2026 Southeastern Residency Conference

Impact of a Pharmacist-led Weight Management Clinic in a Medically Underserved Population within a Federally Qualified Health Center

Rebecca Axson-Wells1, L. Tate Owens1, N. Leigh Joyner1, Carrington Huneycutt1, Joseph Magagnoli2, P. Brandon Bookstaver2, Robert Etheridge1, Reagan K. Barfield2

1Tandem Health, 2University of South Carolina College of Pharmacy 

Background/Purpose: Obesity is a major public health concern associated with diabetes, cardiovascular disease, and hypertension. In South Carolina, 36% of adults are obese, with Sumter exceeding 40%. Access to weight loss medications is limited, particularly in underserved populations. Although pharmacist-led weight management programs have demonstrated improved weight loss, patient outcomes, and adherence, data on their impact within a Federally Qualified Health Center (FQHC) remain limited; therefore, this study evaluates a pharmacist-led weight management clinic in this setting. 

Methodology: This was an IRB-approved, retrospective, observational cohort that included adults with a BMI ≥ 30 kg/m2 who attended ≥ 3 visits in the pharmacist-led weight management clinic. An external comparator group was matched based on obesity class, age, and sex from January 1, 2024 - March 13, 2026. Patients were excluded if they were enrolled in the diabetes self-management education clinic, had a diagnosis of diabetes, or were pregnant.

The primary outcome was the percent change in body weight. Secondary outcomes included changes in blood pressure, heart rate, waist circumference, lipid profile, HbA1c, and patient reported quality of life (QOL). Data was extracted from the electronic health record into a REDCap survey. Data was analyzed using linear mixed-effects and logistic regression models adjusting for baseline covariates. 

Results: The study included thirty-six patients, with eighteen in each group. While there were mostly similar baseline characteristics (mean age 38.5 years; 83% female), there were a few notable differences. The intervention group had higher Medicaid coverage (72% vs. 22%, p = 0.013), baseline waist circumference (54.7 vs. 46.8 inches, p = 0.005), and HbA1c (5.65% vs. 5.32%, p = 0.033).

There were no significant between-group differences in changes from baseline. Weight decreased in both groups (−1.7 ± 3.5 vs. −0.2 ± 5.8 kg, p = 0.36), as did BMI (−0.6 vs. −0.1 kg/m², p = 0.45). Blood pressure declined similarly (SBP: −5.9 vs. −4.6 mmHg, p = 0.81; DBP: −4.0 vs. −5.3 mmHg, p = 0.78). Descriptive results demonstrated positive outcomes, with quality of life maintained or improved in all patients and no observed worsening over time. Patient satisfaction remained consistently high across all domains, with mean scores approaching ‘very satisfied’ and a median of 5 (IQR = 0) for all items.

Conclusion: In this small cohort, the intervention was not associated with significantly greater improvements in weight or cardiometabolic outcomes compared to usual care. However, trends favored the pharmacist-led intervention group despite a higher baseline disease burden and formulary-related treatment limitations. Patients experienced clinical and patient-centered benefits, including enhanced weight management support, medication optimization, and maintenance or improvement in quality of life. Pharmacist-led care also positively impacted the practice through high patient satisfaction, engagement, and support of comprehensive, team-based chronic disease management. 

Optimization of Guideline-Directed Medical Therapy in Veterans Hospitalized with an Acute Heart Failure Exacerbation
Benjamin Brewer, Mary Martin McGill
Birmingham VA Health Care System-Birmingham, AL
Background/Purpose: Recent guidance for treatment of heart failure with reduced ejection fraction (HFrEF) states that patients with HFrEF should have guideline-directed medical therapy (GDMT) initiated and then titrated to maximum dose as quickly as possible . Previous studies have shown inpatient titration of GDMT is safe. The purpose of this study is to evaluate the difference in 30-day readmission rate in patients with HFrEF hospitalized with an acute heart failure exacerbation in patients who have GDMT optimized in order to obtain current real world data GDMT usage and evaluate how GDMT utilization at discharge effects patient outcomes.
Methodology: This will be a retrospective observational chart review conducted by reviewing medical records of patients hospitalized with an acute heart failure exacerbation between 3/15/2025 and 9/24/2025. Inclusion criteria will include admission for heart failure exacerbation and documented ejection fraction (EF) < 40%. Exclusion criteria will include patients discharge to palliative care or patients undergoing dialysis. Patients with more than two admissions will only have the first readmission counted. Readmissions were not counted if for non-HFrEF indication. GDMT is considered an angiotensin converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNi), HF-specific beta blocker (BB), mineralocorticoid receptor antagonist (MRA) and sodium glucose cotransporter 2 inhibitor (SGLT2i) at maximum tolerated doses. Medication reconciliation on admission will be compared to the discharge medication list given to the patient. Patients will be grouped by whether GDMT medication was titrated or if therapy was not escalated.
Results: There were 140 patients reviewed and 65 met inclusion criteria. Of those 65 patients included in the study 32 had GDMT titrated at discharge and 33 did not have GDMT titrated at discharge.  Nine (28%) patients in the optimized group were readmitted within 30-days and 6 (18%) patients were readmitted from the non GDMT optimized group (Relative Risk: 1.40; p-value: 0.40). Patient population is underpowered for statistical significance, but increased readmission rates could indicate clinical significance. Of the patient’s who had GDMT titrated,  the most  commonly titrated medication group was SGLT2i. They were optimized in 14 (44.8%) patients, next were BB and ACEi/ARB/ARNi which was each optimized in 13 patients (40.6%), and the least commonly optimized group was MRAs. They were optimized in 7 (21.9%) of patients. In patients who had GDMT titrated 17 (53.1%) also had loop diuretics add or titrated on discharge compare to 13 (39%) in those who did not have GDMT titrated. The pharmacy cardiology clinic provided quicker post discharge follow-up at an average of five days post discharge and met with 52.3% within 30 days of discharge, compared to cardiology clinic (11 days; 18% of patients), and primary care (7 days; 10.8% of patients). Forty-three of the patients received follow-up from a cardiology pharmacist, cardiology, or primary care and of those patients 4 (9.3%) were readmitted compared to those who did not receive follow-up with 30 days 12out of 22 (54.5%) were readmitted.
Conclusions: There were a few limitations that limit the applicability of these results to the overall population. The study had a small sample size evaluated over a short time period, there are many confounding variables, and data was only collected form a single facility. Follow-ups are limited by failure to reach patient, readmission, and possible lack of established care within BVAHCS. From this data medication titration at discharge was not associated with an increase of 30-day readmission. However, the opportunity to further titrate GDMT upon discharge does exist, specifically in MRAs.
Presentation Objective: Evaluate 30-day readmission rates of HFrEF admissions who have GDMT titrated at discharge in the Birmingham VA Health Care System (BVAHCS).
Self-Assessment: Which of the following is not a first line option for optimizing GDMT?

TITLE: Comparative Effectiveness of Acetazolamide Versus Thiazide-like Diuretics for Sequential Nephron Blockade in Acute Decompensated Heart Failure: A Retrospective Cohort Study

AUTHORS: Angel D. Posadas, Otsanya Ochogbu

BACKGROUND: Intravenous loop diuretics are recommended as first-line therapy for the management of volume overload in acute decompensated heart failure (ADHF); however, many patients experience an inadequate diuretic response, resulting in persistent congestion. Sequential nephron blockade with thiazide-like diuretics or acetazolamide is commonly used to enhance diuresis in patients with diuretic resistance. Traditionally, thiazide-like diuretics have been used as add-on therapy when response to loop diuretics is insufficient. More recently, acetazolamide, a carbonic anhydrase inhibitor, has gained interest as an alternative strategy as studies have shown improved decongestion when compared to placebo. This study aimed to compare the effectiveness and safety of acetazolamide versus thiazide-like diuretics when combined with loop diuretics in adult patients hospitalized with ADHF.

METHODS: A single-center retrospective observational cohort study was conducted at AdventHealth Orlando evaluating adult patients hospitalized with ADHF between January 1, 2023 and January 1, 2025. Patients 18 years or older who received intravenous loop diuretics and adjunctive diuresis with either acetazolamide or a thiazide-like diuretic (metolazone or chlorothiazide) during hospitalization were included. Patients were excluded if they were on acetazolamide or a thiazide-like diuretic prior to admission, on extracorporeal membrane oxygenation, had end-stage renal disease, estimated glomerular filtration rate (eGFR) <15 mL/min/1.73m², or concomitant use of both adjunctive agents. The primary endpoint was average daily net fluid balance assessed for up to 72 hours of adjunctive diuretics. Secondary endpoints included net fluid balance at 24, 48, and 72 hours, change in body weight, hospital length of stay, inpatient mortality, 30-day readmission, and adverse events including hypokalemia, acute kidney injury (AKI), and arrhythmias.

RESULTS: A total of 897 patients were screened and 711 were excluded, primarily due to receipt of both adjunctive agents or lack of concomitant use with intravenous loop diuretics. A total of 186 patients were included in the study, 80 who received acetazolamide and 106 who received a thiazide-like diuretic. Baseline characteristics were generally similar between groups; however, patients receiving thiazides had higher baseline serum creatinine, and higher prevalence of chronic kidney disease (CKD). Baseline loop diuretic dose prior to adjunctive therapy was similar between groups (60 mg vs 80 mg; p=0.177). Median duration of adjunctive therapy was longer in the acetazolamide group compared to the thiazide group (2 vs 1 days; p =0.027). There was no difference in the average daily net fluid balance in patients receiving acetazolamide as compared to thiazides (−1634.9 mL/day vs −1553.0 mL/day; p=0.791). There was also no difference in the net fluid balance at 24, 48, and 72 hours between acetazolamide and thiazide groups. Patients receiving acetazolamide had significant weight reduction from admission to discontinuation of the adjunctive agent (−5.56 ± 6.75 kg vs −2.66 ± 6.05 kg; p=0.027) and a longer hospital length of stay (15 days vs 12.5 days; p=0.016). There was no difference in the incidence of inpatient mortality (6.3% vs 11.3%; p=0.235), 30-day readmission (20.0% vs 22.3%; p=0.712), hypokalemia (21.3% vs 23.6%; p=0.706), and arrhythmias (1.9% vs 2.5%; p=1.000). There was a significantly lower incidence of AKI in patients treated with acetazolamide compared with thiazides (20.0% vs 58.5%; p<0.001).

CONCLUSION: There was no difference in net fluid balance in patients treated with acetazolamide as compared to thiazide-like diuretics in patients admitted with ADHF, however, acetazolamide was associated with greater weight reduction. While a lower incidence of AKI was observed with acetazolamide, the higher prevalence of CKD in the thiazide group may have confounded this finding. Overall, these results suggest comparable diuretic efficacy between both agents, but larger randomized controlled trials are needed to evaluate differences in clinical outcomes and safety.

Background: 
Sodium bicarbonate infusions are primarily used for severe metabolic acidosis and select toxicologic emergencies. Variability in the prescribed concentration and diluents can contribute to medication errors, workflow inefficiencies, and unnecessary waste. On August 19, 2025, Piedmont Healthcare implemented a standardized sodium bicarbonate infusion order set for non-nephrology providers, reducing seven options to two options (150 mEq sodium bicarbonate in one liter of either sterile water for injection or 5% dextrose in water). This study evaluated the financial and operational impact of this standardization intervention. 
 
Methods: 
This single-center, retrospective, pre-post study evaluated orders from a sodium bicarbonate infusion order set at Piedmont Columbus Regional Midtown during a pre-standardization period (May – June 2025) and a post-standardization period (November – December 2025) following implementation of a simplified order set. All objectives were evaluated using data from 50 randomly selected patient charts per period. Patient charts were excluded if the ordering provider was a nephrologist or if the order was never prepared. The primary objective, total cost of waste, was defined as the difference between the cost of the product made and the cost of the product administered using average wholesale prices. Secondary outcomes included pharmacy labor inputs and time to first dose. Descriptive statistics were used to evaluate all outcomes.
 
Results: 
Baseline characteristics were similar between groups, with metabolic acidosis as the most common indication for continuous infusion of sodium bicarbonate. In the pre-standardization group, the most frequently ordered products were 150 mEq of sodium bicarbonate in sterile water or 5% dextrose in water, which informed the retention of these options in the standardized order set. The proportion of wasted infusions among the 50 randomly selected patients per group improved from 23% wasted pre-standardization to 14% wasted post-standardization, an absolute waste reduction of 9%. Using average wholesale price to estimate the primary outcome of cost of waste, extrapolation to the number of infusions dispensed in 2025 demonstrated a reduction in estimated annual waste from $28,315 pre-standardization to $17,220 post-standardization, yielding an annual cost savings exceeding $11,000. For secondary outcomes, pharmacy labor time was similar between groups, while time to first dose improved by approximately 7 minutes in the post-standardization group.
 
Conclusions: 
This study found that implementation of a standardized sodium bicarbonate infusion order set for non-nephrology providers reduced waste and saved cost. There was not a meaningful difference in time spent on pharmacy labor, but there was a slight improvement in time to first dose after standardization. Future directions include implementation of batch preparation of the standardized doses to significantly reduce the amount of pharmacy labor needed per bag, and to further reduce time to first dose.
 
Contact: 
[email protected] 

Authors:
Austin Seawright, Natalie Giddens, Marci Swanson, Alexis Pruitt

Purpose:
Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors have demonstrated significant cardiovascular benefits in patients with heart failure, regardless of diabetes status. Despite strong guideline recommendations, prescribing rates remain suboptimal at the Carl Vinson VA Medical Center. This quality improvement project aims to optimize the use of SGLT2 inhibitors in Veterans with heart failure by identifying eligible patients, initiating therapy when appropriate, and improving adherence to guideline-directed medical therapy.

Methods:
This quality improvement project increased SGLT2 inhibitor initiation among eligible Veterans, improving prescribing rates across heart failure phenotypes. Adverse reaction and discontinuation rates were low and consistent with those reported in clinical trials. Pharmacist‑led outreach and structured follow‑up supported expanded access to guideline‑directed therapy, with opportunities for future enhancement through automated alerts and dashboard optimization. Exclusion criteria included: active prescription for an SGLT2 inhibitor, documented severe allergy to an SGLT2 inhibitor, type 1 diabetes mellitus, history of diabetic ketoacidosis, genitourinary infections, eGFR <20 mL/min/1.73m², age ≥90 years, or deceased status. Chart review was conducted to verify eligibility, evaluate contraindications, and identify potential clinical considerations influencing initiation. Eligible Veterans or their providers were contacted via a multimodal approach to provide education regarding benefits and assess interest in therapy. Those agreeable were referred to a pharmacist‑led clinic for further evaluation and potential initiation of empagliflozin, the VA formulary‑preferred agent. Baseline laboratory values, renal function, blood pressure, and medication history were reviewed prior to initiation. Follow‑up included monitoring for tolerability, adverse reactions, adherence, and continued appropriateness of therapy.

Results:
Of 396 Veterans identified, 339 met inclusion criteria. A total of 83 Veterans (24.5%) initiated an SGLT2 inhibitor following outreach and clinical evaluation. The most common reasons for non‑initiation included urinary incontinence (30.5%), predominantly outside care (12.5%), and inability to reach patients (10.2%). Seven adverse drug reactions were reported, most commonly dizziness or renal function decline, with only two events leading to discontinuation. Seven Veterans discontinued therapy. Five discontinuations were attributed to ADRs, while two Veterans self‑discontinued due to concerns regarding polypharmacy. Initiation rates increased across heart failure classifications.

Conclusions:
This quality improvement project increased SGLT2 inhibitor initiation among eligible Veterans, improving prescribing rates across heart failure phenotypes. Adverse reaction and discontinuation rates were low and consistent with those reported in clinical trials. Pharmacist‑led outreach and structured follow‑up supported expanded access to guideline‑directed therapy, with opportunities for future enhancement through automated alerts and dashboard optimization.

Authors: Jalyn Martin, Justin Joy, Brian Tran, Matthew Brown, Susie Sennhauser, Matthew Gold, Daniel Gold, Kunal Bhatt

Background: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive disease caused by myocardial deposition of misfolded transthyretin (TTR) fibrils, resulting in heart failure. TTR stabilizers, including tafamidis and acoramidis, reduce mortality and hospitalization by preventing tetramer dissociation. However, there is no standardized biomarker to assess treatment response. Clinical follow-up commonly incorporates serum prealbumin, N-terminal pro-B-type natriuretic peptide (NT-proBNP), imaging, and hospitalization rates. Prior studies suggest that lower baseline prealbumin and early post-treatment increases are associated with clinical outcomes, but its prognostic utility in real-world populations remains unclear.

Methods: This was a retrospective chart review of adults diagnosed with ATTR-CM who received TTR stabilizer therapy (i.e. tafamidis, tafamidis meglumine, or acoramidis) at the Emory Advanced Heart Failure Clinic between November 1, 2019, to December 1, 2025. Patients were included in this study if they had both baseline and follow-up (≥ 3 months) prealbumin levels. Ineligible patients were those with previous TTR stabilizer or TTR silencer use, on dual stabilizers, on a concurrent TTR silencer (patisiran, vutrisiran, inotersen, or eplontersen), or enrolled in an active ATTR-CM clinical trial. The primary outcome was the absolute change in prealbumin levels following TTR stabilizer therapy. Secondary outcomes included the association between absolute change in prealbumin and all-cause hospitalization and all-cause mortality (time to event analysis), as well as the absolute change in NT-proBNP following TTR stabilizer initiation. Descriptive statistics, paired t-test, logistical regression, and Cox proportional hazard regression were used to summarize the data.

Results: Of 222 patients screened, 150 were excluded, primarily due to missing follow-up prealbumin measurements. A total 72 patients were included in the analysis, all treated with tafamidis. Prealbumin rose significantly after TTR stabilizer initiation, with a mean paired increase of 8.99 mg/dL (95% CI 7.40 to 10.59; p<0.001). The composite outcome of hospitalization and death occurred in 47 (65.3%) patients, with 14 deaths and 47 hospitalizations. After adjustment for age, sex, and race, each 5 mg/dL higher follow-up prealbumin was associated with a lower risk of hospitalization (HR 0.41; 95% CI 0.21 to 0.78; p=0.007) and the composite outcome (HR 0.37; 95% CI 0.20 to 0.69; p=0.002). No significant association was observed for mortality alone with either follow-up prealbumin or change in prealbumin. Mean absolute change in NT-proBNP was 165.7 pg/mL.

Conclusions: Higher prealbumin after TTR stabilizer initiation was associated with a reduced risk of all-cause hospitalizations and composite events. Baseline prealbumin in prealbumin predicted subsequent cardiac-related hospitalizations and all-cause mortality in an exploratory analysis. Further research in larger cohorts with longer follow-up is needed to validate these findings and further identify predictors of response to TTR stabilizer therapy.
  

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Title: Impact of Anticoagulation Strategies on Thrombotic Events in Patients with Durable Left Ventricular Assist Devices (IMPACT-LVAD)
Authors: Asya Bookal, Danielle McPherson, Michelle Dillon

Background/Objective: Advanced heart failure (HF) poses a significant and increasing burden, affecting around 15% of all HF patients. Treatment options for patients with advanced HF include durable left ventricular assist devices (LVAD) which improve 2-year survival by 80% and may be used either as a bridge to heart transplantation or as destination therapy. There are currently three generations of LVADs; newer generations like the HeartMate 3 (HM3) device have a continuous and fully magnetic levitation which improves hemocompatibility and thus safety. Although newer generation devices have less risk of thrombosis, all devices inherently have some; therefore, long-term anticoagulation is recommended. In the acute perioperative period, the competing risks of bleeding and thrombosis must be balanced, which may delay anticoagulation initiation. Institutional anticoagulation strategies have also been impacted post ARIES-HM3 trial. This study aims to evaluate the incidence of thrombotic and bleeding events after HM3 implantation. 

Methods: This retrospective review includes adults who underwent durable LVAD placement with a HM3 device at AdventHealth Orlando between August 1, 2022 and August 31, 2025. Patients were excluded if they received an alternate device, required additional mechanical circulatory support with device placement, had delayed chest closure, or history of heparin-induced thrombocytopenia (HIT). The primary endpoint is incidence of thrombotic events after HM3 implantation, defined as deep vein thrombosis (DVT), pulmonary embolism (PE), cardioembolic stroke, thrombus induced acute coronary syndrome (ACS), or device-associated thrombus. Secondary endpoints include bleeding defined by the Mechanical Circulatory Support Academic Research Consortium (MCS-ARC), time to therapeutic anticoagulation, anticoagulation time in the therapeutic range (TTR), and time to initiation of warfarin.  

Results: Of 124 patients screened, 88 were included in the study. Patients were on average 58 years old (SD ±13), 65 (74%) were male, 42 (48%) had history of atrial fibrillation, 13 (15%) had history of DVT/PE, 44 (50%) were on therapeutic anticoagulation, and 29 (33%) required MCS preoperatively. Bleeding events occurred in 24 (27%) patients with 12 (50%) being type 2 requiring intervention, but no type 5 fatal bleeding events occurred. Fourteen (16%) patients experienced a thrombotic event with 12 (86%) being upper extremity DVT, 1 (7%) cardioembolic stroke, and 1 (7%) pulmonary embolism. Patients were split into aspirin use pre- and post- ARIES-HM3 trial with all 21 (100%) pre-trial receiving aspirin and 35 (52%) post-trial receiving aspirin. Median time to warfarin initiation was 5 days (IQR 3, 7), time to therapeutic INR was 6 days (IQR 4, 7), and time to therapeutic aPTT was 12 hours (IQR 6, 15). Median TTR for warfarin days 6-10 was 60% (IQR 35, 1), median TTR for parenteral anticoagulation days 1-5 was 49% (IQR 33, 64), and time in subtherapeutic aPTT range was 46% (IQR 24, 60).

Conclusions: Patients who underwent HM3 implantation experienced low rates of thrombotic events despite changes in anticoagulation strategies and did not experience fatal bleeding.

Authors: Joan M. Jakab, William W. Feese, Mitchell S. Hutson, A. Shaun Rowe, & Kaylee W. Behal 
Background: Patients with heart failure have complex medication regimens, often involving a need for additional education and care. Multidisciplinary care improves medication adherence and dose optimization of the four pillars of heart failure therapy. Outpatient multidisciplinary integration in heart failure clinics has shown enhanced medication optimization and reduced hospital admission thus the need to assess inpatient multidisciplinary care. The purpose of this study is to evaluate the impact of a multidisciplinary cardiology-focused unit on guideline directed medical therapy (GDMT) at hospital discharge for patients with heart failure with reduced ejection fraction (HFrEF). 
Methods: This retrospective cohort study examines 364 patients with HFrEF grouped according to discharge location from either the cardiology-focused multidisciplinary unit or any other   unit. Multidisciplinary cardiology-focused units receive heart failure education tailored to each specialty such as disease specific education courses for registered nurses, importance of intake and output documentation, daily weights, and movement by exercise physiology. The primary outcome is GDMT score at discharge. Secondary outcomes include the change in GDMT score from admission to discharge and the percentage of pillars of therapy on each patient’s medication regimen. The subgroup analysis includes pharmacist initiation of GDMT as determined by clinical intervention documentation in the electronic medical record. The secondary safety endpoint includes hospital readmissions at 30 or 90 days.  
Results: At discharge, patients admitted to the multidisciplinary cardiology-focused unit achieved higher GDMT scores compared with patients admitted to other units (5 [2, 6] vs. 3 [1, 5]; p=0.0003). The change in GDMT scores from admission to discharge was significantly greater in the cardiology unit (1 [0, 5] vs. 0 [0, 1]; p<0.0001). Patients discharged from cardiology-focused units had a higher number of GDMT medications prescribed (3 [2, 4] vs. 2 [1, 3]; p=0.0005). Thirty or ninety day heart failure-related readmission rates were similar between groups (8 [6.4%] vs. 13 [5.4%]; p=0.7089). Patients admitted to cardiology-focused units were more likely to have at least one heart failure-related pharmacist clinical intervention during admission (61 [48.8%] vs. 63 [26.4%]; p<0.0001; OR 2.7, 95% CI 1.7–4.2). 
Conclusions: In this retrospective study, patients with HFrEF who were admitted to the multidisciplinary cardiology-focused unit had higher GDMT scores at discharge indicating greater optimization of GDMT. These findings suggest that a multidisciplinary team plays a critical role in identifying gaps in therapy and promoting evidence-based medication optimization during hospitalization. 

Background: Despite its prevalence in clinical practice and its widely accepted role in dual antiplatelet therapy regimens, clopidogrel has demonstrated significant interpatient pharmacokinetic variability and pharmacodynamic responses. Poor metabolizers are at increased risk of cardiovascular events following coronary stenting secondary to their inability to properly metabolize the inactive compound into its active form. Platelet reactivity testing measures the degree of platelet aggregation following the administration of an antiplatelet. Using the VerifyNow-P2Y12 Assay, a P2Y12 reaction unit (PRU) ≤208 indicates adequate platelet inhibition, while a PRU >208 indicates inadequate platelet inhibition.  Current acute coronary syndrome guidelines do not recommend platelet function testing, however the JACC International Consensus Statement on Platelet Function and Genetic Testing in Percutaneous Coronary Intervention recommends consideration of platelet function testing to guide escalation strategies, de-escalation strategies, or in patients being considered for antiplatelet monotherapy with clopidogrel. In response to a sentinel event at Prisma Health where a patient with a PRU >208 was discharged on clopidogrel, PRU results were added to clinical monitoring for pharmacist assessment. The goal of this research is to assess pharmacist intervention following platelet function testing and characterize clopidogrel utilization in response to PRU levels.
Methods: This is a retrospective, observational cohort study including patients admitted to Prisma Health with coronary stenting and a platelet function test performed with resulting PRU level on clopidogrel. Patient cohorts include those with levels ≤208 (clopidogrel responders) and those with levels >208 (clopidogrel non-responders). The primary endpoint is the percentage of patients on clopidogrel with a PRU >208 that were intervened on by a pharmacist. Secondary endpoints include percentage of patients with high-risk characteristics, contraindications to a preferred P2Y12 inhibitor, appropriate PRU timing and transition to alternative P2Y12 inhibitor, and cardiovascular outcomes.  
Results: In progress
Conclusion: In progress

ASSESSMENT OF ADHERENCE TO AN INSTITUTIONAL aPTT LEVEL MONITORING PROTOCOL FOR UNFRACTIONATED HEPARIN INFUSIONS
George Saied, Rachel Hemberger, Mary Beth Brinkman
TriStar Centennial Medical Center – Nashville, TN
Background: The use of continuous infusion unfractionated heparin (UFH) is common for treatment and prophylaxis of venous thromboembolism (VTE), myocardial infarctions (MI), anticoagulant bridging, and is used second line in several other disease states. UFH has been labeled a “High-Risk Medication” since the early 2000s and has severe adverse effects associated with bleeding and platelet abnormalities. The use of UFH requires close monitoring of laboratory findings, specifically the use of Activated Partial Thromboplastin Time (aPTT), to ensure patient safety and medication efficacy. Supratherapeutic aPTT levels result in increased bleeding risk while subtherapeutic aPTT levels result in increased clotting risk. Due to the frequency of aPTT monitoring, there is potential for delays in blood collection and necessary dose adjustments, thus increasing the risk of patient-safety events. Additionally, there is also potential for aPPT protocol recommendation to be misinterpreted or for the dose to be titrated inappropriately, thus leading to patient-safety events. This study seeks to evaluate adherence to our heparin protocol and identify specific areas for process improvement.

Methods: This was an Institutional Review Board-approved, single-center, retrospective cohort study of adult patients (≥18 years) who received a continuous heparin infusion at TriStar Centennial Medical Center from March 22, 2025 through March 31, 2025. The primary endpoint was adherence to the institutional UFH nursing protocol, defined as appropriate heparin bolus administration, dose titration, and timely aPTT ordering per protocol recommendation. Secondary endpoints included reasons for protocol nonadherence, percentage of aPTT values within the goal therapeutic range, time to achieve therapeutic range, and incidence of bleeding and thrombosis. Drips were followed for the first 72 hours after initiation. Descriptive statistics were used for data analysis.

Results: A total of 59 patients were included (Cardiac Serv, n = 36; DVT/PE, n = 23). The primary outcome of full protocol adherence was achieved in only 7 of 59 patients (11.9%). The most common drivers of non-adherence was incorrect initial drip rate and inappropriate dose titration. The mean percentage of aPTT values within the therapeutic range was 43.6%. Patients who experienced an adverse drug reaction (n=9, 15.3%) had a lower mean percentage of aPTT values in goal compared to those without an ADR (28.6% vs. 46.3%; p=0.056). Time to first therapeutic aPTT was significantly longer in the Cardiac Serv cohort compared to the DVT/PE cohort (0.87 days vs. 0.42 days; p = 0.001). Bleeding events occurred in 6 (10.2%) patients (Cardiac Serv 5.6% vs. DVT/PE 17.4%; p = 0.196) and thrombotic events in 7 (11.9%) patients (Cardiac Serv 8.3% vs. DVT/PE 17.4%; p=0.414). No statistically significant difference in adverse events was identified between cohorts, but trends do support increased risk in DVT/PE versus Cardiac Serv protocols.

Conclusions: Protocol adherence to institutional UFH aPTT monitoring was below goal, with fewer than 1 in 8 patients receiving fully adherent care. Non-adherence was primarily driven by incorrect initial rates and incorrect dose titration. Patients who experienced an ADR spent significantly less time within the therapeutic range, which highlights the clinical consequences of protocol deviations. The Cardiac Serv cohort took a longer time to reach first therapeutic aPTT compared to the DVT/PE cohort. These findings show clear opportunities for targeted nursing education, protocol clarification, and system-level process improvements to optimize UFH therapy and enhance patient safety.

 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.

Abstract 
Background and Purpose 
Hypotension is a common barrier to optimization of guideline-directed medical therapy (GDMT) in patients with heart failure with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF). Midodrine, an oral α₁-adrenergic agonist approved for orthostatic hypotension, has been used off-label to support blood pressure and facilitate GDMT initiation or titration in hypotensive heart failure patients. However, data evaluating its impact on clinical outcomes remains limited. This study aimed to evaluate the association between midodrine use at hospital discharge and 30-day all-cause readmission in hypotensive heart failure patients. 
 
Methods 
This retrospective cohort study included adult patients (≥18 years) admitted to the AdventHealth Central Florida Division between October 2024 and November 2025 with HFrEF or HFmrEF (EF <50%) and documented hypotension. Patients were grouped based on discharge with midodrine versus discharge without midodrine. Clinical data was extracted from the electronic health record, including baseline characteristics, use of GDMT at admission and discharge, length of stay (LOS), 30-day all-cause readmission, 30-day mortality, and adverse events such as hypertension and bradycardia. 
 
Results 
A total of 142 patients were included (65 intervention, 77 control). Baseline demographics and clinical characteristics were similar between groups. The 30-day all-cause readmission rate was identical between patients discharged on midodrine and those not discharged on midodrine (34% vs 34%, p=0.99). 30-day mortality was low and comparable between groups (2% vs 1%, p=0.49). Median length of stay did not differ significantly (11 vs 9 days, p=0.54). 
Hypertensive events occurred more frequently in those discharged with midodrine (31% vs 20%), though this difference was not statistically significant (p=0.11). Rates of bradycardia were similar (21% vs 17%, p=0.95). Changes in GDMT dosing from admission to discharge were comparable between groups, with no significant improvement in GDMT up-titration associated with midodrine use. 
 
Conclusions 
In this retrospective cohort of hypotensive HFrEF and HFmrEF patients, discharge on midodrine was not associated with reduced 30-day readmission, mortality, or length of stay compared to patients not discharged on midodrine. While midodrine was frequently used as a supportive agent, its use did not translate into meaningful GDMT optimization and was associated with a numerically higher incidence of hypertensive events.  

Background: Cardiovascular (CV) disease is the leading cause of death worldwide, accounting for nearly eighteen million deaths annually. Among patients with acute coronary syndrome (ACS), up to twenty percent experience a recurrent major adverse cardiovascular event (MACE) within two years. Optimizing lipid lowering therapies to achieve a goal low-density lipoprotein (LDL) is a cornerstone of secondary prevention and reduces the residual risk of MACE. Injectable-lipid lowering therapies have a prominent role in LDL goal achievement for patients deemed statin-intolerant or those who need additional lipid-lowering in addition to their maximally tolerated statin therapy. Despite the proven efficacy of injectable lipid-lowering therapies, their usage remains suboptimal due to access, cost, and workflow barriers. Pharmacist-led lipid clinics have shown to bridge the gap to initiation of injectable lipid-lowering therapy by increasing the use of guideline-directed therapy, identifying and managing statin-intolerance, and improved calculated low-density lipoprotein (LDL-C) goal achievement. This project evaluates the impact of an inpatient pharmacist-led referral process to a pharmacist-managed lipid clinic on the timely initiation of injectable lipid-lowering therapies in post-ACS patients.  
Methods: This single-center, retrospective cohort with pre-post analysis included adults who survived hospitalization for ACS, including non-ST-elevated myocardial infarction (NSTEMI) or ST-elevated myocardial infarction (STEMI), with an LDL greater than or equal to 55 mg/dL or statin-intolerant. Patients were excluded if they were already on injectable lipid-lowering therapy or pregnant or breastfeeding. Patients who met the inclusion criteria were eligible to be referred by the inpatient pharmacy team to a pharmacist-led lipid clinic for ambulatory lipid management post-ACS. A collaborative practice agreement (CPA) allowed clinical pharmacists practitioners (CPPs) to independently conduct lipid management visits, initiate, titrate, or discontinue antihyperlipidemic medications, order and evaluate laboratory tests, provide adherence and lifestyle counseling, and document all care in the electronic health record for physician review. The primary outcome assessed was the proportion of patients that were started on injectable lipid lowering therapy within four weeks of discharge post-ACS event. Secondary outcomes were proportion of patients started on injectable lipid lowering therapy within 12 weeks of discharge post-ACS event, proportion of patients seen in lipid clinic within four and 12 weeks of discharge post-ACS event, median time to seen in lipid clinic, median time to started on injectable lipid-lowering therapy post-discharge, and percent reduction of LDL from baseline to eight or more weeks post-initiation of injectable lipid-lowering therapy. 
Results: A total of 196 patients were screened with 45 patients being included in the pre-PharmD referral group and 151 patients in the post-PharmD referral group. A higher proportion of patients in the post-referral to pharmacist-managed lipid clinic group were initiated on injectable lipid-lowering therapies within four weeks of ACS discharge compared to the pre-referral group [15 (23.8%) vs 0 (0%); p=0.002]. Patients in the post-referral group were also more likely to be seen in lipid clinic within four weeks (OR 0.13; p=0.003) and 12 weeks (OR 0.32; p=0.04) of discharge. 
Conclusion: Implementation of a standardized referral process to an outpatient pharmacist managed lipid clinic post-ACS discharge enhance transitions of care and implementation of guideline-directed lipid-lowering therapy to reduce residual risk of MACE for patients post-ACS. This standardized process increased the number of patients seen by a pharmacist and initiated on injectable lipid-lowering therapies within four and 12 weeks of ACS discharge. These findings suggest that pharmacist-managed lipid clinics can bridge the gap in post-ACS care by ensuring lipid therapy optimization to reduce the risk of recurrent MACE. 
Presentation Objective: Describe the impact of an inpatient pharmacist-led referral process to an outpatient pharmacist-managed lipid clinic on the initiation of injectable lipid-lowering therapies in post-ACS patients. 
Self-Assessment: What are some advantages of referring post-ACS patients to an outpatient pharmacist-led lipid clinic? 

AUTHORS: Sherique S. Shaw, Jeremy Bennett, Brianna Rhodes, Kalyn D. Pounders

BACKGROUND: Approximately 6.7 million American adults over the age of 20 were diagnosed with heart failure (HF) in 2024. This number is expected to rise to 8.7 million by 2030. Heart failure hospitalizations accounted for the highest healthcare costs among cardiovascular related hospitalization at $18.5 billion. The first 30 days following hospital discharge, patients with HF are highly vulnerable to readmission due to residual symptoms, medication changes, and gaps in care transitions.  During the 2024-2025 fiscal year [FY25] at the Atlanta VA only 35-42% of HF admission patients received any follow up by a provider (primary care, cardiologist, or Clinical Pharmacist practitioner (CPP)) within 14 days of discharge. Previous studies have highlighted the role that clinical pharmacists can play in improving hospital readmission rates for patients with heart failure. In FY25, no standardized process existed to enable CPPs to systematically follow up with and intervene for discharged heart failure patients. The Atlanta VA Health Care System implemented a protocol in FY26 Q1 [October 1, 2025 – December 31, 2025] enabling clinical pharmacists to assess and optimize medication regimens for patients discharged following heart failure diagnosis or exacerbation. This project aims to assess the impact of follow-up intervention or optimization via pharmacist involvement on heart failure discharges on 30-day cardiac readmission rates in veterans with heart failure at the Atlanta VA Health Care System.

METHODOLOGY: This project is a retrospective quality improvement project comparing 30-day readmission rates among patients who were assessed by a CPP within 30 days of hospital discharge versus those who did not receive CPP intervention or follow-up. Inclusion criteria for the study are adults 18 years or older who were hospitalized at the Atlanta VA hospital for FYQ1 2025 and FYQ1 2026  and received a diagnosis of heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Exclusion criteria included veterans who are pregnant, complex heart failure, terminally ill or hospice enrolled and if the veterans were discharged to a non-home environment. Eligible Veterans will be identified using the following methods: heart failure diagnosis ICD-10 codes, heart failure population-management dashboard, the 2-day post-discharge dashboard (monitored by primary care nurses who notify CPPs of actionable patients), referrals from the inpatient team via Pharmacotherapy Heart Failure Discharge Consults, and referrals from any primary care team member or specialist. Once identified, CPPs will provide an intervention and document the interaction under the note titled "Pharmacotherapy Heart Failure Post-discharge Note". Intervention for this research is defined as initiating, titrating, or maintaining GDMT at target or maximally tolerated doses. For this project, a readmission is defined as a hospitalization within 30 days of initial discharge for a HF exacerbation. Readmissions will be identified through discharge summaries tab in computerized patient record system [CPRS] or notes filtered by ICD-10 codes under the post-discharge category. We also will be collecting demographic and clinical characteristics including, age, gender, time of hospitalization, active GDMT prescription before hospitalization, active GDMT prescriptions after CPP assessment, patient readmission, primary care provider or clinic, EF classification prior to admission, type of intervention/optimization provided if any. After capturing the data, we will calculate the percentage of HF readmissions with and without CPP intervention for each fiscal year. Upon review of the data, the impact of the pharmacotherapy task force post discharge follow up will be assessed in order to identify areas for quality improvement.

RESULTS:
In FYQ1 2025, there was a total of 106 HF patients, and 16%(17/106) were readmitted within thirty days. In FYQ1 2026, there was a total of 63 HF patients and 24% (15/63) of HF patient readmitted within 30 days. Only 13% (8/63) of the HF patients in FYQ1 2026 received CPP follow up from the intervention team. Of the HF patients that received a CPP follow up, 13% (1/8) were readmitted in 30 days compared to 26% (14/53) of the HF patients that did not receive CPP follow up.
Veterans were identified for intervention after discharge using the multiple methods such as ICD-10 codes, the 2-day post-discharge dashboard, and the pharmacotherapy heart failure discharge consults. Of the 8 patients that received a CPP intervention, 63%(5/8) were identified through pharmacotherapy heart failure discharge consults. All patients identified through this consult (5/5) remained readmission-free at 30 days.

CONCLUSIONS: It is recommended to provide additional education to staff of available options to notify CPPs to heart failure discharge patients to make a greater impact. CPP intervention had lower percentage of 30 day readmission rate.

Title:
An Observational Study of Patients Using U-200 Insulin in Insulin Pumps 

Authors:
Gabrielle E. Hall, Lauren Blumenfeld, Tavajay Campbell, Haley Pressley, Jonathan Hughes, Blake R. Johnson

Practice Site: 
Ascension Saint Thomas

Background: 
The use of concentrated insulin in insulin pumps has been described in a few small studies. These studies describe the use of human regular U-500 insulin via continuous subcutaneous insulin infusion versus multiple daily injections in adults with type 2 diabetes,1 the switch from rapid-acting U-100 insulin to U-500 regular insulin in patients with type 2 diabetes on insulin pump therapy,2 and the use of U-200 insulin in insulin pumps in adolescents and young adults with type 1 diabetes.3 The identified literature gap includes a lack of randomized controlled trials regarding the use of U-200 insulin in insulin pumps, a practice that has not been approved by the FDA.

Methods:
This is a retrospective, observational chart review of patients who used U-200 insulin via Omnipod® insulin pump. Patients were included if an order for Omnipod® and U-200 insulin were active at the same time from January 1, 2022 to November 30, 2025. To be included patients were further required to use the U-200 insulin in their insulin pump, wear a continuous glucose monitor, and complete at least two consecutive visits with their provider while using this regimen. Patients were excluded if they were pregnant or under age 18 at the start of the study period. Outcomes of interest include ambulatory glucose profile results, including time in range, time below range, and time above range, as well as A1c results and instances of stage 2 or 3 hypoglycemia. 

Results:
There were 315 patients using Omnipod® insulin pumps during the study period who were screened for inclusion. Fifteen patients met initial inclusion criteria. Of those fifteen, seven were excluded for not using U-200 insulin via insulin pump, one was excluded for not wearing a continuous glucose monitor, and three were excluded for not completing at least two consecutive visits with the managing provider while using this regimen. The four remaining patients were included in this retrospective chart review and described in a narrative which includes their care plan and associated outcomes. No patients experienced greater than 2% time below range or stage 2 or 3 hypoglycemia. One patient met the time in range goal of >70% after transitioning to using U-200 insulin via Omnipod® insulin pump. Though the other three patients did not meet time in range goals, they experienced improved time in range, time above range, and A1c after transitioning to using U-200 insulin via Omnipod® insulin pump. 

Conclusion:
In this case series of four patients using U-200 insulin via Omnipod® insulin pump, all patients made improvements towards reaching time in range goal >70%, time above range goal <25%, and A1c goal <7%. These findings add to the currently available evidence for this practice and reinforce the need for further study in this area. 

Background: 
Fluoropyrimidines (5-fluorouracil and capecitabine) and irinotecan are chemotherapy agents commonly used to treat upper and lower gastrointestinal malignancies, and various other solid tumors. These medications have important pharmacogenomic (PGx) considerations involving the dihydropyrimidine dehydrogenase (DPYD) and uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1) genes. Variants in these genes can impair drug metabolism and increase the risk of severe hematologic and gastrointestinal toxicity. Between 2024 and 2025, revisions to medication labeling and National Comprehensive Cancer Network (NCCN) guidelines-initiated support for preemptive DPYD testing. While PGx testing is available within the Salisbury VA Health Care System (SVAHCS), the extent to which it is utilized in oncology practice remains unclear.  This quality improvement project evaluated the utilization of multi-gene PGx testing among Veterans receiving fluoropyrimidine- or irinotecan-based chemotherapy within the SVAHCS. 

Methods: 
This IRB-exempt, retrospective, quality improvement project evaluated Veterans initiating fluoropyrimidine (5-fluorouracil or capecitabine) or irinotecan-based chemotherapy across three oncology sites within the SVAHCS between November 1, 2024, and November 30, 2025. Eligible patients were identified using Computerized Patient Record System (CPRS) chemotherapy orders. Patients receiving oncology care exclusively outside the VA system or receiving topical fluorouracil were excluded. A retrospective chart review was performed. REDCap database software was utilized to collect patient demographics, cancer type, chemotherapy regimen, and relevant PGx testing information. For patients who underwent testing, PGx phenotypes, PGx-guided therapy modifications, and testing turnaround times were evaluated. Reasons for omission of PGx testing were also recorded when available. 
 
Results: 
A total of 70 Veterans receiving fluoropyrimidine- or irinotecan-based chemotherapy were identified. 40 Veterans were included in the analysis. The mean patient age was 66.35 years, and the cohort was predominantly male (95%). The most common malignancies were colon cancer (52.5%) and pancreatic cancer (22.5%). PGx testing was ordered in 25 patients (62.5%). Documented rationale for not obtaining PGx testing included: prior tolerance of therapy, prior PGx results on file, needing to rapidly initiate chemotherapy, and awaiting eligibility for an investigational treatment. Of the 15 patients for whom PGx testing was not obtained there was no documented reason for the lack of testing in 7 patients (46.7%). Among patients with PGx results, DPYD phenotypes were normal in 96% (n=24), and intermediate in 4% (n=1). UGT1A1 phenotypes were normal in 72% (n=18), intermediate in 16% (n=4), and poor in 12% (n=3). PGx-guided irinotecan dose reductions were documented in all patients that were poor UGT1A1 metabolizers and receiving irinotecan (n=2). Median turnaround time from PGx order to vendor report was 12 days (IQR: 9-13), and the median time from vendor report to CPRS result posting was 6 days (IQR: 3-9).  
 
Conclusions: 
Multi-gene (PGx) testing for DPYD and UGT1A1 genes increased following updated guidance in October 2025, however, it was not consistently utilized during the review period.  Over one-third of the review population did not undergo testing, with most lacking documented rationale for omission. The lack of definitive guidance before updates to the VA clinical oncology pathways may have contributed to the limited use of PGx testing among these Veterans.  Among those tested, actionable UGT1A1 results led to irinotecan starting dose reductions, demonstrating potential clinical impact. Standardized, preemptive testing workflows represent an opportunity to improve uptake and optimize the safety of chemotherapy within the Veteran population.  

Background:
Mupirocin, an RNA synthetase inhibitor produced by Pseudomonas fluorescens, is widely used for empiric methicillin-resistant Staphylococcus aureus (MRSA) decolonization in hospitalized patients. MRSA nares polymerase chain reaction (PCR) testing is frequently performed on admission to guide antimicrobial therapy; however, the effect of prior mupirocin exposure on PCR detectability is not well described.
Methods:
This retrospective cohort study was conducted across Ballad Health facilities from August 2022 to July 2025. Adults aged ≥18 years with documented MRSA colonization within one year who completed a five-day mupirocin decolonization course during a prior admission and underwent MRSA nares PCR testing on readmission were included.
The primary endpoint was median time in days from mupirocin completion to repeat PCR testing, compared between PCR-positive and PCR-negative groups. Secondary endpoints included MRSA culture positivity on readmission and concordance between PCR and culture results, assessed using McNemar’s test and Cohen’s kappa.
Results:
Among 124 readmissions, 84 (68%) patients had positive and 40 (32%) had negative MRSA nares PCR results. Median time to PCR testing did not significantly differ between PCR-positive (77 days; IQR 38.3–120.8) and PCR-negative groups (52 days; IQR 26–118.5; p = 0.18).
When stratified by time since mupirocin completion, PCR positivity was 59.5% (25/42) within ≤60 days, 78.6% (22/28) at 61–90 days, 66.7% (12/18) at 91–120 days, and 69.4% (25/36) at >120 days. Differences across these intervals were not statistically significant (χ² p = 0.15).
MRSA was isolated in 11 cultures during the index admission and in 23 cultures on readmission, most commonly from wound, respiratory, and blood specimens. During the index admission, 18% (22/124) of patients with a positive PCR had a corresponding positive MRSA culture. On readmission, overall observed agreement between PCR and culture results was 52.4%, with a Cohen’s kappa coefficient of 0.20. McNemar’s test indicated statistically significant discordance between PCR and culture findings (p < 0.05), predominantly attributable to PCR-positive, culture-negative pairs.
Conclusions:
In this study, timing of prior mupirocin exposure was not associated with reduced MRSA nares PCR detectability on readmission. Although culture positivity increased on readmission, concordance between PCR and culture remained limited. Evaluation within a larger cohort is warranted.

Nguyen Minh Anh Ngo, Amanda Sowder
AdventHealth Orlando
Background: Cardiac implantable electronic devices (CIED) are essential for managing arrythmias and preventing sudden cardiac death thereby improving survival. However, transvenous CIED-related infections are a serious complication, occurring in 2% to 4% of high-risk patients yearly. Device-related infections are associated with increased healthcare costs, morbidity, and mortality. The 2023 American Heart Association Update on CIED Infections recommends cefazolin as a standard preprocedural systemic antibiotic, with vancomycin reserved for select patients, and suggest consideration of an antimicrobial envelope in high-risk patients. The use of a novel absorbable antibiotic envelope, coated with rifampin and minocycline eluted to local tissues over nine weeks, has been shown to reduce infection rates in CIED patients compared to standard care; however, data in high-risk populations remain limited. While the BLISTER study validated the use of a risk stratification tool to identify patients most likely to benefit from the antibiotic envelope with a qualifying score threshold over five, the comparison group used in this study received antibiotics that do not align with current recommendations. Currently, practical use of prophylactic antibiotic regimens varies at physicians’ discretion despite existing guidance. This study aims to describe outcomes of antibiotic envelope use compared to real-world antibiotic prophylaxis regimens in high-risk patients undergoing CIED placement.


Methods: Adult patients undergoing transvenous CIED placement, including first placement, generator exchange, or upgrade, at AdventHealth Orlando between October 1, 2024 and September 30, 2025 were identified using electronic health records report generation. Key exclusion criteria included epicardial pacing lead placement, leadless pacemaker, subcutaneous implantable cardioverter-defibrillators, or temporary pacing systems. High-risk patients were identified using the BLISTER score. The primary outcome was incidence of CIED-related infections at 12 months. Secondary outcomes included incidence of pocket hematoma, infection-related hospitalization, and all-cause mortality at 12 months.


Results: During the interim timeframe (October 1, 2024 – December 26, 2024), 265 patients were screened; 50 high-risk patients were identified based on BLISTER score of 6 or greater. Of these, 24 received the antibiotic envelope and 26 received other antibiotic prophylaxis. Baseline characteristics were well-balanced between groups, with a mean age of 70 years, 70% male, and 60% with history of severe left ventricle dysfunction. The majority of patients underwent cardiac resynchronization therapy-related procedure (86% new implant or generator exchange), followed by pacemakers (8%) and implantable cardioverter-defibrillators (6%). Regarding procedure type, 44% had generator exchanges and median procedure duration was 74 minutes (IQR 42 – 112 minutes). Antibiotic appropriateness, based on institutional standards, was 92% in the envelope group and 85% in the other antibiotics group. CIED-related infection at 12 months for the antibiotic envelope versus other antibiotics group was comparable between groups (4.1% vs 3.8%). Secondary outcomes resulted as follows: pocket hematoma (8.3% vs 3.8%), infection-related hospitalization (8.3% vs 15.3%), and all-cause mortality (20.8% vs 15.3%).


Conclusion: In this interim analysis, CIED-related infection rates were similar between patients receiving antibiotic envelope and those receiving other antibiotic prophylaxis regimens. While infection-related hospitalization showed higher rates in the other antibiotics group, these cases were driven by infectious sources outside of CIED. Additionally, the high all-cause mortality across both groups reflects the baseline risk of this patient population. These preliminary findings highlight the potential for cost savings  supporting  a default strategy of prophylactic antibiotics over antibiotic envelope. Moreover, standardized use of pre-procedural risk stratification tool prior to CIED procedures may allow for individualized approaches. Larger prospective studies are warranted to further define the role of antibiotic envelope use compared to real-world antibiotic strategies in high-risk patients.

Antimicrobial Stewardship in the Emergency Department: Evaluation of Discharge Antibiotic Prescribing for UTI and CAP

Delaney Peterson, Mckenzie Hodges, Courtney McDonald, Emma Hornsby, Aayush Patel, Lauren Simmons
Piedmont Columbus Regional Midtown (PCRM) - Columbus, Georgia

Background: Antibiotics are among the most frequently prescribed medications at emergency department (ED) discharge. Community-acquired pneumonia (CAP) and urinary tract infections (UTIs), including cystitis and pyelonephritis, account for a substantial proportion of ED infectious diagnoses and represent key opportunities for antimicrobial stewardship. This study aimed to evaluate adherence to institutional guidelines for ED discharge antibiotic prescribing for UTIs and CAP and to identify actionable targets for improvement.

Methodology: A retrospective, pre–post intervention chart review was conducted at a single hospital-based emergency department. Adult patients (≥18 years) discharged from the ED with a diagnosis of urinary tract infections (cystitis or pyelonephritis) or community-acquired pneumonia and prescribed oral antibiotics at discharge were included. Patients who left against medical advice, left before evaluation, or had end-of-life or palliative status were excluded. Encounters were reviewed during a pre-intervention period (October 1st–December 31st, 2025) and a post‑intervention period (February 1st–March 24th, 2026) following implementation of an updated institutional treatment guideline with accompanying antimicrobial stewardship education. The primary outcome was guideline compliance of discharge antibiotic prescriptions, defined by appropriate drug selection, dose, and duration. Secondary outcomes included the frequency and types of guideline non-compliance. To ensure feasibility and minimize bias, we used stratified random sampling to select equal numbers of eligible encounters per phase and per diagnosis, with UTIs further stratified as cystitis or pyelonephritis.

Results: In Progress
Conclusion: In Progress
Contact: [email protected]

Authors: Chloe McGee, Aubrey Slaughter

Background:
Diabetes mellitus is an endocrine disorder caused by insulin resistance, insulin deficiency, or both leading to hyperglycemia along with an increased risk of microvascular and macrovascular complications if untreated. Children diagnosed with diabetes have a six to nine times higher risk of hospitalization in comparison to their peers without diabetes. At Wellstar MCG Health, pharmacists have not previously been involved with outpatient pediatric endocrinology management. During the 2025 – 2026 residency year, the PGY2 ambulatory care pharmacy resident has developed a new service in which the resident works collaboratively with the pediatric endocrinologist and nurse practitioner to manage medications and provide education for pediatric patients with diabetes mellitus. This implementation of a new pharmacy service is part of clinical care optimization and is not a research intervention.
Multiple studies have demonstrated patient satisfaction with pharmacist management of diabetes within the adult primary care setting; however, data is lacking in the pediatric population. Regarding clinical outcomes, a previous study of pediatric patients with type 1 diabetes managed by a pharmacist found a mean decrease in hemoglobin A1c of 0.54 percentage points at six months in comparison to an increase of 0.32 in the control group. The study did not assess satisfaction with the services provided.6 The purpose of this study is to assess patient and caregiver satisfaction with the services provided by the PGY2 ambulatory care pharmacy resident for patients with diabetes in the pediatric endocrinology clinic.

Methods:
This was an IRB exempt, observational, single center study of patients diagnosed with diabetes who were seen by the PGY2 ambulatory care pharmacy resident at the pediatric endocrinology clinic at Wellstar MCG Health. The primary outcome was patient/caregiver satisfaction with pharmacist engagement. The secondary outcome was change in hemoglobin A1c from baseline to 3 months. Data was collected via two methods. First, an anonymous survey assessing patient/caregiver satisfaction with pharmacist involvement in diabetes management was distributed in the pediatric endocrinology clinic. If agreeable, the patient/caregiver completed a paper survey consisting of 21 questions prior to leaving clinic. Second, a retrospective chart review of the pediatric endocrinology patients seen by the pharmacist was completed. Data analysis included descriptive statistics and Wilcoxon signed rank tests as appropriate.

Results:
A total of 41 surveys were completed. As self-reported on the survey, participants were a median 15 years old with a median 5 years since diagnosis of diabetes. 85.4% of participants had type 1 diabetes mellitus and 58.6% were female. Over 90% of survey respondents gave a positive response of “agree” or “strongly agree” regarding their satisfaction with pharmacist interaction. On a scale of 0 to 10, all respondents rated the pharmacist interaction as an 8, 9, or 10 with nearly 82% choosing 10/10. A total of 16 patients met criteria to be included for the chart review; the median A1c decreased from 11.0% at baseline to 9.3% at follow-up (p-value < 0.001).

Conclusions:
Based on these results, patients and caregivers were satisfied overall with their interactions with the pharmacist. While the study was limited by a small sample size and short-term follow-up, there was a trend towards improvement in A1c after pharmacist involvement. This real-world study, using a dual survey and chart review design, provides new data on patient/caregiver satisfaction and further supports clinical outcomes with pharmacist involvement in pediatric diabetes management. Future research should be conducted after a longer duration of pharmacist diabetes management in pediatric patients.

Authors: Deena Alsabbah, Alexis Shook, Brian Atkinson, and Graham Grush

Background: Pharmacists have proven valuable across various clinical areas and interprofessional teams, especially in ambulatory care settings, improving health outcomes and quality of care. Within the past few decades, sports medicine pharmacy has emerged as a unique specialty, ranging from counseling individuals in local club sports and fitness to advising elite Olympic athletes. Despite this, sports or sports medicine pharmacy remains underrepresented in pharmacy education and practice. The aim of this project was to design a guide for becoming a sports medicine pharmacist in the ambulatory care setting that addresses roles and responsibilities, areas for interprofessional collaboration, and resources to expand knowledge and networking opportunities.

Methods: A literature review was conducted to gather information on sports pharmacy organizations and resources, education and training opportunities, and roles and responsibilities. A 13-question qualitative survey was also distributed to practicing sports pharmacists within 3 sports pharmacy organizations (Sports Pharmacy Network, International Sports Pharmacist Network, and/or U.S. Sports Pharmacy Group) to obtain perspectives on current practice. Responses were summarized to highlight most common themes. 

Results: This abstract describes results from the qualitative survey and how it translates to ambulatory care practice.
Survey respondents (n = 14) reported diverse practice backgrounds across multiple settings, including ambulatory care, independent community pharmacy, student health, athletics, acute care, and scientific writing. The majority of respondents had been practicing for 2-5 years (42.9%), followed by 10-20+ years (35.7%), and 0-1 years (21.4%). 78.6% of respondents reported working with nutritionists, as well as physicians, nurse practitioners, nurses, athletic trainers, physical therapists, sports psychologists, and sports dentists. The most common roles and responsibilities included medication and therapeutic management (50%), clinical assessment and screening (28.6%), personalized care and performance planning (28.6%), consultation and education (71.4%), and scientific and educational content development (21.4%). Respondents frequently managed conditions such as pain and injury, Relative Energy Deficiency in Sport (RED-S), mental health disorders, infectious diseases, and many more.
Primary barriers to sports pharmacy practice included lack of buy-in and awareness from other parties and sustainable reimbursement. Funding sources varied considerably, with 42.8% of respondents receiving private or cash payments, while others relied on educational sites and programs or additional employment.

Conclusions: There are a variety of ways pharmacists can make an impact in sports medicine, particularly in ambulatory care settings. Resources and organizations, like the International Sports Pharmacists Network, Global DRO, WADA, and Sports Pharmacy Network, are just a few of many that provide the necessary education, skills, and networking opportunities for pharmacists and student pharmacists to enter a career path caring for a unique patient population.

Evaluation of Antiepileptic Therapy and Outcomes in Status Epilepticus Patients Presenting to the Emergency Department
Michelle Tubolino, Megan Heath
DCH Regional Medical Center-Tuscaloosa, Alabama
Background/Purpose: Assess guideline-based selection and dosing of the initial antiepileptic drug (AED) administered in the emergency department (ED) in patients presenting with status epilepticus (SE) at a large community hospital.  

Methodology: Retrospective chart review where patients were screened from July 15, 2023 to July 14, 2025. Eligible patients were those who received greater than or equal to one AED in the emergency department and had a status epilepticus diagnosis documented by a provider during that encounter. AED selection and dose were assessed for appropriateness in accordance with the American Epilepsy Society (AES) 2016 guidelines.

Results: 63 patients were included in this study. Thirty-six patients had a documented history of seizure disorder and thirty were on antiepileptic medications at home. Thirty-nine patients received a benzodiazepine prior to ED arrival, with midazolam being the most frequently used. Average time to first AED administration from seizure onset was nine minutes. 18 (28.6%) patients received an appropriate agent and weight-based dose in the ED. Out of the 13 patients who receive guideline adherent weight-based dosing of a second-line agent, 12 had pharmacists involved in their care.

Conclusions: Majority of patients received lower than recommended weight-based doses of benzodiazepines and second-line AEDs in the ED. Most patients who received the appropriate initial agent and dose for status epilepticus had pharmacist involvement in their care, suggesting the impact of pharmacist intervention on treatment optimization.

Presentation Objective: the application of the American Epilepsy Society (AES) treatment guidelines for pharmacologic management of status epilepticus in the emergency department. Self-Assessment: What is one of the most common reasons for benzodiazepine underdosing in status epilepticus?

Comparing Safety and Efficacy of Subcutaneous Unfractionated Heparin Dosing Frequencies for Venous Thromboembolism Prophylaxis in a Community Hospital
Authors: Jonathan Johnson, Adam Harnden, Madison Sanders, M. Trey Dailey, Nancy Bailey, Matthew Hadley
Background: Venous thromboembolism (VTE) is a major cause of in-hospital morbidity and mortality with an estimated 375,000 new cases and approximately 100,000 deaths annually in the United States. Patients in the hospital are at a higher risk of developing VTE due to underlying conditions and acute illness. Using unfractionated heparin (UFH) to prevent VTE is an appropriate choice of therapy to decrease the risk of VTE events and death; however, there is not a consensus on administration frequencies. This study aimed to assess the safety and efficacy between dosing strategies in patients that were admitted to a community hospital.
Methods: This retrospective, institutional review board approved study, was conducted at a 344-bed community hospital in Montgomery, Alabama. A clinical decision support tool was utilized to identify patients receiving UFH 5,000 units subcutaneously twice daily (BID) or three times daily (TID) between January 1, 2024 to December 31, 2024. Patients included in the study were at least 19 years old, non-surgical, and received prophylactic UFH 5,000 units for at least 48 hours dosed either BID or TID. Patient populations excluded were pregnant patients, trauma patients, those on continuous renal replacement therapy, those who had a major bleed upon admission, therapeutic anticoagulation doses for more than 12 hours, received low molecular weight heparin or fondaparinux, or if patients received both UFH dosing schedules for at least 48 hours. Patients were separated into two cohorts of UFH dosing: BID or TID. The primary endpoint of this study was the incidence of VTE events. Secondary endpoints included incidence of the individual components of VTE: deep vein thrombosis and pulmonary embolism. Other secondary endpoints included major and minor bleeding, heparin-induced thrombocytopenia, hospital length of stay (LOS), hospital re-admission, and in-hospital mortality. Data for the study were collected from an on-site secure electronic medical record where patient information was reviewed. Power was calculated through an open-access statistical analysis software such that 120 patients were required to reach 90% power. Appropriate statistical tests were applied to analyze data as well as appropriate use of descriptive statistics.
Results: A total of 140 patients were included in this study with 70 patients in each arm, meeting protocol. A total of 156 patients were excluded with the majority due to not receiving doses for at least 48 hours.  The primary outcome, incidence of VTE, occurred in 1/70 (1%) patients in the TID dosing group compared to no incidence of VTE in the BID group (P=1). The incidence of VTE that occurred in the TID group was due to a deep vein thrombosis. Major bleeding occurred in 1/70 (1%) patients in the TID group and minor bleeding occurred in 1/70 patients (1%) of both the BID and TID groups. Re-admission rates occurred in 35 patients in the BID group compared to 23 patients in the TID group (P=0.06). Incidence of in-hospital mortality occurred in 3 patients in the BID group compared to 10 patients in the TID group (P=0.08). Mean number of days for LOS was 7.94 for the BID group and 10.57 for the TID group (P=0.13).
Conclusion: In this study, patients receiving UFH 5,000 units for VTE prophylaxis had similar safety and efficacy endpoints when comparing BID and TID dosing. Limitations of this study include being a single center study that relied on medical record documentation and having difficulty in extrapolating the results due to the prevalence of hospital acquired VTE.

Agitation and Delirium in the ICU: Management with Valproic Acid
Maddie Treadway; Sarah Wyatt; Robert Steed; Steve Lindley
Background: Agitation and delirium are common complications in critically ill patients, with delirium occurring in up to 80% of mechanically ventilated patients in the intensive care unit (ICU) setting. These conditions are associated with an increased cost to healthcare systems due to prolonged hospital and ICU length of stay, long-term cognitive impairment, and increased morbidity and mortality. Pharmacological management of delirium and agitation in the ICU often involves antipsychotics or sedatives, which are limited by their arrhythmogenic and deliriogenic side effects. Due to the lack of improvement in clinically meaningful patient-centered outcomes, the Society of Critical Care Medicine’s focused guideline update could not make a recommendation for or against the use of antipsychotics over usual care. More recently, valproic acid (VPA), has emerged as a potential alternative for the management of delirium and agitation in the ICU. Despite promising preliminary data for VPA, evidence remains limited, and institutional practices vary widely. The purpose of this study was to evaluate the efficacy and safety of VPA for the management of agitation and delirium in ICU patients.

Methods: This single-center, retrospective descriptive analysis evaluated 60 adult patients admitted to a medical, surgical-trauma, or cardiovascular ICU from 1/1/2022-7/1/2025. Patients were included if they were ≥ 18 years old, admitted to an ICU for ≥ 24 hours, and received scheduled VPA for the management of delirium or agitation for ≥ 3 days. Patients were excluded if they received VPA for any other indication (i.e., seizures), were pregnant, had a critical care pain observation tool score ≥ 3 immediately before VPA initiation, or were prescribed VPA prior to admission. The primary outcome was the overall change in the Intensive Care Delirium Screening Checklist (ICDSC) and Riker Sedation-Agitation Scale (SAS) scores. The secondary outcomes were the incidence of agitation (SAS > 4) and delirium (ICDSC ≥ 4) for up to 7 days and the change in concurrent psychoactive medications over 7 days. The safety outcome was the incidence of adverse events.

Results: A total of 988 VPA orders were identified, corresponding to 182 patients after removal of duplicate orders. Ninety patients met initial screening criteria, with 60 patients included in the outcomes analysis based on availability of ICDSC and SAS scores. Following initiation of VPA, the incidence of agitation decreased from 80% on days 0–1 to 18.3% on days 3–7 (z = - 5.8, P < 0.001). The incidence of delirium decreased from 46.7% on days 0–1 to 25% during days 3–7 (z = - 2.9, P = 0.003). The median concurrent psychoactive medication use was 3 (IQR 1-5) vs. 3 (IQR 1.75-4.25) on day 1 vs. day 7, respectively. Thrombocytopenia (platelets < 100 10*3/µL) occurred in 4 (6.7%) patients, elevated AST (> 80 IU/L) in 12 (20%) patients, elevated ALT (> 80 IU/L) in 8 (13.3%) patients, and hyperammonemia (> 60 µmol/L) in 7 (11.7%) patients.

Conclusion: In this retrospective analysis, initiation of VPA was associated with statistically significant reductions in agitation and delirium scores among critically ill patients. However, interpretation of these results should be made cautiously given the retrospective design, documentation variability, and the complex nature of critically ill patient populations. Further prospective studies are needed to compare VPA to the standard of care for agitation and delirium treatment in the ICU and establish optimal dosing strategies.

BACKGROUND: Sepsis is a leading cause of hospital morbidity and mortality. While current Surviving Sepsis Guidelines emphasize early broad-spectrum antibiotic administration, they do not address sequencing. Evidence suggests that delays in gram negative coverage, against Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa, are associated with increased mortality, and administration of broad-spectrum beta lactams prior to vancomycin may improve survival. In practice, initiation of antibiotic therapy is delayed due to lack of IV access, blood culture collection, medication verification, and absence of standardized order sets. These limitations are greater among spinal cord (SCI) and traumatic brain injury (TBI) patients who have atypical presentations complicating early sepsis recognition. The aim of this study is to assess the order of appropriate antibiotic administration, delays in administration from lack of intravenous (IV) access, and timing of blood culture collection to support creation of a sepsis order set.

METHODS: This is a single-center, retrospective, quality improvement project performed at a rehabilitation center. Patients (≥18 years) admitted between July 1, 2023, and July 31, 2025, who met systemic inflammatory response (SIRS) criteria and received IV vancomycin and one gram-negative agent for sepsis or neutropenic indications were included. Patients were excluded if antibiotic timing was inadequately documented.
Data collected included patient demographics, injury type (SCI or TBI), sepsis indicators, timing of sepsis recognition, antibiotic timing and sequencing, blood culture collection, lactate measurement, IV fluid resuscitation, and IV access placement.  

The primary outcome was sequencing, including gram-negative coverage first followed by gram-positive coverage antibiotics. Secondary outcomes included time between gram-negative and gram-positive therapy, percentage of patients with cultures drawn before antibiotic administration, frequency of IV-related delays, and type of IV line. Data was analyzed using descriptive statistics. 

RESULTS: A total of 65 patients meeting SIRS inclusion criteria were evaluated. The median age was 34 years old (SD 18.8), with males comprising 81.5% of the cohort (n=53). Injury classifications included SCI (n=24, 37%), TBI (n=26, 41.5%), and dual (n=14, 21.5%) diagnoses.
When vancomycin was administered prior to gram-negative therapy, the mean delay to gram-negative coverage was 141 minutes. Upon further analysis, vancomycin was administered first in 15.4% of encounters, while gram negative agents were more frequently administered first, including piperacillin-tazobactam (57%), cefepime (20%), and meropenem (7.6%).  

In 20% of encounters, blood cultures were either obtained after the first antibiotic dose or not obtained. IV access was not established prior to antibiotic ordering in 46.2% of patients. Antibiotics were administered via peripheral IV (75%), midline (11%), or peripherally inserted central catheter (14%). 

CONCLUSIONS: Administering vancomycin first resulted in an expected delay of more than two hours before effective gram-negative coverage. This delay was likely due to the standard vancomycin infusion time at this facility. Because delays in antibiotic administration increase mortality in sepsis, education on Y-site compatibility is essential to allow compatible agents to be administered simultaneously and facilitate faster, more efficient antibiotic delivery. Moreover, 20% of blood cultures were collected inappropriately, compromising diagnostic accuracy and limiting targeted antibiotic therapy, highlighting the need for reinforcement of proper culture collection.

Additionally, nearly half of patients meeting sepsis criteria at the time of antibiotic ordering did not have IV access, reflecting a challenge unique to rehabilitation settings, where the goal is early discontinuation of IV lines to enhance mobility, minimize line associated complications, and support functional recovery. However, for sepsis, a delay in IV access inadvertently leads to a delay in antibiotic administration. 
These findings show inconsistent sepsis workflows and clinically relevant delays which can impact patient outcomes, highlighting the need for a standardized sepsis order set in rehabilitation hospitals to streamline IV access, culture collection, and appropriate antibiotic prioritization.