North Carolina Pharmacist Volume 97 Number 3 by North Carolina Association of Pharmacists

North Carolina Pharmacist Volume 97 Number 3 Summer 2017 A d v a n c i n g P h a r m a c y. Im p r o v i n g H e a l t h .

2017 NCAP Annual Convention Benton Convention Center Winston-Salem, NC

September 22-24, 2017 “Transform Through Innovation”

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Official Journal of the North Carolina Association of Pharmacists 1101 Slater Road, Suite 110 Durham, NC 27703 Phone: (984) 439-1646 Fax: (984) 439-1649 www.ncpharmacists.org Click Here to Follow us! -

JOURNAL STAFF EXECUTIVE EDITOR Penny Shelton

North Carolina Pharmacist Volume 97 Number 3

Summer 2017

Inside • Convention App .............................................................4 • From the Past President .................................................................5 • From the Executive Director .............................................................6

EDITOR/STAFF WRITER Ralph Raasch

• Convention Program...........................................................8-18

LAYOUT/DESIGN Rhonda Horner-Davis

• Student Program.......................................................................19-20

BOARD OF DIRECTORS

• Convention Workshops........................................................23-23

PRESIDENT Stefanie Ferreri

• Roundtable Discussions..........................................................24-31

PAST PRESIDENT Stephen Eckel TREASURER Thomas D’Andrea

BOARD MEMBERS Olivia Bentley Jamie Brown Jennifer Burch David Catalano Lisa Dinkins Ouita Gatton Macary Marciniak Kim Nealy Dave Phillips Justin Reid Jennifer Wilson

NCAP STAFF Linda Goswick Sandie Holley Rhonda Horner-Davis Teressa Reavis Ron Williamson North Carolina Pharmacist (ISSN 0528-1725) is the official journal of the North Carolina Association of Pharmacists. An electronic version is published quarterly. The journal is provided to NCAP members through allocation of annual dues. Opinions expressed in North Carolina Pharma-

• Abstracts..........................................................................33-42 • Convention Highlights.......................................................................43 • Past Presidents........................................................................................44 • From the NCAP Office...........................................................45-49 • Research and Practice...............................................................50 • Reflections.......................................................................................52-61

North Carolina Pharmacist is supported in part by: • Smith Drug Company................................................................................................2 • Pharmacists Mutual Companies................................................................................7

• Epic RX...................................................................................................................42

• Pharmacy Technician Certification Board...............................................................32

• NCAP Career Center................................................................................................51 • Pharmacy Quality Commitment..............................................................................55

• VIP Pharmacy Systems............................................................................................62

cist are not necessarily official positions or policies of the Association. Publication of an advertisement does not represent an endorsement. Nothing in this publication may be reproduced in any manner, either whole or in part, without specific written permission of the publisher.

ADVERTISING

For rates and deadline information, please contact Rhonda Horner-Davis at rhonda@ncpharmacists.org

•From the Past President • Stephen F. Eckel, PharmD, MHA, BCPS cists across similar work settings. However, we cannot stop there. We need to connect and network with pharmacists across the diversity of all practice settings. Each of us has knowledge and experiences that can benefit others, and we can definitely learn from each other’s unique perspectives. Until we make these connections and have a desire to learn from others, and strive to collaborate, we will continue in our professional silos and limit our opportunities to advance our profession collectively.

The Certainty of Uncertainty Providing Opportunities for NCAP Both within health care and in society in general, change is happening all around us. People are making decisions in order to improve a system or to fix a broken one, and others constantly argue about the benefit of the proposed changes. Tension and conflict seem to be all around us, mostly because one person does not believe another’s stated direction is the best for their self-interests or common good. While none of us know the future, we can be certain of its uncertainty. We all recognize that change is happening in health care and that some will thrive as a result of the change and others will be placed on the defensive. Some groups will have the opportunities to expand their professional scope of practice, while others will be left defending their areas of responsibility. How can pharmacy respond in the midst of this change so that we can thrive and not have to be defensive? I believe that if pharmacists in North Carolina take these certain steps, we will be able to create the future we desire. 1.

Have a shared vision of pharmacy. Do we truly believe that we can add value to the patient care process? Are our daily actions in the work place consistent with what we say to others about what they should be doing? While we have all been trained in dispensing medications, our future practice models cannot have this as their sole or primary activity. We are the medication experts, and this separates us from other mid-level practitioners. We need to take responsibility for the medication needs of patients with chronic disease states and comprehensively manage their medications as a major focus of our patient care activities. It is important that all pharmacists believe this and work to make it a reality, no matter the practice site. Desire to work together. There are many diverse practice settings that employ pharmacists across North Carolina. These settings range from critically ill patients to ambulating ones, from prisons to nursing homes. While we desire to optimize our own work settings to make it the best work place possible, we also like to connect and network with pharma-

Recognize our employers are not always focused on advancing the profession of pharmacy. Because of the changes in health care, most of us work for large corporate organizations, no matter the practice setting. While this has many advantages, there are also limitations to it. Each of these corporations needs to have a sustainable business model while achieving its mission. While this can be good at times, it can also interfere with advancing the profession of pharmacy. It is incumbent that each employee gives their best to their workplace and employer. They also have to recognize the limitations on what their employer can accomplish. Thus, there needs to be collaborations outside of the corporation to ensure that professional advances continue, even when the business model currently does not support it.

The only place where these steps can be actualized in North Carolina is through NCAP. Not only does this merged organization provide a shared vision of pharmacy, it also allows for networking among diverse colleagues to occur. Because it only has a mission to advance the practice of pharmacy, it will not make decisions that are in opposition to this goal. While it recognizes the need for sustainable business models, it will not only pursue activities that are already proven, but also try new initiatives. NCAP will always do what is best for the patient and the profession as a whole. I firmly believe that if North Carolina pharmacy got behind and actively involved in NCAP, it could create certainty out of uncertainty for pharmacy and move us toward the professional future that we all desire. Please join me in this journey and help us take the best care of patients that we can. They certainly need this from us, and we are best able to deliver it. I would appreciate any insights and experiences you might have on this perspective. You can let me know what you think by email at seckel@unc.edu. You can also follow me on Twitter at @stepheneckel.

•From the Executive Director• Penny Shelton, PharmD, CGP, FASCP

In Search of Quality Penny Shelton Recently, I purchased three no-iron dress shirts online. I recognize everyone’s style is a little different, I prefer nice crisp, long-sleeved, button-up blouses. Those who know me well and are reading this are probably shaking their heads in the affirmative and muttering, “Yep, that’s Penny!” What has happened to quality? When I buy a no-iron shirt, there should not be any question as to what that means. You take it out of the dryer—no fuss—and it is ready for the hanger or your body, sans the wrinkles. I purchased my new shirts from a well-known, online retailer that I have been buying clothes from for years. After only one wash and dry cycle, clearly wrinkles were present, and the facing or placket for the buttons is now designed so narrow that any little movement makes the shirt gape open. Interestingly, in that same load I also laundered and hung an old favorite shirt from the same online retailer. I have had this “fav” for about a decade. Its label reads “wrinkle resistant”, implying it is not as 6

fuss-free as a “no-iron” shirt. The cuffs are a bit frayed, a couple of the buttons have been replaced, and the color has faded with time, but hanging side-by-side with the new ones, the material was notably more substantial, better made and was indeed wrinkle-free, unlike the more-costly, brand-spanking new ones. This recent purchase and laundry episode got me to thinking about quality, cost, and value. On a regular basis, as consumers, we pay higher prices for less quality or volume than we used to. Whether it is with clothing, as noted above, or your favorite grocery item that over time has either been downsized or reformulated. The changes generally are not in the consumer’s favor and are often cleverly disguised amidst new and improved packaging. This as you know is manufacturing trickery at its best, full of clever words and shiny baubles designed to hopefully distract us from recognizing we are getting less for more. Higher quality has become synonymous with higher cost. In today’s world there are too few examples of where more quality and greater value are being offered for no increase in price. Of course, this got me to thinking about NCAP! Our

Association is offering more for our members, and we have not raised dues nor raised the price of registration for our Annual Convention. In fact, Convention this year has more to offer than ever before, including more networking opportunities and a greater number of continuing education hours, which means there’s actually more value dollar-for-dollar on your investment to come to Convention than ever before. I attend a number of national meetings each year. Recently, I have been astounded by a couple of things. At each national meeting that I attend, when I review the available sessions, some of the most innovative or cutting edge topics are being presented or co-presented by pharmacists from North Carolina. Secondly, the cost, for registration alone, for many of these national meetings approaches or exceeds $1000. It is obvious that we have some of the best talent right here in NC. Check out the full program in this issue and then ask yourself if you can afford to miss out on Convention. If you are seeking greater quality for a reasonable price, the best deal is right here in North Carolina with NCAP. Pharmacy Proud – Penny.

Convention Program

2017 NCAP Annual Convention “Transform Through Innovation” September 22-24, 2017

Benton Convention Center Winston-Salem, North Carolina Developed with UNC Eshelman School of Pharmacy Co-Sponsored by Campbell University College of Pharmacy & Health Sciences High Point University Fred Wilson School of Pharmacy Wingate University School of Pharmacy

Friday, September 22 8:00-5:00 pm

APhA Diabetes Certificate Program – Winston 3BC

7:00-8:00 am

Registration/Continental Breakfast/Silent Auction

Convention Moderator: Courtney L. Bradley, PharmD, BCACP Assistant Professor of Clinical Sciences Applied Laboratory Coordinator High Point University Fred Wilson School of Pharmacy CONCURRENT 8-Hour Workshops A & B (A) ACPE#: 0046-9999-17-207-L04-P “Collaborative Approach to Falls Assessment and Prevention: Pharmacists’ Use of the ASCP/NCOA Falls Risk Reduction Toolkit” Learning objectives for Pharmacists: At the completion of this knowledge-based activity, the participant will be able to: 1) Identify common falls risk factors and recommend appropriate interventions for modifiable risk determinants 2) Identify components of the CDC-STEADI toolkit 3) Describe the purpose of each component of the ASCP-NCOA Falls Risk Reduction Toolkit 4) Assess a patient for falls risk using the ASCP-NCOA Falls Risk Reduction Checklist 5) Describe how to implement and score basic strength, gait and balance assessments Michelle Fritsch, PharmD, BCGP, BCAP CEO, Meds MASH, LLC Penny Shelton, PharmD, BCGP, FASCP Executive Director North Carolina Association of Pharmacists

Alice Bell, PT, DPT, GCS Senior Payment Specialist American Physical Therapy Association Ellen Caylor Schneider, BS, MBA Research Fellow UNC Center for Health Promotion and Disease Prevention University of North Carolina at Chapel Hill Ryan Lavalley, MOT, OTR/L, CDCP Occupational Therapist NC Department on Aging (B) ACPE#: 0046-9999-17-208-L04-P ACPE#: 0046-9999-17-208-L04-T “Mental Health First Aid Adult Training Course” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Recognize the potential risk factors and warning signs for a range of mental health problems, including depression, anxiety/trauma, psychosis and psychotic disorders, substance use disorders, and self-injury. Use a 5-step action plan to help an individual in crisis connect with appropriate professional help 2) Interpret the prevalence of various mental health disorders in the U.S. and the need for reduced negative attitudes in their communities 3) Apply knowledge of the appropriate professional, peer, social, and self-help resources available to help someone with a mental health problem treat and manage the problem and achieve recovery 4) Assess their own views and feelings about mental health problems and disorders

Jerry McKee, PharmD, MS, BCPP Medical Affairs – Director of Pharmacy Community Care of North Carolina

Madonna Greer, CPSS Mental Health First Aid Instructor NAMI – Guilford Board Member CIT Training Committee Member CONCURRENT 4-Hour Workshops C and D 8:00-12:00 pm (C) ACPE#: 0046-9999-17-209-L01-P “Use of Screening, Brief Intervention and Referral for Treatment (SBIRT) by Pharmacists for Patients at Risk for Substance Abuse” Learning objectives for Pharmacists: At the completion of this knowledge-based activity, the participant will be able to: 1) Define SBIRT and understand the rationale for universal screening 2) Define at-risk and dependence levels of alcohol, prescription drug and illicit drug use 3) Distinguish between patients who may benefit from a brief intervention for substance misuse/abuse and those who need referral to specialized treatment 4) Describe how misuse and abuse may interfere with medications and cause/exacerbate comorbidities 5) Demonstrate how to screen for substance use disorders and provide a

brief intervention for patients using motivational interviewing techniques 6) Identify resources for referral for substance use disorders in providers’ location 7) Develop ways to incorporate SBIRT into current practice Kim Hayashi, PharmD SBIRT Educational & Clinical Coordinator Shenandoah University Susan Cooper, PharmD SBIRT Trainer and Education Liaison Shenandoah University (D) ACPE#: 0046-9999-17-210-L01-P “Pharmacogenetics 101: A Primer for Pharmacists” Learning objectives for Pharmacists: At the completion of this knowledge-based activity, the participant will be able to: 1) Define pharmacogentics (PGx) and related nomenclature 2) Compare and contrast various technologies used for pharmacogenetic testing 3) Describe available resources for pharmacogenetic information 4) List drugs/clinical situations where PGx testing is likely to be most useful clinically 5) Evaluate case scenarios from clinical care to highlight opportunities and limitations of personalized medicine testing 6) Recommend specific alternate therapies and/or doses of specific medications based on PGx test results 7) Review different approaches for the clinical implementation of pharmacogenetics 8) Identify the key lessons learned for implementation of pharmacogenetics in clinical practice 9) Recognize the barriers in the process of translating data from pharmacogenetics studies to clinical practice 10) Describe the challenges/opportunities of implementing and using pharmacogenetics testing in daily practice Gillian C. Bell, PharmD Clinical Pharmacist, Personalized Medicine Fullerton Genetics Center Mission Health Lynn G. Dressler, Dr.P.H.

Director, Personalized Medicine Fullerton Genetics Center and Mission SECU Cancer Center Mission Health Tim Wiltshire, PhD

Director – Center for Pharmacogenomics and Individualized Therapy Associate Professor – Pharmacotherapy and Experimental Therapeutics UNC Eshelman School of Pharmacy

Dan Crona, PharmD, PhD

Assistant Professor, Division of Pharmacotherapy and Experimental Therapeutics Faculty, UNC Center for Pharmacogenomics and Individualized Therapy Member (Molecular Therapeutics), UNC Lineberger Comprehensive Cancer Center University of North Carolina

Jai N. Patel, PharmD, BCOP Chief, Pharmacology Research Levine Cancer Institute Carolinas Healthcare System 10:00-12:00 pm ACPE#: 0046-9999-17-211-L04-P “Health-System Pharmacy Practice in North Carolina: Understanding the Current State and Planning a Roadmap for the Future (Invitation Only Event) Learning objectives for Pharmacists: At the completion of this knowledge-based activity, the participant will be able to: 1. Discuss the ASHP Pharmacy Forecast 2. Compare the current practice of North Carolina to the ideals of the Pharmacy Forecast 3. Describe current gaps in practice across North Carolina 4. Create a 5-year roadmap that can guide the advancement of health-system practice in North Carolina Moderators: Stephen Eckel, PharmD, MHA Associate Dean for Global Engagement Clinical Associate Professor Vice Chair of Graduate and Postgraduate Education, Pace Associate Director of Pharmacy, UNC Hospitals Immediate Past President, NC Association of Pharmacists Steve Kearney, PharmD Medical Director SAS US Government 12:00-1:00

Executive Leadership Summit Luncheon (Invitation Only Event) (Followed by a Reverse Trade Show)

12:00-1:00

Lunch Symposium (Jardiance) No CE

Denis I. Becker, MD, FACE Raleigh Endocrine Associates ADA, NC Affiliate, Past-President Sponsored by Boehringer-Ingelheim – Tara Page 1:00-5:00 CONCURRENT 4 Hour Workshops E & F (E) ACPE#: 0046-9999-17-212-L04-P ACPE#: 0046-9999-17-212-L04-T “Developing Self-Leadership Skills: A Workshop for Emerging Leaders” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Describe core principles of successful leadership, including the importance of reflection, the ladder of influence, and self-leadership 2) Create a mission statement that reflects your professional goals and passions 3) Evaluate challenges and barriers that you are currently facing that potentially stand in the way of your professional success 11

Mollie Ashe Scott, PharmD, BCACP, FASHP, CPP Regional Associate Dean and Clinical Associate Professor UNC Eshelman School of Pharmacy

Stephanie Kiser, RPh Clinical Assistant Professor Director, Rural Health & Wellness UNC Eshelman School of Pharmacy (F) ACPE#: 0046-9999-17-213-L01-P “ Antimicrobial Stewardship Workshop: Models for Success” Learning objectives for Pharmacists: At the completion of this knowledge-based activity, the participant will be able to: Antimicrobial Stewardship Programs: Setting the Stage for Success 1) Identify the primary goals of antimicrobial stewardship programs 2) Discuss strategies for establishing a successful antimicrobial stewardship program 3) Provide examples of innovative antimicrobial stewardship program models and initiatives Nicole Nicolsen, PharmD, BCPS Antimicrobial Stewardship Coordinator Clinical Pharmacist, Internal Medicine Vidant Health The Antibiotic Allergy: Opportunities for Antimicrobial Stewardship 1) Explain the importance of accurate antibiotic allergy evaluation and diagnosis in improving antibiotic use 2) Discuss strategies for successful implementation of an antibiotic allergy assessment initiative as part of an antimicrobial stewardship program

Emily L. Heil, PharmD, BCPS AQ-ID, AAHIVP Assistant Professor - Infectious Diseases University of Maryland School of Pharmacy

Antimicrobial Stewardship and the Microbiology Lab: A Win-Win Relationship 1) Discuss the importance ofclinical microbiology laboratory involvement in antimicrobial stewardship programs 2) Describe the role of selective antimicrobial susceptibility reporting in directing appropriate antimicrobial use 3) Examine the use of rapid diagnostic testing for antimicrobial stewardship initiatives 4) Identify opportunities for microbiology lab and antimicrobial stewardship collaboration to optimize resource utilization, promote appropriate antibiotic use and improve patient care Lindsay Daniels, PharmD, BCPS AQ-ID Clinical Pharmacy Specialist, Infectious Diseases University of North Carolina Medical Center Regulatory Standards for Antimicrobial Stewardship: Audience Discussion 1) Identify the major components of The Joint Commission on regulatory standards for antimicrobial stewardship programs 2) Share experiences from different practice settings related to incorporation of the CDC core elements into antimicrobial stewardship programs

Lindsay Daniels, PharmD, BCPS AQ-ID Clinical Pharmacy Specialist, Infectious Diseases University of North Carolina Medical Center

5:00-until

Reception with Exhibitors 50+ Recognition/Rite of Roses/BCBS Awards NCAP Awards and Installation of Officers

Saturday, September 23 8:00-9:00 am

Registration/Continental Breakfast/Silent Auction

8:00-1:30 pm

Poster Session

8:00-5:00 pm

Technician Review Seminar (Requires Separate Registration)

Theodore James Spader, RPh, MS Pharmacy Administration Rite Aid Pharmacy Mark Steven Sheppard, RPh, BS Pharmacy Manager Rite Aid Pharmacy 9:00-9:30

Welcome and “President’s Address”

Stefanie Ferreri, PharmD, BCACP, CDE, FAPhA Clinical Professor UNC Eshelman School of Pharmacy President, NC Association of Pharmacists 9:30-11:00 ACPE#:0046-9999-17-214-L04-P ACPE#:0046-9999-17-214-L04-T “State of the Association Address and Advocacy Update” Learning objectives for Pharmacists and Technicians: 1) Identify three new public health campaigns or projects supported by the North Carolina Association of Pharmacists 2) Describe at least one key outcome or deliverable developed by each of the five standing NCAP Committees 3) Describe one approach being taken by the Board of Directors to strengthen NCAP’s influence 4) Summarize the key legislative items for 2017 Description: This session, a year-in-review, will be devoted to how NCAP is “getting our Mojo back.” Come hear about: (a) New partnerships and public health initiatives, (b) A summary of our advocacy issues, and (c) An overview of work completed by our Committees and Project Teams. (d) In addition, an update of Association quality metrics—where we were, where we are and where we are headed—will be provided. Penny S. Shelton, PharmD, BCGP, FASCP Executive Director NC Association of Pharmacists

Tony Adams Adams & Associates Government Relations 11:00-11:15

Break

11:15-12:00 pm ACPE#:0046-9999-17-215-L04-P ACPE#:0046-9999-17-215-L04-T “Town Hall Meeting” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Describe issues impacting pharmacists in various practice settings 2) Prioritize profession-related issues and identify how the Association can best help 3) Describe the Association’s grassroots approach for mobilizing pharmacists, technicians and students

Description: This session is provided to give attendees an opportunity in a public forum to meet with NCAP officers and the Executive Director. Come voice what impacts you the most and use the forum to discuss ways our Association can help with work environment, professional development needs, regulatory and legislative issues.

Moderator: Penny S. Shelton, PharmD, BCGP, FASCP Executive Director NC Association of Pharmacists Stefanie Ferreri, PharmD,BCACP, CDE, FAPhA Clinical Professor UNC Eshelman School of Pharmacy President, NC Association of Pharmacists Stephen Eckel, PharmD, MHA Associate Dean for Global Engagement Clinical Associate Professor Vice Chair of Graduate and Postgraduate Education, Pace Associate Director of Pharmacy, UNC Hospitals Immediate Past President, NC Association of Pharmacists Thomas D’Andrea, RPh, MBA Vice President of Pharmacy Services Neil Medical Group Treasurer, NC Association of Pharmacists 12:00-1:30

Lunch and Networking

12:00-1:30

Student Mentoring Luncheon (Requires Separate Registration)

1:30-3:00 ACPE#:0046-9999-17-216-L04-P ACPE#:0046-9999-17-216-L04-T “Speak Out, Stand Out, Break Out” Best Practices Round Table Discussions Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Discuss innovative pharmacy practices to empower pharmacists in practice

2) Discuss teaching methods to improve pharmacy precepting 3) Describe advanced pharmacy systems to improve patient care

1:30-5:00

Residency Showcase 1:30-2:30 – For P4s 2:30-3:00 – Break 3:00-5:00 – P1s-P4s

3:00-5:00

CONCURRENTS: 2-Hours

(A) ACPE#:0046-9999-17-217-L01-P ACPE#:0046-9999-17-217-L01-T “Immunization Update” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Discuss disease states, vaccine recommendations, and current updates to the Center for Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommendations for adult vaccines 2) Apply ACIP recommendations to various patient care scenarios 3) Recognize the role of the pharmacy technician within a pharmacy based immunization service 4) Identify innovative strategies for increasing vaccination rates in your pharmacy practice Ouita Davis Gatton, RPh District A Patient Care Coordinator The Kroger Company Anna Armstrong, PharmD Clinical Pharmacist The Kroger Company (B) ACPE#:0046-9999-17-218-L05-P ACPE#:0046-9999-17-218-L05-T “Quality and Safety Metrics: Engaging Pharmacy Technicians” and Panel Discussion Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Describe how metrics are used to measure quality and safety 2) List four common quality and safety metrics that affect your organization 3) Describe two reasons why quality and safety metrics are important to pharmacy technicians 4) Identify at least two metrics used to measure the quality of your practice 5) List three reasons pharmacy technicians should be involved related to quality of medication management and use Elliott M. Sogol, PhD, RPh, FAPhA Vice President, Professional Relations Pharmacy Quality Solutions John M. Kessler, BS, PharmD Chief Clinical Officer SecondStory Health, LLC

Liza Hoomana, CPhT Carteret Health Care (1C) ACPE#:0046-9999-17-219-L04-P ACPE#:0046-9999-17-219-L04-T “USP 800 From the Outpatient Perspective” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Describe the impact of USP 800 on outpatient pharmacy practice. Adam Ripley, PharmD, RPh Owner Pharmacist Sona Compounding Pharmacy (2C) ACPE#:0046-9999-17-220-L04-P ACPE#:0046-9999-17-220-L04-T “USP 800 From the Health System Perspective” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Discuss the impact of USP 800 on health systems. Daryl McCollum, PharmD, MBA Carolinas HealthCare System (1D) ACPE#:0046-9999-17-221-L04-P ACPE#:0046-9999-17-221-L04-T “Drug Diversion” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Discuss practice methods to minimize drug diversion in your pharmacy. Detective Sheila Valdez Fayetteville Police Department (2D) ACPE#:0046-9999-17-222-L04-P ACPE#:0046-9999-17-222-L04-T “Managing Drug Expense Through the Continuum of Care” Panel Discussion Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1) Discuss methods to manage drug expense at various points in patient care Cole Wilson, PharmD Assistant Vice President Ambulatory Pharmacy Services Carolinas HealthCare System Donna J. Field, RPh, MBA AVP, Pharmacy

Levine Cancer Institute Doug Raiff, PharmD, BCPS Medication Stewardship Pharmacist, Center for Medication Policy Duke University Hospital (1E) ACPE#:0046-9999-17-223-L01-P ACPE#:0046-9999-17-223-L01-T “Beyond Metformin with New Insulins, GLP-1 Agonists and SGLT-2 Inhibitors” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: Pharmacists 1) Discuss the new prescribing guidelines for Regular U-500 insulin 2) Compare and contrast the new combination products (Soliqua and Xultophy) 3) Review safety, efficacy and cardiovascular outcomes data 4) Identify clinical pearls and key counseling points Lisa T. Meade, PharmD, CDE Associate Professor Wingate University School of Pharmacy Piedmont HealthCare Endocrinology - Statesville (2E) ACPE#:0046-9999-17-224-L04-P ACPE#:0046-9999-17-224-L04-P “Guideline Update on Sepsis” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: Pharmacists: 1) Discuss general updates in the 2016 Surviving Sepsis Campaign Guidelines 2) Review current, primary literature related to guideline development 3) Investigate new recommendations and techniques for monitoring resuscitation in sepsis 4) Apply guideline recommendations to bedside care 5) Consider future directions in the treatment of sepsis Pharmacy Technicians: 1) List 2 actions pharmacy technicians can take to assist the pharmacist who is caring for a specific patient. Jeremy Hodges, RPh, BCPS NHFMC Critical Care Clinical Specialist Director, PGY2 Critical Care Residency 5:00-6:00 Reception/Preceptor Awards 6:00-7:30 ACPE#:0046-9999-17-225-L01-P ACPE#:0046-9999-17-225-L01-T “OTC Jeopardy” Learning objectives for Pharmacists and Technicians: At the completion of this knowledge-based activity, the participant will be able to: 1. Identify and explain aspects of the effective and safe practice of pharmacy self-care treatments

2. Describe at least two over the counter and prescription medication interactions that pharmacists and pharmacy technicians should be aware of 3. List three OTC medications and their use. Pharmacists should identify counseling points for each of three OTC medications

Moderator: Stefanie Ferreri, PharmD, BCACP, CDE, FAPhA Clinical Professor UNC Eshelman School of Pharmacy President, NC Association of Pharmacists Coordinator: Becky Szymanski, PharmD, BCPS Manager, Clinical Pharmacy Services PGY1 Residency Program Director Carolinas HealthCare System NE Judges:

Jenn (Waitzman) Wilson, PharmD, BCACP Assistant Professor of Pharmacy Levine College of Health Sciences Wingate University School of Pharmacy

Courtney L. Bradley, PharmD, BCACP Assistant Professor of Clinical Sciences Applied Laboratory Coordinator High Point University Fred Wilson School of Pharmacy Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA Assistant Dean of Experiential Programs: Community Clinical Associate Professor Director, PGY1 Community Pharmacy Residency Program UNC Eshelman School of Pharmacy Katie Trotta, PharmD, BCACP Clinical Assistant Professor, Department of Pharmacy Practice Manager, Campbell University Health Center Pharmacy Director, PGY1 Community Pharmacy Residency 7:30 pm-until Student Pharmacist Network Social “Reboot” 534 N. Liberty Street, Winston-Salem, NC

Student Program

2017 NCAP Annual Convention Student Program September 23-24, 2017 Benton Convention Center, Winston-Salem, NC

Co-Sponsored by Campbell University College of Pharmacy & Health Sciences High Point University Fred Wilson School of Pharmacy UNC Eshelman School of Pharmacy Wingate University School of Pharmacy

Saturday, September 23 12:00-1:30 pm

Student Mentoring Luncheon (Private room set up for students from different programs to have lunch and converse with one or two pharmacists)

OR 12:00-1:30

Regular Luncheon

1:30-3:00

Round Tables

1:30-2:30

Residency Showcase/P4/PY4 only

3:00-5:00

Residency Showcase/All Students

5:00-6:00

Reception/Preceptor Awards

6:00-7:30

OTC Jeopardy

Sunday, September 24 Student Leadership Conference – P1/PY1-P3/PY3 ********************************************************************************************** 9:00-4:00 pm (Career Fair and Interviews for P4/PY4 only) – Piedmont 3 & 4 ********************************************************************************************** 19

8:00-8:45 am

Registration/Continental Breakfast

8:45-9:00am

Welcome/Announcements/Introductions – Piedmont 1 & 2 Bob Cisneros, PhD Associate Professor, Pharmacy Practice Department Campbell University College of Pharmacy & Health Sciences

9:00-10:15

“Pharmacy Entrepreneurship & Panel Discussion” Joe Moose, PharmD Moose Pharmacy Director of Strategy & Luminary Development CPESN USA Michelle Fritsch, PharmD, BCGP, BCAP CEO, Meds MASH, LLC Patti Gasdek Manolakis, PharmD President, PMM Consulting, LLC Co-Founder & Chairman of the Board Javesca Feeds P. Kay Wagoner, PhD Associate Director, Eshelman Institute for Innovation EIR UNC Chapel Hill and Blackstone Entrepreneur Network Adjunct Associate Professor, Department of Cell Biology and Physiology UNC Eshelman School of Pharmacy

10:15-10:30 10:30-11:45

Break “Rx Resilience” Lauren M. Penwell-Waines, PhD Assistant Professor Licensed Clinical Psychologist Department of Family and Community Medicine Carilion Clinic-Virginia Tech Carilion School of Medicine

11:45-12:30 pm

Boxed Lunches for All Students

12:30-1:45

“Student Pharmacist Network Introduction Followed by Leadership Activity” Justin Reid, Chair UNC Eshelman School of Pharmacy Sophia DeBerry, Chair-Elect Wingate University School of Pharmacy

1:45-2:00

“Parting Message: Setting Your Course” Penny Shelton, PharmD, BCGP, FASCP Executive Director North Carolina Association of Pharmacists

2:00-4:00

Career Fair Exhibits Only P1/PY1-P3/PY3

“Transform through Innovation” 2017 NCAP Annual Convention Benton Convention Center, Winston-Salem September 22-24, 2017 • Click here to Register now for the NCAP Convention • Click here to reserve your room at the Convention Host Hotel, Embassy Suites by Hilton, Winston-Salem, 460 North Cherry Street, Winston-Salem, NC 27101. Group Code: PHA Cut-Off Date: August 22, 2017 • Click here to register for the APhA Diabetes Certificate Program, September 22 - Benton Convention Center. • Click here to register for the Technician Review Seminar, September 23 - Benton Convention Center. • Click here for a copy of the Exhibitor Registration Form • Click here for a copy of the Residency Showcase Registration Form 21

Convention Workshops

Friday Workshops Collaborative Approach to Falls Assessment and Prevention: Pharmacists’ Use of the ASCP/NCOA Falls Risk Reduction Toolkit 8-Hour Workshop Appropriate Audience: Pharmacists Description: Regardless of practice setting, the majority of pharmacists provide care for older adults. Each year, millions of falls-related injuries occur among older adults. Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall. Falls among older adults are largely preventable; yet each year one-third of Americans aged 65 and older falls, resulting in costly negative outcomes. Medications are a modifiable risk factor for falls; therefore, pharmacists play a key role in preventing and mitigating falls risk. This workshop will provide pharmacists with tools and resources needed to integrate falls prevention risk assessment and intervention into practice in conjunction with other health care providers. Attendees will be provided with the American Society of Consultant Pharmacists (ASCP)— National Council on Aging (NCOA) Falls Prevention Tool Kit, a comprehensive adjunctive assessment to the Centers for Disease Control and Pre22

vention’s STEADI (Stopping Elderly Accidents, Deaths and Injuries) Provider Tool Kit.

hesitation out of starting conversations about mental and behavioral health problems.

The interactive workshop will focus on the clinical aspects of falls prevention for pharmacists and will offer pharmacists the opportunity to learn various assessment skills, as well as identify how to incorporate falls prevention into practice and collaborate with other health care professionals to reduce falls.

This workshop will address risk factors and warning signs for a range of mental health problems, including depression, anxiety, trauma, psychosis, substance use disorders and self-injury. Participants will learn to apply appropriate peer, social and self-help resources, as well as use a 5-step action plan to help an individual in crisis.

Mental HealthFirst Aid Adult Use of Screening, Brief InterTraining Course vention and Referral for Treatment (SBIRT) by Pharmacists 8-Hour Workshop Appropriate for Patients at Risk for Substance Abuse Audience: Pharmacists and Technicians Description: This workshop teaches the participant how to identify, understand and respond to signs of mental illnesses. The training teaches skills needed to reach out and provide initial help and support to someone who may be developing a mental health or substance use problem or experiencing a crisis. Over 1 million people across the United States have been trained in Mental Health First Aid. This training is appropriate for both pharmacists and pharmacy technicians. Most of us would know how to help if we saw someone having a heart attack. We would call 911 and start CPR. However, too few of us know how best to respond to someone having a behavioral health issue. Mental Health First Aid takes the fear and

4-Hour Workshop Appropriate Audience: Pharmacists Description: Pharmacists as healthcare providers often encounter signs of our nation’s growing substance misuse and abuse. This workshop is designed to teach pharmacists SBIRT an important skill set designed to help with early detection and intervention. During this training participants will learn to screen patients for substance misuse and effectively communicate to promote change based on the evidence-based SBIRT model promoted by the federal Substance Abuse Mental Health Services Administration (SAMHSA). The workshop will focus on how

to: promote awareness of substance disorders and how these interfere with medications and contribute to comorbidities; identify and assess for at risk patients; and use appropriate motivational interviewing skills as brief interventions to elucidate change in patient behaviors. The training will also provide the opportunity to determine how best to incorporate SBIRT into the current workflow of the pharmacy or outpatient clinic service. Pharmacogenetics 101: A Primer for Pharmacists 4-Hour Workshop Appropriate Audience: Pharmacists Description: Pharmacogenetics has been described by some as an essential for pharmacists; yet most have not taken steps to learn the basics. Pharmacists as “drug experts” will need to take the lead in understanding how genetic profiles impact drug selection and monitoring for patients. This workshop will address basic pharmacogenetics nomenclature and compare and contrast various technologies used for pharmacogenetic testing. Participants will learn about available resources, as well as specific medications and clinical situations where pharmacogenetics testing is most useful. Time will be devoted to evaluating case scenarios to highlight opportunities and limitations of personalized medicine testing. Participants will learn about alternate recommendations for therapies and dosages based upon specific patient medications and pharmacogenetic profiles. Participants will also learn about an opportunity to have their own pharmacogentic testing completed by a North Carolina lab.

Creating Your Future with Intention: A Workshop for Emerging Leaders

ducing the participants to antimicrobial stewardship opportunities. The importance of strong partnerships will be emphasized, such as with diagnostic testing and microbiology. 4-Hour Workshop In addition, time will be devoted to regulatory standards and CDC core Appropriate Audience: elements. Participants will emerge Pharmacists and Technicians from this workshop with information necessary to implement a new Description: program, service or strengthen an existing antimicrobial stewardship We all have the potential to lead, program. whether it is in our personal or professional lives. This workshop is designed to help reveal leadership capacity within those individuals who have found themselves with new leadership duties or are beginning to show leadership potential. This workshop will address core principles behind successful leadership and will include the importance of reflection, the ladder of influence and self-leadership concepts. During the workshop, participants will create a personal mission statement that reflects individual professional goals and passions. Participants will examine and evaluate potential solutions for challenges and barriers which may stand in the way of professional success. Antimicrobial Stewardship: Models for Success 4-Hour Workshop Appropriate Audience: Pharmacists

BRING CASH!

Description: This workshop will essentially address five aspects of antimicrobial stewardship. First, participants will learn about setting the stage for a successful antimicrobial stewardship program where operational strategies will be addressed. Secondly, time will be devoted to intro-

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Roundtable Discussions “Speak Out. Stand Out. Break Out.” Best Practices Roundtable Discussions In keeping with this year’s Annual Convention theme, Transform through Innovation, these Roundtable topics are dedicated to discussions on various innovative topics from around the great state of North Carolina. Attendees will have the opportunity to participate in up to four roundtable discussions, lasting 20 minutes each during the 90-minute roundtable session. A

· 1.

“Becoming a Rock Star Preceptor”

Examine challenging student/preceptor scenarios and explore strategies for solving those challenges

Joy Greene, PharmD jgreene@highpoint.edu

“Caring for Undocumented Patients”

Charlene Williams, PharmD, BCACP, CDE

Megan Coleman, PharmD, BCPS, CPP

charlene_williams@unc.edu

m.coleman@wingate.edu

Overview: A Preceptor is a teacher and mentor who guides a student through their pharmacy practice rotations during pharmacy school. Pharmacists who are interested in precepting student pharmacists must go through an application process within each school of pharmacy. If a pharmacist meets the school’s specific requirements, a pharmacist is awarded the title of Preceptor. In this session, we will walk pharmacists through the overall application process required for becoming a Preceptor. We will also walk through student/Preceptor scenarios and discuss ways to become an effective Preceptor. Precepting student pharmacists is both rewarding and challenging. Preceptors are often faced with difficult situations when teaching students. We expect this session to bring you confidence in how you can teach and mentor students well. Come join us for this fun, interactive roundtable session and learn strategies for becoming a “Rock Star Preceptor.”

Overview: With the number of undocumented immigrants on the rise, pharmacists can play an integral role in the care of this unique patient population as these individuals often have limited access to healthcare. Many challenges exist when caring for undocumented patients, including language barriers, cultural differences, and cost of medications. This discussion will explore the challenges encountered by pharmacists when caring for this patient population, as well as the resources available for assistance.

Objectives:

Review the process for becoming a preceptor in North Carolina

Describe teaching, mentoring, and training strategies for becoming a “Rock Star Preceptor”

Objectives

Discuss the challenges associated with caring for undocumented patients

Discuss resources available to aid in the care of undocumented patients

“Developing and Sustaining Employee Engagement” Matt Kelm, PharmD, MHA, matthew.kelm@duke.edu Chris Barringer, RPh, chris.barringer@carolinashealthcare.org

Overview: As the pharmacy profession continues to embrace expectations of maintaining high-quality services, whether clinical or operational, it is vital that work culture—the beliefs, thought processes, and attitudes of employees and the ideologies and principles of the organization—is recognized as an important catalyst for success. The culture embedded within any pharmacy department can have a tremendous impact on the department’s ability to achieve its goals and, if managed appropriately, can be a powerful tool in building the foundation for high employee engagement. The presenters will describe programs from two different health care systems aimed at soliciting input from staff regarding their main concerns, as identified by their engagement surveys; identifying and implementing goals and action plans to help improve the work cultures; and providing ongoing communication to staff on progress addressing action items.

70 years; 24 females). At baseline, mean BP was 163/70 mmHg and mean A1C was 9.5%. By 3 months, mean BP decreased to 144 mm Hg and mean A1C to 8.8%, and 71% and 43% of patients reached BP and A1C goals. Objectives:

To develop keys to success for pharmacist involvement on interprofessional teams.

“Introducing the Pharmacists’ Patient Care Process to First-Year Pharmacy Students: A Framework for Curricular Integration”

csherril@highpoint.edu

Describe tactics implemented to hardwire employee engagement efforts.

Overview: The Pharmacists’ Patient Care Process (PPCP) is a cyclic approach to patient-centered care consisting of the following five components: collect, assess, plan, implement, and follow-up: monitor and evaluate. The PPCP was created by the Joint Commission of Pharmacy Practitioners “to promote consistency across the profession… [and] to articulate the patient care process for pharmacists to use as a framework for delivering patient care in any practice setting.” The Accreditation Council for Pharmacy Education (ACPE) Standards 2016 requires that the PPCP be integrated into pharmacy curricula. At the High Point University Fred Wilson School of Pharmacy, the PPCP is introduced to students in the first professional year through a series of laboratory and classroom activities in which students practice patient assessment, clinical guideline retrieval, and documentation, in addition to clinic workflow procedures. Two ambulatory care patient cases are at the center of these activities.

“Interprofessional Patient Care” Jennifer Kim, PharmD, BCPS, BCACP, CPP Cone Health Internal Medicine. AHEC. UNC Assistant Director of Pharmacy Education Jen.kim@conehealth.com Overview: To determine the impact of an interprofessional medication adherence program for elderly patients. Background: In the United States, only about 54% of elderly with hypertension (HTN) and about 57% with diabetes (DM) are controlled. Medication adherence programs for elderly have demonstrated improved outcomes and reduced cardiovascular risk. Setting: Cone Health Internal Medicine Center provides primary care regardless of financial status and is the internal medicine residency program site. In 2016, a Geriatrics Task Force (GTF) was developed including physicians, a pharmacist, nurses, certified medical assistants, a social worker, and a diabetes educator. Methods: The GTF identified elderly with uncontrolled HTN and DM and contacted their pharmacies for refill histories. Medication findings and recommendations were communicated to physicians prior to the patient appointment, and the GTF followed up with patients via telephone. The primary outcome was mean BP and A1C pre-post comparison. Secondary outcomes include percentage of patients achieving target BP and A1C. Results/Outcomes: Twenty-nine patients were included (mean age of

To identify opportunities and challenges with interprofessional patient care.

Christina H. Sherrill, PharmD, BCACP Assistant Professor of Ambulatory Care, High Point University Fred Wilson School of Pharmacy

Objectives ·

Objectives:

Explain the Pharmacists’ Patient Care Process and how it relates to both patient care and student education

Integrate the Pharmacists’ Patient Care Process into student activities

“Leading from the Middle in Pharmacy HealthSystems” Timothy R. Pasquale, PharmD, MBA, FIDSA 25

table session, participants will have the opportunity to learn more about ways to integrate MI into community pharmacy setting in 5 minutes or less using the four MI stages: engaging, focusing, evoking, and planning.

Lydia Wang, PharmD Kamaria K. Brown, PharmD, BCPS Overview: In health-systems pharmacy, one will find multiple rungs on the organizational leadership ladder, including distinct leadership levels at the bottom, middle, and top. Leading from the middle involves its own unique set of skills, benefits, and challenges. Professionals holding a mid-to-senior level position are responsible to their peers, their superiors and those in lower level positions in the organizational hierarchy with whom they work or interact. This session invites attendees to discuss adapting one’s strategies in order to empower others, maximize workplace efficiency, accomplish the goals set forth by the organization, and promote optimal morale, while also maintaining one’s own satisfaction and work-life balance.

Objectives

Objectives:

Discuss key strategies for leading from the middle in the continuum of pharmacy care.

Share successes and challenges with experience in various middle-leadership positions in the health-system.

Increase knowledge of motivational interviewing strategies as an effective tool for patient engagement in the community pharmacy setting.

“Outpatient Pharmacists Collaborating to Improve Patient Care: Pearls from the Western NC Outpatient Pharmacy Partners (WNCOPP)”

andriaeker@gmail.com Overview: As healthcare continues to evolve into a value-based payment system, roles of pharmacists in all practice settings are shifting and we are becoming an integral part of our patients’ healthcare team. It is important for ambulatory care and community pharmacists to collaborate to improve continuity of care in the outpatient setting. In western North Carolina, we have started a group called the Western NC Outpatient Pharmacy Partners. Our vision is to inspire collaboration and innovation among ambulatory care and community pharmacists. This round table will provide pearls on initiating and developing a group focused on collaboration between outpatient pharmacists.

Chelsea Phillips Renfro, PharmD Assistant Professor University of Tennessee Health Science Center College of Pharmacy renfroce@gmail.com

Describe the purpose of motivational interviewing and rational for using it as a pharmacist.

Andria Eker, PharmD, BCACP, CDE, BCGP Chair, Western NC Outpatient Pharmacy Partners

“Motivational interviewing: Empowering Patients to Change Behaviors in 5 Minutes or Less”

Overview: Adherence to chronic medications is a public health concern as these medications only achieve positive health outcomes if patients adhere to their prescribed medication regimen. Furthermore, non-adherence to prescribed medications costs the United States healthcare system $290 billion annually. Many factors contribute to the ability of patients to adhere to these regimens; however, medication adherence is a complex issue that often requires a behavioral change from our patients. To facilitate this behavioral change, pharmacists have started using motivational interviewing (MI). MI is a patient-centered, collaborative, counseling style that can be used to elicit and strengthen a patient’s own motivation for change. This type of counseling has been proven to lead to higher success rates for more efficient and longerlasting health behavior change. During this round

Objectives:

Identify organizations and pharmacists within your communities that would be interested in initiating a group focused on collaboration between outpatient pharmacists.

Discuss opportunities, barriers, and steps to developing a group within your communities focused on collaboration between outpatient pharmacists.

“Overweight and Obesity Pharmacotherapy”

Amanda Woods, PharmD, BCACP, CDE, CPP

Describe the layered learner model and discuss strategies for and challenges of implementation.

Demonstrate the benefits to the learners, site, school, and patients of incorporating various levels of healthcare students and residents in various learning environments.

Amanda.woods@carolinashealthcare.org Overview: The incidence of overweight and obesity is increasing in America, resulting in poorer health outcomes and control of other chronic disease states. Research indicates that maintenance of just 3-5% loss of overall body weight in some cases is sufficient to confer significant improvement in health outcomes. Several medications have been FDA approved in recent years that can aid patients and clinicians in reaching and surpassing these clinical goals. Guidelines recommend the use of pharmacotherapy as one weight loss method in certain patients in combination with diet, exercise, and behavioral change. This discussion will explore the efficacy of the agents available, safety considerations, cost, and methods of getting agents covered and reducing patient outof-pocket costs. Objectives ·

Discuss pharmacotherapy available for the management of overweight and obesity in the US.

Discuss clinical pearls related to the use of these agents including efficacy, safety, place in therapy, cost and coverage.

10. “Precepting: Layered Learner Model and Inte-

gration of Students and Residents into Practice Sites”

11. “Specialty Pharmacy”

Cole Wilson, PharmD Assistant Vice President Outpatient Pharmacy Services Carolinas Health Care System Division of Pharmacy Cole.wilson@carolinashealthcare.org Overview: With the continued growth of specialty pharmacy services, the industry is seeing a major trend in health systems and integrated delivery networks (IDNs) joining the ranks of providers. By establishing their own specialty pharmacies internally, IDNs are able to leverage better control over drug selection and prescribing, patient care and outcomes, and gain share in the specialty market. Health Systems offer some unique and critical advantages over large national chains and independent specialty pharmacies including but not limited to accessing the comprehensive electronic health record, increased face-to-face interactions with care teams and patients, and offering insights and specialty data that pharmaceutical companies and third-party payers are constantly searching for. Objectives: ·

The rise of specialty drug and supply costs

Ian Hollis, PharmD, BCPS, AQ Cardiology

The specialty patient journey

ian.hollis@unchealth.unc.edu

Identify key roles within a multidisciplinary team in specialty pharmacy care

Illustrate the clinical and financial benefits of collaborative practice in specialty care

To describe best practices in optimizing specific roles within the multidisciplinary team

Provide data supporting the benefits of an integrated specialty pharmacy model in patient outcomes

Overview: The layered learner model of teaching and patient care has been in place in medical practice for many years. Pharmacy health systems and educators are reframing the experiential education approach to help meet various needs. In the model, the preceptor acts as the attending pharmacist overseeing various levels of learners, potentially including pharmacy residents (PGY1 and/or PGY2), students, and/or technicians. This session will be designed to explore this concept with meeting attendees and discuss benefits to participants, health systems, and patients, and challenges experienced. Objectives

12. “Team Work Makes the Dream Work: Interpro-

fessional Education Opportunities in the Experiential Setting” 27

Melissa Dinkins, PharmD, BCACP l.dinkins@wingate.edu Wesley Haltom, PharmD wrhaltom@wingate.edu Overview: In 2011, the Interprofessional Education Collaborative (IPEC) outlined several competency domains for interprofessional collaborative practice. Schools of medicine, pharmacy, nursing, dentistry, and osteopathic medicine were at the table to define and agree upon four competencies to prepare students to enter the workforce effectively participating in teamwork and team-based care. Recognizing the importance of interprofessional education (IPE), the Accreditation Council for Pharmacy Education (ACPE) adopted a new standard in the 2016 Standards, which specifically requires pharmacy curricula to “prepare all students to provide entry-level, patient-centered care in a variety of practice settings as a contributing member of an interprofessional team.” This roundtable, designed especially for pharmacist preceptors, will highlight the role of IPE in experiential education, engage participants in sharing their approaches to IPE, and challenge preceptors to incorporate IPE opportunities frequently and intentionally within pharmacy practice experiences. Objectives: · Define IPE in the context of pharmacy practice experiences ·

Identify practical opportunities for incorporation of IPE into your pharmacy practice experience offerings

13. “The Fracture Liaison Service: Improving the

Gap in Care for Patients with Osteoporotic Fracture” Mollie Ashe Scott, Pharm.D, BCACP, CPP, FASHP, Regional Associate Dean and Clinical Associate Professor, UNC Eshelman School of Pharmacy, Clinical Associate Professor, UNC School of Medicine mollies@email.unc.edu

Overview: Patients who experience an osteoporotic fracture are at high risk for subsequent fracture, yet only 25% of patients receive a DXA scan or are prescribed a bisphosphonate post-fracture. Because of this gap in care, an innovative transition of care model called Fracture Liaison Service

(FLS) has developed worldwide. Studies indicated that FLS decreases risk of subsequent fracture and mortality. An interprofessional osteoporosis clinic (OC) staffed by a physician, pharmacist, and a nurse was developed in a family health center in 2007. The pharmacist provides recommendations about medications that increase risk of falls or osteoporosis, performs a dietary history for calcium and vitamin D, coordinates medication access, educates the patient and family about osteoporosis and its complications as well as the benefits and potential adverse events of medications, and implements the pharmacotherapy plan. A study of osteoporotic fractures in the practice was conducted in 2017 to evaluate the quality of post-fracture care. Over 50% of patients did not receive a DXA or a bisphosphonate after fracture, indicating the need for an FLS. This round table will discuss how one practice is seeking to improve the quality of care for patients after osteoporotic fracture. Objectives: ·

Discuss the gap in care for patients with osteoporosis who experience a fracture.

Describe how an interprofessional osteoporosis clinic can improve the quality of care for osteoporosis patients.

14. “The More the Merrier? Exploring Advantages

of Shared Medical Appointments” Jennie Hewitt, PharmD, BCACP Jennie.hewitt@va.gov

Overview: At the Raleigh Veterans Affairs outpatient clinic, our innovative pharmacists have started group medical clinics in a variety of disease states. Currently we offer shared medical visits for hypertension, heart failure, chronic obstructive pulmonary disease, smoking cessation and diabetes. Our group clinics enlist the help of multiple disciplines including nutrition, mental health and nursing. During this roundtable, we will discuss the time efficiency of these groups as well as lessons learned regarding the set up and management of group medical appointments. Objectives ·

Explain pros and cons of shared medical appointments

Discuss how to start/design group medical clinics

Review tips for success in conducting and maintaining group medical clinics

15. “The Pharmacists’ Patient Care Process”

K. Paige Brown, PharmD brownp@campbell.edu Tina Thornhill, PharmD, FASCP, BCGP thornhillt@campbell.edu Overview: The Pharmacists’ Patient Care Process (PPCP) was developed by the Joint Commission of Pharmacy Practitioners as a standardized, consistent approach to patient care that focuses on team-based care in all practice settings. The PPCP consists of five components: Collect, Assess, Plan, Implement, and Follow-up: monitor and evaluate. The Accreditation Council for Pharmacy Education’s 2016 Guidance for Standards recommends using the PPCP to establish a culture of collaboration and communication between the pharmacist, the patient, and caregivers. Students are introduced and taught this concept in their curriculum. Preceptors and pharmacy mentors should integrate this model of care into their clinical rotations and practice sites as a desired goal to reinforce the importance of a consistent approach to patient care.

ships with local inpatient and outpatient providers, community pharmacists at Realo Discount Drugs created innovative clinical services focused on patients transitioning home from the hospital. Realo Jacksonville partnered with a local hospital to provide disease state education, medication reconciliation, and delivery of medications to patients being discharged to home. Through access to the hospital’s electronic health record and personal visits with the patient, a clinical pharmacist was able to participate in the transition of care process. Preliminary data show that patients participating in this innovative service have experienced fewer hospital readmissions than similar patients not enrolled. In New Bern, a clinical pharmacist was scheduled on a weekly basis to meet with patients with COPD or heart failure identified during post-discharge visits at local outpatient clinics. The pharmacist provided in-person and telephonic disease state education, medication information, and symptom assessment. Initial data indicate that patients enrolled in this new service experienced an improvement in symptom control and improved quality of life. Objectives: ·

Discuss novel approaches to transitionof-care services through partnerships between an independent community pharmacy and local outpatient clinic, as well as a local hospital.

Explain lessons learned and summary data gathered during the initiation of both innovative transition-of-care services.

Objectives: ·

Define and review the components of the newly required Pharmacists’ Patient Care Process Evaluate and apply the use of the Pharmacists’ Patient Care Process in a clinical rotation setting

16. “Transitions of Care at Realo Discount Drugs”

Christy Holland, PharmD. Realo Discount Drugs cholland@realodiscountdrug.com Christina Nunemacher, PharmD. Realo Discount Drugs cnunemacher@realodiscountdrug.com Overview: Community pharmacists are uniquely positioned to provide disease state education, medication reconciliation, and provision of medications during transitions of care from an inpatient setting to an outpatient setting. Through partner-

17. “Treatment of Hepatitis C in Primary Care”

Rebecca Grandy, PharmD, BCACP, CPP, Clinical Pharmacist, Mountain Area Health Education Center, Assistant Professor of Clinical Education, UNC Eshelman School of Pharmacy Rebecca.grandy@mahec.net Overview: Cases of Hepatitis C have increased exponentially given the opioid epidemic. Traditionally these patients have been referred to gastroenterology and infectious disease specialists. With advances in Hepatitis C treatment, primary care clinics are in an ideal position to increase access to treatment. Newer treatments for Hepatitis C include well-tolerated oral medications, some with

once daily dosing of a single pill.

Describe how collaborative practice legislation can be utilized in community pharmacy practice to implement innovative patient care services

Identify ways to overcome barriers to implementing collaborative practice agreements in the community pharmacy setting

Objectives: ·

Discuss the opportunities and challenges of treating Hepatitis C in primary care clinics Discuss the pharmacist’s role in treating Hepatitis C

18. “Updates on Healthcare Reform”

Chris Gillette, PhD c.gillette@wingate.edu Overview: This session will provide a brief update on the status of the Affordable Care Act (aka ACA or Obamacare) with a focus on medications. The session will also update participants on the status of the American Health Care Act of 2017, also focusing on patient access to medications. The goal of the roundtable is to enable participants to educate patients on possible changes to medication and insurance accessibility. Objectives ·

Critique current healthcare reform

Formulate patient educational materials on current healthcare reform efforts.

19. “Utilizing Collaborative Practice Legislation in

Your Community Pharmacy Practice”

Cortney Mospan, PharmD, BCACP, BCGP, Assistant Professor of Pharmacy, Wingate University, Levine College of Health Sciences c.mospan@wingate.edu Overview: This roundtable will review current collaborative practice legislation, potential expansion to collaborative practice legislation, and highlights of exemplar collaborative practice legislation from other states. The roundtable will focus on collaborative practices in the community pharmacy setting. Topics will include potential opportunities for physician buy-in and collaboration, requirements to enter a collaborative practice agreement, liability and legal implications, how to maximize current legislation, and how to advance advocacy efforts to further expand collaborative practice to enhance patient care outcomes and access. Objectives 30

20. “Utilizing Pharmacist-Physician Co-visits in a

Family Health Center”

Irene Park, PharmD, BCACP, CPP, Clinical Pharmacist, Mountain Area Health Education Center, Assistant Professor of Clinical Education, UNC Eshelman School of Pharmacy Irene.park@mahec.net Savannah Patel, PharmD, Clinical Pharmacist, Mission Hospital Outpatient Clinical Pharmacy Services, Savannah.Patel@msj.org Overview: In the absence of provider status, innovative interdisciplinary practice models are necessary to create financially viable clinical pharmacy services. In an effort to explore new models of care, we created a pharmacist-physician co-visit model with the hope of increasing both physician and pharmacist productivity. The pilot of this model began in June 2016 and was implemented in a satellite clinic of Mountain Area Health Education Center (MAHEC), a primary care network in Western North Carolina (WNC). Traditionally, patients were scheduled to a separate pharmacy clinic. These patients do not see a physician, and the pharmacist is not able to bill at level of service provided. In the co-visit model, the physician schedule was adapted to accommodate four additional patients per half-day, who would be seen in conjunction with the pharmacist. Based on an eight-month pilot, we estimated that an additional $88,646.47 in revenue can be generated annually. The purpose of this round table discussion would be to provide an overview of the implementation of this model as well as describe the financial benefits of utilizing co-visits. Objectives: ·

Design a clinic model utilizing pharmacistphysician co-visits

Evaluate the financial implications of pharmacist-physician co-visits

21. “What Medically Complex Patients Mean to

Medication Nurses”

Wendy Nash, PharmD, BCPS, BCGP, FASCP, Consultant Pharmacist, Neil Medical Group wendyn@neilmedical.com Overview: Over the last several years, the acuity of residents in LTC/PAC has dramatically increased. These medically complex patients have stretched the resources of the current LTC/PAC model. Medication nurses are at the hub of most of the clinical activity for residents in nursing homes, not just medication administration. As pharmacists, we work through and with medication nurses for multiple functions including medication administration, assessment, and care planning. Under most models, consultant pharmacists are on site at the nursing home once monthly instead of daily. Not only do we assess the resident and the effectiveness of the medication but also the processes of medication administration, assessment and care planning which continue to change with acuity increase. In our practice the pharmacist provides intensive medication reconciliation,

assists with understanding implementation of EHR related to medications, explains evidence-based protocols, helps the nurse to understand how medically complex patients affect them, logistics of drug delivery, and high costs of certain medications. Nor is this a one-time function, instead it is repeated over and over in high turnover situations. Understanding to how to train medication nurses in their key roles is an important function for consultant pharmacists. Objectives ·

Define “acuity creep” in LTC/PAC.

List at least 5 areas where the processes of medication nurses are impacted by medically complex residents.

Abstracts

Convention Abstracts

The numbered abstracts, corresponding to their poster board number, are divided into three sections: Original Research, Quality Improvement Evaluations, and Case Reports. Within each section, the abstracts are in alphabetical order based in the lead author’s last name. ORIGINAL RESEARCH (Note the abstract number corresponds to the poster board on which the investigation/ case report is summarized.)

GPA. This assessment may prove useful in admissions decisions but could also be modified to potentially improve predictive utility.

1. Title: Predictive Value of an Admissions Interview Day Calculations Assessment Authors: Courtney L. Bradley, PharmD, BCACP; Christina H. Sherrill, PharmD, BCACP, Earle “Buddy” Lingle, PhD Institution: High Point University, Fred Wilson School of Pharmacy, High Point, NC

2. Title: Utilization of Serum Uric Acid Levels for Gout Management in an Internal Medicine Clinic Authors: Alison L.P. Compton, PharmD Candidate, Jamie Cavanaugh, PharmD, CPP, BCPS, Timothy J. Ives, PharmD, MPH, FCCP, CPP, Betsy Shilliday, PharmD, CDE, CPP, BCACP, FASHP Institution: Eshelman School of Pharmacy, and Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, The University of North Carolina at Chapel Hill

Objective: To determine the predictive value of pre-admission criteria on performance during the first semester of a four-year pharmacy program, focusing on an interview day calculations assessment and a required one-credit hour calculations course. Methods: Pre-admission data were gathered using PharmCAS applications and interview day assessments. Pre-admission variables included age; gender; ethnicity; race; attendance at a four-year institution; previous degree awarded; total credit hours; number of pre-admission course failures; PCAT composite, chemistry, and quantitative scores; total, pre-requisite, and math GPA; and admissions interview day calculations assessment. Postadmission data included overall first semester GPA and average percent for calculations course assessments, which were gathered using Learning Management Software and Dean’s Office reports. The study was determined to be exempt by High Point University Institutional Review Board. Results: Data were analyzed for all students who matriculated in Fall 2016 (N=59). Eight pre-admissions factors (gender, race, PCAT composite, PCAT chemistry, PCAT quantitative, total GPA, pre-requisite GPA, and admissions interview day calculations assessment) demonstrated correlation to average percent in calculations course assessments. A multivariable regression using PCAT composite, PCAT chemistry, PCAT quantitative (highest scores), total GPA, and admissions interview day calculations assessment provided an R-squared value of 0.425 (p<0.001). The admissions interview day calculations assessment was not correlated to first semester GPA. Conclusion: The admissions interview day calculations assessment was positively correlated with success in a first semester calculations course but not overall first semester

Objective: To compare gout management using serum uric acid monitoring and subsequent presence of pharmacotherapy within an academic internal medicine clinic to the American College of Rheumatology 2012 Guidelines. Comparison was made to the minimum frequency interval of every 6 months and a serum uric acid goal of ≤ 6 mg/dL. Methods: This retrospective chart review study was approved by the UNC Office of Human Research Ethics. Patients diagnosed with gout that had ≥ 1 clinic visit(s) and ≥ 1 serum uric acid level(s) during the study period (May 2014 - May 2016) were included. Exclusion criteria were pregnancy during the study period, or allergy to allopurinol or febuxostat. For uric acid results > 6 mg/dL, the medication list was evaluated for the presence of a urate lowering therapy (ULT) within 5 weeks of the result. Results: 454 patients had a diagnosis of gout, of which 170 had ≥ 1 serum uric acid level(s). 163 were included after application of exclusion criteria. The most recent serum uric acid level was > 6 mg/dL in 111 patients (71.8%). ULT was present on the medication list within 5 weeks of a serum uric acid level result > 6 mg/dL in 56.3% (112/199) of cases. Allopurinol was the ULT agent in 85.7% (96/112) of cases at a mode dose of 100 mg and a median of 186 mg. Among those with a level > 6 mg/dL during the study period, the frequency of serum uric acid monitoring was 0.5 checks per patient per 6 months. Conclusion: Serum uric acid monitoring was less frequent in this study population than guideline recommendations, and a ULT was not present nearly half of the time, provid33

ing opportunities for optimizing management of gout. 3. Title: Adherence to Discharge Medications in Pregnant and Postpartum Women Following Discharge from Women’s Hospital Author: Brittany Cox, PharmD Candidate Institution: Cone Health Women’s Hospital, Greensboro NC; UNC Eshelman School of Pharmacy, Chapel Hill NC Objective: The primary purpose of this study was to determine the adherence to discharge medications in pregnant and postpartum women following discharge from Women’s Hospital. Methods: The medical records of 115 patients who were discharged from Women’s Hospital between February 1st, 2017 and April 30th, 2017 and then subsequently seen at Women’s Hospital Outpatient Clinic (within 6 weeks) were reviewed. Patients were excluded if they had no outpatient medication record available in Epic or if they were not prescribed any medications at discharge. Medications prescribed as PRN were not included in the compliance calculation. Adherence was calculated using the equation: medications filled at outpatient pharmacy/medications prescribed at discharge. Data collected included patient age, race, number of pregnancies, reason for hospitalization, and insurance coverage. Results: Seventy patients with a mean age of 29, and an average of 3 pregnancies, were included into the study. Of the patients included 80% were postpartum, 54% were African American, and 83% were covered under North Carolina Medicaid. On average patients were prescribed 2 medications at discharge. A medication adherence of 100% was achieved in 17 patients, while 4 patients had > 75% medication adherence, 19 patients had > 50% medication adherence, 2 patients had > 25% adherence, and 28 patients had < 25% adherence to discharge medications. Overall, 70 of the total 155 medications prescribed at discharge were picked up, giving an overall adherence of 45%. Conclusion: Adherence to discharge medications in this population of pregnant and postpartum women is < 50% and increasing pharmacy involvement in discharge counseling could help to increase adherence. 4. Title: Phenobarbital as adjunctive therapy in severe alcohol withdrawal syndrome Authors: David Cunningham, Pharm.D., Jason A Ferreira, Pharm.D., BCPS, BCCCP, Denise Kelley, Pharm.D., BCPS; Rachael Carloni, Pharm.D., BCPS Institution: University of Florida Health, Jacksonville, FL Objective: The primary purpose of this study is to assess the impact of adjunctive phenobarbital in combination with benzodiazepines (BZD) for the treat34

ment of severe alcohol withdrawal syndrome (AWS). Methods: This was a retrospective, single-center cohort study comprised of 154 severe AWS patients. Severe AWS was defined as receiving ≥ 10 mg lorazepam equivalents in ≤ 1 hour for the management of AWS. The primary endpoint was a composite of ICU admission, initiation of mechanical ventilation, AWS-related seizures, and the requirement of continuous infusion BZD. Results: The composite endpoint included 27 patients in the BZD + phenobarbital group compared to 32 in the BZD group (p = 0.4). The components of the composite endpoint for the BZD + phenobarbital group compared to the BZD group include: ICU admissions (22 versus 30, p = 0.17), mechanical ventilation (9 versus 6, p = 0.42), patients requiring continuous infusion BZDs (6 versus 7, p = 0.78), and AWS-related seizures (0 versus 3, p = 0.25), respectively. Secondary endpoints analyzed were as follows: total dose of BZDs in mg, incidence of nosocomial infections, number of tracheostomies required due to prolonged intubation wean, the number of patients that received adjunctive medications (clonidine, dexmedetomidine, propofol, antipsychotic, antiepileptic, baclofen and ketamine), length of time of mechanical ventilation, and ICU length of stay. Conclusion: The composite endpoint was lower in the patient group that received phenobarbital. Since there were no significant differences between the two groups, the use of phenobarbital could have contributed to the decrease in unfavorable outcomes that were analyzed. With further research, there is a potential to prevent an escalation in patient care and increased risk of unfavorable outcomes with the utilization of adjuvant phenobarbital in combination with benzodiazepines. 5. Title: Emergency providers’ opioid prescribing behaviors among Medicare Part D beneficiaries in North Carolina, 2013-2014: medication utilization and costs Authors: Michelle DeGeeter, PharmD, CDE, Chris Gillette, PhD, Geoffrey Mospan, PharmD, BCPS, Rebecca Seabock, PharmD Candidate, Brittany Williams, PharmD Institution: Wingate University School of Pharmacy, Wingate NC Objective: This study sought to quantify utilization and costs associated with opioid prescribing by emergency providers for Medicare Part D beneficiaries in North Carolina (NC) and United States (US) from 2013-2014. Methods: This was a retrospective examination of the Medicare Provider Utilization and Payment Data: Part D Prescriber datasets from 2013-2014. The main variables of

interest were total number of prescription claims and total Medicare Part D medication costs for opioid analgesic medications. Generalized estimating equations (GEE) were used to analyze the data. Results: Excluding NC, there were more than 2,030,108 (662 claims per 100,000) opioid claims in the US, costing more than $28.3 million in 2013. In 2014, also excluding NC, there were 2,061,992 (667 claims per 100,000) claims for opioids, costing almost $35.8 million. In NC, there were 67,570 (686 claims per 100,000) opioid claims from emergency providers in 2013 and 72,881 (733 claims per 100,000) opioid claims in 2014 for Part D beneficiaries. Total Part D drug costs associated with opioids from NC increased from $545,574 to $764,016, more than a 40% increase. In NC, there was a statistically significant increase in costs (p < 0.001) but not a significant increase in numbers of claims (p=0.051). Limitations: This study did not examine patient-level data and could not examine diagnoses leading to opioid prescriptions as well as opioid misuse or overdoses. Conclusions: Almost one out of every four Part D prescriptions from ED providers in NC was for an opioid medication. Given the recent focus on controlling opioid prescribing, future research should examine if the new opioid prescribing guidelines reduced opioid use in these providers. 6. Title: Community Pharmacist Preferences in Transition of Care Communications Authors: Mackenzie Dolan, PharmD Candidate; Chelsea Phillips Renfro, PharmD; Stefanie P. Ferreri, PharmD, BCACP, CDE, FAPhA; Betsy Shilliday, PharmD, CDE, CPP, BCACP, FASHP; Timothy J. Ives, PharmD, MPH, FCCP, CPP; Jamie Cavanaugh, PharmD, CPP, BCPS. Institutions: UNC Eshelman School of Pharmacy and School of Medicine, University of North Carolina at Chapel Hill. Objective: To determine community pharmacist preferences in transition of care (TOC) communications. Methods: In this cross-sectional study, data were gathered from a survey of community pharmacists’ preferences for TOC communications, including content, preferred method of communication, and potential barriers. The survey was distributed via email by the North Carolina Board of Pharmacy to all actively licensed community pharmacists in North Carolina. After one month, a reminder email was distributed, and the survey was closed one month later. Results were analyzed using descriptive statistics. Results: Survey responses were received from 343 community pharmacists (response rate=6.1%). Survey responders most commonly worked in an independent, single store (29.2%, n=100) or national chain pharmacy (29.2%, n=100) setting. The preferred method for a TOC communication

was via electronic health record (EHR) messaging (63.0%, n=184); however, 86.0% (n=288) reported not having access to an EHR. Preferred TOC communication content were: an active (93.2%, n=274) and discontinued (86.4%, n=254) list of medications, reason for hospitalization (85.0%, n=250), allergies (78.0%, n=229), and discharge summary (77.6%, n=228). Pharmacist self-identified barriers to utilizing a TOC communication included: lack of care coordination with community pharmacy (35%), lack of support and recognition from other healthcare providers (22.5%), absence of compensation for providing the service (17.5%), and need for organizational buy-in due to time and money involved in implementation (12.5%). When asked if a TOC communication were provided based upon their survey preferences, 97.5% (n=278) of pharmacists indicated it would be useful in their pharmacy. Conclusion: Community pharmacists acknowledged a need for TOC communications, and shared their preferences in content and method of transmission, as well as potential barriers for its integration. Future research is warranted to implement TOC communications between a health system and community pharmacy. 7. Title: Correlation Between Student Interventions and Time Spent at an Academic Medical Center Authors: Johanna Dresser, PharmD Candidate 2018; Meredith Welty, PharmD Candidate 2018; Lisa Brennan, PharmD, BCPS, BCGP; Amy Loken, PharmD, BCPS; Sarah Nisly, PharmD, BCPS, FCCP Institutions: Wake Forest Baptist Health (WFBH), WinstonSalem, NC; Wingate University School of Pharmacy, Wingate, NC Objective: To describe the incidence and types of student interventions per academic year and correlate the frequency and cost-analysis associated with interventions over time. Methods: This study is a single center review of interventions documented by students from June 12, 2017 through April 27, 2018. Student patient care interventions were logged in the electronic medical record (Epic) as part of routine practice. Intervention types and associated cost analyses were developed using published data and medical center pricing. All student rotations completed within the WFBH system during the study period were eligible for inclusion in analysis. The primary endpoint is change over time of the frequency of interventions made per rotation block. The secondary endpoint is change over time of the cost analysis of interventions per rotation block. 35

Results: Between June 12, 2017 to July 14, 2017, 9 students were eligible for inclusion in the data analysis. Preliminary data for the first eligible student block reveals that a total of 341 interventions were performed by 5 pharmacy students. The total cost-savings was $53,545 for all interventions performed by pharmacy students. On average, each pharmacy student performed 37.8 interventions for an average cost-savings of $5,949.44 per student. Conclusions: Preliminary results demonstrate value added by advanced practice pharmacy experience students to an academic medical center. Further analysis of correlation over time is forthcoming. 8. Title: The Use of an Empathy Assignment to Increase Students’ Comfort with Diabetes Nutrition Counseling Authors: Kira Harris, PharmD, BCPS, CDE; Dawn Battise, PharmD, BCACP; Cassie Boland, PharmD, BCACP; Megan Coleman, PharmD, BCPS, CPP; Delilah McCarty, PharmD, BCACP, CDE; Kimberly Nealy, PharmD, BCPS; Rashi Waghel, PharmD, BCACP, CPP; Jenn Wilson, PharmD, BCACP Objective: The primary objective was to determine if the use of an empathy assignment on third year introductory ambulatory care rotations increased students’ comfort in counseling patients about diabetes nutrition. Secondary objectives were to determine if use of the assignment increased students’ empathy and/or knowledge of dietary recommendations for patients with diabetes. Methods: Students completing rotations at nine clinical practice sites, focused on chronic disease state management, were invited to participate in the study. Students assigned to the intervention group completed an empathy assignment in which they tracked calories and carbohydrates in their current diet, designed and followed a diet appropriate for patients with diabetes, and wrote a reflection of their experiences. All other students served as the control group. All study participants completed a pre- and post-survey including demographics, current dietary habits, comfort with nutrition counseling, the Kiersma-Chen Empathy Scale (KCES), and a knowledge-based quiz. Results: Fifty-three students completed both pre- and post-surveys over the two-year study period. Participants had a mean age of 25.3 years and were mostly female (71.7%). Most students had minimal or no diabetes counseling experience at baseline. Student comfort with counseling on a diabetes diet increased by 4.7 points (out of 10) in the intervention group and by 3.5 points in the control group (p=0.044). The mean KCES increased from 86.0 to 92.4 (+6.4) in the intervention group and decreased from 87.7 to 86.5 (-1.2) in the control group (max score 105) (p=0.045). Knowledge based quiz scores increased by 36

9.7% in the intervention group and 8.6% in the control group (p=0.859). Conclusion: This study suggests students completing the empathy assignment had greater improvement in comfort with diabetic counseling and empathy for patients with diabetes. Implementation of a similar assignment for all students may be beneficial. 9. Title: Investigation of factors associated with influenza vaccination uptake in rural Columbus County, NC. Authors: Amber Hooks B.S., Hillary Best B.S., Ashley Rankin B.S., Peter Ahiawodzi Ph.D. Objective: The purpose of this study was to determine which demographics are less likely to vaccinate in a rural healthcare setting. This information can help rural pharmacists target methods and approaches to increase influenza vaccine uptake in these populations. Methods: One hundred patients, 18 years or older, consented to and completed surveys that were distributed upon their visit to one of the three Walgreens Pharmacy locations in Columbus County, NC, between June 1 – July 31, 2016. Information collected included age, sex, race, marital status, education, distance to doctor, distance to Walgreens, and their influenza vaccine uptake within the past year. Logistic regression was used to analyze associations between the various factors and vaccine uptake in the past year. Results: The results indicated patients less than or equal to 35 years old and patients 36-50 years old are 2.07 and 2.52 times more likely, respectively, to not get vaccinated when compared with patients over age 50. Patients with a high school education or less were 1.87 times more likely to not get vaccinated compared to those with more than a high school education. Males were 1.96 times more likely to not get vaccinated when compared to women. The study also indicated that patients who live fifteen minutes or less from their doctor’s office were 2.33 times more likely to get vaccinated compared to patients with over a fifteenminute drive. Patients less than a five minute drive from Walgreens were 1.64 times more likely to get vaccinated compared to those patients who live over 15 minutes from a Walgreens. Conclusion: Patients younger than 50 years old, males, and those with education only up to high school level were less likely to vaccinate. Nearness to a doctor’s office or Walgreens Pharmacy was also noted to influence patients’ influenza vaccine uptake. 10. Title: Examining the Effect of Educational Background on Perceptions of Teaching Preparedness Authors: Kathryn Ray Jones, PharmD Candidate; Wesley Rich, PhD; Timothy Bloom, PhD

Purpose: Pharmacy faculty come from diverse educational backgrounds in terms of terminal degree and post-graduate training. These faculty are a mix of PharmDs and PhDs. Most PhD programs have a required teaching component while few PharmD programs include teaching experience as a graduation requirement. Methods: This study surveyed faculty members at colleges of pharmacy for differences in educational background, teaching experience, and self-perceptions of teaching ability using an online questionnaire. The survey was designed in Survey Monkey and sent to over 400 faculty members. The first portion of the survey collected demographic information while the second portion asked about experience and confidence in areas related to teaching. Four reminder emails were sent on a bi-weekly basis to those who had yet to respond from the initial survey. Results: At the end of the survey period, 105 faculty members had responded. 60% of respondents had a PharmD while nearly 35% had a PhD and 5% had both a PharmD and a PhD as terminal degrees. Across all areas of perceived need for teaching development, there were few differences in respondents based on terminal degree. The largest, and only significant, difference was seen in the area of analyzing exam questions where PhD respondents felt they needed less professional development compared to PharmD respondents (p= 0.039). Faculty members who had taken professional courses related to teaching indicated a stronger need for development related to analyzing exam questions (p=0.03). Overall, female respondents perceived a greater need for planning workshops (p=0.013) and precepting students on rotation (p=0.07) when compared to their male counterparts. Conclusions: When comparing faculty at pharmacy schools across the nation in perceived need for development in certain areas of teaching, there were minimal differences based on the terminal degree of a PharmD or PhD. 11. Title: Educating Future Pharmacists on the Impact of Pharmacogenomics Authors: Aparna Krishnamurthy, Pharm.D. Candidate 2019; Olivia Dong, M.P.H.; Oscar Suzuki, Ph.D.; Rachel Howard, B.S.; Cristina Benton, Pharm.D., Ph.D.; Robert Dupuis, Pharm.D.; Tim Wiltshire, Ph.D.; Amber Frick, Pharm.D., Ph.D. Institution: UNC Eshelman School of Pharmacy, Chapel Hill, NC

Objective: Pharmacogenomics is being increasingly used and practiced in various clinical settings. The success of pharmacogenomics relies heavily on healthcare providers who interpret results and discuss their impact with pa-

tients. More education for healthcare providers is needed to expand the practice and overcome barriers of pharmacogenomics implementation. Methods: We surveyed 147 second-year student pharmacists enrolled in a clinical pharmacology course about their individual perceptions towards pharmacogenomics prior to and following an educational intervention. This intervention included optional personalized genotyping with a novel sequencing assay using molecular inversion probes. Only the pharmacogenes with variants used to make therapeutic recommendations were analyzed (e.g., CYP2C19, CYP2C9, CYP3A5, G6PD, RYR1, SLCO1B1). The results of this educational intervention were compared to those previously obtained using 23andMe. Paired pre- and post-intervention responses were analyzed with the Wilcoxon signed-rank test for Likert items. Results obtained with 23andMe and the sequencing assay were compared using Fisher’s Exact test. Results: Out of 123 (87%) student pharmacists who received results from the sequencing assay, 91% felt they had a better understanding of pharmacogenomics on the basis of undergoing genotyping. Of the 73 students who provided open-ended responses within the post-survey, 65% of students believed that though the feasibility of pharmacogenomic testing in clinics is limited due to cost and accessibility issues, the practice of pharmacogenomics can have a significant part of clinical decision making and will be important for the future of pharmacy practice. Perceptions from these student pharmacists were compared to those from students who historically received genotyping from 23andMe, and interestingly, attitudes in several indicators related to personal reflections on pharmacogenomics were decreased. Conclusion: Opportunities for pharmacogenomics learning should be implemented in various healthcare curricula and environments. Future follow-up questionnaires will qualitatively focus on differences between data obtained from the two genotyping exercises. 12. Title: Evaluation of Levetiracetam Dosing in Traumatic Brain Injury at Mission Hospital Authors: Ryan Marshall, PharmD Candidate, Ryan Tilton, PharmD, Heidi Phillips, PharmD, BCPS, CPP Institution: Mission Hospital, Asheville NC; UNC Eshelman School of Pharmacy, Chapel Hill NC Objective: This study compares the incidence of seizures in the first seven days of hospital stay in traumatic brain injury patients initiated on seizure prophylaxis with levetiracetam. The primary objective is to compare seizure incidence in patients initiated on regimens exceeding 2,000 mg per day compared to patients initiated on lower dose regimens. Secondary objectives included hospital length

of stay, duration of levetiracetam treatment, and time until first seizure. Methods: The medical records of 486 adult patients admitted to Mission Hospital for traumatic brain injury from January 1, 2013 to April 30, 2017 were reviewed. Included patients received at least two administrations of levetiracetam in the first 24 hours of hospital stay, and key exclusions were history of seizure disorder, active seizure on presentation, and patients initiated on more than one antiepileptic medication. Data collected included patient demographics, dose and number of levetiracetam administrations, and seizure date and time as documented by nursing. Results: Of the study patients initiated on a lower dose levetiracetam regimen, 17 of 467 (3.64%) experienced a seizure during the first seven days of hospital stay, while no patients initiated on a higher dose levetiracetam regimen experienced a seizure during the same time period. Conclusion: Traumatic brain injury patients at Mission Hospital initiated on seizure prophylaxis with levetiracetam regimens exceeding 2,000 mg per day were less likely to experience a post-traumatic seizure in the first seven days of hospital stay compared to patients initiated on lower dose regimen. 13. Title: An Analysis of US Childhood Vaccination Uptake and Associated Predictors Utilizing the National Immunization Survey for Years 2008 through 2015 Authors: Meredith McSwain, BS, Ashley Holombo, BS, Michael Jiroutek, DrPH, MS, Melissa Holland, PharmD, MSCR Institution: Department of Clinical Research, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC Introduction: Vaccines prevent 14 million cases of disease and reduce healthcare costs by $9.9 billion for each birth cohort following the recommended vaccination schedule. Approximately 300 children in the US die annually from vaccine preventable diseases. Prior studies have found varying rates of vaccination in young children, possibly due in part to the highly publicized Wakefield study (1998) which was subsequently retracted (2010). Research Question: Is there evidence of an effect of the Wakefield study retraction or other key socio-demographic variables on the receipt of the CDC standard vaccination series? Methods: This retrospective, cross-sectional study examined children 19-35 months old with adequate provider data in the National Immunization Survey from 2008 to 2015. Children were assessed for up-to-date (UTD) status of the standard vaccination series. Individual chi-square tests and a multivariable logistic regression model were utilized to determine predictors of UTD status. Per the 38

complex survey design, data were appropriately weighted and clustered to generate average, annual population estimates. Results: Data from 131,783 children were included, representing an extrapolated national estimate of 5,945,295. The percentage of children UTD increased over the study years from 9.2% (2008) to 60.0% (2015). From the multivariable model, adjusting for factors of interest, being UTD was significantly more likely in the 2011-2015 year group, Hispanics, 24-29 month olds, mother’s age ≥30, and the census regions West, South and Midwest. UTD status was significantly less likely in 30-35 month olds, non-Hispanic blacks, families with four or more children, non-firstborns, two or more vaccine providers, mothers with less than a college degree, those with multiple insurance types and those with Medicaid/SCHIP, and those not receiving a flu shot. Conclusions: Receipt of the CDC recommended standard vaccination series has increased dramatically over the study years. Statistically significant predictors of vaccine uptake corroborate older studies and suggest disparities still exist. 14. Title: A Seminar Series to Prepare Pharmacy Students for the Residency Application Process Authors: Katelyn Palmer, PharmD; Diep Phan, PharmD; Lauren Payne, PharmD; Asima Ali, PharmD; Steven Davis, PharmD, BCGP; Lisa Brennan, PharmD, BCPS, BCGP; Sarah Nisly, PharmD, BCPS, FCCP Institution: Wake Forest Baptist Health, Winston-Salem NC; Wingate University School of Pharmacy, Wingate NC; Campbell University College of Pharmacy & Health Sciences, Buies Creek NC

Objective: With the increased interest in residency programs nationwide, the application process has become more competitive and complex. To date, little is known about the value of a resident-led residency preparatory seminar (RPS). In 2015, Wake Forest Baptist Health (WFBH) created a resident-led RPS to assist advanced pharmacy practice experience (APPE) students in preparing for residency applications. The RPS is coordinated and executed by the post-graduate year (PGY) 1 residents, with participation from the entire residency class. This study was designed to objectively define the impact of the resident-run RPS. Methods: This is a single-center, survey-based, descriptive study to evaluate the impact of a resident-led RPS on the perceptions of APPE student participants. Surveys were sent to all APPE students assigned rotations within the

Triad region. Data was captured for respondents who indicated attendance to at least one RPS. Survey questions evaluated satisfaction with the RPS and asked for feedback on how to improve the seminar. The survey data was collected and analyzed using Qualtrics. Results: A total of 44 students were invited to attend the RPS and eligible to complete the survey. Eighteen respondents indicated an interest in applying for a residency and 15 (83%) of those responding students participated in the WFBH RPS during 2016-2017. All WFBH residents were invited to attend the series, a maximum of 16 eligible residents. For all five sessions, over 75% of respondents who attended agreed the sessions were either extremely or modestly useful. Student participation decreased with each session, with 11 students participating in the final session. Students appreciated the knowledge and experiences of resident facilitators. Students noted timing of the sessions and more detailed information as areas for improvement. Conclusion: A resident-led RPS resulted in positive student perceptions in the residency application process. 15. Title: Evaluation of the North Carolina Standing Order for Naloxone in Community Pharmacies Authors: Victoria Viverette, PharmD Candidate, Meghan Shanahan, PhD, MPH, Timothy J. Ives, PharmD, MPH, FCCP, CPP Institution: Eshelman School of Pharmacy, Injury Prevention Research Center, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC Objective: This study evaluated the implementation of the June 2016 standing order policy for naloxone in North Carolina. The goal of this policy is to increase access and utilization of naloxone to reduce opiate-related overdose deaths. This implementation evaluation assessed awareness of the standing order among pharmacists in the community, as well as the actual distribution of naloxone under the standing order. Methods: Pharmacist managers and staffing pharmacists, from a 20% sample of all independent and chain pharmacies in North Carolina, stratified by region and type of pharmacy, were asked to complete a brief, anonymous telephone survey to evaluate the implementation of the standing order policy thus far. An additional 10% sample using the same criteria was used to replace the original sample for unsuccessful attempts. Results: Pharmacists in 202 pharmacies completed the survey, with 35 pharmacies replaced (response rate = 83.5%). The majority (95.4%; n=196) were aware of the statewide standing order, and 73.3% (n=137) reported having procedures to dispense naloxone under the order. A majority (65.8%; n=133) had naloxone products currently in stock.

Less than half (41.2%; n=83) reported having patients presenting to the pharmacy asking about naloxone, and only 22.4% (n=41) had ever dispensed naloxone under the statewide standing order. Conclusion: Awareness among community pharmacists in North Carolina regarding the standing order is high, yet dispensing under it remains low. Further advancements in policy, community outreach, and patient education may increase naloxone utilization under the statewide order to continue to combat the opioid epidemic. QUALITY IMPROVEMENT EVALUATIONS 16. Title: Use of Electronic Safety Tools to Reduce Adverse Events Related to Alpha-gal Allergy within a Large, Tertiary Care, Teaching Hospital Authors: Jennifer Frakes, PharmD, Allison Lynch, PharmD, BCPS, Kuldip Patel, PharmD, Wendy Rycek, PharmD, BCPS Institution: Duke Health at Duke University Hospital, Durham, NC Objective: The primary purpose of this quality improvement evaluation was to determine if exposure to alpha-gal containing medications could be reduced or eliminated with the use of increased awareness and electronic safety tools to prevent adverse drug events. These electronic tools serve to alert clinical staff of this allergy and the potential triggers. Methods: A multidisciplinary panel of clinicians including pharmacists met to discuss the development of safety tools available within our computerized physician order entry system with the goal to decrease exposure and occurrence of adverse events related to Alpha-gal allergy. Alpha-gal is an increasingly significant tick-born allergy to mammalian meat and its byproducts, which are common in many medications. Delayed reactions as severe as anaphylaxis have been consistently described in the literature, increasing concern for medication safety and provider recognition of this relatively unknown allergy. The current safety tools customized by pharmacy and the multidisciplinary team include iVents, Medication Messages, and a medication ingredient chart specific to drug manufacturer(s). A Best Practice Alert (BPA) is in progress with plans of being used across the health system. These tools reach every nurse, physician, and pharmacist upon opening the chart of a patient with a documented Alphagal allergy. Results: To date, several patients with documented Alphagal allergy have been safely treated at our large, tertiary care teaching hospital. However, the danger of a potential life threatening adverse event remains. Conclusion: Currently, life threatening adverse drug events related to alpha-gal byproducts within medications used in health systems are infrequent. By increasing pharmacy involvement, developing several electronic safety tools, 39

and providing clinical resources which raise awareness of Alpha-gal allergy, the hope is to increase patient medication safety and eliminate avoidable Alpha-gal allergy adverse drug events. 17. Title: Pharmacy student monitoring of direct oral anticoagulants Authors: Hailey Hill, PharmD Candidate, Jennifer Kim, PharmD Institution: Moses Cone Internal Medicine Center, Greensboro NC. Objective: Providers lack guidance regarding best-practice monitoring of DOACs with limited literature describing pharmacist-led DOAC monitoring for adherence and appropriateness.1,2 No information has yet been published describing DOAC monitoring by pharmacy students. The purpose of this study is to determine the impact of a pharmacy student DOAC monitoring program. Methods: This was an observational analysis of a quality improvement initiative. A clinical pharmacist preceptor identified clinic patients on a DOAC by running an Epic report. A fourth-year advanced pharmacy practice experience rotation student was trained for 1 week on reviewing DOAC patients for clinical appropriateness, safety, efficacy, and adherence. Each patient was evaluated by chart review, calling pharmacies for refill histories, and interviewing and educating patients telephonically. After 1 week of training, the pharmacy student reviewed the patients independently and shared findings with the preceptor. They both discussed and communicated findings with primary care physicians and cardiologists, provided recommendations, and performed interventions as applicable. If necessary, patients were seen in clinic for evaluation, education, and help with medication access. Patient care notes were documented in the electronic medical record for each patient. The primary outcome included a description of interventions performed. Results: Eighty-seven patients were included, 62.1% with atrial fibrillation, 34.5% with venous thromboembolism, 47.1% on apixaban, and 45.9% on rivaroxaban. Adherence based on medication possession ratio (MPR): 56 patients were good (MPR of 81-100%), 7 fair (MPR of 61-80%), and 24 poor (MPR of < 60%). To date, 38 interventions were made including providing samples (6 patients), co-pay cards or patient assistance programs (10 patients), additional refills or calling pharmacies to fill prescription (10 patients), and adherence education (9 patients). No prescribing errors were identified. Conclusion: This study shows successful implementation of a pharmacy student DOAC monitoring program with common interventions addressing adherence. References: 1. Ashjian E, Kurtz B, Renner E, Yeshe R, Barnes GD. Evaluation of a pharmacist-led outpatient direct oral anticoagu40

lant service. Am J Health-Syst Pharm. 2017;74:483-9. 2. Shore S, Ho P, Lambert-Zerzner A et al. Site-level variation in and practices associated with dabigatran adherence. JAMA. 2015;313:1443-50.

18. Title: Four-Factor Prothrombin Complex Concentrate: Medication Use Evaluation Authors: Juwon Kwon, PharmD Candidate; Michael A. Maccia, PharmD, BCPS, BCCCP; Rachel Rumbarger, PharmD, BCPS Institution: Cone Health, Greensboro, NC; The UNC Eshelman School of Pharmacy, Chapel Hill, NC Objective: The primary purpose of this study was to determine appropriate use of 4-factor prothrombin complex concentrate (4F-PCC) for urgent reversal of acquired coagulation factor deficiency induced by anticoagulant medications in a hospital-based setting over one year. Secondary objectives evaluated were the change in International Normalized Ratio (INR), thromboembolic events, and survival to hospital discharge after the administration of 4F-PCC. Methods: The medical records of 99 patients who received 4F-PCC from June 1, 2016 to May 31, 2017 were reviewed. Patients were only excluded if 4F-PCC was ordered but not prepared and administered. Data collected included patient demographics, INR value, anticoagulant medication, indication for use, dose of 4F-PCC, concomitant use of vitamin K, and patient outcome. Results: Partial data is available from 48 patients with a median age of 75.5 years. Most patients were on anticoagulants with warfarin (58.3%), apixaban (19 %), rivaroxaban (15%), or edoxaban (2%). Three patients were not on any anticoagulation. 4F-PCC was given in 26 patients for appropriate indications (54%). Appropriate indication for 4F-PCC included life threatening bleeding in 14 patients (54%), bleeding requiring blood product transfusion in 7 patients (27%), and urgent surgery in 5 patients (19%). Among all patients who received 4F-PCC, dose was appropriate in 26 patients (54%) with allowed dose range of ±3 units/kg. Two patients experienced thromboembolic events after 4F-PCC administration. Conclusion: Current use of 4F-PCC is not in accordance with hospital-developed guidelines with substantial costs to the healthcare system. Increasing pharmacy involvement by provider education and prospective review of orders may lead to more appropriate uses of 4F-PCC and improved patient outcomes.

19. Title: Interprofessional quality initiative to reduce cardiovascular risk in underserved patients Authors: Tanya Makhlouf, PharmD Candidate; Jennifer Kim, PharmD, BCPS, BCACP, CPP; Chasta Hopkins, CPhT Institution: Cone Health Internal Medicine Center, Greensboro NC Objective: Cardiovascular disease (CVD) risk can be reduced through pharmacologic agents and lifestyle modifications. There is currently a lack of literature published regarding efforts to reduce CVD risk in underserved populations. The primary purpose of this study was to evaluate the effects of reducing CVD risk in indigent patients. Secondary outcomes include reduction in blood pressure and A1C measurements. Methods: This was a prospective, interprofessional, IRB approved, quality initiative to improve medication access for underserved adult patients. Indigent patients with CVD or CVD risk scores ≥ 10% based on Pooled Cohort Equations, with a no-show rate of ≤ 25%, were identified by pharmacy staff. Pharmacy staff worked with nurses, financial counselor, social worker, dietician, and physicians to implement strategies addressing any medication cost barriers, patient education, and therapy recommendations that may increase adherence. Patients were contacted by phone for follow-up to address any ongoing medications challenges. Results: To date, 16 patients with a mean age of 54 have been enrolled, 2 of which were receiving federal healthcare (12.5%), 5 were enrolled in a program to help with medication cost (31.3%), and 9 were uninsured and not receiving any medication assistance (56.3%). The average household yearly income was $4,968 and average household size was 1.2. The mean baseline CVD risk score was 24.8% and the mean risk scores at 1 and 3 months were 18.6% (N=14) and 15% (N=5), respectively. The mean baseline SBP was 159 mm Hg, mean SBP at 1 month was 146 mm Hg, and mean SBP at 3 months was 130 mm Hg. Thus far, only 4 patients have A1C follow-up data, with a mean baseline A1C of 12% and 3-month mean A1C of 9.8%. Conclusion: Interprofessional collaboration in the indigent population is showing reduction in CVD risk.

CASE REPORTS 20. Title: KRATOM, an emerging opioid receptor agonist Authors: Nidhi Gandhi, Jacqueline L. Olin, M.S., Pharm.D, BCPS, Carrie L. Griffiths, Pharm.D, BCCCP Institution: Wingate School of Pharmacy Introduction: Kratom (Mitragyna speciosa) comes from an evergreen tree in the Rubiceae family, which includes coffee plants. It is native to Southeast Asia and Thailand and consists of active ingredients,

mitragynine and 7-hydroxymitragynine. The leaf extracts provide stimulant effects at low doses of 1-5 grams, opioid-like effects at high doses of 5-15 grams and sedating effects at greater than 15 grams. Chewing the leaf extracts provides the fastest onset of action with feelings of excitement within 5-10 minutes lasting up to an hour. In recent years, increased numbers of adverse effects have been reported with overdose of Kratom as well as withdrawal, which include nausea, constipation, itching, tremors, hallucinations, respiratory depression, hyperpigmentation of the cheeks, and psychosis. Kratom addiction has become an ongoing problem in Europe and the United States. Case: A 21-year-old male was admitted to the hospital with right upper quadrant pain, nausea and dark urine. He had no past medical history. Initial laboratory values included elevated AST 294, ALT 319, alkaline phosphatase 193, total bilirubin 2.86, platelets 139 and WBC 4.3. Ultrasound revealed dilatation of the common bile duct and MRI of the abdomen revealed moderate hepatosplenomegaly. Medication review reported Kratom consumption of up to 12 capsules by mouth at bedtime for pain relief with 10 grams in the last 2 days. Hospital treatment regimen included fluids, tramadol and famotidine. Discussion: Animal studies have shown elevations in ALT, AST and albumin with the use of Kratom and a case report from 2011 revealed a 25-year-old man showing signs of abdominal discomfort from ingestion of Kratom over a few days. Hepatic injury can be a serious adverse effect of Kratom. The potential side effect profile of Kratom outweighs the benefits. Further studies need to be conducted on the use, efficacy, safety, potential risks and treatment options for the use of Kratom. 21. Title: Medical Management of a Case of Escherichia coli Infective Endocarditis Authors: Justin Jones, PharmD Candidate1; Kristopher Kindborg, PharmD Candidate1, Dustin Wilson, PharmD, BCPS1,2 Institutions: 1. Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, 2. Duke University Hospital, Durham, NC Introduction: Infective endocarditis (IE) caused by Escherichia coli is rare. In a multinational database, non-HACEK Gram-negative bacilli caused 1.8 percent (49/2761) of the reported IE cases. Of those, E. coli was the causative pathogen in 14 (29 percent) cases. The current guidelines recommend treating non-HACEK Gram-negative bacilli IE with a beta-lactam, and either an aminoglycoside or fluoroquinolone for a minimum of 6 weeks with or without surgery. Here we report a patient diagnosed with E. coli IE treated with ceftriaxone and gentamicin. Patient: A 50 year-old male with a past medical history significant for aortic valve regurgitation status-post mechani41

therapy and had to complete treatment with ceftriaxone monotherapy.

cal aortic valve replacement presented to the emergency department with a two-day history of chest pain, fatigue, and fever. He was admitted and started on empiric therapy with vancomycin and piperacillin/tazobactam. On day two of hospitalization, patient underwent a transthoracic echocardiogram that showed no evidence of IE. However, 3/3 blood cultures returned positive for Gram-negative rods which subsequently were identified as E. coli. A transesophageal echocardiogram was ordered and showed an abnormal echodensity on the aortic leaflet concerning for a vegetation. The Infectious Diseases consult service recommended to treat the patient as an E. coli IE with ceftriaxone and gentamicin for six weeks. The patient was discharged from the hospital, but unfortunately, was readmitted for acute kidney injury secondary to gentamicin therapy. The patient completed the remaining two weeks with ceftriaxone monotherapy. Discussion: Limited literature exists on the treatment of E. coli IE. The patient reported here was treated with ceftriaxone and gentamicin based on the susceptibility profile of the pathogen. Surgery was not considered since the patient cleared the bacteremia so quickly and showed rapid clinical improvement. Unfortunately, the patient was not able to tolerate the full six weeks of gentamicin

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Convention Highlights A Sneak Peak at Exhibitor Showcase Epic Pharmacies, Inc. Omnicell, Inc. Triangle Compounding Pharmacy Novo Nordisk Boehringer-Ingelheim Pharmaceuticals Fresenius Kabi North Carolina Department of Insurance Pharmacists Mutual SCA Pharmaceuticals Pharmedium Services, LLC Alliant Quality • Friday Lunch Symposium on Jardiance, sponsored by Boehringer-Ingelheim. Speaker: Denis Becker, MD, Raleigh Endocrine Associates. Open to All Registrants. • Student Pharmacist Network Social Gathering held at “Reboot” Saturday around 7:30 • The Georgia O’Keefe Exhibit at the Reynolda House Museum of American Art. Go to: reynoldahouse.org • 2017 Convention Reception and Recognitions. This year’s reception will include the traditional Rite of Roses and 50+ Year recognitions.

North Carolina Pharmacist wishes to recognize the leadership and contributions of the Past Presidents of the North Carolina Association of Pharmacists

Past Presidents Kevin Almond, 2000 William Harris, 2001 Ross Brickley, 2002 Jack Watts, 2003 Mark Gregory, 2004 Davie Waggett, 2005 Dennis Williams, 2006 Beth Williams, 2007 Penny Shelton, 2008 Brenden O’Hara, 2009 Regina Schomberg, 2010 Cecil Davis, 2011 Jennifer Buxton, 2012 Mary Parker, 2013 Michelle Ames, 2014 Ashley Branham, 2015 Stephen Eckel, 2016 44

From the NCAP Office ADAMS AND ASSOCIATES practitioners to prescribe an opioid disciplinary action from the Board antagonist to any governmental of Pharmacy for dispensing a GOVERNMENT or nongovernmental agency (ii) prescription written by a prescriber RELATIONS 1706 Rangecrest Road Raleigh, NC 27612

(919) 841-0964 (919) 801-1837 Cell

ta@adamsgov-relations.com

Legislative Report by Tony Adams

On June 22, the 2017-18 budget was ratified by the NC House and Senate and was sent to Governor Roy Cooper for him to either sign or veto. The appointed Budget Conference Committee of Senate and House members had been working behind the scenes for weeks on coming to an agreement on the different versions of the budget originally passed by both chambers. Governor Cooper, as expected, vetoed the budget bill, H257, but his veto was overridden by both the House and Senate on June 28, thus becoming law.

2017 Ratified Legislation Importance to NCAP

House Bill 243,the Strengthen Opioid Misuse Prevention Act (STOP Act), passed both the House and Senate in overwhelming and bipartisan votes and has been signed into law by Gov. Cooper. The bill extends the statewide standing order for opioid antagonists to allow

designates certain Schedule II and III drugs as “targeted controlled substances and makes changes to the laws governing the prescribing of those targeted controlled substances, (iii) clarifies the allowable funds for syringe exchange programs, (iv) makes changes to the statutes governing the Controlled Substance Reporting System (CSRS) database, and (v) amends language in the 2015 budget to facilitate the interstate connectivity of the CSRS database. Prescriptions for targeted controlled substances will be limited to no more than a 5-day supply upon the initial consultation and treatment of a patient for acute pain, unless the prescription is for post-operative acute pain relief immediately following a surgical procedure, in which case the practitioner may not prescribe more than a 7-day supply. Upon any subsequent consultation for the same pain, the practitioner may issue any appropriate renewal, refill, or new prescription for a targeted controlled substance. The terms “acute pain,” “chronic pain,” and “surgical procedure” are defined. Dispensers are not required to verify that a practitioner falls within one of the exceptions from the requirement that all targeted controlled substances be e-prescribed and dispensers may continue to dispense targeted controlled substances from valid written, oral, or facsimile prescriptions that are otherwise consistent with applicable laws. Dispensers are further immune from civil or criminal liability or

in violation of G.S. 90-106.

Dispensers are required to report certain information on prescriptions they fill within 3 days after the prescription is delivered, but are encouraged to report such information within 24 hours to the Controlled Substances Reporting System (SRS). The bill also requires dispensers to report required information by the close of the next business day after filling a prescription unless the system is temporarily not operational and the inability to report is documented in the dispenser’s records. The Department of Health and Human Services would be required to assess civil penalties of up to $100 for a first violation, up to $250 for a second violation, and up to $500 for each subsequent violation, not to exceed $5,000 per pharmacy in a calendar year to pharmacies found to have failed to report required information within a reasonable period of time after being informed that such information is missing or incomplete; however, pharmacies who, in good faith, attempt to report will not be assessed a civil penalty. H243 also allows the Department to notify practitioners and their respective licensing boards of prescribing behavior that increases risk of diversion of controlled substances, increases risk of harm to the patient, or is an outlier among other practitioner behavior. It also requires recipients of new or renewed pharmacist licenses to demonstrate to the NC Board of 45

Pharmacy registration for access to the CSRS within 30 days of licensure. Practitioners will now be required to review a patient’s 12-month history in the CSRS prior to prescribing “targeted controlled substance” and review the patient’s 12-month history in the CSRS every three months while the targeted controlled substance remains part of the patient’s medical care plan. These reviews would have to be documented in the patient’s medical records, along with the occasion of any CSRS outage that prevents such a review; the practitioner would be required to review the 12-month history upon restoration of the CSRS after an outage. In addition, a practitioner would be able to, but not required to, review a patient’s CSRS history if: (1) the controlled substance is to be administered to the patient in a health care setting, hospital, nursing home, outpatient dialysis facility, or residential care facility; (2) the controlled substance is for the treatment of cancer or a cancer-associated condition; or (3) the controlled substance is prescribed to a patient in hospice or palliative care. H243 also requires a dispenser to review an individual’s 12-month history in the CSRS prior to dispensing a targeted controlled substance whenever: 1) the dispenser believes the individual is seeking controlled substances for reasons other than treatment of a medical condition; 2) the prescriber is located outside of the usual area the dispenser serves; 3) the individual lives outside the usual area the dispenser serves; 4) the individual pays with cash when there is an insurance plan on file with the dispenser; or 5) the individual demonstrates potential misuse of a 46

controlled substance. A dispenser would be required to withhold delivery of a prescription until verified if the dispenser believes it to be duplicative or fraudulent. Dispensers would be immune from civil or criminal liability for actions authorized by this section, and failure to review the system prior to dispensing a controlled substance would not constitute medical negligence.

pharmacy benefits managers. It will require pharmacy benefits managers to permit pharmacists to discuss an insured’s cost share for a drug, disseminate information about lower-priced alternative drugs, and sell a lower-priced alternative drug without penalty. Pharmacy benefits managers will be prohibited from using contractual terms to prevent pharmacies from providing store direct delivery services, from charging insured’s co-payments that exceed the total charges submitted by a network pharmacy, and from House Bill 466, the Pharmacy charging fees or otherwise holding Patient Fair Practice Act, passed pharmacies responsible for the the House and Senate with little costs of adjudicating a claim, unless opposition and has been signed the fee was set out in contract or by Governor Cooper. The bill reported on the remittance advice of permits pharmacists to discuss the adjudicated claim. lower-cost alternative drugs with, and sell lower-cost alternative drugs to, consumers. It prohibits Senate Bill 104 also passed pharmacy benefits managers from the House and Senate with little using contract terms to prevent opposition and was signed by the the pharmacies from providing store Governor. It would make a number direct delivery services. Pharmacy of technical changes to G.S. 90benefits managers will be prohibited 85.15, which governs applications from charging insureds a co-pay and requirements for licensure as that exceeds the total submitted a pharmacist, and mandate that charges by a network pharmacy. It the Board of Pharmacy require allows pharmacy benefits managers applicants for a pharmacy license to to charge pharmacies a fee for costs provide the Board with a criminal related to claim adjudication only history report, at the applicant’s if the fee was set out in a contract expense, from a reporting service or reported on the remittance designated by the Board. advice of the claim. Under current Current law allows the Department law Pharmacy benefits managers of Public Safety (DPS) to provide a are entities who contract with criminal record check to the Board pharmacies on behalf of insurers of Pharmacy for applicants for a to administer prescription drug pharmacy license. Currently, the benefits. Currently, they are Board is not required to request a regulated in their placement of background check, but, if it does, it drugs on the maximum allowable must submit a request that includes cost price list by Article 56A of the fingerprints of the applicant Chapter 58, but they are not subject and any additional information to additional regulation. House required by DPS. DPS then must Bill 466 will change the law by send the applicant’s fingerprints to adding additional requirements for the State and Federal Bureaus of

Investigation for criminal history checks. The Board must keep any information pursuant to this law privileged and confidential, in accordance with applicable State law, and the Board may charge each applicant a fee for conducting the criminal history check. Senate Bill 104 will make a number of technical changes to G.S. 9085.15 and mandate that the Board of Pharmacy require applicants for a pharmacy license to provide the Board with a criminal record report from a reporting system that will be designated by the Board. Information from these reports will remain privileged and confidential in accordance with State law and federal guideline. INCREASE IN PERSONAL CARE SERVICES RATE: Directs that beginning January 1, 2018, the Department of Health and Human Services, Division of Medical Assistance, shall increase to $3.90 the rate paid per 15-minute billing unit for personal care services provided pursuant to Clinical Coverage Policy 3L and for in-home aide, respite care in-home aide, and personal care assistance services provided under the Community Alternatives Program for Children (CAP-C) waiver pursuant to Clinical Coverage Policy 3K-1. This equates to an hourly rate of $15.60. RETROACTIVE PERSONAL CARE SERVICES PAYMENT: Directs the Department of Health and Human Services, Division of Medical Assistance, to amend Section 5.5, Retroactive Prior Approval for PCS, of Clinical Coverage Policy 3L, State Plan Personal Care Services (PCS), to

extend the allowable retroactive period for prior approvals for personal care services from 10 days to 30 days upon the same conditions that are currently required for retroactive prior approval of personal care services. Regarding our effort to introduce a collaborative pharmacy practice agreement bill, we were unable to secure introduction of proposed legislation in the 2017 session of the General Assembly due to the opposition of key members of the House and the NC Medical Society and the NC Family Physicians Association. Since the deadline for introducing a bill this session occurred we have been making significant progress on securing legislative support for our proposal, with several powerful members of both the House and Senate agreeing to work with us on introducing legislation in the 2018 short session. In the interim we will be organizing a grassroots campaign to have our members and other supportive providers contact their local representatives and arrange indistrict meetings to garner support for our efforts. We also followed two other bills during the 2017 session of the General Assembly which negatively impacted our efforts to gain support for our collaborative practice proposal. One, H88, and its companion bill, S73, the Modernize Nursing Practice Act, sought to expand the scope of practice for Advanced Practice Registered Nurses. Neither bill passed during the 2017 session due to vigorous opposition from the NC Medical Society and other physician groups.

The bills are technically still alive for the 2018 short session since these have a financial component. The other bill, S342, Enact Enhanced Access to Eye Care Act, sought to amend the scope of practice of optometry. S342 was strongly opposed by ophthalmologists throughout the state, and the bill was assigned to the Senate Rules Committee, with no action taken on the bill. This was despite the fact that the NC Optometric Society contracted with 15 lobbyists, including some of the most influential ones in the state.

NCAP Partners with NCHA to “Pnockout Pneumonia”: Elevating the Importance of the Pharmacist in this Public Health Initiative Ralph H. Raasch, Editor, North 3. Recent pneumococcal vacciCarolina Pharmacist nation rates for adults aged > 65 years were recently reported by At the end of this column, the an- the CDC and published in MMWR nouncement publication of the on July 14, 2017. Go to: North Carolina Hospital Associa- https://www.cdc.gov/mmwr/ tion’s (NCHA) 2017 Quality Goal volumes/66/wr/mm6627a4. to reduce pneumonia mortality htm?s_cid=mm6627a4_e and readmission rates in North Current CDC recommendations Carolina is presented. First, the are to vaccinate adults aged > 65 following narrative is background years with both pneumococcal information that would be of in- conjugate (PCV13) and polysacterest to the readership. North charide (PPSV23) vaccines in seCarolina Pharmacist and NCAP in- ries. Note the table provided in tend to provide quarterly updates the citation above, and the data on the Pnockout Pneumonia Cam- from North Carolina. An assesspaign over at least the next two ment of claims submitted for years, and to provide support Medicare beneficiaries revealed from the North Carolina Pharma- that only 23.3 percent of these cy Community to this campaign. eligible adults received both vaccines between mid-September The Data 2015 and mid-September 2016. 1. During Second Quarter 2016, Clearly, these vaccination rates in the latest period for which state- North Carolina (and in all states) by-state data are available, North can be significantly improved. Carolina ranked 49th highest Pharmacists can improve these (worst!) out of 50 states in 30- vaccination rates. day mortality rate. The mortality rate was 17.6%. The 30-day read- The Goals as Approved by the mission rate for the same period NCHA Board of Trustees, March ranked North Carolina as 28 out 2017. of 50 states. 1. Over 2 years, reduce the annual mortality rate from the 2016 2. As would be expected because baseline by 7.5%. Such a reducof population differences, mortal- tion would equal the national avity by county (number of deaths) erage for pneumonia mortality of varied widely over 2016. The few- 16.3%. est deaths (75) occurred in Washington County, while 2849 people 2. Over 2 years, reduce pneumodied of pneumonia in Wake Coun- nia readmissions by 5.4%, which ty. Mortality rates were also quite would result in the inclusion of variable on a county-by-county North Carolina Hospitals in the basis. top 25% quartile of hospitals nationally.

The Impact of these Goals on an Annual Basis 1. 1000 North Carolina Lives Saved. 2. 950 Readmissions Prevented. 3. $ 8,835,000 Saved.

ckout o n neumona P

Pneumonia Pnockout Campaign In March 2017, the NCHA Board of Trustees approved a two-year Quality Goal to reduce pneumonia (PNE) mortality and readmission rates to put North Carolina at and below the national average. Specifically, the goal is to: • •

Reduce the PNE mortality rate by 7.5% to the national average over 2 years Reduce PNE readmissions by 5.4% over 2 years to target top 25% quartile

The Board’s approval of this goal signifies an organizational commitment to guide this work and a call to NCHA’s 130 member hospitals and health systems statewide to actively participate. CAMPAIGN PARTICIPATION Participating hospitals and health systems will be asked to identify one to two opportunities to improve based on their internal performance on the identified measures. Community partners and post-acute care providers will be invited to participate with hospitals and health systems. Each organization will commit to lead its improvement efforts. NCHA Quality Center staff, with guidance from an Advisory Council, will provide participating teams with technical support, education and best practice learning/sharing. NCHA will provide data to member organizations to support this work and will coordinate a public education campaign, including media and collateral materials. OPPORTUNITIES • Participate as an NCHA member organization or partner in the Quality Goal. • Provide education, information as part of the learning collaborative. • Support public education/outreach efforts outside the hospital setting. • Commit to funding/underwriting toward the campaign. May/June: July: Aug-Sept: Oct: Nov:

TIMELINE NCHA Quality Center staff introduces goal to member hospitals and health systems and prospective partner organizations Kickoff at NCHA Summer Membership Meeting (July 19-21) Enrollment continues Learning and Action Network/Public campaign begins World Pneumonia Day is November 12

PNEUMONIA FACTS • North Carolina is ranked 49 of 50 states for its pneumonia mortality rate, with 73% of hospitals below the CMS national benchmark. • More than half of all N.C. hospitals are above the national benchmark for 30-day pneumonia readmission rates. • Pneumonia is most often acquired in the community, outside of the hospital setting. • CDC recommends pneumococcal vaccination for all adults 65 years or older. According to 2015 data from the Behavioral Risk Factor Surveillance System, 73.6% of North Carolinians over 65 years old report that they have been vaccinated, slightly above the U.S. average.

CONTACT: For more information, contact Karen Southard, interim executive director of the NCHA Quality Center, at 919-677-4121 or ksouthard@ncha.org or Trish Vandersea, program manager for NC ACT, at 919677-4115 or tvandersea@ncha.org.

Research and Practice

• Update on CMM Grant at UNC, as published in June 2017 ACCP Report. https://www.accp.com/report/index.aspx?iss=0617&art=3 • Update on Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals, July 24, 2017. https://www.cdc.gov/getsmart/healthcare/implementation/ core-elements-small-critical.html • Antibiotic Use in the United States, 2017: Progress and Opportunities. An extensive report on the importance and accomplishments of antibiotic stewardship efforts, July 28, 2017. https://www.cdc.gov/getsmart/pdf/stewardship-report.pdf 50

Reflections A North Carolina Pharmacist in the Middle East

efit to working in the Middle East, although this advantage is shrinking with budget tightening Lisa F. Brennan throughout that region. I was able to pay off my student loans within 2 years. But more importantly, I wanted to explore this area that Abstract unfortunately has come to engender fear in many Americans Globally, clinical pharmacy prac- after the experience of 9/11, the tice is advancing. This article Gulf Wars, and more recently, describes the working experi- the horrors of Syria and the refuence of a North Carolina phar- gee crisis that war has created. macist in two countries in the As Mark Twain said, “Travel is Middle East, Saudi Arabia and fatal to prejudice, bigotry, and the United Arab Emirates (UAE). narrowmindedness, and many Both commonalities and chal- of our people need it sorely on lenges are emphasized, with a these accounts.”1 reflection on the personal value Pharmacy Practice of cross-cultural practice. Introduction “The Middle East” for many people conjures up images of camels, sand dunes, flowing robes and women with veiled faces. For others, it is synonymous with oil and fantastic wealth. Yet, a third more sinister image is the face of terrorism. But the region has undergone tremendous growth in the past several decades, reaching for equality in all aspects of life including healthcare. I was able to observe their system firsthand in my recent sojourn as a clinical pharmacist in Saudi Arabia and Abu Dhabi, UAE. Why Do It? There is a strong financial ben52

ing, run an anticoagulation clinic, and are expanding their practice just as pharmacists in the US are doing. Many of the same health issues took priority as well. Diabetes and its complications constituted a large proportion of the reason for hospitalization for many of the patients admitted to our medicine service. According to the WHO country profiles for 2016, the prevalence of diabetes is 63% higher in Saudi Arabia at 14.4% vs. 9.1% for the US.2,3 Ischemic heart disease was the leading cause of death in 2012 in both Saudi Arabia and the USA.4,5 It was eerily simple to transfer my practice to this hospital.

Saudi Arabia In Saudi Arabia, I served as an internal medicine clinical pharmacist in King Abdulaziz Medical City in Riyadh from June 2012 to June 2014. This is a 1200-bed teaching hospital affiliated with both medical and pharmacy schools in the King Saud bin Abdulaziz University for Health Sciences. The hospital has an ASHP-accredited PGY1 pharmacy practice residency and a well-trained clinical staff. My first surprise was in the similarity of practice with what I had experienced in the United States. Team rounding occurred daily, starting in the emergency department, and then progressing to the medical wards. Pharmacists manage vancomycin and other pharmacokinetic dos-

Abu Dhabi I moved to Abu Dhabi in July 2014 to July 2016 to become part of the team opening the Cleveland Clinic Abu Dhabi (CCAD) hospital, which opened in May 2015. This was a unique opportunity to build the relationships and culture of the hospital from the ground up. Under the leadership of Osama Tabbara, RPh, BCNSP, the pharmacy team established the most professional and dedicated department I have ever had the pleasure to work with, building the reputation for the best department in the hospital. The pharmacy practice at CCAD mirrors the models here in the US with pharmacists as integral team members in all aspects of patient care, such as

team rounding, clinic management, and policy and procedure development. CCAD pharmacy is leading the country in promoting the advancement of pharmacy education with programs such as the first ASHP PGY1 pharmacy residency in the UAE, as well as taking a leading role in the region in pharmacy practice. Challenges in Practice There were definite challenges in my practice in the Middle East compared to the US. The most difficult was the language barrier. The working language of both hospitals was English. However, the patient population in both hospitals spoke Arabic as their primary language. There are two ways to manage this: first, learn the language, and second, use a translator. I did attempt to learn Arabic, but in order to speak professionally this would have taken at least several years of intense study, so I was unable to move beyond a rudimentary interaction in Arabic. Translators were readily available at least via telephone. However, using a translator bypasses that crucial information a healthcare professional receives beyond the words a patient speaks, such as the pause when asked if they take their medication regularly, or facial expressions in answer to any questions. Culturally, patients’ rights to know about their healthcare were viewed differently, with family members often deciding whether a patient should be told about their diagnosis or prognosis. Another instance of cultural difference was in end-oflife decision-making. There was

little acceptance of withdrawal or withholding of care. These cultural differences led to misunderstandings and frustration for many healthcare practitioners. A cultural awareness program at CCAD targeted this gap.

find alternative solutions while prioritizing patient care. Practical Considerations Both hospitals have participated in the ASHP Midyear Meeting, and in the past have listed positions on several US career websites. I found the Saudi Arabia position through ACCP, then the CCAD position through networking. Both contracts were considered permanent. The pharmacy boards of Saudi Arabia and Abu Dhabi accepted my US pharmacist license, but required extensive documentation, such as transcripts and attested translated copies of my diploma. The process took 4-6 months, but communication with my employers allayed my fears at the delay. The contract in Saudi Arabia came with furnished housing on a Western-style compound, while Abu Dhabi came with a generous housing allowance and a settling-in bonus to use for furniture. Compound living was an adjustment, feeling much like dorm life in a university, and frequent embassy balls contributed to a social whirl, although sadly these circumstances insulated me from everyday Saudi life. Abu Dhabi provided more freedom, although with Emiratis making up less than 15% of the population, traditional culture was difficult to experience. Safety is always a concern as an expatriate, but I personally did not feel threatened in either country and felt comfortable out at any time of day or night even as a single female in Abu Dhabi.

In Abu Dhabi, formulary establishment created unique challenges. First, the physicians came from a wide range of nationalities and practice backgrounds. This situation led to requests for unfamiliar medications and interesting discussions on establishing standardized order sets. But the most challenging aspect of formulary management was supply chain establishment. The goal for medication procurement was to acquire US FDA-approved manufactured medications as much as possible to ensure quality generics as well as brand name medications. However, in order to be imported into Abu Dhabi, the drug had to be registered with the UAE Ministry of Health, and also with the Health Authority of Abu Dhabi. Unfortunately, many of the medications chosen for their approval status were either no longer available or for a much different price. Severe delays were overcome by sourcing temporary alternatives locally or making permanent changes to the formulary. The hospital was able to open with all critical medications available. Long-term inventory planning was complicated, hindered by long or unknown delivery times, and thus a need for large reserve stock storage. The incredible cooperation between the logistics and pharma- Conclusion cy personnel surmounted these obstacles by working together to In conclusion, pharmacy practice on the Arabian Peninsula pro-

vides opportunities for professional growth in an evolving environment. I have not discussed the personal growth or travel opportunities I experienced, as this is a pharmacy article. However, I would say that was what I valued most from my time abroad. Life is about connections, not just work and career. I keep a small globe on my desk to remind me of all the people I call colleagues and friends around the world. And as Maya Angelou said, possibly in answer to Mark Twain, “Perhaps travel cannot prevent bigotry, but by demonstrating that all peoples cry, laugh, eat, worry, and die, it can introduce the idea that if we try and understand each other, we may even become friends.”6 Lisa F. Brennan, PharmD, BCPS, BCGP, is Assistant Professor, Wingate University School of Pharmacy, Levine College of Health Sciences, 515 N. Main Street, Wingate, NC 28174,

L.brennan@wingate.edu No conflicts of interest or financial disclosures to make. References Twain, Mark. The Innocents Abroad [by] Mark Twain. London: Collins Clear-type Press, 1869. 2 World Health Organization. Diabetes country profiles, 2016 - Saudi Arabia. www.who.int/ diabetes/country-profiles/sau_ en.pdf?ua=1 (accessed 2017 January 9). 3 World Health Organization. Diabetes country profiles, 2016 - United States of America. www.who.int/diabetes/countryprofiles/usa_en.pdf?ua=1 (accessed 2017 January 9). 4 World Health Organization. Saudi Arabia: WHO statistical profile. www.who.int/gho/countries/sau.pdf?ua=1. (accessed 1

2017 January 9). 5 World Health Organization. United States of America: WHO statistical profile. www.who.int/ gho/countries/usa.pdf?ua=1. (accessed 2017 January 9). 6 Angelou, Maya. Wouldn’t Take Nothing for My Journey Now. Toronto: Random House of Canada, 1993.

SAVE THE DATE Sunday, October 29, 2017 From 2-4 PM NCAP Winetasting and Membership Drive More information to follow via N-CAP News 54

In Memory of the Patient We Never Knew Michael Manolakis, Meagan Scott, Whitney Smith Her story Her life, as it turns out, was a mystery. She had one real friend from her place of work, but her job ended in 2008, when the recession began. Her other work colleagues didn’t like her much; she was a bit too quirky. She lived alone, but we never knew how alone she was. Her work friend became her life friend. Sharing a monthly meal was part of their routine, as was loaning her the car. She was sick, but those who knew her didn’t know how sick. She went to her pharmacy to get medications and paid in cash. She died last week. There was only one person to call. Little did anyone know going into her apartment that this mystery was about to unfold. The thick layer of dust that covered everything told part of the story. Masks were needed when the cleaning began. There was so much stuff in the apartment. We wonder why she collected so much. Was it out of fear? Shame? Was she waiting for someone? Hiding something? Tax forms revealed a different surname used years earlier. Other papers revealed a maiden name. The friend had never known either of these names. Her current name was a simple one; there were just three syllables. It was a new name that separated her from an older, unknown past.

On a wall calendar in her apartment, she had circled dates and wrote about these being her final days. She didn’t mention to her friend that her health had become a very serious issue, but the method of her ways suggests she knew more than she would tell. Her friend had called the week before she died and heard the weakness in her voice. She urged her to get to a doctor. In reply, she said she would call the next morning at 10. In hindsight, we wonder if maybe she thought she would die before 10. She didn’t, and when the friend called back to check on her, she convinced her to call 911. This was the last time they spoke. The first call from the hospital was from a physician. Upon admission, the friend had been listed as the emergency contact. The physician explained the gravity of the situation. She was intubated. Cancer had metastasized to the lungs, which were so deteriorated that little oxygen was being exchanged. She was very ill. A follow-up call came the next day that confirmed she had died. She left her last will and testament taped to her wall in her apartment. It was a hand-written copy that was not found until after she died. In her will, she apologized to God for being a disappointment, and to those she had hurt. Who were these people and what had she done? Hurt them by leaving? The mystery continued to deepen.

The apartment manager called because the friend had been listed as the emergency contact for the apartment as well. When her will was found, the friend was listed as the executor of her estate. No next of kin were identified. There was no one else to contact. A neighbor stopped by while her apartment was being cleaned out. He expressed his sympathy and noted that he had seen her begging The items in the apartment shed no light on who for money on the street. Her friend found a handshe was in her prior life. She had albums full of written sign in her apartment. The simple sign pictures from the places she visited. The images read, “NEED $ FOR MEDICINE. PLEASE HELP were of beautiful places, but not a single image in- IF YOU CAN. THANK YOU.” The message on cluded a person. Did she travel alone? Who was her sign breaks our hearts because we are familthis person? Internet searches for all of her known iar with a Charlotte-based, not-for-profit pharmacy names – in every possible combination – came up that serves the residents of North Carolina who empty. It was as if she vanished one day from one can’t pay for their medicines. They charge nothplace and reappeared here the next. ing and serve thousands of individuals, but they never served her. No referral was ever made by

her pharmacist or pharmacy technician. Her friend was out of town when she died, so there was no final opportunity to learn her story. No chance to connect her with the past she left behind. Perhaps this is a good thing, but we will never know. The mystery remains unsolved. The concept of suffering Eric J. Cassell wrote on the concept of suffering in 1999.1 He tells his reader that diagnosing suffering is different than the usual process of diagnosing a medical condition because “suffering is an affliction of the person, not the body.” In making a diagnosis of suffering we must “listen to what is said and unsaid, watch face and body for expression and actions, smell (fear, hygiene, or perfume), learn to let it all come in without interpreting or judging, and stay silent inside and out (beyond small talk).” As we reflect on Dr. Cassell’s words, we wonder if any health care provider knew that this woman was suffering, and if so, to what extent. Dr. Cassell’s call to action includes asking about suffering and acting with empathy when providing care. We wonder if her pharmacist acted with empathy. As a young pharmacist who began my practice in a community pharmacy [Dr. Manolakis], I struggle to think if I would have known she was suffering. Whether I would have asked? I can’t say for certain that I would have; however, with the benefit of hindsight and accumulated wisdom, I can say with certainty that we must ask. We must do all we can to learn the narrative of our patients’ lives. Our profession’s Code of Ethics reinforces our moral obligations to “respect the dignity of each patient” and to act with a “caring attitude and compassionate spirit” as we “promote the good of every patient.”2 Sadly, this women’s story reminds us that sometimes we let these essential aspects of our practice slip away in our daily transactions. To put it in Dr. Cassell’s terms, we treat the body and not the person. We get caught up in the moment or in the process requirements that challenge our time, and we avoid or forget to ask the patient how they are doing. A search of the pharmacy and medical literature reveals a number of articles on suffering; however, the balance of these lean toward therapeutic con-

cerns rather than the broader concept of suffering we are considering. Jouini et al highlighted the positive contribution the community pharmacist can make in the pharmacotherapeutic treatment of primary care patients with chronic non-cancer pain.3 The authors conclude that “pharmacists can provide information about treatment and discuss barriers, beliefs, and attitudes about pain and its treatment.” However, their focus is about “optimizing effectiveness and minimizing adverse events.” It’s about the body and not the person. While this approach is consistent with our training, it falls short of the empathy required to diagnose suffering. Interestingly, Jouini et al point out an association between emotional wellbeing and patient satisfaction, but their conclusion is to take steps to optimize antidepressant therapy through improved adherence and persistence, as well as making referrals to physicians and psychologists when needed. Again, this aligns with sound clinical practice, but it does not push the pharmacist to connect with the patient at a level where a conversation about suffering will occur. Marlowe and Geiler argue that adequate communication between patient and provider is essential for treatment. They point out that “Providers need to reassure patients that they are not being judged and should initiate discussion regarding tolerance and addiction.”4 Further into their article, they discuss the patient’s right to autonomy and the associated requirement to understand the risks and benefits of therapy. This discussion must include “expected side effects, potential treatments for these effects, and the benefits of therapy.” Marlowe and Geiler do not extend the communication role for the pharmacist to include exploring subjective concerns that may be causing suffering. Wallace envisions the pharmacist as part of the interdisciplinary team, managing chronic opioid therapy. The result of this collaboration would be “to improve therapeutic outcomes, reduce health care costs, and relief of human suffering.”5 Wallace highlights the subjective nature of a patient’s pain level, and further that serving patients’ needs requires “compassion, communication, contribution, and common sense.” These insights are essential for providing care that attends to health 57

Rabow and Lee characterize the aspects of suffering that can be experienced by the patient. These include “uncertainty, loss of control, challenge to self-image and identity, and fear of dying.”7 The authors point out that answering these “deep existential questions” may not be necessary or appropriate for the clinician providing care, but being open and responsive to these questions and making the referral to the palliative care team may be sufficient. It is this idea of “openness” that can elevate the level of care we are capable of providing. This is a care level that is beyond simply treating physical symptoms. Knowing where in your community to refer a patient with these questions is an DeBar et al draw our attention to the 2011 Institute important tool to help treat their suffering. These of Medicine report, “Relieving pain in America: A resources can include spiritual or pastoral care, blueprint for transforming prevention, care, educa- charitable support services, social support serviction, and research,” which “identifies effective pain es, or access to a food pantry. management as a ‘moral imperative.’”6 These authors also describe an interdisciplinary approach The distinction between treating existential and that incorporates pharmacists to educate patients physical suffering with sedation was explored by in an effort to reduce adverse events and improve Blondeau et al in 2005.8 Their research looked at satisfaction with their pain care. They are quick to how a patient’s type of suffering can change clipoint out that this kind of inclusion has been “large- nicians’ attitudes about end-of-life sedation decily unexplored.” Debar et al describe strengths and sions. The clinicians in this study (n=142) includchallenges associated with this team structure for ed physicians (80.5%) and pharmacists (19.5%) delivering care. Their analysis includes the follow- working in the palliative care setting. Existential ing challenge: “Careful attention to training and suffering was defined to include types of suffersupervision is likely important to enable less highly ing that are not characterized as pain and physical trained frontline clinical staff to successfully inter- suffering. Examples include existential anguish or vene with patients, many of whom have had multi- emotional, psychological, or spiritual distress. As ple previous treatment failures and complex multi- it pertains to a distinction between treating exismorbid difficulties.” It is our contention that the kind tential and physical suffering, the authors write “… of questioning and patient dialogue required to un- the nature of the suffering imposes a barrier.” This derstand if, and to what extent, a person is suffer- barrier shows in their results as the reluctance to ing aligns with the training suggested by Debar et use sedation with existential pain as compared to al. We should expect that student pharmacists are physical pain. The authors suggest that providing learning to question patients about suffering as support to someone who is suffering existentially part of their experiential training, and that practic- “means supporting the human condition.” ing pharmacists are being enabled with tools and training to assist them with their delivery of patient We read Blondeau et al as suggesting to pharmacists that we move beyond the traditional medicare and determining patient suffering. cation therapy management parameters when Rabow and Lee provide guidance on attention to we treat individuals who are suffering, since our patient suffering in an article published outside of collective human condition includes physical and the pharmacy literature, but which included phar- existential suffering along with its manifestations. macists. They identify the pharmacist as part of This interpretation aligns with the idea that we the interdisciplinary, palliative care team that must ask our patient if they are suffering. It retreats men with castrate-resistant prostate cancer. quires attention to the person, and this is not an In addition to the treatment of physical symptoms, easy transition for pharmacists who as students and wellbeing. To achieve this end, which includes the relief of physical and existential suffering, we must internalize Wallace’s insights and then be prepared to push our delivery of care into places that may not be comfortable. We must push beyond our training to achieve positive therapeutic outcomes and the mandates of a health care system that demands cost reduction. This will be the point where we come to know the patient’s fears, concerns and worries as if they were our own. This is the point of providing empathic care; the point where existential suffering can be known and attended to.

were primarily trained to look for the objective and measurable data as the measures of success, change, and possible reasons to worry. While this transition may be difficult, it is worth the investment of effort as our patients will benefit.

ing can truly begin to occur for the person where medications may be part, but not all of the care they need.

Lemay articulated Dr. Cassell’s vision in a beautiful essay she wrote titled, “A Pharmacist’s Gift.”11 There are obstacles to providing care that attends She describes her relationship with a family whose to the body, as well as the person with the dis- two daughters have cystic fibrosis and the lessons ease. In an article based on presentations by Ken- she learned through the experiences they shared, neth C. Jackson II, PharmD and Andrew Mannes, which included the funeral for one of the daughMD, the challenges of treating persistent pain are ters. The lesson she took away from these expedescribed. In describing one of these challenges, riences, which is one she works to impart to her Dr. Mannes noted that outward appearance may students, is that “it is not enough for [her students] not reflect severe persistent pain, which is “a situ- just to know the facts about medications; they ation that often contributes to miscommunication must also consider the humanistic aspect of patient care.” Lemay captures with clarity and precibetween patients and providers.”9 sion the attitude that must guide our practice roles Oliveira and Shoemaker considered the “natural if we are to eliminate situations like the begging attitude” that pharmacists maintain, which is de- and suffering previously described. scribed as our “reliance on pharmacologic knowledge for an understanding of medications, a focus on the product, the use of counseling as the major approach with patients, and an emphasis on med- Build context ication adherence and persistence as a goal.”10 The strategies of listening to the patient’s story, Just as we strive to help every patient achieve acknowledging their uniqueness, and wondering maximum therapeutic benefit from their medicawith the patient about their dreams or fears, for tion regimen, which for the patient with physical example, can be used to achieve a state of “open- pain translates to a reduction in pain to a manageness” with patients. It is at this point that phar- able level, we must strive to mitigate existential macists are able to learn from their patients the suffering in the patients we encounter in practice. “meaning [they] ascribe to their illness as well as We are well trained for the first part of this practice their medications.” I [Dr. Manolakis] recall a con- ideal, but the second part is challenging. We proversation I had with a woman many years ago who pose the following framework for achieving this in was living with rheumatoid arthritis (RA). We met our practice settings. at 9 o’clock that morning, which required me to be up by 7:45 to prepare for the day. Upon greeting First, be prepared to ask questions of your patient. her at 9, I asked how her day was going so far, This idea sounds simple and straightforward, but it and she shared that it has been good but it started may be difficult as our training may not have built early. In an effort to simply make conversation, I competency in this communication area, and we asked how early, and she told that she had to start may lack confidence in our ability to question efher day at 4 AM to be ready for our meeting at fectively. It is at this awkward juncture that step9. I was stunned as I had no idea how much her ping forward and giving our best effort must be arthritis impacted her life. I knew it would slow her our professional mandate for we know patients down as RA is associated with joint pain and stiff- are suffering and we can be part of a remedy. Beness, but my realization that this much challenge gin by asking how they are feeling. Then follow and associated distress accompanied her disease that question by asking if their medications are forever altered my perspective of it. I gained an working. This conversation should be comfortable incredible insight into her suffering, and it is at this since success measures may be objectively availplace where pharmacists can gain insights on their able. For example, you might hear about a lab repatient’s suffering. This is the place where heal- sult or a comment about feeling better. Continue to 59

probe on side effects, adherence or missing doses. At this point, the content of your conversation is moving away from objectively measurable data to subjective concerns. Consider the possibility that something just doesn’t feel right at this point in your conversation; perhaps your gut is telling you that something isn’t quite right. You might check a refill history if it’s available for an additional data point, or you could get specific with your questioning. Assume prescription refills not acquired on time, or if difficulty with adherence is mentioned by the patient as a problem. You might ask if cost is a problem or if they have an issue with transportation to the pharmacy.

stranger holding a sign.”

She was a patient in a pharmacy. They would have known her name, but they didn’t know her story. The pharmacist likely understood her medical condition based on her medications, but this did not tell what else was going on in her life. Maybe a pharmacist or technician attempted to help her, but the release of personal information to take advantage of a social service was simply out of the question. There is so much that we don’t know, but what we do know is that she was suffering immensely. And by appreciating the suffering she endured, we reveal the even larger tragedy that in a city with ample health care resources, she died Essentially, you are building context in an attempt disconnected. The pressures of timed prescription to ascertain a glimpse into the patient’s narrative. filling, tremendous prescription volumes, and othThis attempt will take the development of trust, er practice challenges may have stood in the way. and it may take time, but if the goal is to determine These are legitimate concerns, but they must not if the patient is experiencing some level of suffer- stop pharmacists from striving to connect with paing, then the investment is worth the time, effort tients in order to learn about their circumstances and energy. Should you reach that point where and their experiences. your patient begins to share their fears, worries, or questions, then you must be prepared to respond. There is no blame here, rather a lesson to be This is where your knowledge about referral re- learned from her story. Serving patients to our sources to social services, spiritual or pastoral fullest capacity requires the intentional effort to care, or charity support for medication costs will learn the narratives of our patient’s lives. Getting be called upon. As was mentioned earlier, it’s not to know your patients is essential in the effort to that you have to be able to answer every ques- keep them from suffering. This may be a mandate tion a patient may have. Being ready to support, of your faith, as it is ours. It is a mandate of our to listen, and to refer may contribute directly to the profession’s ethical code as we strive to promote our patient’s good with care and compassion. improvement of a patient’s wellbeing. Conclusion Returning to her story, she wrote to a prominent journalist with our local newspaper to share her story. We have a copy of her letter, but to our knowledge, it was never published. Her words describe the interaction she has with the drivers who pass by and the daily challenges she faces. She tells the reader about a woman who gave her $5, which generated the following reflection: “I thank her for the $5, fold my sign and feel tears trying to come through. I have tears of gratitude for these angels who have stopped to talk to me and to help. And I have tears of shame that my life has come to this point. And a prayer that if and when my situation improves, I will remember this day and these tears and will not look away when confronted by a 60

Michael Manolakis, PharmD, PhD, is Associate Professor and Director of Interprofessional Education, Wingate University School of Pharmacy. Meagan Scott, PharmD, is a PGY-1 Ambulatory Care Resident, Wake Forest Baptist Health. Whitney Smith, PharmD, is Staff Pharmacist, CVS Pharmacy. At the time of writing, Drs. Scott and Smith were PharmD students at the Wingate University School of Pharmacy. No funding support was received for this manuscript. Excerpts of this paper were presented at the 2015

Christian Pharmacists Fellowship International Annual Meeting; June 4, 2015. There are no conflicts of interest to report.

TD, Zellmer WA (eds). Nourishing the Soul of Pharmacy: Stories of Reflection. Lenexa, KS: American College of Clinical Pharmacy; 2011:11-13.

References 1. 2. 3.

Cassell, EJ. Diagnosing suffering: A perspective. Ann Intern Med. 1999;131:531-534. Code of Ethics for Pharmacists. http://www. pharmacist.com/code-ethics. Accessed February 22, 2017. Jouini G, Choinière M, Martin E, et al. Pharmacotherapeutic management of chronic noncancer pain in primary care: lessons for pharmacists. J Pain Res. 2014;7:163-173.

Marlowe KF, Geiler R. Pharmacist’s role in dispensing opioids for acute and chronic pain. J Pharm Pract. 2012;25(5):497-502. Epub 2011Apr5.

Wallace JM. The pharmacist’s role in managing chronic opioid therapy. Curr Pain Headache Rep. 2006;10(4):245-252.

Debar LL, Kindler L, Keefe FJ, et al. A primary care-based interdisciplinary team approach to the treatment of chronic pain utilizing a pragmatic clinical trials framework. Transl Behav Med. 2012;2(4):523-530. Epub 2012Aug30.

Rabow MW, Lee MX. Palliative care in castrate-resistant prostate cancer. Urol Clin North Am. 2012;39(4):491-503. Epub 2012Aug27.

Blondeau D, Roy L, Dumont S, et al. Physicians’ and pharmacists’ attitudes toward the use of sedation at the end of life: influence of prognosis and type of suffering J Palliat Care. 2005;21(4):238-245.

Jackson KC, Mannes A. Persistent pain management for improved quality of life. J Am Pharm Assoc. 2003;43:S30-S31.

Check out the Event Calendar on our website at ncpharmacists.org for upcoming events!

10. Oliveira DR, Shoemaker SJ. Achieving patient centeredness in pharmacy practice: Openness and the pharmacist’s natural attitude. J Am Pharm Assoc. 2006;46:56-66. 11. Lemay VA. A Pharmacist’s Gift. In Zlatic 61

North Carolina Pharmacist Volume 97 Number 3

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