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The Great Eight Residency Showcase
June 13, 2018
St. Francis Hospital & Medical Center


 

The Connecticut Society of Health System Pharmacy offers the opportunity for ALL Pharmacy Residents (PGY1 and 2) to submit abstracts. Eight outstanding abstracts are chosen to present their research in a 12-minute Platform Presentation in June. Three final winners are selected.


Note: The Great Eight was introduced in 2012 to spotlight the work of CSHP's Resident members. Potential speakers submit abstracts that are judged using an objective rubric.
1st Place 2018

Optimizing outcomes for methicillin-resistant S. aureus bacteremia (MRSA-B), methicillin-susceptible S. aureus bacteremia (MSSA), and coagulase negative Staphylococcus (CoNS) utilizing rapid diagnostics in conjunction with pharmacy residents across Yale New Haven Hospital (YNHH)

AUTHOR: Nika Bejou, PharmD   Co-Authors: Dayna McManus, PharmD; David Peaper, MD, PhD; Jeffrey Topal, MD

 

Background: Given the severity of S. aureus bacteremia, prompt initiation of appropriate antibiotics is key. YNHH implemented the Cepheid® Xpert MRSA/SA PCR in an effort to decrease the time needed to identify MRSA-B, MSSA-B, and coagulase-negative Staphylococcus (CoNS). The impact of rapid diagnostics has been limited without stewardship or infectious disease (ID) involvement. Our unique notification algorithm utilized our on-call pharmacy residents to allow for 24/7 coverage. The primary objective was time to optimal antibiotic therapy (OAT) before and after implementation of the PCR and algorithm. Secondary outcomes included time to blood culture clearance (BCC), acceptance rate of pharmacist interventions, days of vancomycin therapy avoided, and 30-day mortality.

 

Methods: A retrospective cohort study was conducted in adult inpatients with blood cultures positive for Gram positive cocci in clusters. The pre-implementation, control group (CG) included patients from 4/2017-10/2017 and the post-implementation, intervention group (IG) was from 10/2017-4/2018. Patients < 18 years and polymicrobial bacteremia were excluded. Data collected in addition to primary and secondary outcomes included baseline demographics, allergies and empiric antibiotics. OAT included vancomycin for MRSA or MSSA with severe β-lactam allergy; nafcillin or cefazolin for MSSA; and discontinuation of vancomycin for CoNS deemed a contaminant.

 

Results: Of the 544 patients reviewed, 434 met inclusion criteria: 182 in the CG and 252 in the IG. Average time to OAT decreased from 10 hours in the CG to 5 hours in the IG (P = 0.006). Time to BCC in the CG and IG cohorts decreased from 100 to 43 hours (P = 0.0001). One day of vancomycin was avoided in patients with MSSA-B and 2 days with CoNS. 30-day mortality decreased from 18% (n = 32) in the CG versus 5% (n = 13) in the IG (P = 0.00003). Finally, 95% (n = 153/161) of pharmacist interventions were accepted.

 

Conclusions: Utilizing the on-call pharmacy resident for notification of rapid diagnostic results for S. aureus bacteremia, we saw a significant decrease in time to OAT, BCC, and 30-day mortality. Our study demonstrates that in the setting of limited stewardship resources, additional members of the health care team can be used to optimize antibiotics in conjunction with rapid diagnostics.

2nd Place Tie - 2018

Increasing pharmacist efficiency through electronic health record optimization

Author: Cory Heck,Yale New Haven Health System (YNHHS), New Haven, Connecticut

Co-Authors: G. Rouse, G. Jaszczur, R. Vonderheyde, M. Anderson, T. Papstein, M. Rogers, E. Tichy

 

OBJECTIVE: The electronic health record (EHR) at Yale New Haven Health System (YNHHS) is customizable, allowing for enhancements to optimize pharmacist work flow. Columns within patient lists can be built that will generate action items triggered from clinical information within the patient’s chart. The objective of this project is to determine whether clinical decision support using these customizable columns improves pharmacist productivity as measured by time to intervention.

 

METHODS: Columns were built with the intention of identifying IV to enteral and renal dose adjustment (RDA) opportunities. YNHHS protocols were used to model the alert firing rules within the EHR.  Intervention opportunities were denoted with various icons in columns within the patient lists. To test pharmacist efficiency, eight pharmacists from different specialties across our health-system performed time studies to determine time to intervention with both their current method of identification and again with the enhanced columns. The time study required each pharmacist to evaluate 80 patients for IV to enteral and RDA interventions. The differences in time to identifying the intervention and the number of interventions missed were analyzed utilizing unpaired t tests and Fisher’s exact test respectively.

 

RESULTS: One hundred sixty patients were reviewed in each arm of the study (IV to enteral and RDA with and without enhanced columns). On average it took 9.7 (± 13.0) secs to identify if an IV to enteral intervention required adjustment without the enhanced column and 1 (±3.8) sec on average with the enhanced column (p < 0.05). On average it took 26.7 (±27.5) secs to identify a medication requiring renal dose adjustment without the enhanced column and 1 (±2.8) sec on average with the enhanced column (p < 0.05). Identifying IV to enteral interventions without the column took an average of 3 mins and 14 secs to review 20 patients, compared to 21 secs when using the column. Identifying renal dose adjustment interventions without the column took an average of 8 mins and 53 secs to review 20 patients, compared to 20 secs when utilizing the column. In total, without the enhanced columns 11 / 53 (20%) interventions were missed; compared to 0 / 56 (0%) missed in the enhanced column group (p < 0.05).

 

CONCLUSION: EHR optimization via implementation of customizable column alerts are a useful tool to prioritize interventions and increase pharmacist efficiency. Additional alerts will be evaluated in the future to see if they have the same effect as the IV to enteral and RDA decision support.

2nd place tie 2018

Proton pump inhibitor prescribing habits in an adult medicine continuity care clinic

Author: Natalie S. Winters, PharmD, PGY2 Ambulatory Care Pharmacy Resident   Co-authors: Williams, A.; Ammar, M., Saint Francis Hospital and Medical Center

Background

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal (GI) disease with an estimated prevalence of 20-40%. The recommended treatment is an eight-week course of a proton pump inhibitor (PPI). Chronic PPI use occurs in approximately 40% to 55% of all primary care patients and is associated with long-term side effects including hypomagnesemia, vitamin B12 deficiency, pneumonia, osteoporosis, bone fractures, and enteric infections (Clostridium difficile infection and spontaneous bacterial peritonitis).

Objective

The objective of this study is to determine the percentage of appropriate and inappropriate PPI prescriptions ordered by providers in an adult medicine continuity care clinic for the treatment of GERD within a six-month period.

Methods

This was an institutional review board (IRB) approved, retrospective chart review. All PPI prescriptions ordered for patients 18-100 years of age from January 1, 2017 to June 30, 2017 by a provider in the adult medicine continuity clinic were included in the study. Utilizing an electronic health record (EHR) report, all PPI prescriptions were identified by the date the prescription was ordered. Additional information obtained from the report included the strength, frequency, and quantity of the medication prescribed. Each patient’s EHR was manually reviewed to determine the indication of PPI and to evaluate the appropriateness of the medication. If the PPI was ordered for GERD, appropriateness was determined by the total days’ supply prescribed as well as the documentation of on-going symptoms. The primary endpoint of the study was the percentage of appropriately prescribed PPI prescriptions for the indication of GERD. Secondary endpoints included percentages of PPIs prescribed for non-GERD indications, GERD indications, and percentage of inappropriately prescribed PPIs for GERD based on quantity written.

Results

A total of 112 PPI prescriptions met inclusion criteria for this study. All prescriptions were ordered on a day the patient was seen in the clinic by the provider. Seventy-five percent of the PPIs ordered were for GERD compared to 10.7% for non-GERD indications; 14.3% of PPIs did not have a documented indication in the encounter note or on the patient’s problem list. For the indication of GERD, 35.7% of PPIs were appropriately prescribed. Of the remaining inappropriately prescribed PPIs for GERD, 57.1% were written for more than 60 days, 2.4% were written for a quantity of 56-60 days, and 4.8% were written for a quantity less than 56 days.

Conclusion

The majority of PPIs ordered were inappropriately prescribed due to lack of indication, symptom documentation, or treatment duration. Therefore, this is an area of improvement for providers to assess current PPI use for the patient’s given indication.

3rd place 2018

Effect of CT law requiring prescription drug monitoring program use on emergency department opioid prescribing habits: a single-center retrospective analysis

Author: Abigail L. Zeiner, PharmD Co-Authors: Michelle A. Burak, PharmD, BCPS, and Dayne Laskey, PharmD, DABAT

Objective:  In an effort to reduce the effects of the opioid crisis, Connecticut Public Act 15-198 went into effect on October 1, 2015. This law requires all prescribers or their agents to review a patient’s prescription drug monitoring program (PDMP) profile prior to prescribing a controlled substance with greater than a 72-hour supply. The purpose of this study is to compare opioid prescribing behavior of emergency department (ED) providers before and after the law’s enactment at a large academic tertiary medical center.

Methods: This study is a single-center pre and post-law analysis of Hartford Hospital’s ED patients discharged with prescriptions for opioid medications. Data was collected utilizing reports generated from the ED’s historical computer system, Allscripts™. Patients discharged from the ED from January 1, 2015 to June 30, 2015 were analyzed as the Pre-Law Cohort, and patients discharged from the ED from January 1, 2016 to June 30, 2016 were analyzed as the Post-law Cohort. The primary outcome was the change in the cumulative dose of solid dosage forms of opioids per prescription, calculated in morphine equivalents (MME). All parametric continuous variables were analyzed using the student T-test with non-parametric variables analyzed using the Mann-Whitney U test.

Results: A total of 10,448 opioid prescriptions were screened for inclusion, with 10,307 prescriptions included in the final analysis. A statistically significant decrease in MME per prescription of solid dosage forms was seen in the Post-law cohort compared with the Pre-law cohort (75 (IQR 60-100) vs 80 (IQR 75-150) respectively; p<0.001). The post-law cohort saw 1289 (22.2%) fewer opioid prescriptions, primarily driven by a reduction in the number of schedule 2 opioids prescribed. Reductions were also seen in the number of prescriptions issued for >72 hour supply, prescription day supply, and quantity prescribed.

Conclusions: Following the passage of PA 15-198, a statistically significant decrease in the cumulative dose of opioids per prescription was seen in both solid dosage form prescriptions and all opioid prescriptions. This drop appears to have been precipitated by a transition from using more potent opioids in schedule 2 to less potent opioids in schedule 4 and a modest decrease in quantity per prescription.

 

2018 Great Eight Runner Ups

Evaluation of a pharmacy to dose warfarin consult service

Author: J. Kowalski, PharmD  Co-Authors: T. Falcetti, PharmD, BCPS, BCACP; A. Bastiaanse, PharmD; Saint Francis Hospital and Medical Center, Hartford, CT

Background: Approximately 7.4% of inpatient adverse drug reactions (ADRs) are related to anticoagulants. Previous literature has found that pharmacist managed warfarin showed a trend toward fewer ADRs and supratherapeutic international normalized ratio (INR) versus physician managed warfarin. The potential for reduced ADRs is important because ADRs have been associated with increased morbidity, increased cost, and increased length of stay. Furthermore, the Joint Commission National Patient Safety Goal 03.05.01 requires hospitals to take measures to reduce the “likelihood of patient harm associated with anticoagulant therapy.”

Objective: The objective of this study is to determine if the implementation of a pharmacy to dose warfarin consult service improves patient safety and decreases the incidence of ADRs compared to provider managed anticoagulation with warfarin.

Methods: This retrospective chart review evaluated patients who were newly started on warfarin therapy between June 1, 2016 and June 1, 2017 as part of a pharmacy consult at Saint Francis Hospital and Medical Center in Hartford, CT. Results were compared to provider managed anticoagulation with warfarin, which was described in a previous study. The primary outcomes were the percentage of patients with a supratherapeutic INR of 3.6 or higher and length of stay. Secondary outcomes included the number of days to therapeutic INR, percentage of patients with appropriate duration of overlap anticoagulation therapy, and incidence of bleeding or thrombotic events.

Results: In total, 580 patients were evaluated for inclusion and exclusion criteria, and 31 patients were included in the final analysis. Compared to the provider managed warfarin results from the previous study, the percentage of patients with a supratherapeutic INR was lower with pharmacy managed warfarin (19.4% vs 22.6%, p=0.69). The mean length of stay was 11.32 days ± 8.10 days. The mean number of days to therapeutic INR was higher compared to the provider managed warfarin study (5.24 ± 1.61 vs 4.02 ± 1.69, p<0.01). Fewer patients in the pharmacy managed warfarin study received an inappropriate duration of overlap anticoagulation therapy (9.7% vs 36.3%, p<0.01). No bleeding events occurred for pharmacy managed warfarin, whereas in the provider managed warfarin study, 15.9% of patients experienced a bleeding event (p=0.011). There were no clotting events in either study.

Conclusion: Pharmacy managed warfarin therapy improved patient safety compared to provider managed warfarin therapy by lowering the incidence of supratherapeutic INRs and bleeding events, and increasing the percentage of patients receiving an appropriate duration of overlap therapy.


Evaluation of a sterile product preparation and delivery technology in a community hospital

Author: M. Moura Co-Authors: E. Deptula, S. Bhura; Waterbury Hospital, Waterbury, CT

Objective  The DoseEdgePharmacy Workflow Manager is designed to help minimize instances of medication preparation errors and streamline workflow for sterile product preparation. The workflow guided by the DoseEdgeSystem includes barcode scanning drugs and diluents, in order to prevent errors prior to compounding. While there is data available to support the utilization of DoseEdgein larger tertiary care centers, there lacks evidence to validate its utility in a smaller community hospital. The objective of this study is to evaluate the benefits of this technology through its effect on sterile product preparation in a community hospital.

Methods  This study is Institutional Review Board exempt. This study is a retrospective analysis of inpatient sterile product production in the inpatient pharmacy at Waterbury Hospital located in Waterbury, Connecticut. Data was retrieved from the DoseEdge System, which was implemented for use in the pharmacy’s sterile products area in February of 2016. Data was retrospectively evaluated over a six-month timeframe. The study utilizes information gathered from the DoseEdgeSystem to primarily assess the number of doses wasted subsequent to the system’s implementation. Secondary outcomes quantify the benefits of the system through analysis of rejected doses, turnaround times, as well as prevented errors in relation to cost savings. Data analysis and statistical testing were performed using Microsoft Excel. The chi-square test was used to determine statistical significance and a p-value of less than 0.05 was considered statistically significant.

Results  17,789 doses were included in the pre-DoseEdgeanalysis. 19,401 doses were included in the post-DoseEdge analysis. Before the implementation of DoseEdge, it was found that 1,165 doses were wasted in a six-month period; after the implementation of DoseEdge, it was calculated that 801 doses were wasted in a six-month period (p < 0.001). Re-used doses were accounted for in this analysis. During this six-month timeframe, 150 doses were rejected post-preparation. The average total turnaround time for patient-specific doses was 23 minutes. In a six-month period, 585 errors were prevented through the system’s detection of incorrect product selection during dose preparation, which can be associated with a savings of approximately $31,122.65.

Conclusion   Based on this evaluation, the implementation of the DoseEdgeSystem was effective in reducing the amount of sterile product waste within Waterbury Hospital’s inpatient pharmacy, and served as a cost-reduction strategy in the department’s sterile product preparation.


Expansion of antimicrobial stewardship module to decentralized pharmacists

AUTHOR: Anish Patel CO-AUTHORS: D. McManus, J. Topal, N. Bejou, R. Vonderheyde; Yale New Haven Health, New Haven, CT

OBJECTIVE: The use of clinical decision support systems (CDSSs) within a hospital system enhances the ability of pharmacists to perform antimicrobial stewardship services. The objective of this project is to determine whether incorporating CDSSs into daily pharmacist workflow through real-time actionable alerts will help optimize the use of appropriate antimicrobial agents as measured by time to optimal antimicrobial agent.

METHODS: The electronic health record (EHR) at Yale New Haven Health System (YNHHS) was customized to create an antimicrobial stewardship module (ASM) displaying real-time stewardship alerts. The alerts appear when updated microbiology data becomes available in the patient’s chart and there is an opportunity to optimize the patient’s current antimicrobial regimen. The real-time alerts were incorporated into daily workflow for clinical pharmacists to intervene upon and recommend appropriate antimicrobial therapy. Medical records of patients with Enterococcus spp. bacteremia sensitive to ampicillin from 7/1/17-12/31/17 (pre-intervention group) and 3/15/18-3/31/18 (post- intervention group) were identified and reviewed. The primary outcome was to determine if there was a change in time to optimal antimicrobial therapy pre- and post-implementation of the ASM. The secondary outcome was to determine the percentage of patients with pharmacist involvement in the stewardship recommendation pre- and post-implementation of ASM.

RESULTS: A total of 35 patients that met inclusion and exclusion criteria were analyzed. The time to optimal antibiotic was 40.4 hours and 12.5 hours (p=0.04) for the pre- and post-intervention groups respectively. 55% and 100% of patients in the pre-intervention and post-intervention groups had pharmacist involvement for the stewardship recommendation.

CONCLUSION: A decrease in time to optimal antibiotic was observed after implementation of the antimicrobial stewardship module which was statistically significant. The ASM was successfully implemented and allows decentralized pharmacists to provide additional antimicrobial stewardship services across the health-system.

 

Financial and Clinical Impact of Nasal Methicillin Resistant Staphylococcus aureus Polymerase Chain Reaction swab in Adults with Pneumonia

Author: Oumaima Sahbani CO-AUTHORS: Gillian Kuszweski, David Banach, Jeffrey Aeschlimann, Kevin Chamberlin

John Dempsey Hospital at UConn Health Affiliations: State of Connecticut, University of Connecticut School of Pharmacy

OBJECTIVE: Nasal Methicillin Resistant Staphylococcus aureus (MRSA) Polymerase Chain Reaction (PCR) swabs are utilized to determine probability of infection for patients receiving antibiotics with suspected MRSA pneumonia. MRSA PCR swabs have a reliable negative predictive value, which can result in the discontinuation of empiric antibiotics, including vancomycin. Early discontinuation of vancomycin reduces staff time related to the administration and monitoring and also aligns with Antimicrobial Stewardship goals of de-escalation to prevent potential adverse events related to antibiotic use. The primary objective of this study is to determine the number of saved vancomycin days and the subsequent amount of dollars saved from discontinuation of therapy as a result of a negative MRSA PCR swab in patients hospitalized for pneumonia.

METHODS: Adults 18 years or older being treated with empiric vancomycin for pneumonia are included in the study. This study involves observing nursing, laboratory, and pharmacy staff time related to the preparation, administration, and monitoring of vancomycin, as well as time related to the MRSA PCR swab collection and reporting. The primary outcome is the number of saved vancomycin days and the subsequent amount of dollars saved from discontinuation of therapy. Total cost savings will include direct cost of medications and supplies, and indirect costs related to staff time. Of the fifty swabs being targeted to collect, days of vancomycin saved will be compared to that of an average length of treatment with vancomycin in patients with pneumonia at our institution. Secondary outcomes include length of stay and thirty day readmissions in patients where vancomycin was discontinued secondary to a negative PCR swab. This data will be collected via retrospective chart review and compared to data prior to implementation of PCR swabs.

RESULTS: Cost comparisons have demonstrated that the cost of one day of vancomycin therapy is half of that of the MRSA PCR swab. Preliminary clinical outcomes demonstrate that using the swab as an antimicrobial stewardship tool saves a median of one day of vancomycin therapy. The number of vancomycin days saved will be recorded and results will be presented.

CONCLUSION: It is anticipated that this project will demonstrate cost savings with the use of MRSA PCR nasal swab screening in patients with pneumonia on vancomycin. The cost savings will result from decreasing staff time related to preparation, administration, and monitoring of vancomycin therapy. This antimicrobial stewardship initiative results in de-escalation of antibiotics, which decreases the risk for negative clinical outcomes on patient care.

 

 

 

2017 MOCK INTERVIEWS

3rd Annual Mock Interviews were held on Jan. 10th, 2017 at Hartford Hospital
The CSHP Residents Task Force organized this event for P4 pharmacy students of UCONN and USJ and PGY-1 and PGY-2 pharmacy residents .

Please direct any questions regarding this event to Resident Task Force Co-Chair Kellie Goodlet (kellie.goodlet@hhchealth.org).

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PREP FOR YOUR FUTURE WITH A CV REVIEW

In the fall of 2016, the CSHP Residents' Task Force offered a CV review to both students and residents applying for residencies, fellowships, and jobs in spring 2017.

2016 The Great Eight Winners

  1. Sylvia Narciso (Waterbury Hospital): Evaluating the appropriateness of double gram-negative coverage in severe septic patients in the emergency department
  2. Eva Pan (Hartford Hospital): Evaluation of carboplatin dosing using actual compared to adjusted body weight in gynecologic malignancies
  3. Emily Perriello (Hartford Hospital): Improper continuation of atypical antipsychotics after treatment and resolution of acute delirium in the intensive care unit
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2016 Mock Interview Event

by Mabel Wai, PharmD, BCPS; 2016 Resident Task Force Coordinator

The CSHP Resident Task Force (RTF) hosted its second annual Mock Interview Event at Hartford Hospital on January 14th. Students from The University of Connecticut and The University of Saint Joseph Schools of Pharmacy participated as interviewees. Member pharmacists, preceptors, and pharmacy directors comprised our interview panel.

Overall, the event was successful and we received wonderful feedback. The students found the event very helpful in preparing for future interviews and they greatly appreciated the advice from our pharmacists. Our interviewing panel also had a great deal of fun speaking to our students and sharing their experiences. We hope next year’s session will be just as eventful!

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ASHP President Explains Second Chance for Residency Match  

Next to graduation, pharmacy residency "Match" day is likely "the most anticipated day on the calendars of soon-to-be pharmacy graduates," writes ASHP President John A. Armitstead in InterSections, ASHP's member magazine. The new Phase II of the Match will help to ensure that student pharmacists and postgraduate year 1 residents seeking a second-year residency position will have another structured opportunity to connect with open positions. (source: ASHP NewsLink 12.22.15)


Publishing Opportunities for Residents in the AJHP Residents Edition

Formerly known as the Journal of Health-System Pharmacy Residents, AJHP Residents Edition is the only publishing forum dedicated to pharmacy residents where they can present their peer-reviewed research, contribute to the advancement of patient care and pharmacy practice, and see their work indexed by PubM
ed. Read more  


AJHP Call for Papers: Innovations in Pharmacy Residency Training  

AJHP cordially invites submissions of descriptive practice reports on innovative approaches to ASHP-accredited postgraduate year 1 and postgraduate year 2 pharmacy residency training and application of the ASHP Residency Accreditation Standards. Articles submitted by February 16 will have the best chance for consideration for inclusion in a 2016 issue of AJHP that will contain a collection of articles on innovations in pharmacy residency training.  (source: ASHP NewsLink 11.10.15)


ASHP Reaches Milestone with 2,000 Residency Programs
ASHP last week announced that it reached a new milestone in accreditation, with 2000 residency programs across the country undergoing the organization's accreditation process. The creation of residency training programs in institutions doubled from 500 to 1000 programs between 1999 and 2009 and has since doubled again. (ASHP NewsLink 10.27.15)

ASHP's Resident Reward and Recertification Program
The first program of its kind, ASHP's Resident Reward & Recertification Program takes professional development to the next level. If you are a resident or new practitioner considering a BCPS designation, you can register for our new program and get access to our pharmacotherapy review course—live or online—and the practice test at no cost. In return, you will complete your recertification cycle with ASHP for only $10/month. That price is guaranteed for the entire seven-year recertification cycle and includes more than the required 120 hours. Learn more and register (source: ASHP NewsLink 3.17.15)