Katri A. Abraham*, Lisa Hall Zimmerman, George Delgado, Jr., Janie

207 Pages·2010·1.59 MB·English

EPIDEMIOLOGICAL EVALUATION OF BACTEREMIAS IN COMPARISON OF VANCOMYCIN LOADING DOSES
THE BURN AND SURGICAL INTENSIVE CARE UNITS VERSUS EVERY EIGHT HOUR DOSING IN THE
Katri A. Abraham*, Lisa Hall Zimmerman, George Delgado, Jr., EMERGENCY DEPARTMENT IN ADULT SUBJECTS WITH
Janie Faris NORMAL RENAL FUNCTION TO ACHIEVE THERAPEUTIC
Detroit Receiving Hospital,4201 St. Antoine TROUGH CONCENTRATIONS
Blvd.,Detroit,MI,48201 Lamies Abuakar*, Joseph Levato, Rolla Sweis, Erik Kulstad
[email protected] Advocate Christ Medical Center,4440 W. 95th Street,Oak
Lawn,IL,60453
Background:
[email protected]
Antimicrobial resistance is a growing problem in intensive care
units (ICUs) today. Infections in critically ill patients with Purpose:
antimicrobial-resistant pathogens can cause significant Studies suggest that vancomycin trough concentrations (VTC)
morbidity and mortality. Each year, almost 2 million patients less than 10 mcg/mL have the potential to induce resistance.
acquire a nosocomial infection. About 90,000 patients die as a Recommendations to help quickly achieve target VTC are to
result of their infection. Resistance to antimicrobials is a major administer 20-30 mg/kg loading doses or decreasing the dosing
concern with more than 70% of bacteria causing nosocomial interval. Due to the concerns of inducing resistance with
infections being resistant to at least one of the drugs most subtherapeutic VTC and the delay in achieving appropriate
commonly used. Identifying common pathogens and patterns target levels, the purpose of this study is to evaluate
of antimicrobial resistance in critically ill patients is important to vancomycin loading doses (ranging from 20-25 mg/kg) versus
provide optimal care to these patients. initiating an eight hour dosing interval in the Emergency
Department (ED) at Advocate Christ Medical Center (ACMC) to
Purpose: achieve an initial target VTC of greater than or equal to 10
Evaluate the epidemiology of bacteremias in both the burn and mcg/mL.
surgical ICUs.
Methods:
Methods: This is a prospective, observational study from January 2010 to
This Institutional Review Board-approved retrospective study April 2010. Subjects presenting to the ED at ACMC with an
included patients ≥ 18 years of age, admitted to the burn or order for vancomycin will be dosed by the ED pharmacists.
surgical ICU, and had a bacteremia between January 1, 2000 Inclusion criteria include: subjects 18 to 50 years old,
to June 30, 2009. Patients were excluded if pregnant, or had a creatinine clearance (CrCL) greater than or equal to 60 mL/min
hospital stay less than 72 hours. Baseline data included age, on presentation, and actual body weight (ABW) greater than or
gender, race, baseline laboratory data, percent total body equal to 40 kg. Subjects with prior use of vancomycin within
surface area (TBSA) burns, acute physiology and chronic the past week, diagnosis of febrile neutropenia, meningitis, or
health evaluation (APACHE) II score, Charlson Comorbidity endocarditis will be excluded from the study. Subjects meeting
Index Score, and sequential organ failure assessment (SOFA) inclusion criteria will be randomized to receive an initial loading
score. Clinical and microbiological data collected include date dose of vancomycin based on ABW or initiated on an every
and time blood cultures were obtained, source of bacteremia, eight-hour dosing interval. For subjects receiving a loading
risk factors associated with bacteremia, concomitant infections, dose, continuation of vancomycin will follow the current
antimicrobial regimen administered, date and time to first protocol at ACMC in which subsequent doses will be calculated
antimicrobial dose, and in vitro susceptibilities to antimicrobial based on the Rodvold method and given every 12 hours. For
agents. Outcomes evaluated include hospital and ICU length-of- subjects receiving the decreased dosing interval, the total daily
stay and in-hospital mortality. Additionally, evaluation of the dose will be calculated based on the Rodvold method and
susceptibility of these bacteremias are assessed. divided into three doses given every eight hours. The initial
VTC will be drawn 30 minutes prior to the third dose. All data
Results: will be maintained confidentially.
Results and conclusions to be presented at the Great Lakes
Residency Conference. Results:
Learning Objectives: In Progress
Identify changing antimicrobial resistance patterns at our Learning Objectives:
institution. Recognize the concerns of subtherapeutic vancomycin trough
Discuss outcomes associated with empiric and appropriate concentrations.
antimicrobial selection and time to appropriate antimicrobial Recommend an appropriate vancomycin regimen for young,
therapy in patients with bacteremias. healthy adult patients.
Self Assessment Questions: Self Assessment Questions:
What is/are risk factor(s) for developing an infection with a Which of the following is not a concern of subtherapeutic VTC?
multi-drug resistant organism? a)Resistance
a)Current hospitalization of 5 days or more b)Toxicity
b)Residence in a nursing home or extended-care facility c)Delay in achieving target levels
c)Patient receiving chronic dialysis d)All of the above
d)All of the above e)None of the above
What measures can be taken to help prevent the development True or False. A vancomycin loading dose of 20mg/kg is the
of catheter-associated bloodstream infections in patients? recommended starting regimen for young, healthy adult
a)Perform hand-hygiene before catheter insertion or patients.
manipulation
b)Avoid using the femoral vein for central venous access
c)Use an all-inclusive catheter cart or kit
d)All of the above
IDENTIFICATION OF THE CAUSES OF MEDICATION TRIPLE BLOCKADE OF THE RENIN ANGIOTENSIN
ERRORS IN INPATIENTS INFECTED WITH THE HUMAN ALDOSTERONE SYSTEM IN DIABETIC (TYPE 1 & 2)
IMMUNODEFICIENCY VIRUS (HIV) PROTEINURIC PATIENTS
Jessica L. Adams*, Mark T. Sawkin, Rachel Chambers, Susan Suhail K. Alhreish*, Pete Antonopolous, Leon Fogelfeld, Peter
Davis, Megan Winegardner Hart
Henry Ford Health System,1114 N Campbell Rd,Apt 104,Royal John H. Stroger Jr. Hospital,1900 West Polk Street,Lower
Oak,MI,48067 Level 170,Chicago,IL,60612
[email protected] [email protected]
Purpose: High levels of medication adherence to antiretrovirals Background/Purpose:
are imperative. Previous studies have proven that HIV infected Reductions in albuminuria have been shown to slow the
patients are at a great risk for medication errors in regards to progression of diabetic nephropathy. Patients with diabetic
their antiretroviral regimens when they are hospitalized. The nephropathy that are treated with maximal doses of
objectives of this study were to identify the types of medication Angiotensin Converting Enzyme Inhibitors (ACE-I) and
errors involving antiretrovirals at Henry Ford Hospital in Detroit, Angiotensin II Receptor Blockers (ARB) may present with
MI, evaluate where in the medication use process the errors persistent albuminuria reflecting further Renin Angiotensin
occurred and identify contributing factors in order to implement Aldosterone System (RAAS) activation. This increased RAAS
corrections to the medication use system. activation can lead to microvascular renal disease which may
be more effectively treated with triple RAAS blockade by the
Methods: This retrospective chart review included any patient addition of a direct renin inhibitor, aliskiren. This will allow a
taking at least one antiretroviral medication as an inpatient more complete suppression of circulating aldosterone and
between July 1, 2008 and July 1, 2009, with the first 50 patients further control blood pressure.
at least 18 years old, with a confirmed HIV diagnosis, and who
had been admitted for at least 24 hours included and pregnant Methods:
patients exluded. The National Coordinating Council on This will be a 6 week prospective open-label trial consisting of 2
Medication Error Reporting (NCCMERP) taxonomy was used to groups with early diabetic nephropathy defined by a glomerular
record types of errors incurred, node in the medication use filtration rate (GFR) >60 ml/min calculated using the
process where the error occurred (prescribing, transcribing, Modification of Diet in Renal Disease equation. Patients
dispensing or administration), and contributing factors. Data included will be between the ages of 18-80 with either type 1 or
was analyzed using descriptive statistics. 2 diabetes, blood pressure <130/80 mmHg at the time of
enrollment, stable on maximal doses of an ARB (valsartan
Results: A total of 116 errors were identified. Drug omissions 320mg daily or 160mg BID) and ACE-I (enalapril 40mg daily or
accounted for 16.4% of the errors, dose omissions for 9.5%, 20mg BID) and with albuminuria. Group 1 represents patients
improper dose for 9.5%, wrong frequency for 6.9%, wrong drug with macroalbuminuria (≥ 300mg/g), and Group 2 patients with
for 17.2%, wrong time for 25.9%, monitoring errors for 14.7%. microalbuminuria (30-299mg/g). Patients will be excluded if
56% were prescribing errors, 28.4% were dispensing errors, they have the following: GFR < 60 ml/min; serum potassium >5
15.5% were administration errors and there were no mg/dl; pregnancy; history of angioedema; history of ACE-I
transcribing errors. Examples of contributing factors included induced cough; hypersensitivity to aliskiren; or HbA1c >9%.
knowledge deficits, performance deficits and computer Once consent is obtained, the patient will participate in a
programming errors. screening visit with physical exam performed by a physician,
measuring vital signs, and baseline labs. In addition to the
Conclusions: These results prove that medication errors home medication regimen, the patient will receive aliskiren
involving antiretrovirals occur with high frequency and are 150mg daily for 2 weeks, followed by aliskiren 300mg daily for
possible at different nodes of the drug use process for various 4 weeks. The goal will be to recruit 30 patients, 15 in each
reasons. These results will be used to identify system based group.
changes that could prevent the errors from occurring in future
admissions of HIV infected inpatients. Results/Conclusion:
Learning Objectives: To be presented at the Great Lakes Pharmacy Resident
Conference.
Discuss the types of errors that occur regarding antiretroviral
medications in HIV infected inpatients both globally and at
Henry Ford Hospital. Learning Objectives:
Identify where in the drug use process these errors occurred Recognize the importance of decreasing albuminuria in
and why. patients with diabetic nephropathy.
Identify the recruitment challenges at county hospitals like John
Self Assessment Questions:
H. Stroger Jr. Hospital.
Based on published data, what errors are most common in
patients on antiretroviral therapy? Self Assessment Questions:
Based on Henry Ford Hospital data, which errors were most Which of the following is NOT an adverse effect of aliskiren?
common and where in the drug use process were these errors a)Hyperkalemia
occurring? b)Hypertension
c)Hypotension
d)All of the above
True or False. Diabetic nephropathy can only occur in patients
with type 2 diabetes
EFFECT OF COMPUTERIZED PRESCRIBER ORDER ENTRY ASSESSMENT OF PATIENT OUTCOMES AFTER THE
ON PHARMACIST INTERVENTIONS DURING MEDICATION IMPLEMENTATION OF A PHARMACIST-COORDINATED
RECONCILIATION AT ADMISSION AND DISCHARGE LIPID SHARED MEDICAL APPOINTMENT (LIPID SMA)
Jared Anderson*, Michelle Thoma, Steve Rough WITHIN THE PRIMARY CARE CLINIC AT A VETERANS
AFFAIRS HOSPITAL
University of Wisconsin Hospital and Clinics,600 Highland
Ave,Madison,WI,53705 Ohita Asein*, Kristina Pascuzzi, Mary Ellen ODay
[email protected] Louis Stokes Cleveland VAMC,10701 East
Blvd,Cleveland,OH,44106
Purpose: Pharmacists at the University of Wisconsin Hospital
[email protected]
and Clinics (UWHC) have been responsible for the inpatient
medication reconciliation process since the 1970s. Several Purpose: Cardiovascular disease (CVD) remains the number
studies have previously been completed at UWHC evaluating one cause of death in the United States. Among lipids,
the number of interventions performed by pharmacists at elevated low-density lipoprotein cholesterol (LDL-C) has been
admission and discharge prior to computerized prescriber order clearly demonstrated to be independently associated with
entry (CPOE) implementation in March 2008. The purpose of increased coronary heart disease (CHD) risk. The latest
this study is to evaluate the number and types of interventions guidelines from the National Cholesterol Education Program
made by pharmacists after CPOE implementation, and Adult Treatment Panel III (NCEP ATP III) continue to identify
compare this to pre-CPOE data. LDL-C as the primary target for cholesterol-lowering therapy. In
the fall of 2007, the Louis Stokes Cleveland VA Medical Center
Methods: Pharmacists that work on four services (Medicine, (LSCVAMC), Wade Park Division in Cleveland, OH
Surgery, Transplant and Pediatrics) will be asked to record the implemented a Lipid Shared Medical Appointment (Lipid SMA)
number and types of interventions that they make at admission clinic. The Lipid SMA targets patients with elevated LDL-C
and discharge on each patient for a 10-day period. which has not responded to usual care provided by their
Interventions that will be recorded include omitted medications, primary care provider. The primary objective of this study is to
incorrect dose, medication, schedule or route, duplicate test the null hypothesis that there is no difference in the
medications or therapeutic interchanges made and patient percentage of patients who achieve their LDL-C goal in the
allergies to ordered medications. The estimated time on pharmacist-coordinated Lipid SMA versus usual care provided
making these interventions will also be recorded as well as by other health care practitioners in the same setting.
acceptance rate by prescribers of pharmacist
recommendations. Information collected will be compared to Methods: Retrospective chart review of patients age 18-89
data collected by previous studies prior to implementation of years of age with LDL-C goal of 100 mg/dL or less determined
CPOE. according to NCEP ATP III guideline who received lipid
management in the LSCVAMC pharmacist-coordinated Lipid
Results: Data collection will occur in early February, and will be SMA or by a primary care provider other than a clinical
compiled for presentation at the Great Lakes Pharmacy pharmacist between January 1, 2008 and April 1, 2009. The
Residency Conference in April. primary outcome of this study is the percent of patients who
Learning Objectives: attained LDL-C goal in the Lipid SMA group compared with the
usual care group. Charts will be randomly reviewed by selecting
Describe the impact of CPOE on the number and type of
every other patient listed for each group until 80 patients are
pharmacist interventions made during medication reconciliation
deemed appropriate for each study group (160 total subjects)
during admission and discharge.
according to the defined inclusion and exclusion criteria.
List the three most common interventions that pharmacists
made by pharmacists at admission or discharge following
Results/Conclusions: Data collection and analysis is ongoing.
CPOE intervention
Results will be presented at the Great Lakes Pharmacy
Self Assessment Questions: Residency Conference.
What are the three most common interventions made by Learning Objectives:
pharmacists following CPOE implementation at admission? At Recognize variables that contribute to the success of a
discharge? pharmacist-coordinated Lipid SMA in managing patients with
Do pharmacists spend more time on medication reconciliation dyslipidemia
at admission and discharge prior to CPOE implementation or Evaluate whether LDL-C goals are better achieved if the
after implementation? patients are followed by a clinically trained pharmacist in a Lipid
SMA
Self Assessment Questions:
True/False- The latest NCEP ATP III guidelines continues to
identify LDL-C as the primary target for cholesterol-lowering
therapy.
True/False- Dyslipidemia management provided by a clinically
trained pharmacist in a Lipid SMA reduced time to achieve LDL-
C goals in this study.
DEVELOPING AND IMPLEMENTING STANDARDIZED IMPLEMENTATION OF AN ANTIMICROBIAL STEWARDSHIP
DOSING OF ACETAMINOPHEN AND IBUPROFEN FOR PROGRAM
PEDIATRIC INPATIENTS Mary Anne Bafunno*, Lauryl Kristufek, Mary McNamara
Marie S. Backus*, Cynthia M. Dusik Mercy Health Partners,2600 Navarre Ave.,Oregon,OH,43616
Toledo Hospital/Toledo Children's Hospital,2142 N. Cove [email protected]
Blvd,Toledo,OH,43606
BACKGROUND: Inappropriate use of antimicrobial agents is
[email protected]
prevalent, leading to unnecessary health care costs, resistance
PURPOSE: Medication errors are a concern in all patient development and patient exposure to medication. Studies also
populations but can be especially harmful in the pediatric correlated an increase in resistant bacteria with the increase in
population. When prescribing and administering antibiotic usage. Two factors that have been shown to improve
acetaminophen and ibuprofen a weight-based dose may be outcomes, and decrease resistance, the incidence of
miscalculated or an incorrect dose may be drawn up for secondary infections, and healthcare costs are appropriate
administration. Current prescribing practices at Toledo antimicrobial use and infection control measures.
Childrens Hospital often do not take into consideration how Antimicrobial stewardship guidelines established by the
doses will be delivered based on commercially available Infectious Diseases Society of America (IDSA) and the Society
dosage forms. This often results in prescribed doses that are for Healthcare Epidemiology of America (SHEA) aim to improve
not measurable. The purpose of this study is to develop and appropriate antimicrobial use by facilitating appropriate
implement standardized dosing of acetaminophen and selection, dosing, route of administration and duration of
ibuprofen to decrease medication errors and utilize therapy in order to improve clinical outcomes and decrease
commercially available dosage forms. unwanted effects of antimicrobial use.
OBJECTIVE: To measure the effectiveness of the quality
METHODS: Data was collected retrospectively from October 1, improvement initiative regarding antimicrobial appropriateness
2009 through November 30, 2009 for patients prescribed by comparing data before and after the implementation of an
acetaminophen and ibuprofen in order to evaluate current antimicrobial stewardship program.
prescribing practices. Collected data included patient METHODS: Patients greater than 18 years of age at Mercy St.
demographics, medication, dose, route, frequency, indication Charles Hospital receiving cefepime, daptomycin,
for use, and dosage form utilized for administration. Current imipenem/cilastatin, or piperacillin/tazobactam admitted
prescribing of acetaminophen and ibuprofen was evaluated to between October 1 and December 31, 2008 were included in
identify if doses were prescribed appropriately based on weight the retrospective chart review before program implementation
and if they can be provided by commercially available dosage and those admitted between October 1 and December 31,
forms. Standardized weight-based dosing ranges will be 2009 were included in the prospective review during program
determined based on current milligram per kilogram dosing implementation. The program consists of daily patient
recommendations. This information will be used to implement monitoring with recommendations made to physicians
standardized dosing, allowing medications to be provided in the regarding timely intravenous (IV) to oral (PO) route changes,
appropriate unit of use. A preprinted order set or dosing renal function dose adjustments and de-escalation or cessation
guideline table will be prepared for use by practitioners. of therapy for empiric and directed treatment regimens. The
results are then reviewed for appropriateness based on the
PRELIMINARY RESULTS: Data has been analyzed for thirty- following: appropriate empiric therapy, appropriate dose,
eight patients and fifty total medication orders. Forty-two of the antibiotics discontinued after three days of a negative work-up,
fifty orders were acetaminophen orders and the remaining eight antibiotics changed/de-escalated within 24 hours of culture and
were for ibuprofen. Of those medication orders, fourteen (27%) sensitivity results and antibiotics converted from IV to PO
were not measurable as prescribed. The majority of the non- dosing when the patient is eligible.
measureable orders (93%) were for acetaminophen. RESULTS/CONCLUSIONS: Data collection is in progress.
Results and conclusions will be presented at the Great Lakes
Data analysis is ongoing and comprehensive results will be Conference.
presented at the Great Lakes Pharmacy Resident Conference. Learning Objectives:
Learning Objectives: Recognize the importance and necessity of antimicrobial
Discuss the issues associated with practitioner prescribing of stewardship
acetaminophen and ibuprofen in the inpatient setting. Identify key areas involved in antimicrobial stewardship that
Describe the benefits of implementing standardized dosing. can benefit the patient and the hospital by decreasing
unnecessary drug exposures, resistant bacterial strains, and
Self Assessment Questions: hospital costs.
In which of the following strengths is acetaminophen
Self Assessment Questions:
commercially available as a suppository?
a.40 mg Which of the following is/are important to monitor in an
b.80 mg antimicrobial stewardship program?
c.160 mg a. Timing of IV to PO conversion
d.240 mg b. De-escalation of antibiotics based on culture and sensitivity
reports
True/False: The appropriate weight-based dose of
c. Empiric therapy selection
acetaminophen is 5-10 mg/kg/dose.
d. A and C
e. All of the above
Running a successful antimicrobial stewardship program can
lead to:
a. Decreasing unnecessary drug exposures
b. Increasing resistant bacterial strains
c. Decreasing hospital costs
d. A and C
e. All of the above
CHANGES IN PRESCRIBING PATTERNS AFTER THE EVALUATION OF THE MEDICATION RECONCILIATION
PUBLICATION OF LITERATURE DESCRIBING A PROCESS AFTER THE IMPLEMENTATION RX HISTORY
POTENTIAL INTERACTION BETWEEN CLOPIDOGREL AND CAPTURE
PROTON PUMP INHIBITORS Michael C. Bandy,* Sarah B. Hemker, Joseph Melucci, Randy
Kacie E. Bailey*, Jill S. Burkiewicz, Kathy E. Komperda C. Miles
CPS/Mercy Hospital and Medical Center,2525 S Michigan Mt. Carmel Medical Center,793 West State
Ave,Chicago,IL,60616 Street,Columbus,OH,43222
[email protected] [email protected]
Purpose: Emerging data suggest a potential drug interaction Background:
between PPIs and clopidogrel that decreases clopidogrel It has been estimated that 46% of medication errors occur on
effectiveness and increases the risk of adverse cardiovascular admission or discharge when new orders are written. Since
events. This study evaluates the effect of recent literature 2005, The Joint Commission has been dedicated to preventing
describing this interaction on prescribing patterns. The primary medication errors by establishing a National Patient Safety
objective is to compare the frequency of ACS patients Goal on medication reconciliation. Standard Registers Rx
discharged from a community teaching hospital with History Capture is designed to allow facilities to electronically
prescriptions for both clopidogrel and a PPI before and after access a patients prescription medication history. Once
these publications. The secondary objective is to identify the implemented, a clinician is able to query a patients prescription
frequency of ACS patients prescribed a PPI upon discharge data from SureScript-RxHubs information network and the
with no indication for PPI use. hospitals own health information systems to generate a list of
prescription medications.
Methods: This retrospective observational study identified
patients with ICD9 codes for acute myocardial infarction Purpose:
(410.xx) and unstable angina (411.xx) discharged between The purpose of this study is to evaluate the impact of Rx
December 2008 - February 2009 and July 2009 - September History Capture on the medication reconciliation process and to
2009 and prescribed clopidogrel at discharge. The first time determine if access to patients prescription medication history
period includes prescribing data that occurred before the will improve the accuracy of medication reconciliation.
publications while the second time period includes prescribing
data after the publications. Data was collected using electronic Methods:
medical record discharge summaries. Descriptive statistics Completed medication reconciliation forms were collected for
and chi-square were used for statistical analysis. Before patients admitted into a large community teaching hospital for a
initiation, the institutional review board approved the study. period of two weeks. Forms were categorized as completed,
completed with interruption or not completed. A pharmacist
Results: In total, 290 charts were reviewed and 114 met recorded the start time of the process when the electronic
inclusion criteria. Prior to the publication of data describing the tracking board changed a patients status to admitted or
potential drug interaction, 30.6% of patients were prescribed anticipated admission. The stop time was recorded when the
both clopidogrel and a PPI at discharge compared to 32.3% of pharmacist signed and dated/timed the medication
patients after publication of the data (P=0.847). In the first time reconciliation form. The patient interview was standardized to
period, 73.3% of patients prescribed a PPI did not have an decrease variability between pharmacists. Medication
approved indication compared to 85.7% in the second time reconciliation forms were then collected for a period of two
period (P=0.418). weeks with the assistance of Rx History Capture.
Implementation of Rx History Capture was approximately one
Conclusions: During the two time periods under investigation, month. Pharmacists training was approximately one week. The
there was no statistically significant difference seen in primary outcome was improvement of medication reconciliation
prescribing patterns in response to recent publications form completion. Secondary outcomes were increased time to
describing a potential drug interaction between clopidogrel and completion of a medication history interview, increased quality
PPIs. Additionally, there was no significant difference in the of medication history interviews, improved transfer of home
frequency of patients prescribed a PPI without an appropriate medications to the discharge instructions, and pharmacist
indication. acceptance of Rx History Capture.
Learning Objectives:
Results and Conclusion:
Discuss the current literature describing the interaction
Data collection and analysis currently in progress and will be
between clopidogrel and PPIs
presented at the Great Lakes Pharmacy Resident Conference.
Describe the proposed mechanism of the drug interaction
Learning Objectives:
between clopidogrel and PPIs
Describe the medication reconciliation process and its
Self Assessment Questions: significance in patient care.
True/false: The proposed drug interaction between clopidogrel Recognize the impact of electronic data sources in the
and PPIs is supported by evidence from randomized, placebo- medication reconciliation process.
controlled trials.
Self Assessment Questions:
The FDA has recommended against using which of the
following PPIs concomitantly with clopidogrel? Identify the primary function of Rx History Capture.
A. Pantoprazole Identify the requirements of The Joint Commissions National
B. Omeprazole Patient Safety Goal 8 - Accurately and completely reconcile
C. Lansoprazole medications across the continuum of care.
D. Rebeprazole
CLINICAL CHARACTERISTICS TO PREDICT ADVERSE EVALUATION OF A VANCOMYCIN DOSING PROTOCOL IN
EVENTS WITH LOOP DIURETIC INFUSIONS IN PATIENTS THE NEONATAL INTENSIVE CARE UNIT
WITH ACUTE DECOMPENSATED HEART FAILURE *Ashley Bartell
Megan M. Barnes*; Susie Kim; Kristen T. Reaume; Barry E. Northwestern Memorial Hospital,251 E. Huron,LC-
Bleske; Michael P. Dorsch 700,Chicago,IL,60611
University of Michigan Health System,133 Edenwood Dr,Apt [email protected]
302,Ann Arbor,MI,48103
Background
[email protected]
Vancomycin is an antimicrobial agent used to treat gram-
Intravenous loop diuretics are a mainstay in the treatment of positive infections, including those caused by methicillin-
acute decompensated heart failure (ADHF) patients with resistant Staphylococcus aureus (MRSA) in neonates and
volume overload. While intermittent intravenous loop diuretics infants. Serum vancomycin trough concentrations are used as
have been the conventional method of administration, studies a surrogate marker to determine efficacy of vancomycin dosing
have shown that continuous diuretic infusions may be a more and may also help evaluate vancomycin clearance. Consistent
safe and efficacious method of fluid removal. The purpose of with recently published consensus guidelines recommending
this study is to determine unique predictors of adverse effects serum trough concentrations of 15-20 mcg/ml in adults, target
associated with continuous infusion in patients with ADHF; and serum trough concentrations of 15-20 mcg/ml are also
to establish a conversion factor to an effective oral loop diuretic frequently used in the neonatal population, although no studies
maintenance dose following completion of the continuous have correlated clinical efficacy. At Northwestern Memorial
infusion. Hospital (NMH), recommendations for initial vancomycin doses
for neonates are 20 mg/kg and goal serum trough
This is a single-center, retrospective case control study that concentrations are 10-20 mcg/mL. To date, no previous studies
has been IRB-approved. All patients admitted to UMHS with have evaluated vancomycin dosing regimens in neonates at
ADHF between January 2006 and June 2009 receiving NMH and it is unknown if the current dosing regimen
continuous loop diuretic infusions were included. Patients with consistently achieves desired serum trough concentrations.
incomplete records, infusion for less than 24 hours, The purpose of this study was to determine if the current
concomitant nephrotoxins or dialysis, and those less than 18 vancomycin empiric dosing methodology in the neonatal
years of age were excluded. intensive care unit (NICU) is appropriate to achieve adequate
serum trough concentrations.
This study will compare two patient groups, those with and
without adverse events. Adverse events include acute renal Methods:
failure, ototoxicity, hypotension, hypokalemia, This investigation was a retrospective cohort study evaluating
hypomagnesemia, hyponatremia, arrhythmias, ICD shocks, vancomycin dosing in the NICU at NMH. Criteria for inclusion
myalgias, gout, and contraction alkalosis. In order to carry out was any patient admitted to the NICU between October 2007
this comparison, baseline characteristics will be collected from through December 2009 who received at least two doses of
individual electronic patient medical charts including vancomycin and had at least one vancomycin serum trough
demographics, heart failure characteristics, relevant concentration in the electronic medical record. Other data
medications, co-morbidities, and daily net fluid status. To variables collected included: gestational age, renal function,
establish an effective oral loop diuretic maintenance dose after length of vancomycin therapy and desired serum trough
completion of a loop diuretic continuous infusion, a correlation concentration. The primary endpoint was the fraction of initial
will be made between the loop diuretic dose received over the vancomycin dosing regimens that achieved desired serum
final 24 hours of continuous infusion, the first post-infusion trough concentrations in the study population. Secondary
dose, and the corresponding urine outputs for each. endpoints included any changes in renal function while on
vancomycin therapy.
After completion of this research, we hope to be able to
distinguish patient characteristics that increase the likelihood of Results/Conclusions:
adverse events from loop infusions and identify the effective Data collection and analysis is currently underway. Results and
loop diuretic oral maintenance dose at the completion of a loop conclusions will be presented at the Great Lakes Residency
diuretic infusion. Conference.
Learning Objectives:
Discuss the benefits of continuous loop diuretic infusions vs. Learning Objectives:
intermittent bolus injections. Understand the physiologic differences in the neonatal
Identify potential adverse effects associated with loop diuretic population versus adults
infusions. Identify how physiologic differences can affect the dosing of
vancomycin in the neonatal population.
Self Assessment Questions:
What is the benefit of continuous loop diuretic infusions over Self Assessment Questions:
intermittent bolus injections? In both neonates and adults what is the surrogate marker that
A.Safety is used to determined clinical efficacy of vancomycin?
B.Effectiveness a)Trough concentrations
C.Reduced fluctuations of intravascular volume b)Peak concentrations
D.All of the above c)Serum Creatinine
Which of the following is an adverse effect associated with loop What is the best predictor of clearance of vancomycin in the
diuretic use? neonatal population?
A.Hyperkalemia a)Weight
B.Hypernatremia b)Gestational age
C.Myalgias c)Postnatal age
D.Hypermagnesemia d)Postmenstrual age
EVALUATION OF TREATMENT ALGORITHM FOR
ANTICOAGULANT-ASSOCIATED INTRACEREBRAL PHARMACY TECHNICIANS: AN UNTAPPED RESOURCE
HEMORRHAGE FOR IMPROVING MEDICATION RECONCILIATION IN THE
Peggy D Baylin*, Andrew P. Slivka, Jr EMERGENCY DEPARTMENT
The Ohio State University Medical Center,410 W 10th Matt D Beachnau*, Terry Baumann
Avenue,368 Doan Hall,Columbus,OH,43210 Munson Medical Center,5340 N. Kalchik Rd.,Omena,MI,49674
[email protected] [email protected]
Purpose/Background: Purpose: The objective of this study is to determine if a
The incidence of anticoagulant-associated intracerebral pharmacy technician can obtain accurate and timely patient
hemorrhage (AAICH) has increased dramatically over the past medication lists for reconciliation in the emergency department
two decades. In 2007, the American Heart
Association/American Stroke Association published guidelines Methods: We conducted a pilot study that incorporated a
for the treatment of spontaneous intracerebral hemorrhage. pharmacy technician into a newly designed medication
The Ohio State University Medical Center (OSUMC) Stroke reconciliation process. This system triaged the flow of
Team, in conjunction with the Department of Neurosurgery, obtaining medication histories between pharmacy techs,
developed an institutional guideline for the treatment of nurses, and pharmacists. A pharmacy tech spent one week
intracerebral hemorrhage (ICH). The guideline includes learning how to properly interview patients to obtain an
recommendations for making the diagnosis, managing accurate medication list. We tested our process over a span of
increased intracranial pressure and hypertension, DVT 4 days. At the conclusion of the study, we analyzed
prophylaxis, general medical care, surgical care and prevention timeliness, accuracy, and total percent of medication
of ICH recurrence. Additionally, a treatment algorithm specific reconciliations completed.
to AAICH was developed. A major purpose of the AAICH
algorithm was to provide information to guide uniform, goal- Results: Between October 20, 2009 and October 23,2009 the
directed care to this patient population resulting in better nursing staff completed with 84% accuracy (baseline accuracy
outcomes as well as lower pharmacy-related costs. The 68%), an average of 21 medication reconciliations per day with
guideline was approved by the Evidence-based Practice an average of 3.6 medications per patient and an average time
Committee in April 2008. of 1hr and 10min (time from when the patient came into the ED
The current study is intended to assess the adherence of until the medication profile was updated for reconciliation).
OSUMC physicians treating AAICH to the approved treatment Pharmacists completed, with 94% accuracy (baseline accuracy
algorithm. Effectiveness in the areas of time to INR reversal, 92%), an average of 6 med. recs. per day with an average of
hematoma growth, adverse events related to anticoagulation 11.5 medications per patient and an average time of 2 hrs.
reversal agents and patient mortality will be evaluated. Costs Pharmacy technicians completed with 91% accuracy, an
associated with anticoagulant reversal agents will also be average of 8 med. recs. per day with an average of 9.3
assessed and compared to cost of agents used prior to the medications per patient and an average time of 1 hr. and 40
creation of the treatment algorithm. min.
Methods: Conclusion: This study demonstrated that allowing pharmacy
An IRB-approved retrospective chart review was conducted technicians to obtain medication histories in the
using ICD-9 codes and electronic medical records to identify emergency department would improve the medication
patients admitted with a diagnosis of intracerebral hemorrhage reconciliation process.
while on an anticoagulation agent from May 1, 2008 through Learning Objectives:
June 30, 2009. Eligible patients are those who were admitted
Describe why it is necessary to obtain accurate medication
to OSUMC and treated for anticoagulant-associated
profiles for reconciliation.
intracerebral hemorrhage. Prisoners, pregnant females,
patients under 18 or ≥ 89 years of age have been excluded. Identify "road blocks" that prohibit the development of an
accurate medication list
Results: Self Assessment Questions:
Data assessment is currently in progress.
List two reasonsy why it is important to obtain accurate
Learning Objectives:
medication profiles in the emergecy department.
Describe the benefits and risks associated with various Name two "road bloks" that prevent an accurate medication
treatment strategies for warfarin reversal in intracerebral profile to be obtained.
hemorrhage patients.
Discuss the impact of an AAICH treatment algorithm on patient
outcomes.
Self Assessment Questions:
What are the immediate goals of treatment for AAICH?
List two benefits of using Prothrombin Complex Concentrate
over fresh frozen plasma for INR correction.
TRENDS IN ANTIBIOTIC PRESCRIBING FOR SOFT TISSUE PHARMACIST-LED ADMISSION MEDICATION
INFECTIONS AND PNEUMONIA IN THE ERA OF RECONCILIATION FOR GERIATRIC PATIENTS ADMITTED
COMMUNITY-ASSOCIATED METHICILLIN-RESISTANT TO A GENERAL MEDICINE/SURGERY FLOOR
STAPHYLOCOCCUS AUREUS Robert D. Beckett*, Christopher W. Crank, Ann Wehmeyer
Craig J Beavers*, Douglas Steinke, Russ Judd, David Feola, Rush-Presbyterian St. Luke's Medical Center,1653 W
Brian Murphy, Craig Martin Congress Pkwy,Atrium 0036,Chicago,IL,60612
University of Kentucky HealthCare,800 Rose Street,H- [email protected]
110,Lexington,KY,40536
Medication errors are associated with increased morbidity,
[email protected]
mortality, and length of hospital stay, and are most likely to
Purpose: Since 2000, there has been increasing prevalence of occur at care interfaces. Pharmacist-led medication
community-acquired methicillin-resistant Staphylococcus reconciliation at admission reduces medication errors while
aureus (CA-MRSA). Commonly CA-MRSA presents as skin maintaining cost-effectiveness. Limited resources can make it
and soft-tissue infections (SSTI), yet concern has developed crucial to identify patients most benefiting from pharmacist-led
about CA-MRSA pneumonia. While there is a multitude of medication reconciliation. Geriatric patients are at risk for
literature highlighting increasing trends of CA-MRSA SSTI and admission medication errors and represent a group to target for
pneumonia, there is limited data describing trends in antibiotic such practice. Our purpose was to evaluate the effectiveness
usage for CA-MRSA. The primary objective of this study is to and feasibility of comprehensive medication reconciliation
determine if there has been an increasing trend of anti-CA- performed by a pharmacist in reducing admission medication
MRSA coverage integrated into empiric therapies for SSTI and errors for geriatric patients admitted to a general medicine or
pneumonia in adult Kentucky Medicaid patients. Secondary surgery floor.
objectives will evaluate subsets of the primary population to
determine if there are significant trends within each group. Patients greater than 70 years of age admitted to a medicine or
surgery floor were randomized to receive medication
Methods: Used Kentucky Medicaid claims from January 1, reconciliation per normal practice (i.e. pharmacist, physician,
2001-December 31, 2008 to identify adult patients aged 18 and and/or nurse review of medication list; Group 1) or normal
older who were diagnosed with SSTI or pneumonia and had a practice plus intensive pharmacist-led medication reconciliation
prescription dispensed for an antibiotic(s) within 72 hours of the (i.e. formal medication history utilizing a variety of outside
diagnosis. The secondary objectives had patient information resources; Group 2) within 24 hours. Interventions were
extracted including co-morbid diseases-(ICD-9 codes), evaluated by a geriatrics fellow at 48 hours. The primary
procedures-(CPT codes), gender, rurality-(USDA rural outcome measured was difference in medication profile
continuum) and age. Quantity of anti-MRSA antibiotics were appropriateness at 48 hours between groups. Forty patients
aggregated for each year. The trend of antibiotic usage over per group were calculated to be necessary to obtain 80%
time was charted. Chi-squared statistics and linear regression power to detect a difference in the primary endpoint. Other
were used for data analysis. data collected includes time to medication reconciliation, time
spent per patient, source of information, and intervention
Results (In progress): In the SSTI group, the study found a significance.
difference in the trends of beta-lactams and agents with
coverage for CA-MRSA usage in the study period. Linear At this time, 53 patients have been enrolled in the study. Mean
regression using interaction terms in the model found a patient age was 79 years and 66% of patients were female.
statistical difference between the two trend lines (p<0.001). Pharmacists identified 90 errors (1.7 errors per patient)
Similar results were obtained for the secondary objective requiring intervention. Sixty-six percent of patients had a least
analysis. one error requiring intervention, with a mean of 2.6 errors per
patient. Mean time per patient was 25 minutes. Preliminary
Conclusions: Final results for both disease states and results suggest significant benefit of pharmacist-led medication
conclusions will be presented at the Great Lakes Pharmacy reconciliation for geriatric patients.
Residency Conference. Learning Objectives:
Learning Objectives: Explain the rationale for pharmacist-led medication
To describe the increasing trends of community-acquired reconciliation.
methicillin-resistant Staphylococcous aureus (CA-MRSA) Identify challenges for pharmacist-led medication reconciliation.
To recognize outpatient agents to trend CA-MRSA infections
Self Assessment Questions:
Self Assessment Questions: Where are medication errors most likely to occur?
Which patient would be considered to have a CA-MRSA What are some potential outcomes of medication errors?
infection?
A)50 year old diabetic patient who gets dialysis at a clinic 3
times a week
B)18 year old college football player
C)80 year old woman who resides in a local nursing home
D)36 year old male who was admitted for myocardial infarction
8 months ago
According to algorithm co-developed by the Infectious Disease
Society of American, Centers of Disease Control and American
Medical Association for outpatient management of skin and
soft-tissue infections (SSTI), which agent would you most likely
use first to treat an SSTI?
A)Levofloxacin
B)Amoxicillin/Clavulanate
C)Clindamycin
D)SMZ/TMP
HEPARIN INDUCED THROMBOCYTOPENIA IN NITROFURANTOIN AND ITS APPROPRIATENESS IN
SUBARACHNOID HEMORRHAGE PATIENTS: INCIDENCE, PATIENTS WITH RENAL DYSFUNCTION
TREATMENT, AND OUTCOME *David W. Benner; Erin L. Meilton, Cynthia M. Jacober
Scott T. Benken*, Eljim P. Tesoro, Jeffrey J. Mucksavage, Keri Riverside Methodist Hospital,3535 Olentangy River
S. Kim Rd,Columbus,OH,43214
University of Illinois at Chicago,833 South Wood [email protected]
Street,Chicago,IL,60612-7230
Purpose:
[email protected]
Nitrofurantoin, a urinary anti-infective, is used for both the
PURPOSE: At the University of Illinois Medical Center at prophylaxis and treatment of urinary tract infections. Its
Chicago (UIMCC), subarachnoid hemorrhage (SAH) patients spectrum of activity includes Staphylococcus aureus,
receive venous thromboembolism (VTE) prophylaxis with Enterococcus faecalis, Escherichia coli, Citrobacter, and
unfractionated heparin (UFH) and sequential compression Klebsiella. Nitrofurantoin provides a viable option for patients
devices (SCDs) following surgical or neurointerventional who have resistant cultures to more traditional therapies such
treatment. It is hypothesized that neurosurgical patients have as ciprofloxacin, sulfamethoxazole-trimethoprim, and
an increased risk of Heparin Induced Thrombocytopenia (HIT) cephalexin. Although it provides an effective alternative, the
Type II (clinically dangerous form of HIT) due to their medication does have its limitations. In order to obtain
postoperative status and frequent exposure to heparin products adequate concentrations in the urine a patients creatinine
including the frequent use of indwelling catheters flushed or clearance must be at least 60ml/min per the manufacturer.
impregnated with UFH. At UIMCC, if a patient is suspected of Furthermore, nitrofurantoin is contraindicated in patients with a
developing HIT without thrombosis, the practice has been to creatinine clearance of less than 60ml/min. The purpose of my
following attending physician discretion (e.g. switching the UFH study is to evaluate the appropriateness of nitrofurantoin use in
to fondaparinux prophylaxis with the optional placement of an various patients with regard to empiric indication, renal
inferior vena cava filter (IVCF) to prevent PE). If HIT with function, as well as culture and sensitivity results. Secondarily,
thrombosis (HITTS) is discovered, the practice has been to the educational impact on nitrofurantoin dosing and renal
stop the UFH and place an IVCF. Treatment with full requirements will also be evaluated as a component of the
anticoagulation as recommended by consensus guidelines study.
potentially was delayeddue to perceived high risk of bleeding
complications. The goals of this retrospective study are to Methodology:
determine the incidence of HIT-antibody positive patients with To better understand its use and effects at our institution a
SAH at UIMCC, to examine the treatment strategies for medication use evaluation (MUE) was performed. A
HIT/HITTS employed in our center, and to evaluate the retrospective chart review was done on all patients that
outcomes of this practice. received an order for nitrofurantoin from September 30th 2008
to September 29th 2009. A total of 380 charts were examined.
METHODS: This study will be a retrospective chart review of To determine the appropriateness of prescribing, data collected
adult SAH patients admitted between January 1, 2006 and included patient age, height, weight, kidney function, culture
December 31, 2009 who developed HIT . Subjects will be sensitivity results, and schedule prescribed. Results of the
identified by query of UIMCC laboratory records to identify medication use evaluation will be presented at antimicrobial
patients with a positive HIT-antibody assay. All patients will be stewardship meeting where policies regarding judicious
> 18 years of age and discharged from the UIMCC to qualify. antibiotic use are discussed and drafted. Recommendations
The primary outcome is defined as the incidence of new or will be made based on MUE results to limit inappropriate
worsening thrombosis prior to discharge. Secondary outcomes prescribing and use. Furthermore, results will also be
will include the incidence of major bleeding complications and presented at the pharmacy and therapeutics committee to
the incidence of new or worsening thrombosis at 3 months. finalize and approve any recommendations made. After
policies and protocols are approved, education will be provided
RESULTS: Pending to the medical and pharmacy staff on the proper use of
nitrofurantoin.
CONCLUSIONS: Pending
Learning Objectives: Learning Objectives:
Recognize the theoretical clinical dilemma in treating SAH Determine the appropriateness of nitrofurantoin use and its
patients diagnosed with HIT/HITTS. impact on patients
Describe the outcomes associated with HIT/HITTS List alternative therapies available for those who do not qualify
management at UIMCC in SAH patients. for nitrofurantoin treatment
Self Assessment Questions:
True or False. SAH patients are at a potential increased risk of Self Assessment Questions:
HIT/HITTS. T or F: Prophylactic dosing does not necessitate the same
At UIMCC, typical treatment of a SAH patient diagnosed or renal requirements because of its once daily dosing schedule
suspected with HIT/HITTS may include all of the following T or F: A creatinine clearance of 50ml/min is a contraindication
except: to treatment.
a.Discontinuing UFH
b.Starting LMWH
c.Begin prophylaxis with fondaparinux
d.Place IVCF.
CHARACTERIZATION AND OUTCOMES OF TREATMENT CHARACTERIZATION OF GLUCOSE BEHAVIOR DURING
WITH TRANSARTERIAL CHEMOEMBOLIZATION (TACE) INDUCED HYPOTHERMIA AND REWARMING
FOR HEPATOCELLULAR CARCINOMAS IN ADULT Jenna L. Bernabei*, Dustin Spencer
PATIENTS AT METROHEALTH MEDICAL CENTER(MHMC)
Clarian Health Partners,1701 N. Senate
Katherine M Bentz*, Jan Kover, Borys Hrinczenko Boulevard,AG401/B222,Indianapolis,IN,46202
MetroHealth Medical Center,2500 MetroHealth [email protected]
Dr.,Cleveland,OH,44109
Purpose: Induced hypothermia is utilized to preserve neurologic
[email protected]
function in patients resuscitated from cardiac arrest. Glucose
Background: Hepatocellular carcinoma (HCC) is a serious control in this population has not been studied extensively.
disease with an increasing incidence worldwide. The majority of Hyperglycemia and variability in glucose have been shown to
patients with HCC are not eligible for curative therapies. One of have adverse outcomes in critically ill patients including an
the options available to those who are not eligible is TACE, increase in morbidity and mortality. The purpose of this study is
which results in increased survival over conservative treatment. to characterize glucose behavior and the effect of exogenous
However, TACE is not standardized and institutions have insulin administration during induced hypothermia and
various methods for selecting patients and use differing rewarming.
chemotherapeutic agents. My aim is to characterize both the
patients as well as their outcomes to treatment with TACE for Methods: Retrospective, observational analysis of post-cardiac
HCC at MHMC and compare these outcomes with those of arrest patients completing the induced hypothermia and
other institutions. rewarming protocol between September 2008 and August
2009. Patients were excluded if they were less than 18 years of
Methodology: A retrospective data review will be conducted on age or did not have blood glucose values obtained during the
patients who received at least one TACE treatment from 2000- induced hypothermia protocol. Baseline characteristics
2009. All adult patients will be identified through pharmacy including gender, age, history of diabetes, hemoglobin A1C,
records. Data will be collected from MHMC's electronic medical weight, and height were collected for each patient if available.
records. Extensive demographic information will be collected. Documented sepsis and the use of vasopressors or
All treatments used for HCC will be collected, as well as, corticosteroids were also recorded. The glucose values
date(s) of treatment, components of the chemotherapy, number obtained during induced hypothermia and rewarming were
of treatments, and cumulative chemotherapy doses. Laboratory collected and analyzed as well as the amount of insulin and
values and cardiac studies will be collected in addition to, tumor glucose administered and correlating body temperatures.
stage by AJCC criteria, imaging studies, pathology reports, These values were utilized to evaluate glucose behavior and
performance status and patient outcomes. Study data will be the effect of exogenous insulin during the hypothermia and
analyzed through the use of descriptive statistics. When rewarming process.
appropriate, a students t-test will be used to compare the
outcomes to those of other institutions via local and national Preliminary Demographics (n=32):
databases. The information provided by this study will help to
determine if MHMCs standard TACE procedure has Of the patient population evaluated, demographic information is
comparable outcomes to other institutions and published as follows: Male (69%), average age 54 years, average BMI of
literature. Results may lead to a change in practice at our 31.1. Average hemoglobin A1c was 6.78 g/dL, 24% had
institution. diabetes. During the hypothermia protocol 88% of patients
received exogenous insulin; of those patients 43% received
Results/conclusions: Data collection is ongoing. Results will be subcutaneous and 57% intravenous insulin. Sepsis was
presented at the conference. documented in 16% of patients, 16% were given steroids and
Learning Objectives: 50% received at least one vasopressor.
Identify patients at risk of developing hepatocellular carcinoma
Results and Conclusions: To be presented
and clinical features of the disease.
Learning Objectives:
Explain how chemoembolization is used as a treatment for
hepatocellular carcinoma. Describe glucose behavior during induced hypothermia and
rewarming.
Self Assessment Questions:
Discuss the incidence of hyperglycemia and hypoglycemia
Hepatocellular carcinoma is the most common form of primary relative to body temperature and amount of insulin received
liver cancer and females are at increased risk of developing during induced hypothermia and rewarming.
HCC. True/False
Self Assessment Questions:
The majority of patients with HCC are eligible to receive
curative therapy. True/False Endogenous insulin production increases during induced
hypothermia. T/F
Tight glycemic control reduces morbidity and mortality in
critically ill patients by:
a.reducing risk of infection
b.reducing development of renal failure
c.reducing incidence of polyneuropathies
d.all of the above