available - TSHP

Texas Society of Health-System Pharmacists

Volume 14 w Issue 3

Featured Clinical Article: Cefepime-Induced

Neurotoxicity

2013 Poster Abstracts

TSHP Journal

2 TSHPJournaluVolume14 Issue3 Issue3 TSHPJournaluVolume14 3

TSHP JournalPublishedbythe

Texas Society of Health-System Pharmacists

3000JoeDiMaggio#30-A•RoundRock,Texas78665-3994Ph:(512)906-0546•Fax:(512)852-8514

ISSN:2325-2804

TSHP BOARD OF DIRECTORSPresident -EmoryMartin

Immediate Past President -BrianCohenTreasurer- LindaHaines

President-Elect -LarryEgleSecretary -JabeenJohn

President-Elect Designate-ShaneGreeneSecretary-Elect Designate-StevenKnightAustin Area–LadanPanahi,President

Central Texas–MeganMcKee,PresidentCoastal Bend-JasonMazour,PresidentEast Texas–BillyJoeSartor,President

El Paso Area–DavidRomero,PresidentGulf Coast –BrianFase,President

Heart of Texas –OlaOyetayo,PresidentLubbock Area–CaseyKlesel,President

Metroplex Area–GregoryJohnson,PresidentPanhandle –ShawnaE.King,President

Rio Grande Valley -IsidroRamirez,PresidentWest Texas–MollyMinze,President

Industry Section–MaryAnnWhitacre,ChairNew Practitioner Section–LindaHaines,Chair

Pharmacy Management Section–RosanneThurman,ChairStudent Section–ReginaRoy,Chair

Technician Section–DeborahSard,Chair

****

TSHP 2013 - 2014 Council & Section ChairsCommunicationAffairs–PamelaPrice

EditorialAdvisoryBoard–KathrynPidcockEducationalAffairs–RichardCadleMembershipDevelopment–FeibiChiOrganizationalAffairs–TammyCohenProfessionalAffairs–NancyMyers

PublicAffairs&Advocacy–AaronReich

TSHP StaffPaulF.Davis,ExecutiveDirectorJudyK.Turley,ExecutiveAssistant

LeahM.Cody,Dir.of Communications&MemberServicesRebeccaEnglish,Meetings&MembershipAssistant

The Texas Society of Health-System Pharmacists (TSHP)is the organization representinghealthcare pharmacy practicein Texas. TSHP’smembershipincludespharmacists, techniciansand other healthcare professionalswhose goal is to optimizepharmacypracticeforthepublic’sbenefit.TSHPisanaffiliateof theAmericanSocietyof Health–SystemPharmacists.

Mission StatementThemission of TSHP is to enhance the growth, professionaldevelopment, practice and public acknowledgement of ourmembers’abilitytoimprovepatientcare.

Table of ContentsPresident’sMessage............................................... 3

The Elections are coming (Legislative)........................ 4

Cefepime-Induced Neurotoxicity (Clinical)................. 6

2013PosterCompetitionAbstracts................. 13

• CompetitionWinners.................................. 13• Practitioner:Admin/Mgmt/Leadership... 18• Practitioner:Clinical..................................... 22• Practitioner:Education............................... 26• Resident:PGY1............................................ 28• Resident:PGY2............................................ 38• Student........................................................... 41

Speakingof...TheRoadAhead.......................... 53

TSHP EDITORIAL ADVISORy BOARD2013 - 2014

LincyS.Lal, EditorKathrynN.Pidcock,Pharm.D.,BCPS,AssistantEditor

ToddW.CanadaStephenJ.DavisBeckyK.HarveyCathyL.KooBonnieA.Labdi

JamieMcCarrell,Pharm.D.ReneM.Mani,StudentMember

RachelJ.Musgrove,StudentMemberPamellaS.OchoaSaraC.RuppeltJenniferK.SeltzerBobWright

With Paul’s announcing his retirement this year, the Board of Directors must now pursue a replacement. With the aid of a great search committee, a handful of candidate names will be brought forward for formal interviews by the officers and TSHP Board of Directors. We hope to have a successful candidate identified and hired by the end of 2013. Those are some big shoes to fill, but we are committed to bringing on an individual who can continue the great work Paul has assisted with. We’ll keep the membership updated as we make progress toward that goal.

During World War II, a religious leader by the name of Albert E. Bowen wrote a book entitled “Constancy amid Change” (Deseret News Press, 1944). It was

written to an audience that needed a message of certainty, assurance, and stability during changing times. Healthcare and Pharmacy have been in change for many years now. You’d likely agree with me that “change” feels like our norm.

TSHP as an organization needs a foundation of certainty, assurance, and stability to be most successful in our mission. But we do see a lot of change within the organization on a year-to-year basis.

• TSHP officers turn-over every year (with a few years of built-in overlap).

• Local chapter leadership who sit on our TSHP Board of Directors also change every year (with some entero-chapter recycling sometimes).

One of best anchors of stability for our organization is our paid TSHP staff. Our executive director Paul Davis, through his own efforts and in directing the efforts of the other TSHP staffers, contributes a great deal to “constancy amid change” for TSHP. (Picture his image chiseled into the Rock of Gibraltar above. I didn’t have the nerve to Photoshop him in.)

President’s Message

Emory MartinTSHP President 2013-2014

Constancy amid Change


Legislative Article

The Elections are coming….Careful what you wish for !!!

The people are watching…..Hmmmm. Oh, how many times have I complained of

voter apathy? Well that problem may be over.

The past two elections have certainly “stirred the pot.” The left and the right seemed to have found one thing they agree on, and that is their lack of appreciation for incumbents. On the state level (and I still don’t want to talk about Washington….) Texas voters have taken every opportunity to look for a fresh face and to reject anyone with experience in public office. In 2011, they chose a never-elected, under-funded Ted Cruz over the current Lt. Governor David Dewhurst to be our U.S. Senator and did so all the way down the ballot. This past general election produced 42 new legislators in the Texas House of Representatives. Those “freshmen” legislators joined with the 36 previously elected freshmen in 2009 (now sophomores) to create a chamber filled with a majority who had only served for 2 years or less!!

The 2014 election cycle is coming fast and it looks like the trend will continue. Early projections are indicating that 5 of the 6 statewide elected officers will NOT be running for their current positions. (Gov. Rick Perry, Comptroller Susan Combs, Attorney General Greg Abbott, Agriculture Commissioner Todd Staples, and Land Commissioner Jerry Patterson will all be retiring or running for higher office.) The 6th statewide officer, Lt. Governor David Dewhurst will be challenged by several opponents in his effort to run for re-election.

As for the members of the Texas Senate and House,

we are sti l l waiting for the “domino effect” once decisions are made by current legislators. The Democratic Party realized that their strategy of passing on fielding candidates for all of the statewide elections back in 2009 left them looking a little anemic and has indicated that they will have serious candidates for every election in 2014. That will mean convincing sitting elected democrats to leave their current offices and gamble on running for higher office. That list will include Senator Wendy Davis (who generated the crowds pictured above during her filibuster on abortion legislation) who may run for Governor; Sen. Van de Putte who has been mentioned as a candidate for Lt. Governor; Sen. Carlos Uresti, who has been

encouraged to run for Attorney General.

So looking ahead to the next legislative session in 2015….. It’s possible that we will have 5 new Senators and a new Lt. Governor, and in the House – there may be another 25 new freshmen. This creates an interesting dilemma….. approximately 100 of the 150 House Members will have a maximum of 2 legislative sessions experience. None of them will have been there long enough to have been a committee chairman, or served on a budget conference committee. The continued lack of legislative experience will mean longer learning curves and no institutional memory. In other words, we will start all of our debates from scratch and not have the advantage of the previous fact finding and discovery.

So, what is a pharmacy organization to do??? Just what you are good at….. get to know your candidates, talk about your profession, get involved in campaigns and give to the

Brad SheildsTSHP Lobbyist

TSHP PAC so that we can support candidates who understand and support our issues. And….. if the sun is shining – find a pharmacist who would be willing to run for office. Imagine the support and assistance that an entire profession could muster if just one of their own decided to step forward and represent his community….(prayers to follow).

Get Involved - Support TSHP PAC Whether it’s healthcare reform in Washington, DC, a new law in Texas allowing pharmacists to expand their scope of practice or a regulation from the Board of Pharmacy telling you what steps must be taken in daily practice – our profession is regulated and legislated by public officials. TSHP has an active lobby team that works with the Texas Legislature, Texas Congressional Delegation and all relevant state regulatory agencies to help express the view of health-system pharmacy and advocate for the improvement of care our patients receive. But it all takes money. Your dues dollars help support our team, but we need to support the elected officials who are friends of pharmacy, by helping keep them in office (or in their efforts to get elected)! You know from the media how much it costs to run a campaign for public office, and the people who have supported us need and deserve our help. The TSHP PAC (Political Action Committee) only contributes to candidates for the Texas Legislature (no statewide or national races). We provide campaign support to candidate of both the Democrat and Republican parties who are in key positions to influence healthcare legislation.

Your contribution will help build our treasury so that your dollars, combined with those of your colleagues from throughout the State, will see that our legislative efforts remain effective on your behalf. Contribute today through our secure online payment system or show your support at our Annual TSHP PAC Silent Auction, during the 2014 Annual Seminar, April 11-13, 2014. Texas health-system pharmacy – growing strong and advancing healthcare – thanks to your support and participation.

Click here to contribute today!

http://www.tshp.org/tshp-pac---get-involved.html


Cefepime (Maxipime™) is a broad-spectrum parenteral cephalosporin antibiotic with activity against gram-positive and gram-negative bacteria. Cefepime is a fourth-generation cephalosporin with comparable coverage

to ceftazidime, and exerts its mechanism of action by inhibiting penicillin-binding-protein-mediated bacterial cell wall synthesis, ultimately leading to cell death.1 Compared with cefotaxime, cefepime has 5-9 times more activity against Pseudomonas aeruginosa, and is more active against Enterobacteriaceae

in comparison to ceftazidime.1 Cefepime is indicated for the treatment of uncomplicated and complicated urinary tract infections, pneumonia, uncomplicated skin and skin structure infections, complicated intra-abdominal infections, and as empiric therapy for febrile neutropenic patients.2 Cefepime exhibits linear pharmacokinetics and approximately 80 percent of the administered dose is recovered unchanged in the urine.3 Elimination of cefepime is primarily via renal excretion with an average half-life of 2 hours in healthy volunteers.2 In hemodialysis patients, the average half-life is 13.5 hours and 19 hours for those requiring continuous peritoneal dialysis.2 Therefore, dosage adjustment is required in patients with renal impairment and in those requiring dialysis.2 (Table 1)

Table 1. Recommended Cefepime Dosing Schedule in Adult Patients (Normal renal function, Renal Impairment, and Hemodialysis)2

Creatinine Clearance (ml/min)

Recommended Maintenance Schedule

UTIa UTIa, Pneumoniab Pneumonia b, UTI c, SSSId, Intraabdominale Febrile Neutropeniaf

> 60 500 mg q12h 1 gm q12h 2 gm q12h 2 gm q8h30-60 500 mg q24h 1 gm q24h 2 gm q24h 2 gm q12h11-29 500 mg q24h 500 mg q24h 1 gm q24h 2 gm q24h< 11 250 mg q24h 250 mg q24h 500 mg q24h 1 gm q24hCAPD 500 mg q48h 1 gm q48h 2 gm q48h 2 gm q48hHemodialysis 1 gm on day 1, then 500 mg every 24h thereafter 1 gm q24h

UTI = urinary tract infection; SSSI = skin and skin structure infection; CAPD = continuous ambulatory peritoneal dialysis.a For mild-to-moderate uncomplicated or complicated UTIs, including pyelonephritisb For moderate-to-severe pneumoniac For severe uncomplicated or complicated UTIs, including pyelonephritisd For moderate-to-severe uncomplicated SSSIse For complicated intraabdominal infections when used with metronidazolef Empiric therapy for febrile neutropeniaCefepime should be administered after hemodialysis on hemodialysis days. Whenever possible, cefepime should be administered at the same time each day.

The most commonly seen adverse effects from cefepime are phlebitis, rash, diarrhea, nausea, vomiting, pruritis, fever, and headache.2 In June of 2012, the U.S. Food and Drug Administration (FDA) issued a drug safety communication reminding health care professionals for the need to adjust the cefepime dose in patients with renal impairment.4

Feature

Authors

Feibi Chi, Pharm.D., BCPSClinical Pharmacy Specialist

Department of Pharmacy Services, Michael E. DeBakey VA Medical

Center, Houston, TX

Kathryn Pidcock, Pharm.D., BCPSClinical Pharmacy Specialist

Department of Pharmacy Services, The Methodist Hospital, Houston, TX

Cefepime-Induced Neurotoxicity – a Case at a

VA Teaching Hospital

In the post-marketing phase, nonconvulsive status epilepticus (NCSE) was associated with improper dose adjustment among renally impaired patients.4 In most cases, the seizures resolved after discontinuation of cefepime therapy and/or after hemodialysis to remove excess drug levels.4 Warnings for neurotoxicity, which include encephalopathy (disturbance of consciousness including confusion, hallucinations, stupor, and coma), myoclonus, seizures, and NCSE, are listed in the prescribing information.2 We describe a case in which long-term cefepime administration in the setting of acute kidney injury (AKI) could have led to neurotoxicity symptoms such as slurred speech, encephalopathy, and tremors.

Case reportA 58-year-old Caucasian female was brought in to the emergency department (ED) by her husband for altered mental status (AMS), nausea, vomiting, generalized tremors, and worsening headache for five days. She has a significant past medical history of diabetes, hypertension, hyperthyroidism, and hyperlipidemia. Five weeks prior to presentation, the patient was admitted to the hospital for Pseudomonas externa otitis media and osteomyelitis of the mastoid temporal bone. The patient was discharged

home with intravenous (IV) cefepime 2 gm every 12

hours for 6 weeks. During that admission, patient had a negative workup for meningitis and brain

abscess on clinical exam, magnetic resonance imaging

(MRI) of the brain, and cerebral spinal fluid (CSF)

analysis. Patient also had an MRI venogram of the brain with no evidence of cerebral v e i n t h ro m b o s i s . The patient has no known drug allergies, and her medications consisted of cefepime 2 gm IV q12 hours, ciprofloxacin 0.3% otic solution 5 drops to affected ear daily, glyburide 5 mg orally (po) twice a day (BID), metformin 500 mg po BID, lisinopril 20 mg po daily, metoprolol 25 mg po daily, ondansetron 4

mg po q6h as needed

(PRN), pravastatin 40 mg po daily, and methimazole 10 mg po daily. Patient also reported self-medicaing with naproxen and aspirin “around the clock” for severe headache.

Pertinent physical examination revealed a Caucasian female in no acute distress with an elevated blood pressure of 203/99 mm Hg, pulse 99 beats/minutes, respiratory rate 18 breaths/minute, and an oral temperature of 98⁰F. Neurology was consulted for evaluation of AMS. Upon neurological examination, patient was alert and oriented to person and place; however, patient did not know the year or time. Immediate and delayed recalls were intact, and her language was fluent with mild dysarthria in speech. Cranial nerves were intact, with positive Romberg test and negative Babinski sign. Relevant laboratory work demonstrated AKI with elevated serum creatinine (SCr) of 1.7 mg/dl (normal range 0.6-1.3 mg/dl, baseline 1.1 mg/dl), blood urea nitrogen of 44 mg/dl (7-19 mg/dl), sodium of 140 mmol/L (136-145 mmol/L), hyperkalemia at 6.3 mmol/L (3.6-5 mmol/L), hypermagnesemia at 3 mg/dl (1.6-2.6 mg/dl), and hyperglycemia at 278 mg/dl (70-110 mg/dl). Urinalysis was not collected as patient did not complain of signs and symptoms of urinary tract infection. Computed tomography (CT) of the head without contrast was within normal limits, MRI of the brain without contrast demonstrated overall improvement in osteomyelitis of the mastoid temporal bone, with no evidence of acute infarct or posterior reversible encephalopathy syndrome.

The patient was admitted to the internal medicine team for management of AMS, AKI, and hypertensive urgency. Patient was initiated on IV fluid for decreased oral intake and dehydration; lisinopril was held on admission due to AKI, and amlodipine was started for blood pressure management. Meclizine and promethazine were initiated for management of nausea and vomiting, and tramadol was used for headache. Cefepime was renally adjusted to 2 gm IV q24h based on patient’s renal function (calculated creatinine clearance ~ 35 ml/min based on patient’s weight of 63 kg). By day 3, the patient’s mental status significantly improved, with blood pressure of 135/59 mm Hg, and SCr trended down to 1.6 mg/dl. Patient was discharged home on day 4, with mental status returned to baseline, complete resolution of nausea and vomiting, and SCr of 1.5 mg/dl. Patient was discharged with cefepime renally dosed at 2 gm IV q24h for 3 more days to complete 6 weeks course for treatment of osteomyelitis. Patient was scheduled for outpatient follow up with otolaryngology and neurology. Literature Review (Table 2)5-22 The case reports and case series published to date have demonstrated neurotoxicity in patients of different age ranges, sex, and history of both acute and chronic kidney


diseases (CKD). In these reports, patients received doses that were renally adjusted and doses that exceeded the current recommendations for patients with CKD, with or without dialysis. Symptoms of neurotoxicity include confusion, somnolence, aphasia, agitation, myoclonus, and NCSE. Several cases detailed elevated serum cefepime levels, and electroencephalography (EEG) findings of NCSE. Onset of symptoms after initiation of cefepime ranged from 1 to 16 days. Recovery after discontinuation of cefepime, hemodialysis, and use of anticonvulsants were immediate and up to 12 days after incident.

Table 2. Limited Case Reports of Cefepime-Induced Neurotoxicity5-22

Reference Age, sex Renal function

Cefepime Dose &

Duration

Indication Clinical Findings Latency (days)

Recovery (days)

Other treatmenta

Wong et al5 40, M HD 2 gm/day x 5 days

Pneumonia AMS, generalized tonic-clonic convulsion

5 days 2 days HD

Fishbain et al6

74, F HD 2 gm/days x 4 days

Bacteremia Confusion, AMS, disorientation, muscle twitching

4 days 2 days HD

Martinez-Rodriguez et al7

79, M CKD 1 gm/day Pneumonia Confusion, myoclonus

6 days 4 days Clonazepam, valproate

67, F CKD 8 gm/day Pneumonia Drowsiness, confusion

5 days < 1 day Clonazepam

64, F CKD 1 gm/day Pneumonia Agitation, confusion, myoclonus

5 days < 1 day Clonazepam, phenytoin

54, M CKD 2 gm/day Prophy-laxis Agitation, confusion, 1 day 5 days Clonazepam, diazepam

86, M CKD 4 gm/day Osteo-myelitis

Agitation, confusion, myoclonus

4 days 7 days Valproate, phenytoin

79, F CKD 4 gm/day Pneumonia Confusion, myoclonus

10 days 2 days Clonazepam, phenytoin, valproate

Chatellier et al8

73, F AKI 4 gm/day Knee prosthesis infection

Coma, myoclonic status epilepticus

16 days NR HD

65, M AKI 2 gm/day Gram – bacteremia

Confusion, NCSE 12 days NR HD

73, F AKI 2 gm/day Knee prosthesis infection

Coma, NCSE 15 days NR HD

75, M AKI 2 gm/day Cutaneous infection

Confusion, generalized myoclonia

15 days NR HD

Chow et al9 59, M PD 4 gm/day x 2 days

Strepto-coccal CAPD peritonitis

Confusion, obsessive ideas, dysarthria, dysmetria

5 days 1 day None

60, F PD 1 gm/day x 9 days

Culture negative for CAPD peritonitis

Irrelevant speech, disorientation

4 days 6 days None

Ferrara et al10

82, M HD 1 gm/day x 4 days

Pneumonia Seizure 4 days 2 days HD


Cefepime Dose &

Duration


Recovery (days)

Other treatmenta

Plensa et al11

65, M AKI 6 gm/day x 5 days

Fever Decreased conscious-ness, myoclonus, NCSE

7 days 3 days Phenytoin

Dakdouki et al12


Pneumonia Confusion, auditory/ visual hallucination, agitation

5 days 3 days HD

Abanades et al13

66, F AKI 6 gm/day Febrile neutropenia

Confusion, NCSE, disorientation

11 days 3 days Clonazepam valproate

Lam et al14 67, F CKD 1 gm/day x 3 days, 2 gm/day x 4 days

Urinary Tract Infection

Confusion, lethargy, unresponsive to stimuli (pain and loud voice only), myoclonic jerks

7 days 17 days Clonazepam, levetiracetam

De Silva et al15

77, M HD 4 gm/day Pancreatitis Confusion, myoclonus

4 days 3 days HD

71, M Normal 4 gm/day Otitis media Confusion, asterixis 3 days 2 days None59, F HD 1 gm/day Skin/soft

tissue infection

Drowsiness, confusion, myoclonic jerks

2 days 4 days None

Bresson et al16

NR, M AKI on CKD

6 gm/day Surgical site infection

Seizure, encephalo-pathy

4 weeks 1 day CVVHF

Sonck et al17 74, M CKD 5 gm/day x 7 days

Sepsis Coma, myoclonus 7 days Death None


Empiric Agitation, aphasia 1 day Death None

49, F CKD 1.8 gm/day x 4 days

Empiric Agitation, confusion 4 days Death None


COPD-Exacerbation

Coma, myoclonus 4 days Death None

82, F HD 1 gm/day x 6 days

Sepsis Aphasia, myoclonus, chorea-athetosis, convulsions, coma

4 days Death None

84, M HD 3 gm/day x 6 days, 1 gm/day x 10 days

Bilateral pneumonia

Aphasia, myoclonus, hyperexcita-bility

3 days Death None

53, M CKD 6 gm/day x 11 days

Sepsis Aphasia, coma 10 days Death None

70, F HD 1 gm/day x 6 days

Febrile neutropenia

Myoclonus, coma 5 days Death None

Gangi-reddy et al18

70, F NR Renally-dosed; actual dose NR

Febrile neutropenia

AMS, orofacia myokymia, NCSE

4 days 3 days None



Cefepime Dose &

Duration


Recovery (days)

Other treatmenta

Yadla et al19

65, F HD NR Empiric Global aphasia, chorea type movements, myoclonus

2 days 2-3 days None

45, M HD NR Lower respiratory tract infection

Myoclonus 2 days 3 days None

Hocker et al20

61, F AKI NR Empiric Decreased consciousness, coma, repetitive involuntary movements, dystonia

3 days 3 days None

Kim et al21 74, M HD 1 gm/day x 3 weeks, then d/c; resumed at 1 gm/day

Urinary tract infection

Stupor, aphasia, disorientation, lethargy

4 days 2 days Anticonvulsant

77, F CKD 1 gm/day Urinary tract infection

Decreased consciousness, aphasia, muscle clamp

2 days Death from pneumonia

HD

Durand-Maugard et al22

82, NR AKI 2 gm/day x 3 days, 1 gm/day x 2 days

NR Altered level of consciousness

5 days NR HD

71, NR AKI 8 gm/day NR Convulsions, altered level of consciousness

3 weeks NR HD, clonazepam

75, NR HD 1 gm/48 hr NR Mental confusion 4 days NR Additional HD

84, NR CKD 2 gm/day NR Somnolence after w i t h d r a w a l o f hypnotics, clonic movements

6 days NR None

49, NR HD 6 gm/day x 2 days, 4 gm/day

NR C o n f u s i o n , somnolence

3 days NR Additional HD

82, NR CKD 1 gm/day NR V i s u a l h a l l u c i n a t i o n s , confusion

2 days NR None

77, NR CKD 3 gm/day NR Clonic movements, confusion

54 hours NR Clonazepam

81, NR AKI 4 gm/day NR Status epilepticus NR NR None61, NR CKD 0.5 gm/day,

then 2 gm/day

NR Confusion, status epilepticus

NR NR None

a Treatment in addition to discontinuation of cefepimeHD, hemodialysis; AMS,altered mental status; CKD, Chronic kidney disease; AKI, Acute kidney injury; NR, Not reported; NCSE, non-convulsive status epilepticus; PD, Peritoneal dialysis; CAPD, Continuous ambulatory peritoneal dialysis; CVVHF, Continuous veno-venous haemofiltration; COPD, Chronic Obstructive Pulmonary Disease

Mechanism of NeurotoxicityThe potential mechanism of cefepime-induced neurotoxicity involves the decrease in gamma-aminobutyric acid (GABA) release and increase in excitatory neurotransmission.23,24 GABA is the major inhibitory neurotransmitter within the CNS, and a reduction in GABA produces an increase in CNS excitation and subsequent lowering of the seizure threshold.24

Compared to penicillins, cephalosporins bind to GABA receptors competitively, which may explain the increase in incidence and potential for neurotoxicity.23 Other potential mechanisms for cephalosporin-induced neurotoxicity include promotion of endotoxin release, leading to increase in tumor necrosis factor and worsening encephalopathy.23 A study conducted by Ohtaki et al in 2004 also demonstrated an increase in glutamate concentrations after administration of cephalosporin, which suggests the role of glutamate excitation as a mechanism of cephalosporin induced neurotoxicity.25

Risk Factors for NeurotoxicityThere are several key properties and predisposing factors that may lead to increased risk for cefepime-induced neurotoxicity. Cefepime crosses the blood-brain barrier and penetrates the CNS well, with a CSF to serum concentration ratio of 10%.23,26,27 Patients with an underlying CNS infection or other systemic infection can experience increased absorption through the blood-brain barrier, further increasing the patient’s risk for developing neurological complications while on cefepime.26 Patients with kidney dysfunction are also at an increased risk for cefepime-induced neurotoxicity, as cefepime is eliminated primarily by the kidneys, with the half life significantly prolonged in renal impairment.27 Elderly patients are at high risk for antibiotic-induced neurotoxicity due to impaired renal function with age. The need for higher doses of cefepime may also contribute to increased toxicity. Frei et al demonstrated that cefepime 2 gm every 8 hours was required to achieve a minimum inhibitory concentration (MIC) of 8 mcg/mL for optimal bactericidal effect.28 The high doses of cefepime may predispose patients who are more ill to exposure-related neurological sequelae.27

Patient CaseOur patient presented with signs and symptoms of cefepime-induced neurotoxicity, including slurred speech, encephalopathy, and tremors. Factors that may predispose this patient to increased risk of cefepime-induced neurotoxicity include impaired renal function, exposure to high doses of antibiotics for a prolonged period of time, and increased permeability of cefepime to the CSF due to systemic infection of osteomyelitis of the mastoid temporal bone. We utilized the Naranjo adverse drug reaction probability scale to assess the potential association of cefepime and neurotoxicity in our case.29 A possible association was seen between the

use of cefepime and development of neurotoxicity in this patient. The collection of objective findings such as EEG and measurement of cefepime drug levels may help strengthen the relationship between cefepime use and development of neurotoxicity in our patient case.

ConclusionCefepime is a widely used antibiotic with broad spectrum of activity against gram-negative bacteria. It has a relatively safe side effect profile; however, when giving in higher doses for prolonged period of time, patients with systemic or CNS infections may be at an increased risk for adverse reactions such as neurotoxicity. Due to the pharmacokinetics profile of cefepime, reduction of maintenance doses based on patient’s renal function is necessary in order to reduce the incidence of adverse drug reactions. Clinicians should be aware of the potential neurotoxicity seen when cefepime is administered in the setting of renal impairment, as the signs and symptoms of this reaction may be nonspecific and delayed.

ReFeReNCeS1. Barbhaiya RH, Forgue T, Gleason CR, et al. Pharmacokinetics of

cefepime after single and multiple intravenous administrations in healthy subjects. Antimicrob Agents Chemother. 1992; 36(3):552.

2. Maxipime [package insert]. Lake Forest, IL: Hospira, Inc; Revised June 2012.

3. Barbhaiya RH, Forgue T, Gleason CR, et al. Safety, tolerance, and pharmacokinetic evaluation of cefepime after administration of single intravenous doses. Antimicrob Agents Chemother. 1990; 34(6):1118.

4. FDA Drug Safety Communication: Cefepime and risk of seizure in patients not receiving dosage adjustments in kidney impairment. June 26 2012.

5. Wong KM, Chan WK, Chan YH, et al. Cefepime-related neurotoxicity in a haemodialysis patient [letter]. Nephrol Dial Transplant. 1999;1:2265-6

6. Fishbain JT, Monahan TP, Canonico MM. Cerebral manifestations of cefepime toxicity in a dialysis patient. Neurology. 2000;55:1756-7.

7. Martinez-Rodriguez JE, Barriga FJ, Santamaria J, et al. Nonconvulsive status epilepticus associated with cephalosporins in patients with renal failure. Am J Med. 2001; 111:115-19.

8. Chattelier D, Jourdain M, Mangalaboyi J, et al. Cefepime-induced neurotoxicity: an underestimated complications of antibiotherapy in patients with acute renal failure. Intensive Care Med. 2002;28:214-17.

9. Chow KM, Szeto CC, Hui ACF, et al. Retrospective review of neurotoxicity induced by cefepime and ceftazidine. Pharmacotherapy. 2003;23:369-73.

10. Ferrara N, Abete P, Giordano M, et al. Neurotoxicity induced by cefepime in a very old hemodialysis patient. Clin Nephrol. 2003;59:388-90.

11. Plensa E, Gallardo E, Ribera J-M, et al. Nonconvulsive status epilepticus associated with cefepime in a patient undergoing autologous stem cell transplantation [correspondence]. Bone


Marrow Transplantation. 2004;33:119-20.12. Dakdouki GK, Al-Awar GN. Cefepime-induced encephalopathy.

Int J Infect Dis. 2004;8:59-6113. Abanades S, Nolla J, Rodriguez-Campello A, et al. Reversible

coma secondary to cefepime neurotoxicity. Ann Pharmacother. 2004;38:606-8.

14. Lam S, Gomolin I. Cefepime neurotoxicity: case report, pharmacokinetics considerations, and literature review. Pharmacotherapy. 2006;26(8):1169-74.

15. De Silva DA, Pan A, Lim SH. Cefepime-induced encephalopathy with triphasic waves in three Asian patients [letter]. Ann Acad Med Singapore. 2007;36(6):450-1.

16. Bresson J, Paugam-Burtz C, Josserand J, et al. Cefepime overdosage with neurotoxicity recovered by high-volume haemofiltration [letter]. J of Antimicrob Chemother. 2008;62:849-50.

17. Sonck J, Laureys G, Verbeelen D. The neurotoxicity and safety of treatment with cefepime in patients with renal failure. Nephrol Dial Transplant. 2008;23:966-70.

18. Gangireddy VG, Mitchell LC, Coleman T. Cefepime neurotoxicity despite renal adjusted dosing. Scand J Infect Dis. 2011 Oct;43(10):827-9.

19. Yadla M, Kishore CK, Sriramnaveen P, et al. Neurotoxicity due to cefepime in patients on maintenance hemodialysis [letter]. Saudi J Kidney Dis Transpl. 2011;22(5):1026-7.

20. Hocker S, Rabinstein AA. Cefepime neurotoxicity can mimic postanoxic coma with myoclonic status epilepticus. Neurol Clin Pract. 2011;1(73):84-5.

21. Kim SY, Lee IS, Park SL, et al. Cefepime neurotoxicity in patients

with renal insufficiency. Ann Rehabil Med. 2012;36:159-62.22. Durand-Maugard C, Lemaire-Hurtel AS, Gras-Champel V, et al.

Blood and CSF monitoring of cefepime-induced neurotoxicity: nine case reports [letter]. J Antimicrob Chemother. 2012 May;67(5):1297-9.

23. Grill MF, Maganti R. Cephalosporin-induced neurotoxicity: clinical manifestations, potential pathogenic mechanisms, and the role of electroencephalographic monitoring. Ann Pharmacother. 2008;42:1843-50.

24. Chow KM, Hui AC, Szeto CC. Neurotoxicity induced by beta-lactam antibiotics: from bench to bedside. Eur J Clin Microbiol Infect Dis. 2005;24:649-653.

25. Ohtaki K, Matsubara K, Fujimaru S, et al. Cefoselis, a beta-lactam antibiotic, easily penetrates the blood-brain barrier and causes seizure independently by glutamate release. J Neural Transm. 2004;111:1523-35.

26. Lam S, Gomolin IH. Cefepime neurotoxicty: case report, pharmacokinetic considerations, and literature review. Pharmacotherapy. 2006;26(8):1169-1174.

27. Zemrak WR. Cefepime-induced neurotoxicity: a review of evidence. Hosp Pharm. 2009;44:557-561,574.

28. Frei CR, Wiederhold NP, Burgess DS. Antimicrobial breakpoints for gram-negative aerobic bacteria based on pharmacokinetic-pharmacodynamic models with Monte Carlo stimulation. J Antimicrob Chemother. 2008;61(3):621-628.

29. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30:239-45.

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WINNeRPRACTITIONeR - ADMINISTRATIVe/PRACTICe MANAGeMeNT/LeADeRSHIP

The Birth of an Innovative Obstetrics APPe experienceJ Villareal, C Sanchez, V SantellanChildren’s Hospital of San Antonio, San Antonio, Texas

Background: Pharmaceutical care in the hospital setting varies by specialty and is often multidisciplinary.One area of limited involvement is pharmaceutical care in obstetric (OB) medicine. Great opportunity for pharmacists exists to collaborate with physicians, nurses, and patients to provide obstetric pharmacotherapy education. The purpose of this three-day interdisciplinary experience aims to provide specific education to pharmacy interns related to OB medicine.

Objective: To describe the development of a three-day interdisciplinary OB learning experience during an advanced pharmacy practice experience (APPE) rotation,

to evaluate OB medications, to examine drug therapy interventions in the OB department, and to assess pharmacist intern knowledge in OB pharmacotherapy.

Method: The three-day experience was conducted at Children’s Hospital of San Antonio labor and delivery department. An assessment was conducted prior to the start and after completion of the experience to evaluate knowledge of OB pharmacotherapy. Intern daily schedules were based on a structured checklist.

Result: Interns reviewed forty-four medication profiles during the experience. Three critical medication interventions were made. At the completion of the experience, an overall improvement in case study assessment scores was noted.

Conclusion: The three-day interdisciplinary learning experience allowed pharmacist interns to acquire further knowledge in OB medicine and expand pharmaceutical care in the hospital setting.

Disclosure: No disclosures.

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2013 TSHP Poster CompetitionAbstracts

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WINNeRPRACTITIONeR - CLINICAL

A Cost Comparison of Consumer Price Per Unit of Common Nonprescription Drugs and Durable Medical equipment at Different Types of PharmaciesBL Frei, CK HorlenUniversity of the Incarnate Word, San Antonio, TX

Background: Although nonprescription drug (OTCs) costs are small considering overall healthcare expenses1, it can have the biggest upfront impact on patients. Healthcare system pharmacists may not be familiar with the discrepancies between pharmacies for consumer OTC costs and unable to provide economically smart recommendations.

Objective: To compare the consumer price of common OTCs and DME between pharmacies, types of pharmacies, and geographic area.

Method: Consumer price per unit (cppu) of eighteen OTC medications/DME were collected at 7 pharmacies within similar geographic area and 1 pharmacy from a separate area. The median cppu, standard deviation, and coefficient of variation was calculated for each product.

Result: Lowest cppu was available from regional supermarkets for 9 products, Internet for 8 products, national supermarket for 7 products, and traditional drug store pharmacies for 1 product each. Multiple pharmacies had the lowest cppu for several products. Variation in cppu was largest with glucometers, glucose test strips, and Claritin, respectively. There was no difference in consumer price based on economics of surrounding area; the regional supermarket had the same consumer price despite different economic status of its location.

Conclusion: Regional supermarket pharmacy was most often the lowest price for the products evaluated followed by Internet, and national supermarket/store pharmacies. Healthcare system pharmacists should be aware that there is a large amount of variability in the cost of nonprescription drugs by type of pharmacy but not based on store location or household income of the area.

Disclosure: None

1Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data, January 2012

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WINNeRPRACTITIONeR - eDUCATION

Applicant Selection Process for PGY1 Pharmacy Residency ME Quinones, NS Myers, EE Moss, VB Johnson, CA Berge, AP Rahman, JL Nelson, MY Pio, TM Thomas, KS Alvarez, SM Boatright, DH Chow, JL Hulstein, AM Lockwood, AC Mathew, CL Zoellner, JW Gard, LS Nichols-Williams, EO Unachukwu Parkland Health & Hospital System, Dallas, Texas


Background: Parkland Health & Hospital System has over sixty candidates for the PGY1 Pharmacy Residency program with significant annual increases. The Residency Advisory Council faced challenges with screening candidates and scheduling interviews.

Objective: To find a more efficient mechanism for reviewing, interviewing, and selecting pharmacy residency candidates

Method: Originally, screening consisted of phone interviewing all applicants, which was time-consuming

and inconsistent. Currently, a modified screening tool is being utilized to review all applications. The applicants are ranked according to scores. The review team assesses rankings and comments to determine which candidates would be offered a phone interview. The phone interview is used to further screen applicants to ensure the goals of the applicant align with that of the residency. Candidates for the on-site interviews are determined by the phone interview and screening tool. Originally, interviews spanned over two months, requiring interviewers to spend large amounts of time away from patient care and operations. Currently, one week is used for interviews and candidate ranking.

Result: For the 2013-14 residency year, the program utilized the PhORCAS system. Ninety-eight applications were reviewed using the screening tool, and 39 applicants were selected for phone interviews. Twenty-two candidates were invited for on-site interviews. The screening tool has been further modified and an objective scoring system has been added for the phone interviews.

Conclusion: The candidate selection process has improved in objectivity, consistency and efficiency through the implementation of a screening tool and a more consolidated on-site interview schedule.

Disclosure: None

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WINNeRReSIDeNT PGY1

evaluation of Medication error Reduction with Pharmacist-conducted admission medication reconciliation in an emergency department. CF Lang, KR Winkler, T Dasher, H YangMethodist Hospital, San Antonio, TX

Background: Nearly 1.5 million preventable adverse drug events (ADEs) occur in the United States annually, resulting in more than 7,000 deaths. Research has shown that up to 11% of medication-related problems occurring in hospitals take place during emergency department (ED) visits.

Objective: The primary objective is to assess accuracy and completeness of nurse-generated admission medication reconciliation compared to that of a pharmacist. The secondary objective is to generate a cost avoidance model through pharmacist prevented ADEs.



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Method: During the pre-implementation analysis, admission medication reconciliation information acquired by a nurse was assessed retrospectively by a pharmacist for completeness and accuracy. In phase one of the post-implementation analyses, a pharmacist cross reviewed nurse-completed admission medication reconciliation forms. In phase two, a pharmacist conducted medication reconciliation with their performance reviewed by a second pharmacist.

Result: Retrospectively, 47% of medication reconciliation forms completed by a nurse required a pharmacist’s clarification. In phase one, 82% of patients were found to require a pharmacist’s intervention and this was accomplished with a 0% error rate in phase two. At $45 dollars per medication modification requiring a pharmacist’s intervention, our institution would save $584,850 annually by employing an ED pharmacist. A cost modeling approach estimated an ADE net cost avoidance of $1,287,328 annually.

Conclusion: Our findings indicated that 82% of patients admitted lack complete or accurate nurse- completed admission medication reconciliation. Medication reconciliation conducted by a pharmacist in the ED will avoid clarifications costing approximately $600,000 of annual pharmacists’ salary. In addition, we will realize an estimated $1,287,328 in avoided ADE costs.

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WINNeRReSIDeNT PGY2

Development of a Combination Antibiogram for Pseudomonas aeruginosa Bacteremia ZR Smith, SK Tajchman, BM Dee, JJ Bruno, FP Tverdek University of Texas: MD Anderson Cancer Center, Houston, Texas

Background: Inappropriate initial antimicrobial therapy in patients with septic shock is associated with a fivefold reduction in survival. Current guidelines suggest empiric combination antimicrobial regimens for patients with sepsis secondary to suspected P. aeruginosa infection.

Objective: To determine the antimicrobial regimens that optimize the likelihood of attaining an effective regimen against P. aeruginosa blood isolates through the development of a combination antibiogram.

Method: A retrospective analysis including patients admitted to a large, tertiary care, institution with a blood culture positive for P. aeruginosa from January 1, 2012 to December 31, 2012. The primary outcome assessed was in-vitro susceptibilities of beta-lactam and non beta-lactam regimens via creation of a combination antibiogram. An effective antimicrobial regimen was defined as one that had in-vitro activity to at least 85% of isolates. Furthermore, the addition of the non beta-lactam agent was required to increase the in-vitro activity by at least 5% over the single agent beta-lactam. Secondary objectives included identifying risk factors for multidrug resistant (MDR) P. aeruginosa and determining survival to hospital discharge when attaining zero, one, or two active in-vitro agents. Outcomes were assessed using descriptive statistics, Fisher exact test, and multivariate analysis.

Result: One hundred and twenty-three P. aeruginosa isolates were included in this analysis from 99 patients. Beta-lactam sensitivities ranged from 13 to 79.7%. Combination regimen sensitivities ranged from 74 to 96.7%. All beta-lactam/aminoglycoside regimens were effective antimicrobial regimens. All beta-lactam/ciprofloxacin regimens were ineffective antimicrobial regimens.

Conclusion: Effective antimicrobial regimens in this single institution combination antibiogram included all beta-lactam/aminoglycoside regimens.


Disclosure: Authors have no actual or potential conflicts of interest

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WINNeRSTUDeNT

Findings of medication review services provided by a student pharmacist-led community outreach programVJ Fassio, NQ Dinh, JF Morales, CH PhamThe University of Texas at Austin College of Pharmacy, Austin, Texas

Background: Elderly Americans utilize the highest number of chronic medications, yet may lack understanding of their therapy, which can lead to decreased adherence and an increased risk of developing drug-related problems. Healthy People 2020 stresses the need for improvement in health-related outcomes within this population. A student pharmacist community outreach program, Know Your Medicine (KYM), was implemented to improve medication safety and adherence in the senior population.

Objective: To describe the findings of a student pharmacist-led medication review and education program in senior community centers

Method:Third-year student pharmacists were trained to conduct medication reviews and follow-up calls. One-hour patient interviews were conducted at three senior centers to evaluate medication use, create personal medication records, and discuss health- and medication-related recommendations. Afterwards, senior participants completed patient satisfaction surveys. Two weeks later, follow-up calls assessed completion of recommendations made and barriers to completion.

Result: Participants were predominantly Caucasian (72%), female (72%), and aged 58-94 (mean = 77.5). On average, participants had 4.9 medical conditions, took 12.3 medications monthly, and received 4.4 recommendations. Patient satisfaction surveys showed that 100% had most of their questions/concerns met, 95% found the information presented very useful, and 82% indicated large improvement in understanding their medications. Follow-up call participants reported a 57% completion rate of recommendations made by student pharmacists.

Conclusion: Student pharmacists have the knowledge and ability to educate seniors on the safe and effective use of their medications. Offering comprehensive medication reviews to populations at high risk of drug-related problems provides a patient-focused approach to improving overall health outcomes.

Disclosure: Our work was supported by The University of Texas at Austin College of Pharmacy and The University of Texas at Austin Senate of College Councils.

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WINNeRTeCHNICIAN

Pharmacy Technician Preventing Medication errors Through Medication History Interview At AdmissionD Little, SY YehMemorial Hermann Hospital, Sugar Land, TX

Background: The Joint Commission requires hospitals to have medication reconciliation process in place to ensure continuum of care and promote medication safety. The first step of effective medication reconciliation is to obtain a complete and accurate medication list. Since July 2009, the Department of Pharmacy at Memorial Hermann Sugar Land Hospital has trained certified pharmacy technicians to conduct medication history interview at admission. Medication history interview has been incorporated into technicians’ responsibilities and daily work flow.

Objective: To present cases of medication errors discovered and prevented by pharmacy technicians conducted home medication history interview at admission.

Method: Retrospective review of technicians’ and pharmacists’ interventions was conducted. Data collection includes: type of medication errors and pharmacists’ /pharmacy technician interventions.

Result: Cases of medication errors will be presented.

Conclusion: Medication errors have been prevented by trained certified pharmacy technicians when conducting medication history interview at admission. The Department of Pharmacy’s participation in admission medication reconciliation process is vital to minimizes medication errors during transition of care.

Disclosure: Authors do not have any affiliation or financial interest in an external organization that relates to this presentation

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eNTRIeSPRACTITIONeR - ADMINISTRATIVe/PRACTICe MANAGeMeNT/LeADeRSHIP

1-AWhat are the Issues in Preparing Pharmacy Leaders for the Health-System?T PalmerAxtell Rite-Value Pharmacy, Whitesboro, Texas

Background: The concern regarding the critical need for leadership in health-system pharmacy over the past decades has escalated to new levels in recent years (Miller, Mark, & Powell, 2008). The scarcity for pharmacist leaders enhanced by the projection that 70-80% will retire in the next decade has driven the demand to more than four times that for pharmacists (Chisholm-Burns, et al., 2011). A review of the literature revealed that the need for leadership in health-systems pharmacy has become a critical concern the past decade, and there will be a health-systems pharmacy leadership crisis in the next 5 to 10 years (Mark & Powell, 2008, Pollard & Clark, 2009). Pharmacy health-systems leadership for change in the practice of pharmacy was insufficient due to no real or direct incentive to assume leadership (Kerr, et al., 2009, Jungnicke, Kelly, Hammer, Haines, & Marlowe, 2009). The shortage of qualified, experienced faculty might reduce the leadership and


professional mentoring of student pharmacists (Thompson, 2011). Understanding the issues in preparing pharmacy leaders for the health-system might provide insight into if there will be a health-systems pharmacy leadership crisis in the next 5 to 10 years.

Objective: The objectives of this poster is to educate pharmacy practitioners and seminar attendees about the health-system pharmacy leadership crisis, the impact of the crisis on the systems consumers and stakeholders, and this proposed qualitative phenomenological study which will explore the phenomenon of is there a pharmacy leadership crisis.

Methods(s): The qualitative method is chosen for this proposed study because of the method’s ability for gaining insights into or understanding of opinions, attitudes, and experiences (Rowley, 2012). Qualitative research methods facilitate the attempts to understand the lived, professional experiences of the participants, of this proposed study, with the lack of leadership in the pharmacy profession. These experiences, primarily understood through qualitative research, contribute to the phenomenon of the lack of leadership in the pharmacy profession (Simon, 2006). Qualitative research is also useful to both pharmacy practitioners and pharmacy academics who are involved in researching educational issues in both universities and practice and in developing teaching and learning (Anderson, 2010). This proposed study will sample 20 association executives from the pharmacy industry, directors of pharmacy health systems, executives of community pharmacy systems, and faculty at higher pharmacy education organizations who possess intensive experiences with the health-system pharmacy leadership crisis.

Result: Study in progress.

Conclusion: The argument and research of White (2005) provide the basis of several assumptions of the study. Health-system pharmacy leaders, according to White (2005) recognized a potential lack of pharmacy leadership in the future. I assume there is a shortage of interested and well-prepared health-system pharmacy managers with skills to assume leadership positions (White, 2009). I also assume that the participants would mitigate the concerns of the health-system pharmacy leadership crisis.

Disclosure: T Palmer is a full-time student in the Walden University Doctor of Business Administration (DBA) program, a Texas registered pharmacist consultant, a TSHP member, and has nothing to disclose. He is not aware of any biases that might be perceived as affecting the objectivity of this abstract.

2-Aestablishing a Five Step Approach to evaluating Insulin & Opioid Doses of Unusual SizeES Martin, JD Herrington, TA MeyerScott & White Memorial Hospital, Temple, Texas

Background: An “extra zero” unintentionally added to the dose amount or a “misplaced decimal point” are common errors that risk a tenfold overdose. Confusing a high dose of a long-acting for a short-acting medication also poses a risk for overdose. Because a subset of adult patients require insulin and opioid doses much higher than other patients, discerning whether a high dose is required for a specific patient or is in fact a dosing error is difficult. Dosing errors with these medications pose significant patient risk.

Objective: The objective of this project was to educate our pharmacy staff about the difficulty in discerning a high dose error with insulins and opioids and establish a procedure to follow when confronted with a high dose in a provider’s medication order. Procedures: Opioid and insulin dose levels that would trigger the procedure were agreed upon. Five steps the pharmacist must take prior to approving a high dose were established in a departmental standard procedure. An educational piece was developed and all pharmacists completed it. A review of pharmacist compliance was conducted.

Result: Since implementing the procedure, we have had no high dose errors with insulins or opioids. Two areas for improvement were noted. 1) A need for better documentation by the pharmacists 2) A need to generalize the process to other scenarios where the pharmacist encounters an “unlikely but possible” high medication dose.

Conclusion: A standard approach for pharmacists to follow when evaluating high medication doses may contribute to reducing dosing errors.

Disclosure: ES Martin- none; JD Herrington – none; TA Meyer - none

3-A Taking Pharmacy Practice to the Next Level at a Community HospitalSY Yeh, M CasasMemorial Hermann Hospital, Sugar Land, TX

Background: ASHP Pharmacy Practice Model Initiatives (PPMI) have encouraged health system pharmacy to examine and re-design pharmacy practice model to meet the demands of health care reform, high quality, safer and cost effective

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patient care. Traditional pharmacy distribution model offers minimal direct patient care. An integrated pharmacy practice model can allow hospital pharmacy to provide a more patient-centered and consistent pharmacy service. Objective: To describe pharmacy practice evolution at Memorial Hermann Sugar Land Hospital Method: Strategic plan was developed to reallocate resources and improve efficiency of drug distribution process. Essential clinical responsibilities for pharmacists were identified. Training programs were developed to engage pharmacists in clinical activities. Certified pharmacy technicians were redeployed to take on more responsibilities. Result: Practice model change is an ongoing process. Several services have been implemented. Pharmacists with integrated clinical and distributive roles enable patients to receive consistent essential clinical pharmacy services 24/7. Conclusion: With strong technician and technology support, integrated pharmacy practice model can be implemented in a small community hospital. Disclosure: Authors do not have any affiliation or financial interest in an external organization that relates to this presentation.

4-Aexpanding “Drug Therapy Management by a Pharmacist” - One Texas Hospital’s experienceES MartinScott & White Memorial Hospital, Temple, Texas

Background: The delegation of drug therapy management activities by a physician to a hospital pharmacist is guided by Texas medical and pharmacy regulations. Understanding what the law says is important in understanding how to take steps to expand an institutional pharmacist’s scope of practice.

Objective: We sought to assure compliance with legal requirements and to work with physician leadership to establish a methodology to expand and customize pharmacists’ medication management practice in a way to better meet our various medical teams’ needs.

Procedures: We reviewed our medical staff bylaws to determine if the required language allowing for physician delegation of medication management to pharmacists was present. We reviewed our current P&T policies that describe pharmacist’s scope of practice and drafted a new approach. We presented the concept privately to our Chief Medical Officer. We presented recommended changes to our Medical Executive Committee (MEC) for approval.

Result: Bylaws changes were proposed and a new medication

management policy approved by leadership and implemented. In addition, we have begun meeting with specific physician groups to implement broader pharmacist duties in inpatient medication management.

Conclusion: It is the responsibility of hospital pharmacy department leadership to work with physician leadership to explore how expanding their hospital pharmacist’s scope of practice may benefit patient care. By working with institutional medical staff leadership, pharmacy leaders can tailor and expand pharmacist involvement in medication management.

Disclosure: ES Martin has nothing to disclose.

5-AAchieving Safety by Decreasing Overrides Performed on Automated Dispensing Cabinets: A Collaborative Quality Improvement ProjectCS Glover, M PatelSeton Highland Lakes Hospital Burnet, Texas

Background: The Institute of Safe Medication Practices (ISMP) began to review processes regarding automated dispensing cabinets and safe delivery systems in hospital care units. Hospitals of every size utilize drug dispensing cabinets because they are efficient, convenient, and cost effective. However, if not implemented correctly, there are many opportunities for errors resulting in less than optimal patient safety. In the fall of 2009, Seton Highland Lakes Hospital—a 25-bed, critical access hospital in Burnet, Texas—sought to improve patient safety by decreasing automated cabinet overrides. The resulting performance improvement project incorporated the Institute of Medicine’s Core Competencies for Healthcare Providers for the 21st Century.

Objective: Seton Highland Lakes Hospital has sought to proactively impact patient safety by decreasing automated dispensing cabinet overrides by 25%. This improves communication between departments and builds accountability for compliance and also provides ongoing feedback to associates.

Method: We endeavored to improve safety and increase collaboration by implementing the five Institute of Medicine Core Competencies in our process improvements. These include work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, utilize information technology, and provide patient-centered care.

Result: greater than 60% improvement

Conclusion: Seton Highland Lakes was able to exceed established goals by using the IOM’s Core Competencies to structure interdisciplinary participation. This helped to establish a robust environment of collaboration around medication safety. The project demonstrated a decrease in medication overrides, increased participation of professionals in patient safety, and improved interdisciplinary communication around medication management.

Disclosure: None

6-AAdd a Little SPARK to Your Pharmacy: Using a Secured Instant Messaging System in the Pharmacy Healthcare Setting to Increase Productivity and WorkflowKC Bundick, BA Dovidas, TT NgoDell Children’s Medical Center of Central Texas, Austin, Texas

Background: Enterprise Instant Messaging (EIM) is a form of electronic, real time communication. EIM provides a secure line for communication in a healthcare setting via the hospital internal server. Interruptions are time consuming and disruptive to the workflow and can impede communication within the Pharmacy Department. EIM is convenient and can increase productivity by reducing the time spent on phone calls, voicemail, or email. With the ease and flexibility of EIM, pharmacy personnel can communicate what they need quickly, at their convenience, and update others without pause in their everyday tasks.

Objective: To determine the utility of EIM for improving productivity and workflow in a hospital pharmacy setting.

Method: SPARK (Jive Software®), is the EIM platform utilized by the Pharmacy Department at Dell Children’s Medical Center in Austin, TX. SPARK messages were tracked from 12/10/2012 to 12/28/2012 and from 02/20/2013 to 03/05/2013. Messages were tracked by location sent and category (e.g. doses sent, label printed, clinical inquiry, etc) by pharmacists. A survey to obtain pharmacist’s feedback on the tool was also completed.

Result: Over the time span tracked, the use of SPARK messaging resulted in approximately 900 fewer phone calls and / or emails. Overall, 94% of the pharmacists polled stated that SPARK is a beneficial tool for the Department. Roughly 25% of pharmacists felt that certain issues addressed via SPARK could be more effectively communicated face-to-face.

Conclusion(s) :SPARK is a useful tool for our de-centralized pharmacy model. Opportunities exist for further expansion and standardization of use.

Disclosure: No disclosures

7-AProcess Improvement Team Takes a Shot at Influenza in Rehabilitation PatientsSM Loughlin, SE Lake-Wallace, LW Thomas, LM CuellarTIRR Memorial Hermann, Houston, TX

Background: Current recommendations are for people ≥ 6 months without any contra-indications to receive annual influenza vaccine. Despite this, immunization rates in Texas remain low.

TIRR Memorial Hermann Hospital is a 119-bed facility specializing in the rehabilitation of patients with neurological impairments. Like most hospitals, the immunization process has been a nurse driven activity. Relying on a single discipline has not produced optimal vaccination rates.

Objective: To evaluate overall hospital influenza immunization rates before and after the implementation of a vaccination status tool, to evaluate immunization rates by unit, to study processes involved in influenza vaccination, and to identify areas for improvement.

Method: An interdisciplinary improvement team was formed in September 2012 to improve influenza immunization rates. An electronic immunization assessment tool was implemented in mid December and emailed to nurse managers multiple times daily. All patients discharged in the months of November and December 2012 were included and immunization status was pulled from the electronic health record (EHR).

Conclusion: Hospital influenza vaccination rates increased after implementation of the Immunization Status tool. Influenza vaccination rates increased in almost every unit. Documented reasons for not administering the vaccine included: refusal, omission of screening or vaccine order, unable to assess due to cognitive dysfunction, allergy or contra-indication. The pharmacist’s role as advocate rather than immunizer was important. The most important outcome of the project was the identification of future needs including early and regular education for patients and staff, team coordination for monitoring of vaccination status, and creating mandatory fields in EHR.

Disclosure: Authors have nothing to disclose.

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eNTRIeSPRACTITIONeR - CLINICAL

1-CImpact of Pharmacist educational In-service on Psychotropic Medication Polypharmacy at a State Supported Living CenterAO Farinda

Background: Individuals with intellectual impairments, developmental delays, mental health issues, and related conditions who reside in state supported living centers, there is the potential to be placed many psychotropic medications to manage aggression, agitation, mood, or behavioral disturbances that may arise. The presence of polypharmacy can develop as a result of multiple providers prescribing without proper communication causing duplication of therapies. Pharmacists have the unique opportunity to identify and resolve cases of psychotropic polypharmacy by providing continuing educational in-service on appropriate psychotropic medication prescribing thus helping to decrease the prevalence of psychotropic polypharmacy.

Objective: 1. Evaluate the prevalence of the prescribing psychotropic polypharmacy medications at state supported living center among psychiatrists resulting from clinical pharmacist educational inservice on the appropriateness of medication prescribing. 2. Prospectively review individualized patient charts of selected facility residents to assess frequency of psychotropic medication polypharmacy among psychiatrists pre and post clinical pharmacist educational in-service. 3. Determine whether the involvement of a clinical pharmacist on a psychotropic polypharmacy review committee is associated with the improvement of mental health care and utilization of psychotropic medications at state supported living facility.

Method: The involvement of a clinical pharmacist on a psychotropic polypharmacy committee will be utilized as the platform for evaluating the prevalence of polypharmacy prescribing among the facility’s psychiatrists. This study will involve the prospective examination of psychotropic medication prescribing in the aftermath of a clinical pharmacist’s educational in-service given to psychiatrists on the appropriateness of psychotropic medication prescribing. The study will follow prescribing patterns of psychiatrists over the time span of 6 months and assess frequency of psychotropic polypharmacy as identified by the review of residents’ medication regimens. A survey will also be utilized to assess psychiatrist’s perception of psychotropic medication polypharmacy and usefulness of educational in-service.

Result: The study will report the number of psychotropic

polypharmacy pre and post educational in-service that was given to address behavioral and mental health problems. In addition, the study report the frequency of psychotropic medication polypharmacy and associated cost-saving that are identified during the six month observation phase.

2-CGlycemia ResearchL Panahi

Purpose: It is well known that hyperglycemia negatively impacts patient outcomes in the inpatient setting. Therefore, it is imperative to control glucose levels when patients are admitted into the hospital. There are currently no randomized controlled trials evaluating the use of oral anti-hyperglycemic medications in the hospital setting. However, in 2009 the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) released a consensus statement regarding inpatient glycemic control which recommends insulin as the preferred method of achieving and maintaining glucose control. Optimal strategies for transitioning patients to an outpatient setting are also addressed in this statement, including patient education, clear communication with outpatient providers, and an outpatient follow-up visit within one month of discharge. However, specific medication recommendations at discharge are not discussed. The aim of this study is to evaluate the methods utilized in controlling glucose in the inpatient setting and determining the clinical outcomes of these methods after patients are discharged.

Objective: • To evaluate glycemic control of T2DM patients transitioning

from inpatient to outpatient care• Secondary Objectives• To compare clinical outcomes and glycemic control in T2DM

patients that are transitioned to insulin upon admission to the hospital vs. those not transitioned to insulin

• To compare clinical outcomes and glycemic control in T2DM patients discharged on home medications vs. other diabetic medications

• To compare clinical outcomes and glycemic control in T2DM patients that follow-up with their outpatient provider within one month vs. those that do not

Method: The study population will include Scott and While Health Plan patients with type 2 diabetes who were admitted to a Scott and White hospital from January 1, 2010 to July 31, 2010. Data will be extracted from Scott and White Healthcare prescription, medical, and electronic medical records to determine methods used to control blood glucose, and to compare clinical outcomes, including percentage of patients

achieving glycemic control, length of hospital stay, mortality, and rehospitalization. Significance: To identify the most effective methods in controlling glucose in the inpatient setting and determining the clinical outcomes of these methods after patients are discharged. To have a better understanding of how to manage diabetes type 2 patients when transitioning from the hospital to the outpatient setting.

3-Cevaluation of pharmacy student- versus nurse-performed inpatient medication histories at a community hospitalSP Desai, T Chau, DY HuMemorial Hermann Memorial City - Houston, Texas

Background: Medication-related errors can be the result of discrepancies that occur during the medication history process. Erroneous medication histories can fail to detect drug-related causes of hospital admissions such as adverse drug events, drug-drug interactions, and nonadherence to drug therapy. Pharmacy healthcare professionals have the knowledge base and expertise to obtain accurate medication histories.

Objective: The purpose of this study is to compare pharmacy student- versus nurse-performed inpatient medication histories to enumerate the discrepancies that exist. Data from this study will be used to justify the use of pharmacy personnel-conducted medication histories.

Method: This retrospective chart review utilizes descriptive statistics (number and types of medication discrepancies). Inclusion criteria are patients admitted to the hospital via the emergency department and identified to be taking at least one home medication. Patients will be excluded if the medication history was not performed by both a pharmacy student and an inpatient nurse.

Result: Pharmacy student-performed medication histories differed from nurse-performed histories. For the 94 patients that were analyzed, 361 discrepancies were observed (omission 48%, commission 26%, incorrect dose 15%, incorrect frequency 11%). The medication classes with the most discrepancies were herbal/over-the-counter (OTC) medications at 32% and cardiovascular drugs at 24%.

Conclusion: Due to their extensive pharmacotherapy training, pharmacy students are better suited than nurses to perform medication histories. Medication histories can be performed by pharmacy personnel and allow nurses to focus on other direct patient care activities. With proper knowledge and training, pharmacy technicians could potentially achieve

similar outcomes to pharmacy student-performed medication histories.Disclosure: The study investigators have no disclosures.

4-CImpact of a clinical pharmacist managed medication refill clinicMV Nguyen, M ZareThe University of Texas Health Science Center at Houston and Harris Health System Baytown, TX

Background: Chronic diseases are a significant cause of morbidity and mortality. Difficulty obtaining medications may worsen adherence, further burdening the healthcare system. Due to several vacancies at Baytown Health Center (BHC), physicians were overwhelmed with medication refill requests. Refill request processing time increased, potentially decreasing patient satisfaction. Studies have demonstrated that pharmacist-physician collaboration results in positive outcomes.

Objective: to assess the impact of a clinical pharmacist managed medication refill clinic on physician workload

Method: This is a retrospective chart review of patients requesting medication refills from BHC Pharmacy from October 2008-November 2010. The primary endpoint is the quantity of refill requests processed. The secondary endpoint is the intervention made to improve patient care such as medication discontinuations, dose adjustments, and appointment reminders. The clinical pharmacist processed requests for chronic medications for two hours daily. All other requests were processed by physicians. The inclusion of particular chronic diseases was allowed to be modified following periodic assessment of refill request volume.

Result: The clinical pharmacist processed 5706 refill requests and maintained goal turnaround time. 4864 requests were approved and 842 were denied. Physician refill request volume decreased about 60%. Issues identified and addressed by the clinical pharmacist included patients taking the incorrect medication or dose, therapeutic duplications, abnormal labs, and reminders for lab or physician follow-up.

Conclusion: The clinical pharmacist managed medication refill clinic decreased physician workload and improved patient safety and satisfaction.

Disclosure: The authors have nothing to disclose


5-CAntimicrobial Stewardship education: Impact on Pharmacist Clinical Intervention Documentation NA Thakkar, BS Metzger, TK Boyd, KC Simpson, JE MacQuarrieSt. David’s Medical Center, Austin, Texas

Background: St. David’s Medical Center (SDMC) is a 389-bed community hospital. As part of a multi-strategy approach, SDMC’s Antimicrobial Management Program (AMP) piloted an education initiative for pharmacists and hospital staff in late 2011. In order to measure the clinical and economic impact of this educational initiative, pharmacist-documented Clinical Interventions (CI) pre-initiative (2011) and post-initiative (2012) were compared.

Method: SDMC pharmacists document clinical activities as CI in the electronic system Meditech. CI are categorized by type (e.g. Pharmacy Consult, Antibiotic Recommendation, etc.) and assigned specific cost-savings or cost-avoidance monetary values, in accordance with corporate benchmarks.

Education strategies consisted Pharmacy and Medical Staff newsletter articles, AMP Highlights (infectious disease clinical pearls and cases), online continuing education, in-services, and recognition of individual pharmacist’s significant CI via email. The AMP team also provides ongoing individualized pharmacist education through patient case review.

Primary outcomes evaluated: percent change in total CI, percent change in antimicrobial CI, and percent change in CI-attributed cost-savings. Secondary outcome evaluated: change in types of CIs documented.

Result: Total CI increased by 38%, antibiotic CI increased by 112%, and CI-attributed cost-savings increased by 71% ($172,322). In 2012, antibiotic CIs were a greater percent of the overall CI, increasing from 16% to 24%.

Conclusion: As a result of targeted antimicrobial stewardship education, both CI and CI-attributed cost-savings increased considerably. The AMP team will continue to provide antimicrobial stewardship education in order optimize clinical outcomes and cost-savings opportunities at SDMC.

Disclosure: Brian Metzger MD MPH is a speaker for Forest Pharmaceuticals. Other participants have nothing to disclose.

6-CFrom the Hospital to Home: expanding Transition of Care Services with the Implementation of a Heart Failure PharmacistAS Nasar, ES Martin, PA Meyer

Scott and White Memorial Hospital, Temple, Texas

Background: Heart failure (HF) is one of the most common causes of 30-day hospital readmissions in patients over the age of 65 and has been associated with high morbidity, mortality, and healthcare expenditures. Recent changes in Medicare reimbursement have created the opportunity to employ hospital pharmacists into new roles that may help transition these high risk patients home from the hospital.

Objective: To implement a position for a HF pharmacist as part of a multidisciplinary team, designed to educate patients on their disease state, lifestyle, and medications.

Procedures: A newly designated “HF pharmacist” identified patients on the internal and family medicine teams with a new or acute HF exacerbation. Patients were then followed throughout their stay from the time of identification until discharge. Medications were reviewed to assure adherence to evidence-based HF therapy and patients were counseled on medications including interactions, side effects, and when to seek medical attention. The final step in the process was medication reconciliation at discharge.

Result: The addition of the pharmacist to the teams has not only helped to identify potential barriers in reducing HF readmissions, but has also helped unite each of the various disciplines involved in the program. Although, overall hospital rates of HF readmission remain high, patients have responded positively to the pharmacist’s role and early results for the target patients look promising.

Conclusion: Pharmacists can play an important role in a HF team in helping to reduce HF readmissions

Disclosure: Nothing to disclose

7-CAntimicrobial Surveillance in an emergency DepartmentRR Byrne, JT Nguyen, ME AndersonMemorial Hermann Southeast Hospital, Houston, TX

Background: Antimicrobial resistance results in increased morbidity, mortality, and healthcare costs. Antimicrobial stewardship programs involving a pharmacist can help reduce the emergence of resistance by limiting the use of inappropriate antimicrobials and by optimizing selection, dose, and duration of therapy. Currently at our facility, lab personnel forward the culture and sensitivity (C&S) reports to the emergency department (ED) via a pneumatic tube system for review by the ED pharmacist.

Objective: The purpose of this study is to characterize current trends in surveillance, intervention requirement, and time to positive culture review by an ED pharmacist at a 265-bed community hospital.

Method: A retrospective chart review was conducted of a random sampling of 100 patient visits to the ED who were discharged and subsequently had positive C&S reports that were reviewed by the ED pharmacist from February 2012 through February 2013. Patients were excluded if they were <18 or >90 years of age.

Result: A total of 82 patient charts were reviewed. 27% of the patients were contacted for new prescriptions. 16% of the patients were called to discuss their test results. 55% of the patients were prescribed appropriate antimicrobials and required no intervention. 65% of the positive culture reports were reviewed between 1-3 days.

Conclusion: 89% of the C&S reports were reviewed within 3 days. Cultures reviewed after >3 days may have resulted from a delay of notification from the lab. The implementation of a collaborative practice agreement with the ED physicians could potentially decrease time to patient/PCP notification and intervention.

Disclosure: All authors have nothing to disclose concerning possible financial or personal relationships with commercial entities that may have direct or indirect interest in the subject matter of the presentation.

8-CVancomycin Dosing and Monitoring in a Community HospitalJT Nguyen, RR Byrne, ME AndersonMemorial Hermann Southeast Hospital, Houston, TX

Background: Vancomycin is one of the most widely used antibiotics for the treatment of serious gram-positive infections, specifically methicillin-resistant Staphylococcus aureus (MRSA). Therapeutic guidelines recommend maintenance doses of 15-20 mg/kg of actual body weight to achieve optimal trough concentrations of greater than 10 mcg/mL to avoid the development of resistance. Monitoring of trough concentrations is recommended to reduce the potential of nephrotoxicity for those patients receiving prolonged courses of therapy.

Objective: To characterize vancomycin dosing and monitoring in a 265-bed community hospital that does not utilize a pharmacist-managed dosing protocol.

Method: A retrospective chart review was conducted

of all patients with pharmacy charges and documented administration of intravenous (IV) vancomycin on the medication administration record (MAR) from January 1, 2013 to January 15, 2013. Data collection to evaluate appropriate dosing and therapeutic monitoring included patient demographics, vancomycin doses, and serum levels.

Result: There were 118 patients with pharmacy charges for IV vancomycin. Nine patients were excluded because there was not documentation of vancomycin administration on the MAR. There were 866 vancomycin doses administered, of which 397 were dosed at 15-20 mg/kg. There were 74 vancomycin levels drawn, of which 22 were true troughs drawn appropriately at steady state. There were 10 steady state trough levels that were within therapeutic range of 10-20 mcg/mL.

Conclusion: 45.9% of all doses administered were dosed at guideline recommendations of 15-20 mg/kg. The development and implementation of a pharmacist-managed dosing and monitoring protocol may improve therapy, prevent development of resistance, and reduce potential adverse effects.


9-CMedications Associated with Fall events at a Community Hospital ME Anderson, RR Byrne, JT Nguyen Memorial Hermann Southeast Hospital, Houston, TX

Background: Falls are a common health problem and a significant contributor to morbidity and mortality. Extrinsic factors, such as medications, can contribute to patient falls. Anticonvulsants, antidepressants, antihypertensives, antipsychotics, and sedative-hypnotics have been validated in published research as being associated with increased risk of falls. Not all fall risk assessment tools account for medications associated with increased risk of falls.

Objective: The purpose of this study is to evaluate medications associated with increased risk of falls that were administered to patients within 24-hours of a fall event.

Method: A retrospective chart review was conducted of all falls reported at a 265-bed community hospital between July 1, 2012 and December 31, 2012. Fall events that involved inpatients ≥ 18 years of age were included in the analysis.


Result: A total of 93 fall events were reviewed and 53 fall events were included in the analysis. 52.8% of patients were scored low risk of fall using the Morse Fall Scale. Antihypertensive medications were the most commonly administered within 24-hours of reported falls, accounting for 74% of patients. Opioids, psychotropic agents, and sedative-hypnotics were administered to 49%, 43%, and 42% of patients within 24-hours of falls, respectively.

Conclusion: Antihypertensive, psychotropic, and sedative-hypnotics medications, which have been validated in published trials to increase the risk of falls, were administered to 40% or more of patients within 24-hours of their falls. Use of a fall risk assessment tool that takes into consideration medications might help to reduce the number of preventable falls in inpatients.


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eNTRIeSPRACTITIONeR - eDUCATION

1-ESafety evaluation of Dabigatran, A New Formulary AdditionSL Davis, DR NewcomerMedical Center Arlington, Arlington, Texas

Background: Dabigatran, an oral direct thrombin inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation, was approved for Formulary addition in January, 2011. Dabigatran increases the risk of bleeding and can cause significant and, sometimes, fatal bleeding.

To be compliant with Joint Commission Standard MM.02.02.02, EP #3, the Pharmacy, Nutrition and Therapeutics (PNT) Committee elected to monitor safety and effectiveness of this agent, including indication, dosing, bleeding, concurrent therapy with anticoagulants, and conversion from heparin, enoxaparin, or warfarin to dabigatran.

Objective: To monitor the proper use and effectiveness of dabigatran, a newly added medication to Hospital Formulary.

Method: Hospital staff was initially trained on dabigatran via the PNT Newsletter. An initial retrospective medication use evaluation identified the need for further education regarding concurrent use of anticoagulants and appropriate conversion of warfarin, enoxaparin, or heparin therapy to

dabigatran. Education was targeted to staff via email, flyers, and one-on-one discussions. Monitoring and educational follow-up continued over seventeen months.

Result: Initially, concurrent anticoagulant therapy with dabigatran increased from 32% to 55%, but, after targeted education reduced to 5%. Appropriate conversion therapy, however, declined from 47% to 29%.

Conclusion: Through ongoing education and monitoring, the risk of bleeding from dabigatran with other concurrent anticoagulants was reduced by targeted education and ongoing monitoring. Further education is required when converting from other anticoagulant therapy to dabigatran. This illustrates the value of monitoring ongoing safety and effectiveness of newly added Formulary agents.

Disclosure: Sondra Davis and Darrell Newcomer have nothing to disclose.

3-EComparison of Required Reading Assignments and Voicethread® Vodcasts as Pharmacotherapeutics Class Preparation Activities for Third Year Pharmacy StudentsJT Copeland, MA Oliveira, JM CotaUniversity of the Incarnate Word Feik School of Pharmacy, San Antonio, Texas

Background: Rather than traditional required reading assignments, the flipped classroom model allows students to prepare for class by watching pre-recorded video lectures at home at their own pace while discussing the material with peers and faculty using an online discussion board.

Objective: Compare student preparedness for class with reading assignments versus Voicethread® vodcasts.

Method: Six times in a pharmacotherapeutics course, P3 students were to prepare for class by engaging in a Voicethread® vodcast discussion or reading a 3 to 5 page review article. Individual quizzes of five multiple-choice questions were given during the first 15 minutes of class to assess each student’s class preparation. Demographics and pre- and post-course surveys were given to identify student preferences for pre-class activities. Chi-square (nominal variable) and student T-test (continuous variable) were used.

Result: Ninety-five participated (60% male, 65% less than 30 years old, 64% with previous degree). Ninety-two agreed that pre-class activities allowed the flexibility to learn at their own pace and 89 students felt pre-class activities were well integrated into the course. Mean quiz scores assessing

preparation were higher with Voicethread® than required readings (87.4±10.6% vs 76.0±10.0%; p<0.001). Students tended to prefer Voicethread® over required readings for pre-class activities (84.2% vs 66.3%; p=0.11) although they felt both helped learning (86.3% vs 84.2%; p=0.67).

Conclusion: Students using Voicethread® for class preparation led to higher readiness assurance quiz scores. While students preferred Voicethread® over reading, both types of pre-class preparation activities were thought to help student learning.

Disclosure: The authors have nothing to disclose.

4-EComparison of standardized patients and faculty in assessment of ambulatory patient screening, influenza immunization and professionalism skills in IPPe for second-year PharmD students.B Habeger, RA Patry, SD JamesTexas Tech University Health Sciences Center, School of Pharmacy, Amarillo, Texas.

Introduction: In a previous study, the IPP-II course in AY2012 utilized standardized patients (SP’s), training videos and assessment rubrics with simulation to train and assess second-year PharmD students in ambulatory patient screening, influenza immunization and professionalism skills. Screening skills included blood pressure, blood glucose and blood cholesterol. The major limitation was the lack of faculty validation of SP assessments. The course was continued in AY2013 and was designed to address this limitation.

Objective: To compare SP and faculty assessments for patient screening, influenza immunization and professionalism skills for an identical student cohort.

Methodology: All SP assessments of students were video recorded. A representative sample of SP assessment videos was reviewed and scored by faculty. Faculty scores were directly compared to the SP scores for each assessment video using the Wilcoxon signed-rank test and Kendall’s coefficient of concordance.

Result: There is no statistically significant difference between SP and faculty assessment scores. A limitation to this study is that there may be a difference between faculty using video recordings versus actual assessments. Among other limitations of this study are reliance on video recordings for faculty to view and perform assessments, a small sample size and possible SP variation in the interpretation and use of assessment rubrics. This course should be continued for AY2014 and designed with these limitations being addressed.

Conclusion: There is no conclusive evidence to suggest that faculty can assess student performance better than well-trained SP’s.

Disclosure: The authors do not have any conflict of interest to disclose.

5-EStudent Interventions on Institution Based Clinical Advanced Pharmacy Practice experiencesEP Pitman, CL Hatfield, EA Coyle, ND Ordonez, KW Garey, V BaliUniversity of Houston, Houston, Texas

Objective: One of the main roles of an institution based pharmacist is to make interventions in medication therapy to promote positive patient outcomes, and most pharmacists learn this skill as a pharmacy student while on APPEs. The goal of this study was to determine the types of interventions that pharmacy students were making while on institution based APPEs, the students’ role in the intervention process, and the outcome of student interventions.

Method: A 38-item questionnaire was developed by faculty members from the University of Houston College of Pharmacy (UHCOP) in which students used to document the interventions they made while on their institution based APPE rotations from May 2012 to February 2013. The survey link and directions were posted within the course information on Blackboard and students were asked to document all interventions.

Result: Over 3,100 interventions were documented by students over a nine month period. Of the 14 intervention types, the most common student intervention was a change in drug product selection and agent (23%), followed by wrong dose/ and or frequency (18%), and patient counseling (12%). The medications most commonly involved in student interventions were warfarin and vancomycin (8%) and pantoprazole and enoxaparin (3%). In 53% of the interventions, students initiated the intervention (as opposed to assisted or shadowed their preceptor). In about 60% of the interventions, students made recommendations directly to the prescriber, and the acceptance rate for all interventions was 80%.

Conclusion: This study shows with preceptor guidance, students can successfully make recommendations that are accepted at a high rate by prescribers. Student pharmacists can have a high impact on patient care by making therapeutic or pharmacotherapy interventions.


eNTRIeSReSIDeNT - PGY1

1-r1Identifying Primary Non-adherence Rates of StatinsJ Lu1, K Suh1, J Hardisty2, M Bullano2, P Godley1

1Scott & White Health Plan, Temple, Texas, and 2AstraZeneca LP, Wilmington, Delaware

Background: Similar to medication non-adherence, failure to fill a newly initiated medication (primary non-adherence) may pose challenges to chronic disease management.

Objective: We aimed to observe the primary non-adherence rate of statins within 6 and 21 days of an electronic prescription, and to compare characteristics between primary adherent and non-adherent groups.

Method: This was a retrospective study using electronic prescriptions, pharmacy claims and sales records. Adult patients (n=2879) were included if they were naïve to anti-hyperlipidemic drugs and received their first statin prescription from 2009 through 2012. Outcomes included the primary non-adherence rates within 6 and 21 days after a new statin prescription was written. Patient characteristics were compared between adherent and non-adherent groups using descriptive statistics and logistic regression.

Result: The 6- and 21-day primary non-adherence rates were 29.2% and 21.7%, respectively. Women were less likely to be non-adherent than men (OR: 0.815; 95% CI: 0.693–0.960), and African Americans were more likely than whites to be non-adherent (OR: 1.486; 95% CI: 1.107–1.995). Patients were less likely to pick up prescriptions written by allied health professionals than primary care providers (OR: 0.673; 95% CI: 0.465–0.974).

Conclusion: This is one of the few studies to investigate primary non-adherence in a real-world setting, and the results may be helpful in solving another piece of the overall non-adherence puzzle. Exploratory analysis indicated that male gender and African American race were predictors of primary non-adherence to statins. Future research is needed to examine reasons for primary non-adherence and its clinical implications.

Disclosure: This study was funded by AstraZeneca LP, Wilmington, Delaware. The authors report no other conflicts of interest with regard to the content of this article.

2-r1Time-focused highly active antiretroviral therapy (HAART) initiation in HIV naïve patientsAP Trieu, T ZeraiHarris Health System, Houston, Texas

Background: Current guidelines recommend CD4 count guided initiation of highly active antiretroviral therapy (HAART), but the optimal level initiation still varies between guidelines. Recommendation trends have increased the CD4 counts every guideline revision. In fact, results from the NA-ACCORD trial and the CASCADE group have shown possible benefits of early start therapy within six months of diagnosis. Purpose: The primary objective of this retrospective chart review is to evaluate the difference in all-cause hospitalizations between Early-Start HAART (ESH) and Late-Start HAART (LSH) groups to address optimal HAART initiation based on time.

Method: Newly diagnosed HIV patients between January 2008 and December 2010 were identified using the system’s electronic medical records. New start HAART in naïve patients, with one follow-up visit within the health system and CD4 count at diagnosis, were included in the study. Patients under 18 years, pregnant, or diagnosed outside of the health system were excluded.

The primary difference between ESH and LSH is the initiation of HAART within or after six months of diagnosis. In a subgroup of individuals with concurrent AIDS-defining illness at diagnosis, initiating HAART during treatment for the AIDS-defining illness or deferring therapy until resolution differentiates ESH and LSH, respectively.

Follow-up continued for 24 months after diagnosis or death, whichever occurred first. Both descriptive and inferential statistics will be conducted to analyze data.

Result: A sample population of 500 randomly chosen charts is currently under review for inclusion in the study for data analysis.

Disclosure: AP Trieu has nothing to disclose. T Zerai has nothing to disclose.

5-r1Implementing a New Advanced Pharmacy Practice experience (APPe) Institutional Rotation for Fourth Year Pharmacy StudentsAS Philip, S Cherukara, L Gokhman, S GautreauxHarris Health System, Houston, TX

Background: According to ASHP’s Pharmacy Practice Model Initiative (PPMI), health-system pharmacists bear responsibility for providing experiential education to students enrolled in doctor of pharmacy programs. At Harris Health System, we identified areas of opportunity to expand the clinical scope of practice for pharmacy students completing their institutional APPE rotation.

Objective: The primary objective of this study is to integrate students into the pharmacy workflow by utilizing students to participate in clinical initiatives which were newly implemented in the inpatient setting. Secondary objectives include creating a student template in the electronic medical record that will allow for student documentation of clinical activities.

Procedure(s): APPE advanced students are surveyed in regards to their initial rotation expectations. Secondly, a student schedule and syllabus is created to outline new institutional APPE goals and expectations. The students then complete a 2 hour departmental orientation on clinical initiatives. Pharmacy staff is also in-serviced on changes to the APPE rotation. Students then participate in clinical initiatives, various operational assignments, and document interventions. Surveys are conducted at the conclusion of the rotation for student feedback and continuous improvement.

Result: Study is currently in progress. Outcome measures include number and total percentage of interventions/profile reviews that will be completed by pharmacy students in regards to clinical initiatives per pharmacist day. In addition, number and total percentage of audits completed by students will also be analyzed.

Conclusion: The long term goal of this project is that institutional APPE students will comprise 10% of pharmacy clinical initiative interventions by December 2013.

Disclosure: nothing to disclose

7-r1evaluation of propofol versus dexmedetomidine use in the intensive care unit (ICU) for mechanically ventilated patientsNT Bui, KR Winkler, T Dasher, H YangMethodist Hospital, San Antonio, Texas

Background: Propofol has been the standard of care for sedation in patients who required mechanical ventilation, but due to recent and recurring propofol shortages, physicians have turned to the use of dexmedetomidine. In recent literature comparing dexmedetomidine to propofol, the propofol groups received more analgesics, while

dexmedetomidine decreased sedation requirements and median time to extubation.

Objective: The primary objective is to compare time to extubation. Secondary objectives are to compare the two medications with respect to: hospital and ICU length of stay; use of additional pain medications and benzodiazepines; and adverse effects.

Method: This retrospective study evaluated a data set of 60 patients who underwent intubation with the use of propofol or dexmedetomidine. The study included adult inpatients ≥ 18 years of age admitted to the ICU. Data reviewed included anesthetic and analgesic administration parameters for intubation. Adverse effects potentially associated with the two agents were noted.

Result: The mean durations of intubation for the propofol and dexmedetomidine groups were 28.8 hours and 48.7 hours, respectively, with a p-value of 0.09. Hospital and ICU length of stay were not statistically significant with p-values of 0.48 and 0.82, respectively. The dexmedetomidine group had more use of additional medications to manage pain and agitation. Both groups experienced side effects at similar rates.

Conclusion: This study did not show a significant difference in the duration of intubation between propofol and dexmedetomidine. The dexmedetomidine group showed decreased hospital and ICU length of stay, but the differences were not statistically significant.

Disclosure: nothing to disclose

8-r1Medication Use evaluation of Intravenous Immune Globulin Dosing at UTMBJA Okuboyejo, RL Hernandez, JK WelchUniversity of Texas Medical Branch, Galveston, TX

Background: Intravenous Immune Globulin (IVIG) is a commonly used immunoglobulin for patients with a wide array of immunodeficiencies and inflammatory conditions. A disadvantage of IVIG is the high cost associated with therapy. At UTMB, the annual procurement cost of IVIG is approaching one million dollars. Current dosing recommendations include using actual body weight, with limited data supporting alternative dosing methods.

Objective: The objectives of this study are to determine the usage of IVIG at UTMB and to evaluate potential methods for cost savings using alternative weight based dosing.


Method: A retrospective chart review was conducted and included 63 patients that received at least one dose of IVIG during fiscal year 2012 (FY2012). Neonatal and pregnant patients were excluded. Data collection included patient height and weight, prescribed IVIG dose, indication for IVIG use, the pharmacy cost and patient charge per dose. Potential cost savings were projected using doses calculated with ideal body weight (IBW) for overweight patients and adjusted body weight (AdjBW) for obese patients.

Result: Sixty-three patient charts and 277 IVIG doses were evaluated. Twenty-one patients (33.3%) were overweight and 16 patients (25.8%) were obese. The total cost of IVIG for FY2012 was $887,166.44. Projected cost savings using AdjBW for obese patients and IBW for overweight patients is $120,520.80, which reduces cost by approximately 14%.

Conclusion: Alternative IVIG dosing strategies in obese and overweight patients result in considerable cost savings. However, more studies are needed to evaluate the appropriateness of alternative dosing methods in obese and overweight patients.

Disclosure: JA Okuboyejo, RL Hernandez, JK Welch have nothing to disclose.

9-r1Does the addition of Levaquin to an anti-pseudomonal antibiotic fill the coverage gap?NE Parker, GC Caballero, ML Rodriguez, RK PurcellBaptist Health System, San Antonio, Texas

Background: Double coverage of pseudomonas pneumonia infection has become common practice since 1989 when a study found lower mortality with combination aminoglycoside and beta-lactam. Today, beta-lactams are frequently used in conjunction with fluoroquinolones as standard care despite lack of evidence to support this practice.

Objective: The objective of this study was to determine efficacy of levofloxacin in combination with a beta-lactam in treating pseudomonas aeruginosa (PA) pneumonia resistant to beta-lactams.

Method: This retrospective review included adult patients admitted to the hospital between July 1, 2011 to August 30, 2012 with positive pseudomonas respiratory cultures who were given levofloxacin plus cefepime, piperacillin/tazobactam, or meropenem. Exclusion criteria included hospital admission for less than 24 hours, admission to a specialty unit, or absence of bronchioalveolar lavage

Result: The patient population (n=13) was predominantly female (54%) with a median age of 66 (35-69) years. Over 50% of the patients were chronically vented or had a history of ventilation or tracheotomy (n=7), 2 had concurrent sepsis and 3 had concurrent bacteremia. Only one culture was susceptible to levofloxacin and beta-lactam resistant. Median length of ICU, hospital stay and ventilator days (VD) were 10 (0-29), 14 (4-29), and 10 (0-24) days, respectively. Overall mortality was 30% (4/13) secondary to respiratory failure.

Conclusion: The addition of levofloxacin did not provide additional coverage in this patient population. Resistance was common likely due to the multiple risk factors. Further investigation is necessary to demonstrate significant effects with regards to hospital length of stay and mortality benefit.

Disclosure: Authors have nothing to disclose.

10-r1Association of Prolonged Infusion of Meropenem and Reduced ICU Length of Stay in the Critically IllBR Noteware, A Martin, TL Cooper, R YatesMother Frances Hospital, Tyler, Texas

Background: Pharmacodynamic modeling studies of prolonged infusion of meropenem have demonstrated an increased probability of obtaining therapeutic targets (i.e., T>MIC) against gram negative pathogens in the ICU. The effects of 3-hour intermittent infusion of meropenem compared to standard 30-minute infusion on meaningful patient outcomes in critically ill patients remain unknown.

Objective: To determine if prolonged infusion of meropenem is associated with improved patient outcomes, primarily decreased ICU length of stay (LOS).

Method: A P&T Committee-driven, prolonged infusion meropenem protocol for ICU patients was implemented at MFH in December 2011. Primary and secondary endpoints were compared pre-and post-implementation. Our primary endpoint was ICU length of stay (LOS). Secondary endpoints were in-hospital mortality, overall hospital LOS, duration of meropenem therapy, duration of total antibiotic therapy, ventilator days, and changes in WBCs and temperature. Inclusion criteria included greater than 18 years of age, meropenem therapy in the ICU for more than 48 hours. Exclusion criteria included patients with any of the following: pregnancy, documented severe PCN allergy, both 30-min and 3-hour meropenem infusions. Primary endpoints were analyzed using a Mann-Whitney test for continuous variables and a Fisher’s Exact for categorical variables.

Result: Patients who received prolonged-infusion meropenem had a statistically significantly shorter ICU and total hospital LOS compared to those receiving traditional 30-minute infusion. Prolonged-infusion meropenem was also associated with a 13% decrease of in-hospital mortality.

Conclusion: Implementing a prolonged meropenem infusion protocol in our ICUs resulted in improved patient outcomes while maintaining lower overall drug utilization

Disclosure: None

11-r1Retrospective Review of Neofax® Vancomycin Dosing and Monitoring in the Neonatal ICURE Shewmaker, E Simon, A Faust, G NystromTexas Health Presbyterian Hospital, Dallas, Texas

Background: There is not a consensus on the goal vancomycin trough range for neonates. Neofax® is commonly used at Texas Health Presbyterian Dallas to dose vancomycin. The 2012 version of Neofax® increased the recommended vancomycin trough levels from 5-20 mg/L to 10-20 mg/L, but did not change the dosing nomogram from the 2010 version.

Objective: To determine the effectiveness of the 2010 version of Neofax® dosing recommendations for vancomycin to obtain trough levels between 5-20 mg/L.

Method or Procedure(s): Retrospective chart review was performed on patients who were admitted to the Texas Health Presbyterian Dallas NICU and had at least one vancomycin level between July 1, 2011 and October 1, 2012. Descriptive statistics were performed.

Result: 284 vancomycin levels for 157 courses of therapy in 89 patients were analyzed. Mean and median length of vancomycin courses were 2.59 days and 2 days respectively. Levels were most commonly taken before the 3rd dose of therapy. Of the 157 courses of therapy, 134 were dosed according to Neofax®. 9.7% of the trough levels were < 5mg/L, 48.5% were between 5-10 mg/L, 29.1% were between 10-15 mg/L, and 12.7% were > 15 mg/L. 23 courses of therapy were not dosed according to Neofax® and of those, 69.5% of the trough levels were between 5-20 mg/L.

Conclusion: Of the vancomycin courses dosed according to Neofax®, 86.6% of the levels were between 5-20 mg/L. Only 41.8% were between 10-20 mg/L. If higher troughs are desired, then more aggressive dosing strategies should be used.

Disclosure: No authors of this presentation have any possible financial disclosures or conflicts of interest.

12-r1Safety and efficacy of Ibutilide Use in Oncology Patients A Esmaily-Fard, T Lech, C Bickford, K KarimzadehnajarThe University of Texas MD Anderson Cancer Center, Houston, Texas

Background: Ibutilide is a class III antiarrhythmic agent approved for the rapid cardioversion of recent-onset atrial fibrillation and atrial flutter. Prolongation of the corrected QT interval (QTc), potentially leading to torsades de pointes, is a serious adverse effect associated with the administration of ibutilide. Cancer patients are prone to QTc prolongation for a multitude of reasons including concomitant QTc prolonging medications, nausea, vomiting, diarrhea, constipation, and poor oral intake which may result in electrolyte abnormalities.

Objective: To evaluate the efficacy of ibutilide use in cardioversion of atrial fibrillation/atrial flutter in oncology patients, and to determine its safety in terms of incidence of QTc interval prolongation.

Method: This is a retrospective chart review of adult cancer patients at The University of Texas MD Anderson Cancer Center who received at least one dose of ibutilide from January 1, 2006 to September 30, 2012.

Result: Of the 62 patients included in the study, 53 patients (86%) converted to sinus rhythm within 4 hours of ibutilide administration. Pre-ibutilide QTc interval >450 milliseconds (msec) was seen in 31 patients (50%) and post-ibutilide QTc interval >450 msec was seen in 32 patients (52%). Elevation of the QTc interval >60 msec from baseline post ibutilide administration was seen in 3 patients (5%). No serious adverse events such as torsades de pointes occurred during ibutilide administration.

Conclusion: Ibutilide was shown to be safe and efficacious in cardioversion of atrial fibrillation and atrial flutter in our oncology patients. The results of this study will be used to ensure safe and appropriate administration of ibutilide within our institution.

Disclosure: The authors of this presentation have nothing to disclose.


13-r1evaluation of antimicrobial prescribing in the emergency department of an academic-teaching children’s hospital: preparation for an antimicrobial stewardship program JL Martinez, R Bellanger, E HandCHRISTUS Santa Rosa Children’s Hospital of San Antonio, San Antonio, TX

Background: Inappropriate antimicrobial use is a major concern in the current health environment where the development of new anti-infective drugs is limited. Recent data suggests that 35-72% of hospitalized children receive antimicrobials and up to 50% of these may be inappropriate or unnecessary. Imprudent use of these antimicrobials results in increased rates of multidrug-resistant pathogens and increased risk of patient adverse events or toxicity. Objective: The aim of this study is to evaluate the appropriate selection, usage, and need of antimicrobial agents for community-acquired pneumonia (CAP) and skin and soft tissue infections (SSTI) prescribed in the emergency department (ED) at the Children’s Hospital of San Antonio based on current clinical guidelines and the current hospital antibiogram.

Method: Medical record software was used to populate a list of patients with ICD-9 codes that matched a diagnosis of pneumonia or cellulitis (purulent and non-purulent) starting from the date of December 1, 2012 and projecting back in time two years to identify eligible patients. The initial antimicrobials administered in the ED were assessed for appropriateness based on current guidelines and compared to those used on the floor within the first 24 hours of admission.

Result: The number of patients that received any antibiotics in the ED was much lower in the pneumonia group than in the cellulitis group, 56% and 6% respectively. This led to contrasting results in the number of patients that received appropriate antibiotic therapy and the number of patients that had therapy changed or added once admitted to the floor. The cellulitis group was treated appropriately 86% of the time in the ED and antibiotics were only changed or added 12% of the time on the floor. However, the pneumonia patients were treated inappropriately 71% of the time and 99% had antibiotics changed or added when admitted to the floor.

Conclusion: Cellulitis is appropriately treated with initial antibiotics received in the ED; however, CAP patients usually receive no antibiotics in the ED. There is room for improvement in the management of CAP.

Disclosure: Nothing to disclose.

14-r1Retrospective Review Comparing Glucose Control with endotool Insulin Sliding Scale Versus Standard Insulin Sliding Scale in ICU PatientsCQ Do, GC Caballero, P Cuellar, K Purcell, M RodriguezBaptist Health System, San Antonio, TX

Background: Patients admitted to the ICU with persistent, severe hyperglycemia (blood glucose >180 mg/dL) have higher mortality. Recent trial data suggests that critically ill patients should be maintained at blood glucose <180 mg/dL. Sliding scale insulin is frequently used but is ineffective.

Objective: The objective of this study is to compare glucose control with EndoTool insulin sliding scale (EISS) and standard insulin sliding scale (SISS).

Method: A retrospective review was performed in adult ICU patients from September 2012 to January 2013. Exclusion criteria include < 2 ICU days on sliding scale, other anti-diabetic medications, lack of appropriate IV fluids/nutrition while on EndoTool, or any type of crossover therapy. Target blood glucose is defined as 110 – 180 mg/dL, hypoglycemia as < 110 mg/dL, severe hypoglycemia as ≤ 70 mg/dL and hyperglycemia as > 180 mg/dL.

Result: Baseline characteristics were similar between EISS (n = 25) and SISS (n = 25). Most patients were male (58%), Hispanic (64%), DM2 (66%), and had mean age of 61 years. The last glucose reading prior to transition to sliding scale was 148 ± 51 mg/dL. There was no difference between SISS group and EISS group in severe hypoglycemic episodes (16% vs. 12%, p = 0.59), or hyperglycemic episodes (80% vs. 68%, p = 0.11). Both group had similar hypoglycemic episodes (68% vs. 68%, p = 1) and target blood glucose (88% vs. 88%, p = 1).

Conclusion: This study demonstrated that both groups achieved similar glucose control with EISS and SISS.

Disclosure: All authors have nothing to disclose.

15-r1evaluation of Current Management of HMG-CoA Reductase Inhibitors With Concomitant Daptomycin Treatment At An Academic Teaching InstitutionAV Tatachar, AP Rahman, KP BhavanParkland Health & Hospital System, Dallas, TX

Background: Outpatient parenteral antimicrobial therapy (OPAT) has become standard modality for diabetic patients with foot and bone infections requiring long-term intravenous antibiotic therapy. Daptomycin (Cubicin®) is a cornerstone

of OPAT due to its antimicrobial spectrum and once-daily dosing. Numerous diabetics on HMG-CoA reductase inhibitors for prevention of cardiovascular events require long-term treatment of foot and bone infections with daptomycin, increasing their risk of myocardial toxicity. Due to conflicting evidence and lack of guidelines, there are inconsistencies among providers in the management of statin and daptomycin interaction.

Objective: Evaluate the current management of patients receiving statins concomitantly with daptomycin. Method: This retrospective study evaluated patients admitted from January 2011 to July 2012. Patients included were ≥ 18 years receiving statins concomitantly with daptomycin ≥ 6 mg/kg/day for ≥ 2 weeks. The primary outcome was frequency of clinical toxicity and discontinuation of statin or daptomycin therapy. The secondary outcome was the frequency of statin re-initiation after completion of daptomycin treatment.

Result: Fifteen patients were included in the final analysis. One patient exhibited clinical toxicity with concurrent use. Statins were discontinued in five patients prior to daptomycin treatment; only one patient was re-started on the statin therapy by the same provider prescribing daptomycin. One patient with cardiovascular disease that was preemptively discontinued on statin therapy required coronary angioplasty.

Conclusion: Despite the limited sample size, our data reflects inconsistencies among providers leading to patient safety issues. There is a need for a standardized protocol in the management of concomitant use of statins and daptomycin.

Disclosure: Authors have no conflicts of interest or financial information to disclose.

16-r1Antimicrobial Therapy in Cancer Patients with Febrile Neutropenia in an Academic Institution RM Miller, EM Marley Parkland Health and Hospital System, Dallas, Texas

Background: Neutropenia is a common dose-limiting toxicity with chemotherapy. Fever during chemotherapy induced neutropenia can be the only indication of infection. The Infectious Disease Society of America (IDSA) guidelines have specific recommendations for empiric therapy. However, these recommendations are often not adhered to in clinical practice, which could lead to the development of resistance, increased potential for side effects, and poor outcomes.

Objective: To evaluate the adherence to empiric antibiotic

therapy recommendations set forth by the IDSA.

Method: Cancer patients with a diagnosis of chemotherapy associated febrile neutropenia from August 2011 to July 2012 were included in this retrospective chart review. Patients who did not receive chemotherapy were excluded. The primary outcome was the number of patients receiving empiric treatment for febrile neutropenia in adherence to IDSA guideline recommendations. Secondary outcomes included duration of antimicrobial therapy, length of stay, G-CSF prophylaxis, timing of antimicrobial therapy, positive culture, imaging, and antibiotic susceptibility patterns.

Result: Ninety-three patients were included. Sixty-two patients (67%) had hematological malignancies. HyperCVAD and HiDAC were the most frequent chemotherapy regimens. Eighty-five patients (90%) were initiated on an anti-pseudomonal agent. Fifty-one patients (55%) had one positive culture. α-Streptococcus and Escherichia coli were the most common isolates. Extended-spectrum-β-lactamase Escherichia coli was the most frequent resistant organism. There were 66 patients (71%) with a discharge ANC >500cells/mm3 and 45 patients (48%) initiated on antimicrobial therapy after obtaining cultures.

Conclusion: Adherence to IDSA guidelines are being met in the treatment of febrile neutropenia at Parkland Health and Hospital System per culture sensitivities.

Disclosure: RM Miller and EM Marley have nothing to disclose.

17-r1Furosemide Resistance in the Setting of Hypoalbuminemia: A Retrospective Review of Albumin and Furosemide Co-AdministrationEA John, D Hu, M Narayanan Memorial Hermann Southwest Hospital, Houston, TX

Background: Furosemide is a loop diuretic agent that is highly bound to albumin in the serum and actively secreted into the renal tubular lumen. Decreased albumin availability results in decreased drug delivery to the renal tubule.

Objective: The purpose of this study is to evaluate whether the addition of albumin increases the diuretic efficacy of intravenous furosemide in patients with hypoalbuminemia.

Method: This study is a retrospective observational study evaluating the effects on diuresis in patients receiving intravenous furosemide with and without albumin. Data was collected via electronic medical records. The primary


outcome is the change in urine output (UOP) from baseline up to 6 hours post-infusion. Secondary outcomes include: UOP 12 hours after treatment, changes in intake/output, blood pressure, mean arterial pressure, and weight after treatment, and ICU length of stay.

Result: Analysis was conducted on patients who received intravenous furosemide (n=50) and those who received intravenous furosemide plus albumin (n=50). Both treatment groups demonstrated similar baseline characteristics, with the exceptions of higher baseline serum creatinine in the furosemide plus albumin group and higher serum albumin in the furosemide group. Baseline UOP values were similar in both groups. In the furosemide group, mean UOP at 6 hours (1060mL) showed a 77.3% increase from baseline. In the furosemide plus albumin group, mean UOP at 6 hours (870mL) showed a 78.6% increase from baseline.

Conclusion: The addition of albumin to intravenous furosemide results in similar UOP within 6 hours of therapy.

Disclosure: E John, D Hu, and M Narayanan have nothing to disclose.

18-r1Impact of pharmacist intervention on the appropriate use of stress ulcer prophylaxis in general medicine patientsA Pham, M Narayanan, N Vo, S PatelMemorial Hermann Southwest Hospital, Houston, Texas

Background: There is limited evidence to support the use of stress ulcer prophylaxis (SUP) outside a critical care setting. We hypothesized that the increased pantoprazole utilization at our hospital was associated with inappropriate use.

Objective: To assess the effects of pharmacist intervention on the appropriate use of pantoprazole for SUP.

Method: In this retrospective cohort study, adult patients admitted from June 2012 to December 2012 were evaluated to compare the effects of appropriate SUP pre- and post- pharmacist intervention. The primary outcome is the percentage reduction on the inappropriate use of SUP after pharmacist intervention.

Result: Of the 1365 patients reviewed, a total of 354 patients met inclusion and exclusion criteria. In the pre-intervention group (PRE), 71.8% were initiated on SUP inappropriately in comparison to 63.8% in the post-intervention group (POST). With pharmacist intervention, the inappropriate use of SUP was decreased by 8% (P=0.11). In the PRE group, 19.8% of the patients were discharged with pantoprazole compared

to 14.1% in the POST group. The incidence of GI bleed, Clostridium difficile infection, and pneumonia were 0%, 2.8%, and 1.1% respectively in the PRE group compared to 0.6%, 0%, and 2.3% in the POST group. A total of 1194 pantoprazole doses were dispensed in the PRE group compared to 1100 doses in the POST group.

Conclusion: This study confirms the overutilization of pantoprazole in patients without risk factors for SUP. Pharmacist intervention has demonstrated a trend towards decreasing inappropriate use of SUP, which correlates with cost savings and avoidance of side effects.

Disclosure: No conflicts of interest to disclose by any authors

19-r1Identifying Predictors of Blood Pressure Control and Cardiovascular OutcomesSE Hulvershorn, K Suh, KL Rascati, PJ Godley, K PraslaScott & White Health Plan, Temple, TX

Background: Among patients with hypertension in the United States, only 33% achieve blood pressure (BP) target rates specified by the JNC 7 guidelines.

Objective: To describe hypertension treatment patterns and to compare treatment outcomes based on initiation of a specific antihypertensive medication class. Patient results were described in the overall population and in special populations (e.g., diabetics).

Method: Pharmacy and medical data were evaluated from January 1, 2005 through December 31, 2010. Patient cohorts were stratified based on six antihypertensive drug classes. Only patients naïve to cohort specific drugs were included and analysis was intent to treat.

Result: 19,778 patients met inclusion criteria. Patients taking fixed-dose combinations had the greatest percentage of patients reaching adherence ≥80% (59%) and were most likely to be on a single oral antihypertensive agent. 34.7% of patients were at BP goal at baseline. 57% were at goal at 12 months. Factors predicting goal BP at 12 months were goal BP at baseline, adherence ≥80%, and increasing comorbidity index. Patients who were elderly, African American, had high copayments, diabetes, or chronic kidney disease were less likely to attain goal BP. 24.3% of patients had a cardiovascular-related event within 12 months. Factors decreasing risk of event were female gender and a higher propensity to be prescribed a thiazide diuretic.

Conclusion: Patients with fixed-dose combinations as the

index drug class were more likely to attain adherence rates ≥80% and was a predictive factor in decreasing systolic and diastolic BP, which correlated with a significant improvement in BP control.

Disclosure: SE Hulvershorn: This study was funded by Takeda Pharmaceuticals. K Suh: Nothing to disclose. KL Rascati: Nothing to disclose. PJ Godley: Nothing to disclose. K Prasla: Nothing to disclose.

20-r1evaluation of Self-Administered Outpatient Parenteral Antimicrobial Therapy (OPAT) at a County HospitalDL Yeung, NG Patel, KP Bhavan, MA SwancuttParkland Health & Hospital System, Dallas, Texas

Background: Outpatient parenteral antimicrobial therapy (OPAT) is a practice model that allows patients to complete the recommended duration of parenteral antimicrobial therapy in their own homes while maintaining safety and efficacy, and subsequently reducing complications of an extended hospitalization. Parkland Health & Hospital System (PHHS) is a teaching hospital system that initiated a dedicated OPAT clinic in November 2009. The multidisciplinary team, consisting of Infectious Disease physicians, clinical pharmacy specialists and nurses, monitors therapeutic responses, antimicrobial-specific toxicities, and maintenance of PICC line care for this patient population.

Objective: The purpose of this study is to determine 30-day readmission rates due to complications of OPAT. Outcomes are assessed in order to evaluate the quality and safety of the current OPAT services provided at PHHS.

Method: This retrospective study evaluated adult patients discharged to receive OPAT from February 1, 2011 to January 31, 2012 and who were re-admitted to PHHS within 30 days of discharge.

Result: Of the three-hundred and three (n=303) adult patients who were seen in OPAT clinic, 37 patients had a 30-day readmission. The readmission rate was 12%. Fifty-four (54%) were readmitted for causes unrelated to OPAT. Other causes of readmission included failure of antimicrobial therapy (21%), adverse effects of antimicrobials (11%), bacteremia (8%), non-adherence to medications (3%) and vascular access complications (3%).

Conclusion: OPAT is associated with reduction in hospital costs, nosocomial infections, days of hospitalization. Self-administered OPAT is a safe and effective model for patients requiring intravenous antibiotics at a county institution.

Disclosure: DL Yeung, NG Patel, KP Bhavan, and MA Swancutt have nothing to disclose.

21-r1Implementation of an Adult Immunization Impact Program at a Comprehensive Cancer CenterVP Doan, TN Johnson, K GoldThe University of Texas MD Anderson Cancer Center, Houston, TX

Background: Immunizations are an effective method for providing preventative care against diseases in immunocompromised patients with oncological malignancies. There is no current immunization program in place at MD Anderson Cancer Center. The implementation of an adult immunization program will standardize screening, education, administration and documentation of influenza and pneumococcal vaccines.

Objective: To increase pneumococcal and influenza vaccination rates to 50% by implementing an impact screening and education program for patients on the Thoracic Medical Oncology inpatient and outpatient services.

Method: A process was designed and implemented to involve nurses, pharmacists, and physicians to screen and administer influenza and pneumococcal vaccines on inpatient and outpatient demonstration areas during October 2012 to February 2013. The process included documentation in the electronic medical record and education to healthcare providers and patients on the benefits of immunizations.

Result: Of the 50 patients admitted to the demonstration inpatient floor, immunization screening, documentation and education increased by 48%, 22%, and 55%, respectively. Patients were immunized against influenza and pneumococcal disease 66% and 22% of the time. This was a 38% and 2% increase from baseline, respectively. Of the 50 patients seen outpatient, 38% and 18% of the patients were immunized against influenza and pneumococcal disease. This was a 20% and 12% increase from baseline, respectively. Outpatient screening, documentation, and education increased by 50%, 32%, and 3%, respectively.

Conclusion: The adult immunization program demonstrated positive improvements in vaccine screening, documentation, and education. The results will assist in future expansion of the program throughout the institution.

Disclosures – VP Doan, TN Johnson, and KA Gold have nothing to disclose.


22-r1Correlation of Methicillin-Resistant Staphylococcus Aureus (MRSA) Nasal Colonization and MRSA Lower Respiratory Tract infectionsBA Tilahun, AC FaustTexas Health Presbyterian Hospital, Dallas, Texas

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the causes of bacterial lower respiratory tract infections. Staphylococcus aureus is naturally present in the nares, axilla, groin and skin.Objective: To determine the correlation between MRSA nasal swab results and MRSA lower respiratory tract infections in the Medical Intensive Care Unit (MICU).

Method: This is a retrospective cohort study conducted among adult patients admitted to the MICU between January 2011 and December 2012. Inclusion criteria: ≥ 18 years of age, clinical criteria for pneumonia, MRSA nasal swab and lower respiratory tract culture(s) within 24 hours of admission.

Result: Chart review of 1297 patients with a nasal swab yielded a total of 150 patients who met the inclusion criteria. Twenty-two patients (14.7%) had a positive MRSA nasal swab result. Positive results for MRSA in both the nasal swab and lower respiratory tract culture were present in six patients (4%). Two patients (1.3%) had a negative nasal swab result and a positive respiratory culture for MRSA. The sensitivity and specificity were 75% and 88.7%, respectively. The positive and negative predictive values were 27.3% and 98.4%, respectively.

Conclusion: Based on the specificity and negative predictive value, MRSA nasal screening may be a valuable tool for de-escalation of empiric MRSA-targeted therapy. The high negative predictive value suggests that a patient with a negative nasal swab result is unlikely to have a lower respiratory tract infection caused by MRSA. The poor positive predictive value would indicate that MRSA colonization should not be used to add MRSA-targeted therapy.

Disclosure: All authors have nothing to disclose and have no conflict of interest

23-r1Ceftriaxone versus Cefazolin: A Retrospective Analysis of Methicillin-Sensitive Staphylococcus aureus (MSSA) Osteomyelitis in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Clinic. MA Miller, NK Boyd, NG Patel, KP BhavanParkland Health and Hospital System (PHHS), Dallas, Texas

Background: MSSA is a common pathogen in osteomyelitis, for which treatment generally requires prolonged courses of antibiotic therapy. Cefazolin is one of the preferred antimicrobial agents for MSSA osteomyelitis. However, thrice daily dosing is required to adequately maintain target concentration. At Parkland Memorial Hospital, patients are taught to self-administer intravenous antibiotics prior to discharge, without the assistance of infusion pumps, home health, or home infusion services. Therefore, frequent dosing is less desirable. Ceftriaxone has a prolonged half-life and is dosed more conveniently at once daily. Although ceftriaxone is generally regarded as an alternative agent for MSSA infections and is frequently used in OPAT settings, it is unclear whether treatment outcomes are comparable to cefazolin for MSSA osteomyelitis.

Objective: To compare the effectiveness of ceftriaxone to cefazolin for the treatment of MSSA osteomyelitis.

Method: This is a retrospective analysis of adult patients treated with cefazolin or ceftriaxone for MSSA osteomyelitis, who were followed in the OPAT clinic. Patients meeting inclusion/exclusion criteria were identified using a computer generated report based on outpatient refill histories. Clinical failure was defined as persistent elevations in CRP/ESR above normal values, radiographic evidence of recurrence, ER visit or hospital admission for infection at the same site, and/or need to broaden antimicrobial coverage for presumed failure.

Result: Clinical success was observed in 83% (30/47) vs. 90% (9/10) for ceftriaxone and cefazolin, respectively.

Conclusion: Ceftriaxone is an acceptable alternative to cefazolin for the treatment of MSSA osteomyelitis in an outpatient setting, with similar adverse event rates found.

Disclosure: MA Miller, NK Boyd, NG Patel, and KP Bhavan have nothing to disclose.

24-r1High-Dose Weekly Liposomal Amphotericin B (LAMB) Antifungal Prophylaxis in Pediatric Hematology/Oncology Patients During Hospital ReconstructionMR Ramanathan, EO HandCHRISTUS Santa Rosa Health System, San Antonio, Texas

Background: In August 2012, CHRISTUS Santa Rosa City Centre campus transformed into Children’s Hospital of San Antonio. With change, came reconstruction. Prior literature has shown an increase in invasive fungal infections, particularly aspergillosis, in neutropenic patients during periods of construction. High-dose (10 mg/kg) weekly

liposomal amphotericin B (LAMB) was chosen to prevent these infections.

Objective: To evaluate the risk versus benefit, adverse event rate, and clinical outcomes of prophylaxis with high-dose weekly LAMB in pediatric hematology/oncology patients during hospital reconstruction

Method: Using data retrospectively collected from the institution’s electronic records and paper charts, data were reviewed for each LAMB infusion over the first three months of implementation of the protocol (October 8, 2012 to January 8, 2013).

Result: Nineteen patients received ninety-six LAMB infusions. Five patients experienced infusion-related reactions while none experienced nephrotoxicity. Only one patient was treated empirically for a possible fungal infection for continued fevers.

Conclusion: The safety of the prophylaxis regimen is questionable as approximately 1 in 4 patients experienced a reaction. We are unable to determine the efficacy of the prophylaxis regimen at this time as our rates of invasive mold infections were no different before and after the study period. We will continue to monitor LAMB antifungal prophylaxis in our pediatric hematology/oncology patients during the reconstruction period.


25-R1Impact of Statins in Acute exacerbations of Diastolic Heart FailureRC Wong, M George, O Eshleman, C BrimmerHarris Health System, Houston, Texas

Background: Heart failure is the most common cause of hospitalization among the elderly, and diastolic heart failure (DHF) comprises over half of the heart failure population. The majority of advances in this field have been in systolic, and not diastolic heart failure. Statins may offer a similar benefit to fibrotic remodeling patterns in diastolic heart failure as has been suggested in research with systolic heart failure.

Objective: The objective of this study is to assess the impact of statins on 30-day readmission and survival to hospital discharge among diastolic heart failure patients following hospitalization for an acute exacerbation.Procedures: Patient charts from January 2010 to January 2012 at a large metropolitan county hospital system were retrospectively reviewed for patients hospitalized for an acute

exacerbation of diastolic heart failure. The primary outcome was all-cause 30-day readmission. Secondary outcomes were heart failure related 30-day readmission and survival to discharge.

Result: 66 patients were included in the study. No statistically significant findings were observed. Rates of all-cause 30-day readmissions were 11.3% for statin-users and 0% for non-statin users (p = 0.59). Heart failure related 30-day readmissions between statin and non-statin users were 5.7% and 0% respectively (p = 1.00). In-stay mortality between statin and non-statin users was 1.9% and 0% respectively (p = 1.00).

Conclusion: The data suggest that statins have no impact on the course of diastolic heart failure. Our findings are limited by a small sample size, possible underreporting of hospital readmissions and under-diagnosis of diastolic heart failure.Disclosure: The authors of this study have nothing to disclose.

26-r1Vitamin C For Prevention of Vancomycin Related Kidney InjurySZ Mnjoyan, GK PerryHendrick Medical Center and Texas Tech University Health Sciences Center School of Pharmacy, Abilene, TX

Background: Ascorbic Acid has antioxidant properties and decreases oxidative stress on the kidneys. It has been studied for prevention of kidney damage with gentamicin, cisplatin, cyclosporine and several other agents. No clinical studies have evaluated the use of ascorbic acid to minimize acute kidney insufficiency with vancomycin.

Objective: The objective of this study is to evaluate the efficacy of ascorbic acid is in preventing vancomycin related acute kidney injury.

Method: This study will be conducted as a Quality Assurance project internally for the Hendrick Hospital. We will apply to the Hendrick Medical Center’s International Review Board (IRB) for approval of the project prior to data collection. The pharmacist who receives a vancomycin consultation will obtain permission from the physician to start the patient on oral ascorbic acid 500mg twice daily. The ascorbic acid will be timed to be administered one hour prior to vancomycin administration. Exclusion criteria will include age below 18, previous history of renal calculi, and previous vancomycin administration during the current admission. Patients will also be excluded if their serum creatinine on admission is elevated and does not stabilize within 72 hours. Concurrent administration of other agents which could increase the risk


of nephrotoxicity, such as aminoglycosides, amphotericin B and furosemide will be recorded. Kidney injury will be defined as an increase in serum creatinine ≥ 0.3 or 50% increase from baseline in a period of 48hrs.

Result: Pending

Conclusion: Pending final results

Disclosure: SZ Mnjoyan and GK Perry have nothing to disclose.

_________________________________________

eNTRIeSReSIDeNT PGY2

1-r2Transition from Inpatient to Outpatient Care: evaluation of Insulin Regimens at Discharge and Post-Discharge Follow-ups for Patients on Oral Steroid TapersSE Mathew, E Moss, KS Alvarez, C RheeParkland Health & Hospital System, Dallas, TX

Background: Glucocorticoids are commonly prescribed for acute medical conditions but can increase glucose levels in patients. This presents a problem for patients discharged from the hospital as appropriate insulin regimens and/or post-discharge follow-ups are critical in preventing sustained hyperglycemia and hypoglycemia.

Objective: To evaluate the prescribing patterns of insulin regimens in the presence of oral steroids in patients being transitioned from an inpatient to outpatient setting.

Method: This retrospective study evaluated patients from July 2011 to June 2012 who were discharged on both insulin and oral steroids. Patients with an established PCP and filled their medications within the health system were included. Patients not seen within 6 months of discharge, those receiving chronic steroid therapy unless discharged with an increase in dose, and those non-compliant with medications per outpatient pharmacy records were excluded. The primary outcome was the difference in adverse events in patients with appropriate discharge follow-up versus those without follow-up within 30 days.

Result: Fifty-one patient charts were included in the final analysis. Approximately 17.6% of patients did not have a follow-up scheduled within 30 days post-discharge. Out of those patients, 11.1% were readmitted within 30 days for hypoglycemia. Out of the 82.4% of patients with appropriate post-discharge follow-ups, 2.4% were readmitted for

hyperglycemia and 4.8% required emergency room care for hyperglycemia.

Conclusion: Patients discharged from the hospital on steroid and insulin therapy have more hypoglycemic episodes when there is no follow-up within 30 days of discharge. However, those with follow-up were more likely to have hyperglycemic episodes.

Disclosure: SE Mathew, E Moss, KS Alvarez, and C Rhee have nothing to disclose.

2-r2evaluation of modif ications to a weight-based unfractionated heparin algorithm in the treatment of venous thromboembolism JR Richardson, SE Michaud, KS Putney, M BayatSt. Luke’s Episcopal Hospital, Houston, Texas

Background: Unfractionated heparin (UFH) plays an important role in the treatment of venous thromboembolism (VTE), with rapid achievement of therapeutic aPTT as a critical factor in the reduction of in-hospital mortality and reduction of recurrent thrombosis. A previous retrospective review of 90 patients placed on the weight-based heparin algorithm for VTE revealed 50% of patients took longer than 24 hours to reach therapeutic aPTT, particularly patients weighing more than 90 kg at this study institution. In accordance with these results, revisions were made to the existing weight-based heparin algorithm.

Objective: The purpose of this study is to examine outcomes following revisions to the algorithm for treatment of VTE with UFH, focusing on efficacy and safety of the revisions.

Method: A retrospective chart review was conducted of patients receiving UFH for VTE following implementation of algorithm revisions. The primary endpoint was the proportion of patients reaching therapeutic aPTT within 24 hours. Result: A total of 59 patients were reviewed. Following algorithm revisions, 64.4% of patients reached therapeutic aPTT within 24 hours of UFH initiation. Patients weighing more than 90 kg were more likely to reach therapeutic aPTT within 24 hours following algorithm revision. There were no significant differences in bleeding events following algorithm revisions or changes in warfarin management strategies compared to the original algorithm cohort.

Conclusion: Revisions to the UFH algorithm have resulted in more patients reaching therapeutic aPTT within 24 hours of

UFH initiation without an increase in bleeding complications. Disclosure: JR Richardson, SE Michaud, KS Putney, M Bayat have nothing to disclose.

3-r2Value of post-discharge clinical pharmacy services in a heart failure clinic settingS Parekh, KW Garey, AC Hall, JA Tipton, WP FlowersMemorial Hermann Health System, Houston, Texas

Purpose: It has been known that pharmacist services in the setting of heart failure would decrease 30-day hospital readmission rates. However, the justification of such services has always been a challenge to the hospital administrators. The goal of the project is to create a model for implementation of post discharge heart failure clinics in community hospital settings at Memorial Hermann Health System.

Objective: This study is designed to determine the value of a post-discharge heart failure clinic by evaluating the changes in 30-day heart failure re-admission rates at an established academic center clinic and by analyzing the cost effectiveness of implementation of a similar clinic in a community hospital setting.

Method: Using data retrospectively, 30 – day heart failure readmissions data will be collected via reporting software to compare the rates of hospital readmissions before and after the clinic implementation. For the same time period, readmissions rates will also be evaluated for Memorial Hermann Health System, as a control group. To evaluate the cost effectiveness of the clinic, the costs of the clinic implementation will be weighed against the clinic benefits such as clinic revenue and changes in re-hospitalization costs. The return on investment for the clinic will then be calculated.

Result: Research in progress

Conclusion: Research in progress


4-r2evaluation of a Standardized Treatment Order Set and Associated Outcomes for the Management of Severe Sepsis and Septic ShockAT Vo, L Davis, J Sabo, G LaineSt. Luke’s Episcopal Hospital, Houston, TX

Background: Due to complications associated with sepsis, several studies demonstrate implementation of standardized

treatment order sets provide better compliance with early hemodynamic optimization and improved outcomes.

Objective: To determine if there are any differences in outcomes associated with the management of severe sepsis and septic shock utilizing a standardized severe sepsis treatment order set.

Method: This will be a retrospective study evaluating ICU patients with severe sepsis and/or septic shock at a large, tertiary teaching hospital. If these patients meet criteria, they are placed on the standardized severe sepsis treatment order set (SSTOS). Different analyses will be performed to determine specific endpoints including: mortality rates, ventilation times, length of stay (LOS), and achievement of various resuscitation goals.

Result: When comparing patients who were initiated on the SSTOS to those who were not, there were no significant differences in the primary endpoints of median ICU LOS (6 days, IQR 4-12 versus 7 days, IQR 3-15, p=0.77), median hospital LOS (13 days, IQR 7-25 versus 12 days, IQR 6-22, p=0.71), and in-hospital mortality rates (23% versus 36%, p=0.45).

Conclusion: There was a non-significant reduction in mortality rate by 13% in patients who were initiated on the SSTOS compared to patients who were not.

Disclosure: AT Vo, L Davis, J Sabo, and G Laine have nothing to disclose.

5-r2Cumulative thymoglobulin induction dosing in renal transplant recipientsM Moaddab, MJ RabournSt. Luke’s Episcopal Hospital, Houston, TX

Background: Induction therapy with rabbit anti-thymocyte globulin (Thymoglobulin®) (rATG) has become the preferred agent utilized for high-risk renal transplant recipients to prevent acute rejection. The safe and effective induction dosing of rATG in high immunologic risk kidney transplant recipients has yet to be determined, and very minimal data is available.

Objective: The primary objective of this study was to assess cumulative thymoglobulin induction dosing in high-risk renal transplant recipients to facilitate safe, effective and consistent dosing practices at a large tertiary teaching hospital.

Method: A retrospective observational study in high-risk renal


transplant recipients treated with thymoglobulin induction therapy between January 2007 to December 2012 was performed. Patients were assessed for: type and severity of acute rejection episodes, nadir and 1-year serum creatinine levels, and adverse events including infectious complications and leucopenia.

Result: A total of 38 patients were identified for study inclusion. Patients who received <7.5mg/kg of thymoglobulin induction therapy experienced higher rates of acute cellular (4/24 versus 0/14) and antibody-mediated (2/24 versus 1/14) rejection in comparison to patients who received >7.5mg/kg, respectively. Similar renal allograft outcomes and adverse events were observed within the study population.

Conclusion: Further analysis is necessary to confirm the relationship between cumulative thymoglobulin induction doses, renal allograft outcomes and safety considerations in high-risk renal transplant recipients.

Disclosure: M Moaddab and MJ Rabourn have nothing to disclose.

6-r2Development and Implementation of a Pharmacy Peer Review Process for Quality Improvement G Nweke, J Adams, D Varkey, K Putney, C FrostSt. Luke’s Episcopal Hospital, Houston, TX

Background: Peer review is a quality improvement process, utilizing a group of professional peers, in which final decisions about quality of care are made. The peer review process, although not widely adopted by hospital pharmacy departments, is frequently used among various healthcare disciplines as a means to improve the quality of care provided to patients specifically by identifying opportunities to improve processes of care, proactively mitigating risks, and fostering continuous learning. Among pharmacists, peer review is primarily used as a method to review medication errors and identify system improvements. However, it is also used for quality assurance of pharmacists’ clinical interventions as well as for continuous professional development.

Objective: The purpose of this study is to describe key components involved in the development and implementation of a pharmacy peer review process at a large tertiary teaching hospital and to highlight an example of process improvements resulting from a peer review deliberation.

Method: Prior to creating the peer review process at the study institution, a thorough literature and regulatory evaluation was performed regarding peer review and

assessment of pharmacist competencies. Key characteristics of peer review were identified and implemented: structure (core foundation from which the committee was designed), people (committee composition), and process (how the committee functions and makes decisions).

Result: Peer review has been successfully implemented at the study institution. Committee members were identified and meet quarterly and as needed. A process was developed to describe how the peer review process would be triggered and a standardized method to evaluate competency and performance was established.

Conclusion: Pharmacy peer review provides a method to objectively evaluate the quality of pharmacy services as well as individual performance.

Disclosure: G Nweke, J Adams, and D Varkey have nothing to disclose. C Frost and K Putney serve on the TSHP R&E Foundation Poster Review Committee.

7-r2Timing to Antibiotic Therapy in Septic Patients Presenting Without Hypotension KM Morneau, KM Toale, University of Texas MD Anderson Cancer Center, Houston, TX.

Background: Prompt and appropriate antimicrobial therapy is a cornerstone of sepsis management and has been associated with a 7.6% increase in mortality for every hour delay in administration from the onset of hypotension in septic patients. To date, no studies have specifically elucidated the impact of antimicrobial timing in septic patients presenting without hypotension.

Objective: The primary objective of this study is to determine the mortality associated with time to appropriate antibiotics in septic patients presenting without hypotension. Secondary objectives include evaluating the impact of antimicrobial timing on vasopressor requirements, intensive care unit (ICU) transfer, and hospital length of stay (LOS).

Method: A retrospective chart review of 86 patients who presented to the Emergency Center (EC) of MD Anderson Cancer Center between 9/1/2011 and 8/31/12 with a diagnosis of sepsis, severe sepsis, urosepsis, pneumonia, neutropenic fever, or bacteremia was performed. Patients met the criteria for sepsis and had systolic blood pressures (SBP) ≥ 90 mmHg or mean arterial pressures ≥ 65 mmHg without decreases in SBP of ≥ 40 mmHg. The primary objective was analyzed using logistic regression.

Result: Mean time to antibiotics were 10.9 (6.5-15.4) hours and 12.6 (8.1-17.1) hours for patients discharged alive and dead. Each hour of delay of appropriate antibiotics resulted in a 18% increase in the odds of death (p=0.0527).

Conclusion: A statistically non-significant but clinically important relationship between the delay in appropriate antibiotics and in-hospital mortality was observed. Time to antibiotics was not a significant predictor of vasopressor requirements, ICU transfer, or LOS

Disclosure: The authors of this study have nothing to disclose.

9-r2environmental prevalence of Clostridium difficile at a university-affiliated teaching hospital in Houston, TexasSL Aitken, MJ Alam, KW GareySt. Luke’s Episcopal Hospital and University of Houston College of Pharmacy, Houston, TX

Background: Contamination of the hospital environment with toxigenic C. difficile increases the frequency of C. difficile infection (CDI). Environmental samples obtained from rooms of patients with CDI demonstrated culture-positivity in 33% of samples. Small studies of C. difficile environmental contamination from other hospital locations showed culture positivity in less than 2% of samples.

Objective: The purpose of this study was to determine the environmental prevalence of toxigenic C. difficile from non-patient rooms of a large tertiary care hospital and characterize the isolates.

Method: Samples were obtained from the environment and common-use medical equipment in the work or travel areas of patient care areas and intensive care units throughout the hospital. Sterile, moistened gauze sponges were used to obtain swab samples, which were then placed in a sterile tube containing 25mL brain-heart-infusion broth supplemented with 0.05% sodium taurocholate and incubated in anaerobic jars at 37°C for 7 days. One mL of this culture was then centrifuged and the resulting pellet suspended in 100mcL of normal saline. Fifty microliters of this suspension was then plated onto cefoxitin-cycloserine-fructose agar (CCFA) and incubated in anaerobic jars for an additional 48-72 hours. Potential colonies of C. difficile were identified based on morphology and confirmed by latex agglutination. Toxigenic strains were assessed using multiplex polymerase chain reaction to detect the presence of toxin A (tcdA), toxin B (tcdB) and the binary toxin (cdtA and cdtB).

Result: One hundred and twenty-two environmental

samples were collected from 21 locations including floor (40), medication dispensing cabinets (20), door handles (14), ethanol hand sanitizers (22), washroom (20), and stairs (6). In total, seven of 122 (5.7%) samples were positive for growth of C. difficile . All cultured isolates (100%) were positive for tcdA and tcdB. One of seven (14%) was positive for binary toxin. Five of 84 (6.0%) ICU samples and 2 of 38 (5.3%) patient care area samples were positive. Positive samples were obtained from the floor (n=4; 10%), washroom (n=2; 10%), and medication dispensing cabinet (n=1; 5%).

Conclusion: C. difficile culture positive rates for non-patient room hospital environmental samples were 5.7%. Depending on location and source, rates of positivity ranged from 0-10%. Disclosure: KWG reports continuing research support from Merck. SLA and MJA have no conflicts of interest to disclose.

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eNTRIeSSTUDeNT

1-sIncreasing Patient education of Hormonal Contraceptive Options and Side effects through Targeted and Personalized Patient education AL Garner, KL Dinh, JT Joseph, JK Tran [email protected] The University of Texas College of Pharmacy, Austin, Texas

Background: Patient non-adherence and discontinuation of hormonal birth control is commonly due to unwanted side effects or difficulty of regimen. Of the women who discontinue taking oral hormonal contraception (HC) due to dissatisfaction, 63% discontinued due to side effects and 12% stopped due to concerns about side effects.1

Objective: In hopes to increase patient adherence and satisfaction of HC, we aim to increase knowledge of HC options and associated side effects.

Method: Sixty-three college-aged females were divided into five groups led by pharmacist interns. Each intern rotated among the groups presenting information focused on a specific method of HC and providing an open forum for group discussion. Attendees were asked to fill out a pre-survey prior to the session and a post-survey upon conclusion of the session. One-on-one counseling was then offered in a private setting to participants who had additional questions. Preliminary

Result: Attendees were asked to rate their knowledge of HC on a Likert scale from 1 to 5 (with 1 equaling little-to-none


and 5 equaling very knowledgeable) before and after the session. Average self-rating of knowledge before and after the session were 2.9 and 4.63 respectively, resulting in an average increase of 1.72.

Conclusion: Focused education led to increased knowledge of patient’s own HC, other available options, and associated side effects of HC. It is our hope that an increase in patient knowledge can lead to an increase in patient satisfaction and adherence to hormonal contraception.

Disclaimer: Attendees were awarded points for their organization for participation in the education session.

1 Daniels K, Mosher WD, Jones J. Contraception methods women have ever used: United States, 1982-2010. National health statistics reports; no 62. Hyattsville, MD. National Center for Health Statistics. 2013.

2-sImproving Asthma education in elementary School-Aged ChildrenK Thomas, T Gajera, C Pham, J Tran, S Wadsworth, J Wang, C WhalenThe University of Texas College of Pharmacy, Austin, Texas

Background: The mission of The University of Texas Student Society of Health-System Pharmacists (UT-SSHP) is to improve health outcomes in underserved communities within the local Austin area. To accomplish this goal, the organization developed an asthma education program for elementary school-aged children.

Objective: To educate children with asthma about their disease state and trigger avoidance. To demonstrate correct and effective inhaler and peak flow meter use. To encourage utilization of asthma action plans in asthma management.

Methods(s): Elementary-aged students with asthma were given the opportunity to partake in brief asthma education classes taught by pharmacy students. Elementary school administrators gave approval for the classes, and the nursing staff obtained permission from parents/guardians to have their children participate in the program. Topics discussed during the classes included basic asthma pathophysiology, trigger avoidance, inhaler self-administration, and Asthma Action Plans.

Result: Over the past year, UT-SSHP has visited five underserved elementary schools to promote asthma education. Events included an interactive presentation that helped to educate children on asthma triggers, symptoms,

and proper inhaler technique. As a result of these efforts, the children now have the information and skills needed to optimize their asthma care.

Conclusion: UT-SSHP has carried out its mission to address the health needs of underserved populations in the local Austin community. Through hands-on activities and visual presentations, children gained greater knowledge on asthma attack prevention, symptom control, and inhaler technique.

Disclosure: No disclosures.

3-sAssessment of Renal Dosing Among Older Americans with Chronic Kidney Disease (CKD) in a Community-Owned Health SystemVP Pham, S Agbahiwe, MR GreenHarris Health System and Texas Southern University College of Pharmacy & Health Sciences, Houston, TX

Background: Harris Health System takes pride in putting people first by providing high quality healthcare services. Clinical Pharmacy Specialists (CLPS) are a part of the multidisciplinary team that provides these high quality services, especially in the management of diabetes, hypertension, dyslipidemia, thyroid disorder, and anticoagulation. Chronic kidney disease (CKD) is directly associated with these conditions; however the management of it cannot be compartmentalized any longer. A direct focus on early identification and medication modification will help prevent progression and attain remission.

Objective: The objective of this poster is to assess renal dosing in older Americans with CKD, thereby preventing the progression of this disease state.

Method: A retrospective chart review was conducted using a central medical records database. Older Americans, ages sixty years and older, during January 2010 to December 2011 with CKD at a community-owned healthcare system were included in the study. Patients with end-stage renal disease (ESRD) and kidney transplant were excluded. We randomly selected the patients through Microsoft Excel. The primary outcome measured is the number of CKD patients that were on nephrotoxic medications that required medication modification but may have not received it.

Result: A total of 200 patients were randomly selected, reviewed, and met the study criteria. Results will be presented.

Conclusion: To be presented.


4-sSerum Procalcitonin Use in Diagnosing and Treating Lower Respiratory Tract InfectionsAR Whiddon, JM CottreauUniversity of Houston College of Pharmacy, Houston, TX

Background: Respiratory tract infections are the most frequent indications for antibiotic use, although the majority of these are caused by viruses. This leads to overuse of antibiotics which contributes to bacterial resistance. Procalcitonin may be useful as a guide for antibiotic treatment in patients with respiratory tract infections. It is released in response to bacterial infections but is not elevated in viral infection. The objective of this review is to evaluate existing literature on the role of procalcitonin to guide initiation and cessation of antibiotic therapy in patients with respiratory tract infections.

Method: A Pubmed search was conducted. Studies were included in this review that used procalcitonin levels to initiate and guide antibiotic therapy in adult patients with various lower respiratory tract infections.

Result: Seven studies were included in this review. All of the studies were randomized controlled trials and compared standard intervention to procalcitonin guided therapy. All studies began antibiotic therapy when procalcitonin was >0.25 μg/L with the exception of two studies, which began antibiotics when procalcitonin was >0.5 μg/L. In the seven studies examined, no difference was seen in mortality, hospitalization duration, or days with significant health impairment between the procalcitonin and control groups. However, procalcitonin-guided antibiotic therapy was shown to be effective in reducing antibiotic exposure in these patients.

Conclusion: Procalcitonin-guided therapy was effective in reducing antibiotic treatment days and duration compared to standard therapy. Procalcitonin may serve as a useful diagnostic tool in patients with lower respiratory tract infections.

Disclosure: None

5-sProject Collaborate: Implementation of a Centralized Health Screening Initiative for Pharmacy Student Organizations at the University of TexasMF Curran, NL Casciello

The University of Texas College of Pharmacy, Austin, TX

Background: Project Collaborate was started by the University of Texas American Pharmacists Association Academy of Student Pharmacists (UT-APhA-ASP) and represents one of the single largest student-led health initiatives in the state of Texas.

Traditionally, public health projects were organized independently by various pharmacy student organizations, resulting in inconsistent leadership, inadequate resources, and a limited pool of student volunteers. To overcome these challenges, the student leadership united to create a college-wide community service initiative.

Objective: Centralize public health initiatives at the University of Texas College of Pharmacy to provide quality health screenings and health education services to underserved communities, enable student pharmacists to enhance their patient interaction skills, promote interprofessional collaboration, and advance the profession.

Method: Student leadership formed a task force to investigate options for consolidating efforts. Based on their recommendations, UT-APhA-ASP drafted a proposal for Project Collaborate, an initiative calling for organizations to work together to improve public health outreach. The program launched in Fall 2009 with the support of all student organizations.

Result: Project Collaborate resulted in a marked increase in the number of patients screened and health screenings performed. In 2011-2012, over 300 student pharmacists performed nearly five thousand screenings. In Fall 2012, student pharmacists screened 1217 patients at 10 events, totaling 6053 screenings.

Conclusion: Since 2009, Project Collaborate has transformed the way student pharmacists interact with their communities as healthcare professionals. Project Collaborate has expanded in size and scope to bring healthcare services to under served communities across the state. Expansion plans continue, with additional services expected to launch in 2013.

Disclosure:Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation:Molly Curran: Nothing to discloseNicole Casciello: Nothing to disclose


6-sevaluation of the effects of a Physical and Nutritional education Program Delivered to Children in a Rural CommunityA Gutierrez, J Robles, CF SeifertSchool of Pharmacy, Texas Tech University Health Science Center, Lubbock, TX Background: Childhood obesity has become an epidemic among children particularly in lower socioeconomic classes and minorities highlighting the need to target these groups with education. No information was found targeting minority children in a rural area with a nutrition and physical education program.

Objective: To evaluate the impact of a physical and nutritional education program with physical activity to elementary students who reside in a rural community.

Method: Prospective 12-week cohort study of 4th and 5th grade students residing in Bailey County, Texas. Phase 1: baseline parameters were measured & consent and assent were obtained. Phase 2: 4 weeks of exercise/nutrition education and physical activity and measurement of parameters. Phase 3: parameters measured on week 8 and 12 to evaluate if information was retained.

Result: BMI and BMI percentile were significantly reduced in one month (18.98 ± 8.23 vs. 18.65 ± 7.91, p <0.0067), (76.15% ± 47.44% vs. 75.95% ± 47.91%, p=0.0211), and further reduced at three months with no further intervention (18.65 ± 7.91 vs. 18.59 ± 7.76, p<0.0001),(75.95% ± 47.91 vs. 74.80 ± 50.68, p<0.0001).

SBP was significantly reduced in one month (106.7 ± 5.8 vs. 105.6 ± 4.8, p=0.0037) and again at three months with no further intervention (105.6 ± 4.8 vs. 104.9 ± 4.1, p=0.0228). There was a significant correlation (rs=0.422, p=0.0161) between the difference in BMI and SBP from baseline to 3 months

Conclusion: A nutrition and physical activity program delivered to children in a rural area showed significant reductions in BMI, BMI percentile and SBP over a one month period that continued to improve despite no intervention over the next two months.


7-sMedication Therapy Management by Pharmacist Interns in an Outpatient SettingJB George, MN Dorosk, NQ DauTexas A&M Rangel College of Pharmacy, Kingsville, TX

Background: Medication Therapy Management (MTM) is a service provided by pharmacists to optimize therapeutic outcomes while decreasing adverse events by customizing plans for individual patients. Our purpose is to adopt the MTM criteria in an outpatient clinic setting. This will allow any problems which arise to be resolved before the patient leaves the office.

Objective: To evaluate the impact of student pharmacists in the delivery of medication therapy management services.

Method: Provide medication therapy management services in an outpatient clinic to patients with hypertension, type 2 diabetes, and dyslipidemia and survey their opinion on medication compliance and medication therapy management outcome.

Result: We anticipate offering MTM counseling sessions to 168 210 patients during the course of 14 office visits. We anticipate scheduling appointments with patients who have not been seen for follow up appointments. We estimate that we will reach 70 people using this method.

Conclusion: We hope to see the outpatient clinical model show the same cost effectiveness while also improving communication between the physician and student pharmacist. This model strengths include decreasing time to intervention by allowing the physician to make changes to medication regimen before the patient leaves the clinic. MTM counseling has been shown to find 2.3 drug related problems during the first visit. We expect to fix these errors resulting in better patient outcomes and reduced adverse effects.

Disclosure: No disclosures

8-sHospital staff pharmacist workflow: a comparative analysis of scanned order entry versus computerized provider order entry (CPOe)MD Hatfield, R Cox, SS Sansgiry

Objective: The objective of this study was to quantify the amount of time spent in different activities by hospital staff pharmacists in a scanned order entry versus a computerized provider order entry (CPOE) setting.

Introduction: Recently, there has been a tremendous increase in the preparation on the part of US hospitals to implement CPOE. Employer groups, the federal government, and others have been advocating its implementation since the early 2000s, yet the number of hospitals which have met meaningful use criteria for CPOE is still less than 15%. This number is projected to increase exponentially in a very short time, spurred by incentives from the Centers for Medicare and Medicaid (CMS). With such a large amount of hospitals preparing for CPOE implementation, there is still much to learn about the impact of these systems. Method: An experimental, enhanced pretest-posttest, prospective, time and motion study was conducted in four inpatient pharmacies within the same hospital system. Staff pharmacists were observed for two separate time periods. The intervention pharmacy was observed first as a scanned order pharmacy and then later, after CPOE had been implemented. There was a control pharmacy which used scanned orders for both time periods. There were two treatment control pharmacies, both of which had CPOE for both time periods. A database instrument recorded 37 different pharmacist tasks, which were grouped into six activities: scanned order entry, CPOE order verification, distributive, clinical, administrative, and miscellaneous. Comparisons of the amount of time spent by the staff pharmacist in each of the six different activities were conducted. SAS® version 9.3 was used to analyze the data, with statistical significance set at 0.05.

Result: A total of 114 hours at the scanned order site and 197 hours at the CPOE order site met the inclusion criteria. Non-parametric linear regressions were modeled and the predicted values were analyzed. The predicted mean number of minutes for each recorded hour were, by activity (predicted mean ± SD for scanned orders versus CPOE, p-value): scanned order entry (27.01 ± 3.89 versus 13.82 ± 3.54, <0.05); CPOE order verification (2.77 ± 2.75 versus 16.19 ± 2.16, <0.05); distributive (14.77 ± 1.46 versus 17.60 ± 1.78, <0.05); clinical (5.10 ± 2.24 versus 3.83 ± 1.34, p<0.05); administrative (7.25 ± 2.34 versus 6.67 ± 1.28, p<0.05); and miscellaneous (3.11 ± 0.77 versus 1.89 ± 0.68, p<0.05).

Conclusion: Less time was spent in the scanned order entry, clinical, administrative, and miscellaneous activities, while more time was spent in the CPOE order verification and distributive activity after CPOE implementation. These findings were statistically significant.

9-sCompatibility of dopamine hydrochloride and dobutamine hydrochloride injection with Liposyn III Intravenous Fat emulsion during simulated Y-site administration

JE Esqueda, R Bellanger, K MartinUIW Feik School of Pharmacy, San Antonio, TX

Background: Neonates in the neonatal intensive care unit are fragile due to their low birth weights and may require an intravenous (IV) fat emulsion, such as Liposyn, to provide essential fatty acids and calories. Due to the size and fragility of their veins, multiple access points for IV administration are unavailable, and the nutrition and drugs often must be combined into a single line to enter the body.

Objective: To evaluate the compatibility of dopamine hydrochloride and dobutamine hydrochloride with Liposyn III 10% and Liposyn III 20% during simulated Y-site administration.

Method: Dopamine and dobutamine were diluted in 5% dextrose (D5W) and 0.45% sodium chloride (½ NS) injection to 6, 12 and 32 mcg/mL. Each drug solution was mixed with an equal volume of Liposyn III 10% or Liposyn III 20% in a centrifuge tube. Samples were mixed for 25 seconds and evaluated for pH, particle size, color, clarity, odor and viscosity over a 24 hour period.

Result: The particle size, color, clarity, odor and viscosity of both dobutamine and dopamine in D5W and ½ NS mixed with Liposyn III 10% and Liposyn III 20% did not change over a 24 hour period. The pH of both dobutamine and dopamine in D5W mixed with Liposyn III 20% decreased over a 24 hour period. The pH of dobutamine in ½ NS mixed with Liposyn III 10% increased slightly while the pH of dopamine in ½ NS mixed with Liposyn III 10% decreased over a 24 hour period.

Conclusion: Both dobutamine and dopamine diluted in D5W and ½ NS were compatible at all concentrations when mixed with Liposyn III 10% and Liposyn III 20% over a 24 hour period.

Disclosures: Not applicable

10-sAntibiotic and Antiviral Awareness: A Statewide education Initiative to Decrease Antibiotic Resistance A Diamantopoulos, S Sen, C Anderson, E Bernardo, J Burdine, N Finke, A Fowler, J George, M Laine, A Lehnert, E Martin, O. Okafor, O Patel, R Roy, M Saenz, K Tharp, K Thomas Texas Society of Health-System Pharmacists Student Section Executive Committee, Austin, Texas

Background: Healthcare facilities and communities continue to witness an increasing trend in multidrug-resistant infections. To combat this dangerous trend, healthcare providers must become proactive in educating the public


about antibiotic resistance consequences. Through a statewide initiative conducted over the past four years, the Student Section Executive Committee (SSEC) provides education to our local communities on the appropriate antibiotic utilization to prevent antibiotic resistance and the spread of infection. The SSEC also promotes preventative strategies such as vaccinations and proper hand-washing techniques.

Objective: The objective of this poster is to inform seminar attendees about the SSEC’s methods for educating communities about antibiotic resistance consequences, as well as the steps they can take to prevent resistance and the spread of infection. Additionally, the committee encourages the vaccination use as a means to prevent the spread of the seasonal flu.

Method: The SSEC sought to develop educational resources for each Texas SSHP chapter on topics regarding bacterial/viral infections, appropriate antibiotic use, vaccinations, and other disease prevention methods. SSEC members worked in committees to assemble various community programs utilizing a variety of resources including the Centers for Disease Control and Prevention, Mayo Clinic, The Journal of the American Medical Association, and flu.gov. Materials utilized included “Germ Juice” hand washing kits, games, informational pamphlets, refrigerator magnets, hand sanitizers, and PowerPoint presentations.

Result: Targeted audiences include children in daycare centers, local elementary schools, and after-school programs; college students and parents in local communities; and employees of local health-system facilities. The educational programs have been well received by the community, and the SSEC looks forward to continuing this annual initiative in the future.

Conclusion: To further reinforce pharmacists’ roles as advocates for proper healthcare and medication use, the SSEC educates community members on simple strategies to prevent the spread of infection and decrease antibiotic resistance. Furthermore, it is vital to promote a unified, statewide effort to educate the community on the proper antibiotic use, stewardship, vaccinations, and the antibiotic resistance consequences to combat the spread of infections.

Disclosure: The authors of this poster have nothing to disclose.

12-sSurvey to examine e-Prescribing Adoption Barriers in South Texas

J Mathew, N Samuel, CA DouglasTexas A&M Health Science Center Irma Lerma Rangel College of Pharmacy, Kingsville, Texas

Background: Literature suggests barriers to eprescribing adoption are associated with three key of factors; fear of negative impact on prescription quality and accuracy, inter professional communication barriers, and usability. Usability is the extent a product achieves a specified goal with effectiveness. These factors need investigation to explain the low adoption rate of e-prescribing in the community health care setting.

Objective: The purpose of this study is to explain adoption barriers of e-prescribing in community health care settings. This study evaluates three key factors associated with adoption. The factors are; prescription quality and accuracy, inter professional communication, and usability of the e-prescribing system.

Method: This is a cross-sectional qualitative study. Structured interviews are planned at community pharmacies and medical offices in South Texas. Interviews will collect data on; perception of prescription quality and accuracy, inter professional communication barriers, usability, and demographics.

Result: Research is in progress and results are incomplete. On completion of data collection, descriptive statistics are used to analyze interview responses and open ended responses are analyzed with a thematic analysis. A comparison of data between pharmacies and medical offices is planned.

Conclusion: Research is in progress, and conclusions are yet to be completed. The knowledge gained by this study will guide the development of future e-prescribing systems. Finding will help improve the quality and accuracy of prescriptions, reduce communication barriers among health care providers, and improve overall usability. This study will present a broad examination of the state of e-prescribing in South Texas.

Disclosure: The authors have nothing to disclose financially or otherwise.

13-sUsing Leukocytosis as a severity marker in hospitalized patients with Clostridium difficile infectionOS Patel, DN Shah, KW Garey University of Houston College of Pharmacy and St. Luke’s Episcopal Hospital, Houston, TX

Background: Clostridium difficile infection (CDI) is the

leading cause of antibiotic-associated diarrhea in hospitalized patients. Unexplained leukocytosis is a common manifestation of CDI, however there is little evidence assessing whether high leukocytosis predicts severe outcomes in patients with CDI.

Purpose: There are not many severity markers available to aid in the assessment of patients with CDI. In this study, we assessed whether leukocytosis was associated with demographics, clinical presentation, clinical outcomes, choice of therapy, and co-morbidities in patients with CDI.

Method: We retrospectively analyzed 156 patients with CDI. Multiple variables were used to assess the causes of leukocytosis. These included demographics (gender, race, age) clinical outcomes (recurrence, death, length of hospital stay), clinical presentation (fever, colitis, CDI severity, Horn’s Index), choice of therapy (metronidazole, vancomycin, rifaximin), and co-morbidities (based on Charlson Co-Morbidity Index).

Result: CDI patients with leukocytosis (WBC >10,000 cells/mm3) experienced higher rates of recurrent CDI (p = 0.0283). A higher Charlson Co-morbidity index was also associated with a lower leukocytic response (i.e. unable to mount an adequate immune response). There were no significant findings in terms of demographics, clinical presentation choice of therapy.

Conclusion: It was shown that leukocytosis in patients with CDI had no relationship based on demographics, clinical presentation and choice of therapy. Recurrence was shown to occur at a higher rate in patients with leukocytosis, however, patients with several co-morbidities may have had a lower leukocytic response. These findings may need to be confirmed in a larger study.

Disclosure: The authors of this abstract have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: Garey, K.W. and Shah, D.N.: Merck & Co., Inc All other authors: Nothing to disclose

14-sTigecycline-induced pancreatitisHV Bhakta, R Perez, ES MartinTexas A&M Health Science Center Rangel College of Pharmacy, Kingsville, Texas

Background: Tigecycline has been associated with acute pancreatitis in recent case reports. Because tigecycline is a

relatively new antibiotic and because tigecycline-induced pancreatitis is rare, clinicians may be unaware of the need to monitor patients for signs and symptoms of tigecycline-induced acute pancreatitis.

Objective: To present a patient’s clinical course that may be a case of possible tigecycline-induced pancreatitis.

Method: A patient’s clinical course was followed for possible tigecycline-induced pancreatitis. A review of the current literature was conducted to find evidence of other cases of pancreatitis with tigecycline administration.

Result: The patient’s clinical course during the hospital stay, as it relates to tigecycline administration and the development of pancreatitis, was consistent with similar cases found in the literature. Many of the expected lab value characteristics, patient symptoms, and radiographic evidence pointed toward pancreatitis. The timing of the tigecycline treatment, its discontinuation, and the resulting effects on the patient were indicative of possible tigecycline-induced pancreatitis.

Conclusion: We recommend that patients receiving tigecycline therapy be monitored for symptoms of pancreatitis. We recommend that in patients who are recently started on tigecycline and develop symptoms of pancreatitis, further testing for pancreatitis should be done. If a diagnosis of pancreatitis is made, tigecycline therapy should be discontinued immediately and alternative antibiotic regimens should be considered to avoid further pancreatic damage and possible necrosis.

Disclosure: H Bhakta has nothing to disclose; R Perez has nothing to disclose; E Martin has nothing to disclose.

15-sUniversity of Houston Student Society of Health-System Pharmacists Membership Benefits: Building Networks & Refining Professional SkillsTL MolinaUniversity of Houston College of Pharmacy, Houston, TX

Background: Each year, the UH Chapter of SSHP strives to better cater to our members by offering opportunities for student pharmacists to learn skills in medication review, to gain hands-on experience in clinical pharmacy, and to develop professional networks which they will maintain throughout their pharmacy careers. By continually seeking advancements and establishing venues for collaborative discussion with other chapters and pharmacy leaders, the UH SSHP Chapter will be better equipped and informed to


adapt to the changing face of clinical pharmacy.

Objective: To highlight select membership benefits including Brown Bag Medication Reviews, the Clinical Internship Database, and the Residency Mentoring Social.

Methods or Procedures: The UH SSHP Chapter maintains comprehensive records detailing past events and suggestions for future ideas. The presented information was selected from these records and places focus on the 2012-2013 school year. Seminar attendees are encouraged to engage in open discussions regarding the presented topics.

Result: Not applicable.

Conclusion: Not applicable.

Disclosure: The author has nothing to disclose.

16-sTreatment patterns and utilization of concomitant antibiotics or proton pump inhibitors in hospitalized patients with multiple Clostridium difficile infection recurrencesME Laine, DN Shah, LC Smith, KW GareyUniversity of Houston College of Pharmacy, St. Luke’s Episcopal Hospital, Houston, TX

Background: Recurrence of Clostridium difficile infection (CDI) is one of the most feared consequences of the disease. Treatment of recurrent CDI is a challenge, with limited data available for the management of multiple recurrences.

Objective: The objective of this study was to evaluate treatment patterns and concomitant antibiotic or PPI use in hospitalized patients with multiple CDI recurrences.

Method: This study evaluated hospitalized patients with multiple CDI recurrences, defined as ≥ 2 recurrent CDI episodes. Electronic medication profiles were examined to determine CDI therapy, concomitant antibiotics, or PPIs for each episode.

Result: A total of 24 hospitalized patients aged 61±17 (67% female) with multiple recurrences of CDI were evaluated. Fifteen patients (63%) had two recurrences, five (21%) had three, and four (17%) had greater than 3 recurrences. The majority of patients with two recurrences (n=15) received combination therapy for first recurrent (n=7) or second recurrent episode (n=10), primarily with vancomycin and metronidazole. Patients with greater than two recurrences (n=9) commonly received a combination-based therapy with fidaxomicin, rifaximin or nitazoxanide for treatment of

recurrent episodes. Twenty-one patients (88%) received > 1 antibiotic during an episode of CDI and 23 patients (96%) received a PPI during an episode of CDI.

Conclusion: Metronidazole and oral vancomycin combination therapy were utilized most commonly for initial recurrent episodes. Patients with more recurrences received more novel therapies. The majority of patients received concomitant antibiotics or PPIs during recurrent episodes. Antimicrobial stewardship-based interventions may be essential in the management of patients with multiple CDI recurrences.

Disclosure: The authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: KW Garey and DN Shah: Merck & Co., Inc. All other authors have nothing to disclose.

17-sTime to Positivity of Blood Cultures in Patients with CandidemiaKN Kidwell, ND Beyda, KW Garey University of Houston, Houston, TX

Background: Candida spp. are the 4th leading cause of nosocomial bloodstream infections and a delay in effective antifungal therapy has been associated with increased mortality. Blood culture (BC) followed by morphologic and biochemical testing is the gold standard for detection and identification of Candida in blood. However, these methods require several days to provide results. The time to positivity (TTP) of BCs may delineate differences among species and antifungal susceptibility, and may help guide effective empiric antifungal therapy.

Objective: The objective of this study was to evaluate the relationship between TTP, candida species, and fluconazole susceptibility.

Method: This retrospective, observational study included the first episode of candidemia from patients admitted to St. Luke’s Episcopal Hospital between 2010 and 2013. Positive BCs were identified by the microbiology laboratory using BacTAlert 3D, and speciation was performed using Vitek II. Fluconazole susceptibility was determined by broth microdilution (Sensititre) and interpreted using CLSI breakpoints. TTP was defined as the time between BC collection and when it was reported positive. Student T-test and ANOVA were used to evaluate relationships between TTP, candida species, and fluconazole susceptibility.

Result: A total of 146 patients aged 60 ±16 years (mean±SD)(61% male) were included. C. glabrata (CG) was the most common species (41%), followed by C. albicans (CA) (35%), C. tropicalis (CT) (14%). The mean TTP for CG (64.7h) was significantly longer compared to CA (43.04h) and CT (35.81h) (p <0.05). There was no difference in TTP between fluconazole susceptible vs. resistant isolates.

Conclusion: TTP may be helpful in differentiating CG from other species, but was not associated with fluconazole susceptibility.

Disclosure: Dr. Garey has received research support from Astellas and Merck. All others nothing to disclose.

18-searly experience with 3-Month Ciprofloxacin Prophylaxis for BK Infection in Renal Transplantation AL Lehnert, SJ PatelUniversity of Houston College of Pharmacy, Houston, Texas

Background: BK polyomavirus (BKV) is an infection affecting renal transplant recipients. Previous data suggests possible activity of fluoroquinolones against BKV, although their role in prevention is unknown.

Objective: To review 6-month experience using a ciprofloxacin protocol specifically aimed at preventing BKV.

Method: Beginning in 03/2012 at The Methodist Hospital, renal transplant recipients were discharged on prophylactic ciprofloxacin (CIP) 500 mg once daily for 90 days. Medical records were reviewed to compare CIP patients to a consecutive cohort of patients transplanted from 01/2011 to 03/2012 who did not receive CIP prophylaxis. Statistical methods used include Student test, Fisher’s exact test, Chi-squared test, and Kaplan-Meier curves.

Result: A total of 327 patients (80-CIP and 247-noCIP) were reviewed. There were no differences in age, race, gender, and tacrolimus use. There was a slightly higher rate of rATG induction (74% vs. 61%; p = 0.04) and mycophenolate use (100% vs. 97%, p = 0.05) in the CIP arm, and a lower percentage of living donors (24% vs. 36%, p = 0.03) and prednisone use (79% vs. 89%; p = 0.02). Though not statistically significant, a 27% reduction in BKV was seen at 6 months. No differences were seen in UTI rates, although 9 bacteremias occurred in noCIP patients compared to 0 in CIP patients (p = 0.02). Several antibiotic susceptibility rates were decreased in CIP patients.

Conclusion: Preliminary data suggests a modest reduction in BKV at 6 months with CIP prophylaxis, but this may be at the expense of increased antibiotic resistance.


19-sUniversity of Houston Student Society of Health-System Pharmacists Membership Benefits: Preparation for ResidencyM PayneUniversity of Houston College of Pharmacy (Houston, TX)

Background: Pursuing post graduate training after completion of pharmacy school is a decision that is recently of increasing popularity. The University of Houston Student Society of Health-System Pharmacists has developed a series of “Residency Preparation” meetings. These sessions, which are catered towards pharmacy students in their third and fourth year, are designed to facilitate the preparations involved and the skills required in applying to residency programs.Objective: To highlight the valuable opportunities available to UH SSHP members who intend to pursue a residency.

Method: Not applicable.

Result: Not applicable.

Conclusion: Not applicable.

Disclosure: The author has nothing to disclose.

20-sClinical presentation and baseline characteristics at hospital admission of patients with community-associated Clostridium difficile infectionLC Smith, DN Shah, ME Laine, KW GareyUniversity of Houston-College of Pharmacy, St. Luke’s Episcopal Hospital, Houston, TX

Background: Community-associated Clostridium difficile infection (CDI) is a poorly understood emerging pathogen. Patient characteristics, presenting signs, and prior medication exposure of patients admitted to the hospital with community-associated CDI (CA-CDI) are not clearly understood.

Objective: The objective of this study was to evaluate patient’s clinical presentation at hospital admission in patients with CA-CDI.

Method: This was an evaluation of 30 hospitalized patients


with CA-CDI. CA-CDI was defined as a positive C. difficile toxin assay within 48 hours of hospital admission plus no exposure to a healthcare facility in the previous 12 weeks. Patient’s information from the hospital admit note was utilized to evaluate chief-complaint classified as gastrointestinal (GI)-related vs. non-GI related, co-morbidities and medication use history.

Result: Twenty-nine (97%) patients aged 64± 19 years (73% female) had a GI-related chief complaint of which diarrhea (n=28; 97%), nausea (n=15; 52%) and abdominal pain (n=12; 41%) were most frequent. The common co-morbidities included hypertension (n=19; 63%) and hyperlipidemia (n= 14; 46%). Three patients (10%) had no comorbid conditions. Seventeen patients (57%) had taken an antibiotic of which 12 (71%) patients reported taking a single antibiotic. Eight patients (27%) received a proton pump inhibitor (PPI), while six patients (20%) received both an antibiotic and a PPI agent.

Conclusion: Patients with CA-CDI presented with a number of GI-related complaints. More than half the patients were not exposed to an antibiotic or exposed to a single antibiotic course.

Disclosure: The authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation: KW Garey and DN Shah: Merck & Co., Inc. All other authors have nothing to disclose

21-sAssessment of the Public’s Perception of Texas Pharmacists’ evolving Roles Regarding Patient Care Initiatives AN Martin, LB StokesUniversity of Houston College of Pharmacy, Houston, Texas

Background: The pharmacy profession is one that has constantly evolved. Particularly, the legislation passed in the last 10-20 years, both nationally and in Texas, has significantly expanded the role of pharmacists to include the delivery of patient care. As the profession continues to progress, it is of utmost importance that our patients are aware of our capabilities as pharmacists, comfortable receiving clinical services from us, and supportive of future initiatives to expand our role.

Objective: The objective of this project is to survey the general public concerning their knowledge of the evolving pharmacy profession in order to create a targeted education program in the future that can be used to progress the profession by gaining public support.

Method: A survey containing questions based on key legislation that has been passed in the last 10-20 years allowing pharmacists to participate in patient care initiatives was conducted. The survey results were then put into graphical form in order to identify the target populations with the least knowledge and ultimately how to design appropriate education tools.

Result: This study is the preliminary research for a larger project. Thus far, we have found that age, education level, and interaction with pharmacists influence how much an individual knows about the duties that pharmacists can perform. In addition, the level of knowledge affects how comfortable that person feels in receiving clinical services from a pharmacist.

Conclusion: In conclusion, these preliminary results will feed further research to develop a targeted education program to expand the public view of pharmacists’ roles.

Disclosure: AN Martin and LB Stokes are students at University of Houston College of Pharmacy and have nothing to disclose.

22-sBayview Behavioral Modification Chemical Dependency Intensive Outpatient Program (CDIOP)S Ni, JP Alonzo Texas A&M Health Science Center Irma Lerma Rangel College of Pharmacy, Kingsville, Texas

Background: Bayview Behavioral Hospital is a 68 bed psychiatric facility which is a part of Corpus Christi Medical Center. Bayview offers treatment for conditions such as depression, schizophrenia, suicide, autism spectrum disorders, and chemical dependency. The facility offers 6-week total-care intensive treatment planning for outpatients diagnosed with substance abuse issues which include alcoholism, illicit drug use, and prescription drug abuse. This program is known as the Chemical Dependency Intensive Outpatient Program (CDIOP).

Objective: • To describe the role of clinical pharmacists providing

services to patients enrolled in the Chemical Dependency Intensive Outpatient Program (CDIOP).

• To improve patient outcomes through a variety of methods.

Method: Not Applicable

Result: No definitive statistical results can be measured as this was not assessed. However, patients voluntary

request pharmacy services such as answering medication-related questions and ask pharmacists to provide formal presentations on subjects such as prescription drugs, alcohol and smoking, illicit drugs, and nutrition and supplementation.

Conclusion: Chemical Dependency and Substance abuse is widespread but not limited to young adults in their teens and twenties. Pharmacists participating in multidisciplinary care setting such as the CDIOP can help patients improve compliance with their therapeutic drug plans and achieve behavioral modification leading to cessation of their chemical dependency and substance abuse. Because this practice setting is relatively new to pharmacists, the future role of pharmacists in this setting is uncertain.

Disclosure: Sai Ni Pharm D. Candidiate; JP Alonzo M. Eng, Pharm. D, Assistant Professor, Department of Pharmacy Practice have nothing to disclose.

23-sUHSSHP: Antibiotic Awareness InitiativeN Mai, K DycusnmmaiUniversity of Houston College of Pharmacy, Houston, Texas

Background: People are not always given clear and accurate information concerning appropriate antibiotic use. Such potential dangers can be avoided through the education and continual advocacy.

Objective: The objective of these antibiotic awareness projects was to establish a variety of community programs that involved student pharmacists and to raise awareness about the dangers of antibiotic resistance and the importance of appropriate antibiotic use.

Method: As part of the Antibiotic Awareness Initiative of the TSHP- Student Section Executive Committee, several events were initiated to raise community awareness. “Get Smart About Antibiotic Awareness Week” worked in conjunction with the CDC’s antibiotic awareness campaign. The week involved the use of social media, campus outreach , and a visit to Baker Ripley Charter School to raise awareness about relationships between antibiotics, germs, hand washing and flu season. Students also participated in “Germs Are Not For Sharing Presentations” at the Health Museum. Three presentations were given to over 250 people. The presentations focused on what germs are, how germs are spread, how to prevent sickness, and the importance of hand washing.

Result: The presentations facilitated the transition of student pharmacists into community-building roles. The programs

were positively received and forged solid relationships between the UHSSHP chapter and the community.

Conclusion: The programs provided student pharmacists the opportunity to educate the community about the dangers of antibiotic resistance, the need for appropriate antibiotic use, and the importance of healthcare professionals disseminating clear and accurate health information to the public.


24-sFeasibility Study of Telepharmacy Services for Small Rural Texan HospitalsKJ Walker, CA DouglasTexas A&M Health Science Center - Irma Lerma Rangel College of Pharmacy, Kingsville, Texas

Background: Small rural hospitals face limited pharmacist coverage. A mere 1.1% of hospitals, with 50 beds or less, provide 24-hour pharmacy services reducing timely pharmacist review of medication orders. Research suggests pharmacist review and other services are associated with favorable patient outcomes and are part of accreditation with larger hospitals. One solution is telepharmacy, which can provide 24-hour pharmacist services.

Objective: The aim of this study is to evaluate the feasibility of a financially sustainable telepharmacy service to improve patient safety processes at small rural Texan hospitals.

Method: This is mixed qualitative and quantitative qualitative study and the study population is 50 small rural Texan hospitals. The study will investigate key elements of a feasibility study. 1) Perceived need of pharmacy services, types of pharmacy services, and service levels. 2) Acceptance within the hospital organization, including medical, nursing, and pharmacy departments. 3) Fees, fee structure, and financial sustainability.

Result: Data collection is in progress. Preliminary results suggest a majority of physicians, nurses, and pharmacists indicated a need for telepharmacy. There is a different perception of need among the three departments depending on the specific pharmacy service.

Conclusion(s) Research is in progress and conclusions are incomplete. This study presents a broad examination of the state of pharmacy services in small rural hospital pharmacies across Texas. The knowledge gained from this study will guide the development of a telepharmacy service supporting small rural hospitals.


Disclosure(s) The authors have nothing to disclose financially or otherwise.

26-sInterim Results of a Curricular Audit of Sex and Gender Based Medicine in a Doctor of Pharmacy ProgramCT Hobart, CE Samuelson, NM Nicholson, JS Chen, SS Sankari, KA Hesch, RB SleeperTexas Tech University Health Science Center School of Pharmacy, Lubbock, TX

Background: Sex and gender based medicine (SGBM) is comprised of differences that may affect illnesses or outcomes of therapy that men and women share (“sex-inclusive”), and not just men’s or women’s health exclusively (“sex-exclusive”). Disparities in literature and patient care have led to recommendations to implement SGBM data in health professionals’ curricula; however, most programs do not map this content. This study aims to audit the SGBM data in a Pharm.D curriculum.

Objective: To report interim (Fall Semester) data describing SGBM occurrences in didactic lectures.

Method: Nine students, three from each of the first three years, served as curricular auditors. Students recorded SGBM-specific content from P1-P3 courses using standardized data forms while omitting sex-exclusive data and non-didactic content. Information was scored as “none”, “minor”, “moderate”, or “major” based on the volume or time dedicated to the material. Focus was categorized as “epidemiology”, “pathology/physiology” or “therapy”, and peer reviewed for consistency.

Result: Six hundred lectures were audited, capturing 143 occurrences of SGBM content (23.8%). Content categorized as “Minor” and “Moderate” accounted for 97.9% and 2.1% of occurrences, respectively. Focus categorized as “epidemiology”, “pathology/physiology”, or “therapeutics” accounted for 55.2%, 23.1%, and 21.7%, respectively.

Conclusion: Interim results suggest the majority of SGBM focus relates to epidemiology, with less focus on pathology/physiology and therapy. This project demonstrates curricular auditing at a granular level by students experiencing the material. The inventory captured lays a groundwork for creating targeted SGBM-inclusive content for future programs.

Disclosure: Grant support: Laura Bush Institute for Women’s Health

27-sReducing Non-ADC Missing Doses with Improved Communication Tool – A Collaborative Pharmacy/Nursing ProjectS Ogbonnaya

Background: Missing doses are a contributory factor to inefficiencies of both pharmacy and nursing staff members. Pharmacy experiences a high number of calls from nursing about the availability or unavailability of patient medications. Typically, those calls result from reluctance of nursing staff to search for the medications in the appropriate patient specific bins or the mistrust nursing has that pharmacy will deliver medications on time. Consequently, drug products that are not available in the Automated Dispensing Cabinet (ADC) may be delivered multiple times resulting in product wastage and high drug cost for the pharmacy.Objective:

• Decrease the number of missing dose calls/inquiries from nursing to pharmacy

• Establish guidelines for non-ADC medication delivery times

• Reduce waste due to duplicate medication delivery

Method:• Pharmacy and nursing collaborated to:• Asses the scope of missing doses • Use hospital approved standard administration times

to establish specific times of day when pharmacy must deliver the non-ADC medications to the unit.

• Analyze medication delivery workflow• Create a communication tool acclaimed “When To Expect

My Med”.

Result:• Data collection is ongoing. Pharmacy calls and inquiries

for missing doses to be tracked/monitored/analyzed/trended with:

• A focus on reduction in request • Nursing concerns (reluctance in searching the patient

specific bin and mistrust of pharmacy).

Conclusion: The impact of this initiative will be evaluated over a six-month period with anticipated result that less time will be spent on coordination of re-delivery effort and more time on direct patient care.

Paul F. Davis, R.Ph.Executive Director

Speaking of... (Editorial)

The Road Ahead

What a wonderful time to be entering or continuing your voyage in the world of health-system pharmacy practice.

From where I sit, the next few years are going to be as significant and revolutionary as any in the long history of pharmacy. And TSHP and our leaders are ready to help you and the profession as we travel the path.

With your help, we will:

• Determine the next level for pharmacy practice in our evolution. From ‘drug purveyors’ to ‘the basement’ to the bedside, pharmacy is prepared to expand to a greater clinical role and assume responsibility for drug therapy outcomes. What aspects of our practice act need modification? What role does reimbursement for individual services versus bundled payments play? Should any or all pharmacists be empowered to prescribe? Under protocols? Independently? Can pharmacists evolve sufficiently to become a patient activist and true clinician?

• Learn how a profession rooted in physical products and knowledge will grow as a greater understanding of gene therapy and prevention and maintenance of health replace acute care and invertentionlist therapy? As computer access and technology advance, can pharmacists find a way to utilize knowledge and communications skills to be an effective part of a true healthcare team?

• Find out how many pharmacists – and pharmacy schools – we need. Are we headed for an oversupply and falling salaries or will new roles, a growing population and the baby boomer generation’s aging and retirement create an even greater need?

• See if pharmacists who practice in an employment environment, whether a for-profit or non-profit hospital or pharmacy chain, realize the need to participate in a professional organization and the legislative or regulatory arena.

• Address the role and future of pharmacy technicians. How far can tech-check-tech take us? Is it time to turn over all dispensing duties? Are there some clinical duties that technicians could assist with? What should be the proper level of education required? Is there a place within TSHP and other pharmacy organizations to meet their needs, or do technicians need their own professional organization?

• Learn where IT and electronic health records are going to take us. First stop, everyone should have more or complete access to everything you need to know about a patient to do your job. How far off is it that monitors that you wear are keeping the physician, a nurse, you (?) in daily touch with a patient’s health. How can you move from caring for a ‘bed’ to caring for a person?

In historical terms, pharmacists have just begun to enter the emergency departments, operating rooms, transplant services, nutrition support, and patient and drug therapy management. Are you ready to directly order, accept and act on lab reports? Institute therapy based on a diagnosis?

Are you ready for the national push to require all pharmacists who have patient contact responsibilities to complete residency training? After (generally) a 4 or more year undergraduate degree, 4 years of professional school and maybe another 2 or 3 in a residency program, how much are you worth to healthcare and its payers. And will that be enough to pay off your student loans?

Pharmacists and technicians practicing in many hospitals today are working near the ‘top of their license,’ providing services and improving patient outcomes. Yet pharmacists and technicians with the same licensure and registration perform dramatically fewer services in many outpatient settings. Is it time to create a clear distinction between practice settings, so that individuals are only able to work at locations for which they are qualified? Or will the melding of practices and patient care through Accountable Care Organizations fuzz those boundaries, and will others have to step up to the plate to practice at your level? Who will help

them adapt to the changing reality they face? Who can best serve and represent their needs?

How can we get pharmacists more engaged in utilizing the existing laws and regulations that allow them to practice at a higher level? Since 1999, pharmacists in Texas have been allowed to manage drug therapy under protocols. How many are actually doing that? Since 2009 pharmacists in a hospital, hospital-based clinic, or an academic health care institution have been allowed to sign prescriptions under protocol. To date, of the over 5,000 pharmacists in Texas practicing in a health-system, there are 104 pharmacists signing prescriptions and 413 supervising physicians.

I see nothing ahead that indicates pharmacists will reverse their tendency to create and join ever-increasing specialty organizations. What role does a broad-based entity like TSHP or even ASHP have in a micro-diced world of specialization? How can a specialty which is geographically spread throughout a nation effectively communicate and meet its members’ needs? We’re only at the beginning of the “Internet Age.” Will that become tomorrow’s basis for professional discourse and meetings? Do “brick and mortar” associations even make sense anymore?

Despite the increasing health care coverage brought about by Obamacare and moving towards the day that everyone – or nearly everyone – has someone to pay the bill for them, how long will it be before the ‘next wave’ of cost reductions herald yet another ’black dawn’ for hospital practice. More salary cut backs, reductions in force increased use of automation, delegation to lesser educated and lower paid persons, reduction of support for professional training, travel and membership can’t be too far down the road for an increasingly merging healthcare system.

And – despite the current political environment – how long can the country limp along without recognizing the need for a real universal system of healthcare? Will we be once again left out of that, or only included as part of “prescription services,” or will we find the political will to stand up and make our voices heard to those who are controlling health-care – the legislators and payers?

We will continue to pursue ‘reimbursement’ and ‘provider status,’ as far as I can tell, but can we create a demand for those services? Getting the ability to bill – or more likely help reduce costs – is one thing, but do payers, employers, other providers and patients see a real value in the services? Maybe, as some have suggested, we take the approach of the “White Gloves” medical practice model, where we charge patients a separate fee directly for our clinical services.

Like Yin and Yang*, I think our future holds a blend of what some would view as ‘dark’ while at the same time blending some true ‘good light’.

A career is not unlike a roller coaster ride – at the beginning it seems like a long, slow climb and suddenly you’re shooting through your life. Those of you who are near the beginning can appreciate that analogy. But even those near the end of the ride should remember there are still bumps, curves, hills and changes in direction yet to come.

Ah, the places we’ll go, the sites we’ll see. The excitement of the ride is just beginning.

*The ancient symbol of Yin and Yang represents complementary, not opposing, forces, interacting to form a whole greater than either separate part; in effect, a dynamic system. Everything has both yin and yang aspects, (for instance shadow cannot exist without light). Either of the two major aspects may manifest more strongly in a particular object, depending on the criterion of the observation.

Yang is the white side with the dark dot on it, and yin is the dark side with the white dot on it.

The relationship between yin and yang is often described in terms of sunlight playing over a mountain and a valley. Yin (literally the ‘shady place’ or ‘north slope’) is the dark area occluded by the mountain’s bulk, while yang (literally the ‘sunny place’ or ‘south slope’) is the brightly lit portion. As the sun moves across the sky, yin and yang gradually trade places with each other, revealing what was obscured and obscuring what was revealed.

Yin-Yang*

54 TSHPJournaluVolume14 Issue3

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