2026 Southeastern Residency Conference

ADHERENCE TO RECOMMENDED VACCINATIONS IN A VETERAN RHEUMATOLOGY POPULATION: A QUALITY IMPROVEMENT INITIATIVE  
Avery Zapp, Lilian Culp, Whitney White

Birmingham VA Healthcare System – Birmingham, AL


Background/Purpose: This project aimed to systematically evaluate the vaccination status of patients managed by the rheumatology clinic at a Veterans Affairs Medical Center, with a focus on adherence to current immunization guidelines. The interventions also aimed to promote provider engagement and patient awareness. The effectiveness of a multifaceted pharmacist–provider intervention on vaccination rates among veterans was evaluated.
Methodology: Eligible participants include those who are followed in the Birmingham VA rheumatology clinic, currently taking a JAK inhibitor and due for the herpes zoster vaccination. Intervention included pharmacist dashboard monitoring to evaluate patients due for vaccination, with those patients subsequently sent to providers as reminder for their upcoming appointment. Reminder notifications were also sent to eligible patients. Intervention with nursing staff was also performed to address triage and patient education. Vaccination rates in the rheumatology clinic were assessed before and after the interventions were implemented.  
Results: Twenty-nine patients with upcoming appointments were reviewed, all prescribed tofacitinib or upadacitinib. At baseline, 46 percent had at least one documented dose of recombinant zoster vaccine, while 54 percent had no documentation. Most patients (25 of 29) were established in primary care. Overall clinic vaccination rates increased by approximately 1 percent during the study period, with completion of the two‑dose series rising from 41 percent to 42 percent. The primary barriers were patient preference and hesitancy, often related to safety concerns or misperceptions about risk. Documentation gaps, particularly for vaccines administered outside the VA, likely contributed to underestimation of true vaccination status.
Conclusions: Pharmacist‑driven provider reminders and patient outreach efforts improved awareness of vaccination needs but did not produce a substantial increase in herpes zoster vaccination rates during the short study interval. Persistent patient hesitancy and documentation inconsistencies remained barriers to adherence. These findings highlight the need for ongoing, multifaceted strategies - particularly targeted patient education, streamlined documentation processes, and incorporation of additional staff support - to enhance vaccine acceptance in Veterans receiving JAK inhibitors. Future expansion of this initiative will address additional immunization gaps in the rheumatology population.
Presentation Objective: By the end of this presentation, participants will be able to identify key factors affecting herpes zoster vaccination adherence in Veteran rheumatology patients on JAK inhibitors and develop strategies to improve these rates. Self-Assessment: What intervention is most likely to improve recombinant herpes zoster vaccination rates in veterans receiving JAK inhibitors?

Title: Impact of a Pharmacist-Led COPD Transitions of Care Program on 30-Day Readmission Rates

Authors: Allison Edmondson, Quyen Nguyen, Jeremy Walley

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality in the United States. The total annual medical costs for COPD near 24 billion dollars, with the cost of inpatient care accounting for 6.3 billion of those dollars. Additionally, COPD is a target condition under the Centers for Medicare and Medicaid Services under the Hospital Readmissions Reduction Program. COPD readmissions pose a significant economic burden to the healthcare system and may result from gaps in care during transitions from the hospital back to home. Transitions of care interventions by pharmacists can assist in bridging gaps in care for these patients.

Methods: This study will implement a pharmacist-led transitions of care program for patients admitted to the hospital with a COPD exacerbation. Pharmacists will assist in optimizing COPD regimens, medication and inhaler technique counseling, medication access, education on symptom self-management, and post-discharge follow-up phone calls. The primary objective is to evaluate the impact of the transitions of care service on 30-day readmission rates for COPD exacerbation within the facility. Secondary objectives will include pharmacist interventions performed.

Results: A total of 102 patients were included in the study. Readmission rates among COPD patients prior to the transition of care service in December 2024 to March 2025 were 27%, compared with 17% following the implementation of the service between December 2025 to March 2026. The primary pharmacist interventions performed included recommendations to change inhaler therapy, phone call follow up, and patient education. Among patient home medications, there was a 20.7% increase of patients on guideline-directed COPD therapy from admission to discharge.

Conclusions: The implementation of a pharmacist-led COPD transitions of care service appeared to decrease 30-day readmission rates. Pharmacists can play a role in helping to optimize therapy, medication access, patient education, and enhancing follow-up care.

Purpose: Time-sensitive completion of bundled interventions is the focus of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Centers for Medicaid and Medicare Services (CMS) quality measure, which aims to reduce sepsis-related morbidity and mortality. To avoid missed cases of sepsis, clinicians often rely on the Systemic Inflammatory Response Syndrome (SIRS) criteria as the major identifier of sepsis, which has inadvertently raised concerns for potential overdiagnoses. This study evaluated the incidence of patients diagnosed with sepsis in the emergency department (ED) who did not meet SIRS criteria and/or lacked a documented source of infection. Recognizing such cases may highlight opportunities to reduce unnecessary use of broad-spectrum antibiotics and ultimately support more targeted antimicrobial stewardship in sepsis care.
Methods: This study design was submitted to the Ballad Health System Institutional Review Board for approval. This was a retrospective electronic chart review that included adult patients aged 18 years and older who presented to the ED of Bristol Regional Medical Center, Holston Valley Medical Center, or Johnson City Medical Center between December 2025 and March 2026 with a sepsis ICD-10 diagnosis. Using the electronic health record, we identified patients who were reported to have met the SIRS criteria. Among these qualifying candidates, patients were then assessed whether there was a documented source of infection and whether broad-spectrum antibiotics were administered. Data collected included patient age, gender, ethnicity, respiratory rate, heart rate, temperature, white blood cell count, and antibiotics received. Provider documentation was reviewed to verify whether there was a documented source of infection. All data was reviewed and recorded in a manner that ensured complete patient anonymity. Statistical analysis was conducted to compare groups meeting sepsis criteria, antibiotic use, and documented infection source.
Results: Among evaluated patients, 11% of those diagnosed with sepsis in the ED did not meet greater than two SIRS criteria at initial presentation, while 89% met SIRS criteria. Additionally, 3% of the study population lacked a documented or suspected source of infection. Clinician compliance with SIRS-based sepsis diagnosis across facilities ranged from 81% to 97%, exceeding the pre-study hypothesis of 70%. Cefepime and vancomycin were the most commonly utilized antimicrobials, with broad-spectrum antibiotic use occurring in approximately 90% of patients.
Conclusions: Majority of patients diagnosed with sepsis in the ED met SIRS criteria, with compliance rates higher than initially anticipated. However, a subset of patients did not meet diagnostic criteria or lacked an identifiable infectious source, suggesting potential opportunities for improvement with diagnostic accuracy and reducing unnecessary broad-spectrum antibiotic use. Further studies with larger sample sizes and less exclusion criteria are warranted to better assess antimicrobial appropriateness based on patient-specific risk factors and presumed sources of infection.

Evaluation of the Implementation of a Cardiothoracic Surgery Pre-Operative Anemia Treatment Protocol  

Alyan Saeed, Brendon Banes, Rebecka Hazelwood 
 
Background/Purpose: Patients undergoing cardiothoracic surgery (CTS) frequently present with baseline anemia, which has been associated with increased transfusion requirements, acute kidney injury (AKI), and higher postoperative morbidity and mortality. Prior studies suggest that pre-operative anemia optimization using intravenous iron, erythropoiesis-stimulating agents, and vitamin supplementation may reduce transfusion needs and improve surgical outcomes. In November 2023, Wellstar Kennestone Regional Medical Center (WKRMC) implemented a pre-operative anemia protocol for CTS patients with hemoglobin <12 g/dL; however, its clinical impact has not been formally evaluated. This study aimed to assess the efficacy and safety of the CTS pre-operative anemia protocol.  

Methods: This was an observational, retrospective chart review conducted at WKRMC evaluating adult patients (≥18 years) who underwent CTS between December 1, 2023 and September 1, 2025. Patients with a baseline hemoglobin <12 g/dL were grouped based on whether they received the pre-operative anemia treatment protocol prior to surgery. Patients were followed from three days prior to surgery through seven days post-operatively, hospital discharge, or death, whichever occurred first.   
The primary endpoint was the difference in post-operative hemoglobin levels between patients managed under the protocol and those in the non-protocol group. Secondary endpoints included number of post-operative red blood cell (RBC) units transfused and incidence of AKI within seven days. Safety outcomes included venous thromboembolism, stroke, post-operative infection, and hypersensitivity reactions to IV iron.  
Statistical analyses included paired and independent t-tests, along with Fisher’s exact test for categorical variables.  

Results: A total of 100 patients were included (protocol n=50, non-protocol n=50). Post-operative hemoglobin was similar between patients managed under the protocol and those receiving usual care (8.80 g/dL vs 9.07 g/dL, p=0.25). The mean number of RBC units transfused did not differ significantly between patients managed under the protocol and those receiving usual care (2.28 units vs 2.26 units, p=0.98). Post-operative AKI occurred less frequently in the protocol group compared to the non-protocol group (20% vs 36%, p=0.037). No significant differences were observed regarding the safety end points. There were no cases of IV iron hypersensitivity reactions in the protocol group.  

Conclusion: The pre-operative anemia protocol was associated with a lower incidence of post-operative acute kidney injury in CTS patients, while post-operative hemoglobin levels were similar between groups. These findings suggest that pre-operative anemia management may contribute to improved renal outcomes, despite comparable perioperative hematologic values.  
 

Background: The American Society of Addiction Medicine guidelines recommend benzodiazepines as first-line treatment for moderate-severe alcohol withdrawal syndrome (AWS). Intravenous (IV) lorazepam is a first-line therapy for AWS at Emory Healthcare (EHC) to prevent complications such as seizures and delirium tremens. The quick onset, half-life, and lack of metabolites make IV lorazepam a desirable agent for AWS. There have been intermittent shortages of IV lorazepam, with the most recent shortage beginning in May 2025. In response, EHC built an electronic alert as a soft stop for all IV lorazepam orders to notify providers of the shortage and recommend alternatives. In addition, the AWS order set was modified to replace IV lorazepam with IV midazolam. The goal of this study was to understand medication utilization patterns during this shortage and provide guidance for future shortages.  

Methods: This study was a multi-center, retrospective chart review of adult patients receiving treatment for moderate-severe AWS from 1/30/2025 to 9/7/2025 in the ICU. Pre-shortage and post-shortage groups were determined based on IV lorazepam shortage alerts, which began in EPIC on 5/20/2025. The primary objective was to examine medication utilization patterns of AWS before and after the alert was implemented. Evaluation of this endpoint was determined by medication name, strength, route, frequency, and duration for 48 hours after the alcohol withdrawal order set was active. Secondary objectives measured safety and clinical outcomes and included respiratory rates, hypotension, and changes in scores of Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA), length of stay, mortality, 30-day readmissions, respectively. Data was analyzed using descriptive statistics, t-test, and Mann-Whitney U test.

Results: There were 127 patients in the pre-shortage group and 152 patients in the post-shortage group. Baseline characteristics were similar between groups. The average baseline CIWA scores were similar with first CIWA ≥8 13.44 pre-shortage versus 12.86 post-shortage. IV lorazepam doses were higher in the first 12 hours of the AWS order set ordering time. In the post-shortage group, there was a greater decrease in IV lorazepam dose 12-24 hours post-alert (63.14% versus 43.72%). IV lorazepam orders trended down (57% versus 47%, p-value 0.097), and patients prescribed oral lorazepam trended up (23% versus 32%, p-value 0.081). More patients in the post-shortage group were prescribed chlordiazepoxide (5 versus 16 patients, p-value 0.038) and midazolam (20 versus 45 patients, p-value 0.006). Phenobarbital use did not change significantly (86 versus 89 patients, p-value 0.115). First CIWA <8, was similar at 4.37 pre-shortage versus 3.84 post-shortage. The average time to CIWA score <8 from the first score ≥8 was greater in the pre-shortage group 9 hours and 13 minutes compared to 8 hours and 37 minutes (p-value 0.205). Average hospital length of stay (12.39 versus 11.07 days, p-value 0.290), average ICU length of stay (5.28 versus 5.44 days, p-value 0.725), and mortality (5 versus 7 patients, p-value 0.784) were similar between the two groups. Readmission within 30 days and respiratory depression were higher in the post-shortage group (12% versus 18%, p-value 0.166 and 67% versus 73%, p-value 0.267, respectively).

Conclusion: Following IV lorazepam alerts, medication utilization shifted towards chlordiazepoxide and midazolam. The average cumulative dose of IV lorazepam decreased more in the post-shortage group after the first 12 hours. Phenobarbital use may not have changed due to provider practice styles and the recommended alternatives. This was a retrospective study, alerts for alternative agents could be bypassed, and medications listed may have been used for other indications. Future direction includes evaluating alternative medication usage patterns with a developed phenobarbital order set. A comparative analysis focused on adverse drug events and efficacy may further shape treatment.