-10 code or procedure code, 59 met inclusion criteria and 51 were successfully contacted. At visit 1, 50 of 51 patients agreed to PPI modification and 43 completed pharmacogenomic testing. Nine of the 43 were CYP2C19 intermediate metabolizers, suggesting possible indication for antiplatelet therapy change. All but one patient with CAD indicated for clopidogrel change accepted a therapy modification. Ultimately, 50 of 51 patients had final antiplatelet regimens aligned with CPIC and ACC guidance therefore 98% meeting composite implementation rate.
No thrombotic or bleeding events occurred. Among patients switched to ticagrelor, 1 of 2 experienced dyspnea. Five patients reported worsening dyspepsia after PPI modification, of whom 85% were CYP2C19 rapid metabolizers. Pharmacist interventions included 14 medication reconciliations, 48 adherence counseling sessions, 10 lipid-related interventions, and one antihypertensive intervention.
Conclusion:
This project demonstrated high implementation rates and strong patient acceptance in addressing high-risk clopidogrel-omeprazole DDIs. Genotype-guided antiplatelet therapy was feasible in routine practice and did not result in thrombotic or bleeding events during the project period. Reported adverse effects were minimal and consistent with known drug profiles. These findings support the integration of pharmacist-driven pharmacogenomics and medication optimization into cardiovascular risk-reduction efforts within the Veteran population. Future pathways include identifying eligible patients during inpatient ACS/PCI admissions for earlier PPI modification and pharmacogenomic testing, followed by coordinated outpatient follow-up to optimize antiplatelet therapy.
 

Background
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve glycemic control and provide cardiovascular and renal benefits in patients with type 2 diabetes mellitus (T2DM), heart failure (HF), and chronic kidney disease (CKD). Despite strong outpatient guideline support, data on inpatient use remains limited. Insulin remains the standard of care for inpatient glycemic management due to safety concerns, including euglycemic diabetic ketoacidosis and acute kidney injury. Consequently, inpatient SGLT2i use remains controversial due to conflicting guideline recommendations and limited safety data, particularly in hospitalized patients with CKD and HF.
Methodology
This IRB-approved multicenter retrospective study included hospitalized adult patients (≥18 years) with T2DM, HF, and CKD admitted between August 2023 and November 2025 who received either SGLT2i in combination with scheduled multimodal insulin (intervention group) or scheduled multimodal insulin alone (control group) Exclusion criteria included type 1 diabetes mellitus, pregnancy or lactation, intensive care unit admission, or use of continuous insulin infusion. The primary outcome was glycemic control measured by daily blood glucose levels. Secondary outcomes included percentage of blood glucose readings in target range (100 to 180 mg/dL), inpatient mortality, length of hospital stay (days), number of insulin injections administered per day, incidence of diabetic ketoacidosis (defined as bicarbonate < 18 mmol/L, pH< 7.3, AG > 12, and serum ketone or urine ketone), incidence of hypoglycemic events (defined as blood glucose < 70 mg/dL), incidence of acute kidney injury (defined as an increase in serum creatinine > 0.3 mg/dL or ≥ 1.5 times above baseline), mean change in body weight.
Descriptive statistics summarize baseline characteristics. Normality was assessed using the Shapiro-Wilk test. Categorical variables were analyzed using Chi-Square tests. Continuous variables were analyzed using Student’s t-test or Mann-Whitney U tests, as appropriate. Statistical significance was defined as a two-tailed alpha of 0.05.
Results
A total of 200 patients were included (100 per group). Baseline characteristics were generally similar between groups except the insulin-alone group had lower eGFR at admission compared to the SGLT2i plus insulin group (20.5 vs. 41.1 mL/min/1.73 m2) and higher serum creatinine at admission (2.77 vs. 1.52 mg/dL). Median daily blood glucose levels were numerically higher in the SGLT2i plus multimodal insulin group compared to multimodal insulin therapy alone (165 vs 160 mg/dL; P < 0.001) Comparable percentage of blood glucose readings within target range (57% vs 59% P = 0.645) were observed.
With secondary efficacy outcomes, there were no significant differences in length of stay (6 vs 5 days; P = 0.199), total daily insulin dose (12.5 vs 8.5 units; P = 0.165), or weight change (-0.05 vs 0.28 P = 0.073). Secondary safety outcomes, including inpatient mortality (1 vs 3; P = 0.621), hypoglycemic events (11 vs 18; P = 0.16), and diabetic ketoacidosis (1 vs 0; P = 1.0), were also comparable between groups
The SGLT2i group had significantly lower 90-day all-cause readmission rates (51% vs 72%; P = 0.002) and lower incidence of acute kidney injury (33% vs 49.5%; P = 0.018), but a higher number of insulin injections per day (3 vs 2; P = 0.01).
Conclusions
Albeit being statistically significant, the addition of SGLT2 inhibitors to insulin therapy did not result in clinically meaningful improvements in glycemic control compared with insulin alone. Observed SGLT2 inhibitor use may be associated with significantly lower rates of acute kidney injury and 90-day readmissions, suggesting potential benefits beyond glycemic management. These findings support further investigation into the role of SGLT2 inhibitors in the inpatient setting.

Madison Brotze and Mark LaBossiere
James H. Quillen VA Medical Center – Mountain Home, TN
Contact Information: [email protected]
Background/Purpose: Depression is common among Veterans, and many do not respond to multiple antidepressant trials, resulting in treatment-resistant depression (TRD). TRD contributes to increased symptom burden, higher healthcare use, and more complex care needs. Vilazodone and vortioxetine are two antidepressants that may offer advantages for Veterans with TRD due to their unique mechanisms and potentially better tolerability profiles. This quality improvement project aims to assess current prescribing of these agents, in addition to evaluating rates of discontinuation, adherence, tolerability, and healthcare utilization associated to identify potential opportunities to improve treatment selection and care processes for Veterans with TRD.
Methodology: This project will identify Veterans initiated on vilazodone or vortioxetine at the James H. Quillen VAMC. Time to discontinuation will be evaluated from the date of medication initiation through 3, 6, and 12 months. Medication adherence will be assessed using the medication possession ratio (MPR), and reasons for discontinuation will be collected from the electronic health record. Healthcare utilization measures, including psychiatric hospitalizations and activation of high-risk suicide flags during treatment, will also be reviewed. Data will be compared between vilazodone and vortioxetine to identify trends, gaps, and opportunities to improve antidepressant management for Veterans with TRD.
Results: In progress
Conclusion: In progress 

Title: Retrospective Evaluation of an Antiarrhythmic Monitoring Program
Authors: Kaitlin A Roberts, Rebecca Holt, Cynthia Pohland
Objective: Assess the James H Quillen Veterans’ Affairs Medical Center (JHQVAMC)’s adherence to monitoring recommendations for seven different antiarrhythmic medications (amiodarone, dronedarone, sotalol, dofetilide, mexiletine, propafenone, flecainide).
Self-Assessment Question: Which of the following antiarrhythmics showed significant improvement in adherence to monitoring recommendations between the 2022-2023 resident project and the current resident project? A. Dofetilide, B. Propafenone, C. Dronedarone, D. Flecainide
Background: The purpose of this quality improvement project was to evaluate the current compliance with antiarrhythmic drug (AAD) monitoring program collaboratively developed after a 2023 residency project identified low compliance with routine monitoring.
Methods: Participants were identified by presence of AAD prescription and eligibility was assessed. Patients receiving care at and prescribed an AAD at JHQVAMC between June 2024 – June 2025 were included. Participants were excluded if they were not prescribed an AAD by a VA provider. No more than 50 participants on each antiarrhythmic medication were randomly sampled and retrospectively reviewed to collect the following: demographics (age, sex, race/ethnicity); number of appointments with electrophysiology (EP) providers, non-EP cardiology providers, and cardiology pharmacists; frequency of lab monitoring (potassium (K), magnesium (Mg), liver function tests (LFTs), serum creatinine (SCr), thyroid stimulating hormone (TSH); and frequency of electrocardiograms (EKG). Results of descriptive statistics were used to evaluate compliance with monitoring. The results will then be disseminated to the local EP cardiology team to enhance current practice.
Result: Percentage of appropriate monitoring visits for dronedarone, sotalol, amiodarone, dofetilide, flecainide, mexiletine, and propafenone were 53%, 60%, 80%, 74%, 66%, 90%, and 80% respectively. Percentage of appropriate EKG monitoring for dronedarone, sotalol amiodarone, dofetilide, flecainide, mexiletine, and propafenone was 65%, 66%, 72%, 80%, 72%, 95%, and 80% respectively. The percentage of appropriately monitored labs was as follows: dronedarone had 58% K and LFTs, 16% Mg and TSH; sotalol had 84% K, 46% Mg, 88% SCr; amiodarone had 78% K, 24% Mg, 70% LFTs, 26% TSH; dofetilide had 94% K and SCr, 76% Mg; flecainide had 82% K, 20% Mg, 80% LFTs; mexiletine had 100% K and LFTs, 76% Mg; propafenone had 100% K and LFTs, 40% magnesium.
Conclusions: After pharmacist intervention, JHQVAMC was monitoring the majority of patients on AAD appropriately, with few exceptions that can be improved upon through process improvement such as the creation of lab order sets.

Title: Impact of a Clinical Pharmacist Workflow Change on Heart Failure Readmissions  
 
Authors: Sean Ramoso, Kathrina Gonzales Raymundo, Natalie Ortiz-Gratacos, Richard Lane, Nicholas Mastromarino, Tracey Dobbs 
Contact: [email protected]
 
Background:  
Heart failure (HF) is a complex clinical syndrome and a leading cause of morbidity and mortality in the United States.1,2 Hospital readmissions due to HF are associated with increased costs and continue to be a growing health and economic burden.2,3 The American Heart Association estimates that the total costs of HF will increase from $31 billion in 2012 to $70 billion in 2030.4 To reduce HF readmissions, studies have evaluated the implementation of HF-focused multidisciplinary teams and observed reductions in 30-day HF readmission rates. These initiatives focused on transitions of care interventions such as telephone consultations, clinic follow-ups, and comprehensive patient education.  Pharmacists can play a key role in these multidisciplinary teams through optimization of pharmacological guideline-directed medical therapy (GDMT) as recommended by the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) Guidelines for the Management of Heart Failure. Further studies examining the impact of pharmacy-led interventions on HF readmissions and patient outcomes will be beneficial to identify the pharmacist’s role on the multidisciplinary team. 
 
Methods:  
A single-center, retrospective, chart review was conducted at AdventHealth Apopka between December 23, 2025 to March 30, 2026. A clinical pharmacist workflow change was implemented, where pharmacists completed HF-focused admission and discharge medication reconciliation reviews aimed at optimizing pharmacological GDMT per the 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure. Patients were included if they were 18 years or older, had a diagnosis of HF, and had a HF-focused admission medication reconciliation completed by a pharmacist. Patients were excluded if they were pregnant, had a history of a heart transplant, had a scheduled heart transplant at the time of the index visit, had a diagnosis of dementia, or were discharged to hospice. The primary outcome of this study was the incidence of 30-day cardiovascular (CV)-related readmission rates, based on the index hospital discharge date. Secondary outcomes included 30-day all-cause readmission, inpatient length of stay (LOS), and the incidence of HF GDMT optimization defined as a dose titration, addition/resumption, or discontinuation of a GDMT drug class. 
 
Results: 
At the time of data analysis, the HF-focused pharmacist intervention group consisted of 52 patients who had 30-day readmissions data available. A comparator group of 52 patients admitted during the same study period without a HF-focused pharmacist intervention was utilized. For the primary outcome of 30-day CV-related readmission, this occurred in 9/52 (17.3%) patients in the intervention group and 11/52 (21.2%) patients in the comparator group (p = 0.495). For the secondary outcome of 30-day all-cause readmission, this occurred in 17/52 (32.7%) of patients in the intervention group and 16/52 (30.8%) of patients in the comparator (p = 0.946). The mean length of stay in the intervention group was 4.64 +/- 3.79 days compared with 2.94+/- 4 days in the comparator group (p = 0.056). HF GFMT optimization occurred in 41/52 (77.4%) patients in the comparator group and 28/52 (52.8%) of patients in the comparator group (p = 0.013). 
 
Conclusion: 
A HF-focused pharmacist workflow change was associated with a numerical, but not statistically significant, reduction in 30-day CV-related readmissions. This pharmacist workflow change was also associated with a significant increase in the incidence of HF GDMT. Key barriers to GDMT optimization included weekday-only coverage, challenges in reliably identifying eligible HF patients, competing staffing responsibilities, and variable acceptance of GDMT recommendations which were often deferred to outpatient follow-up. Next steps should focus on expanding pharmacist coverage to increase completion of HF-focused medication reconciliations, refining the HF patient identification report, implementing strategies to improve GDMT recommendation uptake, and evaluating outcomes over a longer timeframe with a larger sample. 
 
References 

1. Heidenreich, P. A., et al. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18). https://doi.org/10.1161/cir.0000000000001063 

1. Urbich, M., Globe, G., Pantiri, K. et al. A Systematic Review of Medical Costs Associated with Heart Failure in the USA (2014–2020). PharmacoEconomics 38, 1219–1236 (2020). https://doi.org/10.1007/s40273-020-00952-0 

1. Kwok, C. S., et al. (2021). Cost of inpatient heart failure care and 30-day readmissions in the United States. International Journal of Cardiology, 329, 115–122. https://doi.org/10.1016/j.ijcard.2020.12.020 

1. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the Impact of Heart Failure in the United States: A Policy Statement From the American Heart Association. Circulation: Heart Failure. 2013;6(3):606-619. doi:https://doi.org/10.1161/hhf.0b013e318291329a 

 

IMPACT OF A PHARMACIST-DRIVEN PENICILLIN ALLERGY RE-LABELING PROCESS IN THE EMERGENCY DEPARTMENT SETTING
Erin Schuld PharmD, Aayush Patel PharmD, Mckenzie Hodges PharmD
Piedmont Columbus Regional Midtown-Columbus GA

Background/Purpose: Approximately 10% of U.S. patients report a penicillin allergy, yet fewer than 1% are truly allergic. Mislabeling often leads to use of broad-spectrum antibiotics, increasing antimicrobial resistance and risk of adverse effects. Pharmacist-driven allergy clarification protocols may improve antibiotic stewardship by enabling safe re-labeling of inaccurate allergy records. This study evaluates the impact of a pharmacist-driven penicillin allergy re-labeling protocol in the emergency department (ED) using the institution’s hypersensitivity pathway and the Pen-FAST risk stratification tool.

Methods: We conducted a single-center, retrospective chart review of adult patients (≥18 years) presenting to the ED between February 2, 2026 and March 31, 2026 with a documented penicillin allergy. Patients were excluded if they could not meaningfully participate in the allergy assessment for any reason.  The primary outcome was the proportion of patients safely and successfully re-labeled using the pharmacist-driven protocol. Secondary outcomes included changes in antibiotic therapy following re-labeling and incidence of adverse reactions during oral or test-dose challenges. Data were abstracted from electronic health records and analyzed using descriptive statistics.

Results: A total of 559 patients were included in this study. 441 patients were not able to have their allergies assessed by a pharmacist. 70 unassessed patients were on antibiotics and, of these, 29 patients potentially could have undergone a change to their antibiotic regimen. 118 patients were able to have their allergy assessed and re-labeled by a pharmacist. 46 assessed patients were receiving antibiotics. Of these 46, 18 patients underwent changes to their antibiotic regimen secondary to the pharmacist assessment. The most frequent change was from a fluoroquinolone, namely levofloxacin, to a cephalosporin with cefepime and ceftriaxone being the most common agents. The second most common change was from aztreonam to a cephalosporin with cefepime and ceftriaxone being the most common agent. 3 challenges (2 amoxicillin and 1 cephalosporin) were performed with no adverse reactions reported.
 
Conclusion: Implementation of a standardized Pen-FAST-based workflow enabled allergy clarification in a high-acuity setting by a clinical pharmacist. Some patients were able to be successfully transitioned to a first line recommended agent secondary to their allergy assessment, supporting the safety of a pharmacist-driven allergy assessment. While a majority of patients assessed by a pharmacist were not receiving antibiotics, full documentation of the allergy assessment in the electronic medical record may have downstream benefits should antibiotics be required during their next encounter. Overall, a pharmacist-driven penicillin allergy re-labeling process in the ED is feasible, safe, and clinically impactful.

Contact: [email protected]

Authors: Emma Cloud, Eric Shaw, Mallory Stringer

Contact: [email protected]

Practice Site: Memorial Health University Medical Center

Background:
Aneurysmal subarachnoid hemorrhage (aSAH) is a subtype of hemorrhagic stroke where the bleed occurs between the brain tissue and the arachnoid mater surrounding the brain. The characteristic symptom is a severe headache which patients often describe as “the worst headache of my life.” These headaches often continue to affect patients beyond the acute period and have a multifactorial etiology requiring a multimodal pain management approach. Guidelines do not have specific recommendations for headache management. Opioids, while a mainstay of treatment, have sedating effects that may confound the frequent neurological monitoring necessary for these patients. Nonsteroidal anti-inflammatory drugs carry an increased risk of bleeding and neuropathic pain medications such as gabapentin and pregabalin warrant further investigation. Butalbital has been shown to decrease pain scores secondary to aSAH and is often utilized as the combination agent acetaminophen/butalbital/caffeine (A/B/C) at our institution. Prior literature has found inconclusive results regarding the safety of A/B/C and its association with cerebral vasospasm. This study aimed to identify a potential relationship between use of A/B/C and occurrence of cerebral vasospasm in this patient population.

Methods:
This was a retrospective chart review conducted at a 711-bed academic medical center between July 2018 and September 2025. Adults admitted to the neurovascular intensive care unit with a diagnosis of non-traumatic aSAH, confirmed by diagnostic angiography, who underwent surgical fixation via clipping or coiling and received A/B/C were included. The following were exclusion criteria: pregnant, incarcerated, Hunt and Hess Score of 4 or 5, and intubated >48 hours. Patients were divided into those who had a vasospasm versus those that did not. Baseline data was analyzed using Chi-Square and Fisher’s Exact tests for categorical data and T-Test for continuous data. Primary and secondary outcomes were analyzed using Mann-Whitney U tests.

Results:
Thirty-seven patients were included in the analysis. The patient population was predominantly female (70.3%), black (48.6%), underwent coiling for surgical fixation (97%), and had an average Hunt and Hess score of 2. Baseline demographics were not significantly different between the two groups with the exception of the vasospasm group being younger (55.9 ± 10.7 vs 42.81 ± 8.6, p<0.001). There was no significant difference in A/B/C usage between patients who had a vasospasm versus those who did not have a vasospasm (2.2 ± 1.7 vs 2.3 ± 1.5; p=0.751). When looking only patients who had a vasospasm, there was no significant difference in A/B/C usage on days they had a vasospasm versus days they did not (2.4 ± 1.8 vs 2.2 ± 1.9; p = 0.955).

Conclusions:
Based off our study population, A/B/C was not associated with occurrence of cerebral vasospasm. This study was limited by variable frequency of pain score measurements across patients, small sample size, and reliance on infrequent transcranial dopplers that could lead to underreporting of vasospasm.

Authors: Rayna Wallace, Jamie Coates, Kristina Hazard

Background: Blood pressure guidelines involve a stepwise approach with lifestyle modifications and medication(s) to achieve target blood pressure. Calcium channel blockers, amlodipine and nifedipine, are recommended as first-line antihypertensive agents due to their efficacy in lowering blood pressure. While amlodipine and nifedipine’s effects on blood pressure compared to other antihypertensive classes have been well studied, there is limited data regarding nifedipine’s role as a direct substitute for amlodipine. This project aims to evaluate the impact of amlodipine to nifedipine conversions by a remote pharmacy hypertension service to explore the conversion as a potential alternative to intensifying antihypertensive regimens with additional agents.

Methods: This IRB-exempt retrospective cohort project includes Kaiser Permanente Georgia members 18 years or older with a hypertension diagnosis who were enrolled in a remote pharmacy hypertension service and prescribed amlodipine 10 mg or switched from amlodipine 10 mg to nifedipine SR 90 mg between May 4, 2021, and May 3, 2025. The primary objective was to determine if the conversion of amlodipine to nifedipine would improve blood pressure in patients with uncontrolled hypertension as compared to patients remaining on amlodipine. The secondary objective was to assess the average change in blood pressure after the conversion of amlodipine to nifedipine in patients with uncontrolled hypertension. The tertiary objective was to evaluate if the conversion of amlodipine to nifedipine in patients with uncontrolled hypertension could result in ambulatory blood pressure goals being met at the next pharmacy hypertension service visit and within 3 months post conversion. Patients who remained on amlodipine 10 mg were matched up to a 1:2 ratio to patients who were converted to nifedipine SR 90 mg. Conditional logistic regression and generalized estimating equation (GEE) models were applied to report outcomes data.

Results: A total of 664 patients met inclusion criteria, of whom 596 remained on amlodipine 10 mg and 68 were converted to nifedipine SR 90 mg. 63 of the nifedipine SR 90 mg patients were matched to 120 patients remaining on amlodipine 10 mg. Conversion from amlodipine 10 mg to nifedipine SR 90 mg was not associated with statistically significant improvement in blood pressure outcomes. There was no significant difference in systolic blood pressure improvement (OR = 1.23; 95% CI = 0.61, 2.47) or diastolic improvement (OR = 1.54; 95% CI = 0.81, 2.92) between groups. At follow-up, the average systolic blood pressure in the nifedipine group was lower by -2.12; 95% CI = -5.65, 1.42 (p = 0.24) and average diastolic blood pressure was lower by -1.66; 95% CI = -4.36, 1.05 (p = 0.23); neither difference was statistically significant. Similarly, there were no significant differences in change from baseline systolic blood pressure (Estimate: -0.80; 95% CI = -2.72, 1.13) or change from baseline diastolic blood pressure (Estimate: -2.04; 95% CI = -4.59, 0.51) between groups. Achievement of blood pressure goals at follow-up (OR 0.95; 95% CI = 0.43, 2.11) and at 3 months (OR = 0.69; 95% CI = 0.33, 1.45) did not differ significantly between patients converted to nifedipine SR 90 mg and those maintained on amlodipine 10 mg.

Conclusions: Conversion from amlodipine 10 mg to nifedipine SR 90 mg was not associated with significant improvements in blood pressure reduction or goal attainment as compared to those remaining on amlodipine 10 mg after an adjusted analysis. These findings suggest that routine conversion to nifedipine SR 90 mg may not provide additional benefit over continued amlodipine 10 mg therapy. Further assessment of these findings may be warranted in a larger nifedipine cohort.

Contact Rayna Wallace at [email protected] with any questions regarding this project.

TITLE: Evaluation of Discharge Medication Prescribing for Patients with Heart Failure Before and After Pharmacist Involvement 
AUTHORS: Uyen Nguyen, Amanda Herndon, and Christine Wong
BACKGROUND: Heart failure (HF) is a leading cause of hospital admissions and readmissions in the United States. The 2022 ACC/AHA/HFSA guidelines recommend that eligible patients with heart failure be discharged on compare guideline-directed medical therapy (GDMT) to reduce morbidity, mortality, and rehospitalization. Despite strong evidence supporting GDMT, many patients are not discharged on all recommended therapies due to system-level gaps, and unaddressed patient-specific barriers. Meta-analysis and observational studies have shown that patients who have medications reviewed by pharmacists prior to discharge are more likely to be discharged on appropriate GDMT. This study aims to assess the effect of pharmacist involvement on adherence to heart failure GDMT prescribing at discharge in a community teaching hospital.

METHODOLOGY: This single-center, comparative study received Institutional Review Board exemption. Retrospective chart review was conducted to compare GDMT prescribing at discharge for all patients with HF before and after pharmacist involvement. During the intervention period, pharmacists received education on assessing HF GDMT eligibility, identifying opportunities for initiation, and ensuring appropriate documentation of contraindications. Providers also received education on potential GDMT initiation, appropriate documentation, medication contraindications, and cost considerations.
Pharmacists reviewed medications and provided recommendations to optimize GDMT for all HF patients prior to discharge. All pharmacist interventions and documentation of contraindications were recorded. Patients who were at least 18 years of age and had a diagnosis of HF were included in the results. Patients who expired or enrolled in hospice or comfort care at any time during the study were excluded. Enrollment of 80 patients in both pre-intervention and post-intervention groups would provide 80% power to detect a 20% difference in the composite GDMT prescribing, with a significant p-value of 0.05.
The primary outcome was the percentage of patients with HF discharged on appropriate composite GDMT. Composite GDMT was defined as adherence to angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor (ACEi/ARB/ARNi), mineralocorticoid receptor antagonists (MRA), and evidence-based beta-blockers (BB) for patients with heart failure with reduced ejection fraction (HFrEF) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) for all patients with heart failure. Secondary outcomes included the percentage of patients prescribed each individual component of GDMT at discharge, including ACEi/ARB/ARNi, BB, MRA, and SGLT2i, when indicated. Adherence was defined as recommended therapy prescribed at discharge or documented contraindications to any component of GDMT.

RESULTS: The primary outcome of composite GDMT before and after pharmacist involvement increased from 40% in the pre-intervention group to 77.5% in the post-intervention group, n= 80 in each group, p-value <0.001. Secondary outcomes showed an increase in each individual component of GDMT. Among patients with HFrEF, n = 31 in each group, prescribing rates in the post-intervention group compared to the pre-intervention group group increased as follow: ACEi/ARB ARNi from 35% to 74%, p 0.002, BB increased from 74% to 100%, p=0.003, MRA increased from 47.5% to 87%, p=0.002. Prescribing of SGLT2i for all HF patients increased from 47.5% to 78%, p<0.001.

CONCLUSIONS: Baseline findings showed significant gaps in the prescribing of GDMT or appropriate documentation of contraindications for patients with heart failure at hospital discharge, particularly with ACEi/ARB/ARNi, MRA, and SGLT2i. Improvements following pharmacist involvement suggest that targeted education, medication review, and real-time recommendations at discharge can increase adherence to evidence-based therapies. The findings highlight the benefit of pharmacist involvement to optimize GDMT, address barriers to prescribing, and improve documentation of contraindications.

Study Objective: To pragmatically assess rocuronium dosing practices for emergency department intubation procedural outcomes and post-intubation sedation practices. 
Methods: We conducted a retrospective, single-center, observational study of adult patients who received rocuronium for intubation in the emergency department at an academic medical center between January 1st, 2022, and December 31st, 2024. Rocuronium doses were categorized as less than 0.6 mg/kg (low-dose), 0.6 to 1.2 mg/kg (intermediate-dose), or greater than 1.2 mg/kg (high-dose). Secondary outcomes included reversal agent use, first-pass intubation failure, intubation indication, intubating service, dosing year, and induction agent selection. Subgroup analysis evaluated post-intubation sedation timing and practices among patients who received either intermediate-dose or high-dose. Categorical variables are reported as counts and percentages, and continuous variables are summarized using descriptive statistics. 
Results: A total of 237 patients met inclusion criteria. Most patients received doses within 0.6 to 1.2 mg/kg (189 (79.7%)), whereas 18 patients (7.6%) received low-dose and 30 patients (12.7%) received high-dose. First-pass intubation failure was greatest in the intermediate-dose group, occurring in 45 patients (23.8%) versus 3 patients (10%) in the high-dose group. Emergency medicine clinicians performed the majority of intubations (82.3%). The median time to sedation initiation was 5 minutes for the low-dose group, 6 minutes for the intermediate-dose group, and 3 minutes for the high dose group. Fentanyl was administered in 100% of patients in the higher-dose group compared with 83.3%% of patients in the low-dose group and 79.6% in the intermediate-dose group. While propofol was administered in 31% of patients who received higher-doses compared to 33.3 % and 57.5% respectively. Overall, a majority of patients received an infusion (124 (52%)) as the post-intubation sedation method with bolus plus infusion (94 (40%)) being the next most common method. 
Conclusion: The majority of patients received doses of rocuronium within the 0.6 to 1.2 mg/kg range, consistent with recommendations in available literature. Lower observed first-pass failure rates among patients receiving lower rocuronium doses, however, the smaller sample sizes in the low and high-dose groups limit the significance of differences in observed event rates. Post-intubation sedation practices varied across dosing groups, particularly with respect to fentanyl and propofol utilization. 

Background
Patients discharged after coronary artery bypass graft (CABG) or aortic valve replacement (AVR) surgery are at high risk for hospital readmissions, medication discrepancies, and adverse drug events during care transitions. Readmission rates following cardiac surgery range from 11-25%, carrying significant clinical and economic consequences with an estimated annual national cost exceeding $250 million for CABG alone.1-3 The transition from hospital to home represents a particularly vulnerable period, as approximately 50% of patients experience medication errors or unintentional discrepancies following discharge. While pharmacist-led medication reconciliation has been shown to reduce medication discrepancies and hospital readmissions in general populations, limited data exist evaluating the clinical impact of these interventions specifically in the cardiac surgery population.

Objective
To evaluate the impact of a pharmacist-led medication reconciliation intervention on clinical outcomes in patients following cardiac surgery, and to identify opportunities to standardize and improve discharge workflows.

Methods
A retrospective chart review was completed to evaluate patients' post discharge with scheduled Transition of Care Management (TCM) appointments between June 2024 to June 2025. Patients were included if they were at least 18 years of age, discharged from AdventHealth Celebration following CABG or valve replacement surgery, and had a scheduled TCM visit. Patients were excluded if they had no scheduled TCM appointment at discharge or death occurred prior to visit. Upon discharge, patients who are referred to TCM are contacted by an ambulatory care pharmacist within the AdventHealth Celebration Clinical Pharmacy Services Teams. At this time, pharmacists perform a medication reconciliation and correct any discrepancies found prior to TCM visit. The primary outcome of the study was 30-day all cause readmission rate. Secondary outcomes included TCM show rate, pharmacist interventions, and medication discrepancies identified.

Results
The study included 297 patients who underwent cardiac surgery. Of these, 212 patients (71%) received pharmacist intervention prior to their transitional care management (TCM) visit, while 85 patients (29%) did not receive intervention. Patients who received pharmacist intervention had a 30-day readmission rate of 18% versus 22% in those who did not receive intervention. TCM visit attendance was 94% in the intervention group versus 92% in the comparison group. The most prevalent medication discrepancy identified during pharmacist contact was commission errors, followed by frequency errors and dosing errors.
Among patients who underwent CABG, the 30-day readmission rate was 20% in those who received pharmacist intervention versus 22% in those who did not. The average time to readmission was 10 days in the intervention group versus 3 days in the comparison group. TCM visit attendance was 94% for the intervention group versus 93% in the comparison group.
Among patients undergoing aortic valve replacement (AVR), the 30-day readmission rate was 11% in those who received pharmacist intervention versus 25% in those who did not. The average time to readmission was 3 days in the intervention group versus 2 days in the comparison group. TCM visit attendance was 93% in the intervention group versus 75% in the no-intervention group.

Conclusion
The delayed time to readmission in the intervention group (particularly CABG) may indicate that pharmacist involvement helps patients manage early post-discharge issues that would otherwise result in rapid readmission. The later readmissions might represent disease progression or complications less amenable to medication management and education.

References
1. Pharmacist and Student Pharmacist Perspectives on Providing Preconception Care in the United States. Journal of the American Pharmacists Association : JAPhA. 2018. Ng C, Najjar R, DiPietro Mager N, Rafie S.
2. Readmissions After Cardiac Surgery: Experience of the National Institutes of Health/­Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network. The Annals of Thoracic Surgery. 2014. Iribarne A, Chang H, Alexander JH, et al.
3. Readmissions Following Isolated Coronary Artery Bypass Graft Surgery in the United States (From the Nationwide Readmissions Database 2010 to 2014). The American Journal of Cardiology. 2019. Khoury H, Sanaiha Y, Rudasill SE, et al.
4. Jošt M, Kerec Kos M, Kos M, Knez L. Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial. Front Pharmacol. 2024;15:1377781. Published 2024 Mar 28. doi:10.3389/fphar.2024.1377781
5. Incidence, Cost, and Risk Factors for Readmission After Coronary Artery Bypass Grafting. The Annals of Thoracic Surgery. 2019. Shah RM, Zhang Q, Chatterjee S, et al.
6. A Multi-Center Analysis of Readmission After Cardiac Surgery: Experience of the Northern New England Cardiovascular Disease Study Group. Journal of Cardiac Surgery. 2019. Trooboff SW, Magnus PC, Ross CS, et al.
7. Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association. Circulation. 2020. Fordyce CB, Katz JN, Alviar CL, et al.Guideline
8. Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge From Hospital to Community Settings: A Systematic Review. Drug Safety. 2020. Alqenae FA, Steinke D, Keers RN

Background: In February 2025, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated guidelines for acute coronary syndrome (ACS) management. Key medication-related updates include a preference for ticagrelor or prasugrel over clopidogrel in patients undergoing percutaneous coronary intervention (PCI), as well as more aggressive lipid management strategies recommending the addition of non-statin therapies in patients who do not achieve recommended low-density lipoprotein cholesterol (LDL-C) targets of < 55-70 mg/dL despite maximally tolerated statin therapy. This study aims to evaluate changes in prescribing patterns following guideline release at a tertiary medical center and to identify potential barriers to adoption.
Methods: This single-center, retrospective cohort study will evaluate adult patients diagnosed with Non–ST-elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI) who underwent PCI between October 1, 2024 and January 31, 2025 (pre-guideline cohort), and June 1, 2025 and September 30, 2025 (post-guideline cohort). Patients requiring coronary artery bypass graft (CABG) surgery will be excluded. A three-month washout period following publication of the updated guidelines until June 1, 2025 was incorporated to allow for integration into clinical practice. Data will be abstracted from the electronic medical record (EMR) and will include patient demographics, ACS presentation, baseline laboratory values, and medication prescribing patterns, including discharge antiplatelet therapy and lipid-lowering therapy. All data will be de-identified prior to analysis. Descriptive statistics will be used to summarize baseline characteristics and prescribing patterns. Categorical variables will be compared between cohorts using chi-square analysis to evaluate differences in guideline adoption before and after publication. Statistical significance will be defined as a p-value <0.05.
Results: A total of 442 patients with STEMI or NSTEMI were screened, of whom 97 met inclusion criteria (pre-guideline cohort n=46; post-guideline cohort n=51). Baseline characteristics were generally similar between groups, although statin intolerance was more common in the post-guideline cohort (13.7% vs 2.2%, p=0.037) and oral anticoagulant use at discharge was lower (9.8% vs 26.1%, p=0.035). Appropriate P2Y12 inhibitor prescribing at discharge increased numerically following guideline publication (50% vs 56.9%), though this difference was not statistically significant (p=0.499); however, the distribution of discharge P2Y12 inhibitor selection differed significantly between cohorts (p=0.001), with increased use of prasugrel and ticagrelor and reduced use of clopidogrel post-guideline. Nonstatin lipid-lowering therapy prescribing increased from 15.2% to 23.5% (p=0.303), while appropriate statin prescribing remained high in both groups (91.3% vs 98%, p=0.129).
Conclusion: Following the 2025 ACS guideline update, prescribing patterns shifted modestly toward guideline-preferred P2Y12 inhibitors and increased use of nonstatin lipid-lowering therapies after PCI, though adoption remained incomplete and may have been influenced by factors such as baseline oral anticoagulant use and cost limitations. These findings highlight the need for continued education and targeted strategies to improve implementation of updated guideline-directed discharge therapy after PCI.

Title: Complications Associated with Prolonged High-Rate Propofol Infusion in ICU Patients 

Authors: Phuongloan Hoang, Brook Jacobs, Rupal Sheth 

Background/Purpose: 
Propofol is a highly lipophilic sedative hypnotic that exerts its effects by stimulating γ-aminobutyric acid (GABA) receptors. It is widely used in the intensive care unit (ICU) for sedation, ventilator synchrony, oxygen optimization, and management of status epilepticus. Advantages include its fast onset and short duration of action. Propofol administration may lead to propofol-related infusion syndrome (PRIS), a rare but potentially fatal complication characterized by metabolic acidosis, cardiac abnormalities, hypotension, acute kidney injury, hepatic dysfunction, and electrolyte disturbances. Diagnosis is challenging because these features overlap with propofol’s expected pharmacologic effects and manifestations of critical illness. PRIS most often occurs with higher infusion rates, prolonged exposure, and concomitant vasopressor therapy. 

Within our health system, the standard continuous infusion range for propofol is between 5 to 80 mcg/kg/min using the ALARIS pump. A soft stop at 50 mcg/kg/min was previously implemented as a safeguard to reduce the risk of PRIS and other potential complications. While this threshold provides an additional layer of safety, concerns arose regarding whether this 50 mcg/kg/min soft stop may have been overly conservative, particularly since PRIS has been reported at lower infusion rates which suggests that risk is not strictly dose-dependent. Maintaining this limit could potentially restrict treatment options unnecessarily, especially for patients who have high sedation requirements and might benefit from higher infusion rates.  Additionally, if adverse safety events are not being observed, reevaluating the threshold could help to reduce alert fatigue for nursing staff, supporting both patient care and workflow efficiency. Recently, a decision was made to raise the soft stop to 60 mcg/kg/min. This study aims to evaluate the incidence of presumed PRIS and to assess whether it is safe to raise the upper dosing threshold for propofol infusions.   

Methods: 
This study was a multicenter, retrospective cohort study that included patients aged ≥18 who received continuous propofol infusions for ≥24 hours at our institution from April through September 2025.  Patients were eligible if they received continuous propofol infusions for ≥24 hours and were grouped based on average propofol infusion rates (<50 mcg/kg/min and ≥50 mcg/kg/min). The primary outcome is the incidence of presumed PRIS defined as the development of 3 or more criteria after the initiation of propofol therapy, one of which must be hypertriglyceridemia or rhabdomyolysis, or a diagnosis of PRIS found in patient’s chart. Secondary outcomes included presumed PRIS incidence in patients receiving propofol at 50-60 mcg/kg/min, ICU length of stay, and initiation of vasopressors or renal replacement therapy.  

Results: 
Of 54 patients, the incidence of overall presumed PRIS was 1.9% (n=1). This patient belonged to the  propofol <50 mcg/kg/min group. Of the four cases that would have met criteria for presumed PRIS (7.4%), three of these cases were excluded due to timing of clinical findings. In those who received continuous propofol infusion for ≥24 hours, secondary outcomes were not statistically significant between the <50 mcg/kg/min and ≥50 mcg/kg/min groups. 

Conclusion: 
Consistent with previous studies, the incidence of presumed PRIS incidence was low in our patient population. Secondary outcomes were not statistically significant. Further studies are needed to determine a clinically meaningful difference in PRIS rates between dosage groups.

Improving VTE Prophylaxis in Multiple Myeloma: An EHR-Based Approach Using IMPEDE and SAVED Risk Stratification
Score in an Outpatient Setting
Purpose:
Multiple myeloma patients are at an increased risk of venous thromboembolism due to drug usage, decreased mobility,
and hypercoagulability. Use of IMPEDE/SAVED score to determine prescribing of VTE prophylaxis has resulted in
significantly lower risk of venous thromboembolism. Real world data are needed to determine whether implementation
of a new electronic health record (EHR) system incorporating these scoring tools improves the effectiveness of guiding
thromboembolism prophylactic treatment in multiple myeloma patients, as clinical trial results may not fully reflect their
impact across diverse patient populations, practice settings, and workflow environments.
Methods:
This retrospective, single-center, quality improvement evaluated newly diagnosed patients with multiple myeloma (MM)
before and after implementation of IMPEDE and SAVED risk stratification score that was integrated in an EHR treatment
order set to guide prophylaxis selection. The pre-intervention group was managed using Varian EHR system, whereas the
post-intervention group used Cerner EHR platform, where the order set was implemented. Although the risk scores were
calculated by the treating physicians, integration of the order set serves as a structured reminder to promote consistent
risk assessment and documentation. The primary outcome was guideline adherence to VTE prophylaxis, with secondary
outcomes including incidence of VTE within six months of prophylaxis and assessing risk reclassification.
Results
A total of 19 patients with MM were included with 8 in the pre-intervention group using Varian EHR, and 11 patients in the
post-intervention group following Cerner EHR implementation with VTE prophylaxis order sets. Guideline adherence to
NCCN recommended VTE prophylaxis based on SAVED and IMPEDE scores were 87.5% and 25% pre-intervention versus
63.6% and 36.4% post-intervention, respectively. No patients receiving prophylactic anticoagulation developed VTE
within six months, and one pre-intervention patient (12.5%) had a prophylaxis change after crossover to the post
intervention period.
Conclusion
Implementation of IMPEDED and SAVED VTE risk stratification score being added to treatment order sets demonstrated
variable adherence to guideline recommended prophylaxis but was associated with no observed VTE events among
patients receiving prophylaxis. Larger studies are needed to further evaluate clinical impact and prescribing consistency