Download Resident Abstracts - Oklahoma Society of Health

dosing protocol, within the affiliated health-system, by comparing
patients and outcomes before and after its implementation.
METHODOLOGY: This study included adult patients within the
affiliated health system who received only 4FPCC for urgent reversal
of warfarin or an oral anti-Xa inhibitor before and after
implementation of the fixed-dosing protocol between June 1, 2013 to
May 19, 2016 and May 20, 2016 to October 3, 2016 respectively.
Data for population comparison included: patient demographics,
agents and indications for chronic oral anticoagulation, presence of
other prescription or inpatient medications affecting hemostasis,
laboratory values and blood component use before and after 4FPCC
administration. Additional data collected to derive the measures for
evaluation of fixed-dosing protocol included: number of 4FPCC
doses to reach international normalized ratio (INR) less than two for
warfarin reversal, cumulative 4FPCC units administered, rates of
thrombotic complications within seven days from 4FPCC
administration, patient mortality, and patient discharge disposition.
RESULTS: Preliminary analysis of 52 patients indicated that 42
patients received weight-based dosing of 4FPCC compared to 10
patients in the fixed-dosing group. Warfarin reversal results
indicated that the average dose of 4FPCC used in the weight-based
dosing category was 31.4 units/kg and 23.6 units/kg in the fixeddosing category. Results also indicated that the reduction in INR
after the first dose of 4FPCC was on average 2.84 in the fixed-dosing
group and 3.39 for the weight-based dosing group. The average time
to first post-dose follow-up was 21 hours in the fixed-dosing group
and 4.8 hours in the weight-based dosing group. Within the warfarin
reversal population, fixed-dosing required no blood product
administration after 4FPCC use. The results from the Factor Xa
reversal population indicated that the average dose within the weightbased dosing group was 40 units/kg compared to 23 units/kg in the
fixed-dosing group. The fixed-dosing group, on average, had less
blood product administration compared to weight-based dosing.
Fixed-dosing for both warfarin and Factor Xa reversal preliminarily
showed longer lengths of stay compared to the weight-based dosing
group. Thrombotic complications occurred in 4% of the weight-based
dosing patients compared to no complications in the fixed-dosing
population.
CONCLUSIONS: Based on the preliminary data, annual product
cost savings for the hospital could be greater than $50,000. There is
also opportunity for appropriate follow-up with fixed-dosing protocol
utilization, decreased waste, and faster administration time.
Oklahoma Society of
Health System Pharmacists
2017 Residency
Research Conference
May 19, 2017
Oklahoma City, OK
ORIGINAL RESEARCH
These abstracts describe original research submitted for presentation.
Categories include clinical practice, diabetes care,
hematology/oncology, infectious diseases, and pediatrics.
Clinical Practice
1. UTILIZATION OF LOCKBOXES FOR CONTROLLED
MEDICATIONS TO REDUCE DRUG DIVERSION AND
PREVENT ACCIDENTAL OVERDOSE. Giau Phan, Polly
Robinson, Stephanie Tillman. St. John Medical Center, Tulsa, OK
INTRODUCTION: Prescription drug abuse is a serious public
health issue that affects every community. The most commonly
abused medications are opioids and benzodiazepines. In Oklahoma,
between 2007 and 2011, there were 2,535 death related to
prescription drugs. Tulsa is ranked 18th out of all counties in the US
for painkiller deaths. More than 68 percent of people age 12 and
older obtain drugs from friends or relatives. This project is designed
to assess the benefit of lockboxes in reducing Tulsa’s prescription
drug abuse problem. The goals are to reduce the potential for
diversion and prevent accidental overdose by unauthorized users.
METHODS: The study is pending approval by the Quality and
Safety Executive Committee as a quality improvement project.
Patients, who are 18 years or older and discharged with prescriptions
for controlled medications, will be prospectively selected from
September 2016 to February 2016. Participants will be surveyed and
provided a lockbox for home use along with written and verbal
counseling on proper storage and disposal of medications. Follow up
via telephone will be scheduled at 3 months to determine the benefit
of the lockboxes as well as any behavioral changes in disposal of
medications. All data will be recorded without patient identifiers to
maintain confidentiality.
RESULTS: Results from this study will be used to assess the
benefits of lockboxes regarding safe storage of controlled
medications in the outpatient setting. It is expected that with
increased utilization of these lockboxes, they will help reduce drug
diversion and prevent accidental overdose.
3. IMPLEMENTATION OF A PHARMACY-DRIVEN
METABOLIC VALIDATION TESTING IN A NATIVE
AMERICAN POPULATION. Jamie Wroge, Stacy Gee, Travis
Freeze, Carrie Law, Steven Fillmore. Chickasaw Nation Medical
Center, Ada, OK.
PURPOSE: The use of metabolic validation with genetic testing is
the first step towards personalized healthcare. The objective of this
study is to determine how metabolic validation in a Native American
population at the Chickasaw Nation Medical Center can help improve
patient care by tailoring drug therapy to the patient which may help to
decrease adverse events, improve targeted therapies and dosing, and
help choose a more efficient, cost-effective medication.
METHODS: The electronic medical record system will be used to
identify patients who qualify for laboratory testing criteria for
metabolic validation testing with one or more of 3 panels including
neurology, cardiology, and/or thrombophilia. Pharmacists will screen
patient and perform the cheek swab. The test is sent for analysis.
Imperative results are sent to the provider immediately and all results
are scanned into the electronic health record note template for the
health care team to review.
RESULTS: A preliminary analysis of 75 patients with metabolic
validation was performed. Of those patients who were tested 81.3%
were poor metabolizers of CYP 3A5, while intermediate metabolizers
2. FOUR-FACTOR PROTHROMBIN COMPLEX
CONCENTRATE OUTCOME MEASURES IN PATIENTS
RECEIVING WEIGHT-BASED DOSING VERSUS FIXEDDOSING IN A HOSPITAL SETTING WITH ESTABLISHED
GUIDELINES FOR USE. John Jacob Cannedy, Julia Chiappe.
INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
INTRODUCTION: Four-Factor prothrombin complex concentrate
(4FPCC) is labeled for urgent reversal of acquired coagulation factor
deficiency, induced by vitamin-K antagonists, and off-label for oral
anti-Xa inhibitors. The health-system’s formulary committee
instituted a fixed-dosing protocol for 4FPCC dosing adapted from
recent literature. The purpose of this study was to evaluate the
clinical effectiveness, safety, cost effectiveness, and degree of
prescriber compliance with the newly established 4FPCC fixed1
of CYP 3A5 accounts for 17.3% of the patients. Ultra-rapid
metabolizers of CYP 1A2 make up 65.3% of patients.
CONCLUSION: Efforts are progressing towards having specific
pharmacogenomics information about Native American population.
More data needs to be collected before a wide spread conclusion can
be made about how the Native American population might respond to
medications.
and Prevention and Advisory Committee on Immunization Practices
guidelines. Patients who meet the study age requirement, with no
exclusion criteria, will be asked to sign an informed consent
statement and participate in pre-educational session surveys assessing
demographics, baseline knowledge, and willingness to receive
vaccines. The educational session, lasting 15-30 minutes, involves a
laptop-based, Jeopardy-style learning game. The session covering
Tdap, PCV13, PPSV23, and HZV will teach patients about these
vaccine-preventable disease states, importance of adult vaccines, and
herd immunity. Next, patients will be given a post-educational survey
and administered any vaccines if interested. Participants with
unknown vaccine history will be asked for permission to contact their
physician and thus may need to return at a later date to receive
vaccines. The University IRB Committee and Walgreens Corporate
have approved this study, which will last for a four-month period
(12/2016-3/2017), with loyalty rewards points offered. The data will
be analyzed with descriptive and quantitative statistics.
RESULTS: As of late March 2017, 54 patients had participated. The
population was mostly Caucasian (67%), female (57%), average age
of 60, and average education level of some college (44%). Only 9 had
a healthcare degree, and 98% had insurance. Over half (70%)
responded “yes” to their healthcare provider discussing vaccines with
them, and 67% answered “yes” they are current on their adult
vaccines; however, several answered “no” or “I do not know” when
asked if they received their Tdap (28%), PCV13 (78%), PPSV23
(81%), or HZV (85%) vaccines. While 22% were willing to receive a
vaccine following the session, only five patients (9%) actually
received vaccines. Average vaccine knowledge survey scores went
up 18% following the educational session. Most patients either
strongly agreed or agreed (98%) that the session helped them
understand vaccines, and 67% answered their adult vaccines are now
a high priority. Unfortunately, store data for the targeted vaccines
indicated a 41% decrease in administration rates from last year. Data
collection will continue through March 2017.
CONCLUSIONS: Pending conclusion of data collection.
4. IMPACT OF PHARMACIST-DELIVERED PATIENT
EDUCATION ON ADHERENCE TO DUAL ANTIPLATELET
THERAPY FOLLOWING ELECTIVE PERCUTANEOUS
CORONARY INTERVENTION OR ACUTE CORONARY
SYNDROMES. Authors: John Dechand, Alexander Schneider,
Stephen Neely, Toni L. Ripley. University of Oklahoma Health
Sciences Center College of Pharmacy Oklahoma City, OK
INTRODUCTION: Adherence with secondary prevention
medications after an acute coronary event declines most significantly
in the first month after discharge. This non-adherence is associated
with an increased risk of death at 12 months and is most substantial
with dual antiplatelet therapy (DAPT). We implemented a pilot
quality improvement (QI) project as a discrete transitions of care
intervention that focused on DAPT education.
METHODOLOGY: This is an analysis of a QI project to evaluate
structured DAPT education from a clinical pharmacist (CP). Patients
who received discharge education on DAPT from a CP between 9-12016 and 12-15-2016 will be compared to those patients who did not
receive education from a CP. The primary endpoint is adherence to
DAPT at 30 days, measured via the proportion of days covered
(PDC) calculation. Secondary endpoints include 30 day readmission
and comparison of patient-reported adherence with pharmacy refill
data. Statistical analysis using the appropriate tests for categorical
variables will be used to compare case and control status. This study
has been submitted for Institutional Review Board approval.
RESULTS: Sixty-five patients received structured DAPT education
during the specified timeframe. Of these 65 patients, 40 that met our
inclusion criteria had pharmacy refill data and patient recall data
available from the QI project, and therefore serve as out intervention
cohort. For the primary endpoint, all patients were defined as
adherent (PDC ≥80%), and 93% of patients were fully adherent (PDC
= 100%). All but one patient filled DAPT on the day of discharge.
Comparison to the control group is in progress.
CONCLUSION: The results will be discussed.
6. EVALUATION OF THE CONVERSION FROM
MEDICATION CHARGE ON DISPENSING TO CHARGE ON
ADMINISTRATION IN A COMMUNITY HOSPITAL. Robert
L. Holliday, Jenny Stemm, Darin Smith, Norman Regional Health
System, Norman, OK.
PURPOSE: Norman Regional Health System is a three-hospital nonprofit community health system that utilizes an electronic medication
administration record for documenting medication administration
through a bar-coded medication system. The pharmacy department
currently generates a patient medication charge upon dispensing the
medication, either directly from the pharmacy or from a dispensing
cabinet. Discrepant billing practices may occur for several reasons
including: 1) Medications not returned to the pharmacy for credit
before processing the bill; 2) medication is lost or dropped on the
floor requiring an additional dose that is inadvertently charged; 3)
lack of administration documentation. By changing to a charge on
medication administration process, the heath system will ensure
greater accuracy in billing. The health system will benefit from
prevention of potential loss of Medicare reimbursements due to
billing errors identified during an audit.
METHODS: A complete list was made of all the areas where
medications are dispensed and charged. This included the Pyxis
machines, crash carts, totes and trays, outpatient infusion, and the
dialysis unit. The areas were selected and audited against a patient’s
bill to check for accuracy. A baseline was established based on the
number of discrepancies. From the audits, it will be determined
whether it will be appropriate for that area to be switched to a charge
on administration status. Upon completion, pharmacy will work with
Health Information Technology to implement the conversion to
charge on administration. After implementation, a follow up audit
will be completed to evaluate for improvements and accuracy in
5. BRIDGING THE VACCINATION KNOWLEDGE GAP
WITH AN EDUCATIONAL GAME TO INCREASE
ADMINISTRATION RATES IN ADULTS, 50 YEARS AND
OLDER. Kristi D. Rice, Nancy T. Williams, Henry W. Kinnard.
Southwestern Oklahoma State University/Walgreen Co., Oklahoma
City, OK.
PURPOSE: In the last few years, the United States has faced
outbreaks of whooping cough in our infant population, increased
occurrences of hospitalizations from shingles, and rising numbers of
deaths from Streptococcus pneumoniae. Many people realize that
vaccines are important for children; however, barriers inhibit adults
from receiving their vaccinations. Objectives: 1) identify baseline
knowledge and willingness to be vaccinated with tetanus, diphtheria,
acellular pertussis (Tdap), pneumococcal 13-valent conjugate
(PCV13), pneumococcal 23-valent polysaccharide (PPSV23), and
herpes zoster (HZV) vaccines; 2) analyze feedback on an educational
game as a teaching tool; and 3) compare vaccination rate data to prior
year, in adults 50+ years.
METHODS: Approximately 50-75 adults 50+ years will be recruited
while visiting the community pharmacy. A secondary community
pharmacy site nearby will be selected, if recruitment is low at the
primary site. This study will follow the Centers for Disease Control
2
billing practices. Pre- and post-implementation pharmaceutical
revenue will also be evaluated.
RESULTS: Preliminary data show that the most common billing
discrepancies occur with saline flushes, intravenous fluids, and
medications administered in surgery or catheterization lab.
Medications that are administered during surgery are documented in
an anesthesia record rather than on the electronic medication
administration record.
CONCLUSION: Based on preliminary data, switching certain areas
within the health system to charge on administration may lead to
improved billing practices. Areas that document on a paper record,
such as surgery or catheterization lab, may need to be delayed in the
switch to charge on medication administration until a solution for
charting on the electronic medication administration record can be
found.
of improvement in glycemic control and a patient satisfaction survey
of the pharmacist-managed diabetes service. It will be submitted for
approval by the University of Oklahoma Health Sciences Center
Investigational Review Board. Patients will be identified from the
diabetes pharmacotherapy service within the Oklahoma City
Veterans Affairs Health Care System (OK VAHCS). To be included
in the study, patients must have a hemoglobin A1c (A1c) value of 9.0
percent or greater in the six months prior to their first clinic
appointment, as well as an A1c value taken after at least one clinic
appointment and within the three to six months following clinic
enrollment. Patients with a diagnosis of type I diabetes mellitus will
be excluded. Patient encounters between July 1st, 2015 and
December 31st, 2016 will be retrospectively reviewed. Absolute
change in A1c and achievement of an A1c less than 9.0 percent and
less than 7.0 percent will be measured to determine the improvement
in A1c following enrollment in a pharmacist-managed diabetes
pharmacotherapy clinic. Data will also be collected to evaluate
predictors of successful A1c lowering as a secondary endpoint.
Baseline demographics will be collected. In addition, patients
enrolled in the diabetes service will be offered the opportunity to
participate in a telephone-conducted patient satisfaction survey.
RESULTS AND CONCLUSION: Results are pending evaluation of
data, and will be presented at the conference.
7. THE STANDARDIZATION OF ADMISSION AND
SPECIALTY ORDER SETS TO MINIMIZE DUPLICATE
MEDICATION ORDERS. Victoria N. Felder, Jerri Cody, Debbie
Poland. Norman Regional Health System, Norman, OK.
PURPOSE: To quantify the frequency of duplicate orders, identify
medications frequently associated with duplicate orders, and analyze
the impact of current physician practices utilizing order sets
containing as needed medication orders.
METHODS: Using data retrospectively collected from the
institutions electronic records, patients with more than one order for
acetaminophen in a one week time period were assessed for number
and type of order set used.
RESULTS: 841 orders for a total of 480 patients were analyzed;
ultimately 69 patients were found to have two or more order sets that
were ordered with duplicate acetaminophen orders, totaling 172 order
sets. These were sorted into the following categories: the same
physician ordering the same order set (9), the same physician
ordering different order sets (39), different physicians ordering the
same order set (15), and different physicians ordering different order
sets (36). Patients with more than two order sets (23 patients), could
fall into more than one category.
CONCLUSION: The duplication of medication orders via various
order sets occurs frequently, with 107 excessive order sets ordered in
a one week time period. This has the potential to lead to duplicate
orders on the patient’s profile, potentially leading to medication
errors such as multiple administration of the same medication. These
excessive order sets also require additional pharmacist time to verify
and ensure that patients do not have medications duplicated, which
could be utilized elsewhere in the pharmacy.
9. CLINICAL IMPLICATIONS AND PRESCRIBER
ATTITUDES REGARDING NEW FDA
RECOMMENDATIONS WITH METFORMIN PRESCRIBING.
Elizabeth A. Cook, Katherine S. O’Neal, Michael J. Miller, Ann E.
Lloyd, Laura J. Chalmers. University of Oklahoma College of
Pharmacy - Tulsa Campus, Tulsa, OK
INTRODUCTION: Metformin is a renally eliminated drug endorsed
by the American Diabetes Association as first-line therapy for
treatment of type 2 diabetes (T2DM) because of its efficacy, safety,
and mortality outcomes. The U.S. Food and Drug Administration
(FDA) revised prescribing recommendations, requiring labeling
changes to reflect dosing according to estimated glomerular filtration
rate (eGFR) rather than serum creatinine. This revision expands
eligibility to those with mild to moderate renal impairment. The
purpose of this study is to identify potential gaps in prescribing
practices following this revision, as well as assess knowledge and
attitudes of providers concerning the renal adjustment of metformin.
METHODOLOGY: This is an IRB approved retrospective chart
review coupled with an anonymous survey. An electronic medical
record system will be used to identify patients, seen by providers at
an academic outpatient clinic in Tulsa, Oklahoma from January 1,
2015 to December 31, 2015. Patients eligible for review must have a
diagnosis of T2DM. The following data will be collected: date of
birth, sex, ethnicity, serum creatinine, eGFR, and the date that these
laboratory values were measured. The dates of outpatient
appointments, prior to and following receipt of laboratory results, as
well as the total daily dose of metformin, prior to and following lab
results, will also be collected. Data will be used to calculate the
change in patient eligibility for metformin therapy within the
provider network based on newly issued guidelines concerning dose
adjustment based on eGFR. Additionally, a survey will be distributed
to physicians and advanced practice providers. Non-identifiable
demographic information for each provider surveyed will be
collected. Providers will be asked a series of questions regarding their
knowledge of, as well as attitudes toward, the new prescribing
information for metformin issued by the FDA.
RESULTS: Research in progress.
CONCLUSION: Research in progress.
Diabetes Care
8. IMPACT OF A PHARMACIST-MANAGED DIABETES
CLINIC ON PATIENTS WITH POORLY CONTROLLED
DIABETES. Kate Lutek, Todd Marcy, Lauren Snodgrass, Susan
Rourke-Webb. Oklahoma City VA Health Care System, Oklahoma
City, Oklahoma
INTRODUCTION: Type 2 diabetes poses a significant threat to the
health of the United States, affecting approximately 29.1 million
Americans. Complications of diabetes occur at higher rates with
increasing glycemia and can include blindness, amputation, and endstage renal disease. Many patients in the United States have poorly
controlled diabetes. Clinical pharmacists are well-trained and wellpositioned to address barriers in achieving glycemic control. The
purpose of this study is to determine the effectiveness of pharmacists
in the management of patients with poorly controlled diabetes and to
determine the patient-satisfaction of an outpatient pharmacistmanaged
diabetes
service.
METHODOLOGY: This study will include retrospective evaluation
3
treatment of multi-drug resistant staphylococcal and enterococcal
infections during the same time period. Efficacy was determined by
negative microbiological cultures, improvement in clinical response,
laboratory values, and vital signs. Data that were collected and
assessed include: patient's demographic information, length of
hospital stay, laboratory values, antimicrobial use, length of
antimicrobial therapy, organism(s) isolated, source of isolate, and
susceptibility patterns.
RESULTS: Results from this study will be used to support the
clinical framework for determining an appropriate regimen for
resistant staphylococcal and enterococcal infections. It is expected
that the use of daptomycin plus ceftaroline will improve clinical
outcomes in patients with multi-drug resistant staphylococcal and
enterococcal infections.
Hematology/Oncology
10. COMPARISON OF TIME TO ABSOLUTE NEUTROPHIL
COUNT RECOVERY IN PATIENTS WHO RECEIVED
FILGRASTIM OR TBO-FILGRASTIM. Nan Patterson, Teresa
Cooper, Jacyntha Sterling. Saint Francis Hospital, Tulsa, Oklahoma
INTRODUCTION: Febrile neutropenia (FN) is a serious side-effect
of myelosuppressive chemotherapy treatment.
Historically,
filgrastim has been frequently prescribed by physicians to treat
neutropenia in patients undergoing chemotherapy. Tbo-filgrastim is
a competitor to filgrastim with a similar safety profile, but at a
reduced cost. The objective of this study was to evaluate filgrastim
and tbo-filgrastim for best prescribing patterns not relating to cost.
METHODOLOGY: A retrospective chart review was performed on
inpatient and outpatient subjects who have received at least one dose
of filgrastim or tbo-filgrastim from January 1, 2015, to December 31,
2015. Subjects were identified using charge data for filgrastim or
tbo-filgrastim. Patients were excluded from the study if they are stem
cell donors, if they had unknown treatment history, or non-oncology
neutropenia. Qualifying patients were divided in two groups: those
who received filgrastim and those who received tbo-filgrastim.
Eligible patients were randomized and placed into two arms of
filgrastim or tbo-filgrastim with 100 patients in each arm. Each arm
had a distribution of 75% inpatients and 25% outpatients.
RESULTS: Overall, the differences between filgrastim and tbofilgrastim were not clinically significant. The primary outcome of
time to absolute neutrophil count (ANC) in both filgrastim and tbofilgrastim groups were both 11 days. Inpatient lengths of stay
between the groups were equal (15.8 days). Inpatient ANC at
discharge for both groups were considered recovered (6.8 vs. 8.1).
Incidence of FN was slightly increased in the tbo-filgrastim group
(13% vs 10.6%). There was a 0.7% increase for confirmed infection
in the filgrastim group which was not clinically significant.
CONCLUSION: Overall results indicated that there was no
significant difference in patient outcomes when comparing filgrastim
to tbo-filgrastim. Pharmacy formularies can safely choose
granulocyte colony-stimulating (GCSFs) on the basis of cost savings
without compromising patient outcomes. Further study is necessary
to investigate competitor GCSFs to determine ANC time of recovery.
12. DAPTOMYCIN DOSING IN OBESE PATIENTS:
ANALYSIS OF ADJUSTED BODY WEIGHT VERSUS
ACTUAL BODY WEIGHT . Ashley N. Fox, Ryan E. Owens, Beth
H. Resman-Targoff, Bryan P. White, Katherine Kupiec, Winter J.
Smith. The University of Oklahoma College of Pharmacy, Oklahoma
City, OK
INTRODUCTION: FDA-approved daptomycin dosing is based on
actual body weight (ABW), despite limited information regarding
appropriate dosing for patients who are obese. Pharmacokinetic
studies suggest daptomycin area under the concentration-time curve
(AUC) is increased in obesity, while clearance and volume of
distribution are reduced. Daptomycin use in obesity is associated with
safety concerns, such as elevations in creatine phosphokinase (CPK)
concentrations associated with increasing doses which may
necessitate discontinuation of daptomycin therapy.
The purpose of this study is to compare daptomycin clinical and
safety outcomes in obese patients dosed by adjusted body weight
(AdjBW) to a historical cohort dosed by ABW.
METHODOLOGY: This retrospective study will evaluate
daptomycin use in obese patients dosed on AdjBW (January 2014 –
December 2015) versus a historical control (January 2012- December
2013) dosed using ABW. Inclusion criteria include: adult patients
with a body mass index (BMI) of 30 kg/m2 or more who received
daptomycin for at least 72 hours. Exclusion criteria are: daptomycin
started prior to admission, infections with retained hardware, renal
dysfunction, isolates not susceptible to daptomycin, or patients
presenting with rhabdomyolysis. Demographics, concurrent
medications, culture data, daptomycin indication, and daptomycin
dose in mg/kg will be collected using a standard form. Safety data
collected include baseline and serial CPK, patient-reported
myopathy, and discontinuation of daptomycin due to adverse events.
The primary outcome is clinical failure, defined as: development of
resistance or recurrent signs and symptoms of infection necessitating
antibiotic modification. Secondary outcomes include microbiologic
success defined as at least one documented finding of microbiologic
eradication and no evidence of subsequent clinical failure. A
combined safety endpoint including elevation in CPK, patientreported myalgia, and rhabdomyolysis requiring discontinuation of
daptomycin will also be evaluated. Baseline characteristics will be
evaluated using descriptive statistics. Multivariate logistic regression
will be used to determine differences between cases and historical
controls after adjusting for covariates in outcomes. Survival curves
will be used to determine time to clinical success or failure.
RESULTS: An interim analysis including patient demographics,
clinical failure, microbiological success, and safety endpoints will be
presented.
CONCLUSION: Conclusions regarding daptomycin dosing for
patients with obesity will be presented.
Infectious Diseases
11. EVALUATION OF THE USE OF DAPTOMYCIN PLUS
CEFTAROLINE FOR THE TREATMENT OF MULTI-DRUG
RESISTANT STAPHYLOCOCCAL AND ENTEROCOCCAL
INFECTIONS. Amanda Bozell, Kari McCracken; St. John Medical
Center; Tulsa, OK
INTRODUCTION: In the setting of daptomycin-nonsusceptible
vancomycin-resistant Staphylococcus aureus (VRSA), vancomycinintermediate S. aureus (VISA), or vancomycin-resistant enterococci
(VRE), limited data is available to support the use of alternative
agents. Ceftaroline is a newer cephalosporin that has a broad
spectrum of activity, which includes activity against methicillinresistant S. aureus (MRSA), methicillin-sensitive S. aureus (MSSA),
VISA, and VRSA. When used in combination, ceftaroline has been
found to promote daptomycin binding to the cell membrane,
therefore, increasing its efficacy.
The primary outcome of this study is to determine the efficacy of
daptomycin plus ceftaroline in treating resistant staphylococcal and
enterococcal infections. Reported adverse events were recorded and
identified as the secondary outcome.
METHODOLOGY: Medication use data was collected to identify
patients who received daptomycin plus ceftaroline from January 2015
through December 2016. Laboratory data was collected and analyzed
to evaluate the efficacy of daptomycin plus ceftaroline in the
4
METHODOLOGY: The electronic medical record was used to
identify 188 patients admitted between January 1, 2015, and
December 31, 2015, who received a minimum of 48 hours of
intravenous vancomycin therapy and had ≥1 steady state trough
obtained. Patients were excluded if they were receiving hemodialysis,
pregnant, weighed <45 kg, age <18 years, received >1 dose of
vancomycin outside of the pharmacy dosing service, or had no steady
state trough. Data was collected on: demographics, vancomycin
loading and maintenance doses, frequency, trough concentrations,
follow-up consults, adherence to the dosing service, nephrotoxicity,
concurrent nephrotoxic drugs, and comorbidities. Descriptive
statistics were calculated to compare outcomes.
RESULTS: Initial vancomycin trough concentrations were classified
as therapeutic for 29 (30%) non-obese patients and 24 (26%) obese
patients. 56 (58%) and 42 (46%) had initial trough concentrations
that were sub-therapeutic, and 11 (11%) and 26 (28%) of non-obese
and obese patients, respectively, had supra-therapeutic initial trough
concentrations. 17 patients (10%) experienced nephrotoxicity at any
point during vancomycin therapy. There were a total of 529 followup consults for all patients (average 3 per patient). There were a total
of 62 and 53 subtherapeutic levels and 43 and 49 supratherapeutic
levels for non-obese and obese patients, respectively. Overall clinical
staff adherence to dosing service parameters was 36%.
CONCLUSION: Patients were more likely to have a therapeutic or
subtherapeutic initial trough, and less likely to have a
supratherapeutic initial trough. It is unclear whether this correlates
with changes made to the pharmacy dosing service given a high
amount of variation in overall dosing service adherence.
13. EVALUATION OF URINARY TRACT INFECTION (UTI)
MANAGEMENT IN A COMMUNITY HOSPITAL WITH
SUBSEQUENT PATHWAY DEVELOPMENT AND
IMPLEMENTATION. Lauren May, Fran Esfahani, Brian Hughes,
Norman Regional Health System, Norman, OK.
PURPOSE: To evaluate current UTI-related practices, focusing on
appropriate ordering, assessment, and treatment of urine cultures,
with subsequent development and implementation of a UTI diagnosis
and treatment pathway to decrease inappropriate urine culture
ordering and streamline appropriate antibiotic treatment of true
infection.
METHODS: Phase one included an Investigational Review Boardapproved randomized retrospective chart review of patients identified
from a urine culture surveillance report dating from January to June
2016. Patients were excluded if pregnant, less than 18 years of age,
or if there was insufficient information in the medical chart to
evaluate appropriateness of therapy.
Phase two includes
development and implementation of a UTI diagnosis and treatment
pathway. Subsequent data collection (phase 3) is to occur in late
Spring 2017 in the same manner as phase one to determine
improvement in appropriate urinalysis and antibiotic ordering after
pathway implementation.
RESULTS: Phase one analysis of 150 patients was performed. Of
the patients identified, 16 met exclusion criteria. The location of
urine sample collection was in the emergency department in 93 out of
134 patients. In 58% of patients, urine samples were collected for
appropriate reasons (i.e. presence of any of the following: altered
mental status, sepsis, urinary symptoms, signs of infection, or fall in
elderly patients). Urine sample collection was deemed inappropriate
in the remaining 42% of patients based on the absence of documented
urinary
symptoms
with
primary
complaints
of
neurologic/psychologic, respiratory, cardiac, or abdominal symptoms
or admission to inpatient rehabilitation unit. Urine cultures resulted
with significant colony counts, no growth, contamination, or
insignificant colony counts in 34%, 34%, 25%, and 7%, respectively.
Appropriate treatment, whether that be giving or withholding
antibiotic therapy, occurred in 91% of patients analyzed. Of the 21
patients identified as having asymptomatic bacteriuria, 38% were
inappropriately treated with antibiotics. CONCLUSION: Analysis of
phase one data suggests a significant number of urine samples
gathered in the emergency department and on admission to inpatient
rehabilitation unit are in patients without urinary symptoms
documented; however, antibiotic selection for empiric treatment in
those patients with suspected urinary tract infection was generally
appropriate and consistent. Pathway development and removal of a
default “urinalysis with reflex culture” order from many of the
standard order sets may help to improve appropriate evaluation and
subsequent treatment of urinary tract infections even further.
15. EVALUATION OF EMPIRIC APPROPRIATENESS OF
DISCHARGE ANTIBIOTIC PRESCRIPTIONS FROM AN
ACADEMIC MEDICAL CENTER EMERGENCY
DEPARTMENT. Sara Kim, Shelton Knudsen, Kelly Murray, Aaron
Lane. Oklahoma State University Medical Center, Tulsa, OK
INTRODUCTION: Antimicrobial resistance is a growing problem
that could be improved by implementing antibiotic stewardship
activities into different practice settings. However, this has been a
challenge for emergency departments (ED) due to the unclear
diagnoses and the fast-paced environment. Pharmacists can have a
significant impact with stewardship in EDs by aiding practitioners
with empiric antibiotic selection and dosage. The objectives of this
study are to evaluate the appropriateness of empiric antibiotic
prescriptions written upon discharge for emergency department
patients at an academic medical center and to describe medication
errors found in the sample of antibiotic prescriptions.
METHODOLOGY: This study has been approved by the OSU
Center for Health Sciences Institutional Review Board. The study
used content analysis to evaluate a random sample of 1000 empiric
antibiotics that were submitted into the electronic medical record for
discharged ED patients from July 1, 2015 to June 30, 2016. One
clinical pharmacy resident and one ED medical resident reviewed the
medication orders for errors following training in error identification,
operational definitions, coding, and other information included in
content analysis procedures. Open-ended data were coded and
viewed by an ED clinical pharmacist for agreement on coding
categories. Coding for the final data set was based on majority rule.
The final data set was then evaluated based on age of patient,
provider type, antibiotic prescribed, antibiotic and dosage selected,
indication for antibiotic, type or description of error, and
appropriateness of antibiotic selected. Clinical practice guidelines and
institutional antibiograms were used to determine the appropriateness
of empiric antibiotic selection. Descriptive statistics were used to
address the study objectives.
RESULTS: Discharge prescription error rate out of 500 prescriptions
was 14.4%. Pediatric prescriptions comprised of 11.1% of the errors,
and adult prescriptions comprised of 88.9% of the errors. The most
common error type was due to dosing outside the recommended
14. EVALUATION OF A PHARMACIST-LED
VANCOMYCIN DOSING SERVICE IN THE MANAGEMENT
OF OBESE VERSUS NON-OBESE PATIENTS. Molly
Grasberger, Ann Lloyd, Vivian Carson, Jacyntha Sterling
Saint Francis Hospital, Tulsa, OK
INTRODUCTION: Vancomycin dosing in obesity is an area which
lacks clear guidance due to altered pharmacokinetics versus nonobese. Pharmacist-led dosing protocols are associated with more
patients being optimally dosed and less nephrotoxicity. The purpose
of this study is to evaluate initial vancomycin trough concentrations
for obese and non-obese patients dosed by the pharmacy vancomycin
dosing service. Secondary outcomes include the number of supraand subtherapeutic levels, number of follow-up consults and changes,
and incidence of nephrotoxicity. A post hoc analysis was conducted
to evaluate changes in dosing outcomes as a result of service changes
implemented in 2013.
5
range. Prescriptions written with incorrect frequency schedules and
durations of therapy comprised the majority of the errors. ED
residents wrote the highest percentage of prescriptions (357), and had
an error rate of 15.1%. The most prescription errors were made with
the antibiotics nitrofurantoin, azithromycin, and penicillin.
CONCLUSION: Discharge prescription errors are common in the
emergency department setting. The most common errors seen were
those that were dosed outside the recommended range. The
researchers hope to further identify specific methods and
implementations in which pharmacists can aid in decreasing the
number and frequency of prescription errors. The researchers will
continue to evaluate 500 additional prescriptions to identify any
prescription
error
patterns
that
may
exist.
patients with HIV grows, there is an increased need for monitoring of
significant drug interactions and ensuring appropriateness of
antiretroviral therapy upon initiation and maintenance in the inpatient
setting. Therefore, the purpose of this study is to assess the use of
antiretrovirals in an inpatient academic medical center, specifically
determining errors that occur in a sample of antiretroviral regimens.
METHODOLOGY: The electronic medical record system was used
to identify patients who had been prescribed antiretrovirals in the
inpatient setting. The following data was collected: sex, age, weight,
height, serum creatinine, antiretroviral allergies, antiretroviral(s)
selected, admitting team/hospitalist group, inpatient medication list
and home medication list. Each profile was assessed for
appropriateness of antiretroviral regimens prescribed and potential
interactions.
RESULTS: A total of 138 patient encounters were evaluated to date.
Results from these encounters show 78.2% of HIV encounters were
handled appropriately, 13% of encounters resulted in some form of
an error, 7.97% of encounters had a potential for error, and 0.95% of
encounters fell in the other category. Of those handled appropriately,
31.8% received the correct antiretroviral therapy and 46.3% did not
receive antiretroviral therapy. Errors were divided into 3 categories:
inappropriate doses (5.7%), incomplete regimens (5.7%), and
significant drug interactions (1.44%). The encounters with a potential
for error included patients whose prescriptions may have been timed
inappropriately.
CONCLUSION: Pharmacists play an important role in antiretroviral
stewardship to identify significant drug interactions and ensure
optimal antiretroviral therapy. Despite 78.2% of patient encounters
being handled appropriately, 13% of encounters resulted in an error.
Implementation of a pharmacist led antiretroviral stewardship
program could help alleviate errors including: inappropriate doses,
incomplete regimens and drug interactions. More research is needed
to finalize these results and determine the best way to implement a
novel antiretroviral stewardship program in an academic setting.
16. EVALUATION OF FIDAXOMICIN USAGE PATTERNS
AND NAP1 PREVALENCE IN CLOSTRIDIUM DIFFICILE
INFECTION ACROSS THE VETERANS HEALTH
ADMINISTRATION. Stephanie E. Giancola, Riley Williams II,
Sharanjeet Thind, George Kurdgelashvili, Grant H. Skrepnek, Chris
A. Gentry. Oklahoma City VA Health Care System, Oklahoma City,
OK
INTRODUCTION: The epidemic shift in Clostridium difficile
infections (CDI) that occurred in the early 2000s is partly attributed
to the emergence of the North American pulsed-field gel
electrophoresis type 1 (NAP1) strain. The NAP1 strain is highly
virulent, causing higher recurrence of CDI, morbidity, and mortality.
These factors have led to calls for improved therapeutic options.
Fidaxomicin, approved by the FDA in 2011, is a highly-potent
antimicrobial agent against C. difficile. The purposes of this study
are to assess trends in NAP1 prevalence across the Veterans Health
Administration (VHA) system, to describe patient characteristics and
outcomes following fidaxomicin treatment in the VHA system, and to
assess compliance with VHA fidaxomicin criteria for use.
METHODOLOGY: A retrospective, observational, nationwide
study of patients with CDI at any Veterans Affairs Medical Center
(VAMC) found to routinely test for presence of NAP1 between July
1, 2011 and June 30, 2016 will be conducted. Trends will be
described by timeframe, geographic regions, and facility complexity
level. All patients treated with fidaxomicin for CDI at any VAMC
between June 1, 2011 and October 31, 2016 will be identified. The
primary endpoint will be compliance with the fidaxomicin criteria for
use. Alternative uses outside of criteria for use guidance will be
described. Descriptions of usage trends will include sub-analyses by
geographic regions, timeframe, facility complexity level, and
presence of NAP1. Secondary outcomes for patients who received at
least 72 hours of fidaxomicin will include outcomes of clinical failure
and/or CDI recurrence, hospital length of stay where applicable, and
30-day all-cause mortality.
RESULTS: Routine testing for NAP1 was found for 32 VAMC’s.
The prevalence of C. difficile strains exhibiting presence of NAP1
was 21.9% (1802/8224). One thousand ninety-nine patients received
at least one dose of fidaxomicin during the study period, including
620 inpatient courses. The characteristics of patients and their
courses of fidaxomicin will be described, as well as the trends in
NAP1 prevalence.
CONCLUSION: NAP1 prevalence and fidaxomicin usage patterns
across nationwide VAMC’s will be characterized.
18. CLINICAL OUTCOMES OF SINGLE TABLET VS.
MULTI-TABLET ANTIRETROVIRAL REGIMENS IN HIVINFECTED INDIVIDUALS. Jeannie Ong, Michelle D. Liedtke, R.
Chris Rathbun, and Grant H. Skrepnek. University of Oklahoma
College of Pharmacy, Oklahoma City, OK
INTRODUCTION: Highly active antiretroviral therapy (HAART)
reduces disease progression in individuals infected with the human
immunodeficiency virus (HIV) and reduces associated morbidity and
mortality. Since the FDA-approval of Atripla in 2006, single tablet
regimens (STR) have been associated with improved medication
adherence, virologic suppression, higher patient satisfaction, fewer
hospitalizations, and reducing healthcare costs. Five additional STR
have been FDA-approved in the past 5 years; however, data are
presently lacking on the comparative effectiveness of these STR vs.
other ART. This study will examine clinical outcomes with newer
STR formulations compared with traditional multi-tablet regimens to
determine whether benefits are realized.
METHODOLOGY: This study will be retrospective, observational
study of existing HIV-infected patients at the OU Infectious Disease
Institute (IDI) clinic located on the OU Health Sciences Center
campus in Oklahoma City, OK between 2011 and 2016. Adult, HIVinfected individuals managed by the OU Infectious Disease Institute
clinic who received antiretroviral therapy will be eligible for
inclusion in the study. Eligible patients will be identified by medical
provider utilizing the OU Pharmacists Care Center (OUPCC) claims
data. HIV-seropositive patients on antiretroviral therapy will be
identified using prescribing provider from the IDI clinic and a generic
product identifier. Claims data will be collected from OUPCC.
Medication possession ratio will be calculated to analyze refill claims
data to assess patient adherence to antiretroviral therapy.
Demographic (e.g. age, race, sex, HIV risk category, HIV treatment
naïve or experienced) and disease parameters (e.g. baseline CD4 cell
17. ASSESSMENT OF ANTIRETROVIRAL USE AT AN
ACADEMIC MEDICAL CENTER. Adre Cullen, Connel
Christina, Bury John; Oklahoma State University Medical Center,
Tulsa, OK
INTRODUCTION: HIV is a disease where outcomes are
determined by medication therapy and pharmacists play an integral
role in the multidisciplinary management. As the population of
6
count, plasma HIV RNA, date of HIV diagnosis, co-morbidities) will
also be collected from electronic medical records to examine
associations with the various clinical outcomes.
RESULTS: In progress.
CONCLUSION: It is our expectation that patients receiving STR
will demonstrate improved clinical outcomes such as superior
medication adherence and will achieve higher rates of virologic
suppression. As a result of this study, the outcome of this
investigation will inform clinicians on the relative benefits of STR
versus MTR when selecting antiretroviral therapy.
HCV-related care within the Gastroenterology (GE) Department.
Since the change in service, GE still receives all HCV referrals,
conducts the initial patient work-up and evaluation, and selects the
treatment regimen. Complicated cases, defined as a Veteran with
cirrhosis and/or requiring ribavirin-containing regimens, are retained
under care of the GE Department. Uncomplicated cases are referred
to a clinical pharmacy specialist who verifies and initiates the
treatment regimen, provides education and counseling to the Veteran,
and then facilitates transition of care and treatment monitoring
follow-up to the Veteran’s Primary Care Physician.
This study aims to determine if these changes have had any impact on
sustained virologic response (SVR) and compliance rates of Veterans
treated for uncomplicated cases of HCV infection. Furthermore, the
data and results of this study will help reveal patient-specific and
systematic factors that may contribute to HCV treatment failure and
non-compliance. This site-specific data can be utilized to evaluate
the effectiveness of the new service model and identify areas of
improvement for the treatment and management of Veterans with
HCV.
METHODOLOGY: The study is an institutional review boardapproved, retrospective, descriptive chart review. Adult Veterans
aged 21 years and older with HCV infection who received a
prescription for ledipasvir/sofosbuvir between January 2015 through
October 2016 from either GE or Clinical Pharmacy were included in
the study. Veterans were excluded if they had biochemical signs of
cirrhosis and/or received ribavirin-containing HCV regimens. Data
collection includes Veteran demographics, past medical history,
social history, labs, imaging, medication history, and hepatitis
treatment and follow-up course per provider documentation. The
primary outcome of the study is to determine differences in SVR
between Veterans receiving treatment with ledipasvir/sofosbuvir for
uncomplicated HCV infection under the care of GE compared to
Clinical Pharmacy/Primary Care. Secondary outcomes include
differences in HCV medication and treatment monitoring follow-up
compliance rates between the two groups, and determination of
variables that may contribute to non-compliance. Statistical analysis
will utilize the Chi-squared test for the primary outcome and for
categorical variables, and a t-test to compare calculated means and
standard deviations from all continuous and descriptive independent
variables. All statistical tests will be conducted with a priori alpha
level
of
0.05
utilizing
statistical
software.
RESULTS: data collection in progress
CONCLUSION: pending results
19. DETERMINATION OF MEDICATION POSSESSION
RATIO ACCORDING TO ANTIRETROVIRAL CLASS. Krista
Williams, Michelle D. Liedtke, R. Chris Rathbun, Grant Skrepnek.
University of Oklahoma. Oklahoma City, OK
INTRODUCTION: The use of highly active antiretroviral therapy
(HAART) revolutionized the management of the human
immunodeficiency virus. It is essential to be able to monitor patient
adherence; although, no gold standard exists to measure adherence to
antiretroviral therapy in clinical practice. Medication possession
ration (MPR) is a readily available mechanism to measure adherence
and offers a more objective method than patient self-report.
METHODOLOGY: The objective of this retrospective
observational study is to examine the relationship between adherence
and viral suppression and to determine the Medication Possession
Ratio (MPR) required to achieve viral load suppression according to
medication class. Approximately 1600 patient records from January
1, 2015 to December 31, 2016 will be evaluated for inclusion in this
study. Eligibility criteria include HIV-seropositive patients on
HAART who receive care at the Infectious Disease Institute Clinic,
receiving medications from the OU Pharmacist Care Center and have
at least 4 viral load during the study period. Exclusion criteria
include: pregnancy, less than 4 viral loads, imprisonment, use of
pharmacies other than OUPCC, and on ART less than 6 months.
Viral loads will be collected from the electronic medical record for
patients who meet inclusion criteria. Next, MPRs will be calculated
for the patients. Medication Possession Ratio will be calculated using
the following formula:
𝑀𝑃𝑅 =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑎𝑦𝑠 ′ 𝑠𝑢𝑝𝑝𝑙𝑦 𝑜𝑓 𝐴𝑛𝑡𝑖𝑟𝑒𝑡𝑜𝑟𝑖𝑣𝑎𝑙 𝑑𝑖𝑠𝑝𝑒𝑛𝑠𝑒𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑎𝑦𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
where the number of days’ supply in the interval will reflect the
number of days between the first fill date for antiretroviral therapy
and the end of the study period (designated as December 31, 2016).
MPR values will be expressed as percentages.
RESULTS: In progress
CONCLUSION: Pending results
21. DETERMINATION OF MEDICATION POSSESSION
RATIO FOR VIRAL SUPPRESSION IN HIV-INFECTED
ANTIRETROVIRAL-NAÏVE PATIENTS. Marcus Tad Autry,
Chris Rathbun, Michelle Liedtke, Grant Skrepnek, and Jamie Miller
The University of Oklahoma College of Pharmacy, Oklahoma City,
Oklahoma
INTRODUCTION: The advent of newer and safer fixed-dose
combination antiretrovirals (ARV) has made the treatment of HIV
simpler and more convenient from a patient perspective. However,
the failure of these regimens due to non-adherence and the
development of resistance has the potential to eliminate more
tolerable ARV regimens as treatment options. Determining adherence
thresholds that predict a high likelihood for chronic viral suppression
is important for the chronic management of HIV infection.
Furthermore, determination of adherence thresholds for the three
primary regimen types (non-nucleoside reverse transcriptase,
protease, and integrase inhibitor) that are associated with viral
suppression would allow practitioners to make more informed
treatment decisions based upon adherence measures before the
appearance of breakthrough viremia, thereby decreasing the risk of
developing resistance. Previous research has established adherence
thresholds that are associated with virologic suppression; however,
this research included treatment-experienced individuals whose prior
20. IMPACT OF A CHANGE IN SERVICE ON SUSTAINED
VIROLOGICAL RESPONSE RATES IN VETERANS
RECEIVING LEDIPASVIR/SOFOSBUVIR FOR
MANAGEMENT OF HEPATITIS C. Scott Mirgeler, Riley
Williams II, Jennifer Bird, Rona Furrh. Oklahoma City VA
Healthcare System, Oklahoma City, OK
INTRODUCTION: The Veterans Health Administration (VHA) is
the single largest provider for the treatment and management of
Hepatitis C Virus (HCV) in the United States. With the introduction
of new and highly effective direct-acting antivirals, there is potential
to cure HCV infection and reduce the risk of complications such as
cirrhosis and hepatocellular carcinoma in the Veteran population.
In May 2016, the Oklahoma City VA expanded its HCV treatment
workforce capacity by engaging clinical pharmacy specialists and
primary care physicians to aid in the management of non-complicated
HCV cases. Previously, Veterans with HCV infection received all
7
use of ARV could affect adherence, and thus the threshold, needed
for suppression. The adherence thresholds for the three primary
regimen types are currently undefined in the treatment-naïve
population.
METHODOLOGY: A retrospective observational cohort study will
be conducted of HIV-infected patients greater than 18 years of age at
a university affiliated outpatient infectious diseases clinic. Treatmentnaïve individuals who have received antiretroviral therapy at the OU
Health Sciences Center Infectious Diseases Institute for at least one
year between January 2011 and December 2016 will be identified.
Antiretroviral claims data for medication possession ratio (MPR)
determination will be obtained from the designated drug assistance
program pharmacy. Real-time PCR HIV-1 RNA, CD4, and
demographic data will be collected from electronic medical records.
Composite MPR will be calculated for the full antiretroviral (ARV)
regimen. Viral load area-under-the curve (vAUC) will be quantified
using WinNonLin pharmacokinetic software to assess continuous
viral suppression over the study period. Regression will be used to
examine existing relationships between refill adherence rates and
different levels of HIV viremia and will be offset for the overall
duration of patient follow-up and controlled for age, sex,
race/ethnicity, antiretroviral regimen type, and MPR. A marginal
effects analysis will be used to determine the predicted probability of
viral suppression (defined as HIV-1 RNA < 50 copies/mL) and MPR.
Analysis will be stratified by antiretroviral regimen class to
determine whether differences in specific thresholds exist.
RESULTS: Interim analysis regarding patient demographic and
clinic care-related data will be presented.
CONCLUSION: Conclusions regarding study findings to date will
be presented.
mg/kg and duration of therapy was 6.0 ± 3.0 days. The mean Vd and
CL were 0.48 ± 0.11 L/kg and 0.05 ± 0.01 L/kg/hr, respectively. The
mean Ke and t1/2 were 0.11 ± 0.03 hrs-1 and 6.79 ± 2.15 hours,
respectively. Fifteen infants (21.7%) met the criteria for AKI.
CONCLUSIONS: Final conclusions will be presented
23. PEDIATRIC DELIRIUM EDUCATION: DETERMINING
THE EFFICACY OF EDUCATING PEDIATRIC STAFF ON
DELIRIUM AND SCREENING TOOL UTILIZATION PRIOR
TO PROTOCOL IMPLEMENTATION. Allyson D. Gabbard,
Leslie Patatanian, INTEGRIS Baptist Medical Center, Oklahoma
City, OK.
INTRODUCTION: Pediatric delirium has received increasing
attention over the past 15 years and has been associated with
outcomes including increased morbidity, mortality, hospital stay
duration, and healthcare costs. Several pediatric delirium screening
tools have been developed and validated, but approximately 71% of
healthcare facilities with a pediatric intensive care unit (PICU) don’t
regularly screen their patients. Roughly 2% evaluate all patients
every shift as recommended. Significant knowledge gaps exist with
regards to pediatric delirium, and want of effective education may be
partially at fault for the lack of action being taken. The purpose of
this study is to evaluate the efficacy of education modules in
preparing pediatric staff for implementation of a pediatric delirium
screening protocol. Development of effective education will remove
barriers preventing healthcare facilities from addressing this
condition thus allowing the focus to shift from education to
prevention and treatment.
METHODOLOGY: After completion of a study consent form,
subjects began phase I of the study comprising a 21-question
assessment administered before and after finishing a general
education module on pediatric delirium. After completion of these
steps, subjects proceeded to phase II comprising an education module
detailing proper utilization of the Cornell Assessment of Pediatric
Delirium (CAPD) followed by a 14-question post-assessment.
Subjects completed these steps at their convenience through the use
of provided instructions documents. Assessments were made
available through the online service SurveyMonkey®. Education
modules were made available online as invisible YouTube® videos.
RESULTS: Preliminary: Forty-seven subjects signed informed
consent forms, and 30 subjects within the nursing and pharmacy
professions have initiated the study. All 30 subjects completed the
phase I pre-assessment yielding an average score of 46%,
approximately 10 questions answered correctly out of 21 questions.
Seventeen subjects completed the phase I post-assessment yielding an
average score of approximately 77%, 16 questions out of 21
questions answered correctly. This shows the phase I education
module enabled subjects to answer 6 more questions correctly on the
phase I post-assessment thus improving their phase I pre-assessment
scores by 31%. Nine subjects completed the phase II post
assessment, and none had prior education on utilization of the CAPD.
These subjects produced an average score of 88% equaling
approximately 12 out of 14 questions answered correctly.
CONCLUSION: Based on this preliminary data, pediatric delirium
education modules are effective at improving pharmacist and nurse
knowledge on pediatric delirium.
Pediatrics
22. COMPARISON OF AMIKACIN PHARMACOKINETICS
IN NEONATES WITH AND WITHOUT CONGENITAL
HEART DISEASE. Amy Nguyen, Peter Johnson, Katie Hughes,
Michael Anderson, Kris Sekar, Robert Welliver, Jamie Miller.
University of Oklahoma College of Pharmacy, Oklahoma City, OK
INTRODUCTION: Aminoglycosides are commonly used in the
neonatal ICU (NICU) in combination with other antibiotics for
treatment of early and late onset sepsis. Although gentamicin or
tobramycin are often first-line, the use of amikacin has escalated in
certain facilities due to observed antimicrobial resistance patterns.
However, there is a paucity of data in the neonatal population,
especially in neonates with congenital heart disease (CHD). The
purpose was to compare amikacin pharmacokinetics and acute kidney
injury (AKI) in neonates and infants with and without CHD.
METHODS: This was a descriptive, retrospective study of neonates
and infants who received amikacin from January 1, 2013 through
December 31, 2016. Infants with CHD defects were classified as
cyanotic or acyanotic. Non-CHD controls were matched in a 2:1
fashion according to postmenstrual age (PMA). The primary
objective was to compare the volume of distribution (Vd) and
clearance (CL) of amikacin in neonates with CHD versus controls.
Secondary objectives included comparisons of elimination rate (Ke)
and half-life (t1/2). In addition, the incidence of AKI was compared
between groups. AKI was defined as a reduction in urine output to
<0.5 mL/kg/hr > 8 hours, an absolute increase in serum creatinine
(SCr) by 0.3 mg/dL, or an increase in SCr greater than 50% from
baseline.
Between-group analyses will be performed using
Wilcoxon-Mann-Whitney test, Student’s t-test or Chi-square, or
Fisher’s exact analysis as appropriate with a p-value < 0.05.
RESULTS: Seventy-one CHD patients met inclusion criteria and
were matched to 142 control patients. To date, data collection has
been completed only for the CHD patients. The mean weight was
2.83 ± 1.18 kg. The mean amikacin dose utilized was 13 ± 1.66
24. IMPLEMENTATION OF STRATEGIES TO REDUCE
ALERT FATIGUE ASSOCIATED WITH ELECTRONIC
ORDER ENTRY IN A CHILDREN’S HOSPITAL. Christine
Hughes, Bob M. John, Marlene V. Hall, David V. Donald, Jacyntha
Sterling. Children’s Hospital at Saint Francis, Tulsa, OK
INTRODUCTION: Electronic Health Record (EHR) systems allow
for improved patient safety, improved treatment outcome, and
streamlined processes. However, the high frequency of notification
8
alerts during order entry in an EHR results in alert fatigue. With alert
fatigue, alerts are so common that the end user ceases to pay attention
to them and so may overlook a critical alert, which could influence
patient safety and treatment outcome. This study aims to better
understand patterns of alerts and overrides in order to identify system
and education opportunities that improve safety and enhance the
ordering system process for the Children’s Hospital.
The primary goal of this study is to reduce the number of medication
alerts that could lead to alert fatigue by improving alert quality
without negatively impacting patient health and safety. Evaluation
and analysis of alerts will drive system and/or education changes to
ensure that the most frequent alerts are more meaningful to the end
user.
The secondary goal is to gauge perception of medication alert quality
and quantity by ordering providers.
METHODS: The goals will be achieved by reviewing alerts from
data extracted from medication alert system reports from the
institution’s EHR with a team comprised of clinical pharmacists and
the information technology (IT) EHR specialist. A provider survey
will also be conducted before and after implementation to evaluate
differences in perceptions of the quality and quantity of the alerts.
The results of this study should include a process by which alert
notifications can be regularly monitored and managed for maximum
safety and efficacy.
RESULTS: Not yet available
CONCLUSION: Not yet available
questionnaires had 72-77 items divided into five sections related to 1)
patient opinions regarding clinic provision of education, 2)
confidence regarding their knowledge, 3) questions related to ageappropriate education, 4) questions related to their usual sources of
information, and 5) a knowledge assessment using a validated scale
for that age group. This study has been approved by the University
of Oklahoma Institutional Review Board.
RESULTS: This research project is currently in progress.
26. PHARMACOKINETIC SIMULATIONS OF FENTANYL
CONTINUOUS INFUSIONS IN NON-OBESE VERSUS OBESE
CHILDREN. Sin Yin Lim1; Sukyung Woo1; Jamie L. Miller1-2;
Grant H. Skrepnek1; Henry D. Emily2, Peter N. Johnson1-2. University
of Oklahoma Colleges of Pharmacy1 and Medicine2; Oklahoma City,
OK
INTRODUCTION: A paucity of studies have evaluated the
pharmacokinetics (PK) of medications in obese children. The
objective was to compare fentanyl continuous infusion PK between
obese (OC) and non-obese children (NC).
METHODOLOGY: This PK simulation study utilized a semiphysiologic approach to evaluate fentanyl PK using historical
inpatient data in <18 year-olds admitted in 2011. OC was defined as
children < 2 years with weight-for-length >97.7th percentile or BMIfor-age >95th percentile for >2-17 year-olds. The primary objective
was to compare the total clearance (CL) and steady state volume of
distribution values (Vss) based on obesity status in different age
groups (0 to <2, 2, 6, 10, 14, and 17 years). The secondary objective
was to compare fentanyl plasma concentration-time profiles
simulated for three OC and three NC ages 4, 9, and 15 years, based
on weight-adjusted does of 1 mcg/kg/hr using total body weight. An
additional simulation was conducted for 15 year OC and NC using a
fixed dose of 50 mcg/hr. Simulations were performed using Berkley
Madonna software. A multivariable regression analyses was
conducted to determine the association of Vss and CL with obesity,
females, and age. Data analysis was conducted using a Student’s t
test with a p-value <0.05.
RESULTS: Historical data included 4376 patients, with 807 (18.4%)
classified as OC. The majority (52.9%) were male with a median age
of 8.1 years [interquartile range (IQR) 4.3-13.0]. There was an 1130% decrease in weight-normalized total CL in OC versus NC in all
groups. However, statistically significant differences were only found
in 6, 10, 14, and 17 year-olds, p<0.05. Controlling for sex and age,
the Vss were two to five times higher in OC. Weight-normalized Vss
values also increased more than two-fold in OC compared to NC. In
early drug disposition (<24 hours) for the simulated OC and NC 4, 9,
and 15 year-olds, weight-adjusted doses resulted in similar
concentrations between groups. However, after >24 hours, weightadjusted dosing in OC resulted in higher concentrations than NC.
Steady-state concentrations using weight-based dosing increased by
25%, 77%, and 44% in OC versus NC 4, 9, and 15 year-olds
respectively. Time to steady-state and elimination half-lives were
two to four-fold longer in OC. Fixed dose (mcg/hr) provided similar
PK profiles in OC and NC 15 year-olds.
CONCLUSION: Weight-normalized total CL was lower in OC in all
ages. Weight-normalized Vss values were higher in OC versus NC.
The PK effect of obesity resulted in a significant increase in steadystate concentrations in 4, 9 and 15 year-old OC. Exploring alternative
dosing strategies is warranted for OC.
25. CYSTIC FIBROSIS PATIENT EDUCATION – IS THE CF
CENTER MEETING PATIENT AND FAMILY NEEDS? Kevin
Lonabaugh, Katherine O’Neal, Heather McIntosh, Michelle Condren.
University of Oklahoma College of Pharmacy; Tulsa, OK
INTRODUCTION: Cystic fibrosis (CF) is a complex chronic
disease state involving multiple organ systems. Medication regimens
include numerous therapies and utilize various routes of
administration. Patients and their families require education about
the role of these medications as well as how to use them. In addition,
patients are expected to receive information regarding the disease
state itself and considerations for daily living with CF. Current
guidelines have identified educational goals from birth through preschool, however the timing for providing that education is not
explicitly described past the pre-school age. Prior research has
highlighted knowledge gaps amongst patients with CF, especially in
areas related to genetics and reproduction. Studies have also
suggested that patient knowledge is associated with increased
adherence and that medical professionals are an important
educational source. It is therefore critical that CF centers create a
systematic means of providing patient and family education. Clinical
research has yet to evaluate patient perceptions of the education they
have been provided as well as when they would like that education to
occur. The purpose of this study is to improve the quality of patient
education in the clinic by evaluating patient perceptions of education
provided there as well as their own self-confidence related to
particular topics within CF. The study will assess how well their
self-confidence matched their knowledge about CF topics and will
define patient-specific goals for timing of education and sources of
information.
METHODOLOGY: This prospective study recruited patients and
caregivers at a single accredited Cystic Fibrosis Foundation center
from January 2017 through April 2017. Patients and their caregivers
were included upon presentation for a normal care visit. Patients
were excluded if their primary language was a language other than
English, if they had a history of lung transplantation, or if they had a
diagnosis of CF-related metabolic syndrome (CFMS). The
questionnaires were developed by experts in CF and piloted before
distribution. Five versions of the questionnaire were developed for
the different respondents (adolescent patient, adult patient, child
caregiver, adolescent caregiver, and adult caregiver). The
9