2017 POSTER ABSTRACTS - Kansas Council of Health … Abstracts... · Regional Health Center Steven Wayne Blanner Doctor of Pharmacy, ... days • SMX/TMP 160/800 mg PO BID x 3 days

2017 POSTER

ABSTRACTS

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Encore Presentation #1

Author: Blake Baumann, Pharm.D., Saint Luke's Hospital Scott Aldridge, Pharm.D., BCPS, Saint Luke's Hospital Mark Woods, Pharm.D., FASHP, BCPS, Saint Luke's Hospital Saint Luke's Hospital

Title: Albumin use in patients experiencing intradialytic hypotension

Purpose: This project is designed to evaluate the effectiveness of current albumin usage for intradialytic hypotension (IDH) within Saint Luke’s Health System and in turn implement correct pharmacologic and non pharmacologic options for patients experiencing IDH. Methods Medical records from patients receiving albumin or saline for hypotension during dialysis from December 1st, 2015 to August 31st, 2016 across five metro Saint Luke’s hospitals will be reviewed. Patients receiving continuous renal replacement therapy (CRRT) or peritoneal dialysis (PD) will be excluded. Blood pressure prior to albumin administration and one hour after albumin administration, dose of albumin administered, time from the start of dialysis until albumin was administered and mean arterial pressure prior to albumin administration and one hour after administration will be recorded for each patient. Results: Research in progress Conclusions: Research in progress

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Author: Brianne Nicole Sutherland, PharmD, Shawnee Mission Medical Center; Alexandra Oschman, PharmD, BCPPS, Children's Mercy Hospital; Betsy Knappen, APRN, MSN, Shawnee Mission Medical Center and Children's Mercy Hospital; Jodi Jackson, MD, Shawnee Mission Medical Center and Children's Mercy Hospital; Niccole Winistoerfer, PharmD, BCPS, BCPP, Shawnee Mission Medical Center Shawnee Mission Medical Center

Title: Antenatal opiate exposure and effects on neonatal outcomes: Observations at a community birth center

Purpose: Neonatal abstinence syndrome (NAS) is a withdrawal syndrome that occurs at birth following prenatal exposure to opioids. Maternal antepartum use of opioids has increased dramatically in the United States over the last decade, with the incidence of NAS demonstrating corresponding growth. While the factors contributing to the severity of NAS remain largely undefined, potential variables may include specific type of opiate exposure, extent of exposure, and concomitant use of other substances. This study was designed to evaluate whether associations exist between severity of neonatal abstinence syndrome and specific characteristics of antenatal opiate exposure. Methods This study is a retrospective cohort analysis of infants born at Shawnee Mission Medical Center between September 1, 2014 and August 31, 2016, who were identified as at risk for NAS due to prenatal opioid exposure. The inclusion criteria are as follows: documentation of chronic opioid use during pregnancy from maternal disclosure or positive maternal/infant drug screen, and infant scored for NAS utilizing the modified Finnegan score. Exclusion criteria will include earlier than 32 weeks gestation or NAS secondary to prenatal exposure to nonopiates. Characteristics of antenatal opiate exposure will be defined by opioid type and extent of exposure. The primary endpoint will be severity of NAS, defined by neonate requiring pharmacologic treatment with morphine. Secondary endpoints will include infant length of stay and admission to the neonatal intensive care unit (NICU). The results of this study will serve to enhance existing knowledge related to the management of neonatal abstinence syndrome. Results: Research in Progress Conclusions: Research in Progress

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Author: Zahra Crystal Nasrazadani Doctor of Pharmacy, University of Kansas PGY1 Pharmacy Resident Salina Regional Health Center Steven Wayne Blanner Doctor of Pharmacy, University of Missouri - Kansas City Board Certified Pharmacotherapy Specialist Residency Program Director, Clinical Pharmacist Salina Regional Health Center Salina Regional Health Center

Title: Assessment of clinical benefit of double coverage in confirmed Pseudomonas infections

Purpose: As antibiotic resistance increases and antimicrobial stewardship efforts intensify, clinicians must reevaluate routine practices to ensure optimal therapeutic approaches, particularly with regard to empiric antimicrobial treatment strategies. The objective of this study is to assess the probability of clinical benefit when greater than one antimicrobial agent is utilized for empiric treatment of presumed Pseudomonas aeruginosa infections, a technique colloquially known as “double coverage.” Due to the disproportionately high rate of patient mortality and antibiotic resistance associated with this organism, developing effective Pseudomonas treatment strategies is critical to stewardship efforts. Methods: Methods: This study was submitted to the Institutional Review Board and approved. The electronic medical record was utilized to isolate the records of inpatient admissions for which Pseudomonas aeruginosa was identified as a causative organism upon microbiological culture. The following data was collected: length of stay, indication for antimicrobial use (and intubation or catheterization status, when the associated indication is a respiratory or urinary tract infection, respectively), empiric antimicrobial regimen and treatment regimen, treatment day on which susceptibility data was finalized, antimicrobial resistance, adverse drug reactions related to the antimicrobial therapy, selected comorbidities, steroid use, whether the patient was admitted to the critical care unit, and the patient outcome (discharge versus expiration). The patient record was utilized to assess the sequence of events during the course of treatment and to determine the utility of the double coverage strategy. Based on antimicrobial resistance and other patient-specific risk factors, data was evaluated to ascertain the probability of clinical benefit versus risk of unnecessary treatment and adverse events. Finally, aggregate data was also analyzed to identify any critical patient population whose high risk stratification may warrant the more aggressive double coverage approach.

Results: This study was limited by its retrospective nature, which permitted evaluation of culture-confirmed Pseudomonal infections. Pseudomonas is often the causative organism in infectious processes that are difficult to culture, such as lower respiratory or skin and soft tissue infections. Despite this significant limitation, the study revealed a tendency to fail to recognize patients at higher risk for Pseudomonas, specifically those with catheter-associated urinary tract infections. Further, practitioners often did not appropriately narrow antimicrobial regimens once cultures and susceptibilities were known, reflecting a propensity to undertreat in the former instance and overtreat in the latter. Due to the study's primary limitation, a small sample size both underestimates the actual frequency of double coverage and limits the ability to extrapolate further conclusions.

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Conclusions: Despite a perceived ubiquity of this practice, double-coverage was utilized less frequently than suspected in culture-confirmed Pseudomonal infections at the study site. High-risk patients were often overlooked for empiric coverage, whereas definitive treatment was often not narrowed as recommended in treatment guidelines, such as those developed by the Infectious Diseases Society of America. As drug experts, pharmacists play an essential role in antimicrobial stewardship efforts and, as such, a new clinical intervention was developed at the study site to assist clinicians in developing appropriate therapeutic strategies. Proactively collecting data as the result of this study has resulted in the identification of a similar patient sample size in just three months versus the study's ten-month timeframe. Treatment plans should always be individualized to address the unique needs of each patient; going forward, the development of a combination antibiogram may help guide future efforts to further tailor medication therapies.

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Author: Lauren Aversman, PharmD - PGY1 Resident - Lawrence Memorial Hospital Jeff Pierce, PharmD - Clinical Coordinator - Lawrence Memorial Hospital Mackenzie Magid, PharmD Candidate - University of Kansas, Lawrence Memorial Hospital Lawrence Memorial Hospital

Title: Assessment of Fluoroquinolone Use for Uncomplicated Urinary Tract Infections in a 173-Bed Community Hospital Emergency Department

Purpose: The U.S. Food and Drug Administration recently updated the Black Boxed Warning and safety-labeling for fluoroquinolones (FQ), advising health care providers to limit the use of these agents for patients with serious bacterial infections. Therefore, their use should be avoided in patients with uncomplicated urinary tract infections (UTI), unless no alternative treatment options remain. Per the Infectious Disease Society of America (IDSA), an uncomplicated UTI is defined as cystitis occurring in healthy, non-pregnant, non-menopausal women who are absent of fever, flank pain, or other suspicion for pyelonephritis. The primary objective is to assess fluoroquinolone use for the treatment of uncomplicated UTIs. The secondary objective is to assess the overall antibiotic selection for UTIs at a 173-bed community hospital. Methods: This quality improvement project will be a retrospective chart review of patient visits in the Emergency Department for an uncomplicated UTI. Patient charts will be identified from the electronic medical record based on the ICD-10 diagnosis code of N39*. The following data points will be abstracted from the electronic medical record database: patient age, gender, pertinent drug allergies, antibiotic received, duration of therapy, prescribing physician, and assessment of risk factors for uncomplicated versus complicated UTI. Patients less than or equal to 18 years of age or those identified to have a complicated UTI (i.e. pregnancy, men, indwelling catheters, etc.) will be excluded. Data will be collected and recorded using a standardized chart review process. All patient identifiers will be removed and data will be maintained in a confidential manner. This study will be submitted to the Institutional Review Board for approval.

Results: Inclusion criteria was met by a total of 85 patients. Five patients (5.9%) received a fluoroquinolone in the emergency department. Fluoroquinolone use was determined to be inappropriate in each patient due to preferred antimicrobial options available. Two out of five patients who received a FQ had documented allergies to sulfa and penicillin; One patient was allergic to sulfa and cephalexin; One patient had no known drug allergies; One patient had previously received moxifloxacin for sinusitis, but continued the same treatment for a UTI inappropriately. Cephalexin accounts for nearly 66% (n=56) of all antibiotics prescribed for uncomplicated UTIs, which is not a preferred agent as first line therapy according to the IDSA guidelines; however, IDSA guidelines also state the use of beta-lactam antibiotics, including cephalexin, may be appropriate in certain settings. When assessing all antibiotics prescribed for UTIs, 76% (n=65) of prescriptions were prescribed outside IDSA guidelines in relation to agent selected. Of the twenty prescriptions (24%) prescribed within the IDSA guidelines, a correct dose and frequency was prescribed 100% of the time. The duration of antibiotic therapy was correctly prescribed only 70% (n=14) of the time.

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Conclusions: The use of fluoroquinolones for UTIs in a 173-bed community hospital emergency department was minimal. Further education should be done to emphasize use of the following preferred agents and appropriate regimens for uncomplicated urinary tract infections: • Nitrofurantoin 100 mg PO BID x 5 days • SMX/TMP 160/800 mg PO BID x 3 days • Fosfomycin 3 gm PO once

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Author: Shannon Sullivan, PharmD, Lawrence Memorial Hospital PGY1 Pharmacy Resident Christina Graham, PharmD, BCPS, Lawrence Memorial Hospital Residency Director Pat Parker, MSP, RPh, Lawrence Memorial Hospital Director of Pharmacy Daniel Pons, PharmD Candidate, Lawrence Memorial Hospital Lawrence Memorial Hospital

Title: Comparison of medication reconciliation completed by a pharmacist versus emergency department personnel

Purpose: Purpose: Obtaining an accurate medication history for patients admitted to the hospital is a very important component of patient safety. In many hospital settings, these medications histories are obtained by emergency department providers not by a pharmacist. A multitude of studies confirm medication histories completed by non-pharmacy personnel are incomplete and contain errors potentially compromising medication safety. Conversely, literature suggests pharmacists provide a more complete medication history with less errors. The purpose of this study was to compare medication histories obtained by ED providers versus pharmacists. Additionally, this study aimed to identify the type of interventions made on medication histories. Methods: This was a two month, retrospective study comparing all medication histories for admitted patients obtained by ED providers versus a pharmacist. Currently, an ED physician or nurse obtains a medication history from the patient or patient representative. Once the patient is admitted to the floor, a pharmacist or pharmacy intern also obtains a medication history. Following each medication history, the pharmacist completes an electronic form in the patient’s medical record detailing the interventions made. These interventions are classified as follows: add/delete a medication, wrong frequency, wrong dose, allergy added, and allergy clarified. Patient charts were reviewed to identify the type of interventions made by pharmacists with an emphasis on high risk and narrow therapeutic index medications. Patients who were not admitted to the hospital through the emergency department, pediatric patients and patients admitted to the mother baby unit were excluded from this study. This study was submitted to the Institutional Review Board for Approval. Patient identifiers were removed and all information was maintained in a confidential manner.

Results: Of the medication histories obtained by emergency department personnel, only 5% required no intervention from the pharmacy team. The most common interventions were adding/deleting a medication (48%), wrong dose (33%), wrong frequency (28%), allergy clarification (15%), and therapeutic omission (5%). The medication classes which most frequently contained errors were blood pressure medications, over the counter (OTC) medications, pain medications and anti-depressants. High risk medications were identified incorrectly in 50% of cases they were prescribed and narrow therapeutic index medications were identified incorrectly in 48% of cases they were prescribed. The high risk medications with the most errors were warfarin (71% of cases) and insulin (75% of cases).

Conclusions: Medication histories obtained by a pharmacist or pharmacy intern are more complete and contain fewer errors than those obtained by emergency department personnel. Medication histories obtained by pharmacy personnel contain fewer errors in high risk medications and narrow therapeutic index medications.

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Author: Carleigh A. Cozad, PharmD, PGY-1 Resident, Salina Regional Health Center Linda Y. Radke, PharmD, BCPS, FASHP, Clinical Coordinator, Salina Regional Health Center Salina Regional Health Center

Title: Evaluating compliance to a hypoglycemic protocol in a community hospital.

Purpose: Salina Regional Health Center contributed to the Kansas Health Collaborative database collecting data for the Hospital Engagement Network 2.0 (HEN 2.0) which reported an incidence of severe hypoglycemia of 9 percent. The purpose of this study was to evaluate adherence to the hypoglycemic protocol at SRHC and determine areas for improvement in the treatment of severe hypoglycemia Methods The electronic medical record system was used to identify patients with blood glucose readings <50 mg/dL between January 2016 and June 2016. Treatment for hypoglycemic episodes was evaluated for adherence to the current hypoglycemic protocol. The following data was collected: -Date and time of hypoglycemic event -Date and time of hypoglycemic protocol initiation -Initial treatment -Time of 15 minute blood glucose recheck -Documentation of call to provider for critical lab Inclusion criteria: -Blood glucose reading less than 50mg/dL -Adult patient (18 years of age or older) Results: -106 episodes of hypoglycemia occurred during observation period. -94% of the time, the protocol had been activated. -93% of the time, a 15-minute blood glucose recheck was completed per protocol. -28 patients had multiple episodes of hypoglycemia during their stay. -71% of the time, there was documentation of protocol-based treatment. -37% of the time, provider notification was documented. Conclusions: This project has led to the discovery of several places in which adherence to the hypoglycemic protocol at SRHC can be improved in order to provide better patient care. The following are interventions that are being made: -Initiation of protocol: The hypoglycemic protocol will now be tied to the order of point of care glucose checks by providers. -Adherence to protocol: Education will be provided to the nursing staff through collaboration with the diabetes educator to improve consistency of documentation, physician notification, and proper treatment. -Prevention of reoccurrences: Pharmacists will now monitor patients with episodes of blood glucose <50 mg/dL to identify opportunities to intervene in drug therapy.

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Author: Alaina E. Linafelter, PharmD Candidate 2017, Clinical Pharmacy Intern Patrick E. Parker, RPh, MSP, Director of Pharmacy Christina R. Graham, PharmD, BCPS, Clinical Pharmacist Christina Lawrenz, RPh, BCPS, Clinical Pharmacist Derrick Eddy, PharmD Candidate 2018, Clinical Pharmacy Intern Lawrence Memorial Hospital, Lawrence, Kansas Lawrence Memorial Hospital

Title: Evaluation of enoxaparin dose adjustments in renally impaired or obese patients in a medium-sized community hospital

Purpose: Purpose: Enoxaparin is a commonly used anticoagulant for venous thromboembolism (VTE) prophylaxis in the inpatient setting with benefits such as reduced laboratory monitoring and a relatively quick onset of action. The Pharmacy & Therapeutics (P&T) Committee created guidelines for dosing at-risk populations with renal impairment (bleeding risk from reduced clearance) or obesity (thrombosis risk from inadequate dosing). Pharmacists have a collaborative practice agreement to adjust for renal dosing, but not for obesity. The purpose of this study was to determine the frequency and accuracy of dosing adjustments in these at-risk populations. Methods: All inpatients age 18 or older with an order for enoxaparin over a three-month time frame were included in this retrospective, chart review. Patients receiving enoxaparin for an indication other than VTE prophylaxis or patients currently receiving dialysis were excluded. Patient’s concurrent weight, height, and estimated creatinine clearance were used to evaluate the initial doses ordered by the practitioner, the doses verified by the pharmacist, and the dose adjustments made later in therapy. P&T guidelines recommend enoxaparin 30 mg subcutaneously daily for individuals with renal impairment, defined by an estimated creatinine clearance less than 30 mL/min, and a dose of 0.5 mg/kg subcutaneously daily for obese individuals, defined by a body mass index of greater than or equal to 40 kilograms per square meter. The primary outcome measure was the percentage of patients whose renal function or body mass index warranted dosing alterations per P&T guidelines. The secondary outcome measures were the percentages of accurate dose modifications made by the pharmacist or prescriber. The study received an expedited approval from the Institutional Review Board and P&T committee.

Results: A total of 450 encounters were screened for this study. Sixty-six patients were excluded. Of the remaining 384 encounters, 111 patients met criteria for dose alterations per P&T guidelines. The patients were further divided into those with renal impairment (48, 12.5 percent), obesity (66, 17.2 percent), or both (3, 0.8 percent). Overall, 56.3 percent of patients with renal impairment and 25.8 percent of obese patients had doses correctly modified according to P&T guidelines. The prescriber accurately modified the first dose in 5 (10.4 percent) of the renal patients and 10 (15.2 percent) of the obese patients. Pharmacists correctly modified the doses of an additional 22 (45.8 percent) patients with renal impairment, but incorrectly modified the dose for 1 (2.1 percent) patient. Pharmacists correctly modified the doses of an additional 7 (10.6 percent) obese patients, but incorrectly modified 6 (9.1 percent). Estimated creatinine clearances improved from initial calculations for 16 (33.3 percent) of the 48 renally impaired patients to the point where dose adjustments would no longer be required. Of

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these 16 patients, only 5 received dose adjustments based on their initial creatinine clearance, and 2 of these 5 patient’s doses were readjusted to normal following their improvement in renal function.

Conclusions: A significant number of patients required dose adjustments of enoxaparin for renal impairment (12.5 percent) and obesity (17.2 percent). The collaborative practice agreement increases P&T guideline adherence in patients with renal impairment; however, there is room for improvement. Education of pharmacy staff may be of value. The P&T Committee may reconsider the addition of obesity dosing to the collaborative practice agreement.

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Author: Georgia, Galanou, Luchen, PharmD Candidate 2017, University of Kansas School of Pharmacy, student. Manpreet, Kaur, PharmD Candidate 2017, University of Kansas School of Pharmacy, student. Brittany, Lee, Melton, PharmD, Ph.D., University of Kansas School of Pharmacy - Pharmacy Practice Assistant Professor. Karen, Elizabeth, Moeller, PharmD, University of Kansas School of Pharmacy - Pharmacy Practice Clinical Associate Professor. University of Kansas

Title: Evaluation of sleep agent use for the treatment of insomnia in suicidal patients

Purpose: Insomnia has been linked to suicidal thoughts and behaviors. As a result, it has been theorized that effectively treating insomnia can potentially lead to a reduction in suicidal risk. This study sought to evaluate the prescribing patterns for sleep medications in the adult psychiatric unit between suicidal and non-suicidal patients. 2. Methods: A retrospective chart review was conducted for patients admitted to the adult psychiatric unit of a Midwestern academic hospital between July 1st, 2014 and June 30th, 2015. Patients were identified through the Healthcare Enterprise Repository for Ontological Narration (HERON) database. Patients were included in the study if they were 18 years of age or older, and had a length of stay between 2 and 14 days. Data collected were compared between suicidal and non-suicidal patients, and included: patient demographics, suicidal attempts, behaviors or ideation, primary discharge diagnosis, and the number and class of sleep medications patients received prior to admission, during admission and at discharge. Data analysis was conducted using SPSS v.23. Chi-square was utilized to assess differences in race, diagnosis, gender, and medication class, while independent t-tests were used to assess differences in length of stay, age, and number of medications, between suicidal and non-suicidal patients with an a-priori a=0.05. The institutional review board at the University of Kansas Medical Center approved the study. Results: Four hundred and fifteen patients met the inclusion criteria for this study, of which 262 (63.1%) had an admission for suicidal ideations or behaviors. Demographics for suicidal and non-suicidal groups varied significantly for race (71.8% vs 60.1% white for suicidal and non-suicidal, respectively; p=0.02), and length of stay (6.43 days vs 4.87 days; p <0.01, suicidal and non-suicidal, respectively). Suicidal patients were more likely to have a primary diagnosis for mood or anxiety disorders (p<0.01, 0.04, respectively), while non-suicidal patients were more likely to have a thought disorder primary diagnosis (p<0.01). The most commonly prescribed sleep agents amongst all patients during hospitalization were sedating antidepressants (69.1% in suicidal and 64.1% in non-suicidal patients), benzodiazepines (31.3% and 39.9% respectively), and sedating antihistamines (24% and 22.9%, respectively). In both groups, the number of medications received at discharge was larger than the number received prior to admission (0.85 vs 0.43 for suicidal, and 0.66 vs 0.36 for non-suicidal; p<0.01 for both groups). Upon discharge suicidal patients were prescribed a larger number of sleep agents than non-suicidal patients (0.85 vs 0.66; p <0.01), and class-wise received a greater number of sedative antipsychotics (7.3% vs 2.6%; p=0.046).

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Conclusions: Overall, use of sleep medications was similar between suicidal and non-suicidal patients during hospitalization. However, suicidal patients were more likely to continue on their sleep medication at discharge. This may suggest suicidal patients’ insomnia symptoms were more prevalent or severe during hospitalization and required on-going treatment. Regardless of suicidal status, patients on average received more than one sleep agent during admission and were prescribed significantly more sleep medications upon discharge than prior to admission. Further studies are required to evaluate the effectiveness of sleep medications in suicidal patients and their potential in decreasing suicidal risk.

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Author: Ryan Donald Fleer, PharmD Heidi Marie Calvin, PharmD, BCPS AQ-ID Rudd Hetrick, PharmD, BCPS Ma Chu, PharmD Candidate 2017 Glenn Mackay, MD Dr. Fleer, Dr. Calvin, Dr. Hetrick, and Dr. Mackay are employed by Shawnee Mission Medical Center. Ms. Chu is a current pharmacy student at the University of Missouri-Kansas City Shawnee Mission Medical Center

Title: Implementation of a targeted antimicrobial stewardship program designed to minimize fluoroquinolone use in a community hospital

Purpose: Fluoroquinolones are among the most popular antibiotics used by prescribers in the United States. Their broad spectrum of bactericidal activity makes them highly effective against a variety of gram positive and negative organisms. While highly effective, fluoroquinolones are not without consequences; a recent FDA safety communication broadened the boxed warning, advising providers to reserve fluoroquinolones for more serious infections due to potentially permanent adverse effects associated with the antibiotic class. Similarly, concerns have arisen due to increased resistance of Escherichia coli and Pseudomonas aeruginosa. Prior studies have observed increased susceptibility to fluoroquinolones following implementation of antimicrobial restriction programs. Methods: This is an ongoing retrospective cohort study conducted at Shawnee Mission Medical Center in Shawnee Mission, KS. The study will be submitted to the hospital Institutional Review Board for approval. An antimicrobial stewardship protocol designed to limit empiric fluoroquinolone therapy was implemented in October 2016. This protocol was developed based upon both IDSA guidelines and input from the clinical infectious diseases pharmacist and physicians; it will function as a guideline for appropriate fluoroquinolone alternatives. Following development, this protocol was distributed hospital-wide, and utilization was encouraged via recommendations made by the clinical pharmacy staff. Treatment groups will include 100 patients randomly selected before and after protocol implementation (November 2015 to March 2016 and November 2016 to March 2017, respectively) using an AB number generator. Patients will be included if they received any antibiotic as empiric therapy, defined as initial treatment for any infection prior to availability of antimicrobial sensitivities. Primary outcomes will include the number of inpatient days of fluoroquinolone therapy/1000 patient days, in addition to the number of Emergency Room (ER) prescriptions/100 ER visits. Secondary outcomes include appropriateness of antibiotic selection, as determined by IDSA guidelines, and hospital seven-day readmission rates. Chi-square tests will be used for nominal data, and a t-test or Mann Whitney-U test will be used for continuous data as appropriate.

Results: N/A

Conclusions: N/A

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Author: Michael Starling, PharmD, MBA, BCPS; Jeff Little, PharmD, MPH, BCPS, FACHE Saint Luke's Hospital

Title: Optimizing medication distribution through use of EHR medication messages

Purpose: Pharmacy is frequently contacted for questions regarding medication dispensing and distribution of patient doses. The vast majority of patient doses are dispensed and distributed in accordance with pharmacy workflow. However, unanticipated difficulties do occur, resulting in unintended stock-outs of unit based automated dispensing cabinets and misplacement of delivered medications. This quality improvement project is designed to improve the medication use process. Methods: Recently, Saint Luke’s implemented “missing dose” medication messages within the electronic health record to enhance nursing communication to pharmacy regarding missing medications. This communication allows the pharmacy to prioritize these medication requests and distinguish them from medication refills which are sent via the “request dose” message, and also allows for aggregation of missing dose data to look for trends and investigate possible solutions. The purpose of this quality improvement (QI) project is to improve internal processes regarding pharmacy medication distribution at Saint Luke’s Hospital. This project aims to improve pharmacy medication distribution by obtaining data generated by the use of these medication messages, analyzing trends, and making process improvements. We will look to identify trends based on medication, hospital unit or period of day. We will then look to make changes based on identified trends and improve the medication use process, medication distribution workflow, and ultimately decrease the frequency of missing medications.

Results: Research in Progress

Conclusions: Research in Progress

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Author: Ashley Austin, PharmD PGY2 Critical Care Pharmacy Resident, The University of Kansas Health System; Jace Knutson, PharmD, BCPS, BCCCP Critical Care Pharmacist, The University of Kansas Health System; Lyndsey Ruiz PharmD Critical Care Pharmacist, The University of Kansas Health System The University of Kansas Health System

Title: Secondary Infection Risk with Stress Ulcer Prophylaxis in Patients Naive to Acid Suppression

Purpose: Physiological stress in critically ill patients may lead to gastrointestinal mucosal damage. A histamine-2 receptor antagonist (H2RA) or proton pump inhibitor (PPI) are recommended agents for stress ulcer prophylaxis (SUP); however, concerns regarding the development of hospital acquired Clostridium difficile infection (CDI) and pneumonia with use of these agents have emerged. This study investigated if use of a PPI led to increased risk of these secondary infections compared to a H2RA in patients not receiving prior acid suppression. Methods We performed a retrospective, cohort review of hospital acquired CDI and pneumonia in critically ill patients receiving either a H2RA or PPI from January 2014 to December 2015. Secondary infections were identified by medical coding and confirmed via chart review. Patients that received these agents prior to admission or received both classes during admission were excluded. A total of 13,720 patients received SUP during the study period, split nearly even between groups. To approximate a total acid suppression naïve population, 1,000 of these patients were evaluated for prior to admission use and the percentages were extrapolated to represent a total population for risk analysis. The review estimated that 60% of patients were not on a PPI and 92% of patients were not on a H2RA prior to admission, leaving 4,123 and 6,294 patients per respective group. Results: A total of 79 patients with secondary infections were included in the analysis (46 PPI and 33 H2RA). Baseline characteristics were similar between groups, including antibiotic exposure in CDI patients. Secondary CDI occurred in 21 PPI and 13 H2RA patients. Secondary pneumonia occurred in 29 PPI and 21 H2RA patients. The risk of secondary CDI (RR 1.56; 95 CI, 1.10-1.96) and pneumonia (RR 1.47; 95 CI, 1.09-1.81) was greater in the PPI group. Conclusions: Use of a PPI may be associated with a greater risk of CDI and pneumonia when compared with a H2RA in patients previously naïve to acid suppression. These findings support the use of a H2RA over a PPI for SUP in absence of other deciding factors.

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Original Presentation #1

Author: Andrew Spurgin, Pharm.D., Pharmacy Resident, Children's Mercy Hospital Claire Elson, Pharm.D. BCPPS, Clinical Pharmacy Specialist, Children's Mercy Hospital Jennifer Goldman, MD, Infectious Disease Physician, Children's Mercy Hospital Sarah Suppes, Pharm.D, Clinical Pharmacy Specialist, Children's Mercy Hospital

Title: A characterization of adverse drug reactions in pediatric patients with cystic fibrosis

Purpose: Cystic fibrosis (CF) is an autosomal recessive genetic disorder affecting the functionality of a chloride transport channel called cystic fibrosis transmembrane conductance regulator (CFTR). This deficiency results in a net flow of water away from the epithelial surface, and thickening secretions throughout the body. While multiple organs are impacted, lung disease is the primary cause of mortality in patients with CF. Lung disease is multifactorial caused by chronic inflammation, pulmonary obstruction and chronic bacterial colonization and infection of the lungs. Treatment of these pulmonary infections consists of extended courses of both intravenous and orally administered antibiotics. The primary objective of this research study is to characterize the incidence of adverse drug reactions (ADRs) in pediatric patients with CF who received their care at Children’s Mercy Kansas City Cystic Fibrosis Center. Secondary objectives include determining the impact of age on development of adverse drug reactions, as well as analyzing the economic impact imposed on patients with documented adverse drug reactions due to changes in provider’s prescription patterns. Methods: A retrospective chart review of all patients receiving care at Children’s Mercy Kansas City Cystic Fibrosis Center as of August 31, 2016 was conducted. The project was approved by the IRB at Children’s Mercy Hospital (CMH). Patients were included if they were aged 0-21, had a diagnosis of CF, received healthcare and follow-up for CF at the CMH Kansas City Cystic Fibrosis Center, and had least one hospital admission or clinic visit at CMH between September 1, 2013 and August 31, 2016. Data collected included patient demographics; ADR information (reaction, offending agent, date of reaction, Naranjo score, if available); forced expiratory volume at one second as percent predicted (FEV1%) at time of ADR, at study start, and at study end; oral antibiotics prescribed post-ADR (drug and duration of therapy); and microbiology culture and susceptibilities within 90 days of antibiotic prescription (using most recent culture).

Results: Research in progress.

Conclusions: Research in progress.

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Author: Monica K. Rauch, PharmD PGY1 Pharmacy Resident Kansas City VA Medical Center Amy D. Cummings, PharmD, BCACP Clinical Pharmacist Kansas City VA Medical Center Elizabeth Eickman, PharmD, BCACP Clinical Pharmacist Kansas City VA Medical Center Kansas City VA Medical Center

Title: Clinical Pharmacists Impact on Reducing the Risk of Hypoglycemic Events Amongst at Risk Elderly Diabetic Patients

Purpose: In response to the US Department of Health and Human Services (HHS) identification of hypoglycemia as a national health problem, the Department of Veterans Affairs’ launched a National Hypoglycemic Safety Initiative (HSI). As one in four veterans within the Veterans Health Administration Health System have diabetes, this initiative was designed to greatly impact patient care through enhancing personalized goals and lower the risk of hypoglycemic events. The purpose of this study is to identify the impact patient aligned care team (PACT) pharmacists have on reducing the risk of hypoglycemic events amongst elderly diabetic patients. Methods: Patients at risk for hypoglycemia were identified through the national HIS dashboard based on risk factors including advanced age, renal dysfunction, cognitive impairment, most recent A1c and medications prescribed. Clinical pharmacists reviewed patient charts and contacted patients to further assess risk factors and occurrence of hypoglycemic events. Medication therapy adjustments were made by pharmacists when indicated during the patient encounters. Data was collected regarding frequency of hypoglycemic events, risk factors, diabetic knowledge, therapy satisfaction and PACT pharmacists’ interventions. The primary outcome of this study is to identify the impact clinical pharmacists have on reducing the number of elderly patients at risk for hypoglycemia through modification of risk factors as identified by the HSI dashboard. Secondary outcomes include the quantity and nature of pharmacist interventions and analysis of cost savings resulting from pharmacist interventions. Descriptive statistics will be used to illustrate data.



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Author: Laura Prohaska, PharmD, Pharmacy Resident, The University of Kansas Hospital; Erica Hochard, PharmD, BCOP, Pharmacist, The University of Kansas Hospital; Ellen Burke, PharmD, Pharmacist, The University of Kansas Hospital; Dennis Grauer, PhD, MS, Pharmacy Practice Professor, The University of Kansas School of Pharmacy; David Henry, MS, BCOP, FASHP, Pharmacy Practice Professor, The University of Kansas School of Pharmacy; Michelle Rockey, PharmD, BCOP, Pharmacist, The University of Kansas Hospital; Prakash Neupane, MD, Physician, The University of Kansas Hospital The University of Kansas Hospital

Title: Management of Pemetrexed-Associated Toxicities

Purpose: Pemetrexed is indicated for the treatment of nonsquamous non-small cell lung cancer (NSCLC) and malignant pleural mesothelioma (MPM). The rate of pemetrexed-induced cutaneous reactions, including rash and edema, ranges from approximately 14-37% despite recommended dexamethasone pretreatment started the day prior to pemetrexed. In previous small retrospective analyses, no correlation was observed between the incidence of rash in patients receiving only one day versus three days of dexamethasone pretreatment. Furthermore, the incidence of severe neutropenia was not increased in a previous study of patients initiated on folic acid and cyanocobalamin supplementation less than 24 hours prior to first pemetrexed dose. At the University of Kansas Hospital (TUKH), many NSCLC and MPM patients receive a single dexamethasone dose and cyanocobalamin injection the day of pemetrexed treatment. Our study aims to further explore the impact of shortened pretreatment and supportive care schedules on the incidence of cutaneous reactions and hematologic toxicities in patients who receive pemetrexed. The primary objective was to compare the incidence of pemetrexed-induced cutaneous reactions in NSCLC and MPM patients who received a single dose of dexamethasone prior to pemetrexed with a historical cohort of patients who received standard dexamethasone pretreatment. A secondary objective included characterization of hematologic toxicities in patients who received first doses of cyanocobalamin injection and folic acid the same day as first pemetrexed treatment. Methods A retrospective, single center chart review was performed of NSCLC and MPM patients who received pemetrexed at TUKH from 1/1/2011 to 9/30/2016 and compared to a historical cohort pemetrexed treatment arm. Results: A total of fifty-five patients met inclusion criteria. Four patients (7.27%) experienced rash after receiving single dose dexamethasone pretreatment prior to pemetrexed compared to 14% in the historical cohort (p=0.151). A significant increase in edema (23.6 % vs 4.5%, p<0.001) was observed in the single dose dexamethasone group. No significant differences were observed between our study and the historical cohort in regards to febrile neutropenia (5.4% vs. 1.9%, p=0.183) or grade III/IV neutropenia (10.8% vs. 5.3%, p=0.184).

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Conclusions: The results of this study suggest that single dose dexamethasone pretreatment does not impact the rate of rash in pemetrexed patients. The increased rate of edema in this study was found to be statistically significant but the clinical significance remains unknown. Initiation of cyanocobalamin supplementation on the first day of pemetrexed treatment does not appear to impact the occurrence of neutropenic events.

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Author: Stephanie Duehlmeyer, PharmD, Children's Mercy Hospital Christopher Klockau, PharmD, BCOP, Children's Mercy Hospital Ashley Duty, PharmD, MS, Children's Mercy Hospital Children's Mercy Hospital

Title: Rasburicase utilization at an academic pediatric hospital

Purpose: The purpose of this study is to evaluate the adherence to the current Children’s Mercy Hospital (CMH) guideline for rasburicase use. Children’s Mercy Inpatient Pharmacy spent approximately $27,000 on doses of rasburicase dispensed in the last year. Identifying and characterizing patients receiving rasburicase will allow for determination if the clinical practice guideline is being utilized. Adherence to the guideline will provide insight into future areas of cost reduction. Methods: This study has been submitted and approved with the Institutional Review board. This is a retrospective chart review of patients who received rasburicase at Children’s Mercy Hospital between July 1st, 2012 and July 30th, 2016. The data was analyzed using descriptive statistics (mean, median, and range) to characterize the information collected.

Results: Of the 21 patients included, 62% were male, the majority had a diagnosis of acute lymphoblastic leukemia. Adherence to the CMH rasburicase guideline was done 26% of the time, while 74% were non-adherent. Common instances of non-adherence to the guideline included the patient not receiving IV hydration and/or allopurinol for 12 hours prior to the rasburicase dose, along with patients only have a serum uric acid > 8 mg/dL or a serum creatinine of > 1.5 x ULN, but not both.

Conclusions: The data collected and analyzed for this medication use evaluation demonstrates that the orders for rasburicase are not always in adherence to the CMH criteria for use.

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Author: Alexander Milligan, Pharm.D Children’s Mercy Hospital Diana Yu, Pharm.D, BCPS-AQ ID Clinical Specialist, Infectious Disease Children’s Mercy Hospital Claire Elson, Pharm.D, BCPPS Clinical Specialist, Cystic Fibrosis/ Pulmonology Children’s Mercy Hospital Children's Mercy Hosptial

Title: Utilization of nebulized antibiotics at Children's Mercy Hospital

Purpose: Tobramycin and aztreonam are the only FDA indicated nebulized antimicrobials. Additionally, they are only approved in the cystic fibrosis (CF) patient population for eradication and chronic utilization, leading to increased off-label use of these agents and other antimicrobials. By characterizing the use of nebulized antimicrobials, we will be able to determine the patient populations associated with their use, the frequency of their use, and the associated indications of their use. Methods This study has been approved by the Institutional Review Board. A query of inpatient nebulized antibiotic orders was performed to generate a list of potential candidates. The following data was collected: patient age, gender, ethnicity, allergies, nebulized antibiotic name, order sentence and comments, and duration of therapy. A chart review was performed to extract the following data: Pertinent past medical history, prescribing service, indication for nebulized antibiotic, concurrent systemic antibiotics, and documented adverse drug reactions to the prescribed nebulized antibiotic (e.g. bronchospasm, anaphylaxis). All data will be recorded without patient identifiers and maintained confidentially. Data was analyzed to determine if a quality improvement plan is warranted at our institution. Results Over 60% of orders for nebulized antibiotics were utilized for non-FDA approved indications. About 90% of patients treated for ventilator-associated infections had a past medical history significant for chronic ventilation. The pediatric intensive care unit uses nebulized antibiotics frequently for the treatment of ventilator-associated infections (VAI). A total of 28 patients with a diagnosis of CF received nebulized antibiotics without a FDA approved indication (i.e., vancomycin, colistimethate).VAIs had a mean treatment duration of 5.5 days. At CMH, tracheitis is treated for a standard of 5 days, while ventilator-associated pneumonia is treated for a standard of 8 days. Most VAI patients were chronically ventilated and had a tracheostomy, which helps explain this treatment duration. Out of the 85 off-label use, 14 patients received nebulized antibiotics alone, which is inappropriate. Conclusions: Nebulized antibiotics are frequently used off-label in the pediatric population (e.g VAI). Nebulized antibiotics should not be utilized as monotherapy for the treatment of pulmonary infections, which is a main area of concern. The results of this study will help guide us in creating a policy for improving the utilization of nebulized antibiotics at CMH.

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Author: Melissa Ruddle, Pharm.D., BCPS Jacoob Michalski, Pharm.D., BCPS Kimberly Day, Pharm.D. Saint Luke's Hospital

Title: Evaluation of a gentamicin dosing protocol in the neonatal intensive care unit (NICU)

Purpose: Gentamicin is commonly used in the NICU. Various dosing strategies are available and based on gestational age, post-natal age, weight, post-menstrual age or a combination. Our health-system has used a dosing protocol that used weight categories to determine dosing and designed to achieve a trough below 2 mcg/mL. More recent literature recommends a trough below 1 mcg/mL. In January 2016, we modified the gentamicin protocol to reflect dosing provided in NeoFax. The purpose of this study is to compare how often target drug levels are achieved comparing our original neonatal gentamicin dosing protocol and the newly adopted empiric dosing strategy. Methods: This study will be performed in a total of four NICUs, one level II, two level IIIa and one level IIIb NICU, all within our health-system. This study was approved by the Institutional Review Board as a quality improvement project. All patients admitted to the NICU during the study period who had both a gentamicin trough and peak plasma level drawn will be included in the study. Patients will be excluded if their levels were not obtained in timing with our guideline and could not be extrapolated using Sawchck-Zaske kinetics. Subjects will be identified in retrospective fashion using a reporting function in the electronic medical record. Demographics, gentamicin dosing specifics, culture results, lab results and clinical disposition will be collected through the electronic medical record. This study will look at target drug level attainment comparing our original gentamicin protocol to the new dosing protocol. The goal trough is below 1 mcg/mL and the goal peak is 5-12 mcg/mL, depending on the organisim’s reported minimum inhibitory concentration when known . Secondary endpoints include the incidence of nephrotoxicty, ototoxicity and clinical cure rate defined as microbial clearance in repeat cultures, stabilization of leukocytes, and/or provider’s assessment of infectious resolution.

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Author: Yunhsuan Patricia Hoover, PharmD PGY-1 Pharmacy Resident Olathe Health; Amber J. Lucas, PharmD, BCPS, FASHP Clinical Pharmacist, Neonatology, Obstetrics and Cardiology PGY-1 Women’s and Children’s Health Preceptor Olathe Medical Center Olathe Health Center

Title: Evaluation of pharmacists’ clinical interventions at a community hospital

Purpose: Heath care payments are increasingly tied to quality and value-based care. The pay-for-performance model requires measurable health quality and outcomes. Pharmacists provide clinical services and medication interventions on a daily basis through approved protocols, medical staff consults, and pharmacist-identified medication-related issues. Some examples of interventions include: pharmacovigilance in medication safety, therapy optimization, pharmacokinetic consultations, formulary management, treatment monitoring, and patient counseling. The objective of this study is to quantify clinical interventions performed by pharmacists and assess their potential impact on patient care in a community hospital. Methods Pharmacists at a community hospital document their clinical interventions in the electronic medical record system through their normal course of daily activity. The following data are documented: types of intervention, initiator of the clinical intervention, associated medication order(s), the prescriber, prescriber's response, clinical significance of the intervention, patient outcome, pharmacist intervention time, and any additional information provided by the pharmacists. For the purpose of this study, the electronic reporting system will identify all pharmacist clinical interventions documented between November 2016 and February 2017. In addition, the study investigators will collect the patient census each month. The study investigators will further calculate provider acceptance rate of recommendations, pharmacist time per intervention, and number of pharmacist-led intervention(s) per patient. Based on results of other similar studies, the investigators will then quantify cost-savings and cost-avoidance of pharmacist interventions. All information will be recorded without patient identifiers and with patient confidentiality maintained. Results: Research in Progress Conclusions: Research in Progress

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Author: Angelika Cyganska, Pharm.D. Midwestern University Chicago College of Pharmacy Position and place of employment: PGY1 Pharmacy Practice Resident at Saint Luke's Hospital of Kansas City Joseph Blunck, Pharm.D., BCPS University of Wisconsin Position and place of employment: Clinical Pharmacist at Saint Luke's Hospital of Kansas City Scott Aldridge, Pharm.D., BCPS University of Missouri-Kansas City Position and place of employment: Clinical Pharmacist at Saint Luke's Hospital of Kansas City

Title: Fixed versus variable dosing of 4-factor prothrombin complex concentrate for warfarin reversal of non-intracranial bleeding

Purpose: Kcentra® is a four factor prothrombin complex concentrate (4F-PCC) used for vitamin K antagonist reversal in patients with acute major bleeding or the need for urgent surgery. Since the approval of this product, there have been multiple studies assessing the safety and efficacy of a lower fixed-dose of 4F-PCC that have resulted in similar clinical outcomes as compared to the variable dosing regimen, with a significant cost reduction. The purpose of this study is to evaluate a process change regarding Kcentra dosing at Saint Luke’s Health System. Previously at this institution, Kcentra was dosed following weight-based dosing dependent on initial INR. On the basis of experience at other institutions and previous studies, Saint Luke’s Health System has implemented a fixed 4F-PCC dosing protocol in January 2017. The aim is to evaluate the effectiveness and safety of the new dosing protocol and affirm that clinical outcomes are similar to those after variable dosing, with significant cost savings. Methods Retrospective data was collected to assess the cost effectiveness of a lower fixed-dose protocol. A patient list was obtained from the blood bank of patients who had received Kcentra at Saint Luke’s Health System over three years. Chart checks were done to identify non-intracranial bleeds specifically associated with warfarin. Data was collected from all patients who met inclusion criteria and who received Kcentra during that time period. Baseline data collected includes the indication for reversal, baseline and post-infusion INR, the dose of Kcentra received, and the administration of other blood products. Kcentra dispensing was moved from the blood bank to the pharmacy at Saint Luke’s Health System starting in January 2017. Data was collected from eligible patients starting January 1, 2017 after implementation of the fixed dose protocol. Following Saint Luke’s Health System order sets upon presentation with a warfarin-related acute bleed, patients receive Vitamin K and an appropriate dose of Kcentra following the protocol flowsheet. Patients receive a fixed dose of either 1,000 or 1,500 units based on initial INR. Patients with an initial INR of 2-3.9 receive 1,000 units of Kcentra. Patients with an initial INR of 4.0 and higher, or patients with an unknown INR, receive 1,500 units. An INR is drawn 30 minutes after infusion and determines whether a second dose of Kcentra will be given. Physicians also assess any clinical signs or symptoms of bleeding and use clinical judgment to determine the need for a second dose. Patients of interest are those who are eligible to receive the new dosing regimen, which include patients aged 18 years or older presenting with warfarin-related non-intracranial bleed or the need for urgent procedure. Factors that preclude patients from receiving Kcentra include pregnancy, history of heparin induced thrombocytopenia, disseminated intravascular coagulation, intracranial hemorrhage, and bleeding caused by any agent other than warfarin. Collected data points include

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indication for anticoagulation, indication for reversal, concomitant antiplatelet or NSAID use, dose of Kcentra, baseline and post infusion INR, clinical success in cessation of bleeding as determined by physician, and the need for a second dose. Results: Research in Progress Conclusions: Research in Progress

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Author: Nick Bennett, PharmD, BCPS, Saint Luke's Hospital Sarah Boyd, MD, Saint Luke's Hospital Cindy Essmeyer, MD, Saint Luke's Hospital Andrew Warnes, MHSA Donna Buchanan, PhD Saint Luke's Hospital

Title: Impact of an integrated approach to antimicrobial stewardship with rapid diagnostics in a multi-hospital health system

Purpose: Antimicrobial overuse significantly burdens health care systems, accentuating the value of antimicrobial stewardship programs. In 2015, the Antimicrobial Stewardship Program (ASP) was launched at Saint Luke’s Health System (SLHS) concurrently with two new rapid diagnostic microbiology technologies which dramatically decrease time from culture collection to pathogen identification (ID). The aim of this study is to determine if integrating ASP personnel with rapid ID technologies results in improved outcomes for patients who had positive blood cultures during their hospitalization. Methods: The study was supported through the SLHS Innovation Center and was deemed exempt by the Investigational Review Board. Previously, microbiology staff would call positive blood culture results to the floor nurse, who then contacted the attending physician. Starting in June 2016, microbiology staff now communicate positive blood culture results to an ASP member or other SLHS pharmacist, who then interprets the results, analyzes local antibiograms, assesses patient-specific information and subsequently relays that information to the appropriate physician. The goal of this process change was to leverage the expertise of the ASP members or SLHS pharmacists to maximize outcomes for patients, streamline communication, and decrease unnecessary antimicrobial use. In addition, the process change minimizes nurse interruptions which allows them to devote more time to their patients. Outcome measures for patients after the start of this change will be compared to a pre-intervention group who had positive cultures between August-December in 2013 and 2014. Primary outcomes include time to appropriate therapy and optimal antimicrobial therapy. Secondary outcomes are numerous, but focus on clinical, process, and fiscal impacts of the updated blood culture communication process.


Conclusion: Research in progress.

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Author: Lance A. Pramann, PharmD, PGY1 Pharmacy Resident, KCVA Josh R. Howitt, PharmD, Inpatient Supervisor, KCVA Kansas City VA Medical Center

Title: Impact of Guideline Based Antiarrhythmic Menu on Selection and Monitoring of Pharmacologic Agents in an Inpatient Setting

Purpose: The American Heart Association, American College of Cardiology, Heart Rhythm Society, and Society of Thoracic Surgeons published guidelines for the management of a patient with atrial arrhythmias in 2014 with intent to optimize patient outcomes and improve patient care. These guidelines provide direction for practitioners in the selection and monitoring of pharmacologic agents for preventing atrial fibrillation and maintaining sinus rhythm. As there are no published recommendations for improving provider adherence to guidelines, the implementation of a guideline based order menu will be tested. The purpose of this study is to evaluate the impact of a computerized patient record system (CPRS) antiarrhythmic order menu on prescribing habits and compliance with current guideline recommendations. Providers utilizing the order menu will choose guideline directed antiarrhythmic medications and doses based on patient specific factors including, congestive heart failure, structural heart disease, hypertension, coronary heart disease, and renal function. Methods: The objectives will be assessed by comparing percentage of orders following guidelines, including selection of appropriate antiarrhythmic based on patient specific factors, correct renal dosing, and appropriate monitoring of QTc intervals and electrolyte values, pre- and post-order menu implementation.

Results: Research in progress

Conclusions: Research in progress

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Author: Elizabeth A. Ficek, Pharm.D., PGY2 Infectious Diseases Pharmacy Practice Resident, Kansas City VA Medical Center Jamie L. Guyear, Pharm.D., BCPS, AQ-ID, Clinical Pharmacy Specialist, ID/HIV, Kansas City VA Medical Center Kansas City VA Medical Center

Title: Implementation of Antibiotic Timeouts for Broad Spectrum Antimicrobial Agents at the Kansas City VA Medical Center

Purpose: An estimated 30 to 50% of all hospitalized patients receive antibiotics during the course of stay, but up to half of all antimicrobial use is inappropriate. Antibiotic overuse has long been associated with the emergence of multi-drug resistant organisms. Improving and optimizing antimicrobial use is a key strategy to slow the emergence of resistance. ‘Antibiotic timeouts’, or a formal review of antibiotics after 48 to 72 hours of treatment, is a strategy endorsed by the Centers for Disease Control and Prevention (CDC) in the Core Elements of Hospital Antibiotic Stewardship Programs in an effort to minimize inappropriate antibiotic use. The purpose of this study is to determine if implementation of a standardized antibiotic timeout after 48 hours of treatment with certain broad spectrum antibiotics leads to decreased utilization of these agents. Methods: Standardized antibiotic time-outs took place starting in October 2016. Patients with active orders for vancomycin, piperacillin/tazobactam, meropenem, and levofloxacin (IV and PO) for greater than 48 hours were reviewed a minimum of 3 times weekly by the Infectious Diseases Clinical Pharmacist or the PGY2 Infectious Diseases Pharmacy Resident. Recommendations for de-escalation were made based on patient specific characteristics and clinical judgment. Documentation of recommendations were made in the patient’s electronic medical record. For the above antibiotics, days of therapy (DOT) per 1,000 patient bed days and average DOT per patient were compared for a pre-intervention period of October 2015 – March 2016 to a post-intervention period of October 2016 – March 2017.

Results: Preliminary results comparing usage rates from October through December of 2015 to the same time period in 2016 show a decrease in DOT per 1,000 patient days for all four antibiotics (135 vs. 118 for vancomycin, 21 vs. 20 for meropenem, 94 vs. 65 for levofloxacin, and 115 vs. 101 for vancomycin). A decrease in average DOT per patient was seen for piperacillin/tazobactam (6 vs. 5 days). Average DOT per patient remained the same in the pre- and post-intervention period for vancomycin (5 vs. 5 days) and levofloxacin (5 vs. 5 days), and increased for meropenem (5 vs. 9 days).


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Author: Elizabeth Ann Bedel, PharmD Amy Danielle Cummings, PharmD, BCPS Patrick Montgomery Spoutz, PharmD, BCPS Kansas City Veterans Affairs Medical Center

Title: IMPROVING HYPERTENSION MANAGEMENT THROUGH POPULATION HEALTH STATISTICS: A TEAM APPROACH

Purpose: Purpose According to the CDC, only half of the 70 million American adults with high blood pressure have their hypertension controlled. Healthcare Effectiveness Data and Information Set (HEDIS) benchmarking tools demonstrate hypertension remains uncontrolled within the Veterans Affairs (VA) population. The use of multidisciplinary teams have been proven to be effective in lowering blood pressure. However, few studies have highlighted the use of a dashboard to improve hypertension control. The purpose of this quality improvement project is to determine if intervention of a pharmacist-driven multidisciplinary team and utilization of the Hypertension Dashboard are effective to decrease patients’ blood pressure in a rural setting. Methods The VISN 15 Hypertension Dashboard will be created and utilized to identify eligible veterans in one Patient Aligned Care Team (PACT) in a rural setting based on the HEDIS measure of age between 18 and 59 years old with a most recent systolic blood pressure of greater than 140 and/or diastolic greater than 90mmHg. Clinical pharmacists and physicians will initiate antihypertensive medications based on the VA Department of Defense Clinical Practice Guidelines for Management of Hypertension. Clinical pharmacists will educate the team licensed practical nurse (LPN), and registered nurse (RN) on proper blood pressure monitoring technique and non-medication interventions nurses can make to improve blood pressure control. The primary outcomes of this project and the evaluation thereof are to improve identification and treatment of patients with uncontrolled hypertension.



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Author: Lisa H. Phan, PharmD PGY1 Pharmacy Resident Olathe Medical Center 20333 W. 151st St Olathe, KS 66061 Jennifer M. McKenna, PharmD, BCPS Clinical Coordinator, Pharmacy Services PGY1 Pharmacy Residency Program Director Olathe Medical Center 20333 W. 151st St Olathe, KS 66061 Ann M. Spry, PharmD, BCPS Clinical Pharmacist, Critical Care PGY1 Pharmacy Residency Coordinator Olathe Medical Center 20333 W. 151st St Olathe, KS 66061 Nicole M. Wilson, PharmD Clinical Pharmacist, Infectious Diseases Antimicrobial Stewardship Program Coordinator Olathe Medical Center 20333 W. 151st St Olathe, KS 66061 Olathe Medical Center

Title: Pharmacist-driven intervention and duration of antimicrobial therapy for pneumonia at hospital discharge

Purpose: Purpose: Antimicrobial therapy in the outpatient setting and at transitions of care remains a largely unexplored area of opportunity for antimicrobial stewardship. Extended durations of therapy may compromise patient safety, contribute to the development of resistance, and increase healthcare costs. This study aims to optimize the duration of antibiotic therapy for pneumonia at hospital discharge through incorporation of focused pharmacist-driven interventions. Methods: This is a single pre-test post-test quasi-experimental study conducted at an acute care community hospital. Patients with a definitive diagnosis of pneumonia between December 1, 2015 through April 1, 2016 or December 1, 2016 through April 1, 2017 were considered for inclusion into the study. The primary endpoint is the proportion of patients in each group who received a total duration of antimicrobial therapy consistent with guideline or evidence-based recommendations. Secondary endpoints include the average duration of therapy, 30 day all-cause readmission, pharmacist intervention at or prior to discharge, and antibiotic days of therapy prevented by pharmacist intervention.



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Author: 1) Vivian Thuc-Anh Nguyen, PharmD U.S. Department of Veterans Affairs PGY1 Pharmacy Resident Kansas City VA Medical Center 2) Janelle Vittetoe, PharmD, BCACP U.S. Department of Veterans Affairs Clinical Pharmacy Specialist Kansas City VA Medical Center 3) Kyleigh Ryan Gould, PharmD U.S. Department of Veterans Affairs Clinical Pharmacy Specialist Kansas City VA Medical Center 4) Patrick Spoutz, PharmD, BCPS U.S. Department of Veterans Affairs Population Health Specialist VA Heartland Network (VISN 15) 5)Christopher Sedgwick, PharmD, BCPS U.S. Department of Veterans Affairs PGY2 Pharmacy Outcomes/Healthcare Analytics Resident, Kansas City VA Medical Center Kansas City VA Medical Center

Title: Pharmacist-Led Initiation of Statin Therapy in Veterans with Atherosclerotic Disease Using a Population Management Approach

Purpose: The use of statin medications in patients with atherosclerotic cardiovascular disease (ASCVD) has been proven to reduce all-cause mortality and subsequent cardiovascular events. However, statins remain underutilized for secondary prevention of ASCVD in veteran populations. Pharmacist-directed management programs are associated with increased provision of appropriate medication therapy for indicated populations to improve clinical outcomes. The purpose of this study is to characterize the influence of a pharmacist-directed initiative of identifying patients at the Kansas City VA Medical Center (KCVAMC) with history of ASCVD not currently being managed on statin therapy and initiating therapy when clinically appropriate. 2. Methods: The VISN 15 ASCVD Risk Reduction Panel Management Tool was used to identify eligible veterans whose primary care provider utilizes pharmacists to co-manage dyslipidemia. Four primary care providers were included and approximately 90 eligible patients were identified at baseline in November 2016. The electronic panel management tool was continually updated based on real-time data. Pharmacists initiated statin therapy adhering to the VA/Department of Defense Clinical Practice Guidelines for Management of Dyslipidemia and KCVAMC statin criteria for use. The intended goal is to reach approximately 80% of the identified eligible veterans by the end of March 2017 via telephone interventions. Patients initiated on statin therapy by pharmacist intervention continued to receive follow-up care by their primary care provider and PACT (patient aligned care team). The primary outcome is to determine the proportion of eligible veterans initiated on statin therapy. Additionally, the proportion of eligible veterans with statin intolerance or who refuse statin re-trial and prevalence of ASCVD type will be evaluated. Descriptive statistics will be used to illustrate data. Results: Research in Progress Conclusions: Research in Progress

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Student Presentation #1

Author: Katie Marie Rau, Student; University of Kansas School of Pharmacy Anna Cleland-Leighton, Student; University of Kansas School of Medicine Sarah Shrader, PharmD; University of Kansas School of Pharmacy Jana Zaudke, MD; University of Kansas School of Medicine University of Kansas Medical Center

Title: Incorporating the role of student co-directors to assist with the integration and assessment of behavioral health services into interprofessional team-based primary care

Purpose: Purpose: Interprofessional (IP) team-based health care is an important delivery model to improve healthcare quality. Offering students authentic interprofessional education (IPE) experiences in practice-based settings is important to train future healthcare professionals. In IPE and team-based healthcare, it is important to integrate behavioral health. While current data shows 20-40% of primary care patients have behavioral health needs, no information exists about using IPE to integrate behavioral health services into primary care. This study evaluated the role of initiating student co-director positions into a primary care practice model, called the Interprofessional Teaching Clinic (IPTC), and improvements in depression screening and patient outcomes. Methods: Four interprofessional students, including medical, pharmacy, occupational therapy, and doctoral clinical psychology, were selected for an extracurricular IPE experience as the IPTC student co-directors from May 2015-2016. The role of the student co-directors in this study was to guide and assist IP clinical rotation students with completion and documentation of depression screenings for patients receiving primary care in the IPTC. Student co-directors were available in clinic daily to provide assistance to IP students by guiding a huddle at the start of clinic and serving as a resource for maximum utilization of behavioral-health consultation and services. From January 1, 2015 through June 30, 2015, 493 patients were seen in the IPTC and provided outcomes for the baseline to six-month comparisons. A subset of 311 out of these 493 participants were seen again between July 1, 2015 and December 31, 2015, and provided outcomes for the six-month to twelve-month comparisons. Participants were screened annually for depression with a verbal administration of the Patient Health Questionnaire (PHQ) 2 and 9, documented in the electronic health record (EHR). A PHQ 2 score over 3 triggered administration of the PHQ 9 and consultation with clinical psychology students and preceptors. A positive PHQ9 triggered follow up and, when appropriate, a mood disorder diagnosis was documented in the EHR. A retrospective analysis was conducted and SAS software was used for statistical analysis.

Results: The mean age of patients in this cohort was 45.6 years old, the majority being female (75.7%) and private insurance holders (51.7%). Self-pay patients and Medicare and Medicaid holders were also represented. At baseline, the annual PHQ screening rate was 9.13% with a prevalence of depression at 22.5%. The baseline to six-month comparisons showed an increased depression screening rate with PHQ of 39.41% (+30.6%, p < 0.0001) and an increased prevalence of depression at 26.37% (+3.87%, p < 0.0001). The six-month to twelve-month comparisons showed a further increase of PHQ screening rate of 74.28% (+25.73%, p < 0.0001) and a further increase in prevalence of depression of 31.51% (+5.14%, p=0.1797). Overall, an increase of 56.33% from baseline was observed for patients who were screened

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annually for depression, and an overall increase of 9.01% was observed for depression prevalence within the IPTC.

Conclusions: The purpose of screening for depression annually in primary care settings is to provide appropriate treatment for otherwise undiagnosed depression. With the addition of the role of student co-directors within IPTC, the outcomes from integrating behavioral health within IPTC increased significantly within twelve months. This enhancement of behavioral health integration not only provided student co-directors with an opportunity to see the importance of psychology within an IP team-based primary care setting but also significantly improved the overall care of patients within this clinic.

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Author: Chenshan Zhou, Pharm.D. Candidate 2017, Megan Penner, Pharm.D. Candidate 2018, Jeff Pierce, Pharm.D., Heather Smith, CPhT, Patrick Parker, RPh MSP Lawrence Memorial Hospital

Title: Institution wide evaluation of medication overrides from automated medication dispensing cabinets after process improvement changes: One year later

Purpose: Overrides from medication dispensing cabinets are necessary for emergent and urgent patient care, but should be limited to ensure patient safety and drug security. It was found that there is little consensus across the region for standards of overrides. Lawrence Memorial Hospital (LMH) is a 176-bed community hospital using automated dispensing cabinets for the bulk of patient medications. LMH revised its medication override policy by limiting the overridden medications to those only approved by the institution as safe for emergent use. Limiting the number of medications should reduce the total number of overrides and improve patient safety.

Methods: A Plan-Do-Check-Act cycle was used for process improvement. A previous study provided the baseline for the cycle of improvement by providing definitions of appropriate and inappropriate overrides as well as a frequency of occurrence by nursing unit. Improvement plans included establishing a list of approved override medication approved by the Medication Use Team and the Pharmacy and Therapeutics committee and only allowing charge nurses access all of the institution’s formulary for emergency override. The available reasons for override include removing refrigerated med, Douglas Fire and Med, kits, medication order reviewed by qualified healthcare professional, urgent situation, and enter free text reason. Medication overrides were approved for emergency use for any product in the cabinet. Retrospective data review was collected from August 1, 2016 to August 15, 2016. The ratio of overrides to total doses removed was compared to the previous improvements and baseline project. The overrides were stratified by reason for override and nursing unit. Nursing unit data were stratified by “inappropriate” (if there was either no physician order, no pharmacist verification, or if they were assessed by the pharmacist as not meriting override) or “appropriate” (if all criteria were met). Overrides for supplies, kits, and refrigerator access to obtain IVs are also deemed appropriate so excluded from the total count because these are not a concern. Results: In the two week period examined, there were 275 (1.7%) overrides out of 15,940 removals (baseline 1079, 5%, overrides out of 21,645 removals). Overall, the number of medication overrides decreased as did the percentage of medication overrides compared to previous years after process improvement changes. Of these overrides, 190 (86%) were appropriate compared to a baseline of 858 (81%). Thus, only 30 (14%) were inappropriate compared to a baseline of 198 (19%). The number of data excluded increased from baseline of 23 to 55. All of the excluded data were due to no medication removal found, versus previous year’s data included both no medication removal found and incomplete patient information and thus inability to assess appropriateness of medication override removal. A chi squared test was used to evaluate statistical significance. We can be 93% confident that our changes are due to the process improvements.

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Conclusions: The process improvement changes of limiting the number of medications reduced the total number of overrides and improve patient safety. All overrides threaten patient safety by omitting safety parameters in place, such as avoidance of look-alike/sound-alike drugs and multiple drug strengths. Areas with less critically ill patients, such as internal medicine, had fewer overrides, compared to ICU, due to decreased emergent situations with the exception of LDR. The list of inappropriate medication overrides and the current list of appropriate medications for overrides will be presented to the Medication Use Team for assessment and further improvements.

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Author: Ellen Margaret Burke, PharmD; Clinical Pharmacist, University of Kansas Health System. Ashley Martin, PharmD Candidate 2017; Pharmacy Student, University of Kansas School of Pharmacy. Audrey Paige Claire Shamet, PharmD Candidate 2017; Pharmacy Student, University of Kansas School of Pharmacy. University of Kansas School of Pharmacy

Title: Assessment of Total Parenteral Nutrition Usage in Gynecologic Oncology Patients at an Academic Medical Center

Purpose: Purpose Total parenteral nutrition (TPN) is often used in gynecologic oncology patients due to the increased risk of malnutrition caused by direct effects of the cancer on the gastrointestinal tract, obstruction of the gastrointestinal tract by external compression or direct invasion, or by systemic effects that lead to anorexia. Indications for TPN use in perioperative gynecologic oncology patients include initiation 7-10 days preoperatively in a malnourished patient who cannot be fed enterally, patients with postoperative complications that prevent oral or enteral intake for more than 7-10 days, and patients with enterocutaneous fistula. The purpose of this study is to evaluate the appropriateness of TPN use in perioperative gynecologic oncology patients at the University of Kansas Hospital. If inappropriate use is identified, any potential cost savings and complications caused by TPN can be further evaluated. Methods A single center retrospective chart review will be conducted on gynecologic oncology patients who received TPN either perioperatively or due to loss of bowel function from November 2015 to November 2016 at the University of Kansas Hospital. Patients will be identified by reports available in the electronic medical record.

Results: Research in progress

Conclusions: Research in progress

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Author: Erin L. O'Grady, Pharm.D. Candidate. Pharmacy Student Intern- Olathe Medical Center Jennifer M. McKenna, Pharm.D., BCPS. Clinical Coordinator and PGY1 Pharmacy Residency Program Director- Olathe Medical Center Olathe Medical Center

Title: Evaluation of Cost Savings-Associated with an Ideal Body Weight Dosing Protocol for Intravenous Immune Globulin (IVIG)

Purpose: To determine the avoidance and reduction in IVIG expenditures with a dosing protocol using ideal body weight.

Methods: A retrospective review of all patients receiving IVIG during 2015 was conducted. A Powervision report from Cerner provided the list of patients that received IVIG in 2015 and the medical record was used to identify the IVIG dose administered, date of IVIG administration, brand of IVIG administered, actual body weight and ideal body weight. The total dose administered to the patient was divided by the patient’s actual body weight (ABW) to determine the weight-based dose. The weight-based dose was multiplied by the ideal body weight (IBW) to determine the amount of IVIG that would have been given had IBW been used. The difference in grams between the amount administered using ABW and the amount that would have been administered using IBW was calculated and multiplied by cost per gram of IVIG to obtain the cost avoidance using IBW. Results: Twenty-two patient charts were reviewed. One patient provided their own IVIG and was excluded. Fifteen patients received Flebogamma or Octagam, and 5 patients received Gammagard. In our study period, use of IBW would have resulted in 1522 fewer grams of IVIG dispensed and an estimated cost avoidance of $108,968. This is a 28% reduction in annual expenditures on IVIG. Conclusions: IVIG is a high cost, limited resource medication making its stewardship imperative. Larger doses of IVIG undergo a higher rate of catabolism and can elicit more adverse side effects, especially in obese patients. IVIG must be administered slowly, thus higher doses result in longer administration times and a higher cost of administration in the outpatient setting. Given the clinical support and financial motivation, a pharmacist-managed dosing protocol using IBW for all new IVIG orders was implemented. A follow-up evaluation is in progress to determine actual cost savings for 2017 as a result of the IBW dosing protocol.

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Author: David Williams, PharmD, BCPS, Saint Luke's Hospital, Clinical Pharmacist Specialist Saint Luke's Health-System

Title: Fluticasone Furoate/Vilanterol Use at a Regional Health System: Assessment of Wasted Doses

Purpose: To determine potential cost savings by examining dispensing patterns of fluticasone furoate/vilanterol 100/25 mcg inhalers.

Methods: A retrospective chart review of patients receiving fluticasone furoate/vilanterol 100/25 mcg inhalers was conducted at a regional academic health-system. Patients admitted after March 1, 2016 and discharged before June 30, 3016 were included. Information collected included patient encounter number, location of admission, and descriptive inhaler activity (verification, dispense, and administration events). Number of administrations were calculated for each dispensed inhaler. Costs associated with dispensed and wasted administrations were evaluated.



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2017 POSTER ABSTRACTS - Kansas Council of Health … Abstracts... · Regional Health Center Steven Wayne Blanner Doctor of Pharmacy, ... days • SMX/TMP 160/800 mg PO BID x 3 days