Evaluation of a Pharmacist-Led Implementation of Standardized Medication Administration Times for Inpatients Receiving Hemodialysis.

BACKGROUND: Missed medication doses are a common and often preventable medication-related error that have been associated with an increased length of stay and mortality. Hemodialysis is a common, relatively predictable reason that patients are unavailable, resulting in missed doses. OBJECTIVE: To evaluate the implications of a pharmacist-led intervention to standardize the medication administration times for patients requiring hemodialysis who were prescribed antihypertensives, antiepileptics, apixaban, and/or antimicrobials. METHODS: A retrospective preanalysis and postanalysis of a pharmacist-led intervention were performed at a single-center, safety net hospital. Patients receiving dialysis and prescribed one of the targeted medications were included. The primary endpoint was the composite of missed and delayed doses. RESULTS: A total of 25 patients receiving 126 dialysis sessions in the preintervention group and 29 patients receiving 80 dialysis sessions in the postintervention group were included for analysis. For the primary endpoint, 118 (18%) versus 57 (9.3%) doses were missed or delayed in the preintervention versus postintervention group, respectively (P < 0.001). The primary endpoint was driven by fewer delayed doses in the postgroup. The number of antimicrobials given on a correct schedule increased in the postintervention group (98.3% vs 99.1%, P = 0.044). CONCLUSION AND RELEVANCE: A pharmacist-led intervention for standard medication administration times in patients requiring hemodialysis increased the number of prescribed medication doses given and given on time. The intervention also led to more antimicrobials administered at appropriate times relative to dialysis sessions.

A Multisite Retrospective Study Evaluating the Implementation of the Pasero Opioid-Induced Sedation Scale (POSS) and Its Effect on Patient Safety Outcomes.

The Joint Commission recommended the Pasero Opioid-induced Sedation Scale (POSS) to minimize opioid-induced respiratory depression. However, there is a paucity of data describing its impact on patient safety. This study assessed the impact of POSS implementation or reeducation on naloxone use in patients receiving hydromorphone. This retrospective, Institutional Review Board-approved study performed with the Indianapolis Coalition for Patient Safety was conducted in two phases, 3 months before and after intervention. The intervention was POSS implementation or reeducation at six sites in a variety of practice settings. A total of 212 patients were evaluated. For the primary endpoint, naloxone use occurred in 1.9% of patients in each group and occurred in 3.1 versus 3.5 patients per 1,000 patient days pre- versus postintervention (p = .902). For secondary endpoints, POSS documentation increased post- versus preintervention, 78.1% versus 26.4% (p < .001). More patients experienced unintended sedation based on the Richmond Agitation and Sedation Scale or POSS post- versus preintervention, 12.2% versus 3.8% (p = .04). When the POSS was used, unintended sedation was likely detected before respiratory depression occurred and before naloxone was required. The lack of change in naloxone use and increased sedation postintervention may reflect that a POSS score 3 or 4 is a better marker of unintended sedation and should be considered as an endpoint instead of naloxone in future studies. The implementation or reeducation of the POSS at six area health-systems resulted in increased documentation of POSS and opioid-induced unintended sedation detection with no change in naloxone use.

Deprescribing opportunities for elderly inpatients in an academic, safety-net health system.

BACKGROUND: Deprescribing is one way to reduce inappropriate polypharmacy in older adult patients. Although algorithms have been published to guide practitioners in deprescribing, it is still unknown how applicable these algorithms are to the general older adult population. OBJECTIVES: The primary objective was to assess the applicability of published deprescribing protocols in hospitalized older adult patients. METHODS: This retrospective study included patients aged 65 years or greater who were discharged from an internal medicine team between January 1, 2017 and June 30, 2017. Along with age and admission to internal medicine wards, other eligibility criteria were extracted from published deprescribing protocols. The primary endpoint was the proportion of patients eligible for deprescribing based on published algorithms. Secondary endpoints included the proportion of patients receiving medications which were included in an algorithm, proportion of patients using medications included in the algorithms who were eligible for deprescribing, and proportion of patients with medications deprescribed during the hospital stay. RESULTS: Two hundred sixty-seven patients were included and 124 (46.4%) used a medication with a published deprescribing algorithm. Thirty-four percent of all patients and 74% (92/124) of patients prescribed medications included in algorithms were eligible for deprescribing. Seven percent (6/92) of patients eligible for deprescribing had medications deprescribed during the hospital stay. CONCLUSION: The application of deprescribing algorithms in hospitalized older adults identified a significant opportunity to initiate deprescribing practices.

Developing brokered community transportation for seniors and people with disabilities.

Communities are exploring ways to increase transportation coordination to improve access for seniors. One such effort is a brokered transportation system in which one agency serves as the central point of contact for ride information or actually arranging transportation for clients of multiple programs by use of a combination of transportation services. A team of social work faculty and students from the University of New Hampshire (UNH) Social Work Outreach Center, a center that provides service learning opportunities to students, collaborated with a local coalition to investigate the specific transportation needs of the region's senior citizens. A total of 641 people participated in the survey. Results indicate that the study population experiences problems reliably meeting daily living needs due to inconsistent or unavailable private and public transportation options. Study findings also indicate the promising potential of brokered transportation systems, particularly for isolated seniors in rural and suburban areas with relatively limited public and private transportation options.

STRmix™ collaborative exercise on DNA mixture interpretation.

An intra and inter-laboratory study using the probabilistic genotyping (PG) software STRmix™ is reported. Two complex mixtures from the PROVEDIt set, analysed on an Applied Biosystems™ 3500 Series Genetic Analyzer, were selected. 174 participants responded. For Sample 1 (low template, in the order of 200 rfu for major contributors) five participants described the comparison as inconclusive with respect to the POI or excluded him. Where LRs were assigned, the point estimates ranging from 2 × 104 to 8 × 106. For Sample 2 (in the order of 2000 rfu for major contributors), LRs ranged from 2 × 1028 to 2 × 1029. Where LRs were calculated, the differences between participants can be attributed to (from largest to smallest impact): This study demonstrates a high level of repeatability and reproducibility among the participants. For those results that differed from the mode, the differences in LR were almost always minor or conservative.

Implementation and Preliminary Clinical Outcomes of a Pharmacist-managed Venous Thromboembolism Clinic for Patients Treated With Rivaroxaban Post Emergency Department Discharge.

OBJECTIVE: The objective was to describe the implementation, work flow, and differences in outcomes between a pharmacist-managed clinic for the outpatient treatment of venous thromboembolism (VTE) using a non-vitamin K oral anticoagulant versus care by a primary care provider (PCP). METHODS: Patients in the studied health system that are diagnosed with low-risk VTE in the emergency department are often discharged without hospital admission. These patients are treated with a non-vitamin K oral anticoagulant and follow-up either in a pharmacist-managed VTE clinic or with their PCP. Pharmacists in the VTE clinic work independently under a collaborative practice agreement (CPA). An evaluation of 34 patients, 17 in each treatment arm, was conducted to compare the differences in treatment-related outcomes of rivaroxaban when managed by a pharmacist versus a PCP. RESULTS: The primary endpoint was a 6-month composite of anticoagulation treatment-related complications that included a diagnosis of major bleeding, recurrent thromboembolism, or fatality due to either major bleeding or recurrent thromboembolism. Secondary endpoints included number of hospitalizations, adverse events, and medication adherence. There was no difference in the primary endpoint between groups with one occurrence of the composite endpoint in each treatment arm (p = 1.000), both of which were recurrent thromboembolic events. Medication adherence assessment was formally performed in eight patients in the pharmacist group versus no patients in the control group. No differences were seen among other secondary endpoints. CONCLUSIONS: The pharmacist-managed clinic is a novel expansion of clinical pharmacy services that treats patients with low-risk VTEs with rivaroxaban in the outpatient setting. The evaluation of outcomes provides support that pharmacist-managed care utilizing standardized protocols under a CPA may be as safe as care by a PCP.

Permeabilization activated reduction in fluorescence: A novel method to measure kinetics of protein interactions with intracellular structures.

Understanding kinetic information is fundamental in understanding biological function. Advanced imaging technologies have fostered the development of kinetic analyses in cells. We have developed Permeabilization Activated Reduction in Fluorescence (PARF) analysis for determination of apparent t1/2 and immobile fraction, describing the dissociation of a protein of interest from intracellular structures. To create conditions where dissociation events are observable, cells expressing a fluorescently-tagged protein are permeabilized with digitonin, diluting the unbound protein into the extracellular media. As the media volume is much larger than the cytosolic volume, the concentration of the unbound pool decreases drastically, shifting the system out of equilibrium, favoring dissociation events. Loss of bound protein is observed as loss of fluorescence from intracellular structures and can be fit to an exponential decay. We compared PARF dissociation kinetics with previously published equilibrium kinetics as determined by FRAP. PARF dissociation rates agreed with the equilibrium-based FRAP analysis predictions of the magnitude of those rates. When used to investigate binding kinetics of a panel of cytoskeletal proteins, PARF analysis revealed that filament stabilization resulted in slower fluorescence loss. Additionally, commonly used "general" F-actin labels display differences in kinetic properties, suggesting that not all fluorescently-tagged actin labels interact with the actin network in the same way. We also observed differential dissociation kinetics for GFP-VASP depending on which cellular structure was being labeled. These results demonstrate that PARF analysis of non-equilibrium systems reveals kinetic information without the infrastructure investment required for other quantitative approaches such as FRAP, photoactivation, or in vitro reconstitution assays. © 2016 Wiley Periodicals, Inc.