2026 Southeastern Residency Conference

Purpose: Historically, trauma resuscitation has focused on three main complicating factors known as the “lethal triad”: hypothermia, acidosis, and coagulopathy. However, recent literature has begun to recognize hypocalcemia as a fourth pillar in mortality rates. Data has shown up to 97% of patients can experience an exacerbation of hypocalcemia during massive transfusion protocol (MTP), of which 71% may experience severe hypocalcemia (ionized calcium < 0.9 mmol/L). The purpose of this study is to evaluate the effect of a standardized protocol for calcium repletion in trauma patients requiring MTP. 
Methods: This was a single center, retrospective, descriptive, observational study among trauma patients who presented to Wellstar Kennestone Regional Medical Center Emergency Department (WKRMCED). Data was collected prior to implementation of a calcium repletion protocol from July 1, 2023 to May 31, 2024, and post-protocol implementation from August 1, 2024 to June 30, 2025. Patients were included if they presented to WKRMCED during the specified treatment dates as a tier 1 trauma requiring activation of MTP for administration of blood products. Patients were excluded if they were pregnant, ≤ 15 years old, had activation of MTP for a non-trauma related reason, did not have documentation of calcium levels after transfusion, or if the calcium replacement protocol was not followed after transfusion of blood products. The primary outcome was calcium levels up to 24h following the last documented blood product given post-transfusion. Secondary outcomes included total amount of blood products transfused within 24h of MTP initiation, hospital length of stay, intensive care unit length of stay, and in-hospital mortality.  
Results: Of the 6217 patients screened for inclusion in this study, 122 met inclusion criteria. Patients were screened further based on the predefined exclusion criteria and a total of 98 patients were included in the study (pre-protocol n=62; post protocol n=36).  Although this study was observational, and descriptive statistics were used, there did not appear to be any vast differences, numerically in demographic information. The primary outcome increased nearly 25% from pre-protocol (51.5%) to post-protocol (75%). Regarding the secondary outcomes, more elemental calcium was given in the post-protocol group, and there was a decrease from pre- to post-protocol in the time difference between the first unit of blood being given and the first dose of calcium being administered (pre-protocol: median 1.17 hours, IQR 3.21 hours; post-protocol: median 0.45 hours, IQR 0.65 hours). In the pre-protocol group, the baseline to follow up iCAL was 1.07 to 1.1. Comparatively, the difference in baseline to follow up iCAL in the post-protocol group was 0.195 mmol/L, which is a 6.5 times greater increase than the pre-protocol of 0.03 mmol/L. 
Conclusions: The implementation of a calcium repletion protocol during MTP in trauma suggests maintenance of higher serum calcium levels and thus may decrease the risk of complications during trauma resuscitation. Future studies should focus on the inclusion of larger populations for better generalizability and defining a dose of calcium (gluconate, chloride, or both) that is most efficacious among any trauma patient requiring massive transfusion protocol. 

Authors: Madison Farkas and Gregg Knowles

Background: Periprocedural management of chronic anticoagulation is an important consideration for patients undergoing invasive cardiovascular procedures such as cardiac catheterization. Anticoagulant therapy is often temporarily held to reduce procedural bleeding risk; however, delayed or missed resumption after the procedure may increase the risk of thromboembolic complications. Current evidence, including the 2022 CHEST Guideline and Expert Panel Report: Perioperative Management of Antithrombotic Therapy and findings from the PAUSE trial, supports standardized, time-based strategies for interruption and resumption of anticoagulants to balance bleeding and thrombotic risks. Despite these recommendations, variability in real-world practice and inconsistent documentation of post-procedure anticoagulant management may result in unnecessary therapy interruptions and increased patient safety risks. The purpose of this research is to determine the frequency of delayed resumption of anticoagulation in post cardiac catheterization patients and evaluate the impact of a pharmacy-driven intervention on addressing gaps in care

Methods: This single-center, pre-post implementation study evaluated periprocedural anticoagulation management in patients undergoing cardiac catheterization at a large community hospital. An electronic daily report was developed to identify patients who may require resumption of chronic anticoagulation following cardiac catheterization. The report populates based on the following criteria: (1) presence of post–cardiac catheterization orders, (2) documentation of an anticoagulant on the patient’s home medication list, and (3) absence of an active inpatient anticoagulant medication order. The report is reviewed daily by the investigator to identify patients whose chronic anticoagulation may have been held for the procedure but not yet resumed. For patients meeting these criteria, the medical record is reviewed to assess procedural details, bleeding risk, and clinical appropriateness for anticoagulation resumption. If anticoagulation appears appropriate and has not been restarted within 48 hours of the cardiac catheterization, the investigator communicates with the responsible clinical team to recommend therapy resumption when clinically indicated. The primary endpoint of this study is Proportion of patients without appropriate resumption of anticoagulation post cardiac catheterization. The secondary endpoint is the Proportion of patients with anticoagulation resumed following pharmacist intervention.

Results: Delayed resumption of home anticoagulation within 48 hours of cardiac catheterization occurred in 38% (25/66) of patients in the pre-implementation group and 45% (22/49) of patients in the post-implementation group. Among patients in whom anticoagulation was not resumed, inappropriate holds were identified in 9% (6/66) pre-implementation and 12% (6/49) post-implementation. In the post-implementation group, pharmacy intervened in 5 of 6 cases of inappropriately held anticoagulation (1 patient was lost to follow-up). Of these, 4 interventions were accepted, resulting in resumption of therapy. Common reasons for inappropriate holds included omission from the home medication list and delayed recognition prior to pharmacist intervention. Overall, pharmacy intervened to request anticoagulation resumption in 10% (5/49) of patients. The mean number of patients identified on the daily anticoagulation surveillance report was 0.84 (SD 0.87).

Conclusion: Delayed anticoagulation resumption occurred more frequently than originally reported which emphasized the need for process improvement. Pharmacy involvement via the daily surveillance report played a key role in ensuring appropriate and timely resumption when clinically indicated.

Evaluation of Febrile Neutropenia Prophylaxis Use in Inpatient Oncology
Olivia Jones, PharmD; Sarah Bowman, PharmD, BCOP; Samantha Lightle, PharmD
Huntsville Hospital – Huntsville, AL


Background: Febrile neutropenia is a common and potentially serious complication among patients with hematologic malignancies. The National Comprehensive Cancer Network (NCCN) provides evidence-based guidance to identify oncology patients who qualify for prophylactic antimicrobial therapy to prevent febrile neutropenia. Consistent application of these recommendations is critical for reducing infection-related morbidity and mortality. Prior evaluation at our institution has highlighted gaps in guideline adherence, particularly among high-risk populations such as patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), myelodysplastic syndromes (MDS), and multiple myeloma (MM). The purpose of this retrospective chart review is to evaluate current antimicrobial prescribing patterns and associated outcomes in these populations.


Methodology: This single-center, IRB-approved, pre–post implementation study was conducted at Huntsville Hospital to evaluate prescribing patterns of prophylactic antimicrobials and associated outcomes in patients at high risk for febrile neutropenia. The pre-intervention group included hospitalized patients with the aforementioned hematologic malignancies between January 1, 2025 and August 31, 2025. Data extracted from the electronic medical record included demographics, chemotherapy regimens, risk factors, use of prophylactic antimicrobial agents, and incidence of febrile neutropenia. Following analysis of baseline data, a disease specific decision support tool and educational initiative were developed and delivered to oncology nurse practitioners and pharmacists in early March 2026. Post-intervention data was collected from the same patient population following March 10, 2026.  The primary outcome was percentage of eligible patients who received appropriate prophylactic antimicrobials.


Results: A total of 87 patients were included in the pre-implementation group and 15 patients in the post-implementation group. Appropriate prophylactic antimicrobial use among eligible patients increased from 42.8% (3/7) to 100% (3/3) for antibacterial prophylaxis and from 50% (10/20) to 100% (3/3) for antifungal prophylaxis. Antiviral prophylaxis increased from 50.9% (26/51) to 57.1% (8/14). Median time to prophylaxis initiation decreased from 80.7 to 4.7 hours for antibacterial agents and from 17.9 to 4.7 hours for antifungal agents. Antiviral prophylaxis showed minimal change in time to initiation (19.6 vs 18.6 hours). Febrile neutropenia incidence did not differ consistently between groups. In the pre-implementation cohort, patients who received prophylaxis had lower absolute neutrophil counts and longer hospital lengths of stay compared to those who did not receive prophylaxis.


Conclusions: A pharmacist-driven educational initiative was associated with improved adherence to guideline-recommended prophylactic antimicrobial use, particularly for antibacterial and antifungal agents, and significantly reduced time to initiation. Variability in antiviral prescribing practices may explain the more modest changes observed in this group. These findings highlight the impact of pharmacist involvement and support further efforts to standardize prophylaxis use earlier in hospitalization.

Sarah Layne, Chelsea Mitchell, Sterling Torian, Austin Roberts
TriStar Centennial Medical Center – Nashville, Tennessee

Background: Blood pressure (BP) control is an essential component in management of patients with acute ischemic stroke (AIS). Significant reductions in BP can lead to hypoperfusion and worsened cerebral injury, whereas uncontrolled hypertension can increase the risk of hemorrhage and cerebral edema. In patients undergoing mechanical thrombectomy (MT), current guidelines recommend a pre-procedure BP less than 185/110 mmHg, but intra-procedural goals have yet to be established. Literature evaluating intra-procedural BP goals in patients undergoing mechanical thrombectomy is lacking. Current randomized controlled trials have evaluated the use of anesthesia, which may impact hemodynamics. Further studies are needed to determine if there is an ideal blood pressure target to prevent neurologic deterioration and worse functional outcomes. The purpose of this study was to evaluate the effect of intra-procedural blood pressure on clinical and safety outcomes in acute ischemic stroke patients undergoing mechanical thrombectomy.

Methods: This was a single-center retrospective cohort study conducted through chart review from October 1, 2022, to June 30, 2025. Patients who underwent MT within the study timeframe were included. Exclusion criteria consisted of any intra-procedural hemorrhagic complication, lack of successful reperfusion (TICI score 0-2a), missing baseline Glasgow Coma Scale (GCS), or patients aged less than 18 years old. Patients were divided into two groups, those who had an intra-procedural systolic blood pressure (SBP) less than 140 mmHg or a drop in SBP by at least 40 mmHg (group 1) and those who did not meet the criteria (group 2). The primary outcome was incidence of neurologic deterioration at 24 hours post-mechanical thrombectomy, defined as a decrease in GCS score of at least 2 from the baseline score. The secondary outcome was incidence of intracranial hemorrhage at 48 hours. Subgroup analyses were performed for patients who received intravenous (IV) fibrinolytics and those who did not, and separately for patients with any intra-procedural SBP less than 120 mmHg compared with those who had SBP greater than 120 mmHg.

Results: Fifty-four patients were screened. Five patients did not meet inclusion criteria, and thirteen patients were excluded (n=5 lack of successful reperfusion, n=1 intra-procedural hemorrhagic complication, n=7 missing baseline GCS). This resulted in a final sample size of thirty-six. All patients met criteria for group 1 (n=36). Six patients (16.7%) developed neurologic deterioration at 24 hours. Eighteen patients (50%) had some degree of intracranial hemorrhage, as determined by any mention of hemorrhage on brain imaging. In the subgroup analysis comparing patients who received IV fibrinolytics with those who did not, 1 of 9 patients (11%) in the fibrinolytic group had neurologic deterioration, compared with 5 of 27 patients (18.5%) in the non-fibrinolytic group. Neurologic deterioration occurred in all six (100%) patients in the SBP less than 120 mmHg subgroup.
 
Conclusions: Our study found that 16.7% of patients had neurologic deterioration 24 hours post-procedure. All patients who received MT had an intra-procedural SBP less than 140 mmHg or a drop by 40 mmHg; therefore, we were unable to detect differences between groups for our original analysis. While not powered for significance, patients who did not receive fibrinolytic therapy as well as those with intra-procedural SBP less than 120 mmHg had numerically higher percentages of neurologic deterioration at 24 hours. Further research is warranted to determine the optimal intra-procedural SBP goal for patients undergoing MT.
 
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Background: Accurate medication histories reduce the likelihood of medication errors in patients being admitted to the hospital. Medication histories can inform inpatient providers of what medications the patient is taking prior to the emergency department encounter. Existing literature corroborates that pharmacist involvement in the medication history process leads to less discrepancies. Regarding patients in the emergency department with behavioral health problems, pharmacists are ideally qualified to collect accurate medication histories in this patient population. At our institution, medication histories for behavioral health patients are nursing-led. The purpose of this study is to determine the accuracy of medication histories collected for behavioral health patients in the emergency department.   
 
Methodology: Over a specified 4-month period, patients admitted to the behavioral health units of CaroMont Regional Medical Center’s emergency department (ED) had their medication histories performed by a member of the pharmacy team following completion by nursing staff. Patients aged 18 years or older roomed in behavioral health areas of the ED with a medication history completed by nursing staff were eligible for inclusion. Pregnant and incarcerated patients were excluded. For each patient, investigators utilized interviews with the patient or patient’s caregiver(s), prior to encounter medication lists, medication dispense histories, facility medication administration records, and telephone consultations with primary care providers, pharmacies, or facilities to collect information regarding a patient’s prior to encounter medications. Investigators then compared findings from the pharmacist-completed medication histories to the medication history completed by nursing staff. Any discrepancies between medication histories were collected as data and corrected in the electronic medical record. Additional data collected included patient demographics, reason for emergency department visit, and time taken to complete each medication history. Primary endpoint data were reported descriptively for the number of discrepancies across the cohort. Secondary endpoint data were reported descriptively for number of prior to encounter medications per patient, number of discrepancies per patient, and types of discrepancies (including omissions/erroneous exclusions, commissions/erroneous inclusions, drug name errors, drug formulation errors, drug dose errors, and drug regimen errors).
 
Results: During the specified data collection period, 92 patients were screened. Thirty patients had prior to encounter medications reviewed. Female sex accounted for 53.3% of patients and median age was 34 years. Reasons for exclusion are described below.  

Exclusion Reason n (%) 
Chief Complaint not Psychiatric 51 (82.1) 
Patient Admitted 5 (8.3)
Patient Discharged 2 (3.2)
Patient Condition 2 (3.2)
Prior to Encounter Medications Reviewed by PTA Technician 1 (1.6) 
Prior to Encounter Medications Not Reviewed by Nursing During Encounter 1 (1.6)

Across the 30 patients whose prior to encounter medications were reviewed, 71 discrepancies were identified- an average of 2.33 discrepancies per patient. Patients had an average of 6.23 prior to encounter medications, and the average time for medication history completion was 6.13 minutes. The specific type of discrepancies among the 71 identified are broken down in the table below. 

Discrepancy Type n (%) 
Commission 31 (43.1)
Omission 21 (29.9)
Regimen 9 (12.8)
Dose 8 (11.4)
Formulation 2 (2.8)
Name 0 (0)
 
Conclusion: Based on our findings, pharmacy personnel are in a position to optimize the detection and correction of discrepancies following an initial nursing driven review of behavioral health patients’ prior to encounter medications. Due to the nature of how the study was conducted, limitations of this study include that it cannot be determined how many discrepancies were already corrected by nursing personnel, or how many discrepancies were not identified by investigators. Additional limitations are that the mental state of patients may have contributed to inadequate histories, as well as previous medication changes having gone undetected during transfers to other care areas. 

Oksana Buksa, PharmD, April Williams, PharmD, BCPS, Michele Moseley, PharmD, BCPS, Anna Cross, PharmD, Erik Roberts, CPhT
Huntsville Hospital – Huntsville, Alabama

Purpose/Background:
Huntsville Hospital has announced the implementation of a hospitalist-led geographic rounding pilot that began on October 1st, 2025, which was designed to allow providers to care for patients within the same inpatient unit, thereby maximizing efficiency and improving continuity of care, with the goal of decreasing hospital length of stay. The service currently spans three inpatient floors and encourages hospitalists to prioritize rounding on patients who are discharging home first, followed by those discharging to post-acute care facilities, and subsequently, all other patients remaining.  In addition, Huntsville Hospital has a robust Transitions of Care team that includes pharmacists who play an integral role in facilitating patient discharges by reviewing discharge medication reconciliation and communicating with providers to clarify medication orders as needed, as well as providing essential medication education to patients. The purpose of this research is to evaluate the outcomes of pharmacist-driven interventions within a hospitalist-led geographic rounding model focused on improving patient outcomes and coordination of care. If the results from this pilot demonstrate positive outcomes and are well received by participating rounding physicians, then the program may be expanded to additional inpatient units within the hospital.

Methodology:
This single center, Institutional Review Committee (IRC)–approved pre and post analysis was designed to evaluate the primary outcome, defined as the time from discharge order placement to patient discharge from the hospital. Secondary outcomes include hospital length of stay, total number of discharge reconciliations reviewed by the Transitions of Care pharmacy team per month, average time required to complete individual discharge interventions, and the total number of discharges classified as having significant clinical impact. Pre-implementation data was collected from the following dates: July 1st-September 30th, 2025. Post implementation data was collected from patients discharged by physicians participating in the rounding pilot between November 1st, 2025 and January 31st, 2026. Outcomes were compared between the three month pre and post implementation periods. Baseline characteristics include age, race, sex, and discharge disposition. Statistical analysis was conducted to evaluate categorical and continuous data using descriptive statistics. These analyses aim to evaluate the potential impact of the rounding pilot and pharmacist-driven discharge processes on the timeliness of hospital discharge and overall patient care outcomes.

Results:
A total of 1,201 discharges occurred during the post-implementation period, of which 418 patients (75.3%) were included in the rounding pilot with documented Transitions of Care (TOC) discharge notes. The primary outcome, the time from discharge order placement to patient discharge from facility, decreased overall in the post-implementation period. However, when stratified by discharge disposition, this time increased for home/self-care patients but not for facility discharges, which may be attributable to the higher proportion of facility discharges in the post period, requiring more complex coordination of care. Additionally, duplicate discharge orders were identified, which may have prolonged discharge timing, as these patients were not ready for discharge at the time of initial order placement. For secondary outcomes, patient length of stay did not decrease in the post-implementation period, which could be impacted by seasonal variability and differences in patient acuity between the pre- and post-implementation groups. The average time to complete TOC discharge notes and the number of interventions with significant clinical impact remained similar between groups.  

Conclusion:
Although the results from this study did not demonstrate a consistent improvement in the primary outcome across all discharge dispositions, geographic rounding can still enhance patient care through improved coordination and interdisciplinary communication. The integration of Transitions of Care pharmacists into geographic rounding supports earlier involvement in the discharge process and facilitates optimized medication reconciliation, discharge planning, and patient education.

Title: Evaluation of the impact of lower extremity wound order set revision

Authors: Katie Hindman, Adesuwa Utomwen, Dustin Zeigler, Jeremy Frens

Objective: Discuss the utilization of an updated lower extremity wound order set

Self-Assessment Question: 

• True or False: The updated lower extremity wound order set had numerically increased adherence compared to the prior order set.

Background: Diabetic foot infections (DFIs) pose a significant threat to quality of life, being a leading cause of non-traumatic lower extremity amputations. Therefore, it is essential to utilize effective antibiotics to treat these infections. The International Working Group on the Diabetic Foot (IWGDF) and Infectious Diseases Society of America (IDSA) published updated guidelines in 2023, advising that empiric coverage for Pseudomonas aeruginosa is not necessary in Western countries and temperate climates. A prior systematic review on the epidemiology of P. aeruginosa in DFIs found a global prevalence of 16.6%, with the lowest prevalence of 11.1% being in Western countries. A review of patients at our institution, Cone Health, with toe and/or foot amputation(s), supported these findings with only 1.7% of cultures identifying P. aeruginosa. The most isolated pathogens were Staphylococcus aureus and coagulase-negative Staphylococcus species. The lower extremity wound order set at Cone Health was modified, removing empiric P. aeruginosa coverage due to its low incidence. The purpose of this study is to evaluate prescriber compliance with the updated order set and assess microbiological concordance between prescribed empiric therapy and cultured pathogens following the modifications.

Methods: This was an IRB approved, determined exempt, retrospective cohort analysis of individuals with diabetic foot infections at a single health system encompassing four community hospitals. The revised order set went live in February 2025. The review spanned a pre-intervention cohort from June to December 2024 and a post-intervention cohort from June to November 2025. Adults aged 18 years or older with confirmed DFI with or without osteomyelitis were included in this study. Those individuals admitted to the intensive care unit or with the presence of chronic foot ulceration were excluded. Infection-related information collected included wound classification, utilization of order set, inpatient antibiotics utilized, duration of antibiotics, type of amputation, culture results, pathology results and discharge antibiotics. The primary outcome of this study is adherence to order set recommendations, defined as aligning with the antibiotic recommendations per infection severity. Secondary outcomes include proportion of patients with microbiological match to empiric antibiotics, 30-day mortality rate and 30-day readmission rate.

Results: The post-intervention cohort demonstrated a modest increase in adherence to lower extremity wound order set recommendations compared to the pre-intervention cohort (34% vs 30%, p=0.55). Among patients with available culture data, all 17 individuals in the pre-intervention cohort received empiric antibiotics concordant with culture results compared to 26 of 30 patients (87%) in the post-cohort (p=0.075). Streptococcus species were the most commonly isolated gram-positive organisms in both cohorts (10 cases in the pre-cohort and 11 in the post-cohort). There was a higher prevalence of Proteus mirabilis and Enterobacter cloacae in the post-cohort, but these organisms demonstrated minimal resistance to penicillins and cephalosporins. The use of vancomycin and cefepime decreased from the pre- to post-intervention period, while utilization of linezolid and ampicillin/sulbactam increased.

Conclusion: The revised lower extremity wound order set was associated with a numerically higher rate of adherence compared to the prior version, with approximately half of providers in each cohort utilizing the order set. Empiric antibiotics demonstrated microbiological match in most cases. The organisms cultured in this study align with those typically observed in DFIs in the United States. The updated order set represents an advancement in antimicrobial stewardship in DFIs through the inclusion of preferred alternatives. Limitations of this study include variability in obtainment of pathology and cultures between providers as well as a small sample size. Future directions include reinforcing appropriate utilization of the DFI order set and evaluating discharge antibiotic therapy to assess the potential benefit of creating standardized recommendations.

Background: 

• Intra-abdominal infections (IAIs) are a frequent cause of hospitalization which occasionally require empiric broad-spectrum antibiotic use. Despite current guidelines indicating that P. aeruginosa is uncommon in low-risk, community-acquired IAI, antipseudomonal agents remain frequently prescribed. This unnecessary use increases risks of nephrotoxicity, resistance, and higher healthcare costs.2 For low-risk patients without significant comorbidities, healthcare exposure, or septic shock, narrower regimens are recommended.1 Persistent inappropriate prescribing highlights an opportunity for targeted antimicrobial stewardship interventions to optimize empiric therapy, improve patient outcomes, and reduce unnecessary broad-spectrum exposure. 

Objectives: 

• Evaluate the impact of pharmacy-led provider education on reducing inappropriate antipseudomonal antibiotic use in patients with low-risk intra-abdominal infections 

• Primary outcome: Percentage difference of patients receiving antipseudomonal antibiotics before and after the intervention 

• Secondary outcomes: Days of therapy (DOT) per 1,000 patient days, hospital length of stay, incidence of C. difficile infection, and identification of P. aeruginosa on culture during hospitalization, impact of infectious disease (ID consult) on de-escalation 

Methods: 

• Retrospective chart review approved by the local Institutional Review Board (IRB) 

• Chart review to evaluate empiric antibiotic use in adult patients with low-risk intra-abdominal infections (IAIs), as defined by the 2024 Surgical Infection Society guidelines. 

• During the pre-intervention period between May 1st, 2025 and September 30th, 2025, patients are assessed for documented infection diagnosis and empiric antibiotic selection to determine the frequency of antipseudomonal antibiotic use. Data gathered from this review is used to develop an educational presentation for hospitalist providers to highlight recommended therapy for low-risk IAI. 

• A post-intervention chart review between November 1st, 2025 and March 30th,  2026 will be performed to reassess prescribing practices 

• Inclusion criteria 

• Age ≥18 

• Admitted to Baptist Health Lexington with primary diagnosis of diverticulitis, peritonitis, cholecystitis, cholangitis, pancreatitis, or appendicitis 

• Received antimicrobial therapy 

• Exclusion criteria 

• Pregnant or incarceration. Met criteria for high-risk infection (admitted to ICU during hospital stay, required surgical intervention, received IV antibiotics in previous 90 days, recent Pseudomonas culture, immunocompromised, post-operative infection or inadequate source control, age ≥ 80) 

Results: 

• Baseline characteristics were similar between pre- and post-intervention groups, with diverticulitis most common. The educational intervention did not significantly reduce inappropriate antipseudomonal use, which remained high. A numerical decrease in overall antimicrobial exposure was observed but was not statistically significant. No C. difficile testing or P. aeruginosa cultures were identified. Antimicrobial use shifted overall, driven by reduced ertapenem use, while other broad-spectrum agents remained common. Infectious disease consultation was associated with higher rates of de-escalation. 

Conclusions: 

• Provider education alone did not significantly reduce inappropriate antipseudomonal use in low-risk IAI. Persistent broad-spectrum prescribing suggests the need for more active stewardship strategies. The absence of P. aeruginosa supports guideline recommendations, and the impact of ID consultation highlights the value of multidisciplinary involvement. 

References 

1. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update Jared M. Huston, Philip S. Barie, E. Patchen Dellinger, Joseph D. Forrester, Therese M. Duane, Jeffrey M. Tessier, Robert G. Sawyer, Miguel A. Cainzos, Kemal Rasa, Jeffrey G. Chipman, Lillian S. Kao, Frederic M. Pieracci, Kristin P. Colling, Daithi S. Heffernan, Janice Lester, and Therapeutics and Guidelines Committee  

1. Lodise TP, Izmailyan S, Olesky M, Lawrence K. An Evaluation of Treatment Patterns and Associated Outcomes Among Adult Hospitalized Patients With Lower-Risk Community-Acquired Complicated Intra-abdominal Infections: How Often Are Expert Guidelines Followed? Open Forum Infect Dis. 2020 Jun 19;7(7):ofaa237. doi: 10.1093/ofid/ofaa237. PMID: 32676511; PMCID: PMC7353956. 

Purpose: The literature surrounding optimal treatment of massive pulmonary embolisms (PE) is unclear. Numerous studies have been published regarding treatment options including anticoagulation, fibrinolytic therapy, thrombectomies, catheter-directed fibrinolytic therapy, and surgical embolectomy with limited direct or combination therapy comparisons. This study aims to evaluate anticoagulation alone to anticoagulation plus intervention (fibrinolytics, thrombectomy, catheter-directed fibrinolytic therapy) in the treatment of massive PE in emergency department patients across Prisma Health. 

Methods: This study is a retrospective cohort study, evaluating patients diagnosed with massive PE presenting to a Prisma Health emergency department from May 1, 2021, to August 31, 2025. The primary outcomes will be time to first improvement in hemodynamic instability markers of either systolic blood pressure (≥ 120 mmHg without vasopressors), O2 saturation (≥ 94% on room air or 2 liters nasal cannula) or heart rate (≤ 100 beats per minute or patient’s baseline) as well as average time to composite improvement for those meeting at least 2 or more markers of hemodynamic instability. Additional variables collected and evaluated will include anticoagulant used, intervention if any, available imaging, in-hospital mortality, and readmission for PE. Outcomes will be evaluated using logistic regression for primary outcomes and other descriptive analyses. 

Results: Out of 860 patients screened, 41 patients were included in the anticoagulation + intervention and 22 were included in the anticoagulation only group. The median age was 62 years in the intervention group compared with 70.5 in the anticoagulation only group. 78% of patients vs 95.5% of patients presented with comorbid conditions such as heart failure, COPD, and cancer. All of the first documented vital signs in the emergency department were outside of our set thresholds. Of the 41 patients in the intervention group, 23 received fibrinolytics only, 4 received a thrombectomy only, 14 received a fibrinolytic plus a thrombectomy, and none received catheter-directed fibrinolytic therapy. Of the patients who received a fibrinolytic only, 19 received alteplase compared to 4 who received tenecteplase (p=0.002). There was no difference seen in which vital sign improved first between the intervention group and the anticoagulation only group, as well as our subgroup population: alteplase vs tenecteplase patients. The median time to vital sign improvement (in hours) was significantly lower at 5 hours vs 8.5 hours between our two major groups (p=0.024). The logistic regression showed that there was no vital sign that stood out as the main driving factor for the improvement seen. 34.1% of patients in the intervention group had a bleed compared to 9.1% in the anticoagulation group. There was no difference seen in terms of major bleeds, mortality, or readmission rates. 

Conclusion: Patients given anticoagulation plus an intervention had quicker time to vital sign improvement compared to patients given anticoagulation only. There was no difference in terms of mortality or readmission rates between the two primary groups and the two fibrinolytic subgroups. Future studies are needed to explore what kinds of interventions bring the best outcomes for massive pulmonary embolism patients.

Comparative Evaluation of IV Push Versus IV Infusion Administration of Levetiracetam 
Tavin Cook, Ashley Crisler, T.J. Henderson, Aayush Patel 
Piedmont Columbus Regional Midtown, Columbus GA

Background:
Levetiracetam is commonly administered as an IV infusion; however, IV push (IVP) administration has the potential to improve medication turnaround times, reduce nursing workload, and lower medication preparation costs without compromising safety. In January 2026, Piedmont Columbus Regional implemented IVP levetiracetam hospital wide. The objective of this study is to compare the timeliness of administration and cost difference associated with IVP levetiracetam versus IV infusion levetiracetam. 

Methods:
This study was a single-center, Institutional Review Board (IRB)–approved, retrospective chart review. The overall study timeframe spanned from October 13, 2025, to March 13, 2026. The pre-implementation period was October 13, 2025, to January 12, 2026, and the post-implementation period was January 14, 2026, to March 13, 2026. The study included adult patients aged 18 years or older who received intravenous levetiracetam at doses of less than 2 grams.  An EHR Slicer/Dicer data collection tool was used to collect points of time of order entry, order verification, and administration of medication. Cost analyses were conducted by integrating direct drug cost. The primary objective is to assess the difference in time from order verification to administration of once dose levetiracetam pre and post implementation. Secondary objectives include direct drug cost, time-critical medication compliance, and adverse drug reactions. Statistical analysis for the primary outcome used Mann-Whitney-U, secondary outcome descriptive analysis and chi-square testing. 

Results:
IV push levetiracetam demonstrated a numerically faster time to administration compared to IV infusion (19.7 vs 23.9 minutes), though this difference was not statistically significant (p=0.41). Time-critical medication compliance was significantly higher with IV push (85.7% vs 81.8%, p<0.001), and no adverse drug reactions were reported in either group. Additionally, IV push was associated with substantially lower direct drug costs, translating to significant projected annual savings.

Conclusions:
IV push levetiracetam is a cost-effective alternative to IV infusion that improves time-critical medication compliance while maintaining a comparable safety profile. Although a faster administration trend was observed, it did not reach statistical significance. Overall, IV push represents a practical and efficient strategy for levetiracetam administration within institutional practice.

Contact:
[email protected]