2026 Southeastern Residency Conference

Impact of Pharmacist-Led Blood Glucose Management on Patients in the Medical Intensive Care Unit  
Abigail Reeves, Ann Maxwell, Megan Lail, Marwan Elya 
 
Background
Hyperglycemia affects up to 60% of critically ill patients and is associated with increased morbidity, mortality, and healthcare costs. Beginning in January 2026, “Hospital Harm” Severe Hypoglycemia and Severe Hyperglycemia, two measures established by The Centers for Medicare and Medicaid Services, will become mandatory for annual hospital reporting. Pharmacist-managed insulin protocols have demonstrated improved glucose control and reduced severe hypoglycemia, but data in intensive care units remainslimited. This study aims to evaluate the impact of clinical pharmacist consultation for insulin management versus physician or advanced practice provider management on blood glucose time within goal range in critically ill patients. 
 
Methods
This study was a single center, retrospective, chart review of adult patients admitted to the medical intensive care unit (MICU) between June 1st, 2025, through January 31st, 2026. After the first 24-hours of MICU admission, patients 18 years of age and older were screened for inclusion criteria, including new-onset or past medical history of diabetes, glycated hemoglobin (A1c) > 6.5% within three months or during admission, two blood glucoses >180 mg/dL or receipt of insulin therapy. Based on provider discretion, the consult “Pharmacy to manage insulin” was ordered, and electronic medical record (EMR) documentation was utilized to write a daily progress note. Progress notes included history of diabetes, home diabetes regimen if applicable, last three A1C values, current insulin regimen, other diabetes medications, steroid use, dextrose-containing fluids, diet, and changes indicated. Pharmacists managed insulin only during the patients' MICU stay, with the capability to add or adjust long-acting and short-acting insulin. Pharmacistmanagement of blood glucose was conducted from 8:00 a.m. - 5:00 p.m and if urgent adjustment was needed outside of these hours, the intensivist intervened. The consult was limited to the MICU and was discontinued when each patient was physically transferred from the unit. A guidance document was developed for reference after service hours and during cross coverage. 
 
Results
The post-intervention group (n=124) demonstrated improved glycemic control compared to the pre-intervention group (n=112). The post-intervention group achieved a higher number of blood glucose values within the goal range (68.8% vs. 62.7%, p=<0.001). At the patient level, the post-intervention group had a higher median percentage of blood glucoses within goal range (80% vs. 64.3%, p=0.001). Hypoglycemic events showed no significant differences between groups, with similar proportions of patients experiencing hypoglycemia (22% vs. 19%, p=0.575), and no significant change in the total number of hypoglycemic events (2% vs. 1.23%, p=0.067). However, the post-intervention group had a significantly lower proportion of patients with hyperglycemic events (73% vs. 89%, p=0.001) and fewer total hyperglycemic events (30% vs. 36%, p<0.001). Additionally, the percentage of ICU days with hyperglycemia was significantly reduced in the post-intervention group (46% vs. 60%, p<0.001). These findings suggest that the intervention improved glucose control, particularly by reducing hyperglycemic events, without increasing hypoglycemia.  
 
Conclusions
Pharmacist consultation for insulin management was associated with an increase in the number of blood glucose values within the target range and a reduction in hyperglycemic events. These improvements occurred without a significant change in hypoglycemia, indicating that glycemic control improved without increasing hypoglycemic risk.

Background: Tirofiban is an intravenous glycoprotein IIb/IIIa inhibitor used after intracranial stenting procedures to reduce the risk of thrombotic complications. However, tirofiban is associated with an increased risk of bleeding, including intracranial hemorrhage (ICH). Balancing thrombotic prevention with bleeding risk remains a challenge in patients undergoing intracranial stent placement. Obesity may influence the safety and effectiveness of antiplatelet therapies due to alterations in drug distribution. Data evaluating tirofiban use in obese patients who have undergone intracranial stenting procedures is limited. Specifically, the impact of obesity on major bleeding and treatment failure outcomes has not been well studied. The purpose of this study is to compare the incidence of intracranial hemorrhage or stent reocclusion, between obese and non-obese patients receiving tirofiban after intracranial stenting procedures. 
Methods: This retrospective chart review included adult patients (≥18 years) who underwent elective or emergent intracranial stenting and received intravenous tirofiban during hospitalization at a comprehensive stroke center between July 1, 2018, and June 30, 2025. Patients were grouped based on body mass index (BMI) into obese (BMI ≥30 kg/m²) and non-obese (BMI <30 kg/m²) groups.  The primary outcome was treatment failure, defined as a composite outcome of intracranial hemorrhage or stent reocclusion confirmed by imaging during the hospitalization. The secondary outcome was major bleeding, defined by the International Society on Thrombosis and Haemostasis (ISTH) criteria as fatal bleeding, bleeding in critical areas, a drop in hemoglobin of ≥2 g/dL, or leading to a transfusion of ≥2 units of blood. Data collected included demographic characteristics, BMI, relevant comorbidities, indication for the procedure, tirofiban dosing and duration, renal function, and concomitant antiplatelet or anticoagulant therapy. Outcomes were assessed during the tirofiban infusion only. Baseline characteristics were summarized, and outcomes were compared between groups using t-tests, chi-square analysis, or Fisher’s exact test. 
Results: A total of 101 patients were included in the analysis, with 59 non-obese and 42 obese patients. Obese patients were younger (54.9 ± 15.1 vs 63.8 ± 14.7 years, p=0.007) and had higher creatinine clearance values (137.4 ± 75.4 vs 85.7 ± 36.5 mL/min, p<0.0001) compared to non-obese patients. As expected, obese patients had significantly higher dosing and actual body weights and received larger tirofiban loading doses. Other baseline characteristics, including sex, severity scores (Hunt & Hess, NIHSS), duration of tirofiban infusion, overlap with oral antiplatelet therapy, and renal dose adjustments, were similar between groups. The primary composite outcome of ICH or stent reocclusion occurred in 30.5% of non-obese patients and 40.5% of obese patients (p=0.299). Major bleeding occurred in 32.2% of non-obese patients compared to 42.9% of obese patients (p=0.273). Rates of individual outcomes, including ICH (22.0% vs 38.1%, p=0.079) and stent reocclusion (11.9% vs 2.4%, p=0.071), were not significantly different between groups. There was no significant difference in major bleeding when comparing severely obese patients (BMI ≥40 kg/m²) to non-severely obese patients (33.3% vs 37.1%, p=0.245). 
Conclusions: In this retrospective analysis, obesity was not associated with a statistically significant increase in treatment failure or major bleeding among patients receiving tirofiban following intracranial stenting. However, numerically higher rates of intracranial hemorrhage were observed in obese patients, suggesting a potential safety signal. Given the overall high bleeding risk and lack of obesity-specific dosing guidance, caution remains warranted, and larger, prospective studies are needed to better define optimal dosing strategies and bleeding risk in this population.

Background/Purpose: Statins are essential in preventing stroke recurrence by atherosclerotic plaque accumulation, which can trigger acute ischemic strokes (AIS) when disrupted. Based on the differences in the pharmacokinetic profiles of atorvastatin and rosuvastatin, it is unclear if one agent is more effective at reducing the rates of stroke recurrence in adult survivors of AIS. The purpose of this study is to evaluate the rates of stroke recurrence in AIS patients receiving high-intensity statin therapy (HIST) with rosuvastatin or atorvastatin.  

Methods: In this retrospective cohort study adult patients with a diagnosis of AIS and discharged with HIST were screened if admitted from July 1, 2016, to October 31, 2020. High-intensity statin use was determined by having atorvastatin 40-80 milligrams daily or rosuvastatin 20-40 milligrams daily on the patient’s discharge medication list. The primary outcome of this study was rates of stroke recurrence within five years. Secondary outcomes evaluated were stroke recurrence within twenty-one days, stroke recurrence within one year, and rates of statin discontinuation within five years. 

Results: 5-year stroke recurrence from the initial AIS found that 10 (12.5%) of the atorvastatin and 6 (15%) of the rosuvastatin patients had an episode of stroke recurrence (OR 1.235; 95% CI, 0.415-3.681; p = 0.778). Similar to the primary outcomes, none of the secondary outcomes were statistically significant. 

Conclusions: Our results support either statin would be efficacious for secondary prevention, though there is an increased risk of myopathy associated with lipophilic statins (i.e., atorvastatin). Due to our studies' small sample size, it would be advantageous for future research to utilize a larger sample size to determine a potential clinical difference.  

Purpose: Chronic obstructive pulmonary disease (COPD) is one of the most prominent disease states, affecting nearly 16 million people and ranking as one of the top ten causes of mortality. Improper treatment of COPD can lead to disease progression, increased risk of exacerbations, decreased quality of life, and a negative financial impact on the patient. Inhaled corticosteroids (ICS) are not recommended as initial treatment in COPD per the 2025 GOLD report and overprescribing can lead to unnecessary risks. The objective of this study is to investigate the current utilization of ICS therapy in COPD at the Central Alabama Veterans Health Care System (CAVHCS).

Methods: This quality improvement project is a retrospective, observational review of the prescribing of ICS  to Veterans with a diagnosis of COPD being treated at CAVHCS from October 1, 2019 to September 5, 2025. A more extensive chart review was completed on a random sample of 100 Veterans from an original sample size of 3,791. Data collected includes Veteran demographics, COPD diagnosis (ICD code), active inhaler prescriptions, documented indications for ICS use, eosinophil counts, FEV1/FVC results, CT scans, X-Rays, history of exacerbations, and hospitalization rates. The data was compiled in a de-identified Microsoft Excel spreadsheet for analysis. Primary outcome assessed was the percentage of Veterans with COPD who have been appropriately prescribed ICS-inhaler therapy.  Secondary outcomes include the rate of eosinophil counts monitored prior to initiation of ICS-inhaler therapy, the rate of exacerbations in Veterans with a COPD diagnosis on ICS-inhaler therapy, and the difference in lung function (FEV1/FVC) prior to and following initiation of ICS therapy in Veterans with COPD. 

Results: 100 Veterans at CAVHCS diagnosed with COPD were randomly selected for screening and assessment and exactly half of them were prescribed ICS therapy. Of the 50 patients found to be prescribed ICS therapy, 30 of them were prescribed by prescribers actively working at CAVHCS. The other 20 Veterans were prescribed ICS therapy from those outside of the health care system or were prescribed at another VA facility and their medications were reconciled and continued.  For the 30 Veterans who had been prescribed ICS therapy by our health system’s providers, 50% of them were determined to have been appropriately prescribed. Of the remaining 50% of patients, 33% were determined to have been inappropriately prescribed and in 15% of patients we were unable to determine appropriateness (e.g unavailable records). In regard to secondary outcomes, there were eight documented and diagnosed episodes of exacerbations. PFTs were documented in 64% of patient charts screened and 85% of Veterans had documented eosinophils.

Conclusions: Results from this project have outlined a prominent disconnect between evidence-based guidelines and prescriber patterns. This affirms the need for providing comprehensive education to our prescribers on the good practice of ICS therapy prescribing. Giving education to providers will close the gap between provider knowledge and prescribing practices, in turn leading to decreased side effects from unnecessary medication use and improved outcomes for our Veterans.

Background: Diabetes mellitus and hyperglycemia affect 25% to 40% of hospitalized patients and are associated with prolonged hospital stay, increased infections, and mortality. The 2026 American Diabetes Association (ADA) Standards of Care recommend insulin initiation for persistent hyperglycemia ≥180 mg/dL, with glycemic targets of 100-180 mg/dL for noncritically ill patients and 140-180 mg/dL for critically ill patients. The Centers for Medicare & Medicaid Services (CMS) tracks severe glucose excursions (≥300 mg/dL and ≤40 mg/dL) as electronic clinical quality measures (eCQMs) under the Hospital-Acquired Condition Reduction Program (HACRP). These thresholds represent the more extreme glycemic events that CMS tracks for regulatory reporting and payment penalties, distinguishing them from the broader ADA clinical classification.  Effective this year, hospitals are required to track and report eCQMs related to hyperglycemia and hypoglycemia with financial penalties for non-compliance. Additionally, these metrics may become visible in CMS and other quality measurement systems to increase public transparency in regard to inpatient glucose control.  Multiple studies have demonstrated that pharmacist interventions can improve glycemic control and reduce hypoglycemic events. The purpose of this study was to assess the impact of pharmacy involvement in glycemic monitoring within our facility’s inpatient population.

Methods: This single-center, retrospective, comparative study evaluated glucose levels in patients ≥18 years who were admitted to a community hospital. Glucose levels drawn during continuous insulin infusions were excluded. The pre-intervention group (December 1, 2024–February 28, 2025) was compared to the post-intervention group (December 1, 2025–February 28, 2026) following protocol implementation and pharmacist education. Patients were identified using automated electronic health record (EHR) alerts that flagged patients who met predefined glycemic criteria. Hyperglycemia alerts are generated when blood glucose exceeds 300 mg/dL on a single occurrence or exceeds 180 mg/dL on two occasions within 24 hours. Hypoglycemia alerts are generated for any blood glucose value <70 mg/dL. Pharmacists reviewed flagged patients' A1c, insulin regimens, glucose trends, nutritional status, renal function, and steroid use before providing recommendations to providers. Primary outcomes included the proportion of glucose measurements ≥300 mg/dL and ≤40 mg/dL. Secondary outcomes included intermediate ranges: ≥180 to <250 mg/dL, ≥250 to <300 mg/dL, and >40 to ≤70 mg/dL. The study was powered to detect a 10% relative reduction in severe hyperglycemia (≥300 mg/dL) at 80% power. Statistical significance was assessed using chi-square tests, with p < 0.05 considered significant.

Results: A total of 74,060 blood glucose measurements were analyzed in the pre-intervention period compared to 67,682 measurements in the post-intervention period. There was no statistically significant difference among baseline characteristics between the two groups. The proportion of severe hyperglycemic measurements (≥300 mg/dL) decreased significantly from 3.19% to 2.94% (ARR 0.25%; p = 0.007). The proportion of severe hypoglycemic measurements (≤40 mg/dL) showed no significant change (0.16% vs 0.15%; ARR 0.01%; p = 0.77). Significant reductions were observed in measurements ≥180 to <250 mg/dL (17.20% vs 14.84%; ARR 2.36%; p < 0.001) and ≥250 to <300 mg/dL (4.46% vs 3.80%; ARR 0.66%; p < 0.001). Level 1 hypoglycemia (>40 to ≤70 mg/dL) showed no difference (1.55% vs 1.66%; ARR −0.11%; p = 0.09).

Conclusions: Implementation of a glycemic monitoring protocol with pharmacist review was associated with significant reductions in severe and intermediate hyperglycemic levels without increasing the incidence of hypoglycemia. These findings support pharmacist involvement in improving glucose control in an inpatient setting. Future directions include the development and implementation of a pharmacist-driven glucose management protocol within our facility. Further evaluation would need to be done to assess patient-level outcomes such as length of stay, infection rates, and 30-day readmissions.

Association between cephalexin dosing frequency in uncomplicated urinary tract infections and treatment failure in discharged Emergency Department patients
Kameron Francis, Rachel Musgrove, Analise Williams, Fataba Gailor, Meghan Hammond, Devon Burhoe
Background/Purpose: Urinary tract infections (UTI) are among the most common bacterial infections seen in the health care system. Cephalexin, commonly prescribed for UTI, has no standardized dosing frequency indicative of superiority. Cephalexin can be prescribed twice daily, three times daily, or four times daily. This study aims to assess treatment failure with various cephalexin dosing frequencies in the treatment of UTI.
Methodology: A multicenter, retrospective, observational cohort study which collects eligible patients via ICD-10 codes. Eligible patients are those > 18 with documented diagnosis of acute cystitis or uncomplicated UTI with a positive urine culture with susceptibility to cefazolin. Patient must be prescribed cephalexin two, three, or four times daily for five to seven days. Exclusion criteria include complicated or recurrent UTI requiring prophylactic antibiotics, patients without cultures preformed or requiring renally adjusted cephalexin. Treatment failure within 30 days defined as patients who: return symptomatic to the emergence department (ED), present with signs and symptoms of urinary tract infection after initiation of cephalexin treatment seeking medical attention outside of the ED, or required an antibiotic change after the initiation of a 5–7-day course of cephalexin.
Results: 131 patients were included in the study with over 80% of the subjects being female. The subjects were evenly distributed between three dosing strategy groups. 14 subjects (10.7%) had treatment failure occur after receiving their initial cephalexin course (p-value 0.984). Patients most often failed treatment due to returning to the emergency department symptomatic after the initial cephalexin treatment. The average time to treatment failure was 22 days. Six subjects required a change in antibiotic regimen, and half of these subjects received cephalexin twice daily initially. The most common alternative antimicrobial regimen was vancomycin with piperacillin/tazobactam due to the development of urosepsis. There was no incidence of bacterial resistance in any of the 131 subjects.
Conclusions: There was no difference between the rate of treatment failure and the three different dosing strategies for cephalexin in uncomplicated urinary tract infections. Among the fourteen patients that failed therapy, most often it was due to returning to the emergency department symptomatic within 30 days of initial treatment. There were higher rates of an alternative antimicrobial therapy needed due to urosepsis in the twice daily group. Overall, our data aligns with current data which shows no association between treatment failure and dosing strategy in uncomplicated urinary tract infections.

Authors: Julie A. Gordon, Jon E. Folstad, Charley A. Hepfinger, Camille P. Robinette, Allison E. Strain, Anita A. Kelkar

Background: Heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF) are highly prevalent among the aging population and contribute to significant morbidity and reduced quality of life. Unlike heart failure with reduced ejection fraction, guideline-directed medical therapy (GDMT) has not demonstrated clear mortality benefits in this population, and treatment primarily focuses on symptom management and comorbidity control. Obesity is a major modifiable risk factor in HFpEF and HFmrEF that contributes to worsening symptoms and increased hospitalizations. Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists, including semaglutide and tirzepatide, have demonstrated effective weight loss and clinical benefits in this population. However, their impact on heart failure related outcomes has not yet been evaluated at the Salisbury VA Health Care System (SVAHCS). This project aims to evaluate if semaglutide and tirzepatide lead to clinical improvement in Veterans with HFpEF or HFmrEF and how prescribing patterns influence outcomes at the SVAHCS.

Methods: This quality improvement project was a retrospective chart review of Veterans with HFpEF or HFmrEF prescribed semaglutide or tirzepatide for at least six months between January 2022 and July 2025 at the SVAHCS. Collected variables included demographics, duration and dose of therapy, medication titration schedule (standard vs. slow), prescribing discipline (Pharmacy, Endocrinology, Primary Care), and number of titration-related clinic visits attended during therapy. The primary outcome was percentage change in body weight. Secondary outcomes included changes in B-type natriuretic peptide (BNP), ejection fraction (EF), HgbA1C, LDL, blood pressure medication and loop diuretic requirements, and symptoms of heart failure. Prescribing discipline, titration method, and follow-‑up frequency were evaluated.

Results: A total of 266 patients were identified using the Weight Management Patient Report Dashboard. After chart review was performed to confirm eligibility, 52 patients were included, most of whom had HFpEF (90%) and obesity (96%). Patients who remained on the agent for at least 12 months experienced an average weight loss of 6.26% (p-value <0.001). Improvements were observed in weight, LDL, HgbA1C, BNP, and EF, although sample sizes varied. Compared to other disciplines, pharmacist-managed patients attended the highest number of clinic visits during therapy titration and exhibited the greatest percentage of weight loss (p-value=0.24) as well as the largest reduction in BNP (p-value=0.93). However, these differences were not statistically significant. Although most patients (81%) underwent slow titration, those receiving standard titration reached maximum dose more rapidly and achieved greater weight loss (p-value=0.15). Across the cohort, 29% had an antihypertensive medication reduced or discontinued, and patients achieving ≥5% weight loss were more likely to require loop diuretic dose reduction, suggesting improved volume status and symptom control.

Conclusion: Semaglutide and tirzepatide were associated with meaningful weight loss and favorable cardiometabolic trends in Veterans with HFpEF or HFmrEF. Differences in outcomes across prescribing disciplines highlight the importance of follow‑up frequency, access to care, and titration intensity, with pharmacist‑managed care demonstrating the strongest improvements.

Contact: [email protected]

Title: The Incidence and Timing of Venous Thromboembolism After 4-Factor Prothrombin Complex Concentrate Administration in Trauma Patients 

Authors: Gregory Gurin, Sharon Jordan, Aysu Erdemir 

Grand Strand Medical Center – Myrtle Beach, SC 


Background/Purpose: Non-activated 4-factor prothrombin complex concentrate (4F-PCC) has been increasingly utilized in trauma patients for hemostasis. This class of medication and the trauma population can increase the risk of thromboembolic complications, necessitating safe and effective prophylaxis. This study is designed to examine the relationship between incidence and timing of venous thromboembolism (VTE) with delayed prophylaxis after 4F-PCC administration in trauma patients. 

Methodology: This retrospective study analyzed 2,664 patients aged ≥18 years admitted through the emergency department for traumatic injury and received ≥1 dose of 4F-PCC within 24 hours of arrival. Patients were noted to have high-risk trauma features that include traumatic brain injury, spinal cord injury, long bone fracture, pelvic fracture, and solid organ injury. The primary outcome was the incidence and timing of in-hospital venous thromboembolism. Secondary outcomes included in-hospital mortality, intensive care unit (ICU) admission, ICU length of stay (LOS), and 30-day mortality rate. 

Results: Among patients in the final analytical cohort that received chemoprophylaxis, VTE occurred in 103 (3.9%) cases. VTE occurred in 5.1% of patients receiving delayed prophylaxis (>48 hours) compared with 2.4% of those receiving prophylaxis within 48 hours. Male sex (HR = 2.05, p < 0.001), history of VTE (HR = 5.59, p < 0.001) and solid organ injury (HR =2.43, p = 0.011) was associated with an increased risk of developing VTE. In survivors, the same risk factors increase the risk of VTE in addition to spinal cord injury (HR = 3.3, p = 0.017) and increased Elixhauser comorbidity score (HR = 1.16, p = 0.004). Concurrent use of pro-hemostatic agents (tranexamic acid and desmopressin) did not increase the risk of VTE. The median time from 4F-PCC administration to VTE was 135.1 hours (57.4-234.9 hours). Delayed prophylaxis was not associated with a higher risk of in-hospital mortality (HR 1.07; 95% CI 0.84–1.36; p = 0.60) or 30-day mortality (OR 1.10; 95% CI 0.86–1.39; p = 0.46). Delayed prophylaxis was associated with a 2.12-fold increase in the odds of ICU admission (OR = 2.12; 95% CI, 1.63–2.76; p < 0.001). Among patients with any ICU stay, delayed prophylaxis was associated with 60% longer ICU length of stay (IRR = 1.60; 95% CI, 1.46–1.76; p < 0.001). These results represent multivariable adjustments using major demographic and baseline clinical variables.

Conclusions: Delayed pharmacological VTE prophylaxis after 4F-PCC administration in trauma patients was not associated with higher risk of VTE or mortality. However, delayed prophylaxis was associated with increased ICU admission rates and longer ICU LOS. Although 4F-PCC was not associated with increased VTE risk or mortality, current medical management should continue to prioritize VTE prophylaxis once hemostasis has been achieved to minimize complications.

Contact email: [email protected]

“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.” 

Title: Falling into Z-drugs: An Analysis of Z-drug Use and Fall Risk in Older Adults 
Authors: Madelyn Singleton, Laura Schalliol, Kelsee Tignor, Taylor Dabney 
 
Purpose: 
This study evaluates the association between Z-drug use and fall risk, evidenced by STEADI Fall Risk Assessment scores (≥4 indicating elevated risk). Z-drugs, including zolpidem (Ambien®, Edluar®), eszopiclone (Lunesta®), and zaleplon, are listed as potentially inappropriate medications in the 2023 Beers Criteria. Findings will help clarify their impact on fall risk and improve prescribing and medication safety in older adults. 
 
Methods: 
This study is a single-center retrospective chart analysis including patients 65 or older who completed a Medicare Annual Wellness Visit (MAWV) between January 1 and October 31, 2025, with a STEADI Falls Risk Assessment and an active Z-drug prescription. The STEADI tool utilized is a 12-point questionnaire with scores of ≥4 indicating increased fall risk. Patients were excluded if they had dementia, received hospice or palliative care, or if they resided in a nursing home. 

From the de-identified patient list the following data points were collected: patient sex, age, weight, date of MAWV, STEADI Fall Risk Assessment Score, Z-drug prescribed including dose and start date, diagnosis of insomnia or a movement or neurological disorder, documented mobility issues or hearing impairment, care setting, number of medications at time of MAWV and medication list, and history of a fall documented at MAWV.  As applicable, a Z-drug end date and insomnia ICD-10 code were recorded. The primary outcome is to evaluate the association between STEADI fall risk scores and the use of Z-drugs. The secondary outcome is to evaluate the association between polypharmacy, defined as ≥5 active medications, and STEADI fall risk scores. Collected data will undergo descriptive statistical analysis. 
 
Results: 
Of 78 patients screened, 67 patients were included in the analysis. The average age of the study population was 73 years old and the average STEADI score was 2.3. The most prescribed Z-drug was zolpidem with 52 patients (75%) taking this medication. This study found that 13 patients (19.4%) demonstrated an increased fall risk as shown through the STEADI score with a Z-drug prescription.  Additionally, 12 patients (17.9%) were identified as having both an increased fall risk and experiencing polypharmacy.  
 
Conclusion: 
In conclusion, the study findings suggest that within the study population there is not an association between Z-drug use and increased fall risk as evidenced by STEADI Fall Risk Assessment Scores of 4 or more.

Authors: Amanda Dunlap, Dillion Frazier, and Cy Sims

Background: Tafamidis and vutrisiran are novel therapeutics shown to improve mortality rates and reduce hospitalization among cardiac amyloidosis patients. However, these medications are associated with substantial costs and prescribing challenges. Considering the high cost, lack of data in a rural healthcare system, and the increasing role of pharmacists in specialty pharmacies, there is a significant administrative interest in gaining a better understanding of the impact these medications have within our community. This project investigated the real-world adherence and outcomes of tafamidis and vutrisiran in a rural setting.

Methods: Tafamidis patients were identified using reports from Therigy. Reports included new starts of tafamidis from January 1, 2022-July 31, 2025, pharmacy turnaround times, and missed doses reported during follow-up. Vutrisiran patients were identified from Soarian Financials by filtering patients who received a prescription for vutrisiran from June 1, 2025-July 31, 2025. Patient charts were reviewed and followed for 6 months prior to treatment initiation and 6 months after the first prescription. The primary outcome of the study was to determine adherence to tafamidis and vutrisiran. Adherence was defined for tafamidis based on pharmacy dispensing records used to calculate the medication possession ratio greater than 80% signified adherence. Adherence for vutrisiran was based on documentation of administration in the patient medical record within 7 days of the next scheduled dose. Secondary outcomes were cardiovascular related hospital admission rates within the same patient 6 months pre-and post-drug initiation, the time from receiving the prescription to dispensing, the number of patients converted from tafamidis to vutrisiran, discontinuation of therapy as documented in the medical record or no fills within 60 days for tafamidis or a missed scheduled injection for vutrisiran, and insurance coverage.

Results: Of 153 patients included in the tafamidis group, 142 patients (92.8%) were found to be adherent. 11 patients (7.2%) were nonadherent with MPR score ranging from 66%-78%. In the vutrisiran group 4 of 13 patients were found to adherent, 7 were nonadherent as they did not receive a dose within 7 days post next scheduled dose, and 2 unable to obtain as the prescription was transferred to a different facility. Vutrisiran administration timing between doses ranged from 90-109 days for the 8 patients who received more than 1 dose, and 1 patient receiving 3 doses. Cardiovascular-related hospital admission rates were similar in the pretreatment group 9.8% vs 7.7% (tafamidis vs vutrisiran) while posttreatment admissions were higher in the vutrisiran group 13% vs 30%. The average time from receiving a prescription for tafamidis to the medication being dispensed from the pharmacy was 4.5 days and 32.2 days for vutrisiran. 13 tafamidis patients were additionally prescribed vutrisiran, and 3 patients were converted from tafamidis to vutrisiran. 7 tafamidis patients discontinued therapy while 3 vutrisiran patients discontinued. 152 patients in the tafamidis group had insurance coverage while 1 patient received 340b pricing. All vutrisiran patients had insurance coverage.

Conclusion: Tafamidis demonstrated high adherence rates, 92.8% of patients achieving a medication possession ratio ≥80, and had short pharmacy turnaround times. The findings highlight important adherence and operational challenges associated with specialty drugs especially in a rural setting. While also demonstrating the importance of specialty pharmacists optimizing access, minimizing delays, supporting adherence, and coordinating care for these patients.

Unmasking the Neurologic Exam: Sugammadex for Neuromuscular Blockade Reversal in Neurocritical Care 
 
Authors: Autumn Locke McClung1; Gianna Marie Antinone2; Michael L. Behal1; Mary W. Massaro; Thomas J. Christianson1,4; Paige Ledlow1; Bryn E. Ferguson3; Sarah J. Kugler,3; Robert E. Heidel4; Leslie A. Hamilton1,3 
 
1University of Tennessee Medical Center, Knoxville, TN  
2Inova Fairfax Hospital, Falls Church, VA  
3University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN  
4University of Tennessee Health Science Center College of Medicine, Knoxville, TN 
  
Background 
Evidence supporting sugammadex for neuromuscular blockade reversal is largely derived from perioperative and traumatic populations, with limited data in nontraumatic neurocritical care patients. Residual blockade following emergent intubation may delay neurologic assessment and impact time-sensitive decisions. This study evaluated the safety and effectiveness of sugammadex in facilitating neurologic assessment and informing clinical decision-making in this population. 

Methods 
This retrospective, observational cohort study was conducted at a large academic medical center in Knoxville, Tennessee. Adult patients with nontraumatic neurologic injury who received sugammadex for NMB reversal between April 2016 through December 2024 were included. Patients were excluded if they were pediatric, pregnant, had traumatic neurologic injury, or received sugammadex for routine postoperative anesthesia reversal. The primary outcome was the impact of sugammadex on neurologic decision-making, defined as escalation or de-escalation of care following reversal. Secondary outcomes included adverse events, train-of-four monitoring when available, and successful NMB reversal defined as improvement in neurologic examination using Glasgow Coma Scale scores. Four a priori subgroup analyses were conducted, including comparisons of sugammadex dosing strategies relative to neurologic injury severity, neurologic injury type and the incidence of escalation or de-escalation of care, and patients intubated at an outside hospital or by Emergency Medical Services (EMS) versus the study institution. Statistical analyses were performed using SPSS (Version 31). Descriptive statistics summarized variables, and subgroup comparisons were conducted using chi-square tests, with significance defined as p<0.05. 

Results 
A total of 153 patients were included. Patients had severe neurologic injury, with a median presenting Glasgow Coma Scale (GCS) of 5 (IQR 3–8) and pre-intubation GCS of 4 (IQR 3–8). Intracranial hemorrhage syndromes were most common (57.5%), followed by ischemic stroke (22.9%) and status epilepticus (22.9%). Intubation occurred prior to arrival in 39.9% of patients and at the study institution in 60.1%. Rocuronium was the predominant paralytic (92.2%) at a median dose of 1.2 mg/kg (IQR 1.04–1.33). Most patients received sugammadex 2–4 mg/kg (64.1%), with fewer receiving <2 mg/kg (7.8%) or >4 mg/kg (15%). Following sugammadex administration, 23.5% of patients underwent escalation of care, most commonly neurosurgical intervention, while 24.8% experienced de-escalation, including 19% of patients who transitioned to comfort-based management. No neurologic deterioration was attributed to sugammadex. Adverse events were infrequent, including hypotension (13.7%) and bradycardia (11.1%). Subgroup analyses demonstrated no significant differences in outcomes across dosing strategies or neurologic injury subtypes. 

Conclusions 
Sugammadex demonstrated a favorable safety profile in nontraumatic neurocritical care patients and was not associated with neurologic deterioration. Nearly half of patients underwent escalation or de-escalation of care following sugammadex administration, supporting its role in expediting neurologic assessment and facilitating timely, clinically meaningful management decisions.

Inpatient Pharmacist-led Penicillin Allergy Delabeling (iPPADL)
Authors: Caleb Gosnell, Benjamin Britt, Vince Buttrick, Erik Turgeon at Lexington Medical Center
Background/Purpose: Reports of penicillin allergies are common, as many as 25% of patients have a penicillin allergy in their medical record. Most of these patients have mild reactions, such as urticaria. Patients with a remote history of allergy from childhood are <5% likely to have a retained allergy to penicillins. Recent studies have identified pharmacist-led allergy de-labeling approaches with a focus on antimicrobial stewardship have positive outcomes on alternative antibiotic utilization, Clostridioides difficile infection rates, inpatient length of stay, and patient costs. Barriers to traditional approaches include the need for either skin testing supplies with appropriate training or additional stock of oral amoxicillin. In a cost-saving approach, it may be efficacious to use patient medical history and interviewing to assess the possibility of de-labeling.
Methodology: This was a pre- and post-intervention review of inpatient encounters at a single-center 607-bed community teaching hospital. The intervention for this study was the implementation of a pharmacist-led penicillin allergy delabeling protocol. Pharmacists determine eligibility by reviewing PEN-FAST assessment results, reported allergy reactions, and previous inpatient penicillin/aminopenicillin administrations. Patients with a PEN-FAST score of 0 with a non-immune mediated reaction, such as nausea, qualified for de-labeling.  Patients with a PEN-FAST score of 0 or 1, with a minor immune-mediated reaction, such as urticaria, were further evaluated for prior inpatient administrations of a penicillin or aminopenicillin. If tolerated, the patient qualified for delabeling. All patients received bedside education of the process of qualifying for delabeling and required verbal consent to remove the allergy from the medical chart.  The pre-intervention group consisted of inpatients with a penicillin allergy and PEN-FAST assessment between July 1, 2025 – October 31, 2025. The post-intervention group consisted of inpatients with a penicillin allergy and PEN-FAST assessment between November 1, 2025 – February 28, 2026. Outcomes were then assessed manually by the investigator through electronic health record (EHR )-generated data and manual chart review.
Results: During the pre-intervention phase, a total of 1,912 admissions had a labeled penicillin allergy and 215 had a PEN-FAST score reported with 75 patients eligible for delabeling. In the post-intervention phase, a total of 1,527 admissions had a penicillin allergy. Of those admissions, 232 had a PEN-FAST score reported. Seventy-nine patients were eligible for delabeling with 25 qualifying by a non-immune reaction and 54 with a penicillin class administration. Piperacillin/tazobactam was the major contributor with 38 eligibilities. A total of 18 patients were delabeled with most (14) qualifying via penicillin class administrations. Three patients refused the intervention, and two patients were relabeled at a subsequent outpatient encounter.
Conclusions: A pharmacist-led allergy delabeling protocol based upon chart review and patient interview is a low-cost alternative to skin testing, though its success is highly limited by workflow time constraints, altered patient mentation, EHR reporting logistics, and patients located on floors without decentralized pharmacists. Another potential limiting factor is that this study did not account for patients with short length of stays that could further decrease the time available for assessment and intervention. Future considerations are a more direct identification process through pharmacist notification rather than a passive report that must be actively reviewed. Additionally, expanding the protocol to include conversations with medical decision-makers for patients with chronic altered mental status. In the future, the protocol will shift to a stewardship initiative to capture more patients, improve decentralized communication of opportunities, and potential expansion to oral challenge in patients who are low risk for a true allergy without qualifying administrations.

Title: Implementation of Prescriber Antibiotic Scorecards in a Rural Community Hospital

Authors: Valeriy Shipilov PharmD, Joshua Pruitt PharmD, BCIDP

Purpose: Antimicrobial stewardship is an essential practice component in acute care settings as about 30% of all antibiotics prescribed in U.S. acute care hospitals are unnecessary or suboptimal.  Tracking and reporting of antimicrobial utilization are two core elements of stewardship programs and aid benchmarking, transparency, and accountability. Previous studies on implementation of antimicrobial utilization reports have limited data on efficacy of these interventions on prescribing trends. The purpose of this study is to implement and track the impact on provider prescribing habits in a rural community hospital.

Methods: This report was developed and implemented at a rural community hospital with an average daily census of 125. Prescriber antibiotic utilization will be tracked by determining the number of shifts worked by a prescriber and the number of broad-spectrum antibiotics prescribed in a month. Data will be tracked and analyzed with a reporting software available through the hospital's electronic health record.  Broad spectrum antibiotics will be defined as cefepime, meropenem, levofloxacin, and piperacillin-tazobactam. Broad spectrum antibiotic utilization will be reported to providers monthly as a rolling average of the number of targeted antibiotics prescribed per shift worked. Prescribers will be privately provided with their randomized identification number in an effort to blind data of their peers. 

Results: We saw a statistically significant reduction in antibiotics prescribed per shift over time after the intervention (p = 0.019). There was no trend observed that was independent of the intervention (p=0.951) and there was no statistically significant immediate effect based on the intervention (p=0.076). We did not see a statistically significant reduction in days of therapy for targeted antibiotics (p=0.191) after the implementation of the scorecard. 

Conclusions: Overall, we saw a statistically significant reduction in antibiotics prescribed per shift after the implementation of our prescribing scorecard. Although there was no effect on days of therapy, the results support the use of antibiotic scorecards as a means of tracking and reporting prescribing habits to physicians. Additionally, the reduction in use of broad-spectrum antibiotics has allowed us to meet quality goals for antibiotic prescribing, and we hope to expand the scope of the report to target reduction in days of therapy and possibly intravenous to oral switching. 

Contact Information: [email protected]

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Objective: To evaluate whether collaborative management with a clinical pharmacist in a family medicine setting leads to more adult patients with type 2 diabetes mellitus (T2DM) achieving hemoglobin A1c (A1C) reduction within 3–6 months compared to matched patients receiving usual care.

Background: T2DM remains a major contributor to morbidity and mortality, particularly in rural populations where access to care and provider shortages can make disease management difficult. Clinical pharmacists integrated into primary care teams may improve glycemic outcomes through medication optimization. While prior studies have demonstrated improved A1C outcomes in pharmacist-managed diabetes clinics, many evaluate outcomes over 6–12 months. Limited data exist assessing short-term (3–6 month) glycemic response under collaborative models embedded within rural family medicine practices.

Methods: This retrospective, single-system, 1:1 matched cohort study included 34 adult patients with T2DM seen at a family medicine clinic between July 31, 2024, and July 31, 2025. Seventeen patients with ≥1 documented visit and management by a clinical pharmacist were matched to 17 patients without pharmacist involvement based on provider, age (±5 years), sex, and baseline A1C category (<8%, 8–10%, >10%).
The primary outcome was any A1C reduction (yes/no) from baseline to 3–6 months. Secondary outcomes included A1C reduction ≥1% and achievement of A1C goal (<7% or individualized target) within 3–6 months.

Results: Within 3–6 months, 9 of 17 (52.9%) pharmacist-managed patients demonstrated A1C reduction compared to 5 of 17 (29.4%) patients receiving usual care. When evaluating clinically meaningful reductions (≥1%), 7 of 17 (41.2%) pharmacist-managed patients and 4 of 17 (23.5%) usual care patients met this reduction. For goal attainment, 3 pharmacist-managed patients and 6 usual care patients met A1C target, however, most were already at goal at baseline (2 and 4 patients, respectively). Among patients not at goal at baseline, new goal attainment occurred in 1 of 15 (6.7%) pharmacist-managed patients and 2 of 13 (15.4%) usual care patients.

Conclusion: Collaborative management in a rural family medicine setting was associated with a higher proportion of patients achieving short-term A1C reduction, including clinically meaningful reductions ≥1%, compared to usual care. While goal attainment rates were similar and limited by small sample size, these findings support integration of pharmacists into rural primary care teams to promote early glycemic improvement.

Comparison of Dexamethasone versus Methylprednisolone in Acute Respiratory Distress Syndrome (ARDS)
Authors: Kayla Phillips, PharmD, Lindsey Mclendon PharmD Candidate, Lauren Floris, PharmD, BCPS, BCCCP
Background:
Acute respiratory distress syndrome (ARDS) represents about ten percent of all intensive care unit (ICU) admissions with nearly a fourth of these requiring intubation.1 Early phase ARDS is characterized by alveolar inflammation leading to hypoxemia.3 Steroids can inhibit the progression of this inflammation by decreasing cytokine release and promoting clearance of alveolar edema.2 The Society of Critical Care Medicine (SCCM) consensus update in 2024 suggests using corticosteroids in all patients with ARDS, regardless of the severity but no drug or dosing regimen was advised over another.4 The purpose of this study is to determine if there is a difference in duration of mechanical ventilation when either dexamethasone or methylprednisolone is used in the management of ARDS.
Methods:
We conducted a single center, retrospective, chart review to evaluate the effects of dexamethasone compared to methylprednisolone in adults ICU patients diagnosed with ARDS. This study included adult patients admitted from January 1, 2021, to August 31, 2025, who were intubated with a diagnosis of ARDS and received either intravenous (IV) dexamethasone or IV methylprednisolone within 72 hours of intubation. Patients who received both dexamethasone and methylprednisolone, diagnosed with COVID-19, history of adrenal insufficiency, prescribed steroids at baseline, or those who only received one dose of IV steroids were excluded from this study. The primary outcome was days alive and ventilator free at 28 days compared between the two steroid groups. Secondary outcomes included duration of mechanical ventilation, duration of steroid use, ICU and hospital length of stay, rate of ICU readmission within 90 days, ARDS severity defined by PaO2/FiO2 ratio, and mortality rate. Safety outcomes recorded are hypernatremia, fluid overload, uncontrolled hyperglycemia requiring insulin, gastrointestinal bleeding, and new infection acquired during admission post-steroid use.
Results:
A total of 45 patients were included (22 dexamethasone, 23 methylprednisolone). Baseline characteristics were similar between groups. There was no significant difference in the primary outcome of days alive and ventilator-free at 28 days between dexamethasone and methylprednisolone, 16 days vs 15.2 days respectively (p= 0.82). Secondary outcomes including ICU readmission within 90 days, did not differ between groups (2/22 vs 0/23, p=0.14). Safety outcomes were comparable with no significant differences in rates of hyponatremia (6/22 vs 7/23, p=0.82) or hyperglycemia requiring insulin (13/22 vs 18/23, p=0.17).
Conclusion:
In this single center retrospective study of patients with ARDS, dexamethasone and methylprednisolone were associated with similar ventilator free days and comparable secondary and safety outcomes. This study was not powered to detect small differences between treatment groups, and larger prospective studies are needed to further evaluate optimal corticosteroid selection.

Authors: Logan Wildman, Vanessa Velazco, Tracey Bastian

Background: The use of systemic corticosteroids for acute chronic obstructive pulmonary disease (COPD) exacerbation has been associated with shortened recovery time, improvement in FEV1, decreased patient length of stay, and the prevention of treatment failure; however, differences in patient outcomes using varying corticosteroid dosing strategies has yet to be demonstrated in large scale randomized controlled trials. The purpose of this study is to compare the effects of corticosteroid dosing strategies on outcomes in acute COPD exacerbation.

Methods: This was a single-center, IRB exempt, retrospective chart review study. All patients selected for data extrapolation were hospitalized at Williamson Medical Center within the dates of September 1st, 2024 and September 1st, 2025. Patients were extrapolated for data collection utilizing the ICD diagnosis code for acute COPD exacerbation (J44.1). Patients were evaluated in a 1:1 ratio based upon the amount of cumulative prednisone equivalents they received within 48 hours of admission (>1.5 mg/kg of prednisone equivalents versus ≤1.5 mg/kg prednisone equivalents). Weight based grouping was utilized to account for the varying nature of physician preference in terms of systemic corticosteroid selection. Primary endpoints included total hospital length of stay and readmission rate within 30 days for recurrent COPD exacerbation. Secondary endpoints included need for mechanical intubation and change in oxygen requirements at discharge. Lastly, safety endpoints included: incidence of hyperglycemia, severe hyperglycemia, and nosocomial infection.  In total, 208 patients were identified for data collection. After exclusion, 128 patients were included for data extrapolation. Fisher’s t-test calculations were utilized to determine statistical significance for nominal and ordinal data. Mann-Whitney- U calculations were utilized when evaluating the statistical significance of continuous variables.

Results: In total 128 patients were included for analysis. 71 patients were assigned to the >1.5 mg/kg prednisone equivalents group and 57 patients were assigned to the ≤1.5 mg/kg prednisone equivalents group. Baseline characteristics were similar between the two groups, with the exception of weight (>1.5 mg/kg: 89.4kg vs ≤1.5 mg/kg: 68.6kg), BMI (>1.5 mg/kg: 29.9 kg/m2 vs ≤1.5 mg/kg: 24.2 kg/m2), and cumulative prednisone equivalents distribution (>1.5mg/kg: 318mg vs ≤1.5 mg/kg: 600mg). These baseline characteristics were determined to be statistically significantly different between groups. For primary outcomes, the utilization of >1.5 mg/kg prednisone equivalents within 48 hours of patient admission resulted in an average patient length of stay of 4.62 days and 6 instances of readmission for subsequent COPD exacerbation. In comparison, patients who received ≤1.5 mg/kg within 48 hours of admission were found to have an average length of stay of 5.58 days and 4 instances of readmission for subsequent COPD exacerbation. Differences between groups for both length of stay (U = 1781.5, p =0.123) and repeat admission for exacerbation (p = 1.00) were found to be statistically insignificant. For secondary endpoints, need for mechanical intubation (p = 1.00) and change in oxygen requirement at discharge (p = 0.562) were found to be similar between groups. Lastly, safety endpoints of hyperglycemia incidence (p = 1.00), severe hyperglycemia incidence (p = 0.196), and nosocomial infection incidence (p = 0.323) were determined to be similar among groups.
 
Conclusions:  There were no statistically significant differences in hospital length of stay or 30 day readmission rates in patients receiving >1.5 mg/kg prednisone equivalents when compared to  ≤1.5 mg/kg prednisone equivalents within 48 hours of admission for acute COPD exacerbation.  Secondary endpoints, including need for mechanical intubation and change in oxygen requirements at discharge, as well as safety endpoints, were similar between groups. Additional evidence from larger cohorts would be valuable in evaluating outcomes associated with varying corticosteroid dosing strategies in this patient population.   

Clearing the Air: Impact of a Pharmacist-led Pulmonary Medication Management Clinic 
 
Chloe Warren, Christopher Rogers, Lauren Young, Danielle Dennis, Sabrina Fineberg, Dana Walters, Kellie Ball 
University of Tennessee Medical – Knoxville, TN 
 
Purpose: To evaluate the impact of a pharmacist-led medication management clinic, providing patient education and specialty medication access support in the setting of high costs, insurance and PBM restrictions, and limited pharmacy networks that contribute to treatment delays 

Methods: This retrospective chart review consists of 172 patients who are active patients with the pharmacist-led medication management clinic services between December 2023 and June 2025. Eligible patients were 18 years or older, had at least one documented visit with a clinical pharmacist, carried a diagnosis of asthma, chronic obstructive pulmonary disease, or interstitial lung disease, and were referred by a pulmonologist for medication education and access assistance. The primary outcome looked at the percentage of days covered for medications filled at a health-system specialty pharmacy. Secondary outcomes included the total time to treatment measured in days. Additional data collection included the pulmonary disease state of the patient and initial visit billing code utilized. 

Results: Overall, 90.6% of patients achieved greater than 90% of days covered (PDC), which is above the standard metric of 80% for specialty medication adherence. As for the secondary outcome, the average time to treatment was 2.17 days.  

Conclusion: Overall, this study reinforces the expanding role of clinical pharmacists in specialty care delivery models. By addressing both clinical and administrative barriers, pharmacists are uniquely positioned to improve access, adherence, and overall quality of care for patients receiving specialty medications. Their involvement not only supports patients but also alleviates workload burdens for providers and enhances coordination across the healthcare system.

Link: https://docs.google.com/document/d/e/2PACX-1vS6hc93X09DzHIrP9LAM05FIvxd6iYh9am_wF7kl1NMMFZyVzSKUCQQS2gGv_oCROiAuk2Ht5MxuwF-/pub

 
Authors: Seana-Pierre Williams, Jaleesa Myers 
Wellstar Cobb Medical Center, Austell, GA 
 
Purpose: Left ventricular thrombus (LV thrombus) is a complication arising from left ventricular dysfunction, secondary to acute myocardial infarction or nonischemic cardiomyopathies. The current standard of care for the management of LV thrombus involves anticoagulation with warfarin, a vitamin K antagonist (VKA). While large-scale randomized controlled trials comparing the efficacy of direct oral anticoagulants (DOACs) to VKAs in this context are lacking, several retrospective analyses have demonstrated that DOACs may be non-inferior to VKAs with respect to mortality, incidence of stroke, and thrombus resolution. However, controversy remains regarding the off-label use of DOACs for this indication. The primary objective of this study is to evaluate the safety and efficacy of DOACs in comparison to warfarin in patients diagnosed with LV thrombus, and to assess anticoagulant prescribing patterns in the management of LV thrombus within Wellstar Health System.  
 
Methods: This study was a multicenter, retrospective chart review. Patients admitted to Wellstar Health System with a diagnosis of intracardiac thrombus (ICD-10 codes: I51.3 or I23.6), aged 18 years and older, and received either a DOAC (apixaban, rivaroxaban) or VKA (warfarin) for the management of LV thrombus were eligible for inclusion in this study. Data was collected from electronic medical records between January 1, 2023, and January 1, 2025. The target sample size was 100 patients, with 50 patients in each treatment cohort. Data was collected on the first 100 patients to meet the inclusion criteria within the specified time frame. The primary outcome of this study is the incidence of thromboembolic events, defined as recurrent left ventricular thrombus, stroke, or systemic embolism occurring within 90 days of treatment initiation. Secondary outcomes include left ventricular thrombus resolution within 90 days, hospital length of stay, incidence of bleeding events requiring blood transfusion within 90 days, and 30-day hospital readmission rates. 
 
Results: A total of 100 patients diagnosed with LV thrombus were included in this study. Fifty patients received warfarin and 50 received a DOAC. Of the patients prescribed a DOAC, 5 received rivaroxaban and 45 received apixaban. There was no statistically significant difference in the composite outcome of the incidence of thromboembolic events within 90 days between the warfarin and DOAC groups. There were no statistically significant differences between the warfarin and DOAC groups when comparing the rate of stroke (0% vs. 0%) and systemic embolism (2% vs. 4%). No recurrent LV thrombus within 90 days of treatment initiation were noted in either treatment groups. There were no bleeding events requiring blood transfusions within 90 days. The median length of hospital stay was 10 days (IQR 7–17) in the warfarin group versus 9 days (IQR 4–13) in the DOAC group with no statistically significant difference between groups. Thirty-day hospital readmission rates did not differ significantly between the groups.  
 
Conclusion: Based on the results of this study, DOACs may be as safe and efficacious as warfarin for the management of LV thrombus. This data underscores the importance of further large-scale, randomized controlled clinical trials to inform treatment decisions. Currently, the choice between warfarin and DOACs is informed by limited comparative data. However, both pharmacologic treatment options are used in clinical practice. 
 

Author's Names: Morgan Keller, PharmD; Susan Smith, PharmD, BCCCP, FCCM, FCCP; Madison Wiklund, PharmD Candidate 2027; Marlie Windgate, PharmD Candidate 2027; John Carr, PharmD, BCPS, BCCCP

Background:
Anesthetics such as propofol and midazolam can contribute to fluid retention and reduce diuretic responsiveness in the perioperative setting. It is unclear whether this same effect occurs in critically ill patients, and if alternative sedatives could mitigate such a risk. The goal of this study is to determine whether the use of dexmedetomidine, propofol, or midazolam is correlated with a difference in the incidence of fluid overload and diuretic resistance in critically ill patients who are mechanically ventilated in the intensive care unit.

Methods:
This investigation is a single center, retrospective, observational cohort study evaluating mechanically ventilated patients for differences in fluid balance and diuretic use while receiving propofol, midazolam, or dexmedetomidine during mechanical ventilation. Patients were grouped by primary sedative agent and data pertaining to baseline demographics, illness severity, and comorbidities were collected. Patients were excluded for pregnancy, acute/severe neurologic disorder, simultaneous use of multiple sedatives, Child-Pugh class C liver failure, dialysis or continuous renal replacement therapy at the time of initiating sedative, and/or patients who underwent surgery or procedure with sedation during the study period or within 72 hours prior. The primary outcome of fluid balance is measured as net fluid balance 72 hours after sedation initiation. Daily fluid input and output, diuretic dosing, hemodynamic parameters (mean arterial pressure, blood pressure, and heart rate), and electrolyte laboratory values were collected from patient electronic medical records. Statistical analysis was performed by multivariable regression to adjust for potential confounders, including chronic kidney disease and home diuretic use.

Results:
Twenty patients were enrolled in this study, including 8 receiving midazolam, 11 receiving propofol, and 1 receiving dexmedetomidine. Baseline characteristics were similar across age, baseline creatinine, peak creatinine, creatinine clearance, and Glasgow coma score. The primary outcome of this study is net fluid balance at 72 hours, and showed no statistically significant difference between groups (midazolam 2212.3 mL [1084.7-7601], propofol 3286 mL [1266-11032], and dexmedetomidine 8915 mL; p=0.475). Secondary outcomes including furosemide diuresis equivalents, urine output, ventilator free days at day 14, ICU length of stay, and vasopressor requirements at day 14 showed no difference across sedative groups. Additionally in multivariable analyses, no significant differences were observed between midazolam, propofol, and dexmedetomidine in SOFA scores, CrCl, and total furosemide diuresis equivalents.

Conclusions:
In this study of mechanically ventilated intensive care unit patients, there were no significant differences in fluid balance at 72 hours in patients receiving midazolam, propofol, or dexmedetomidine. Secondary outcomes including ventilator free days, ICU length of stay, and vasopressor requirements were also similar across the three sedation groups. Potential limitation factors include feasibility and exclusion criteria of multiple simultaneous sedatives and dialysis, considering the acuity of the patient population studied. Future directions should target a larger study group with less stringent exclusion factors to confirm this finding.

Title: Evaluation of Guideline-Recommended Duration of Levetiracetam Prophylaxis Prescribed in Patients After Traumatic Brain Injury
Authors: Michael Kim, Kameron Hicks, Rachel Friend, Donley Galloway
Background: Traumatic brain injuries (TBI) may lead to early post-traumatic seizures (PTS), especially in instances of severe TBI and to a lesser extent in mild to moderate TBI. Early PTS are mechanistically distinct from late PTS and most often occur within seven to fourteen days of the inciting TBI. They are associated with poor morbidity and mortality outcomes. Recent guidelines by the Neurocritical Care Society suggest that there is no statistical difference in the reduction of early seizures with or without the use of antiseizure medications. However, levetiracetam is commonly used as seizure prophylaxis due to its favorable adverse drug effect profile. The use of antiseizure medications for a shorter duration of time of ≤ 7 days is recommended because the studies have identified no statistical difference with longer duration of antiseizure medication therapy and worse adverse effect incidence. As the use of prophylactic levetiracetam provides limited benefits in preventing early seizures, the purpose of this study is to evaluate its current prescribing practices to potentially provide evidence to support standardized as lengthy duration and high dose is not well supported by current evidence.
Methods: This was an IRB approved single-centered, retrospective evaluation of adult patients diagnosed with traumatic brain injury and given levetiracetam as seizure prophylaxis who were admitted to one of four inpatient neurologic or trauma units between June 1, 2025, to May 31, 2025. Patients were excluded if they had any prior history of seizures, on any maintenance antiepileptic medications, used any other antiepileptic medications for seizure prophylaxis, or were prisoners. The primary outcome of this study was the rate of guideline recommended duration of levetiracetam prophylaxis. Secondary outcomes included documented seizure activity within the encounter, dose and frequency of levetiracetam used as prophylaxis, number of patients discharged home with levetiracetam, and any documented CNS or hypersensitivity reactions from levetiracetam. The collected data was analyzed using descriptive statistics and chi-square test.
Results: A total of 111 patients were included. The rate of guideline recommended duration of levetiracetam for seizure prophylaxis after TBI was 43.2% (n=48/111. The rate of guideline directed duration of therapy in just the inpatient days of prophylactic therapy yielded 82% (n=91/111). Within the subgroups, the rate of guideline directed duration of therapy was 47.4% (n=27/57) in the STICU, 48.6% (n=17/35) in the NICU, 18.2% (n=2/11) in E5, and 25% (n=2/8) in E4. The frequency of the maintenance prophylaxis was twice daily dosing. The doses administered inpatient were varied, but was most commonly 500 mg twice daily (63.1%, n=71/111). The number of those discharged on levetiracetam was 51.4% (n=57/111) with durations ranging from 1-90 days and doses ranging from 500mg-1000mg. Possible CNS effects from levetiracetam was seen in 21 patients (18.9%). One patient (0.9%) had evidence of seizure activity.
Conclusions: Guideline recommended duration of levetiracetam as early post-traumatic seizure prophylaxis was seen in less than half of the patients within this institution’s main trauma and neurologic units when accounting for both initial inpatient and outpatient continuation of prophylactic therapy. Most patients in the inpatient setting received the recommended duration of therapy of seven days or fewer, but prescription orders at discharge for prophylaxis up to 90 days were observed. With the only seizure having been seen in the severe TBI patient, potential adverse drug effects seen, and long duration of prophylaxis that the majority of these patients received, more conservative management with seizure prophylaxis may be warranted. Future studies that evaluate the seizure incidence between evidence supported shorter duration of therapy and extended duration of therapy may contribute to the potential de-prescribing efforts of pharmacists.

Contact Information: [email protected]

The purpose of this study was to evaluate the effect of a pharmacist-led transitions of care (TOC) consult service, specifically designed to address medication access barriers, on patients undergoing inpatient percutaneous coronary interventions. The study sought to assess the program’s impact on medication adherence and hospital readmission rates at 30- and 90-days post-discharge, while also contextualizing these outcomes within the existing body of literature. This retrospective study evaluated the impact of pharmacist-led interventions during TOC consults on medication adherence and hospital readmission. The study period extended from April 1, 2023, through April 1, 2025, providing a two-year window to ensure adequate patient capture. Data were extracted from the electronic health record and entered into REDCap, with all protected health information excluded to maintain confidentiality and compliance with institutional review standards. The primary outcome was the first-fill rate of antiplatelet medications among patients admitted under the post–coronary artery stent pathway who underwent percutaneous coronary intervention during their inpatient stay at this academic medical center, assessing whether pharmacist engagement improved timely medication initiation in a population at elevated cardiovascular risk. Secondary outcomes included 30-day and 90-day readmission rates, documentation of pharmacist clinical interventions across inpatient and outpatient settings, and the type of medication access support provided to patients who filled their antiplatelet prescriptions at the hospital’s affiliated outpatient pharmacy at discharge, providing additional insight into the broader impact of pharmacist involvement during care transitions. The primary endpoint was analyzed using a chi-square test, and descriptive and inferential statistics were applied to secondary outcomes as appropriate. Collectively, this study aimed to characterize the role of pharmacists in optimizing medication use, reducing readmissions, and improving outcomes for patients undergoing percutaneous coronary intervention.

• Title: Impact of docusate de-implementation on invasive laxative use in intensive care unit patients with thoracic trauma
• Authors: Isaiah Hicks, Blake Henderson, Spencer Roper, Amanda McKinney
• Objective: Explain the impact of docusate de-implementation and consider benefits to patients and institutions.
• Self-Assessment Question: Which of the following are reasons that contribute to the use of docusate in many institutions? Select all that apply.
• Background: The purpose of this study is to establish if the de-implementation of docusate from opioid pathways reduced the use of invasive laxatives in trauma surgical intensive care unit patients with thoracic trauma.
• Methods: The primary outcome of this retrospective chart review was the use of invasive laxatives such as rectal suppositories (i.e. glycerin, bisacodyl) and enemas (i.e. sodium phosphate; lactulose; admixture of saline, mineral oil, glycerin). Mean number of non-invasive laxatives (e.g. polyethylene glycol, senna, magnesium citrate), intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), and morphine milligram equivalents (MMEs) were secondary outcomes. Patients were divided into pre-removal and post-removal groups.
• Results: In this study, 378 patients were screened, and 160 patients were included in statistical analysis. There was no statistically significant difference in invasive laxative use between pre- and post-removal groups (30.9% vs 27.3%, p = 0.62). There was no statistically significant difference in mean number of non-invasive laxatives used (1.45±0.6 vs 1.48±0.5, p = 0.52), mean HLOS (8.1±5.2 days vs 8.2±5.5 days, p = 0.73), or mean MMEs (31.3±54.3 vs 39.4±42.7, p = 0.07). Mean ICU LOS was statistically significant between the pre- and post-removal groups (3.3±2.1 days vs 2.8±2.2 days, p = 0.04).
• Conclusion: A reduction in invasive laxative use after the removal of docusate from opioid order pathways was not established, likely due to limited sample size. Notably, removal was associated with shorter ICU LOS. Further analysis focusing on financial impact would provide insight into potential cost savings and decreasing pill burden.
• (Link to Abstract Document)

Impact of GLP-1 and GLP-1/GIP Receptor Agonists on Perioperative Glycemic Control in Arthroplasty

Authors: Julia Sitek, Charles Hartis, Zachary Klick, Minal Patel, Amit Saha, Ashley Talbott, Sarah Kittner, Emily Schaefer 

Objective: Describe the effect of GLP-1 and GLP-1/GIP receptor agonists on perioperative blood glucose levels. 

Background:  
Obesity and type 2 diabetes (T2DM) are well-established risk factors for osteoarthritis, a leading cause of joint degeneration requiring arthroplasty. Both conditions, along with perioperative hyperglycemia, have been associated with worse postprocedural outcomes and increased risk of mortality.  Glucose-like peptide-1 (GLP-1) and GLP-1/glucose-dependent insulinotropic polypeptide receptor agonists (GLP-1/GIP RA) are becoming increasingly popular due to their indications for T2DM and weight management. Perioperative management of GLP-1 and GLP-1/GIP RAs, specifically the optimal holding duration in surgery, remains controversial. Case reports describing intraoperative aspiration events have prompted recommendations to hold these agents before surgery. Conversely, emerging evidence suggests potential benefits of continuing these medications preoperatively, including improved metabolic outcomes. Given their long-half-lives, these agents may continue to confer glycemic benefits even when held; however, withholding them may increase the risk of perioperative hyperglycemia. Therefore, the purpose of this study is to determine the effect of GLP-1 and GLP-1/GIP RAs on perioperative glycemic control in patients undergoing arthroplasty.  

Methods: 
This multicenter, retrospective, cohort study compared the incidence of perioperative hyperglycemia in patients with T2DM with or without a GLP-1 or GLP-1/GIP RA. Patients 18 years and older with T2DM who underwent primary elective total knee or hip arthroplasty and had available preoperative and postoperative blood glucose data were included in this study. Those with type 1 diabetes, an operative diagnosis of periarticular knee or lower extremity fracture, an American Society of Anesthesiologists classification of 4 or higher, or a need for general anesthesia were excluded. The primary outcome was the percentage of patients with preoperative and postoperative blood glucose levels of 180 mg/dL or greater. Secondary outcomes include any incidence of a hyperglycemic event during admission, 30-day incidence of prosthetics joint infections (PJI) and surgical site infections, incidence of aspiration or regurgitation during procedure, postoperative nausea and vomiting, and 30-day all-cause mortality. Data collection includes baseline demographics, hospitalization characteristics, and drug characteristics, specifically the agent, dose, and time withheld before surgery. Descriptive statistics were used to summarize the incidence of the primary outcome. Inferential statistics were analyzed using Student-t tests for continuous endpoints and Chi-square tests for categorical endpoints. 

Preliminary Results: Among patients undergoing total knee or hip arthroplasty across five hospitals between March 2, 2024 and September 1, 2025, 104 patients were included in the analysis. The cohort was 53.8% female with a mean age of 69 years, mean A1c of 6.5%, and mean BMI of 32.65 kg/m². Preoperatively, 42.3% were on a GLP‑1 or GLP‑1/GIP RA preoperatively. The primary outcome occurred in one (2.3%) patient on a GLP‑1 RA and one (1.7%) patient not receiving a GLP‑1 or GLP‑1/GIP RA preoperatively [OR of 1.37 (95% CI : 0.08 – 22.55, P-Value 0.82)]. The secondary outcome of any event of hyperglycemia during admission occurred in 19 (43.2%) patients receiving a GLP‑1 or GLP-1/GIP RA and 24 (40%) patients not receiving a GLP‑1 or GLP‑1/GIP RA [OR 1.14 ( 95% CI : 0.51 – 2.51, P- Value 0.74)]. Among GLP‑1 or GLP‑1/GIP RA users, the mean duration of medication hold prior to surgery was 10 days. No patients experienced a surgical site infection, PJI, or aspiration/regurgitation event during the study period.  

Conclusion: Holding GLP-1 or GLP-1/GIP RAs for elective total knee or hip arthroplasties does not affect perioperative glycemic control. The benefit of holding GLP-1 or GLP-1/GIP RAs for primary elective arthroplasty may outweigh the risk as no statistically significant increase in incidence of hyperglycemia was observed.

Valproic Acid for Seizure Prophylaxis and Reduction of Headache Burden Following Subarachnoid Hemorrhage
Michael Wagner, Kristin Lanier, Jenna Sorgenfrei

Background:  
Aneurysmal subarachnoid hemorrhage (aSAH) management includes possible surgical intervention, blood pressure control, management of hydrocephalus, vasospasm prevention, and seizure prophylaxis. Guidelines do not currently recommend a specific seizure prophylaxis agent for aSAH. Levetiracetam is commonly selected in favor of the benign side effect profile and overall patient tolerability, yet it does not address any additional symptoms of aSAH. Valproic acid not only provides seizure prophylaxis but has demonstrated benefits in both migraine prophylaxis and headache treatment. The objective of this study is to determine if switching from levetiracetam to valproic acid reduces headache burden in patients based on utilization of pain medication for breakthrough symptoms  

Methods: 
A single-center, retrospective, cohort study identified adult patients admitted to the neurological intensive care unit of Prisma Health-Upstate between September 1, 2023 to September 1, 2025 with a diagnosis of aneurysmal subarachnoid hemorrhage. Seizure prophylaxis with levetiracetam was compared to valproic acid to determine the difference in overall headache burden based on breakthrough pain medication administration. Secondary outcomes include seizure incidence, intensive care unit length of stay, transcranial doppler changes, and incidence of adverse effects 

Results: 
A total of 115 patients were included with 66 in the levetiracetam group and 49 in the valproic acid group. Patients were prescribed similar pain regimens including scheduled gabapentin, lidocaine patches, and acetaminophen as needed in both the valproic acid group and levetiracetam (39.4% vs. 67.3%). For the primary outcome of daily headache incidence, there was a statically significant difference in favor of the levetiracetam group (3.0 vs. 2.4, P = 0.02). Additionally, patients in the valproic acid group demonstrated more frequent use of both as needed and breakthrough pain medication utilization. No differences were found in adverse effects.  

Conclusions:
Seizure prophylaxis with valproic acid did not reduce headache incidence or pain medication utilization following nontraumatic subarachnoid hemorrhage. These findings support the use of either valproic acid or levetiracetam as seizure prophylaxis, with no added benefit seen in the valproic acid group.  


Resident Contact: [email protected]

Impact of Education on Subcutaneous Electronic Glucose Management System Usage in a Community Hospital
Makenzie Foster & Taylor Riedel-Rogers

Background:
The American Diabetes Association recommends using basal/bolus insulin for the management of hyperglycemia in non-critically ill hospitalized patients.1 The incidence of hypoglycemia while on a basal/bolus insulin regimen in the hospital setting can be as high as 33%.2 A hypoglycemic event during admission has been shown to increase mortality rates, complications, and hospital length of stay.1 The use of electronic glucose management systems (eGMS) in hospitalized patients has been shown to decrease incidence of hypoglycemia compared to those managed solely by providers.3 Additionally, patients managed by eGMS were found to have a higher percentage of blood glucose levels within target range compared to traditional provider management.4 Baptist Health Lexington implemented a subcutaneous glucose management system in 2022. This study aims to assess the duration of subcutaneous eGMS use prior to and following a single session of subcutaneous eGMS education to pharmacists and nurses at Baptist Health Lexington.

Methods:
This study is an IRB-approved study where a pre-post analysis of subcutaneous eGMS duration is conducted following a single session of eGMS education. A retrospective review of patient charts will be conducted on patients who received blood glucose management through eGMS at Baptist Health Lexington prior to implementing a single session of pharmacist and nurse education from 03/01/2025 to 08/31/2025. Additionally, a retrospective review of patient charts will be conducted following the implementation of eGMS education from 10/01/2025 to 03/31/2026 for those managed by subcutaneous eGMS. The primary endpoint of this study is the duration of subcutaneous eGMS use following a single session of pharmacist and nurse eGMS education. The secondary endpoints are the number of patients transitioning from intravenous to subcutaneous eGMS, the incidence of hypoglycemic events and the total number of patients managed by subcutaneous eGMS.

Results: 
The retrospective analysis identified 101 patients in the pre-intervention group and 66 patients in the post-intervention group. Following a single session of pharmacist and nurse subcutaneous eGMS education, the duration of subcutaneous eGMS was found to be statistically significant (p-value 0.025). The incidence of hypoglycemic events was 7 out of 101 patients in the pre-intervention group and 3 out of 66 patients in the post-intervention group (p-value 0.73). The number of patients transitioning from intravenous to subcutaneous therapy was 33 out of 101 in the pre-intervention group and 19 out of 66 in the post-intervention group. 

Conclusion: 
Pharmacist and nurse subcutaneous eGMS education resulted in a statistically significant increase in the duration of subcutaneous eGMS therapy. However, a statistically significant difference was not found for the incidence of hypoglycemic events or number of patients transitioning from intravenous to subcutaneous therapy following a single session of pharmacist and nurse education. There are still opportunities for improvement in the utilization of subcutaneous eGMS at Baptist Health Lexington and further education on eGMS is currently being pursued at a system level.

References:
1. El Sayed, Nuha A., et al. “16. diabetes care in the hospital: standards of care indiabetes—2024.” Diabetes Care, vol. 47, no. Supplement_1, 11 Dec. 2023, https://doi.org/10.2337/dc24-s016.
2. Aloi, Joseph, et al. “Comparison of an electronic glycemic management system versus provider-managed subcutaneous basal bolus insulin therapy in the hospital setting.” Journal of Diabetes Science and Technology, vol. 11, no. 1, 25 Sept. 2016, pp.12–16, https://doi.org/10.1177/1932296816664746.
3. Bouldin, Mary Grace, et al. “Evaluation of the efficacy and safety of an EGLYCEMIC management system in a community hospital setting.” Journal of Diabetes Science and Technology, vol. 15, no. 2, 16 Dec. 2020, pp. 236–241, https://doi.org/10.1177/1932296820980026.

Resident Contact Information:
Makenzie Foster, PGY1 Pharmacy Resident
Email: [email protected]

Purpose/Background: Euglycemic diabetic ketoacidosis (EDKA) falls under the umbrella of diabetic ketoacidosis (DKA) and can occur in patients with type 1 or type 2 diabetes mellitus. EDKA is thought to be caused by a renal threshold for glucosuria that is lower due to increased gluconeogenesis and free fatty acid metabolism. A common medication class prescribed to patients with diabetes mellitus, sodium-glucose cotransporter-2 (SGLT2) inhibitors, are thought to inhibit both glucose and sodium resorption at the renal proximal tubule which leads ultimately to glucosuria and negative fluid balances. These mechanisms lead to a loss of bicarbonate and cause ketogenesis, which ultimately leads to EDKA. The purpose of this study is to evaluate the effect of pharmacy monitoring on the appropriate clinical courses in patients on sodium-glucose cotransporter-2 inhibitors who are admitted for euglycemic diabetic ketoacidosis in a regional medical center.
Methodology: Data will be collected based on a pre- and post-evaluation of the electronic medical record. Prospective data collection will be done through a daily report of patients that are greater than or equal to 18 years old, admitted to CaroMont Regional Medical center, have an SGLT2 inhibitor on their prior to admission medication list, and have a diagnosis of diabetes on their hospital problem list. Patients will be excluded if they are less than 18 years old, have no diagnosis of diabetes mellitus, have a glucose on admission that is > 250 mg/dL, are pregnant or incarcerated. Once the daily report is run, the clinical pharmacist will ensure the correct lab values and medications are ordered. If a patient meets EDKA criteria, a clinical pharmacist will evaluate the need for additional evaluation, including β-hydroxybutyrate, to strengthen diagnostic criteria and guide potential treatment. Retrospective data collection will be done through the collection of pre-specified criteria and analysis of the treatment course in patients that presented with EDKA. Both data sets will be taken from the same months, one year apart. The data sets will be compared to assess the effectiveness of pharmacy interventions. The primary endpoint of the study will be the time to resolution of euglycemic diabetic ketoacidosis. Time to insulin infusion, length of stay, number of admissions, and number of clinical pharmacist interventions will also be assessed.  
Results: Pending 
Conclusions: Pending
Presentation Objective: To describe the benefit of pharmacy interventions in the treatment course of patients that present with euglycemic diabetic ketoacidosis secondary to receiving sodium-glucose cotransporter-2 inhibitors for management of their diabetes prior to admission.  
Self-Assessment: What are the criteria for a diagnosis of euglycemic diabetic ketoacidosis?
Authors: Rylee Williams, Joe Norton, Joanna Nixon

Title 
Evaluating Vancomycin AUC Monitoring in Adult Cystic Fibrosis Patients 
 
Authors 
Taylor J. Merritt, Carrie Tilton Callahan, Kelly Soyeong Ko, Cynthia Shin-Yee Tsai, Heidi King Berman, Nicole L. Metzger  
 
Practice Site 
Emory University Hospital 
 
Objective  
Audience members will be able to evaluate the impact of AUC-based vancomycin monitoring on therapeutic target attainment and safety outcomes compared with traditional trough-based monitoring in adult patients with cystic fibrosis (CF)  
 
Background  
Area under the curve (AUC)–based vancomycin monitoring is recommended to improve efficacy and reduce nephrotoxicity. However, evidence supporting its use in adult people with cystic fibrosis (PwCF) remains limited.  
 
Methods  
This single-center, retrospective observational study included hospitalized adults with CF who received intravenous vancomycin and at least one appropriately drawn vancomycin level. Patients were excluded if they were pediatric, pregnant, incarcerated, had unstable renal function, or did not have vancomycin for > 48 hours. Encounters were grouped based on strategy: AUC or trough-based monitoring. Therapeutic targets were defined as: AUC of 400–600 mg·hr/L or trough of 15–20 mg/dL. Primary outcome was the proportion of encounters achieving therapeutic targets at first appropriate level. Secondary outcomes included time to therapeutic target attainment, number of regimen adjustments, length of hospital stay, and incidence of acute kidney injury. An exploratory analysis was conducted by reclassifying patients in the trough-based group who met institutional AUC-dosing criteria and assessing whether therapeutic targets would have been achieved when using an institutional AUC calculator.   
 
Results  
A total of 43 encounters representing 27 patients met inclusion criteria, with 16 encounters in the AUC-based group and 27 in the trough-based group. Therapeutic exposure targets at first level draw were achieved in 37.5% of AUC-monitored encounters compared to 14.8% of trough-monitored (p-value 0.14). Mean time to therapeutic target attainment was similar between groups, and no cases of acute kidney injury occurred in the AUC group compared to 7.4% in the trough-based group. Length of hospital stay and number of vancomycin levels collected were comparable between strategies. In the exploratory analysis, patients regrouped from trough to AUC demonstrated 48.3% therapeutic targets at initial draw compared to 0% in the trough-based group. 
 
Conclusions  
AUC-based vancomycin monitoring did not demonstrate a statistically significant improvement over trough-based monitoring in adults with cystic fibrosis; however, a trend toward improved therapeutic target attainment and no increase in nephrotoxicity was observed. These findings support consideration of AUC-based monitoring in this population and add to the limited data available for adult patients with cystic fibrosis. 
 
Self-Assessment Question 
Which statement best reflects the findings from this study?  
A) AUC-based monitoring significantly reduced AKI in PwCF   
B) AUC-based monitoring significantly improved target attainment   
C) Trough-based monitoring resulted in fewer regimen changes   
D) AUC-based monitoring demonstrated a trend toward improved target attainment without increasing AKI 
 
 
Contact Email 
[email protected] 

Background: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following traumatic injury. Trauma patients are at an increased risk for VTE secondary to dysregulation of the coagulation system, reduced mobility, and the type of traumatic injury. Low molecular weight heparin (LMWH) is the drug of choice for VTE prophylaxis in this population because of its increased bioavailability, longer half-life, and predictable pharmacokinetics. Subcutaneous heparin is alternatively recommended for patients with a creatinine clearance less than 30 mL/min or with end stage renal disease on hemodialysis. Timely initiation of appropriate VTE prophylaxis is crucial to preventing fatal complications in trauma patients. VTE prophylaxis must be initiated early and continue throughout the admission without missing doses for orthopedic and most other surgical procedures. Limited guidance has been established and VTE prophylaxis strategies generally rely on institutional protocol and surgeon’s discretion. Given the challenges of balancing bleed risk and VTE prevention, there is a need for a standardized protocol guided VTE prophylaxis in trauma patients. The purpose of this study was to determine the impact of implementing a VTE prophylaxis protocol in trauma patients admitted to the intensive care unit.

Methods: This was an observational, pre-post study completed at Piedmont Columbus Regional Midtown in Columbus, GA during two independent time periods. The primary objective of this study was to determine rate of compliance with evidence based VTE prophylaxis in the pre-implementation group compared to the post-implementation group, including appropriate dose of VTE prophylaxis, time to administration of VTE prophylaxis, and time to perioperative re-initiation of VTE prophylaxis. The secondary objectives were incidence of VTE, incidence of major bleeding, number of initial anti-Xa levels in goal for patients who received LMWH, and days needed to achieve goal anti-Xa level for patients who received LMWH. The primary outcome was analyzed using Chi-square test and the secondary outcomes were analyzed using either Chi-square test or Fisher's exact test. Patients were excluded if their length of stay was less than 24 hours, they were pregnant, had coagulopathy on admission, clinical signs of ongoing hemorrhage, had an indication for therapeutic anticoagulation on admission, or traumatic brain injury meeting high-risk Modified Berne-Norwood Criteria.

Results: For the primary objective of protocol compliance for VTE prophylaxis, 25% of patients in the pre-group met compliance with the protocol versus 41% in the post-group. For secondary objectives, three patients in the pre-group had a VTE occurrence whereas none did in the post-group. Six patients in the pre-group had an incidence of major bleeding, compared to none in the post-group. Only 10 patients in the pre-group had anti-Xa level monitoring obtained and 13 patients in the post group. Of which, 40% had an initial anti-Xa at goal in the pre-group versus 54% in the post-group. The days needed to achieve anti-Xa goal was also not significantly different after implementation of the protocol.

Conclusion: Implementation of a standardized VTE prophylaxis protocol improved appropriate selection of dose and time to initiation without increasing frequency of bleeding.

Contact: [email protected]

Background: Anticoagulation therapy in hospitalized patients is inherently high-risk with complex dosing requirements and significant potential for drug interactions. Heparin is an anticoagulant that utilizes laboratory monitoring to target therapeutic concentrations, but accuracy of anti-Xa levels can be falsely elevated due to recent direct oral anticoagulant (DOAC) exposure. Our practice advisories (OPAs) are utilized within the electronic health record (EHR) to improve clinical decision-making and advance patient safety. The study site employs OPA alerts to identify elevated anti-Xa levels in patients who may have had recent exposure to a DOAC with the goal of helping practitioners decide if a reagent that removes DOAC effect on anti-Xa (DOAC-StopTM) should be utilized.  The objective of this study was to analyze the impact of an OPA for elevated anti-Xa levels in patients receiving heparin infusions with recent potential or known DOAC exposure, focusing on clinical appropriateness of DOAC-StopTM utilization and safety outcomes. 
Methods: This single center, retrospective cohort study analyzed patients with an elevated anti-Xa OPA alert(s) between January 1st and April 3rd, 2024 focusing on clinical appropriateness and safety outcomes. OPAs alerted for patients who were on a heparin infusion, had an elevated anti-Xa ≥ 1, and were within three days of admission or had documented receipt of a DOAC within the previous five days. Exclusion criteria included pregnancy, incarceration, switching between heparin protocols during the admission, and administration of enoxaparin within 24 hours of the elevated anti-Xa. The primary outcome assessed the appropriateness of subsequent actions in response to the OPA. Appropriateness was defined based on a treatment flowchart developed for study. Secondary outcomes included incidence of bleeding within 24 and 48 hours of the alert(s) per the International Society on Thrombosis and Haemostasias (ISTH) bleeding criteria and a subgroup analysis of DOAC-StopTM utilization by level of care and nursing shift. 
Results: A total of 100 patients were included in the final analysis. At baseline, 46% of patients were receiving apixaban, 6% rivaroxaban, and 48% were not receiving any anticoagulant within the 72 hours prior to heparin initiation. Clinical use of DOAC-StopTM following the first OPA was deemed appropriate for 92% of initial advisories and inappropriate for 8%. Inappropriate use, according to the study-developed flowchart, included administering DOAC-Stop™ to patients without prior DOAC exposure and omitting it in high-risk patients with prior exposure. There was no statistically significant difference between appropriate clinical use based on time of shift (p = 0.426) or by level of care (p = 0.119). Bleeding events were mostly attributable to clinically relevant non-major bleeding or major bleeding defined as a hemoglobin decrease of 2 mg/dL or more that required no clinical intervention. These events occurred within 0-24 hours in 11% of patients and within 0-48 hours in 18% of patients.  
Conclusions: While the true effect of this OPA is difficult to discern given lack of a control group, the high level of appropriate advisory response indicates that it was successful in identifying potential candidates for DOAC-StopTM and ensuring that high-risk patients received adequate anticoagulation evaluation. Practice advisories and protocols do not account for every scenario, and clinical judgement must be utilized to determine candidacy for DOAC-StopTM.