2026 Southeastern Residency Conference

Background: Rapid-sequence intubation (RSI) involves administration of an induction agent and neuromuscular blocking agent to facilitate patient comfort and endotracheal intubation. Following RSI, initiation of post-intubation sedation is essential to maintain patient comfort, reduce agitation, and prevent awareness with paralysis (AWP), which has been associated with psychological distress and other adverse outcomes. Several factors may contribute to AWP, including the use of long-acting neuromuscular blocking agents such as rocuronium, underdosing of induction agents, and delays in initiation of post-intubation sedation. In many emergency department (ED) settings, post-intubation sedation may be delayed, inconsistently initiated, or omitted, potentially increasing the risk of “awake paralysis.” At our community hospital, pharmacists are not routinely involved in the RSI process, as medication orders are auto-verified and pharmacy staff are not alerted when intubations occur. Additionally, the existing RSI order set does not include guidance for post-intubation sedation. Pharmacists may play an important role in supporting medication selection, preparation, and timely initiation of sedation following RSI. The purpose of this study was to evaluate to evaluate post-intubation sedation practices following RSI in the ED at a community hospital.

Methodology: This single-center, IRB-reviewed, determined exempt retrospective evaluation assessed adult patients undergoing RSI in the ED between January 2025 and March 2025. Adult patients aged ≥ 18 years who underwent RSI with an induction agent and neuromuscular blocking agent in the ED were included. Patients were excluded if intubation or post-intubation management was performed by a non-ED provider, RSI occurred outside the ED, the patient died in the ED, or ED length of care was less than one hour. Outcomes evaluated included receipt of a sedative within one hour following RSI and time to first sedative administration. Continuous variables were summarized using descriptive statistics, and categorical variables were reported as frequencies and percentages.

Results: A total of 186 patients were screened, of which 52 patients met inclusion criteria for evaluation. The mean age was 65 years (SD 13.3), and 54% were female. The most common indication for RSI was respiratory distress (58%), followed by altered mental status (21%) and unresponsiveness (13%). Etomidate was the most commonly used induction agent (79%), and rocuronium was the most frequently used neuromuscular blocking agent (77%). Overall, 81% of patients received at least one sedative agent within one hour following RSI. Fentanyl was the most commonly used agent (88%), while propofol was the second most frequently used sedative (63%), followed by midazolam (21%). The mean time to first sedative dose was 29.4 minutes.

Conclusion: In this evaluation of post-intubation sedation practices following RSI in the ED, most patients received a sedative within one hour; however, variability in the timing and initiation of therapy was observed. Delays or absence of sedation following RSI may increase the risk of complications such as inadequate sedation and awareness with paralysis. These findings highlight an opportunity to improve the consistency and timeliness of post-intubation sedation practices. Greater pharmacist involvement during RSI events may help optimize medication selection and promote more timely initiation of sedation. Future efforts should focus on establishing a consistent pharmacy presence in the ED and developing a standardized workflow to facilitate pharmacist involvement during RSI events.

Background: Opioid-induced constipation (OIC) is a frequent and challenging side effect of pain management in critically ill patients. While it is standard of care to initiate conventional laxatives concurrently with opioid therapy, they do not directly address the underlying mechanism of OIC. Oral naloxone offers a targeted approach by acting as a mu-opioid receptor antagonist. Due to its low oral absorption, it is thought to primarily exert peripheral effects, helping relieve constipation with minimal impact on central analgesia. Despite its theoretical safety profile, evidence regarding its effects on pain control is not well defined in the available literature. This study aimed to evaluate the effect of oral naloxone on pain scores and opioid requirements in a large, real-world cohort of critically ill patients.

Methods: This multicenter, retrospective pre–post cohort study was conducted across eight community teaching hospitals within AdventHealth Central Florida Division South. Adult patients admitted to an intensive care unit (ICU) who received at least one dose of oral naloxone for OIC and received opioid treatment for at least 24 hours prior to the first dose of oral naloxone were eligible. Patients with chronic opioid use, concurrent peripherally acting mu-opioid receptor antagonists, or chronic naloxone use were excluded. The primary outcome was within-patient change in pain scores 24 hours before and after naloxone initiation, stratified by assessment tool. Secondary outcomes included changes in scheduled and rescue opioid use (morphine milligram equivalents [MME]) and bowel movement occurrence. Continuous outcomes were analyzed using the Wilcoxon signed-rank test and categorical outcomes using the exact McNemar test.

Results: Among 105 patients, fentanyl was the predominant opioid (81%). Pain was most commonly assessed using the Critical Care Pain Observation Tool (CPOT) (77%), followed by the Numeric Rating Scale (NRS) (20%), and Visual Analogue Scale (VAS) (3%). No significant change in pain scores was observed in the CPOT group (median 0.10 vs 0; p = 0.073). NRS scores showed a small but statistically significant decrease (median 2.9 vs 2.5; p = 0.031), while VAS scores did not change significantly (median 2.6 vs 1.8; p = 0.593). Scheduled opioid use decreased significantly (median 555 vs 357.5 MME; p = 0.004), with no change in rescue opioid use (median 5 vs 0 MME; p = 0.831). Bowel movement occurrence increased from 13% to 44% (p <0.001).

Conclusion: In critically ill patients predominantly receiving fentanyl infusions, oral naloxone was not associated with increased pain scores and was associated with increased bowel movement occurrence. These findings suggest that oral naloxone may be a safe adjunct for the management of OIC in ICU patients without compromising analgesia.

EVALUATION OF MEDICATION ACCESS INTERVENTIONS BY TRANSITIONS OF CARE PHARMACIST FOR PATIENTS REQUIRING HIGH-COST CARDIAC MEDICATIONS  
Esther Cho, Alexandra Cooper, Laura Provost, Nathan Wayne, Maegan Whitworth Wellstar MCG Health – Augusta, GA 
Background/Purpose: Centers for Medicare and Medicaid Services (CMS) monitors 30-day readmission rates per the CMS Hospital Readmission Reduction Program based on relative conditions or procedures including acute myocardial infarction (AMI), heart failure (HF), and coronary artery bypass graft (CABG). These three conditions have a high readmission rate per the CDC 2021 national data, with HF having the highest readmission rate at 22% (AMI 16% and CABG 13%). Current studies show TOC interventions, by a multidisciplinary team, lower 30-day readmission, but there is no literature focusing on an exclusive pharmacist-led intervention, with a specific focus to medication access such as medication affordability. n these studies, since most hospitals do not have a dedicated Transitions of Care (TOC) pharmacists, “standard of care” is considered to be general patient care, whereas TOC interventions are established to ensure continuity and coordinate care to patients. Therefore, further evaluation is required to evaluate the effectiveness and impact of pharmacist-led TOC intervention.

Methodology: This is a retrospective chart review of adult patients who were discharged from a cardiac floor with high-cost cardiac medications (e.g. Eliquis, Entresto, Jardiance) between November 4, 2024 – May 31, 2025. Interventions made by a non-TOC pharmacist, pregnant patients, and prisoners were excluded in this study. The primary outcome is overall 30-day readmission rate. Secondary outcomes include quantification and classification of TOC pharmacy interventions, patient assistance applications initiated and/or approved, percentage of prescriptions filled at discharge, and 30-day readmission cause.

Results: Overall, 186 patients were included in the pharmacist-led TOC intervention group and 79 patients were included in the non-TOC intervention group. No significant difference was observed in rate of readmission within 30 days of discharge between TOC intervention and non-intervention groups (24% vs 20%, p=0.62). However, higher percentage of patients in the intervention group filled new high cost medication prescriptions at discharge (60% vs 47%, p=0.30), more medications were prescribed to meds-to-beds pharmacy (47% vs 32%, p=0.22), and patients in the TOC intervention group were less likely to be readmitted for medication related events (2% vs 12%, p=0.11).

Conclusions: No difference was observed in overall 30-day readmission rate between pharmacy-led TOC intervention group vs non-TOC intervention group. More providers prescribed new high-cost medications to Wellstar MCG Meds-to-Beds pharmacy, and a higher percentage of new prescriptions were dispensed at discharge with TOC pharmacist intervention. Additionally, patients were less likely to be readmitted for medication-related events in the TOC intervention group.

Title: Pharmacist Led COPD Medication Recommendations During Discharge Medication Review

Authors: Bridget Arellano, Ali Diaz, Dahlia Kaiser
AdventHealth Orlando, Orlando, FL

Background/Purpose: Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity, with national 30-day readmission rates near 30%. To reduce rates of readmission, the Center for Medicare and Medicaid Services (CMS) implemented a Hospital Readmission Reduction Program, incentivizing improved communication and coordination for patients at discharge. Currently our COPD readmission rate is approximately 20%. To address this, our hospital initiated a pharmacist-led discharge medication reconciliation (DMR) workflow to optimize COPD therapy with a goal to maintain readmission rates below 16%. However, the clinical reach of this program and the rate of provider acceptance of these recommendations is not well established. This study aimed to evaluate physician acceptance of pharmacist-driven COPD therapy recommendations and its association with 30-day readmission rates.

Methods: This retrospective chart review included patients ≥65 years of age with COPD, discharged home from AdventHealth Orlando between January and September of 2025. Data collected included demographics, pharmacist interventions, recommendation types, provider response, and 30-day readmission outcomes. Descriptive statistics were used to evaluate intervention frequency, acceptance rates, and readmission outcomes.

Results: A total of 168 patient encounters and 119 unique patients were analyzed. Pharmacist interventions were made in 14 (8.3%) patient encounters, and the majority (n=10; 71.4%) were to recommend adding an additional agent to the patient’s current regimen. Of the 14 pharmacist interventions, 9 (64.3%) were accepted by the provider. Overall, 30-day readmissions occurred in 22 (18.5%) patients and 59 (35.1%) encounters. Out of the nine encounters with accepted interventions, 4 (44.4%) had a 30-day readmission. Due to the low intervention rate, comparative analysis between accepted and non-accepted recommendations was limited.

Conclusions: Pharmacist interventions during discharge medication reconciliation were very limited in this dataset of elderly patients with COPD. Although readmission rates in this specific population remained above goal, the low number of interventions restricts conclusions regarding the impact of recommendation acceptance on patient readmission rates. Future efforts should focus on the DMR workflow and evaluate various barriers surrounding pharmacist interventions on optimizing COPD therapy.

Background:
Accurate inventory management is essential for operational efficiency, yet traditional models relying on periodic third-party counts limit real-time visibility and delay error correction. Over the previous years, several audit processes have been trialed, each with varying trade-offs related to ease of use, time requirements, utility, and interruption of standard workflows. A significant amount of time was spent after the counts were completed, reconciling discrepancies in the third party data including medications that could not be accurately identified based on barcode scans. Our institution recently transitioned from a biannual, vendor-supported inventory process to an internally managed model, revealing workflow inefficiencies and gaps in issue identification due to reliance on delayed data systems and fragmented scanning processes. To improve workflow and data integrity, a real-time barcode scanning tool was developed and iteratively refined to facilitate live inventory validation.

Methods:
The tool enables immediate feedback during both full inventory counts and targeted audits. Key development considerations included optimizing data refresh processes, accommodating large and variable datasets, and enhancing usability through simplified visual indicators to reduce user fatigue.  Over time, improvements focused on minimizing error rates and improving workflow integration.

Results:
Implementation of the tool improved operational efficiency by reducing the need for dual auditors and minimizing workflow interruptions. The system enhanced auditor autonomy by removing the need for individual assignments and enabling users to validate counts independently in real time. It also decreased duplication of counts and enabled immediate identification and correction of discrepancies, reducing the number of recounts required.

Conclusions:
A real-time barcode scanning approach to inventory management enhances efficiency, accuracy, and staff autonomy. This solution addresses key limitations of traditional inventory processes and supports proactive discrepancy resolution. Ongoing evaluation during a full live-count inventory will further quantify its impact on time savings and error reduction.