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2016 HOUSTON METHODIST CLINICAL PHARMACY GROUP 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 quality and safety. 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 quality and safety 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 pharmacists, residents and pharmacists • Maximize the use of automation and information technology • Maximize cost efficiencies and resource utilization

TABLE OF CONTENTS 3 | Letter from the Director of Pharmacy Services 4 | Pharmacy Research Committee Members 5 | Letter from the Pharmacy Research Committee Chair 6–23 | 2015–2016 Houston Methodist Hospital Residency Class 6 \ PGY1 Pharmacy Residency Veronica Ajewole, PharmD Lan Bui, PharmD Kristen Heiner, PharmD Rita Jebrin, PharmD Tara Molina, PharmD Yevgeniy (Gene) Raskin, PharmD

12 \ International Graduate Residency Tracy Yixin Chen, PharmD, MBA Luma Succar, PharmD

14 \ PGY1 of PGY1/PGY2 Health-System Pharmacy Administration Residency Amanda Beck, PharmD Linda Nguyen, PharmD

16 \ PGY2 of PGY1/PGY2 Health-System Pharmacy Administration Residency Sarah Cox, PharmD, MS Roya Tran, PharmD, MS

18 \ PGY2 Critical Care Residency Annette Lista, PharmD Matthew Rubertus, PharmD

20 \ PGY2 Oncology Residency Cynthia El Rahi, PharmD Elizabeth Ryan Pritchard, PharmD

22 \ PGY2 Infectious Diseases Residency Vu Ta, PharmD, BCPS

23 \ PGY2 Internal Medicine Residency Alexandra Whiddon, PharmD, BCPS

24 \ PGY2 Solid Organ Transplant Residency Nicole Casciello, PharmD, MBA

Houston Methodist Receives $50,000 Award for Excellence in Medication-Use Safety from the ASHP and Cardinal Health Foundations The American Society of Health-System Pharmacists (ASHP) Research and Education Foundation and Cardinal Health Foundation awarded Houston Methodist with the 2015 Award for Excellence in MedicationUse Safety. The award is the only national honor that recognizes a pharmacist-led interprofessional team for implementing significant institution-wide improvements in medication safety. At a ceremony held during the 2015 ASHP Midyear Clinical Meeting in New Orleans, Houston Methodist received $50,000 to further effect and promote medication safety. PROJECT: Clinical Management of High-Risk Medication Use to Mitigate the Incidence of HospitalAcquired Delirium in the Geriatric Population Delirium, a common, serious, and potentially preventable source of morbidity and premature death among hospitalized elders, is poorly recognized and can precipitate cognitive and functional decline. Preventing delirium is the most important goal, yielding the greatest benefits on quality of life and cost savings. Medications account for approximately 40 percent of delirium cases. Exposure to benzodiazepines, opioids, and drugs with anticholinergic properties have been identified as risk factors for delirium. Houston Methodist internal data revealed that about 44 percent of elderly inpatients received orders for one or more targeted deliriogenic medications. The hypothesis was that high-risk medication use can be mitigated through a multipronged, team-based approach and that such reduction could positively impact incident delirium. Pharmacy leaders collaborated with an interprofessional team to develop multihospital, multidisciplinary, multipronged initiatives aimed at reducing patient risk. The results of this award-winning initiative include increased nurse screening, decreased use of high-risk medications, reduced incidence of delirium, and implementation of the initiative at four community hospitals within the system. Additional information on this award: Video on medication safety program:


ON BEHALF OF THE HOUSTON METHODIST HOSPITAL PHARMACY MANAGEMENT TEAM, I want to extend my sincere appreciation to all of our graduating residents this year. As another residency year comes to a close, I continue to be in awe of the growth demonstrated by everyone completing one of our pharmacy residency programs. Our residents fully invest in their respective opportunities to grow both personally and professionally, and in the process, made lasting impacts on numerous facets of Houston Methodist Hospital Pharmacy’s goal of optimizing patient outcomes. In the spirit of continuous improvement, a dedicated group of pharmacists sought to elevate the level of pharmacy practice research and education. As a result, we developed a fantastic resource not only for our residency programs but for our department as a whole. This year marks the inaugural year of the Pharmacy Research Committee (PRC) at Houston Methodist Hospital, and I am especially proud of the work the committee has done thus far. The mission of the PRC is to ensure excellence in the quality and feasibility of research and the quality of research training provided by the Department of Pharmacy at Houston Methodist Hospital. The PRC serves as a centralized support structure for residents, preceptors, and residency program directors. I sincerely thank the members of our inaugural PRC, who have served as outstanding practitioners and mentors in developing strong research projects and as resources to our residency programs. I cannot tell you how many times I converse with my colleagues around the country about all the great things that happen here — and their response is almost always the same:

“You need to publish! Share your knowledge!” We have made great strides in this regard over the years. Not too long ago, it was a remarkable event to have a member of our residency class publish in a peer reviewed journal. Today, this is becoming the norm. For this success, we have our residents, residency graduates who have stayed to practice here, and residency mentors to thank. I want to conclude by issuing a challenge to our incoming residents and their mentors. To paraphrase a quote I once read — the days we are supremely satisfied in the end aren’t those where we sat by, waiting for life to happen. the days that are supremely satisfying are those where we had everything to do, and we got the job done. There are myriad opportunities here at Houston Methodist Hospital to make your mark in the lives of the people we care for here, and potentially many others through our efforts to conduct strong research and share it. Take advantage. I look forward to your continued success. Thank you for all that you have done and continue to do for our patients and our advancing profession.

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




Joshua T. Swan, PharmD, MPH, BCPS Chair

Katherine K. Perez, PharmD, BCPS-AQ ID Project Approval Lead

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

Michael W. Sirimaturos, PharmD, BCCCP, BCNSP Education/Credentialing Lead

Jill C. Krisl, PharmD Assessment Lead

Anthony C. Colavecchia, PharmD, MS, BCPS Continuing Education Lead

Michael Johnson, PhD External Statistician Consultant



Michael G. Liebl, PharmD, BCPS Clinical Pharmacy Manager


THIS YEAR MARKS THE INAUGURAL YEAR OF THE PHARMACY RESEARCH COMMITTEE (PRC) AT HOUSTON METHODIST HOSPITAL. It is my pleasure to recognize the commitment of the inaugural PRC members and celebrate the research success of the 2015 to 2016 Houston Methodist Hospital residency class! Starting this year, the Department of Pharmacy will recognize the scholarship of the residency class at the end of each year through this annual research report. The mission of the PRC 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. The PRC serves as a centralized support structure for residents, preceptors, and program directors of the diverse and ever-growing portfolio of postgraduate pharmacy residencies at Houston Methodist. During this inaugural year, the PRC developed research infrastructure to support its mission by developing 1.

A peer-review process to help investigators maximize impact and quality of proposed projects

2. A process for aligning residents with major research projects that accounts for the resident’s previous research experience, complexity of the project, and potential impact of the study 3. An educational series of didactic lectures and interactive workshops to train residents on literature review, epidemiology, statistics, and regulatory approval 4. Department templates for study protocols, poster presentations, and platform presentations All of this tremendous success was made possible by the dedication and passion of the following members of the 2015 to 2016 PRC: •

Project Approval Lead: Katherine Perez, PharmD, BCPS

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

Education/Credentialing Lead: Michael Sirimaturos, PharmD, BCCCP, BCNSP

Assessment Lead: Jill Krisl, PharmD

External Statistician Consultant: Michael Johnson, PhD

Continuing Education Lead: Carmine Colavecchia, PharmD, MS, BCPS

As inaugural chair of the PRC, I am incredibly proud of the research infrastructure that was developed over this first year, and I’m excited to build upon this success in the coming year!

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



Impact of a one-time hospital coaching session by a clinical pharmacist on self-reported medication adherence among psychiatric patients: A retrospective evaluation of a prospective intervention Veronica Ajewole, PharmD; Saadia A. Basit, PharmD; Anthony Colavecchia, PharmD, MS; Jason Q. Chau, PharmD; Heather B. Chung, RN, PhD; Joshua Swan, PharmD, MPH PURPOSE


Low medication adherence occurs frequently among psychiatric patients and is associated with increased hospitalization, health care cost, morbidity, and mortality. The objective of this study is to assess the impact of a one-time, in-hospital coaching session provided by a clinical pharmacist on medication adherence of psychiatric patients.

For the control group (n=38), mean MMAS-8 score increased from in-hospital (4.4 ± 1.2) to home visit (6.0 ± 2.0) for a mean within-person change of 1.7 ± 2.2. For the intervention group (n=49), mean MMAS-8 score increased from in-hospital (4.3 ± 1.2) to home visit (6.3 ± 1.8) for a mean within-person change of 2.0 ± 2.3. In-hospital coaching by a clinical pharmacist was not associated with a statistically significant increase in mean within-person change in MMAS-8 scores (adjusted coefficient=0.68, 95%CI=-0.38 to 1.74, p=0.20) using linear regression that adjusted for cognitive impairment, depression, insurance, pharmacist-provided discharge counseling, postdischarge phone calls, and postdischarge pharmacist interventions.


This retrospective evaluation of a prospective intervention included hospitalized psychiatric patients with low medication adherence. Medication adherence was measured using the eight-item Morisky Medication Adherence Scale (MMAS-8), a self-reported medication adherence tool categorized as low (score, 0 to 6), medium (score, 6 to <8), or high (score, 8). This study compared mean within-person changes in MMAS-8 scores from hospitalization to a home visit within 30 days of discharge among patients who were (intervention) and were not (control) coached.


Among psychiatric inpatients, a single in-hospital pharmacist coaching was not associated with a significant increase in self-reported medication adherence.


Veronica Ajewole, PharmD Veronica earned her BS in biochemistry from University of Ado Ekiti in Nigeria after which she served as a Quality Control Personnel in an ISO-certified large-scale drug manufacturing company for a few years before relocating to the United States. Veronica graduated with a Doctor of Pharmacy from Texas Southern University College of Pharmacy and Health Sciences in 2015. Following completion of her PGY1 Pharmacy Residency, Veronica will continue her postgraduate training as a PGY2 in oncology at Houston Methodist Hospital. Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Effects of chlorhexidine bathing on hospital-acquired Clostridium difficile infection in a surgical intensive care unit Lan N. Bui, PharmD; Joshua T. Swan, PharmD, MPH; Beverly A. Shirkey, PhD; Randall J. Olsen, MD, PhD; Scott W. Long, MD, PhD; Edward A. Graviss, PhD, MPH PURPOSE

In the CHlorhexidine Gluconate BATHing (CHG-BATH) randomized controlled trial, bathing with 2% chlorhexidine solution significantly decreased the risk of acquiring four common types of hospital-acquired infections (HAIs) (bloodstream, urinary tract, pneumonia and surgical site) in surgical intensive care unit (ICU) patients compared to soap and water bathing. Clostridium difficile, the most common HAI pathogen in ICU, was not included as a trial outcome. This study uses data from the CHG-BATH trial to evaluate the incidence of Clostridium difficile infection (CDI). We hypothesized that compared with daily soap and water bathing, bathing with 2% chlorhexidine solution every other day decreases the risk of hospital-acquired CDI. METHODS

Adult patients admitted to the surgical ICU from July 2012 through May 2013 with an anticipated ICU stay for at least 48 hours were included. Patients were randomized to bathing with 2% chlorhexidine solution alternating with soap and water every other day or to bathing with soap and water daily for up to 28 days. Each included patient was retrospectively adjudicated by two independent blinded investigators for CDI outcome if they had a positive Clostridium difficile molecular assay, received an administrative billing code for CDI, received oral vancomycin or fidaxomicin, or had radiology evidence of pseudomembranous colitis.

The primary outcome was the proportion of incident CDIs among patients who stayed in the study for at least 48 hours and did not have a prevalent CDI, compared between the two study arms. Using a two independent sample test of two proportions (Chi-squared test) power estimate with a fixed sample size of 325, two-sided alpha of 0.05, beta of 0.20, and estimated incidence of 8% in the control arm, this analysis would have 80% power to detect a 6.5% absolute risk reduction. RESULTS

Of 350 randomized patients, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Thirty-eight patients (11.7%) met the criteria for a potential CDI and underwent adjudication for classification as no CDI, prevalent CDI, or incident CDI. For patients bathed with soap and water versus chlorhexidine, counts of incident CDIs were 2 versus 3; counts of prevalent CDIs were 6 versus 7. There were no significant differences in the incidence of CDIs between the two study arms (1.3% [2 of 152] soap and water versus 2.0% [3 of 148] chlorhexidine, p=0.63). CONCLUSION

Compared with daily soap and water bathing, 2% chlorhexidine bathing every other day did not decrease the risk of hospital-acquired CDI among surgical ICU patients. The incidence of CDI observed in the control group was lower than what was expected when the a priori power calculations were performed.


Lan Bui, PharmD Lan completed her prepharmacy prerequisites at University of Houston and earned her Doctor of Pharmacy from Texas Southern University College of Pharmacy and Health Sciences in 2015. Upon completing her residency, Lan is seeking a clinical pharmacist position in Houston. Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS Presented at 2016 Midwest Pharmacy Resident Conference, Omaha, Neb.; 2016 American Society of Health-System Pharmacists Summer Meeting, Baltimore, Md.



Retrospective analysis of pharmacy managed anticoagulation in hospitalized left ventricular assist device patients Kristen Heiner PharmD; Jill Krisl, PharmD; Amaris Fuentes, PharmD; May Achi, PharmD; Duc Nguyen, PhD; Edward Graviss, PhD, MPH; Jerry Estep, MD PURPOSE

On April 20, 2015, the inpatient management of left ventricular assist device (LVAD) anticoagulation (warfarin/ heparin) at the study institution shifted from physician/nurse coordinator driven to a pharmacy-managed protocol. The purpose of this study is to describe early outcomes of the newly implemented pharmacy-managed anticoagulation protocol in hospitalized LVAD patients. METHODS

This was a retrospective, single center, descriptive cohort analysis conducted at a tertiary academic medical center. All patients with a HeartMate II® and an order for pharmacymanaged heparin and/or warfarin from April 20, 2015 to August 31, 2015 were included. The primary outcome was the percent time within patient specific therapeutic INR range for warfarin, and the percent time within therapeutic PTT range (60–80 seconds) for heparin. Secondary outcomes included: time to therapeutic INR, total time with pharmacy-managed anticoagulation, length of hospital stay, bleeding events, and thrombotic events.

one therapeutic PTT. The average rate at first therapeutic was 13 units/kg/hr, with a median of 67.8 hours to achieve a PTT within the therapeutic range. The median (95% CI) percent of time the PTT was in the therapeutic range (60–80 seconds) was 28.3% (18.4–36.7) for all pharmacy-managed heparin; it was 31.4% (27.2–37.9) for encounters with at least one therapeutic PTT. Of the 113 admissions with pharmacy-managed warfarin, 66 (58.4%) had an INR goal range of 1.8 to 2.5. Thirty seven (32.7%) of the admissions had a therapeutic INR on admission, while 57 (50.4%) had a therapeutic INR at discharge. The median (95% CI) percent of time the INR was within the patient specific therapeutic range was 29.9% (15.5–35.0). When the same outcome was evaluated with a variance of the patient specific therapeutic range +0.1, the percent of time within therapeutic INR range was 36.0% (29.0–45.6). This same outcome was 46.3% (38.9–60.9) for admissions with at least one therapeutic INR. Bleeding events occurred during 16 encounters, 10 of these were classified as major bleeds. There were a total of six venous thromboembolisms and no pump thrombosis events. CONCLUSION


There were 115 unique LVAD patient encounters (62 unique patients). Patients received pharmacy-managed warfarin in 113 encounters and heparin in 27 encounters. Of the 27 admissions with pharmacy-managed heparin, 23 had at least

The results of this study suggest that in patients with HeartMate II®, pharmacy-managed anticoagulation is effective and safe.


Kristen Heiner, PharmD Kristen completed her pharmacy prerequisites at the University of Rhode Island. She received her Doctor of Pharmacy at the University of Rhode Island College of Pharmacy in 2015. Following completion of her PGY1 Pharmacy Residency, Kristen will be pursuing a PGY2 in emergency medicine at UF Health Jacksonville in Jacksonville, Fla. Primary project preceptor: Jill Krisl, PharmD Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Impact of warfarin vs. novel oral anticoagulants on hospital length of stay in patients with chronic kidney disease Rita Jebrin, PharmD; Allison Wilson, PharmD; David Putney, PharmD, MPH; Meghan McComb, PharmD PURPOSE


Hospital length of stay (LOS) can be prolonged in patients with renal insufficiency due to bleeding and thromboembolic complications during anticoagulant therapy. Warfarin has been the staple treatment in this patient population, but novel oral anticoagulants (NOACs) provide an appealing alternative to warfarin due to minimal monitoring requirements. Yet, the impact of renal insufficiency on clinical outcomes in patients receiving NOACs has not been clearly elucidated.

Overall, hospital LOS was significantly shorter in patients who were receiving one of the NOACs than in those who were receiving warfarin therapy (10 days versus 18 days, respectively; p <0.01). During treatment, new thromboembolic event occurred in 4 patients in the NOAC group and 10 patients in the warfarin group (p= 0.2). Major bleeding events occurred in 3 patients during NOACs therapy and in 5 patients during warfarin therapy (p= 0.5). Death due to a bleeding event occurred in 1 patient in each treatment group.


A single center, retrospective cohort analysis was conducted among patients 18 years of age or older. A total of 200 chronic kidney disease (CKD) patients who were receiving warfarin therapy or one of the NOACs (apixaban, dabigatran, and rivaroxaban) for stroke prophylaxis in atrial fibrillation, or for the treatment of deep vein thrombosis, or pulmonary embolism were included in the study. The primary outcome was hospital LOS in each treatment group. Secondary outcomes include new thromboembolic or bleeding events, death during hospitalization, and hospital readmissions within 90 days of discharge.


In conclusion, NOAC therapy was associated with a shorter hospital LOS and comparable efficacy and safety outcomes compared to warfarin therapy in patients with CKD stage III-IV including dialysis patients.


Rita Jebrin, PharmD Rita earned her Doctor of Pharmacy from Jordan University of Science and Technology in 2013. Then she moved to the United States and completed her pharmacy internship at Houston Methodist Hospital. Following completion of her residency, Rita will move to Abu Dhabi for an ambulatory clinical pharmacist position at Cleveland Clinic. Primary project preceptor: Allison Wilson, PharmD, BCPS Presented at 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Evaluation of a steroid wean protocol in heart transplant recipients Tara Molina, PharmD; Jill Krisl, PharmD; Samantha Kuten, PharmD; Myung Park, MD; Arvind Bhimaraj, MD; Jerry Estep, MD PURPOSE


Outcomes following heart transplant (HT) depend heavily on maintenance immunosuppression wherein the challenge remains to optimize efficacy while minimizing drug-related adverse effects. Advancements in immunosuppressive agents have allowed transplant centers an opportunity to examine the feasibility of steroid withdrawal, given the welldocumented deleterious effects of chronic corticosteroid therapy. The purpose of this retrospective study was to evaluate the safety and efficacy of the HT steroid wean protocol (SWP) at Houston Methodist Hospital.

Thirty-six HT patients (61 ± 10.7 years, 78% white, 69% male) with an average of 5.5 years posttransplant met inclusion criteria. Maintenance immunosuppression consisted predominantly of tacrolimus (83%) and mycophenolate (89%). Overall, 89% (n=32) of patients were successfully weaned off steroids; of these, 75% (n=24) remain steroid-free at last follow-up. The most common reason for SWP discontinuation was patient intolerance. The incidence of acute cellular rejection (ACR), defined as biopsy-proven International Society for Heart & Lung Transplantation grade 2R or higher, was 6% (n=2/36), and 9% (n=3/32) at 4 weeks and 1 year, respectively.


HT recipients more than one year posttransplant who underwent the institution’s SWP between 2013 and 2015 were reviewed. Steroid weaning was initiated at prednisone 5 mg daily, and then decreased by 1 mg per day every 2 weeks until complete discontinuation by week 9. Patients were monitored with AlloMap™, echocardiogram, and endomyocardial biopsy (EMB) per protocol.


Our data suggests that the SWP was not associated with excessive rates of ACR and is an option for clinically stable HT recipients.


Tara Molina, PharmD Tara earned her BS in Honors Biochemistry with a minor in Spanish language from Baylor University in 2011 and subsequently completed her Doctor of Pharmacy at the University of Houston College of Pharmacy in 2015. Following completion of her PGY1 Pharmacy Residency, Tara will continue her postgraduate training as a PGY2 in critical care at Houston Methodist Hospital. Primary project preceptor: Jill Krisl, PharmD Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Urinary tract infection-associated bacteremia outcomes stratified by treatment modality Yevgeniy Raskin, PharmD; Katherine Perez, PharmD; Judy Ikwuagwu, PharmD; William Musick, PharmD PURPOSE


Gram-negative bacteremia is a complication of urinary tract infections (UTIs) that often leads to hospitalization and is usually treated for a minimum duration of seven days with intravenous (IV) antibiotic therapy. Data is lacking to indicate whether UTI-associated bacteremia treatment could be deescalated earlier to non-IV-equivalent oral (PO) antibiotics. The purpose of this investigation was to compare the clinical and microbiological outcomes of full-course (at least seven days) IV or IV-equivalent antibiotics versus early PO switch within five days after IV treatment initiation to nonIV-equivalent PO antibiotics (beta-lactams or Bactrim) in patients with UTI-associated gram-negative bacteremia.

There was no significant difference in the rate of clinical success between the early switch (N=52) and full course IV (N=52) group (75% vs 71%, respectively; p=0.66). Nor were there significant differences between: early switch and full course IV groups in time to defervescence (0.9 vs 1 day; p=0.98), microbiological eradication rate (100 vs 98%; p=1), and time to microbiological eradication (2.6 vs 2.0 days; p=0.38). Between the early switch and full course IV groups, there was a significant difference in time to clinical success (1.8 vs 2.7 days; p<0.01) and length of stay (4.0 vs 5.7 days; p<0.01). No other outcomes were significantly different between treatment groups.



In this retrospective case-control study, in-patients with positive blood and urine cultures with the same gram negative bacteria within 72 hours of admission were identified through a query of the electronic medical record. Out of these patients, cases with early switch (on day four or five of treatment) to PO antibiotics were included, matched 1:1 with controls (at least seven days of IV antibiotics) based on sequential matching of organism, gender, age, and Charlson comorbidity score.

When clinically appropriate, antimicrobial therapy may be switched from IV to PO beta-lactams or Bactrim early in the course of therapy to achieve similar outcomes and shorter length of stay than full-course IV antibiotics.


Yevgeniy (Gene) Raskin, PharmD Gene earned a BS in Biology and BS in Psychology at the University of Illinois at Chicago. He then earned his Doctor of Pharmacy from the University of Illinois at Chicago in 2015. Following the completion of his residency, he is pursuing a clinical pharmacist position in Chicago. Primary project preceptor: William Musick, PharmD, BCPS AQ-ID Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Integrating rapid pathogen identification and antimicrobial stewardship for patients with enterococcal bloodstream infections Tracy Chen, PharmD, MBA; Katherine Perez, PharmD; William Musick, PharmD; Randall Olsen, MD, PhD PURPOSE


Enterococcus species is the third leading organism recovered from nosocomial bloodstream infections (BSI) in the United States. Delays in identification of infecting pathogens force prescribers to initiate empirical broadspectrum antibiotic therapy in suspected patients. Treatment is further complicated by high rates of inherent and acquired antimicrobial resistance among enterococcal isolates. Matrixassisted laser desorption ionization time-of-flight (MALDITOF) mass spectrometry is a rapid, reliable, and costeffective diagnostic tool for the identification of organisms routinely found in the microbiology laboratory. The purpose of this study is to examine the clinical and economic impact of integrating results from MALDI-TOF for rapid organism identification with real-time notification to antimicrobial stewardship program (ASP) pharmacists on patients with enterococcal BSI compared with traditional methods.

Two hundred thirty-nine patients were eligible for the study. The median time from index blood culture to organism identification by MALDI-TOF was 25.6 hours compared to 40.8 hours in the preintervention cohort (p<0.001). TAT to susceptibility results was 1.7 hours shorter in the intervention cohort (61.8 h vs. 63.5 h, p<0.05). Among all patients, 75.7% received empiric vancomycin therapy to which the enterococcus spp. was susceptible in vitro. In patients who did not receive active therapy at time of organism identification, targeted antibiotic therapy was started 38.4 h earlier in the intervention cohort (30.4 h vs. 68.8h, p<0.001). Patients with vancomycin-resistant enterococcus (VRE) BSI were started on daptomycin or linezolid 25 hours earlier in the intervention group (33.0 h vs. 57.8 h, p=0.01). Patient ICU and hospital length-of-stay were not significantly different between two cohorts. Inpatient mortality was reduced in the intervention cohort (12% vs. 15%, p>0.05), although the study was not sufficiently powered to reach statistical significance. In the intervention period, ASP pharmacists initiated 104 stewardship interventions, averaging 0.96 intervention per patient, with a high acceptance rate of 97%.


This is a retrospective, single-center, quasi-experimental cohort study. Adult inpatients with at least 1 blood culture with Enterococcus spp. between January 2011 and December 2012 (preintervention period) and March 2013 through March 2015 (intervention period) were screened for eligibility. The primary endpoint was to determine the turnaround time (TAT) for enterococcus identification. Secondary endpoints included TAT for organism susceptibility results, time to active antibiotic therapy, length-of-stay in the intensive care unit (ICU) and hospital, and all-cause inpatient mortality. Pharmacist-initiated interventions were characterized by types.


MALDI-TOF successfully reduced time to identification of Enterococcus spp. In the intervention cohort, time to active antimicrobial therapy was significantly shorter in patients with VRE bacteremia and those who did not receive active therapy at the time of organism identification. The antimicrobial stewardship program produced meaningful interventions with effective outcomes.


Tracy Yixin Chen, PharmD, MBA Originally from China, Tracy earned her Doctor of Pharmacy and MBA from the dual degree program at the University of Rhode Island in 2015. She will complete the PGY1 international graduate program in October 2016 and plans to pursue a PGY2 in solid organ transplant. Her goals are to practice as a transplant pharmacy specialist before returning to China and helping her home country develop transplant pharmacy clinical services. Primary project preceptor: Katherine K. Perez, PharmD, BCPS Presented at 2016 Midwest Pharmacy Residency Conference, Omaha, Neb.; 2016 American Society of Health-System Pharmacists Summer Meeting, Baltimore, Md.



Impact of pharmacist telephone follow-up calls on patients with chronic obstructive pulmonary disease discharged from hospital to home Luma Succar, PharmD; Rejena Azad, PharmD; Katherine Perez, PharmD; Kayode Giwa, PharmD; April Moretto, RN; Rafael Felippi, PharmD PURPOSE


Chronic obstructive pulmonary disease (COPD) represents a major public health problem. In 2015, Centers for Medicare and Medicaid Services established a payment penalty for unplanned 30-day COPD readmissions. Recently, there has been increased interest in the benefits of continuity of care (CoC) related to reducing complication risks, increasing compliance, improving preventive care, and decreasing medical care costs. Pharmacists play a major role in CoC interventions. In an effort to address CoC for patients suffering from COPD, our institution has implemented a pharmacist-led, telephone based, discharge follow-up support program. The purpose of this study is to characterize the types and frequencies of interventions and discrepancies that occur at transition of care in Medicareinsured COPD patients contacted by a CoC pharmacist.

From a total of 458 eligible patients, 346 were successfully contacted by a pharmacist and formed our study population. The mean age was 74 years. The median length of hospital stay was three days, and the median time to the first postdischarge successful call was eight days. Pharmacists were able to identify various medication-related discrepancies, COPD and non-COPD related: 17% of the patients were non-adherent, 12% failed to receive one or more of their discharge medications, 8% had improper drug selection, 6% had untreated indications, 6% had adverse drug reactions, and 5% had improper dosing. Incomplete or inaccurate medication reconciliations were detected in 57% of patients. Pharmacists offered disease state education to 266 patients (77%). They also provided counseling on other preventive care measures and monitoring parameters, recommended scheduling follow-up appointments, and assigned patients to care navigator coordinators for help with physician referral, updating patient contact information, or medical record transmission.


We retrospectively reviewed charts of Medicare-insured patients with a principal diagnosis of COPD exacerbation, discharged from any of the five hospitals within the Houston Methodist system between January 2014 and May 2015. Discrepancies and interventions were classified under categories adapted from the American Society of Health-System Pharmacists (ASHP) statement of pharmaceutical care categories for medicationrelated problems and a previously published medication discrepancy tool.


Pharmacist involvement in the CoC process through postdischarge follow-up calls offers COPD patients a support system to medication management, emphasizes the various elements of the discharge plan, allows prevention and resolution of medication-related problems, and is not limited to the patientâ&#x20AC;&#x2122;s principal diagnosis. PGY1 INTERNATIONAL GRADUATE RESIDENCY

Luma Succar, PharmD Luma earned her BS in pharmacy and Doctor of Pharmacy from the Lebanese American University College of Pharmacy. She is expected to complete her PGY1 residency training in October 2016. Following completion, she will complete a PGY2 critical care residency at Houston Methodist Hospital with the 2017â&#x20AC;&#x201C;2018 residency class. Primary project preceptor: Rejena Azad, PharmD, BCPS Presented at 2016 Midwest Pharmacy Residency Conference, Omaha, Neb.; 2016 American Society of Health-System Pharmacists Summer Meeting, Baltimore, Md.



Impact of a unit-based pharmacy technician at a tertiary academic medical center Amanda Beck, PharmD; Anthony Colavecchia, PharmD; David Curlee, RPh PURPOSE

Pharmacy departments struggle with inefficiencies related to missing doses of medications and reordering parenteral drips for patients. In a typical month, Houston Methodist Hospital (HMH) has between 3,000 and 5,000 missing doses with around 80 to 100 missing doses per unit per month comprising less than 1% of total doses dispensed. A unit-based pharmacy technician (UBT) offers a viable solution to mitigating missing doses and improving pharmacy services offered to units. The only literature published includes case reports and anecdotes regarding the impact of a UBT on a hospital unit. The primary objective of this pilot is to improve the pharmacy department’s medication distribution process by decreasing the amount of missing doses. METHODS

A quasi-experimental study was conducted on general medicine and intermediate care units for a seven week period from Sept. 28, 2015, to Nov. 20, 2015, including a one week wash out period from Sept. 28, 2015, to Nov. 5, 2015. Study units were selected based on percent of missing doses, patient population, and types of medications frequently dispensed. A nursing satisfaction survey was administered to all full time day nurses on study units before the pilot and during week five of seven during the pilot.

Missing dose data pre and post implementation was collected via the hospital’s dispensing software, and validated with the pharmacy’s order manager software. The financial impact product costs associated with missing doses were calculated. The primary endpoint is the proportion of missing doses before and after implementation. RESULTS

Results show the mean number of missing doses on the primary unit before and after decreased (3.6+2.6 vs. 3.1+3.6; p=0.78). The mean number of missing doses on the secondary unit increased after implementation (4.7+3.9 vs. 7.4+3.7; p=0.02). The primary outcome of the proportion of missing doses also increased after implementation (163/151,561 vs 258/80951; p≤0.01). Missing dose requests per week ranged from 9 to 43 requests, the highest rate taking place during week five of seven. The calculated medication cost avoided over 14 week’s totals $6897.86. Nursing satisfaction with pharmacy services improved (35% vs. 77%; p≤0.01). The greatest improvement in nursing satisfaction was seen in the time locating missing medications (12% vs. 62%; p≤0.01). CONCLUSION

There was a statistically significant increase in the proportion of missing doses and nursing satisfaction on the general medicine and intermediate care study units.


Amanda Beck, PharmD Amanda completed a Bachelor of Science in Biomedical Sciences at Texas A&M University in 2011. She received her Doctor of Pharmacy from the University of the Incarnate Word, Feik School of Pharmacy in San Antonio in 2015. Next year Amanda will be completing the second part of the two year administrative program at Houston Methodist while obtaining a Master’s of Science in Pharmacy Administration and Management from the University of Houston. Primary project preceptor: David Curlee, RPh Presented at 2016 Texas Society of Health-System Pharmacy Alcalde, Frisco, Texas



Implementation of a sterile compounding workflow management system: A time motion study Linda Nguyen, PharmD; Anthony Colavecchia, PharmD, MS; Khiet Nguyen, PharmD, MS; Linda Haines, PharmD, MS PURPOSE


To evaluate how sterile compounding workflow technology (SCWT) impacts workflow turnaround time of doses dispensed, workflow efficiency and error rate.

Five hundred twelve sterile compounds were included in the preimplementation analysis of turnaround time, which were further categorized in: batch preparations (n=419) and nonbatched preparation (n=93). Mean turnaround time of all sterile compounds in minutes was 2.3±1.8. In comparison, turnaround time of batched preparations and non-batch preparations were 0.4±0.1 vs 11±9.6. Two errors were captured by the Patient Safety Net and 32 errors captures manually by pharmacist at point of final verification. Preliminary results from the washout period illustrated an increase in average weekly turnaround time from 16.1 minutes to 19.4 minutes throughout the process implementation. Two hundred ninety-one in-process errors captured were due to build errors. Ninety-one errors were captured by pharmacists at point of verification resulting to rework.


This study is a single-center, quality assurance, and quasiexperimental study of medications dispensed from the sterile products area in Central Pharmacy. Data will be collected for four weeks pre- and postimplementation with a one month washout period. The primary endpoint is the mean difference in turnaround time of sterile compounds between pre- and postimplementation from label print time to final verification. The secondary objectives are to compare the mean turnaround time of immediate (STAT) medications and batch preparations, quantity and cost of wasted sterile products captured through pharmacy credits, and number of preparation errors.


Preliminary data identified many challenges with implementation of a new technology. Final results may provide justification for implementation of the IV workflow software at all system hospitals and satellite pharmacies throughout 2015 and 2016.


Linda Nguyen, PharmD Linda earned her Bachelor of Science in general science from Oregon State University. She earned her Doctor of Pharmacy degree at Oregon State University/Oregon Health and Science University in 2015. Most recently she has completed the first year of her health-system administration residency. Primary project preceptor: Linda Haines, PharmD, MS, BCPS Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Texas Society of Health-System Pharmacy Alcalde, Frisco, Texas



Association between health literacy and 30-day health care use after hospital discharge in the heart failure population Sarah Cox, PharmD, MS; Kevin Garey, PharmD; Meghan McComb, PharmD; Michael Liebl, PharmD; Allison Wilson, PharmD; May Achi, PharmD; David Wallace, PharmD PURPOSE


Low health literacy increases the risk for hospital readmissions. Despite this, the measurement and use of health literacy to guide discharge counseling and planning in heart failure patients is not commonly performed. A short 3-Question Brief Health Literacy Screen (BHLS), is available and takes less than three minutes to complete but has never been evaluated to identify if health literacy affects 30-day health care use after discharge in patients with heart failure. The purpose of this study was to assess 30-day readmissions and emergency department (ED) visits based on health literacy evaluated by the BHLS in an acute care heart failure population.

Two hundred sixty-four patients aged 66.6Âą14.3 (meanÂąSD) years met inclusion/exclusion criteria of whom 175 (66.3%) had a BHLS score >9 (adequate health literacy) and 89 (33.7%) had a BHLS score <9 (low health literacy). Predictors of low health literacy included older age (p=0.019), lower education level (p<0.001) and unemployed (p=0.048). After controlling for potential confounders, low health literacy was independently associated with 30-day health care use after hospital discharge (OR:1.80; 95% CI: 1.04-3.11; p=0.035).


This was a prospective observational cohort study conducted at a large quaternary health system. Hospitalized patients with a diagnosis of heart failure were assessed for health literacy using the BHLS. Unplanned health care use after discharge including 30-day all-cause ED visits and hospital readmissions was assessed using univariate and logistic regression models.


Using a short, three-question validated survey instrument, we demonstrated that low health literacy was associated with increased 30-day unplanned health care use after discharge in this heart failure population. These results provide a clinically useful, easily incorporated tool that could identify high-risk patients at need for interventions.


Sarah Cox, PharmD, MS Sarah completed her prepharmacy requirements at the University of Missouri and earned her Doctor of Pharmacy in 2014 at the University of Missouri-Kansas City School of Pharmacy at MU. She earned her Master of Science in Pharmacy Leadership and Administration at the University of Houston College of Pharmacy. Sarah has accepted a position as an assistant professor of pharmacy practice management at the University of Missouri-Kansas City School of Pharmacy at MU. Primary project preceptor: Meghan McComb, PharmD Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Pharmacy student motivational interviewing intervention in hospitalized patients â&#x20AC;&#x201D; A pilot study Roya Tran, PharmD, MS; E. James Essien, MD, DrPH; Kayode Giwa, PharmD; Kathryn Pidcock, PharmD; Susan Abugosh, PhD PURPOSE


Motivational interviewing (MI) is a style of patientcentered counseling that is brief, and has demonstrated efficacy in addressing a variety of health issues. It is a nonconfrontational counseling style aimed at helping patients understand and resolve their ambivalence about behavior change. Despite the strong evidence associated with improved medication adherence and health outcomes from delivering MI, traditional education and training for pharmacy students involves little or no exposure to practice effective behavioral change techniques such as MI with patients in actual clinical settings. The purpose of this study is to determine feasibility of coordinating and training APPE students to deliver MI education with patients who have hypertension and low medication adherence. A secondary purpose is to assess changes in pre and post measures of self-reported blood pressure, medication adherence, and self-efficacy with a motivational interview intervention.

A total of 155 patients records were prescreened for uncontrolled blood pressure upon admission with only 28 patients (18%) consenting to participate in the study. Of those who consented, 15 patients (54%) successfully followed up by phone to provide postintervention data on self-reported blood pressure, adherence, and self-efficacy scores. There was a trend for decreased blood pressure (p<0.01, n=12) and improved medication adherence scores (p<0.001, n=15) for patients with successful follow up. There was no significant difference in the proportion of patients who had poor self-efficacy before and after the study (p<0.25, n=15).


These objectives were assessed by piloting a few students on general medicine rotations to screen and consent patients to participate in inpatient counseling as well as outpatient phone follow-up. Descriptive statistics were calculated and chi-square analysis was conducted to evaluate pre and post differences in self-reported adherence, blood pressure, and self-efficacy.


This pilot study demonstrated feasibility of training pharmacy students to use core MI skills to counsel patients within the hospital setting. While there was a low rate of patient consenting to the study due to allocation of student time to the enrollment process, there was a favorable trend in reducing patient blood pressure and improving the proportion of medication adherence in patients followed up by phone. Extending the enrollment time period, and allocating more dedicated time of study participants to the training and consenting process may improve consent rates in future study designs.


Roya Tran, PharmD, MS Roya earned her Doctor of Pharmacy at University of Florida in Gainesville, Fla. in 2014. Most recently, she obtained a Master of Science in pharmacy administration and leadership from the University of Houston. Upon completion of the health-system pharmacy administration residency training, she will serve as the inpatient operations manager for Vanderbilt Childrenâ&#x20AC;&#x2122;s Hospital in Nashville, Tenn. Primary project preceptor: Susan Abugosh, PhD Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Evaluation of methylene blue in vasodilatory shock in non-mechanical circulatory support device patients Annette Lista, PharmD; Kevin Donahue, PharmD; Julin Thomas, PharmD; Kalliopi Fitousis, PharmD; David Putney, PharmD, MPH PURPOSE

The loss of vascular tone in vasodilatory shock is frequently due to a severe inflammatory response secondary to infection and is a major cause of morbidity and mortality in the intensive care unit. Vasodilation due to smooth muscle relaxation by nitric oxide is one cause of hypotension. Methylene blue is a selective inhibitor of guanylate cyclase, a second messenger involved in nitric oxide-mediated vasodilation. By inhibiting guanylate cyclase, methylene blue may minimize the effects of nitric oxide and subsequent vasodilatation. The purpose of this study to provide new knowledge on the effects of methylene blue across multiple shock etiologies and patient populations. METHODS

This was a single center retrospective descriptive study. Eligible patients were > 18 years of age and received methylene blue for vasodilatory shock from Jan. 1, 2011, to Sept. 31, 2015. The primary endpoint of this study was to determine clinical response to methylene blue, defined as a change in mean arterial pressure (MAP) > 10% without an increase in vasopressor requirements. RESULTS

Sixty-one patients met eligibility criteria. Baseline demographics as follows: mean age 13.5 (±14), 36 (59%) were male, 31 (51%) were Caucasian, and 42 (69%) were

admitted to the surgical and liver intensive care unit (ICU). The primary shock etiology was 38 (62%) septic, 18 (30%) cardiogenic, and 5 (8%) hemorrhagic. Methylene blue was ordered as a bolus and infusion in 33 (54%) patients, bolus alone in 27 (44%) patients, and infusion alone in 1 (2%) patient at a mean bolus dose of 1.25 mg/kg (±0.45) and infusion 0.5 mg/kg/hr (±0.30). There were 20 (33%) that met the primary endpoint compared to 41 (67%) of patients who did not meet the primary endpoint, p = 0.62. Preliminary results suggest that there is no difference in change of MAP by greater than 10% from baseline without any change in vasopressor support from baseline. Of those who responded to methylene blue, the time from ICU admission to methylene blue initiation was 6 (±6) hours compared to 11 (±15 hours), p = 0.06, which could suggest some benefit in earlier initiation of therapy. However, the overall mortality included 3 (15%) of responders that survived compared to 6 (15%) of non-responders that survived. CONCLUSION

There were no observed differences in association with methylene blue and improvement of mortality or increase in MAP as defined in this study with methylene blue utilization. Preliminary data suggests there is a lack of evidence to support methylene blue use.


Annette Lista, PharmD Annette earned her BS in Pharmaceutical and Healthcare Studies at the University of the Sciences in Philadelphia, PA. She earned her Doctor of Pharmacy at the University of the Sciences in Philadelphia, PA in 2014. She completed a PGY1 pharmacy residency at Einstein Medical Center in Philadelphia, PA. Annette has accepted a Clinical Specialist II in Critical Care position at Houston Methodist Hospital. Primary project preceptor: Kevin Donahue, PharmD, BCPS Presented at 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Effect of antithrombin III supplementation on the activity of unfractionated heparin therapy: A retrospective cohort study Matthew Rubertus, PharmD; David Putney, PharmD; Kalliopi Fitousis, PharmD; Kevin Donahue, PharmD PURPOSE


Unfractionated heparin is a commonly used anticoagulant in critically ill patients for a variety of indications. Antithrombin III is required for heparin to exert its anticoagulant activity. The definition of heparin resistance has not been well described in critically ill patients, and the impact of acute antithrombin III supplementation in this population is unknown.

The proportion of patients achieving therapeutic anticoagulation at 12 hours in the antithrombin III supplemented group, as compared to the control group, was 48.1% versus 37.0% (p=0.337). Safety outcomes were not significantly different between the two groups, and there was no difference in any outcome for the subgroup of patients requiring mechanical circulatory support.



This single-center, retrospective cohort study where 27 patients receiving ATIII supplementation were matched 1:2 with 54 patients that were not supplemented. The primary outcome was the proportion of patients achieving therapeutic anticoagulation 12 hours after acute antithrombin III supplementation. Safety outcomes and a subgroup of patients requiring mechanical circulatory support devices were also analyzed.

For patients admitted to the intensive care unit, there was no difference in efficacy or safety with acute supplementation of antithrombin III in regards to anticoagulation parameters and bleeding risk.


Matthew Rubertus, PharmD Matt earned his BS in pharmaceutical science from The Ohio State University in 2010, and his Doctor of Pharmacy from the University Of Tennessee College Of Pharmacy in 2014. He completed his PGY1 Pharmacy Residency at Emory University Hospital in Atlanta. Matt has accepted a position as a critical care clinical specialist in the cardiac ICU at St. Louis University Hospital in St. Louis. Primary project preceptor: Kevin Donahue, PharmD, BCPS Presented at 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Efficacy of late afternoon plerixafor administration for stem cell mobilization Cynthia El Rahi, PharmD; James Cox, PharmD; Rammurti Kamble, MD PURPOSE

Inadequate hematopoeitic progenitor cell (HPC) mobilization is seen in approximately 25% of patients undergoing stem cell collection prior to autologous hematopoeitic stem cell transplantation (HSCT). Plerixafor is indicated in combination with granulocyte-colony stimulating factor (G-CSF) for HPC mobilization prior to autologous HSCT for non-Hodgkin’s lymphoma (NHL) and multiple myeloma (MM). It reversibly inhibits the binding of stromal cell-derived factor-1, expressed on bone marrow stromal cells, to the CXC chemokine receptor 4 resulting in mobilization of HPCs from bone marrow into peripheral blood. Pharmacodynamics studies in healthy volunteers demonstrated a sustained elevation in the peripheral blood (PB) CD34+ count from 4 to 18 hours with a peak between 10 and 14 hours. In response to this, the manufacturer recommends administration of plerixafor approximately 11 hours prior to initiation of apheresis, which translates into an administration time of 10–11 p.m. In June 2013, the FDA added language to the safety labeling warning of the risk of anaphylactic reactions occurring during and immediately after administration, and recommended that patients be monitored for at least 30 minutes after administration. Following this guidance and based on pharmacodynamic data suggesting sustained effects of plerixafor at 18 hours, our clinic changed practice in July 2013 to administer plerixafor at 4 pm. To date, there are few descriptions showing the efficacy of earlier administration of plerixafor in achieving desired HSC collection efficiencies.

This aim of this study was to retrospectively compare the stem cell collection efficiency of patients treated with plerixafor before and after the change in practice at our institution. METHODS

A retrospective chart review of patients with NHL and MM, who received a plerixafor-containing mobilization regimen prior to autologous HSCT, was conducted. RESULTS

208 patients were included in the analysis (68 and 140 patients in the 4 p.m. and 10 p.m. administration time groups, respectively). 91% of patients in the 4 p.m. group achieved minimal CD-34+ cell goal (2 × 106 CD34+ cells/kg) in ≤2 apheresis days compared to 89% in the 10 p.m. group (p=0.804) resulting in comparable stem cell collection efficiency. CONCLUSION

Late afternoon administration of plerixafor is as effective as 10 p.m. plerixafor administration. This finding validates our current practice for late afternoon administration of plerixafor.


Cynthia El Rahi, PharmD Cynthia earned her Doctor of Pharmacy from the Lebanese American University College of Pharmacy in 2012. Most recently, she worked as a clinical pharmacist at Houston Methodist Hospital after completion of her PGY1 Pharmacy Residency at Houston Methodist Hospital before beginning her PGY2 training. Cynthia has accepted an oncology clinical specialist position at Houston Methodist Hospital. Primary project preceptor: James Cox, PharmD Presented at 2016 Hematology Oncology Pharmacy Association Annual Conference, Atlanta, Ga.



Retrospective evaluation of safety and efficacy of direct oral anticoagulants versus low-molecular weight heparin and vitamin K antagonist in patients with cancer Elizabeth Pritchard, PharmD; Jose Murillo, PharmD, MHA, MBA; David Putney, PharmD, MPH PURPOSE


Direct oral anticoagulants (DOACs), including direct factor-Xa inhibitors apixaban, edoxaban, and rivaroxaban and direct thrombin inhibitor dabigatran, are FDA-approved for the treatment and prevention of recurrent venous thromboembolism (VTE) and prevention of stroke in patients with non-valvular atrial fibrillation (NVAF). Patients with cancer accounted for only 2.3% to 9.4% of the total study population in clinical trials. Current guidelines do not recommend DOACs for acute and chronic management of VTE in cancer patients. Rather, low-molecular weight heparin (LMWH) is preferred, with a vitamin K antagonist (VKA) as an alternative agent for chronic management. For patients with NVAF, there are no formal recommendations. The goal of this study is to evaluate safety and efficacy of DOACs compared to LMWH and VKA in cancer patients.

A total of 258 patient charts were reviewed. Patients were grouped based on anticoagulant used for the majority of initial hospital admission with 80 patients included in the DOAC group, 95 patients in the LMWH group, and 83 patients in the VKA group. There were statistically significant differences between the groups; differences included: age, race, renal function of patients, acute DVT, NVAF, and other indications for anticoagulation, and cancer diagnosis of breast, gastrointestinal, gynecologic, and hematologic. DOACs drug utilization were: apixaban 43%, rivaroxaban 40%, and dabigatran 17%. There was no statistically significant difference in major bleeding events amongst the groups. Major bleeding events did not differ across the groups (15% vs. 17% vs. 18%; p=0.87). The most common type of major bleeding event across all groups was gastrointestinal bleeding. One subdural hematoma events occurred in each group. Non-major bleeding events were similar across all three groups (14% vs. 7% vs. 7%; p=0.29). Recurrent VTE occurred in six DOACs patients, 11 LMWH patients, and five VKA patients and was not statistically significant (p=0.44).


This retrospective, exploratory study utilized data from hospitalized, adult patients with cancer who received both chemotherapy and anticoagulant therapy during a single admission between January 2012 and October 2015. Patients who received anticoagulation therapy indicated for VTE prophylaxis, chemotherapy utilized for non-cancer diagnosis, or chemotherapy as part of conditioning regimen for stem cell transplant were excluded. The primary safety endpoint was incidence of major bleeding. Secondary endpoints include incidence of recurrent VTE and nonmajor bleeding.


DOACs appear to be a feasible alternative based on the safety and efficacy endpoints of this study. Future trials comparing DOACs to standard of care LWMH will help define DOACs role in treatment and prevention of VTE in cancer patients. PGY2 ONCOLOGY RESIDENCY

Elizabeth Ryan Pritchard, PharmD Ryan completed her pharmacy prerequisites at East Tennessee State University prior to earning her Doctor of Pharmacy at Bill Gatton College of Pharmacy at East Tennessee State University in 2014. She completed her PGY1 Residency at Blount Memorial Hospital in Maryville, Tenn. She has accepted a position as Assistant Professor at the University of Arkansas for Medical Sciences College of Pharmacy in Little Rock, Ark. She will also practice as a clinical pharmacist in the Hematology/Oncology Palliative Care Clinic at the Winthrop P. Rockefeller Cancer Institute. Primary project preceptor: Eleanor Hobaugh PharmD, BCOP Presented at 2015 University HealthSystems Consortium, New Orleans, La.



Validation of an AUC-targeted vancomycin dosing nomogram in hospitalized patients Vu Ta, PharmD; Katherine Perez, PharmD; Judy Ikwuagwu, PharmD; William Musick, PharmD PURPOSE


Despite ubiquitous use over the past 50 years, controversy remains regarding the most optimal dosing and monitoring strategy for vancomycin. The 2009 vancomycin monitoring consensus guidelines recommend vancomycin troughs as the most practical monitoring parameter for clinical practice, while recognizing evidence showing that 24 hour areaunder-the-curve over minimum-inhibitory-concentration (AUC/MIC) targets of 400–550 are associated with positive patient outcomes. Furthermore, recent research has shown vancomycin troughs correlate poorly with clinical outcomes. The problem persists that AUC is difficult to obtain routinely in practice. We seek to develop and clinically validate a vancomycin dosing nomogram targeting AUC/MIC with the goal of also keeping serum trough levels within acceptable ranges to minimize toxicity and maximize prescriber adoption.

One hundred seventy-five patients were included (100 in the pre-nomogram group, 75 in the nomogram group). Target AUC attainment and median AUC were similar in both groups (60 vs 69%, p=0.282 and 465 vs 457, p=0.2879). Six patients in the pre-nomogram group had AUC above the target of 800, compared none in the nomogram group. Target trough attainment was higher in the nomogram group (46% vs 61%, p=0.041), while median troughs were similar (12.3 vs 12.1, p=0.74). Incidence of acute kidney injury (as defined by KDIGO) also trended towards improvement in the nomogram group (28% vs 18.7%, p=0.142). A greater proportion of patients in the pre-nomogram group received the one gram every 12-hour regimen compared to the nomogram group (49% vs 17%, p<0.001). CONCLUSION


A single center, retrospective, pre- and postimplementation study. We proposed a vancomycin dosing nomogram based upon previously published, population-derived pharmacokinetic models, targeting AUC/MIC of 400–800 and serum trough levels 10–20mg/L. The nomogram was applied prospectively to hospitalized adult patients with stable renal function (CrCl 30–120ml/min) and protocolized by pharmacy-driven consults to dose vancomycin. The primary outcome is AUC target attainment of 400–800. Outcomes from the nomogram group were compared to pre-nomogram patients’ dosed using traditional trough monitoring by clinical pharmacists.

The proposed AUC-target vancomycin nomogram did not significantly increase AUC target attainment as predicted. However, it eliminated patients with potentially toxic AUC values and improved target trough attainment. There was also a trend towards lower incidence of acute kidney injury, and more patients received individualized dosing using the nomogram.


Vu Ta, PharmD, BCPS Vu earned her BS in chemistry from University of California–Davis in 2008 and Doctor of Pharmacy from University of Houston College of Pharmacy in 2014. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital. Vu has accepted a position as an antimicrobial stewardship pharmacist at Christus Trinity Mother Frances Hospital in Tyler, Texas. Primary project preceptor: William Musick, PharmD, BCPS-AQ ID Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Retrospective analysis of hospital-acquired venous thromboembolism: Evaluation of time to occurrence based on risk stratification Alexandra Whiddon, PharmD; Melanie Ruegger, PharmD; Mobalaji Adeola, PharmD; David Putney, PharmD PURPOSE


In-hospital venous thromboembolism (VTE) causes significant morbidity and mortality in hospitalized medical and surgical patients. Risk factors have been identified which predispose patients to developing VTE, which include hip or leg fracture, major general surgery, central venous lines, malignancy, and previous VTE, among others. Risk assessment models have been developed to identify patients at risk for VTE while hospitalized. The objective of our study is to determine the time to in-hospital VTE development based on baseline risk stratification.

The cohort included 400 patients, 224 (56%) males, with a median age of 66 years. VTE included lower extremity DVT (n=212, 53%), upper extremity DVT (n=75, 19%), PE (n=68, 17%), and combination DVT + PE (n=45, 11%). Upon admission, the median risk score was 5, most patients were classified as highest risk (n=220, 73%). At the time of VTE event, the median risk score had increased to eight (p<0.001 for the comparison between the admission risk score and time of VTE risk score). The median time to VTE event was eight days. Patients in the low risk group developed a VTE within 12.5 days, moderate risk in eight days, high risk in eight days, and highest risk in seven days. Analysis of the primary endpoint, time to VTE based on baseline risk assessment, revealed a statistically significant difference between the risk groups.


A retrospective analysis was performed on patients aged 18 years or older admitted to Houston Methodist Hospital and developed a VTE during their hospital admission from Sept. 1, 2011, to June 30, 2015. Patients were identified using diagnosis codes for upper extremity DVT, lower extremity DVT, and PE not present on admission. Risk assessment was performed by study investigators using the Houston Methodist Hospital risk assessment tool at the time of admission and at the time of VTE development. The primary endpoint of this study was the time to in-hospital VTE based on baseline risk stratification.


This study shows that the time to VTE in a broad hospitalized patient population differs significantly based on the risk group upon admission.


Alexandra Whiddon, PharmD, BCPS Alexandra earned her BS in biological sciences with minors in chemistry and French from Louisiana State University in 2010. She then attended pharmacy school at the University of Houston College of Pharmacy, graduating with her Doctor of Pharmacy in 2014. She completed her PGY1 Pharmacy Residency at Houston Methodist Hospital. Alexandra has accepted a position as an internal medicine clinical specialist at Houston Methodist Hospital. Primary project preceptor: Melanie Ruegger, PharmD, BCPS Presented at 2015 University HealthSystem Consortium, New Orleans, La.; 2016 Midwest Pharmacy Residents Conference, Omaha, Neb.



Hospitalizations, survival, and complications: 1-year outcomes for elderly lung transplant recipients Nicole Casciello, PharmD, MBA; Amaris Fuentes, PharmD; Jill Krisl, PharmD; Neeraj Sinha, MD; Thomas Kaleekal, MD PURPOSE

In 2014, The International Society for Heart and Lung Transplantation published consensus guidelines listing age greater than 65 years as a relative contraindication to lung transplant due to reduced physiologic reserve and presence of comorbidities that may lead to poorer outcomes. The purpose of this study is to assess clinical outcomes and posttransplant complications among elderly lung transplant recipients (LTR) as compared to younger cohorts at our institution. METHODS

This is a single center, retrospective, cohort study. Eligible patients received a single or double lung transplant between Jan. 1, 2012, and Dec. 31, 2014 and were 50 years or older at the time of transplant. Patients who received a redo lung or multi-organ transplant, or expired prior to discharge were excluded. The primary endpoint is number of days alive and outside a health care facility in the first year posttransplant.

p=0.04) and Caucasians (66.2% vs. 72.3% vs. 89.1%; p=0.01) compared to the youngest cohort. Lung allocation scores were similar among the cohorts (42.7±16.2 vs. 43.8±17.9 vs. 45±16; p=0.73); however, more patients in the two older cohorts received a single lung transplant (30.9% vs. 56.2% vs. 78.1%; p<0.01). Preliminary results suggest no difference in total days alive and outside a health care facility in the first year posttransplant (289.4±98.9 vs. 268.5±110.4 vs. 270.6±112.9 days; p=0.43), 1-year patient survival (91.2% vs. 83% vs. 81.3%; p=0.22), or total hospitalized days in the first year posttransplant (16.2±22.9 vs. 21.8±26.8 vs. 19.6±22.7 days; p=0.34). Furthermore, posttransplant length of stay (LOS) (16.3±8.7 vs. 18.6±12.2 vs. 15.2±8.8 days; p=0.10) and intensive care unit LOS (7.3±8.4 vs. 9.9±11.1 vs. 7.0±8.8 days; p=0.10) during the index admission were similar among the cohorts. A greater percentage of patients ages 60-69 years were discharged to long-term acute care facilities after the index admission (29.4% vs. 51.4% vs. 40.6%; p=0.02). CONCLUSION


Two hundred thirty-seven patients met eligibility criteria as follows: 50–59 years (n=68); 60-69 years (n=105); and greater than 70 years (n=64). The two older cohorts had a greater percentage of males (54.5% vs. 71.4% vs. 71.9%;

Preliminary data suggests outcomes in elderly LTR in the first year posttransplant may be similar to their younger counterparts.


Nicole Casciello, PharmD, MBA Nicole earned her BS in food marketing from Saint Joseph’s University, an MBA from The Wharton School at The University of Pennsylvania, and Doctor of Pharmacy from The University of Texas at Austin College of Pharmacy. Prior to pharmacy school, she served as a management consultant and marketing executive. Most recently, she completed her PGY1 Pharmacy Residency at Duke University Hospital. She has accepted a position as a heart and lung transplant clinical specialist at Indiana University Health. Primary project preceptor: Amaris Fuentes, PharmD, BCPS Presented at 2016 American Transplant Congress, Boston, Mass.




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Houston Methodist Hospital Department of Pharmacy Annual Report 2016  
Houston Methodist Hospital Department of Pharmacy Annual Report 2016