HOUSTON METHODIST DEPARTMENT OF PHARMACY Annual Research Report | 2016–2017
2016 – 2017 HOUSTON METHODIST PHARMACY RESIDENTS
Houston Methodist Department of Pharmacy The Department of Pharmacy collaborates with the health care team to provide innovating, personalized, cost-effective pharmaceutical care in a culture dedicated to safety and quality. Houston Methodist Department of Pharmacy’s vision is to be recognized as a global leader of pharmaceutical care in the health care setting. To that end, we strive to: • Continuously improve the safety and quality of patient care and the medication management process • Cultivate an environment of collaboration and teamwork • Provide high-quality training and education to our technicians, student interns, residents, and pharmacists • Maximize the use of automation and information technology • Maximize cost efficiencies and resource utilization
TABLE OF CONTENTS
2 | Letter from Daniel L. Metzen, PharmD, MBA
3 | Letter from Alex C. Varkey, PharmD, MS
System Director of Pharmacy Services - Houston Methodist Director of Pharmacy Services – Houston Methodist Hospital
4 | Pharmacy Research Committee Members
5 | Letter from Joshua T. Swan, PharmD, MPH
Pharmacy Research Committee Chair
6 | Pharmacy Research Funding ASHP Foundation Pharmacy Residency Expansion Grant ASHP Foundation Master’s Residency Practice-Based Research Grant National Institutes of Health R01 Subaward
8–24 | 2016–2017 Houston Methodist Hospital Pharmacy Residency Class 8 | PGY1 Pharmacy Residency Meghann L. Davis, PharmD Ekim Ekinci, PharmD, MS R. Christina Xia, PharmD T. Cindy Yang, PharmD
12 | PGY1 International Graduates Pharmacy Residency
Nghi (Andy) V. Bui, PharmD Elsie Rizk, PharmD
14 | PGY1/PGY2 Health-System Pharmacy Administration Residency Sunny B. Bhakta, PharmD Pei Jen Lin, PharmD Amanda M. Beck, PharmD, MS
17 | PGY2 Critical Care Pharmacy
Residency Amanda A. Holyk, PharmD Tara L. Molina, PharmD
19 | PGY2 Infectious Diseases
Pharmacy Residency Ryan R. Keul, PharmD
20 | PGY2 Internal Medicine Pharmacy Residency . Tate Cutshall, PharmD B
21 | PGY2 Oncology Pharmacy Residency eronica B. Ajewole, PharmD V Lindsay A. Edmondson, PharmD
23 | PGY2 Solid Organ Transplant
Pharmacy Residency
Robin Klasek, PharmD Derek D. Owen, PharmD
LETTER FROM THE SYSTEM DIRECTOR OF PHARMACY SERVICES ON BEHALF OF THE HOUSTON METHODIST PHARMACY MANAGEMENT TEAM, I would like to take the opportunity to thank the members of the pharmacy team and the Pharmacy Research Committee for their dedication and contribution to scientific research. Through the efforts of the Pharmacy Research Committee, pharmacy seeks to improve our knowledge and ability to provide quality of care for even our most complex patients. This annual report serves to demonstrate the drive for excellence in patient care and pharmacy practice among our department. Thanks to each and every one who contributed to this endeavor. We look forward to opportunities to grow our involvement in research opportunities across our system hospitals.
Daniel L. Metzen, PharmD, MBA System Director of Pharmacy Services
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LETTER FROM THE DIRECTOR OF PHARMACY SERVICES ON BEHALF OF THE HOUSTON METHODIST HOSPITAL (HMH) PHARMACY MANAGEMENT TEAM, I want to extend my sincere appreciation to all of our graduating residents. As another residency year comes to a close, I continue to be in awe of the growth demonstrated by everyone completing our pharmacy residency programs. Our residents fully invest in their respective opportunities to grow both personally and professionally, and in the process, make a lasting impact on HMH Pharmacy’s effort to optimize patient outcomes. The 2016 – 2017 residency year will forever be known as a year of transitions, and incredible resolve. HMH Department of Pharmacy Services successfully navigated five major technology go-lives within a one-year period, including: • DoseEdge® – Sterile Compounding Workflow Software • Upgrade from Pyxis® 4000 to Pyxis® ES – automated dispensing cabinets • Epic® – electronic health record and establishment of barcode medication administration • IV ONCO® – robotic preparation of select chemotherapy doses • Intelliguard® – RFID-enabled medication inventory management system Each of these major transitions took considerable commitment to not only train on these new systems, but take ownership of an immense amount of new knowledge and workflows and actively engage in the conversion and optimization processes. Our successes with these transitions in technology, in addition to our continued success in clinical practice, are a true testament to HMH pharmacy’s commitment to advancing patient care. At Houston Methodist Hospital, we take “Leading Medicine” seriously. I continue to be impressed with the quality of pharmacy’s efforts in growth and innovation, and I have our residents and their preceptors to thank for most of that. We remain in position to develop and share innovative practices because of our Pharmacy Research Committee, a group dedicated to ensuring excellence in the quality and feasibility of research conducted by HMH pharmacy. As we move ahead to the 2017 – 2018 residency year, we will continue with laser focus on what we do each and every day. That includes enhancing our medication distribution, clinical services, and regulatory/quality compliance efforts to provide an environment of unparalleled safety, quality, service, and innovation for our patients. No matter your role, you play an integral part in our department’s mission and remain the greatest reason for our success. I leave you with this quote:
“The moment we believe that success is determined by an ingrained level of ability as opposed to resilience and hard work, we will be brittle in the face of adversity!” – Joshua Waitzkin While challenges may continue to lie ahead, it is our sense of hard work, integrity, and resilience that will allow us to continue thriving as a highly successful part of the patient care team. No matter our role, we must constantly strive towards a better form of ourselves for the patients we serve. We will continue to be asked to do more, and we must continue to answer the call. I look forward to your continued success. Thanks for all that you have done and continue to do for patients.
Alex C. Varkey, PharmD, MS Director of Pharmacy Services
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PHARMACY RESEARCH COMMITTEE MEMBERS
Joshua T. Swan, PharmD, MPH, BCPS Chair
Jill C. Krisl, PharmD, BCPS Project Approval Lead
David R. Putney, PharmD, MPH, BCPS - AQ Cardiology Project Alignment Lead
Michael Johnson, PhD External Statistician Consultant & University of Houston Collaboration Lead
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Katherine K. Perez, PharmD, BCPS-AQ ID Vice Chair – Project Development Lead
Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM Education Lead
Amaris Fuentes, PharmD, BCPS, BCCCP Visibility Lead
A. Carmine Colavecchia, PharmD, MS, BCPS Project Support Lead
Sara L. Varnado, PharmD, BCPS Houston Methodist Collaboration Lead
LETTER FROM THE PHARMACY RESEARCH COMMITTEE CHAIR It is my honor and privilege to recognize the commitment of the 2016 – 2017 Pharmacy Research Committee members and to celebrate the research success of Houston Methodist pharmacy over the last year. The mission of the Pharmacy Research Committee is to ensure excellence in the quality and feasibility of research conducted and the quality of research training provided by the Department of Pharmacy at Houston Methodist. In 2015 – 2016, the Pharmacy Research Committee developed four core programs to meet our mission: Project Approval, Project Alignment, Education, and Project Support. This year, the Pharmacy Research Committee built upon the tremendous success of our first four programs and created four exciting new programs:
1. Project Development: This program aims to provide pharmacy investigators with support to develop research proposals for future projects and grant applications. One early success of this program was supporting Sunny Bhakta, PharmD, on his winning application for an American Society of Health-System Pharmacy Foundation Master’s Resident Practice-Based Research Grant. A new series of pharmacy resident workshops that started in early spring helped pharmacy residents develop major project proposals that set the foundation for research for next year’s 2017 – 2018 pharmacy residency class. 2. University of Houston Collaboration: This program aims to establish a research collaboration between pharmacy investigators at Houston Methodist and faculty and students in the Department of Pharmaceutical Health Outcomes and Policy at the University of Houston. During this inaugural collaboration year, five doctor of philosophy candidates provided epidemiology and biostatistical support for five Houston Methodist pharmacy resident major research projects. 3. Houston Methodist Collaboration: This program aims to collaborate with research oriented committees and offices throughout Houston Methodist to improve research education for pharmacy investigators and to identify opportunities for research collaboration. 4. Visibility: This program aims to communicate results of pharmacy research both internally and externally to maximize impact and sustainability. This program supports the annual Pharmacy Research Report, annual Pharmacy Research Symposium, and pharmacy research website. In additional to doubling our portfolio of programs, Pharmacy Research Committee membership expanded from eight to 10 members. Additionally, the Pharmacy Research Committee appointed a new vice chair position to provide additional leadership for established programs. I would like to formally thank all members of the Pharmacy Research Committee for their hard work, enthusiasm, and dedication that was critical for these successes, and I look forward leading this amazing group over the next year.
Joshua T. Swan, PharmD, MPH, BCPS Chair, Pharmacy Research Committee
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PHARMACY RESEARCH FUNDING AMERICAN SOCIETY OF HEALTH-SYSTEM PHARMACY FOUNDATION GRANTS The American Society of Health-System Pharmacy (ASHP) Foundation provides a number of research grant programs that foster young investigators and encourage collaborative, multi-disciplinary research. Houston Methodist Hospital Department of Pharmacy was awarded two grants this year totaling $30,000. The PGY2 Solid Organ Transplant Residency Program and residency director, Kyle L. Dawson, PharmD, MBA, BCPS, were awarded one of 10 Pharmacy Residency Expansion Grants. The ASHP Foundation established the grant program in 2011 to answer the shortage of pharmacy residency programs. The $25,000 grant allowed the Houston Methodist program to expand to two PGY2 residents to help address the needs of a growing solid organ transplant population. The program will continue to provide post-graduate training for two pharmacy residents for continued contributions to patient care, research, and quality improvement efforts. Sunny B. Bhakta, PharmD, PGY1 resident of the PGY1/2 Health-System Pharmacy Administration Residency and MS Candidate in Pharmacy Leadership and Administration at the University of Houston, received a $5,000 Master’s Resident Practice-Based Research Grant. The grant provides support for practice-based research conducted by residents in ASHP accredited pharmacy residency programs related to the ASHP/ ASHP Foundation Practice Advancement. Bhakta, along with collaborators A. Carmine Colavecchia, PharmD, MS, BCPS, and Linda Haines, PharmD, MS, BCPS, of Houston Methodist Hospital and Michael Johnson, PhD and Kevin W. Garey, PharmD, MS, FASHP, of the University of Houston College of Pharmacy, will evaluate the impact of a systematic approach to optimizing medication alerts in a health-system. The project aims to utilize a committee led initiative that involves modification of the medication alerting structure within the health system to improve alert sensitivity and response rates. ADDITIONAL EXTRAMURAL RESEARCH FUNDING Joshua T. Swan, PharmD, MPH, BCPS, was awarded a $73,000 subaward from Vanderbilt University Medical Center to collaborate on the 6R01HL111111 grant from National, Heart, Lung, and Blood Institute at the National Institutes of Health. This subaward established Houston Methodist Hospital as an enrollment site for the Maximizing the Efficacy of Sedation and Reducing Neurological Dysfunction and Mortality in Septic Patients With Acute Respiratory Failure (MENDS II) clinical trial. This multicenter, randomized, clinical trial will compare dexmedetomidine versus propofol for the outcome of delirium-free, coma-free days among ventilated and critically ill adults with sepsis.
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Antibiotic exposure associated with hospital-acquired Clostridium difficile infection at a tertiary-care medical center Meghann Davis, PharmD; Harlan Sparrow IV, MA; Judy Ikwuagwu, PharmD; William Musick, PharmD; Kevin Garey, PharmD, MS; Katherine Perez, PharmD PURPOSE
Clostridium difficile is the most common causative pathogen of health care-associated infections in the United States. There are more than 450,000 new cases of Clostridium difficile infection (CDI), 29,000 attributable deaths, and a significant cost burden to acute healthcare facilities of up to $4.8 billion annually. Moreover, approximately 20 to 30% of individuals with a first episode of CDI will experience recurrence despite adequate antibiotic treatment. The most important modifiable risk factor to prevent CDI is to minimize exposure to antibiotics, particularly broad-spectrum agents. We sought to identify specific high-risk antibiotics and incorporate into an antibiotic risk algorithm to maximize antimicrobial stewardship interventions to reduce hospital-acquired CDI within Houston Methodist. METHODS
A retrospective cohort study was conducted among adult patients admitted to one of five sites within Houston Methodist from October 2014 to September 2016. CDI cases were identified by documented positive molecularbased laboratory results. Antibiotic exposure was characterized by equivalent days of therapy, with a lookback period of either 30 days prior to documented positive CDI result or hospital discharge for cases and controls, respectively. Antibiotics were categorized as low, medium, or high risk based on a previously validated algorithm. A multivariate logistic regression was used to analyze CDI
risk associated with specific antibiotics in combination with other known risk factors such as the Charlson comorbidity index, receipt of a proton pump inhibitor (PPI), and age. RESULTS
A total of 97,130 patients were included in this investigation. Approximately 2% of patients were CDI positive and 65% of patients received at least one antibiotic of any risk category during admission. The mean Charlson comorbidity index was 1.88 Âą 2, and 40% of patients received PPI therapy. Receipt of either a low, medium, or high risk antibiotic did increase CDI risk, but a more consistent increase in risk was observed when comparing antibiotic risk categories based on equivalent days of therapy. Broad-spectrum antibiotics, including ampicillinsulbactam, piperacillin-tazobactam, ceftriaxone, cefepime, carbapenems, and sulfamethoxazole-trimethoprim were the agents associated with the highest risk of CDI. A more severe Charlson comorbidity index increased CDI risk independent of receipt of a high risk antibiotic. In contrast, receipt of a PPI posed a consistent risk only when combined with receipt of a high risk antibiotic. CONCLUSION
We identified specific antibiotics that increase the risk of healthcare-acquired CDI. The results of this investigation will be used to develop targeted antimicrobial stewardship interventions and optimize inpatient antibiotic therapy to eliminate hospital-acquired CDI within Houston Methodist.
PGY1 PHARMACY RESIDENCY
Meghann L. Davis, PharmD Meghann earned her BS in Biomedical Sciences from Texas A&M University in 2012 and PharmD from the University of Houston College of Pharmacy in 2016. Following the completion of her PGY1 residency, Meghann will continue her post-graduate training as a PGY2 Pharmacy Resident in solid organ transplant at Houston Methodist Hospital. Primary project preceptor: Katherine K. Perez, PharmD, BCPS-AQ ID Presented at: 2016 VizientÂŽ Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Venous thromboprophylaxis: a point prevalence study of sequential compression device compliance at a tertiary academic medical center Ekim Ekinci, PharmD, MS; Melanie Ruegger, PharmD; A. Carmine Colavecchia, PharmD, MS; David Putney, PharmD, MPH PURPOSE
In-hospital venous thromboembolism (VTE) is a complication that results in increased hospital length of stay, financial burden, morbidity, and mortality. Sequential compression devices (SCDs) are commonly ordered for hospitalized patients as a mechanical prophylaxis measure for lowering VTE risk. While a handful of studies evaluated SCD compliance in post-surgical and critically ill patients, limited current literature exists on general medical patients’ SCD compliance. The purpose of this study was to evaluate compliance with active SCD orders in a broad patient population, including medical, surgical, and critically ill patients, at predefined time points at a tertiary academic medical center. METHODS
This observational, single-center study with a pointprevalence component determined patients with active SCD orders through the electronic medical record (EMR) and evaluated SCD compliance between the times of 0600-0800 and 1400-1600 on study day. Patients were considered compliant with SCD orders if they were ambulating, or if they were either in bed or sitting with SCDs worn on legs, turned on, and functioning. Overall SCD compliance was defined as being compliant at both time points. Patients’ EMRs were accessed to obtain demographic, VTE prophylaxis and contraindications to VTE prophylaxis, SCD charting information, and calculate Caprini risk scores. Following patient discharges, study data was
matched with a claims database to determine in-hospital VTE development rate. Variables associated with overall SCD compliance were assessed. RESULTS
Overall SCD compliance was significantly lower in both medical and surgical units compared to intensive care units (11.3% medical, 16.2% surgical, 31.8% intensive care; medical vs. surgical p=0.652; medical vs. intensive care p<0.001; surgical vs. intensive care p=0.005). No difference was found in SCD compliance between morning and afternoon time points for the entire study population (26.9% morning vs. 25.3% afternoon; p=0.198). Median Caprini risk scores for patients in medical, surgical, and intensive care units were 4, 5, and 6, respectively. Overall, 69.9% of patients were deemed to be on adequate VTE prophylaxis for their Caprini risk level. CONCLUSION
Overall SCD compliance was suboptimal based on institutional standards. Patients in medical units were found to have lower SCD compliance rates compared to patients in surgical and intensive care units, despite being at an elevated in-hospital VTE development risk. Patient SCD compliance did not differ significantly between morning and afternoon time points. Efforts should be focused on understanding and mitigating reasons for SCD noncompliance.
PGY1 PHARMACY RESIDENCY
Ekim Ekinci, PharmD, MS Ekim earned her BS in Chemistry from Rice University in 2010 and PharmD and MS in Pharmaceutical Outcomes and Policy from the University of Kentucky College of Pharmacy in 2016. Following completion of her PGY1 residency, Ekim will continue her post-graduate training as a PGY2 Pharmacy Resident in oncology at Houston Methodist Hospital. Primary project preceptor: Melanie C. Ruegger, PharmD, BCPS Presented at: 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Evaluation of neuromuscular blockade reversal on postoperative outcomes in a cardiovascular surgery population R. Christina Xia, PharmD; Divina Tuazon, MD; Fariedeh Bostan, PharmD; Nandita Kachru, PhD; Amaris Fuentes, PharmD PURPOSE
RESULTS
Residual neuromuscular blockade, which is associated with respiratory complications, prolonged intensive care unit (ICU) stays, skeletal muscle weakness, and poor recovery, can occur postoperatively in 30 to 60% of patients. Neostigmine is a reversal agent used to eliminate residual blockade, however, conflicting data exists on the association of neostigmine with respiratory complications, postoperative nausea/vomiting, and cardiac effects. The primary objective of this study was to examine the effect of neostigmine use on the duration of postoperative mechanical ventilation (MV) and other post-operative complications.
Duration of MV was significantly shorter among neostigmine users (7.36 [IQR 5.17 to 23] vs. 5.23 [IQR 3.93 to 9.33] hours, p=0.03). In addition, more neostigmine users met the early extubation benchmark of less than six hours compared to non-users (55 vs. 34 patients, respectively, p=0.04) A multiple linear regression on the primary endpoint revealed that neostigmine use was associated with a 34% (20.4 minute, p=0.007) reduction in the duration of MV as compared to non-users. No significant differences were found in regards to the secondary endpoints: incidence of postoperative pneumonia, incidence of postoperative atelectasis, non-invasive positive pressure ventilation use after extubation, need for reintubation during hospitalization, PaO2/FiO2 at time of first postoperative arterial blood gas, hospital length of stay, ICU length of stay, need for assisted living post discharge, or total antiemetic doses used up to postoperative day three.
METHODS
A single center, retrospective chart review was conducted from January 2015 to April 2016. The study cohort included adult patients who received a pre-specified cardiac procedure and a non-depolarizing neuromuscular blocking agent. Exclusion criteria included patients who received any type of organ transplant or mechanical circulatory support devices with the exception of intra-aortic balloon pumps. The primary endpoint was the duration of postoperative MV, defined as the time from end of procedure to time of initial extubation.
CONCLUSION
Neostigmine use significantly decreased the duration of postoperative mechanical ventilation in cardiovascular surgery patients. In addition, significantly more neostigmine users met the Society of Thoracic Surgeryâ&#x20AC;&#x2122;s early extubation benchmark of less than six hours. Neostigmine use was also not found to be associated with respiratory complications or postoperative nausea/vomiting, and did not impact hospital and ICU length of stays.
PGY1 PHARMACY RESIDENCY
R. Christina Xia, PharmD Christina earned her BS in Pharmaceutical Sciences in 2014 and PharmD in 2016 from the University of Pittsburgh School of Pharmacy. Following the completion of her PGY1 residency, Christina will continue her post-graduate training as a PGY2 Pharmacy Resident in critical care at Houston Methodist Hospital. Primary project preceptor: Amaris Fuentes, PharmD, BCPS, BCCCP Presented at 2016 VizientÂŽ Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Direct oral anticoagulants versus aspirin for venous thromboembolism prophylaxis after orthopedic surgery T. Cindy Yang, PharmD; Michelle Murillo, PharmD; Aisha Vadhariya, BPharm; Allison Wilson, PharmD; David Putney, PharmD, MPH; James Muntz, MD PURPOSE
RESULTS
Venous thromboembolism (VTE) is a potential complication following major orthopedic surgery. The 2012 American College of Chest Physicians’ (ACCP) guideline recognized certain direct oral anticoagulants (DOACs) and aspirin as acceptable options for VTE prophylaxis following orthopedic surgery; however, there are no trials comparing safety and efficacy of DOACs versus aspirin. This study aims to compare VTE and bleeding risks in patients that underwent total knee replacement (TKR), total hip replacement (THR), or hip fracture surgery (HFS) that received DOACs or aspirin for thromboprophylaxis.
A total of 420 patients were included in this study with 210 patients in each arm. The proportion of patients who met the primary outcome of bleeding or VTE was similar between the DOACs and the aspirin group (12.9% vs 13.3%, respectively; p-value>0.5 in all propensity score matched quartiles). Bleeding occurred in 12.4% of the patients receiving DOACs compared to 12.6% in the aspirin group (p=0.89). VTE events were numerically lower in the DOAC group but the result was not statistically significant (0.5% and 1.4%). Readmission due to VTE or bleeding events as well as proportion of patients with major bleeding were also similar between the groups. VTE prophylaxis with DOACs was associated with a significantly higher proportion of blood transfusion of at least two units of blood postoperatively compared to the aspirin group (7.1% compared to 2.9%; p=0.04).
METHODS
A single center, retrospective chart review was performed on patients who underwent TKR, THR, or HFS from 2011 - 2015. Patients were stratified into groups based on agent received for VTE prophylaxis: one of the DOACs or aspirin greater than 81mg daily. Primary endpoint evaluated was the net clinical outcome of bleeding and thrombosis rates. Secondary endpoints include bleeding rates, thrombosis rates, transfusion rates and 90 day readmission rates due to bleeding or thrombosis. The primary endpoint was analyzed using adjusted logistic regression model with propensity score added as an independent variable. Secondary endpoints were analyzed with student’s t-test for continuous outcomes and Chisquare test or Fisher’s exact test for categorical outcomes.
CONCLUSION
DOACs and aspirin were shown to be similar in efficacy and safety for VTE prophylaxis in patients who underwent major orthopedic surgeries. Although DOACs are associated with more post-operative transfusions requiring two or more units of blood, no differences in bleeding rates were detected.
PGY1 PHARMACY RESIDENCY
T. Cindy Yang, PharmD Cindy earned her PharmD from the University of Houston College of Pharmacy in 2016. Following completion of her PGY1 residency, Cindy will continue her postgraduate training as a PGY2 Pharmacy Resident in internal medicine at Houston Methodist Hospital. Primary project preceptor: Michelle U. Murillo, PharmD Presented at: 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Prevalence of cognitive impairment in elderly patients upon hospital admission detected by Mini-Cog assessments performed by pharmacy students Nghi (Andy) Bui, PharmD; Mobolaji Adeola, PharmD; Rejena Azad, PharmD; Joshua Swan, PharmD, MPH; Kathryn Agarwal, MD; Manvi Sharma, MS; Michael Liebl, PharmD; George Taffet, MD PURPOSE
Hospitalized patients with cognitive impairment may have difficulty understanding medication education provided by healthcare workers and are at increased risk for hospital readmission. Mini-Cog is a validated assessment tool that can be used to detect cognitive impairment in approximately three minutes with minimal training. This study evaluates the feasibility of using pharmacy students to perform Mini-Cog assessments and estimates the prevalence of cognitive impairment within 24 hours of hospital admission. METHODS
This prospective, single-center study enrolled patients aged 65-years and older admitted from the emergency department from January 2017 to April 2017. Fourth year pharmacy students on Advanced Pharmacy Practice Experience rotations were trained to administer Mini-Cog assessments following completion of a pre-specified training program. The primary outcome was the prevalence of cognitive impairment defined as a Mini-Cog score of three or less among elderly patients (age â&#x2030;Ľ65) within 24 hours of hospital admission from the emergency department. Physicians, nurses, and pharmacists were notified of all patients with abnormal Mini-Cog results. Social workers were consulted to provide additional assistance post discharge. Secondary outcomes includes the average number of observed Mini-Cog practice assessments required for pharmacy students to meet the
competency requirements to assess feasibility and the presence of a caregiver at bedside at the time of patient assessment. RESULTS
The prevalence of cognitive impairment was 56% (55 of 98). Among those 55 patients, 42 (76%) failed the Clock-drawing test, and from this group, only four patients were able to recall all the words in the three-word recall test. A total of eight pharmacy students were trained for the project. The average number of training assessments required to become competent at performing the Mini-Cog was 4.6 Âą 1.1. Caregiver availability at bedside at time of cognitive assessment was 32% (31 of 98). Among 55 patients with cognitive impairment, 22 (40%) had caregivers at bedside at the time of cognitive assessment. CONCLUSION
The prevalence of cognitive impairment within 24 hours of hospital admission from the emergency department was 56%. This high prevalence could impact the amount of information retained by patients during medication education sessions, especially if caregivers are not present during medication education. This study provides evidence that Mini-Cog assessments can be performed by fourth year pharmacy students during routine patient education provided on hospital rotations..
PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES
Nghi (Andy) V. Bui, PharmD Andy earned his PharmD from the University of Houston College of Pharmacy in 2016. Following completion of his PGY1 residency, Andy plans to pursue a PGY2 Pharmacy Residency in infectious diseases. Primary project preceptor: Mobolaji A. Adeola, PharmD, BCPS Presented at 2017 Houston Medication Safety Symposium, Houston; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska; 2017 American Society of Health-System Pharmacists Summer Meeting, Minneapolis
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Comparison of anti-Xa versus activated partial thromboplastin time monitoring of unfractionated heparin after vascular surgery: a single-center retrospective study Elsie Rizk, PharmD; Allison Wilson, PharmD; Michelle Murillo, PharmD; David Putney, PharmD, MPH PURPOSE
Vascular surgery patients often require anticoagulation with intravenous unfractionated heparin (UFH) after their procedure to prevent intervention site thrombosis. At our institution, a higher incidence of bleeding events was noted in vascular surgery patients when UFH infusions were monitored via anti-Xa levels compared to activated partial thromboplastin time (aPTT) values. The purpose of this study was to compare the two monitoring strategies in terms of major bleeding events in the vascular surgery population. METHODS
This study was a single center, retrospective chart review that included patients who had a vascular surgical procedure and were placed on a pharmacy-managed IV UFH protocol post-operatively. Exclusion criteria were pregnancy, age less than 18 years, and monitoring switched from anti-Xa to aPTT (or vice versa) during the same hospital stay. The primary outcome was the proportion of patients experiencing major bleeding events postprocedure. Major bleeding was defined as: bleeding in a critical area or any bleeding causing a hemoglobin drop of greater than or equal to 2g/dL within 24 hours or leading to transfusion of two or more units of packed red blood cells (PRBC). Secondary outcomes included any bleeding episodes documented, the proportion of patients who
received PRBC transfusions post-procedure, incidence of thrombosis, and the proportion of patients who had supratherapeutic levels at the time of bleeding. RESULTS
A total of 134 patients met our inclusion criteria of having a vascular surgical procedure and a pharmacy-managed IV UFH therapy post-operatively. Seventy-two patients managed via anti-Xa monitored heparin protocol, from January 2013 to September 2014 were compared to 62 patients with aPTT monitoring from October 2014 to May 2016, after the re-institution of an aPTT monitored pharmacy heparin protocol. Major bleeding occurred in 16% of the patients who received an anti-Xa monitored heparin protocol versus 8% of the patients whose received an aPTT monitored protocol (p=0.19). A bleeding episode was documented in 26% of the patients in the anti-Xa group versus 14% in the aPTT group (p=0.08). CONCLUSION
The use of anti-Xa levels for heparin titration did not lead to an increase in major bleeding in vascular surgery patients compared to aPTT monitoring. The clinical significance of the higher number of bleeding episodes observed with antiXa monitoring needs to be assessed in larger studies.
PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES
Elise Rizk, PharmD Elsie earned her PharmD from the Lebanese American University College of Pharmacy in 2016. Following completion of her PGY1 residency, Elsie is seeking a clinical pharmacist position in Lebanon. Primary project preceptor: Allison D. Wilson, PharmD, BCPS Presented at 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska; 2017 American Society of Health-System Pharmacists Summer Meeting, Minneapolis
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Sterile compounding robot’s impact on safety, efficiency, and cost in a cancer center pharmacy Sunny Bhakta, PharmD; A. Carmine Colavecchia, PharmD, MS; David Curlee, RPh; William Coffey, DDS, RPh; Alex Varkey, PharmD, MS; Daniel Metzen, PharmD, MBA PURPOSE
RESULTS
Sterile compounding automation provides a safe, effective, and unique addition to traditional sterile compounding. Mixed results from early adoption reports and the lack of published results of long-term prospective evaluation of newer automated robotic compounding technologies led to this study evaluating the impact of a sterile compounding robot in cancer center.
An overall reduction in dose turnaround time was observed following implementation of the robotic technology (9.2 ± 3.7 minutes, p=0.01), resulting in a mean turnaround time of 52.3 minutes. Financial efficiency resulted in a projected positive cumulative cash flow of more than $560,000 at five years post capital expenditure and a breakeven point at 3.2 years post-implementation. Supply cost savings contributed to 26.5% of the overall cost savings. Despite a 42% increase in order preparation volume of the cancer center pharmacy, labor efficiency accounted for nearly 73.5% of the overall financial efficiency of the technology. Safety evaluation through failure modes and effects analysis demonstrated a risk reduction from traditional compounding with a risk priority range of 2 to 90 for 10 process steps out of a maximum possible value of 500. Average deviations of the four core drugs compounded in the device was -0.006% from the requested dosage.
METHODS
This 33-week, quasi-experimental study was conducted to evaluate the impact on turnaround time (TAT) of drugs compounded by automated robotic compounding technology (ARCT). TAT was assessed using interrupted time series regression, which may isolate how an intervention changes an outcome of interest over time. Financial efficiency was estimated based on supply cost reduction and labor efficiency accounting for workload fluctuations over time. Safety was described using a team-based risk assessment involving failure modes and effects analysis.
CONCLUSION
Our results support that the implementation of a newer generation ARCT had an overall positive impact on efficiency, safety, and cost within a cancer center pharmacy.
PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY
Sunny B. Bhakta, PharmD Sunny earned his PharmD degree from the University of Houston College of Pharmacy in 2016. Sunny is also a MS candidate in Pharmacy Administration and Leadership at the University of Houston College of Pharmacy. Primary project preceptor: A. Carmine Colavecchia, PharmD, MS, BCPS Presented at 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Alcáldé Southwest Leadership Conference, Galveston, Texas
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Financial impact of transitioning from medication charge on dispense to charge on administration Pei Jen Lin, PharmD; Stephen Ma, MBA; Patrick Birney, PharmD, MS; Julie Atay, PharmD, MBA; A. Carmine Colavecchia, PharmD, MS; Alex Varkey, PharmD, MS; Jane Scott, RPh; Linda Haines, PharmD, MS PURPOSE
As health care institutions implement new electronic health record (EHR) systems and barcode medication administration (BCMA) technology, medication charging models may shift from charge on dispense (COD) to charge on administration (COA). Transitioning to COA may significantly impact pharmacy operations and revenue. There are potential risks of financial loss due to medication barcoding issues, low BCMA compliance, incorrect drug administration documentation, drugs missing from the EHR formulary, incorrect multipliers used for billing units, incorrect NDCs and numeric drug identifiers submitted for claims, and other factors. The objective of this study was to evaluate the financial impact of transitioning from COD to COA upon implementation of a new EHR. METHODS
This single-center, retrospective, quality improvement project was exempt from Investigational Review Board review. The pre- and post-EHR implementation timeframes consisted of January-March 2016 and June-August 2016, respectively. Inpatient (IP) and outpatient (OP) medication charge records were collected from the legacy hospital billing system and the new EHR system. The primary endpoint of the study evaluated the percent change in pharmacy gross revenue (PGR). Secondary endpoints analyzed were percent changes in: gross IP revenue per IP day, gross OP revenue per OP visit, PGR of top 10
drug categories, PGR of top 10 high-cost drugs, quantitycharged of top 10 high-cost drugs, and charge per unit of top 10 high-cost drugs. RESULTS
A total of 12,907 drug items were evaluated and categorized to their respective therapeutic classification. The overall pharmacy gross revenue observed a 3.4% decrease. IP revenue per IP day observed a 1.2% decrease and gross OP revenue per OP visit observed a 2.8% increase. Blood derivatives, antineoplastic agents, and serums/toxoids/vaccines observed increases of 40.3%, 12.7%, and 9.6%, respectively. Of the top 10 high-cost drugs: five observed similar percent changes in revenue and quantity charged due to utilization practices; two drugs observed increases in charge per unit due to more accurate NDC charge methods; one observed a decrease in charge per unit due to brand-to-generic purchasing change. CONCLUSION
Transitioning to COA has potential financial risks and may result in a decrease in gross pharmacy revenue. Performing continuous internal revenue audits is important and may help to identify areas of opportunities to increase charge capture rates to minimize any negative impact. A thorough evaluation and understanding of the billing process is important to accurately assess the revenue impact.
PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY
Pei Jen Lin, PharmD Pei Jen earned her PharmD degree from the University of Houston College of Pharmacy in 2016. Pei Jen is also a MS candidate in Pharmacy Administration and Leadership at the University of Houston College of Pharmacy. Primary project preceptor: Linda A. Haines, PharmD, MS, BCPS Presented at: 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Texas Society of Heath-System Pharmacists Alcáldé Leadership Conference, Galveston, Texas
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Primary care pharmacist impact on health care utilization Amanda Beck, PharmD, MS; Alexandra Tatara, PharmD; Rafael Felippi, PharmD; Melanie Ruegger, PharmD; Julianna Fernandez, PharmD; Linda Haines, PharmD, MS; Michael Liebl, PharmD; Kevin Garey, PharmD, MS PURPOSE
RESULTS
In response to the lack of literature describing medical resident and pharmacist inter-professional impact on health care utilization, the University of Houston College of Pharmacy and the Department of Pharmacy at Houston Methodist Hospital (HMH) studied the effect of clinical services provided by a pharmacist to patients seen in a medical resident ambulatory clinic. The purpose of this study was to implement a pharmacy service in a primary care practice designed to improve patient quality of care demonstrated by decreased rate of 30-day health care utilization.
There was a significant decline (p=0.03) in hospitalizations, with patients having a 62% reduction in the risk of hospitalization in the pilot population, and an increase (p<0.001) in number of uncontrolled hypertensive patients receiving hypertension medication interventions. The percent of patients with a diagnosis of hypertension (p=0.03) was higher in the pre-pilot population 41.5% (169/407) when compared to 35% (170/484) in the pilot population. Key components of the model include: pharmacist-driven medication reconciliation and patient education, pharmacist participation in multidisciplinary clinic rounds, and targeted uncontrolled disease state medication interventions. The ultimate goal is enhanced patient-driven inter-professional collaboration to decrease health care utilization.
METHODS
We conducted a single center, quasi-experimental, pre- and post-implementation study of pharmacy clinical services. The pilot population of 484 patients was evaluated and compared to 407 patients not receiving pharmacy clinical services (pre-pilot population). Chi-square test was used to compare the pre-pilot to pilot population as well as logistic regression of hospitalized patients.
CONCLUSION
Pharmacy services in primary care are beneficial as shown by decreased hospital utilization and pharmacists should become involved in the long-term outpatient care of patients in the primary care setting.
PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY
Amanda M. Beck, PharmD, MS Amanda earned her BS in Biomedical Science from Texas A&M University in 2011 and her PharmD degree from the University of the Incarnate Word in 2015. She also received her MS in Pharmacy Leadership and Administration from the University of Houston College of Pharmacy in 2017. Following completion of her PGY2 residency, Amanda will assume the role of pharmacy operations manager at Houston Methodist Hospital. Primary project preceptor: Linda A. Haines, PharmD, MS, BCPS Presented at 2016 VizientÂŽ Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Implementation and evaluation of a volume-based enteral nutrition protocol in the intensive care unit Amanda Holyk, PharmD; Valerie Belden, PharmD; Michael Sirimaturos, PharmD; Kathryn Chiles, RD, LD; Nicole Fontenot, RN, MSN; Annette Lista, PharmD; Raul Sanchez, MD PURPOSE
RESULTS
Studies indicate critically ill patients receive only 50-70% of goal calories. Underfeeding may lead to impaired immune response, increased mortality, and increased length of hospital stay. Traditionally, rate-based enteral feeding has been used with a slow titration and a fixed, hourly rate regardless of interruptions. Volume based feeding (VBF) is an alternative method where a 24-hour tube feeding goal volume is established and accounts for interruptions in tube feeds. The primary objective of this study was to investigate the effect of a rate based vs. volume based protocol in the medical (MICU) and neuroscience (NICU) intensive care unit.
The study included 189 patients (100 rate-based (RB), 89 volume-based (VB)). Baseline characteristics including age, gender, weight, and length of nutrition were similar for both groups with the exception of BMI. The primary outcome of the proportion of goal calories administered from enteral feeding order placement until seven days, transfer from the unit, or oral diet order placed showed a statistically significant difference in overall delivered calories in the VB group as compared to the RB group (102.1% vs 75.1% p<0.001). The VB group also had more patients meet 80% of goal calories (70.8% vs. 42% p<0.001). Time to goal rate (hours) was shorter in the VB group (7.7 vs 13, p<0.013). There were no differences in median length of ICU stay, mortality, or days of mechanical ventilation. Other outcomes that will be analyzed include protein delivery, gastric residual volumes, and glucose levels.
METHODS
The study was a single center, retrospective, beforeand-after study looking at patients admitted to the MICU or NICU from September 1, 2015 to August 31, 2016 (rate-based) and November 22, 2016 to March 31, 2017 (volume-based) with a feeding tube inserted or already in place and with a tube feed order during ICU stay. The VBF protocol included a decision tree, whereby physicians select a safe and appropriate formula and goal volume for initiation. Patients were titrated to goal rate within four hours barring any intolerance. A bedside VBF rate chart was utilized by nurses to determine “catch-up” rates when a patient has been off of enteral feeds. Calorie and protein goals for both groups were determined using guideline recommendations based on BMI. The total daily volume, calories, and protein were determined through charting and formula choice.
CONCLUSION
In conclusion, the results of our study demonstrate an increase in overall calories delivered and an increase in the number of patients meeting 80% of goal calories. Volumebased feeding should be considered for eligible ICU patients. Further analysis will occur to determine the effects on protein delivery and safety outcomes.
PGY2 CRITICAL CARE PHARMACY RESIDENCY
Amanda A. Holyk, PharmD Amanda earned her BS in Pharmacy in 2013 and her PharmD from Wilkes University Nesbitt School of Pharmacy in 2015. She completed her PGY1 residency at Memorial University Medical Center in Savannah, GA. Following completion of her PGY2 residency, Amanda will assume the role of ICU clinical specialist at Mount Nittany Medical Center in State College, Pennsylvania. Primary project preceptor: Valerie S. Belden, PharmD, BCPS Presented at 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Safety and efficacy of dexmedetomidine in non-surgical adults with heart failure and reduced ejection fraction Tara Molina, PharmD; Kevin Donahue, PharmD; Mukhtar Al-Saadi, MD; David Putney, PharmD, MPH PURPOSE
RESULTS
Dexmedetomidine (DEX) is an alpha-2 adrenergic agonist with sedative and anxiolytic properties. DEX carries warnings for increased side effects in cardiovascular disease patients with heart block, bradycardia, or severe ventricular dysfunction though patients with heart failure are largely underrepresented in available trials. The purpose of this study was to evaluate the safety and efficacy of DEX for sedation in patients with reduced ejection fraction heart failure (HFrEF).
A total of 351 HFrEF patients receiving dexmedetomidine were screened for inclusion. Sixty-five HFrEF patients met inclusion criteria and 65 patients without HFrEF served as the control group. At baseline, patients included were an average of 65-years-old, had a BMI of 28 mg/m², and an average sequential organ failure assessment (SOFA) score of five. Patients in the non-HFrEF group were more commonly female gender. The initial rate of DEX infusion (0.4±0.2 vs. 0.3±0.1 mcg/kg/h; p=0.33) and maximum rate of infusion (0.5±0.2 vs. 0.5±0.2 mcg/kg/h; p = 0.34) was similar between the two groups and indicated similar exposure times as well (2.8±2.6 vs. 2.3±2.9 days; p=0.27). The majority of patients included in this study were mechanically-ventilated (89.2% vs. 86.2%; p=0.59), and though patients with HFrEF were mechanicallyventilated for more days prior to DEX initiation (4.5±4.4 vs. 2.9±3.6 days; p=0.03), there was no difference in time to extubation following DEX initiation between the two groups (5.2±5.6 vs. 6±7.1 days; p=0.49). Regarding the primary endpoint, at one hour following the initiation of DEX, an absolute reduction in MAP was observed in both groups, but was greater in the HFrEF population (-9.6% vs. -5.2%; p=0.002).
METHODS
This study was conducted within the cardiac care and medical intensive care unit at Houston Methodist Hospital, a large tertiary care institution in Texas. Data collected evaluated patients receiving DEX between January 2012 and December 2015. Patients were classified by Vizient® Database coded HFrEF diagnosis. Patients without HFrEF were randomly selected as the control group. The primary endpoint assessed the change in mean arterial pressure (MAP) within six hours following administration of DEX. Secondary endpoints included heart rate, vasoactive medication utilization at six hours pre- and post-DEX initiation, ICU length of stay, mortality, and duration of mechanical ventilation.
CONCLUSION
The data generated from this patient cohort can impact the safety of DEX prescribing practices in HFrEF patients. Prior to initiating DEX for sedation, clinical consideration for patients who are at high-risk of hemodynamic instability should be made. PGY2 CRITICAL CARE PHARMACY RESIDENCY
Tara L. Molina, PharmD Tara earned her BS in Biochemistry from Baylor University in 2011 and PharmD from the University of Houston College of Pharmacy in 2015. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital. Following the completion of her residency, Tara will assume the role of critical care clinical pharmacist at Bon Secours St. Francis Hospital in Greenville, South Carolina. Primary project preceptor: Kevin R. Donahue, PharmD, BCPS Presented at 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Revision of and implementation of an AUC-targeted vancomycin dosing nomogram in adult hospitalized patients Ryan Keul, PharmD; Katherine Perez, PharmD; Judy Ikwuagwu, PharmD; Vu Ta, PharmD; William Musick, PharmD PURPOSE
RESULTS
In 2009, consensus guidelines recommended vancomycin troughs as the most practical monitoring parameter for use in clinical practice, despite evidence supporting positive patient outcomes when targeting 24-hour area under the curve over minimum inhibitory concentrations (AUC/ MIC) of ≥400. Recent publications have concluded that vancomycin troughs correlate poorly with clinical outcomes. The objective of this study is to revise and re-implement an AUC/MIC targeted vancomycin dosing nomogram.
The study included 275 patients (100 in the pre-nomogram group, 75 in the original nomogram group, and 100 in the revised nomogram group). Target AUC attainment was 60% vs. 69% vs. 88% for the pre-nomogram, original nomogram, and revised nomogram groups, respectively (p=0.282). The mean AUC ± standard deviation was 485.50±185.79, 441.37±115.06, and 499.76±95.07 for the pre-nomogram, original nomogram, and revised nomogram groups, respectively (p=0.02). Target trough attainment was highest in the revised nomogram group; 46% vs. 64% vs. 78% for the pre-nomogram, original nomogram, and revised nomogram groups, respectively (p<0.0001). Incidence of acute kidney injury according to the KDIGO definition was lowest in the revised nomogram group; 28% vs. 18.7% vs. 14% for the pre-nomogram, original nomogram, and revised nomogram groups, respectively (p=0.045).
METHODS
The AUC-targeted vancomycin dosing nomogram was revised based upon a previously published, population derived, two-compartment pharmacokinetic model. It was applied prospectively to hospitalized, adult patients with vancomycin pharmacy consults in place, weighing between 50–100 kg, with stable renal function, and a CrCl of 30-120 ml/min. The primary outcome was AUC target attainment of 400-800, and secondary outcomes included target trough attainment of 10-20 mg/L and nephrotoxicity. Outcomes from the revised nomogram group were compared to patients dosed via the original AUC-targeted nomogram and pre-nomogram patients dosed via traditional trough monitoring by clinical pharmacists.
CONCLUSION
The revised AUC-targeted vancomycin dosing nomogram significantly increased target trough attainment while decreasing rates of nephrotoxicity. The revised nomogram displayed a higher mean AUC attainment and decreased variability in the range of AUC values. The revised nomogram provides a standardized tool for AUC-targeted vancomycin dosing among adult, hospitalized patients.
PGY2 INFECTIOUS DISEASES PHARMACY RESIDENCY
Ryan R. Keul, PharmD Ryan earned his BS in Biomedical Science from Texas A&M University Corpus Christi in 2010 and PharmD from Texas A&M Health Science Center – Irma Lerma Rangel College of Pharmacy in 2015. He completed his PGY1 pharmacy residency at Baylor Scott and White Medical Center in Temple, Texas. Following the completion of his residency, Ryan will assume the role of antimicrobial stewardship clinical pharmacist at Texas Children’s Hospital in Houston. Primary project preceptor: William L. Musick, PharmD, BCPS-AQ ID Presented at 2016 Vizient® Pharmacy Network, Las Vegas; 2017 Antibiotic Resistance Symposium: Novel Frontiers in Antimicrobial Research, Houston; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska.
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Comparison of time to in-hospital venous thromboembolism in obese patients B. Tate Cutshall, PharmD; Alexandra Tatara, PharmD; Navneet Upadhyay, MS; Melanie Ruegger, PharmD; Mobolaji Adeola, PharmD; David Putney, PharmD PURPOSE
RESULTS
Obesity is a known risk factor for the development of venous thromboembolism (VTE). Studies have evaluated multiple factors related to the development of VTE, but insufficient data exists evaluating time to in-hospital VTE development. This study aims to evaluate time to in-hospital VTE in hospitalized obese patients.
A total of 246 patients were included: 52% male, 66% white, median age 63-years with 146 in group 1, 55 in group 2, and 45 in group 3. Time to VTE was similar between the groups, 8 (group 1) vs. 8 (group 2) vs. 9 days (group 3), p=0.38. Secondary outcomes revealed a shorter time to VTE in acute care compared to ICU patients (7.5 vs. 10 days, p=0.01), non-surgical compared to surgical patients (6 vs. 9 days, p=0.004), and the type of prophylaxis used (p=0.003). A post-hoc analysis showed that the difference between prophylaxis strategies was driven by no prophylaxis vs. pharmacologic plus mechanical (4.5 vs. 9.5 days, p<0.001).
METHODS
This is a single-center, retrospective cohort study evaluating patients with a body mass index (BMI) greater than 30kg/ m2 admitted from September 2011 to June 2015 that developed a VTE during hospitalization. Patients were categorized into three different groups based on BMI: 3034 (group 1), 35-40 (group 2), and greater than 40 (group 3) kg/m2. The primary endpoint compared time to VTE between the groups. Secondary endpoints compared time to VTE between acute care vs. intensive care units (ICU), surgical vs. non-surgical patients, and four prophylactic strategies (no prophylaxis, mechanical alone, pharmacologic alone, and pharmacologic plus mechanical). Statistical analysis was completed using the Kruskal-Wallis test, Mann-Whitney U test, and Chi-squared test.
CONCLUSION
While the degree of BMI did not significantly impact time to VTE, the type of patient and prophylaxis used had significant differences. Given the increased risk of VTE in obese patients, optimized prophylaxis, preferably with pharmacologic plus mechanical, should be used despite a lack of guided therapy. This study demonstrates the need for a more uniform approach to prophylactic strategies in obese patients.
PGY2 INTERNAL MEDICINE PHARMACY RESIDENCY
B. Tate Cutshall, PharmD, BCPS Tate earned his PharmD from Samford University in 2015. He completed his PGY1 Pharmacy Residency at Methodist University Hospital in Memphis, Tennessee. Following completion of his residency, Tate will assume the role of internal medicine specialist at the University of Alabama-Birmingham Hospital in Birmingham, Alabama. Primary project preceptor: Melanie C. Ruegger, PharmD, BCPS Presented at 2016 VizientÂŽ Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska.
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Characterization of chemotherapy-induced peripheral neuropathy: a prospective pilot study Veronica Ajewole PharmD; James Cox, PharmD; Joshua Swan, PharmD, MPH; Eleanor Hobaugh, PharmD; Amy Schneider, PharmD; Christen Ford, RN, BSN; Beverley Lamoth, RN, MSN; Laura Okolo, MSN, DNP; Kelty Baker, MD PURPOSE
RESULTS
Chemotherapy-induced peripheral neuropathy (CIPN) is a common treatment-related adverse effect. The Functional Assessment of Cancer Therapy/Gynecologic Oncology Groupâ&#x20AC;&#x201C;Neurotoxicity (Fact/GOG-Ntx) questionnaire is a validated subjective tool for assessment of CIPN. Higher scores reflect less neurotoxicity and better quality of life (QOL). A change in NtxS score of greater than five points or 10% is considered clinically significant. There are no evidence-based consensus approaches to prevent or treat CIPN. However, the use of alpha-lipoic acid, thiamine, and pyridoxine both alone and in combination have decreased the severity of CIPN and diabetic neuropathy. Anecdotal reports and physician experience at our institution suggest efficacy when these agents are used in combination for prevention of CIPN. The objective of this prospective, single-center, pilot, cohort study is to generate data on incidence, prevalence, and symptomatic development of CIPN from baseline to week six and week 12 of chemotherapy treatment.
Of 33 patients who were approached for informed consent, 28 (85%) (6 of which were taking combination OTC supplements) provided consent and were enrolled in the study. FACT/GOG-Ntx questionnaire was completed by 28 patients (100%) at baseline, 25 patients (89%) at week 6, and 24 patients (86%) at week 12. The average (standard deviation) neurotoxicity scores were 36.5 (6.6) at baseline, 34.0 (8.3) at week 6, and 30.6 (7.6) at week 12. Among patients with multiple assessment, neurotoxicity score changed from baseline by -2.7 points (95% confidence interval (CI) -5.5 to 0.1, p=0.061) at week 6 and -6.0 points (CI: -8.8 to -3.2, p=<0.001) at week 12. Among 22 patients that were not taking combination OTC supplements, neurotoxicity score changed from baseline by -2.9 points (CI: -5.5 to -0.4, p=0.025) at week 6 and -6.4 points (CI: -10.2 to -2.7, p=0.002) at week 12. Among 6 patients that were taking combination OTC supplements, neurotoxicity score changed from baseline by -1.8 points (CI: -13.4 to 9.8, p=0.702) at week 6 and -4.6 points (CI: -8.8 to 0.4, p=0.038) at week 12.
METHODS
This study is approved by the Institutional Review Board. Patients 18-years or older with a diagnosis of lymphoma or multiple myeloma receiving neurotoxic chemotherapy were enrolled within two weeks of first treatment. The primary endpoint was the absolute change in Fact/GOG-Ntx score from baseline to weeks six and 12. Secondary endpoints included absolute change in QOL score as well as NtxS and QOL stratified by specific chemotherapy agent, time from therapy start date, and cumulative dose.
CONCLUSION
The findings from this study are interesting and call for further robust studies to evaluate the difference in the trend of neurotoxicity score that was observed among patients that were not taking combination OTC supplements versus patients that were taking combination OTC supplements.
PGY2 ONCOLOGY PHARMACY RESIDENCY
Veronica B. Ajewole, PharmD Veronica earned her BS in Biochemistry from the University of Ado Ekiti in Nigeria and her PharmD from Texas Southern University in 2015. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital. Following the completion of her residency training, she will assume a role as a Clinical Assistant Professor of Pharmacy Practice at Texas Southern University with her practice site at Houston Methodist Hospital Cancer Center. Primary project preceptor: James E. Cox, PharmD Presented at 2016 VizientÂŽ Pharmacy Network, Las Vegas; 2017 HOPA Conference, Anaheim, CA; 2017 Midwest Pharmacy Residency Conference, Omaha, Nebraska.
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Antineoplastic agents given towards end-of-life in stage IV solid tumors Lindsay Edmondson, PharmD; Hanna Zaghloul, PharmD; Eric Bernicker, MD PURPOSE
RESULTS
Chemotherapy administration towards the end-of-life is a controversial topic within the cancer community. Decreasing the proportion of patients who receive chemotherapy in the last two weeks of life has been identified as a quality indicator by the American Society of Clinical Oncology. In addition to avoiding chemotherapy near the end-of-life, palliative care consultation has been identified as a significant factor to improving quality of death. The purpose of this study is to determine the proportion of adult oncology patients who died as a consequence of their cancer and received chemotherapy or targeted therapy within the last two weeks of life.
Final results include a total of 64 patients who met inclusion criteria. Twenty-percent of patients received chemotherapy or targeted therapy within 14 days of death: 8% received chemotherapy and 12% received targeted therapy. The majority of patients who received chemotherapy or targeted therapy in the last two weeks of life were on their first or second line of treatment. Sixtypercent of patients received a palliative care consultation at some point during their last admission.
METHODS
This is a single center, retrospective chart review. Patients were included if they expired at Houston Methodist Hospital (HMH) between March 2013 and March 2016 with metastatic GI, gynecologic, breast, lung, renal, or prostate cancer, and the cause of death was directly related to their malignancy. The date of last chemotherapy administration prior to death, regimen used, line of chemotherapy, and use of palliative care consultation was recorded.
CONCLUSION
Ultimately, the decision to pursue palliative anticancer treatment should be made between the provider and the patient, with an effort to fully inform patients of their prognosis and available treatment options. Palliative care consultation should be considered early in hospital admission to improve quality of care.
PGY2 PHARMACY ONCOLOGY RESIDENCY
Lindsay A. Edmondson, PharmD Lindsay earned her PharmD from Duquesne University in 2015. She completed her PGY1 Pharmacy Residency at Seton Healthcare Family in Austin, Texas. Following completion of her residency, Lindsay will assume the role of clinical oncology pharmacist at Allegheny General Hospital in Pittsburgh, Pennsylvania. Primary project preceptor: Hanna A. Zaghloul, PharmD, BCOP Presented at 2016 VizientÂŽ Pharmacy Network, Las Vegas; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraksa; 2017 Hematology/Oncology Pharmacy Association Conference, Anaheim, California.
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The incidence and outcomes of fever of unknown origin after pancreas transplantation Robin Klasek, PharmD; Samantha Kuten, PharmD; Samir Patel, PharmD; Duc Nguyen, MD, PhD; Edward Graviss, PhD; A. Osama Gaber, MD; Richard Knight, MD PURPOSE
Fever occurrence following transplantation is fairly common and is often due to infectious etiologies. However, previous observational studies indicate that 20–30% of febrile episodes in transplant recipients were not associated with infectious causes. At Houston Methodist Hospital, fever of unknown origin (FUO) is a common cause for readmission following pancreas alone (PA) and simultaneous pancreas kidney (SPK) transplant. This study aimed to characterize the incidence and outcomes of pancreas recipients with FUO during the first post-transplant year. METHODS
All PA and SPK recipients transplanted from January 2011 to October 2015 were included. Patients with early pancreas graft thrombosis within one week post-transplant were excluded from analysis. Additionally, a comparator cohort of kidney alone transplant recipients with preexisting diabetes transplanted during the same time period was reviewed to determine if the FUO phenomenon was related to pancreas transplantation. Diagnosis of FUO was based upon previously accepted criteria adapted from Durack et al. (1991). RESULTS
A total of 202 transplant recipients were reviewed. Six patients were excluded, leaving 98 in the PA or SPK transplant cohort and 104 patients in the kidney alone cohort. There were no documented FUO occurrences amongst kidney-alone recipients in the first year post-
transplant. PA or SPK patients were on average 42-yearsold, and consisted of 51 (55%) male and 81 (88%) SPK recipients. Compared to kidney-alone patients, 23 (25%) PA or SPK patients experienced FUO resulting in 34 admissions (mean length of stay eight days), with average time to first FUO admission of 31 days post-transplant. Eight patients had multiple readmissions for FUO. Overall, FUO accounted for a total of 173 admission days. Evaluation of FUO consisted of blood/urine cultures (100%), CMV PCR (100%), chest x-ray (100%), non-head CT (78%), head CT (4%), MRI (9%), indium scan (22%) and lumbar puncture (4%). After ruling out infectious etiology, 17 patients were managed empirically with median dose of 750 mg of intravenous (IV) methylprednisolone. Empiric treatment with IV methylprednisolone lead to resolution of fever and shortened hospital stay, but did not affect FUO readmission rates. Rates of documented infection and rejection at one year were similar in FUO and FUO free patients. Several risk factors for FUO were identified, though the clinical significance of these is under investigation. CONCLUSION
Twenty-five percent of pancreas recipients developed FUO at an average of 31 days post-transplant. In contrast, no kidney-alone recipients developed FUO. FUO was associated with frequent admissions, extensive diagnostic testing, and prolonged hospitalizations. However, FUO was not associated with detrimental graft or patient outcomes during the first year. Further study into risk factors or mechanism is warranted.
PGY2 SOLID ORGAN TRANSPLANTATION PHARMACY RESIDENCY
Robin Klasek, PharmD Robin earned his PharmD from Massachusetts College of Pharmacy and Health Sciences in 2014. He completed his PGY1 Pharmacy Residency at Houston Methodist Hospital. Following completion of his residency, Robin will assume a pharmacist position at Brigham and Women’s Hospital in Boston, Massachusetts. Primary project preceptor: Samantha A. Kuten, PharmD Presented at 2016 Vizient® Pharmacy Network, Las Vegas; 2017 American Transplant Congress, Chicago; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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Single-center experience with Epstein-Barr virus screening in lung transplant recipients to identify patients with post-transplant lymphoproliferative disorder Derek Owen, PharmD; Kyle Dawson, PharmD; Brett Pierce, PharmD; Ahmad Goodarzi, MD; Neeraj Sinha, MD; Jihad Youssef, MD; Thomas Kaleekal, MD PURPOSE
Long-term survival following lung transplant is limited by many factors, including malignancy. Post-transplant lymphoproliferative disorder (PTLD) is often, but not always, related to the reactivation of Epstein-Barr Virus (EBV). While the standard diagnosis of PTLD usually includes imaging and histopathology, this study aims to determine the utility of using plasma EBV PCR testing to assist in the identification of patients with PTLD after lung transplant. METHODS
In this single-center retrospective chart review, all lung transplant recipients from January 2009 – December 2015 were reviewed for the presence of EBV viremia at any time post-transplant using plasma PCR testing. EBV testing was initially “for cause” and later became protocolized. All patients with at least one positive EBV PCR were reviewed for a PLTD diagnostic work-up (PET CT and/or CT chest or abdomen) within 30 days and identification of PTLD at any point post-lung transplant. RESULTS
This study included 690 lung transplant recipients, with 587 being screened at least one time post-transplant for EBV viremia. Of the 587 patients screened, 110 (18.7%) tested positive at least once. The median time to first positive EBV PCR was 745 (IQR 172-1436) days and the median value
was 445 (IQR 294-669) copies/mL. In only 19 of the 110 cases, a positive EBV PCR led directly to a diagnostic workup for PTLD, while others were managed conservatively with close follow-up. Patients worked-up for PTLD had a greater median EBV PCR than those who were not (813 copies/ mL vs. 457 copies/mL, p=0.001). Seven patients were diagnosed with EBV-associated PTLD. The median peak EBV PCR was greater in patients who developed PTLD than those that did not (1,931 copies/mL vs. 476 copies/ mL, p=0.0125). When specifically considering patients with a peak EBV PCR > 1,000 copies/mL, 4 of 19 (21%) developed PTLD. CONCLUSION
The incidence of a positive EBV PCR at any time post lung transplant was 18.7%, with only 4.5% of these patients developing EBV-associated PTLD. Of note, 21% of patients with a peak EBV PCR > 1000 copies/ mL developed PTLD. This experience suggests that lung transplant patients with low-level EBV viremia (e.g., <500 copies/mL) are less likely to develop PTLD and can potentially be managed conservatively while patients with an EBV PCR > 1000 copies/mL may be indicated for further diagnostic work-up and closer monitoring.
PGY2 SOLID ORGAN TRANSPLANTATION PHARMACY RESIDENCY
Derek D. Owen, PharmD Derek earned his BS in Pharmacy Studies in 2014 and PharmD from Northeastern University in 2015. He completed his PGY1 Pharmacy Residency at Indiana University Health in Indianapolis. Following completion of residency, Derek will assume the role of liver and small bowel transplant pharmacist at Cincinnati Children’s Medical Center in Cincinnati. Primary project preceptor: Kyle L. Dawson, PharmD, MBA, BCPS Presented at 2016 Vizient® Pharmacy Network, Las Vegas; 2017 International Society of Heart and Lung Transplantation Annual Meeting, San Diego; 2017 Midwest Pharmacy Residents Conference, Omaha, Nebraska
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