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.

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.

Title: Improving naloxone prescribing rates for Veterans with stimulant use disorder (StUD) through AudioCARE technology at the Atlanta VA Healthcare System
Presenters: Kathryne Spratlin, PharmD
Authors: Lauren Ramshur, MD; Stephanie Oh, PharmD; Kathryne Spratlin, PharmD; Melanie Pafford, NP; Natalie Haslem, NP; Mary K. Pounders, PharmD, BCACP
Background:
StUD is a prevalent diagnosis among the Veteran population. Veterans with StUD are at increased risk of accidental opioid overdose due to contamination of the illicit drug supply. Harm reduction interventions are recommended strategies to reduce stimulant-related overdose deaths.  Using a real-time dashboard, eligible Veterans were identified based on diagnosis of StUD without an active naloxone prescription. This project aimed to evaluate whether AudioCARE technology, an automated Veteran outreach program, can improve naloxone distribution amongst at-risk veterans with StUD in hopes of improving rates of accidental opioid overdoses.
Methodology: 
This prospective quality improvement project utilized automated outreach to identify and engage Veterans at risk for accidental opioid overdose due to StUD. A real-time dashboard identified eligible patients with an active diagnosis of StUD without an active naloxone prescription. Through AudioCARE technology, these Veterans were contacted via an automated phone call and given the options to receive a naloxone kit, decline a naloxone kit, or request additional information. Actions were taken based on each individual Veterans’ response. Those who did not respond were listed as non-responders and were re-contacted using the same process 120 days after the date of initial attempt. The dashboard was reviewed monthly to assess the number of actionable Veterans remaining. Prescribing rates, successful rates of contact, and the impact of secondary outreach were evaluated to assess the impact of the AudioCARE intervention.  
Results: 
AudioCARE outreach successfully identified 1,439 actionable Veterans. After completion of the initial call process, 370 Veterans indicated interest in receiving a naloxone prescription. Prior to implementation of AudioCARE process, 40.1% of Veterans with StUD had an active naloxone prescription; after the first round of outreach, this increased to 47.9%. A second round of calls targeted the 952 Veterans who were unable to be reached during the first round. Of those contacted, 108 additional Veterans requested a naloxone prescription. This further increased the percentage of Veterans with StUD who had active naloxone orders to 48.3%.
Conclusions: 
The AudioCARE process was a feasible strategy to improve naloxone access and support harm reduction efforts for at-risk Veterans with StUD at the VA. Future areas of interest include expansion to other high-risk populations, medication adherence outreach, preventative care initiatives, and chronic disease management support. 
  

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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