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.)

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

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

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 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 treatment 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.

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 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 patients. 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 37

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 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,

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 anticoagulant 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 mechani-

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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