2017-2018 Houston Methodist Pharmacy Annual Report

HOUSTON METHODIST DEPARTMENT OF PHARMACY Annual Research Report | 2017–2018

2017 – 2018 HOUSTON METHODIST PHARMACY POSTGRADUATE TRAINEES Houston Methodist Department of Pharmacy The Department of Pharmacy collaborates with the health care team to provide innovative, personalized, cost-effective pharmaceutical care in a culture dedicated to safety and quality.

Houston Methodist Department of Pharmacy’s vision is to be recognized as a global leader of pharmaceutical care in the health care setting. To that end, we strive to: • Continuously improve the safety and quality of patient care and the medication management process • Cultivate an environment of collaboration and teamwork • Provide high-quality training and education to our technicians, student interns, residents, and pharmacists • Maximize the use of automation and information technology • Maximize cost efficiencies and resource utilization

TABLE OF CONTENTS

2 | Letter from Daniel L. Metzen, PharmD, MBA

3 | Letter from Alex C. Varkey, PharmD, MS, FAPhA

System Director of Pharmacy Services - Houston Methodist Director of Pharmacy Services — Houston Methodist Hospital

4 | Pharmacy Research Committee Members

5 | Letter from Joshua T. Swan, PharmD, MPH

Pharmacy Research Committee Chair

6 | Clinical Pharmacy Fellowship in Outcomes Research 7 | Pharmacy Research Funding

8 | Pharmacy Research Awards

1 0–31 | 2017–2018 Houston Methodist Hospital Pharmacy Postgraduate Trainees Class 10 | PGY1 Pharmacy Residency Krutina Garcia, PharmD Jesse Harris, PharmD Jade Hefler, PharmD Christine Pham, PharmD Isha Rana, PharmD Tracey Thomas, PharmD

16 | PGY1 International Graduates Pharmacy Residency

Godsfavour Umoru, PharmD Ai-Chen (Jane) Ho, PharmD, MSPH

18 | PGY1/PGY2 Health-System

Pharmacy Administration Residency Akeem Bale, PharmD Stella Kim, PharmD Sunny Bhakta, PharmD, MS Pei Jen Lin, PharmD, MS

22 | PGY2 Critical Care Pharmacy Residency Luma Succar, PharmD R. Christina Xia, PharmD

24 | PGY2 Infectious Diseases Pharmacy Residency

Mathew Mason, PharmD

25 | PGY2 Internal Medicine

Pharmacy Residency ianrui Yang, PharmD, BCPS T

26 | PGY2 Oncology Pharmacy Residency kim Ekinci, PharmD, MS E Jenna Solomon, PharmD

28 | PGY2 Solid Organ Transplant Pharmacy Residency

Y. Tracy Chen, PharmD, MBA, BCPS Meghann Davis, PharmD

28 | Clinical Pharmacy Fellowship in Outcomes Research

Lan Bui, PharmD, BCPS Elsie Rizk, PharmD

LETTER FROM THE SYSTEM DIRECTOR OF PHARMACY SERVICES ON BEHALF OF THE HOUSTON METHODIST DEPARTMENT OF PHARMACY, I would like to thank the members of the pharmacy team who contributed to the endeavors of the annual report as we seek to improve our knowledge and ability to provide unparalleled quality care for the patients we serve. The knowledge obtained through our medication outcomes research and economic research ultimately allows us the opportunity to optimize our patients’ medication therapy value (effectiveness, safety and cost). This dedication to excellence in patient care is a prominent characteristic within the pharmacy team. Thanks again to each and every one of you as we look forward to opportunities to grow our involvement in research.

Daniel L. Metzen, PharmD, MBA System Director of Pharmacy Services

System Pharmacy and HMH Department of Pharmacy Leadership

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LETTER FROM THE DIRECTOR OF PHARMACY SERVICES ON BEHALF OF THE HOUSTON METHODIST HOSPITAL (HMH) PHARMACY MANAGEMENT TEAM, I want to extend my sincere appreciation to all of our graduating residents. As another residency year comes to a close, I continue to be in awe of the growth demonstrated by everyone completing our pharmacy training programs. Our residents and fellows fully invest in their respective opportunities to grow both personally and professionally, and in the process, make a lasting impact on HMH Pharmacy’s effort to optimize patient outcomes.

The 2017-2018 residency year marked the 30th anniversary of pharmacy residency training at Houston Methodist Hospital. Over the last 30 years, our pharmacy training program portfolio has grown to include eight ASHP-Accredited Pharmacy Residencies and one Fellowship. We continue to make important advancements in pharmacy practice through the adoption of new technologies and through the interdisciplinary research efforts of many from the HMH Pharmacy Team. The crux of our research activity continues to reside in our pharmacy training programs, and it should go without saying that we are indebted to the hard work and dedication of our pharmacy learners, preceptors/practitioners, and support staff.

Among accomplishments in the 2017-2018 Residency Year: • Pharmacy investigators from across the Houston Methodist system received external funding for four research projects totaling more than $175,000 • Four research conference abstracts from our pharmacy residents and clinical pharmacists received recognition at national medical conferences • One of our pharmacy residents was appointed as a research liaison for an international pharmacy organization Each of these achievements took considerable commitment to take ownership of an immense amount of work. Our successes in research and scholarship are a true testament to HMH pharmacy’s commitment to working alongside other health care disciplines in advancing patient care.

At Houston Methodist, we take “Leading Medicine” seriously. I continue to be impressed with the quality of pharmacy’s efforts in growth and innovation, and I have our residents, fellows, and their preceptors to thank for most of that. We remain in position to develop and share innovative practices in part because of our Pharmacy Research Committee, a group dedicated to ensuring excellence in the quality and feasibility of research conducted by HMH pharmacy.

As we move ahead to the 2018 – 2019 residency year, we will continue with laser focus on what we do each and every day. That includes enhancing our medication distribution, clinical services, and regulatory/quality compliance efforts to provide an environment of unparalleled safety, quality, service, and innovation for our patients. With the opening of Walter Tower, we look forward to new challenges that come with expanding our reach, and the successes that come with patience, hard work, and the ability to adapt and innovate. No matter your role, you play an integral part in our department’s mission and remain the greatest reason for our success. I leave you with this quote:

“Always do your best. What you plant now, you will harvest later.”

– Og Mandino

Our patients always deserve our best – and it is the reason we all work so hard to develop safe and effective processes and practices from which our patients will benefit. Thanks for all that you have done and continue to do for patients.

Alex C. Varkey, PharmD, MS, FAPhA Director of Pharmacy Services

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PHARMACY RESEARCH COMMITTEE MEMBERS

Joshua T. Swan, PharmD, MPH, BCPS Chair

Jill C. Krisl, PharmD, BCPS Project Approval Lead

Michael Johnson, PhD External Statistician Consultant & University of Houston Collaboration Lead

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David R. Putney, PharmD, MPH, BCPS - AQ Cardiology Project Alignment Lead

Amaris Fuentes, PharmD, BCPS, BCCCP Visibility Lead

Katherine K. Perez, PharmD, BCPS-AQ ID Vice Chair – Project Development Lead

Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM Education Lead

Sara L. Varnado, PharmD, BCPS Houston Methodist Collaboration Lead

Engie Attia, PharmD, BCPS Member

A. Carmine Colavecchia, PharmD, MS, BCPS Project Support Lead

Samir J. Patel, PharmD, BCPS Member

LETTER FROM THE PHARMACY RESEARCH COMMITTEE CHAIR It is my honor and privilege to recognize the commitment of the 2017 – 2018 Pharmacy Research Committee members and to celebrate the research success of the Houston Methodist Pharmacy Department over the last year.

The mission of the Pharmacy Research Committee is to ensure excellence in the quality and feasibility of research conducted and the quality of research training provided by the Department of Pharmacy at Houston Methodist. In 2015 – 2016, the Pharmacy Research Committee developed four core programs to meet our mission: Project Approval, Project Alignment, Education, and Project Support. The Pharmacy Research Committee continued to build upon this success and created four additional programs starting in 2016 – 2017: Project Development, University of Houston Collaboration, Houston Methodist Collaboration, and Visibility. During 2017 – 2018, the Pharmacy Research Committee continued to maintain and optimize these programs. Some notable achievements throughout the year include: • In August 2017, the Houston Methodist Department of Pharmacy’s postgraduate training programming expanded to include a Clinical Pharmacy Fellowship in Outcomes Research. Two fellows were recruited into the new training program during the inaugural year.

• The University of Houston Collaboration was strengthened through the creation of an elective course titled “Practical Training in Hospital Clinical Research,” which introduces upper-level doctoral students to practical research training in active, ongoing, real world, multidisciplinary clinical research in a hospital setting I would like to formally thank all members of the Pharmacy Research Committee for their hard work, enthusiasm, perseverance, and dedication over the last year. I look forward to leading this amazing group in the future.

Joshua T. Swan, PharmD, MPH, BCPS Chair, Pharmacy Research Committee

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CLINICAL PHARMACY FELLOWSHIP IN OUTCOMES RESEARCH

The Houston Methodist Department of Pharmacy would like to officially welcome our newest training program, the Clinical Pharmacy Fellowship in Outcomes Research, under the direction of Joshua Swan, PharmD, MPH. The mission of this fellowship is to provide highly customized research training to clinical pharmacy fellows to support their development as independent clinical scientists. The fellowship will immerse the fellows in Swan’s research portfolio and will provide structured education and first-hand applied experiences in the topics of epidemiology, biostatistics, clinical pharmacology, and biomedical ethics/regulation. Two fellows were hired during the inaugural year of the fellowship program: Lan Bui, PharmD, BCPS in August 2017 and Elsie Rizk, PharmD in December 2017.

Broadly, the objective of the fellowship is to develop the fellow’s capacity to improve health care capacity by impacting large groups of patients through the following mechanisms: • Remove variation and streamline health care delivery processes in a health care setting • Identify medication use practices that are not safe and cost-efficient • Develop interventions and protocols that deliver medical care in a standardized fashion that is consistent with high-quality research • Develop evidence summaries and economic projections to support the medication formulary process in a hospital setting

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PHARMACY RESEARCH FUNDING Joshua T. Swan, PharmD, MPH, BCPS received a $35,000 award in the Ernest Cockrell, Jr. Scholar in Clinical and Translational Research Program that is part of Dr. Mauro Ferrari’s Ernest Cockrell, Jr. Presidential Distinguished Chair at the Houston Methodist Research Institute. This award was used to establish System Pharmacy’s new Clinical Pharmacy Fellowship in Outcomes Research training program.

Dr. Swan was awarded a $77,690 subaward from Vanderbilt University Medical Center to collaborate on the 6R01HL111111 grant from National Heart, Lung, and Blood Institute at the National Institutes of Health. This was the second year Houston Methodist Hospital was an active enrollment site for the Maximizing the Efficacy of Sedation and Reducing Neurological Dysfunction and Mortality in Septic Patients With Acute Respiratory Failure (MENDS II) clinical trial. This multicenter, randomized, clinical trial will compare dexmedetomidine versus propofol for the outcome of delirium-free, coma-free days among ventilated and critically ill adults with sepsis.

Dr. Swan was awarded $61,000 in research funding from VigiLanz Corporation to support a one-year Clinical Pharmacy Fellow in Outcomes Research position at Houston Methodist. This funding is being used to support the development of the Houston Methodist Opioid Stewardship Program that aims to optimize safe opioid use and pain management in the hospital and emergency department settings across Houston Methodist. The Houston Methodist Opioid Stewardship Team will collaborate with VigiLanz to develop tools that can help clinicians track opioid stewardship interventions in real time through alerts, reports and dashboards.

Ran Xu, PhD, PharmD, BCPS, BCCCP, Administrative Specialist at Houston Methodist The Woodlands Hospital, received a $2,500 Chester A. Bond Memorial Research Grant from the Texas Society of Health System Pharmacy for her project titled “Utilization of robotic-assisted video conferencing to extend pharmacists’ presence on patient care floors to provide transition of care clinical services in a newly opened community hospital.” This grant assists pharmacist practitioners in hospitals and health systems, students, and faculty pursue original research and worthwhile projects that result in improving health outcomes for Texans.

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PHARMACY RESEARCH AWARDS Ekim Ekinci, PharmD, MS, PGY2 Oncology Pharmacy Resident, was granted a Top 10 Trainee Award for her poster titled “Olanzapine versus fosaprepitant for chemotherapyinduced nausea and vomiting prophylaxis in patients receiving single-day high-dose melphalan” at the Hematology/Oncology Pharmacist Association Annual Conference in Denver, Colorado. This project was completed with her research team, James E. Cox, PharmD; Joe E. Ensor, PhD; Edward T. McLean, PharmD, BCOP; Carlos Ramos, MD; Premal D. Lulla, MD; Rammurti T. Kamble, MD; and George Carrum, MD. Ten posters were selected from almost 200 posters presented at the conference for recognition for trainee research for residents, fellows and students specializing in hematology/oncology.

Rafael Felippi, PharmD, BCPS, Pharmacy Clinical Specialist II at the Houston Methodist Physicians’ Alliance for Quality, was awarded a Platinum Award by DecisionHealth for Outstanding Achievement in Care Transitions – Medication Management for a project titled “Hospital automated calling program to identify and resolve post-discharge clinical and medication related issues during care transitions.” This project was completed with team members Theresa Pinn, RN; Ashlyn Proske; and Janice Finder, RN, MSN. The award recognizes programs that support patients’ and/or caregivers’ knowledge and ability to manage medications as determined in their plan of care.

Ai-Chen (Jane) Ho, PharmD, MSPH, PGY1 Pharmacy Resident – International Graduates Program, was named Pharmacy Practice Research liaison for the Young Pharmacists’ Group of the International Pharmaceutical Federation. The International Pharmaceutical Federation (FIP) is the largest international non-profit organization representing 4 million pharmacists and pharmaceutical scientists around the globe in 140 countries. The Pharmacy Practice Research group allows exchange of pharmacy practice research between senior researchers, early career researchers, postdoctoral fellows, pharmacist practitioners and PhD or MSc students in order to produce high quality evidence at an international level.

Samantha A. Kuten, PharmD, BCPS, Pharmacy Clinical Specialist II in Solid Organ Transplant, was given poster of distinction recognition at the 2017 American Transplant Congress in Chicago for her poster titled “Neurogenic orthostatic hypotension: an iatrogenic complication of successful pancreas transplantation?” This project was completed with team members Ericka Simpson, MD; A. Osama Gaber, MD; Duc T. Nguyen, PhD; Edward A Graviss, PhD; Samir Patel, PharmD, BCPS; and Richard Knight, MD. The American Transplant Congress recognizes research with review scores in the top 10 percent of their category as posters of distinction.

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PHARMACY RESEARCH AWARDS Christine Pham, PharmD, PGY1 Pharmacy Resident, received Best in Congress Poster recognition at the 2018 American Transplant Congress in Seattle, WA for her poster titled “Evaluation of vitamin D status on immune-mediated graft function at 1-year after kidney transplantation.” This project was completed with research team Brett Pierce, PharmD; Shweta Bapat; Samantha Kuten, PharmD; Linda Moore, MS; and A Osama Gaber, MD. Best in Congress Poster recognition is awarded to posters based on voting recognition by ATC attendees.

R. Christina Xia, PharmD, PGY2 Critical Care Pharmacy Resident, was granted the 2017 Alan I. Fields Award for practitioners with less than two years’ experience for her project titled “Evaluation of neuromuscular blockade reversal on postoperative outcomes in cardiovascular surgery.” This project was completed with her research team, Divina Tuazon, MD; Fariedeh Bostan, PharmD; and Amaris Fuentes, PharmD, BCPS, BCCCP. In addition to presenting her verbal abstract at the Society of Critical Care (SCCM) Annual Congress in San Antonio, Texas, the award provided a travel stipend for conference attendance.

In 2009, the Alan I. Fields Award was founded by the Texas Chapter of SCCM in recognition of Dr. Alan I. Field’s contributions to the Texas Chapter and his accomplishments in critical care medicine. The award is presented to members of the Texas Chapter for their high-quality research abstracts accepted at the SCCM Annual Congress. Two awards are given every year: one to a critical care trainee or practitioner with less than two years’ experience and one to a practitioner with two or more years’ experience. The Department of Pharmacy has a long standing history of Alan I. Fields Award winners. Previous winners include: 2010 Sapana Desai, PharmD, BCPS: “Nucleated Red Blood Cells are Associated with a Higher Mortality Rate in

Patients with Surgical Sepsis” 2012

Amaris Fuentes, PharmD, BCPS, BCCCP: “Comparison of Calculated versus Urine Measured Creatinine Clearance in the Critically Ill”

2014

Lan Bui, PharmD, BCPS: “Effect of Delirium Motoric Subtypes on ICD-9 Documentation of Delirium in the Intensive Care Unit”

2014 Joshua T. Swan, PharmD, MPH, BCPS: “Randomized Controlled Trial of Chlorhexidine vs. Soap & Water

Bathing for Prevention of Hospital Acquired Infections in the Surgical ICU” 2015

Joshua T. Swan, PharmD, MPH, BCPS: “Post-operative Acute Kidney Injury among Patients Admitted from the Emergency Room for Major Surgery”

2016 Amanda Holyk, PharmD: “Evaluating Outcomes of Poractant alfa vs. Calfactant in Neonates”

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Effectiveness of 4-factor prothrombin complex concentrate and vitamin K versus fresh frozen plasma and vitamin K in vitamin K antagonist-associated intracerebral hemorrhage Krutina Garcia, PharmD; Jonathan Balk, PharmD; A. Carmine Colavecchia, PharmD, PhD; John Volpi, MD; Shyam Panchal, MD; Sean Barber, MD; Niaz Deyhim, PharmD; Valerie Belden, PharmD PURPOSE

RESULTS

Warfarin is a commonly prescribed anticoagulant in the United States. Increased utilization of anticoagulants has led to an increased incidence of intracerebral hemorrhage (ICH). Agents administered for reversal include fresh frozen plasma (FFP), 4-factor prothrombin complex concentrate (4PCC), and vitamin K. The slow onset of vitamin K necessitates the usage of FFP or 4PCC. Limited evidence exists comparing the clinical outcomes of vitamin K and FFP versus vitamin K and 4PCC in warfarin-associated ICH. The purpose of the study was to evaluate the change in hematoma volume expansion and clinical effectiveness for patients exposed to FFP versus 4PCC.

Assessment of inclusion and exclusion criteria resulted in a total population of 29 patients: 14 FFP and 15 4PCC. Baseline demographics were similar between the FFP and 4PCC patients with the exception of the international normalized ratio (INR) prior to treatment. The median INR prior to treatment was 3.5 in the 4PCC group and 2.5 in the FFP group (p=0.04). The primary endpoint of hematoma volume expansion, neurological deterioration, or rebleed was found to occur in 50% of 4PCC and 46% of FFP patients (p=0.48). For secondary endpoints, the systolic blood pressure (SBP) post-treatment, time to INR correction, and time to product administration were greater in the FFP patients.

METHODS

The study was a retrospective, multicenter, cohort study of patients with warfarin-associated ICH from January 2013 to September 2017 at Houston Methodist. The study included patients 18 years of age or older, who were diagnosed with an ICH on warfarin and received at least one dose of vitamin K and either FFP or 4PCC. Notable exclusion criteria included traumatic brain injury, brain death upon admission, and administration of other factor concentrates.

CONCLUSION

For warfarin-associated ICH, there was no difference in hematoma expansion and neurologic deterioration in patients who receive FFP versus 4PCC. Use of 4PCC was more common in patients with a higher pretreatment INR, while FFP utilization was associated with higher SBP and longer time to administration.

PGY1 PHARMACY RESIDENCY

Krutina Garcia, PharmD Krutina earned her BS in Biomedical Engineering from the University of Houston in 2007 and PharmD from the University of Houston in 2017. Following completion of her PGY1, Krutina will begin a role as a clinical pharmacist with the Houston Methodist Physicians Alliance for Quality.

Primary project preceptor: Jonathan Balk, PharmD, BCCCP Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Evaluation of post-operative clinical outcomes in Jehovah’s Witness patients who receive prothrombin complex concentrate during cardiac surgery Jesse Harris, PharmD; Sara Varnado, PharmD; Elizabeth Herrera, MD; Eric Salazar, MD; A. Carmine Colavecchia, PharmD, PhD PURPOSE

RESULTS

Patients who refuse allogeneic blood transfusion have an increased theoretical risk for morbidity and mortality associated with intraoperative bleeding and coagulation deficiencies. Despite the theoretical risks, published data demonstrates equal outcomes in patients who refuse blood transfusions and undergo coronary artery bypass graft (CABG) and/or valve surgeries. When excessive bleeding occurs, minimal options exist to mitigate blood loss and morbidity in these patients. The purpose of this study was to determine the impact of four-factor prothrombin complex concentrate (4PCC) use on hemoglobin (Hgb) in Jehovah’s Witness (JW) patients undergoing cardiac surgery.

Seventy-nine JWs met inclusion criteria and underwent CABG and/or valve surgery. Of these, 19 received intraoperative 4PCC. Bivariate analysis found that Hgb change from baseline to nadir was significantly greater in patients who received 4PCC compared to patients who did not (-3.8 [interquartile range (IQR), -2.5 to -3.6 g/dL] versus -2.4 [IQR, -1.4 to -3.6 g/dL]; p=0.02). Multivariable linear regression found no difference in Hgb change in patients who received 4PCC versus those who did not and increased bypass time increased change in Hgb. In regards to secondary endpoints, patients who received 4PCC had significantly higher intraoperative blood loss compared to those who did not (1387 mL [IQR, 800 to 2000 mL] versus 921 mL [IQR, 700 to 1000 mL]; p=0.02). No other secondary endpoints were significantly different.

METHODS

This retrospective, single-center study evaluated the impact of 4PCC on baseline Hgb to nadir Hgb seven days postoperatively among patients who refused allogeneic blood products during cardiac surgery. This study identified all JWs who underwent CABG and/or valve related procedures from January 2011 to June 2017. Multivariable linear regression was used to control for confounding variables to evaluate the primary endpoint. Secondary outcomes included estimated intraoperative blood loss, postoperative length of stay, incidence of thromboembolic complications within 30 days of initial procedure, in-hospital postoperative events, and post-op mortality within 30 days of initial surgery.

CONCLUSION

In Jehovah’s Witnesses undergoing cardiac surgery, intraoperative use of 4PCC was not associated with a difference in Hgb change within 7 days postoperatively when adjusting for confounding variables.

PGY1 PHARMACY RESIDENCY

Jesse Harris, PharmD Jesse earned his PharmD from Texas Southern University in 2017. Following the completion of his PGY1 residency, Jesse will continue his postgraduate training as a PGY2 Pharmacy Resident in critical care at Houston Methodist Hospital.

Primary project preceptor: Sara Varnado, PharmD, BCPS Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Oral fosfomycin versus standard intravenous therapy for extended-spectrum beta-lactamase and carbapenem-resistant Enterobacteriaceae urinary tract infections Jade Hefler, PharmD; Katherine Perez, PharmD; Benjamin Lewing, MS; William Musick, PharmD PURPOSE

RESULTS

Urinary tract infection (UTI) caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae (CRE) has become more common and poses a significant challenge to clinicians due to limited treatment options. Multi-drug resistant uropathogens often require broad-spectrum agents that further contribute to antibiotic resistance. The objective of this study was to compare the safety and efficacy of fosfomycin to standard intravenous (IV) therapy for ESBL and CRE UTIs. Oral fosfomycin has the potential to minimize IV antibiotic exposure, reduce antibiotic costs, and shorten hospital length of stay (LOS).

There were 70 eligible patients (39 in fosfomycin group, 31 in standard therapy group) with ESBL or CRE UTIs during the study timeframe. There was no statistically significant difference in functional cure rate (94.9% with fosfomycin versus 96.8% with standard therapy; p=0.83) or microbiologic cure rate (35.9% with fosfomycin versus 45.2% with standard therapy; p=0.43). Patients in the standard therapy group had a significantly longer mean LOS (15.3 days versus 7.3 days with fosfomycin; p=0.04), mean duration of active antibiotic therapy (7.6 days versus 3 days with fosfomycin; p<0.0001), and mean time from urine culture to discharge (10.3 days versus 6.6 days with fosfomycin; p=0.002).

METHODS

A retrospective cohort investigation was performed of patients admitted between June 2016 and September 2017 at a seven-site multi-hospital system. Eligible patients were divided into two groups: fosfomycin and standard IV therapy. To be included, the urinary organism had to be susceptible to fosfomycin regardless of group assignment.

To be placed in the fosfomycin group, patients could receive no more than 72 hours of other active antimicrobial therapy.

A one-sided Fisherâ&#x20AC;&#x2122;s exact test was used to analyze the primary endpoint of functional cure, defined as either a negative repeat urine culture or lack of follow-up urine culture/analysis prior to discharge.

CONCLUSION

Fosfomycin appears to be a safe and effective alternative to standard IV therapy for ESBL and CRE UTIs. There was no significant difference found in functional or microbiologic cure rates between the two groups. Additionally, the use of fosfomycin resulted in reduced LOS, duration of therapy, and time to discharge.

PGY1 PHARMACY RESIDENCY

Jade Hefler, PharmD Jade earned her BS in Food Science and Human Nutrition from the University of Florida in 2014 and PharmD from the University of Florida College of Pharmacy in 2017.

Following the completion of her PGY1 residency, Jade will continue her postgraduate training as a PGY2 Pharmacy Resident in oncology at Houston Methodist Hospital.

Primary project preceptor: William Musick, PharmD, BCPS-AQ ID Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Evaluation of vitamin D status on immune-mediated graft function at 1-year after kidney transplantation Christine Pham, PharmD; Brett Pierce, PharmD; Shweta Bapat; Samantha Kuten, PharmD; Linda Moore, MS; A Osama Gaber, MD PURPOSE

RESULTS

The ubiquitous expression of vitamin D receptors on antigen-presenting cells has sparked investigation into its immunomodulatory effects. While previous literature has described the effect of vitamin D on graft function, the impact on immunologic outcomes has yet to be explored.

The purpose of this study was to determine whether an association between vitamin D levels and immune-mediated graft function exists.

We performed a review of 240 KTRs; 82% were discharged on ergocalciferol 50,000 IU weekly following index hospitalization. Overall rates of rejection and development of dnDSAs were 15% and 17% respectively, with no immunemediated graft losses. Compared to patients with sufficient 25(OH)D levels at 1 month post-transplant, insufficient (OR=1.5, 95% CI 0.5 to 3.9, p=0.37) and deficient (OR=1.6, 95% CI 0.7 to 4.0, p=0.24) levels were not associated with the composite outcome at 12 months posttransplant. Individual immunologic outcomes did not differ significantly between groups.

METHODS

Kidney transplant recipients (KTRs) were categorized by vitamin D levels [25(OH)D] at 1 month post-transplant as deficient (<20 ng/mL), insufficient (20-30 ng/mL), or sufficient (>30 ng/mL). Immune-mediated graft function was measured by a composite endpoint of immunologic graft loss, biopsy-proven acute rejection, and development of de novo donor specific antibodies (dnDSAs) at 12 months post-transplant. The composite outcome was analyzed using a multiple logistic regression adjusting for age, race, gender, number of mismatches, living versus deceased donor, and panel reactive antibody >20%.

CONCLUSION

Our data suggested no correlation between vitamin D levels and immunologic graft outcomes; however, further studies are warranted given its well-known role in the immune system.

PGY1 PHARMACY RESIDENCY

Christine Pham, PharmD Christine earned her PharmD from St. Louis College of Pharmacy in 2016. Following completion of her PGY1 residency, Christine will continue her postgraduate training as a PGY2 Pharmacy Resident in solid organ transplantation at Houston Methodist Hospital.

Primary project preceptor: Brett Pierce, PharmD, BCPS Presented at 2017 VizientÂŽ Pharmacy Network, Orlando; 2018 Midwest Pharmacy Residents Conference, Omaha, NE; 2018 American Transplant Congress, Seattle, WA

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Atypical antipsychotics compared to haloperidol for acute delirium in hospitalized older adults Isha Rana, PharmD; Kayode Giwa, PharmD; Aisha Vadhariya; Mobolaji Adeola, PharmD PURPOSE

RESULTS

This study evaluated the safety and efficacy of four atypical antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone) versus haloperidol for the treatment of acute delirium in hospitalized older adults.

All patient characteristics were similar at baseline (p>0.05).

Of the patients receiving haloperidol, 25 of 56 achieved a negative screen, while 29 of 71 patients receiving an atypical antipsychotic achieved a negative screen (p=0.67). Four patients receiving haloperidol and two patients receiving an atypical antipsychotic met the composite safety endpoint (p=0.40). The mean time to negative screen was 2.2 (±2.7) days in the haloperidol group and 1.7 (± 1.3) days in the atypical antipsychotics group.

METHODS

Data was evaluated from June 2016 to September 2017, on patients aged 70 or older admitted to an acute care or intensive care unit at Houston Methodist Hospital. Study subjects were identified as those with a positive Confusion Assessment Method for the ICU (CAM-ICU) or 4AT at least 24 hours after admission, with administration of a study medication within 24 hours of the positive screen. The primary endpoint was the proportion of patients achieving a negative delirium screen after medication administration for delirium. Secondary endpoints included time to a negative screen for patients achieving the primary outcome, and the composite incidence of QTc prolongation, serious arrhythmias, or extrapyramidal symptoms. The primary endpoint was analyzed using multivariable logistic regression.

CONCLUSION

No significant difference was found in achievement of the primary outcome, though there was a higher incidence of QTc prolongation in the haloperidol group. Findings of this study support the higher incidence of safety events in patients receiving haloperidol and may offer atypical antipsychotics as a possibly safer alternative for the management of hospital acquired delirium in older adults

PGY1 PHARMACY RESIDENCY

Isha Rana, PharmD Isha Rana earned her PharmD from Long Island University in 2017. Following completion of her PGY1 residency, Isha will continue her postgraduate training as a PGY2 resident in HealthSystem Pharmacy Administration at University of Illinois at Chicago Medical Center.

Primary project preceptor: Kayode Giwa, PharmD, BCPP Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Evaluation of heparin induced thrombocytopenia using probability scores in a mechanical circulatory support population Tracey Thomas, PharmD; Amaris Fuentes, PharmD; Qingqing Xu, MS; Kevin Donahue, PharmD PURPOSE

Patients on both temporary and long term mechanical circulatory support (MCS) devices carry a high risk for thrombocytopenia. Due to the routine use of heparin, heparin induced thrombocytopenia (HIT) is frequently suspected. HIT Expert Probability (HEP) and 4T scoring tools are pre-test scores validated in the general medicine population to assess the probability of HIT diagnosis. This descriptive study seeks to assess the association of 4T and HEP scores to available HIT diagnostic tests in patients requiring MCS. METHODS

Patients requiring MCS (intra-aortic balloon pump, Impella®, and left ventricular assist device) were evaluated for heparin PF4 antibody optical density (OD) and/or serotonin release assay (SRA) results. A 4T and HEP score at the time of heparin antibody ordering were calculated using variables required for each scoring system. The HEP score evaluates 8 clinical features which include features evaluated in the 4T score; however, the HEP score specifically describes other causes of thrombocytopenia, including the presence of MCS. Utilizing previously described ranges for heparin PF4 antibody and SRA tests in HIT diagnosis, patients were categorized into two HIT probability categories: probable and not probable.

Descriptive statistics were used for 4T and HEP scores in both HIT probability categories and t test with unequal variance and receiver- operating characteristic (ROC) analysis were used to determine the association and agreement between each scoring tool and HIT probability.

Descriptive statistics were used for 4T and HEP scores in both HIT probability categories and t test with unequal variance and receiver-operating characteristic (ROC) analysis were used to determine the association and agreement between each scoring tool and HIT probability.

RESULTS

A total of 85 patients were identified who had HIT diagnostic tests ordered while on MCS; 7 patients were classified as HIT probable and 78 patients were classified as HIT not probable. The mean 4T score was 2.87 ± 1.10 for not probable group compared to 5.00 ±1.53 for probable group, (p=0.01) and the mean HEP score was -2.34 ± 2.60 for not probable group compared to 3.29 ± 1.50 for probable group, (p<0.001). Based on ROC analysis, 4T score and HEP score had an area under the curve of 0.88 ± 0.06 and 0.96 ± 0.02, respectively demonstrating high predictability of HIT. Utilizing sensitivity and specificity analysis through ROC curves, a cut off score of 3 (sensitivity=0.81, specificity=0.86) for 4T score and 1 (sensitivity=0.92, specificity=1.00) for HEP score was established.

CONCLUSION

Both 4T and HEP scores have high predictability of HIT in the mechanical circulatory support population, and the utilization of HIT predictive scoring tools in MCS patients may be utilized to reduce frequent ordering of diagnostic tests.

PGY1 PHARMACY RESIDENCY

Tracey Thomas, PharmD Tracey earned her PharmD degree from the University of Houston College of Pharmacy in 2017. Following the completion of her PGY1 residency, Tracey will continue her post-graduate training as a PGY2 Pharmacy Resident in solid organ transplantation at Vanderbilt University Medical Center in Nashville, Tennessee.

Primary project preceptor: Amaris Fuentes, PharmD, BCPS, BCCCP Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Characterization of oncology related medication issues in the emergency department among oncology patients who received chemotherapy two weeks prior: a single-center descriptive study Godsfavour Umoru, PharmD; Hanna Zaghloul, PharmD; Edward McLean, PharmD PURPOSE

RESULTS

Cancer patients present to the emergency department (ED) with a diverse set of treatment or disease related symptoms. Symptom management is complex and often different for oncology patients compared to non-oncology patients. This study aims to identify the most common chemotherapy-related adverse events in oncology patients upon presentation to the ED.

In the inclusion group (n=393), 46% were male (n=180).

The most common adverse events identified were fever/ neutropenia (15%, n=58), pain (17%, n=68), and dehydration (15%, n=59). The highest scoring potential for pharmacist interventions due to medication-related issues occurred in patients with febrile neutropenia (n=30) followed by pain (n=27). Seventeen patients (56%) received suboptimal dose of antibiotics for febrile neutropenia in the ED and time to antibiotics was greater than 1 hour for 6 patients (20%). Ten patients who presented with pain were discharged from the ED on opioids without bowel regimens. No significant opportunities for pharmacist interventions were identified in patients with dehydration.

METHODS

A database was created to identify patients who presented to the ED and received chemotherapy within the two weeks prior to admission. Patients who received chemotherapy for non-oncologic indications were excluded. Retrospective reviews of chief complaints and admitting diagnoses in medical records were conducted to identify the top three adverse events upon presentation to the ED. Medications received within 24 hours of the ED admission were evaluated for appropriateness and possible oncologyrelated interventions. For each medication-related issue identified, an impact scoring rubric was generated to assess the feasibility and potential for pharmacists to have intervened in a standardized way. The most impactful/ highest scoring intervention was determined by the sum of the potential for impact scores multiplied by the proportion of patients who would have benefited from the intervention.

For statistical analysis, the mean Âą standard deviation and descriptive proportions were used to express continuous and categorical variables respectively.

CONCLUSION

Initial assessment of oncology-related symptoms and subsequent therapy in the emergency department are critical to patient outcomes. Dose optimization of antibiotics for febrile neutropenia and bowel regimens for patients who receive opioids will be the target of a pharmacy consult to improve care for oncology patients in the ED.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Godsfavour Umoru, PharmD Godsfavour earned his BS in Chemistry from Cameron University in Oklahoma in 2013 and PharmD from Ohio State University in 2017. Following the completion of his PGY1 residency, Godsfavour will complete a PGY2 oncology residency at Houston Methodist Hospital with the 2019-2020 residency class.

Primary project preceptor: Hanna Zaghloul, PharmD, BCOP Presented at 2018 Midwest Pharmacy Residents Conference, Omaha, NE; 2018 ASHP Summer Meeting, Denver, CO.

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Effect of hemodynamic instability on time to initiation of postintubation sedation in the emergency department Ai-Chen (Jane) Ho, PharmD, MSPH; Daniela Espino, PharmD; A. Carmine Colavecchia, PharmD, PhD PURPOSE

RESULTS

Rapid Sequence Intubation (RSI) is the preferred method to secure a patientâ&#x20AC;&#x2122;s airway in the emergency department (ED).

Administration of sedative medications along with paralyzing agents facilitates procedure visualization during RSI. Delays may occur when administering continuous sedation post-RSI in patients who are hemodynamically unstable.

The purpose of this study was to determine time to initiate post-intubation sedation or analgesia in hemodynamically stable patients after RSI compared to patients who are not hemodynamically stable.

A total of 197 patients were included in the study. Out of these, 37 patients were deemed hemodynamically unstable and 160 patients were hemodynamically stable at the time of RSI. More females were in the hemodynamically unstable group (20/37; 54%) when compared to the hemodynamically stable group (70/160; 44%). Propofol was the most common sedative utilized for continuous sedation after RSI. For the primary outcome, hemodynamically unstable patients received sedation on average 53 minutes after the NMB compared to the hemodynamically stable group of 27 minutes (p=0.007).

METHODS

This was a retrospective cohort study of adult patients admitted to the ED from July 2016 to October 2017.

Patients were included if they were admitted to the ED with recorded administration of etomidate and received a neuromuscular blocking (NMB) agent in a RSI event.

Patients were divided into those who were hemodynamically stable versus those who were not hemodynamically stable. Hemodynamic instability was defined as diastolic blood pressure (DBP) less than 60mmHg or mean arterial pressure (MAP) less than 65mmHg. The primary outcome was time to initiation of post-intubation sedation or analgesia in each of the aforementioned groups. Secondary outcomes are hemodynamic endpoints and occurrence of hypotension post intubation.

CONCLUSION

Without controlling for other variables, the time to initiation of continuous sedation in patients who were hemodynamically unstable was significantly longer than hemodynamically stable patients at a single institution.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Ai-Chen (Jane) Ho, PharmD, MSPH Jane earned her BS in Pharmacy from Taipei Medical University in 2007 and PharmD from Nova Southeastern University in 2017. She also received her MS in Public Health in health education and health communication from the Johns Hopkins University Bloomberg School of Public Health in 2012. Following completion of her PGY1, Jane would like to pursue work as a clinical pharmacist or a PGY2 in internal medicine/ambulatory care.

Primary project preceptor: Daniela Espino, PharmD, BCPS Presented at 2018 Midwest Pharmacy Residents Conference, Omaha, NE; 2018 ASHP Summer Meeting, Denver, CO.

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Assessing the value of a unit-based emergency department satellite pharmacy services Akeem Bale, PharmD; A. Carmine Colavecchia, PharmD, PhD; Amanda Beck, PharmD, MS; Daniela Espino, PharmD; Linda Haines, PharmD, MS PURPOSE

RESULTS

NOW/ASAP orders are defined as medication orders written to prevent a life-threatening emergency. Per Houston Methodist Hospital medication turnaround policy, the total turnaround time for NOW/ASAP should not exceed 60 minutes. This study aimed to assess the impact of a unitbased satellite pharmacy in the emergency department on medication turnaround.

After the satellite pharmacy implementation, a decrease in the median medication turnaround time was observed pre- and post-intervention [-29.9 minutes (-49.5 to -10.4); p=0.004]. The proportion of medications administered within 60 minutes of order entry increase post-intervention by 12.2% (p<0.0001).

CONCLUSION

METHODS

A 53-week quasi-experimental study was conducted to assess the value of a unit-based satellite pharmacy in the emergency department. The primary endpoint was the weekly median turnaround time of NOW/ASAP orders from order entry to administration. Secondary endpoints included proportion of NOW/ASAP medication orders administered within 60 minutes of order entry and a subgroup analysis turnaround time for each medication. The impact of the satellite pharmacy on nursing satisfaction was also analyzed as a secondary outcome. Interrupted time series regression analysis was used to assess the primary endpoint over the study time period.

A unit-based satellite pharmacy implementation in the emergency department led to improved turnaround time, as well as increased compliance with hospitalâ&#x20AC;&#x2122;s medication turnaround time policy.

PGY1 - PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Akeem Bale, PharmD Akeem earned his BS in Pharmaceutical Sciences from the University of Toledo in 2015 and PharmD from the University of Toledo in 2017. He is also a MS candidate in Pharmacy Administration and Leadership at the University of Houston College of Pharmacy.

Primary project preceptor: Linda Haines, PharmD, MS, BCPS Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Value of cost transparency during electronic medication prescribing in an academic medical center Stella Kim, PharmD; A. Carmine Colavecchia, PharmD, PhD; Sunny Bhakta, PharmD, MS; Linda Haines, PharmD, MS PURPOSE

RESULTS

Healthcare expenditures have increased, prompting a need for change. One contributing factor involves lacking information on medication costs and potential lower-cost alternatives at order entry. We sought to examine changes in prescribing habits before and after implementing the display of real-time medication cost and cost-effective alternatives at order entry.

The LMA alert was added to the electronic health record software and implemented on March 29, 2018. A total of 1,029 orders were collected system wide from March 1 – 26, 2018 and April 1 – 26, 2018 to capture pre and post LMA implementation. The medication pairs examined were the following: chlorothiazide intravenous (IV) formulation and metolazone tablet, minocycline IV formulation and minocycline tablet/capsule, and methylnaltrexone subcutaneous (SQ) formulation and naloxegol tablet.

Prior to the implementation of the LMA, the proportion of parenteral orders (parenteral orders divided by total parenteral and oral comparison orders) for chlorothiazide, minocycline, and methylnaltrexone were 15.8%, 2.5%, and 39.8%, respectively. After the implementation of the LMA, the proportion parenteral orders for chlorothiazide and methylnaltrexone significantly decreased to 6.7% (p<0.01) and 29.6% (p=0.02), and the proportion of parenteral orders for minocycline did not significantly change. The annualized cost savings for the 2 drugs approximates to $67,000.

METHODS

This quality improvement quasi-experimental study evaluated provider prescribing habits before and after implementing the display of real-time medication cost and cost-effective alternatives. During the first phase, the study team identified three medications to provide costs and alternatives to providers at order entry with a best practice advisory. The advisory was added to the organization’s electronic health record software and designed to activate around specified parameters. Orders within an order set were not targeted.

From the advisory, otherwise known as a lower medication alternative (LMA), the prescriber was given the option to continue with the original order, accept the alternative or cancel the order. Specific BPAs were assessed using interrupted time series regression.

CONCLUSION

We identified a lower medication alternative(s) for high cost medications utilized within our health system. The results of this investigation will be used to seek additional medications that may benefit prescribers with cost transparency upon order entry. Further efforts will focus on understanding various actions taken on the LMA alert to optimize the overall transparency of medication cost.

PGY1 -PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Stella Kim, PharmD Stella Kim earned her BS in Molecular Cell Biology from the University of California, Berkeley in 2011 and PharmD from University of Houston in 2017. She is also a MS candidate in Pharmacy Administration and Leadership at the University of Houston College of Pharmacy.

Primary project preceptor: A. Carmine Colavecchia, PharmD, PhD, BCPS Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Evaluating the impact of a systematic approach to optimizing medication alerts in a health-system Sunny Bhakta, PharmD; A. Carmine Colavecchia, PharmD, PhD; Kevin Garey, PharmD, MS PURPOSE

RESULTS

Limited literature evaluates a sustainable process for optimization of medication alerts when implementing a new electronic health record (EHR) technology with clinical decision support (CDS) capabilities. This study aimed to provide health-system enterprises with a systematic approach to optimize medication alerts with new EHR technology and evaluate the effect of strategic interventions to improve the effectiveness of medication related CDS.

After reclassification of drug-drug interactions, a significant increase in weekly provider modification and acknowledgement rates occurred (2.1 ± 0.2%, p <0.001; 1.5 ± 0.3%, p<0.001). Total alerts per 100 medication orders significantly decreased after drug-drug interaction classification (pre-intervention median: 88.4 vs postintervention 63.1, p=0.017).

CONCLUSION

METHODS

An 81-week quasi-experimental study was conducted to evaluate the impact of interventions made to medication related CDS alerts by a multi-disciplinary committee. The primary endpoint was weekly provider acknowledgement rates of medication alerts after drug-drug interaction reclassification. Secondary endpoints included weekly provider modification rates in response to drug alerts, monthly number of alerts per 100 medication orders, and subgroup analysis of various types of medication alerts on a weekly basis. Data on alert and warning frequency, severity, and response type were analyzed before and after committee interventions to determine the impact of committee led interventions. Interrupted time series regression analysis was utilized to assess primary and secondary endpoints over the study time period.

Committee led interventions to drug-drug interactions facilitated an overall increase in both medication alert acknowledgement and modification rates, as well as an overall reduction in the total quantity of generated alerts.

PGY2 -PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Sunny Bhakta, PharmD, MS Sunny completed his PharmD degree from the University of Houston in 2016 and MS in Pharmacy Administration and Leadership in 2018 at the University of Houston College of Pharmacy. He will be joining the Houston Methodist pharmacy leadership team after completion of the Health-System Pharmacy Administration Residency as a Pharmacy Administrative Specialist in Operations, Education, and Training.

Primary project preceptor: A. Carmine Colavecchia, PharmD, PhD, BCPS Presented at 2017 Vizient® Pharmacy Network Meeting, Orlando, FL; 2018 First Databank™ and Epic® Regional Conference, Austin, TX; 2018 Alcáldé Southwest Leadership Conference, The Woodlands, TX

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Effect of best practice alerts on nurses’ intentions to perform medication education: an application of the theory of planned behavior Pei Jen Lin, PharmD, MS; Alex Varkey, PharmD, MS; A. Carmine Colavecchia, PharmD, PhD; Thani Gossai, PharmD; Linda Haines, PharmD, MS; David Putney, PharmD, MPH; Susan M. Abughosh, PhD; Divya Varkey, PharmD, MS PURPOSE

RESULTS

Inadequate education about medications can increase the risk of medication-related errors. The national average of patients who reported that staff “Always” explained about medicines before administration was 65% for the measurement period from October 2015 to September 2016. The authors of this study aim to understand the motivational factors that may influence nurses’ behavioral intentions to perform medication education to patients at the bedside and determine the effect of best practice alerts (BPA) on nurses’ intentions to perform medication education.

The study sample composed of 150 nurses working on the six pre-designated pilot units for medication education BPAs. There was a total 193 questionnaires received and analyzed: 95 in the pre-BPA group and 98 in the postBPA group. Attitude and subjective norm were significantly correlated with nurses’ intentions to perform medication education. After the implementation of medication education BPAs, there was a significant increase on the control beliefs and perceived power to perform medication education.

METHODS

A multi-disciplinary team consisting of pharmacists, nurses, and informaticists developed an innovative solution utilizing BPAs to facilitate medication education. This pre-post questionnaire study was conducted at a 907-bed academic medical center. The survey was developed based upon a framework called, the theory of planned behavior, to examine motivational factors that may influence nurses’ intention to perform medication education. An elicitation study was arranged in focus groups to develop the questionnaire that was given to nurses before and after the implementation of the medication education BPAs. Descriptive statistics, logistic and multivariate regression analyses were used to achieve the objectives of this study.

CONCLUSION

The theory of planned behavioral was useful in understanding the motivational factors that may influence nurses to perform medication education. Interventions that address key influential factors may be helpful in driving medication education initiatives.

PGY2 -PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Pei Jen Lin, PharmD, MS Pei Jen earned her PharmD degree from the University of Houston College of Pharmacy in 2016. She received her MS in Pharmacy Leadership and Administration from the University of Houston College of Pharmacy in 2018. Following the completion of her PGY1/PGY2 HealthSystem Pharmacy Administration Residency program, Pei Jen will assume the position of Pharmacy Manager at Froedtert & the Medical College of Wisconsin in Milwaukee.

Primary project preceptor: Alex Varkey, PharmD, MS, FAPhA 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Texas Society of Heath-System Pharmacists Alcáldé Leadership Conference, The Woodlands, TX

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Effectiveness and safety of four-factor prothrombin complex concentrate versus fresh frozen plasma use during left ventricular assist device implantation surgery Luma Succar, PharmD; A. Carmine Colavecchia, PharmD, PhD; Kevin Donahue, PharmD; Sara Varnado, PharmD; Eric Salazar, MD, PhD; Elizabeth Herrera, MD PURPOSE

RESULTS

During left ventricular assist device (LVAD) implantation and the early postoperative period, surgical bleeding requiring blood product transfusions is the most commonly reported adverse event and is associated with increased mortality. The purpose of this study was to determine the effectiveness and safety of four-factor prothrombin complex concentrate (4PCC) versus fresh frozen plasma (FFP) administered intraoperatively on blood product requirements during LVAD implantation surgeries.

Forty two patients were included in the 4PCC group and 34 in the FFP group. Patients in the 4PCC group received a median of 3 PRBC units (IQR 1 to 6 units) compared to 3.2 PRBC units (IQR 2.7 to 6 units) in the FFP group (p=0.16). A statistically significant difference was noted in the number of intraoperative PRBC units transfused in the 4PCC compared to the FFP group (3 units versus 1 unit, p=0.009). Estimated blood loss and the proportion of patients with delayed chest closure were numerically lower in the 4PCC group (1000 mL versus 1500 mL, p=0.08; 76.5% versus 57.1%, p=0.06). There were no differences between the groups in chest tube output, incidence of DVT and stroke, and ICU LOS.

METHODS

In this retrospective, observational cohort study, we identified all Heartmate II® implantation surgeries at Houston Methodist Hospital from October 2013 to October 2017. Patients were included if they were 18 years of age or older, had a new or exchanged Heartmate II® LVAD implanted, and received 4PCC or FFP intraoperatively. The primary study outcome was the number of packed red blood cell (PRBC) units transfused intraoperatively and up to 24 hours postoperatively in the 4PCC group compared to FFP. Secondary endpoints included the number of intraoperative PRBC units transfused, delayed chest closure, chest tube output up to 72 hours, estimated blood loss intraoperatively, deep vein thrombosis (DVT) or stroke, and postoperative intensive care unit (ICU) length of stay (LOS). Appropriate statistical tests were utilized based on the type and distribution of data.

CONCLUSION

In conclusion, this retrospective study demonstrated that the intraoperative administration of 4PCC during LVAD implantation surgery is similar in efficacy and safety to FFP. Further analysis with multivariable linear regression will allow better assessment of the impact of 4PCC administration by controlling for possible confounding variables

PGY2 CRITICAL CARE PHARMACY RESIDENCY

Luma Succar, PharmD Luma earned her BS in Pharmacy from the Lebanese American University in 2014 and PharmD from the Lebanese American University in 2015. She completed her PGY1 residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Luma will assume the role of a clinical specialist in critical care at Houston Methodist Hospital.

Primary project preceptor: Kevin Donahue, PharmD, BCPS Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Texas Medical Center PGY2 Critical Care Research Forum, Houston

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Role of thromboelastography in predicting and defining pump thrombosis in left ventricular assist devices patients R. Christina Xia, PharmD; Sara Varnado, PharmD; Ashrith Guha, MD, MPH; Edward Graviss, PhD, MPH; Duc Nguyen, MD, PhD; Ana Cruz-Solbes, MD; Jerry Estep, MD; Jill Krisl, PharmD PURPOSE

RESULTS

Optimal anticoagulation for left ventricular assist device (LVAD) recipients prevents thrombotic events while minimizing bleeding. Routine plasma based coagulation tests may not accurately reflect overall hemostasis.

Clinicians currently rely on surrogate markers to guide the initial diagnosis of pump thrombosis (PT).

Thromboelastography (TEG) is useful in assessing global coagulation and fibrinolysis. A recent study found the coagulation index (CI) to be the most significant TEG parameter that defined “normocoagulability” in mechanical circulatory support device patients. Our study aims to determine the role of CI in predicting and defining PT.

A multivariate linear mixed model analysis of the PT versus non-PT group found a significant mean change in CI over time when followed out to 24 months post-implant [0.71 (95% CI 0.1-1.32, p=0.02)]; this was first significant at six months. Within each arm, CI significantly decreased in the non-PT group but did not significantly differ within the PT group. The PT group also had a significant mean change in MA and G value over time when followed out to 24 months post-implant compared with non-PT group. No significant differences were found between the two groups with regard to death, transplant, or neurological events.

CONCLUSION

METHODS

This was a single center, retrospective nested case-control cohort study with a repeated measures design of all HeartMate II® LVADs implanted between January 2011 and June 2017. We compared serial CIs over time in patients who had confirmed or suspected PT to those who did not. Patients were screened for PT and matched 1:1 to the non-PT group based on time of LVAD implantation (+/- 6 months) and age (in decades). Linear mixed modeling was used to assess the mean change over time of TEG parameters and its association with the development of thrombotic events. Post hoc marginal pairwise comparisons were performed to determine the adjusted means of changes of each continuous variable from baseline to 24 months, both within each group and between the two groups.

Compared to the non-PT group, the PT group had significantly higher mean changes in CI over time when followed out to 24 months post-implant. Our study demonstrates that CI may be a useful tool for evaluating LVAD thrombosis.

PGY2 CRITICAL CARE PHARMACY RESIDENCY

R. Christina Xia, PharmD Christina earned her BS in Pharmaceutical Sciences from the University of Pittsburgh in 2014 and PharmD from the University of Pittsburgh in 2016. She completed her PGY1 pharmacy residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Christina will assume the role of clinical mechanical circulatory support device pharmacist at the Mayo Clinic in Rochester, Minnesota.

Primary project preceptor: Jill Krisl, PharmD, BCPS & Sara Varnado, PharmD, BCPS Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Texas Medical Center PGY2 Critical Care Research Forum, Houston

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Comparison of rapid molecular diagnostic platforms in conjunction with antimicrobial stewardship efforts for gram-positive bloodstream infections Mathew Mason, PharmD; William Musick, PharmD; Patricia Cernoch, MS; Judy Ikwuagwu, BS, PharmD; James Davis, PhD; S. Wesley Long, MD, PhD; Randall Olsen, MD, PhD; James Musser, MD, PhD; Katherine Perez, PharmD PURPOSE

RESULTS

The purpose of this study is to compare the time to optimal antimicrobials for patients with gram-positive bloodstream infections utilizing two different rapid molecular diagnostic platforms: matrix-assisted laser desorption time-of-flight mass spectrometry (MALDI-TOF MS) or BioFire Diagnositics FilmArray Blood Culture Identification (BCID) panel.

A total of 264 patients were included in the primary analysis, 196 patients in the MALDI-TOF MS arm and 96 patients in the BCID arm. Both groups were well-matched with regards to baseline characteristics, prevalence of infecting organisms, and sources of bacteremia. Time to optimal antimicrobial therapy was significantly shorter in the BCID arm compared to the MALDI-TOF MS arm (27.5 hours versus 61.4 hours, p=0.026). Of patients on initial inactive therapy, time to active therapy was significantly reduced in the BCID arm (22.2 hours versus 30.4 hours, p=0.049). There was a trend towards faster organism identification in the BCID arm; however, this difference was not significant (p=0.055). There were no differences in time to antimicrobial susceptibilities, hospital length of stay, and inpatient mortality.

METHODS

This is a single center, retrospective, quasi-experimental, preand post-intervention study of gram-positive bacteremia due to either Staphylococcus aureus or Enterococcus species.

Patients were admitted to Houston Methodist Hospital from October 1, 2016 to October 8, 2017 (pre-intervention group; MALDI-TOF MS) and October 9, 2017 to March 31, 2018 (post-intervention group; BCID). Patients were identified through clinical microbiology records accessed via a clinical decision support software. In both groups, real-time antimicrobial stewardship follow-up with alerting of organism identification and availability of antimicrobial susceptibilities were performed. In the BCID arm, preliminary results with the absence or presence of resistance genes were also reported. The primary outcome was time to optimal antimicrobial therapy. Secondary outcomes included time to active therapy in patients on initial inactive therapy, time to organism identification and antimicrobial susceptibilities, length of stay, and inpatient mortality.

CONCLUSION

Coupled with real-time antimicrobial stewardship efforts, use of the BCID panel was associated with a faster time to optimal antimicrobial for patients with gram-positive bacteremia compared to MALDI-TOF MS. Patients on inactive or no antibiotics were also placed on active therapy faster than with MALDI-TOF MS.

PGY2 INFECTIOUS DISEASES PHARMACY RESIDENCY

Mathew Mason, PharmD Matt earned his BS from the University of Delaware in 2012 and PharmD from Thomas Jefferson University in 2016. He completed his PGY1 residency at Christiana Care Health System in Newark, Delaware. Following completion of his PGY2, Matt will assume the role of an infectious diseases pharmacist at the University of Kansas Medical Center.

Primary project preceptor: Katherine Perez, PharmD, BCPS (AQ-ID) Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Comparison of levothyroxine dosing in patients with and without heart failure Tianrui Yang, PharmD; Melanie Ruegger, PharmD; A. Carmine Colavecchia, PharmD, PhD; Archana Sadhu, MD; Bhargavi Patham, MD; Alexandra Tatara, PharmD PURPOSE

RESULTS

Evidence has shown that low thyroid hormone levels may lead to worse prognosis including a higher mortality rate in patients with heart failure (HF). Thyroid replacement increases cardiac output and exercise performance without causing significant adverse events. The purpose of this study was to compare levothyroxine doses in patients with and without HF.

Three hundred patients were included in the study with 100 patients in each arm. Average levothyroxine doses (mcg/ kg) were 1.5 ± 0.7, 1.6 ± 0.8, and 1.6 ± 0.9 for no HF, other types of HF, HFrEF, respectively (p=0.61). Factors found to be significantly related to levothyroxine dosing included gender, drug-drug interactions, and the time from documented levothyroxine dose and the TSH level. No differences were found in secondary outcomes including TSH levels, free T4, T3, and percentage of patients with elevated TSH among HFrEF, other types of HF, and no HF patients. Among heart failure patients, average ejection fractions were also similar comparing patients with elevated TSH, normal TSH, and low TSH.

METHODS

This single center, retrospective cohort study compared levothyroxine doses in ambulatory hypothyroid patients with a diagnosis of HF confirmed by an echocardiogram and those without a history or diagnosis of HF. Patients with clinic visits between December 2016 and July 2017 were included in the study. Patients were stratified into 3 groups: no HF, HF with reduced ejection fraction (HFrEF, EF<40%), and other types of HF. The primary endpoint of average levothyroxine dose was analyzed using multivariable linear regression with clinically meaningful and available variables determined a priori. Secondary endpoints included average ejection fraction (EF) in HF patients with elevated thyroid stimulating hormone (TSH) compared to normal TSH, percentage of patients with elevated TSH in the HF population compared to patients without HF, and average dose of levothyroxine in patients with normal TSH.

CONCLUSION

While both HFrEF and the other types of HF showed trends of higher levothyroxine doses in the linear regression, no statistically significant differences were detected in levothyroxine dose in HF patients compared to patients without HF.

PGY2 INTERNAL MEDICINE PHARMACY RESIDENCY

Tianrui Yang, PharmD, BCPS Tianrui earned her PharmD from the University of Houston in 2016. She completed her PGY1 residency at Houston Methodist Hospital. Following completion of her PGY2, Tianrui will be pursuing a faculty position with University of Texas at Tyler.

Primary Project Preceptor: Alexandra Tatara, PharmD, BCPS Presented at 2017 Vizient® Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Olanzapine versus fosaprepitant for chemotherapy-induced nausea and vomiting prophylaxis in patients receiving single-day high-dose melphalan Ekim Ekinci, PharmD, MS; James E. Cox, PharmD; Joe E. Ensor, PhD; Edward T. McLean, PharmD; Carlos Ramos, MD; Premal D. Lulla, MD; Rammurti T. Kamble, MD; George Carrum, MD PURPOSE

RESULTS

Olanzapine is an oral atypical antipsychotic that recently became a first-line treatment option for chemotherapyinduced nausea and vomiting (CINV) prevention. While olanzapine’s utility for CINV has been studied in a variety of patient populations, its use in patients receiving conditioning regimens for stem cell transplantation (SCT) warrants further investigation. At Houston Methodist Hospital, an olanzapine-based CINV prophylaxis protocol consisting of olanzapine, ondansetron, and dexamethasone (OOD) was instituted in April 2017 for use in multiple myeloma (MM) patients receiving singleday high-dose (SDHD) melphalan prior to SCT. Prior to OOD, a fosaprepitant, ondansetron, and dexamethasone (FOD) protocol was used. The purpose of this analysis was to compare the efficacy of the OOD and FOD prophylaxis protocols.

Preliminary analysis included 66 patients, FOD (n=43) and OOD (n=23). Baseline characteristics were similar between the two cohorts. Proportion of days requiring rescue CINV medications was significantly higher with FOD (median 71.4% versus 14.3%, p=0.001).

Percentage of patients requiring rescue CINV medications was significantly higher with FOD for all phases assessed (acute 0-24 hours: 30.2% versus 8.7%, p=0.0467; delayed 24-120 hours: 90.7% versus 43.5%, p<0.0001; very delayed 120-168 hours: 90.7% versus 60.7%, p=0.0037). Mean adherence to protocols were 97.1% ± 8.11 for FOD, 96.6% ± 5.23 for OOD. Blood glucose levels between Day -2 and +2 were similar between the two cohorts. Only one patient receiving OOD (4.3%) was switched to FOD due to hypotension thought to be related to olanzapine.

METHODS

CONCLUSION

Inclusion criteria were diagnosis of MM, SDHD melphalan conditioning prior to SCT, inpatient stay for minimum of seven days following melphalan. Exclusion criteria were diagnosis of amyloidosis, presence of uncontrolled arrhythmia, pregnancy, or current antipsychotic use. The primary endpoint was proportion of days requiring rescue CINV medications within seven days of melphalan administration, reported as a percentage out of seven days. Wilcoxon rank-sum test was used to analyze primary endpoint.

Compared to a fosaprepitant-based regimen, an olanzapine-based regimen led to a statistically significant decrease in the proportion of days on which patients required rescue CINV medications, with good tolerability.

Time to engraftment, days of hospitalization, and cost effectiveness analysis are ongoing.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Ekim Ekinci, PharmD, MS Ekim earned her BS in chemistry from Rice University in 2010, and her PharmD and MS in Pharmaceutical Outcomes and Policy from the University of Kentucky College of Pharmacy in 2016. She completed her PGY1 residency at Houston Methodist Hospital. Following completion of her PGY2 residency, Ekim will assume the role of clinical pharmacy specialist in oncology at Kaiser Permanente in Denver, Colorado.

Primary project preceptor: James Cox, PharmD Presented at 2017 Vizient® University Health System Consortium, Orlando, FL; 2018 Hematology/Oncology Pharmacy Association Annual Conference, Denver, CO; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Evaluation of the prescribing patterns, adverse effects, and drug interactions of oral chemotherapy agents Jenna Solomon, PharmD; Veronica Ajewole, PharmD; Amy Schneider, PharmD; Manvi Sharma, PhD; Eric Bernicker, MD PURPOSE

RESULTS

Oral chemotherapy offers advantages to intravenous chemotherapy, while creating a unique set of challenges.

Potential barriers include treatment complexity with unique toxicities and drug interactions, patient responsibility for medication adherence and monitoring, reduced healthcare contact, and increased financial burden. The purpose of this study was to estimate the prevalence of drug-related problems among a sample of patients treated with oral chemotherapy agents.

Upon review of 100 patients, the median time to chemotherapy availability from the day of prescription to patient receipt was 8 days. Financial and communication issues associated with chemotherapy acquisition occurred among 65% of patients. Toxicity checks were conducted by the provider at 30, 60, and 90 days for 80%, 65%, and 48% of patients, respectively. Treatment-related toxicities secondary to an oral anti-cancer agent was reported by 79% of patients, with 55% classified as severe. A drug interaction was identified to be present in 55% of the records resulting in an increased toxicity in 15% of the patients.

METHODS

A single center, retrospective chart review was conducted on patients that were newly prescribed oral chemotherapy at the Houston Methodist Cancer Center between January 2017 and August 2017. The primary endpoint was incidence of drug-related toxicities within 90 days of starting treatment. Secondary endpoints include incidence of drug-drug interactions, proportion of patients receiving medication education by a clinical pharmacist, and quantification of issues related to medication access. Data points collected included oral chemotherapy prescribed, date of initial prescription, time to prescription acquisition, barriers to medication access, performance of toxicity checks, and reported side effects.

CONCLUSION

Data from this study has highlighted avenues for pharmacists to make an impact on patients newly started on oral chemotherapy. Opportunities exist to increase patient education, ensure appropriate follow-up, and prevent and manage treatment-related toxicities.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Jenna Soloman, PharmD Jenna earned her PharmD from the University of Rhode Island in 2016. She completed her PGY1 residency at Mission Hospital in Asheville, North Carolina. Following completion of her PGY2 residency, Jenna will assume the role of oncology clinical specialist at Woman and Infants Hospital in Rhode Island.

Primary project preceptor: Amy Schneider, PharmD, BCOP Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Hematology/Oncology Pharmacy Association, Denver, CO; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Treatment and outcomes of orthotopic liver transplant patients secondary to hepatitis C virus: a single center experience Y. Tracy Chen, PharmD; Brett Pierce, PharmD; Mozhgon Moaddab, PharmD; Rafik Mark Ghobrial, MD PURPOSE

RESULTS

Treatment of acute cellular rejection (ACR) in patients with orthotopic liver transplantation (OLT) secondary to hepatitis C virus (HCV) remains a major challenge due to cliniciansâ&#x20AC;&#x2122; fear of corticosteroids increasing HCV infectivity and reactivity. Direct-acting antiviral agents (DAAs) offer significant advantages over peg-interferon and ribavirin.

More patients are achieving sustained virologic response (SVR) before undergoing transplant, yet post-transplant outcomes related to HCV remain unclear.

A total of 110 patients were enrolled. At the time of transplant, 69 (62.7%) patients had HCV viremia; 52 (75.4%) of them achieved SVR-12 with primarily sofosbuvirbased DAA regimens post-transplant. Suspected ACR occurred in 14 (12.7%) patients, 9 of whom had achieved SVR prior to the suspected ACR. Treatment consisted of intravenous methylprednisolone and/or hydrocortisone; doses of methylprednisolone were empirically reduced by approximately 50% if patients had positive HCV viremia at the time of treatment. No recurrence of HCV infection after receiving corticosteroids was reported in patients if they had already achieved SVR. Of the study cohort, 66 (60.0%) patients had concurrent HCC at the time of transplant.

HCC recurred after transplant in 9 (8.2%) patients, all of which had positive HCV viremia at the time of transplant.

One year post-transplant graft and patient survival rates were 95.5% and 91.8%, respectively.

METHODS

A retrospective, single-center, descriptive chart review of patients who received OLT for HCV-related liver disease between 2010 and 2016 was conducted at a 900-bed quaternary-care academic hospital. Patients with multiorgan transplantation or coinfection with hepatitis B infection or human immunodeficiency virus were excluded.

We described rates of suspected ACR and treatment modalities, recurrence of HCV infection and hepatocellular carcinoma (HCC), and patient and graft outcomes within one year post transplantation.

CONCLUSION

Treatment of ACR with corticosteroids was not associated with recurrence of HCV infection post-transplant. DAA treatment achieved satisfactory outcomes in OLT patients with HCV recurrence. HCC recurrence post-transplant was present only in patients with HCV viremia at the time of transplant.

PGY2 SOLID ORGAN TRANSPLANTATION PHARMACY RESIDENCY

PGY2 ONCOLOGY PHARMACY RESIDENCY

Y. Tracy Chen, PharmD, MBA, BCBS Tracy earned her PharmD and MBA from the University of Rhode Island in 2015. She completed her PGY1 residency at Houston Methodist Hospital. Following the completion of her PGY2 residency, Tracy will assume the role of abdominal clinical transplant pharmacist at State University of New York Downstate Medical Center in Brooklyn.

Primary project preceptor: Brett J. Pierce, PharmD, BCPS Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE; 2018 American Transplant Congress, Seattle, WA.

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Identification of variables associated with acute cellular rejection in adult heart transplant recipients with steroid-only induction Meghann Davis, PharmD; Jill Krisl, PharmD; Sara Varnado, PharmD; Edward Graviss, PhD, MPH; Duc Nguyen, MD, PhD; Ashrith Guha, MD; Jerry Estep, MD; Myung Park, MD PURPOSE

Graft failure is one of the leading causes of death among heart transplant (HT) recipients. While certain variables have been identified that potentially place recipients at higher risk for acute cellular rejection (ACR), such as African American ethnicity and history of mechanical circulatory support (MCS), further study is needed to develop a risk index to predict ACR in this population. The purpose of this study was to describe risk factors for ACR in adult HT recipients who receive steroid-only induction.

METHODS

This was a retrospective, single-center, cohort study of adult HT recipients who were transplanted between January 2013 and May 2017. Patients who received induction therapy other than steroids, were less than 18 years old at time of transplant, multi-organ transplants, or re-transplants were excluded. Patient baseline demographics, immunologic and infection history, donor characteristics, post-transplant complications and immunosuppression regimen, and results of all protocol biopsies performed up to six months post-transplant were recorded. The primary endpoint was to identify risk factors associated with first ACR episode at six months post-transplant. Secondary endpoints included determining the total incidence of ACR up to six months post-transplant, time (days) to first therapeutic tacrolimus

level, and percentage of time (days) that tacrolimus levels were within therapeutic range within the first two weeks post-transplant. Univariate survival analysis and Cox proportional hazards modeling were used to determine the potential risk factors associated with the development of acute rejection within six months after transplant.

RESULTS

A total of 153 patients received a HT between January 2013 and May 2017 at our center, of which 108 were included in analyses. Approximately 25% of patients were African American, and almost 80% had a temporary or durable MCS device pre-transplant. Acute rejection was not significantly associated with modifiable patient characteristics or post-transplant immunosuppression management. The incidence of having at least one ACR episode within six months post-transplant was 83.3%, while patient survival at last follow up was 96%.

CONCLUSION

While a large proportion of our cohort experienced ACR at six months post-transplant, univariate and multivariate analyses failed to identify modifiable risk factors for rejection. Overall outcomes remained positive, with approximately 96% patient survival reported.

PGY2 SOLID ORGAN TRANSPLANTATION PHARMACY RESIDENCY

Meghann Davis, PharmD Meghann earned her BS in Biomedical Sciences from Texas A&M University in 2012 and PharmD from the University of Houston College of Pharmacy in 2016. She completed her PGY1 residency at Houston Methodist Hospital. Following the completion of her PGY2, Meghann will assume the role of an abdominal transplant pharmacist for Vidant Medical Center in Greenville, North Carolina.

Primary project preceptor: Jill Krisl, PharmD, BCPS Presented at 2017 VizientÂŽ Pharmacy Network, Orlando, FL; 2018 Midwest Pharmacy Residents Conference, Omaha, NE

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Impact of chlorhexidine bathing on antimicrobial utilization in surgical intensive care unit patients: a secondary analysis of a single-center randomized controlled trial Lan Bui, PharmD; Joshua Swan, PharmD, MPH; Katherine Perez, PharmD; Hua Chen, MD, PhD; Johnson ML, PhD; Elsie Rizk, PharmD; A. Carmine Colavecchia, PharmD, PhD; Edward Graviss, PhD, MPH PURPOSE

Bathing intensive care unit (ICU) patients with chlorhexidine gluconate prevents multiple types of hospital-acquired infections (HAIs). This secondary analysis evaluated the impact of chlorhexidine bathing on total antimicrobial utilization in a surgical ICU using data from the chlorhexidine-bath (CHG-BATH) randomized trial.

METHODS

The primary outcome of this study was to compare total antimicrobial defined daily doses (DDDs) per patient-day between two study groups: chlorhexidine bathing every other day versus soap-and-water bathing daily. Systemically administered antibiotics and antifungals were included in the analysis. Antivirals (except oseltamivir), antiparasitics, and prophylaxis antimicrobials were excluded. DDDs were calculated using the World Health Organization Anatomical Therapeutic Chemical/DDD 2018 Index. In the original CHG-BATH trial, HAIs were observed from 48 hours after randomization to 48 hours after the end of interventions, to account for latency period of HAIs. In this study, the observation period for antimicrobial utilization started 48 hours after randomization and ended 14 days after end of CHG-BATH trial follow-up, to account for completion of antimicrobial regimens, or hospital discharge, or death, whichever occurred first. The primary outcome was analyzed

using linear regression adjusted for Acute Physiology and Chronic Health Evaluation II score. P-values <0.05 (twosided) were considered statistically significant.

RESULTS

Of 325 patients previously enrolled in the CHG-BATH trial, 312 (157 in soap-and-water, 155 in chlorhexidine) were included in this analysis. The median (inter quartile range [IQR]) of total DDDs per patient-days were 1.35 (0.75 to 2.32) in soap-and-water and 1.3 (0.49 to 2.15) in chlorhexidine, p=0.8, 95% confidence interval (CI) (-0.34 to 0.26). The median (IQR) of total agent-days per patient were 1.56 (0.83 to 2.43) in soap-and-water and 1.47 (0.67 to 2.17) in chlorhexidine, p=0.406, 95% CI (-0.35 to 0.14).

CONCLUSION

Compared with daily soap and water bathing, 2% chlorhexidine bathing every other day was not associated with a decrease in antimicrobial utilization. Further analyses are needed to determine differences in total antimicrobial acquisition cost and subgroups of antimicrobial classes and agents.

FELLOW â&#x20AC;&#x201C; CLINICAL PHARMACY FELLOWSHIPPGY2 IN OUTCOMES SOLID ORGAN RESEARCH TRANSPLANTATION PHARMACY RESIDENCY

Lan Bui, PharmD, BCPS Lan earned her PharmD from the Texas Southern University College of Pharmacy in 2015. She completed her PGY1 residency at Houston Methodist Hospital. Following the completion of her fellowship, Lan will assume the role of an assistant professor in pharmacy practice at Samford University in Birmingham, Alabama.

Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS Presented at 2018 International Society For Pharmacoeconomics and Outcomes Research (ISPOR), Baltimore, MD.

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Valid and feasible quality indicators to measure the impact of opioid stewardship interventions in the hospital and emergency department settings Elsie Rizk, PharmD; Joshua Swan, PharmD, MPH; Ohbet Cheon, PhD, MPA; A. Carmine Colavecchia, PharmD, PhD; Lan Bui, PharmD; Bita Kash, PhD, MBA; Sagar Chokshi, MD; Hua Chen, MD, PhD; Michael Johnson, PhD; Michael Liebl, PharmD; Ezekiel Fink, MD PURPOSE

Hospital and emergency department (ED) clinicians need a defined set of appropriate quality indicators (QIs) that can be used to optimize pain management and track pain and opioid stewardship efforts. The purpose of this project was to develop a set of valid and feasible QIs for an opioid stewardship program in the hospital and ED settings.

METHODS

Consensus was established using a 5-step process: (1) literature search, (2) feasibility screen, (3) validity screen, (4) expert panel discussion, and (5) priority ranking. Candidate QIs were extracted from published literature. Feasibility screening excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant to pain management in the hospital and ED settings. Validity screening used an electronic survey that was distributed to key stakeholders including physicians, pharmacists, nurses, administrators, managers, and outcome researchers.

Stakeholders rated each QI using a 9-point Likert scale assessing the validity of each QI based on predefined criteria. Each QI was preliminarily categorized as follows: appropriate, inappropriate, or uncertain based on its mean rating and 95% confidence interval. These results were presented during expert panel discussions where stakeholders discussed preliminary category assignments,

revised QI wording, added new QIs, and verbally voted to include or exclude each QI. Priority ranking used a second electronic survey of stakeholders to rank the priority of included QIs using a 9-point Likert scale.

RESULTS

Literature search yielded 214 raw QIs that were collapsed into 97 unique QIs. Feasibility screening excluded 30 QIs. The validity survey was distributed to 228 stakeholders with 46 (20.2%) stakeholders providing completed responses.

Expert panel discussion yielded 19 valid and feasible QIs. The top 5 QIs by priority were: the proportion of patients with (1) naloxone administrations, (2) as needed opioids with duplicate indications, and (3) long acting or extended release opioids, (4) the average dose of morphine milligram equivalents administered per day, and (5) the proportion of opioid discharge prescriptions that exceed 7 days of treatment.

CONCLUSION

Multi-professional stakeholders across a health-system participated in this consensus process and developed a set of 19 valid and feasible QIs that can be targeted through opioid stewardship interventions to optimize pain management in the hospital and ED settings.

FELLOW â&#x20AC;&#x201C; CLINICAL PHARMACY FELLOWSHIP IN OUTCOMES RESEARCH

Elsie Rizk, PharmD Elsie earned her PharmD from the Lebanese American University in 2016. She completed her PGY1 residency at Houston Methodist Hospital. Following completion of her first year of fellowship training, Elsie Rizk will continue her postgraduate training as a second-year fellow in the Clinical Pharmacy Fellowship in Outcomes Research program at Houston Methodist.

Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS Presented at 2018 ASHP Summer Meeting, Denver, CO.

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QUICK FACTS HOUSTON METHODIST SYSTEM

8

Hospitals

915,817

Patient encounters

107,228

Admissions

22,381

Employees

4,387

Physicians

HOUSTON METHODIST RESEARCH INSTITUTE

1,900 637 414 1,092 3,867

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Credentialed researchers Faculty Active clinical trials Peer-reviewed publications Collaborations around the world

$161

Million in research and education funding

$51

Million total extramural research funding

HOUSTON METHODIST houstonmethodist.org/pharmacy

102018