Development and Implementation of a Combined Master of Science and PGY1/PGY2 Health-System Pharmacy Administration Residency Program at a Large Community Teaching Hospital.

Purpose: The purpose of this article is to share experiences after the development of a health-system pharmacy administration residency with a MS degree and express the need for additional programs in nonacademic medical center health-system settings. Summary: Experiences with the development and implementation of a health-system pharmacy administration residency at a large community teaching hospital are described. Resident candidates benefit from collaborations with other health-systems through master's degree programs and visibility to leaders at your health-system. Programs benefit from building a pipeline of future pharmacy administrators and by leveraging the skills of residents to contribute to projects and department-wide initiatives. Tools to assist in the implementation of a new pharmacy administration program are also described and include rotation and preceptor development, marketing and recruiting, financial evaluation, and steps to prepare for accreditation. Conclusion: Health-system pharmacy administration residents provide the opportunity to build a pipeline of high-quality leaders, provide high-level project involvement, and produce a positive return on investment (ROI) for health-systems. These programs should be explored in academic and nonacademic-based health-systems.

Multimodal Analgesia and Opioid Use in Critically Ill Trauma Patients.

BACKGROUND: Opioids are the mainstay of pain management in critically ill trauma patients. However, the risks of opioid use mandate a different approach. Multimodal analgesia employs a combination of opioid and nonopioid agents using different mechanisms that have synergistic effects in treating pain. This study examines the effects of multimodal analgesia on the opioid requirements of critically ill trauma patients. STUDY DESIGN: This was a pre-post cohort study of adult trauma ICU patients before and after implementation of a multimodal pain management order set. Patients were excluded if their hospital stay was less than 5 days, head Abbreviated Injury Scale score was greater than 1, or pre-injury medications included methadone or buprenorphine. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period on days 2 through 5 of admission and the last 24 hours before discharge using standardized ratios. The primary endpoint was cumulative OME doses over the second through fifth days of admission. RESULTS: There were 65 patients in the pre-group and 62 in the post-group. Median cumulative OME dose was significantly lower in the post-group (125.6 mg, interquartile range [IQR] 45.0 to 415.0 mg) compared with the pre-group (481.5 mg, IQR 174.8 to 881.3 mg), p < 0.001. Patients who received 3 or more multimodal agents had a lower cumulative OME dose (116.3 mg, IQR 52.5 to 496.5 mg) compared with those who were on 1 to 2 multimodal agents (363 mg, IQR 115.5 to 743 mg) or 0 multimodal agents (479 mg, IQR 185 to 736.5 mg), p = 0.024. There were no differences between pre-group and post-group mean pain scores on hospital day 5 (4.48 ± 0.34 vs 3.50 ± 0.38, p = 0.058) or at hospital discharge (3.43 ± 0.34 vs 3.56 ± 0.32, p = 0.789). CONCLUSIONS: Implementation of a multimodal pain management strategy significantly reduced opioid use in critically ill trauma patients without compromising patient comfort.

Clinical Outcomes and Sustainability of Using CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention.

BACKGROUND: CYP2C19 loss-of-function (LOF) alleles impair clopidogrel effectiveness after percutaneous coronary intervention. The feasibility, sustainability, and clinical impact of using CYP2C19 genotype-guided dual antiplatelet therapy (DAPT) selection in practice remains unclear. METHODS: A single-center observational study was conducted in 1193 patients who underwent percutaneous coronary intervention and received DAPT after implementation of an algorithm that recommends CYP2C19 testing in high-risk patients and alternative DAPT (prasugrel or ticagrelor) in LOF allele carriers. The frequency of genotype testing and alternative DAPT selection were the primary implementation end points. Risk of major adverse cardiovascular or cerebrovascular and clinically significant bleeding events over 12 months were compared across genotype and DAPT groups by proportional hazards regression. RESULTS: CYP2C19 genotype was obtained in 868 (72.8%) patients. Alternative DAPT was prescribed in 186 (70.7%) LOF allele carriers. CYP2C19 testing (P<0.001) and alternative DAPT use in LOF allele carriers (P=0.001) varied over time. Risk for major adverse cardiovascular or cerebrovascular was significantly higher in LOF carriers prescribed clopidogrel versus alternative DAPT (adjusted hazard ratio, 4.65; 95% confidence interval, 2.22-10.0; P<0.001), whereas no significant difference was observed in those without a LOF allele (adjusted hazard ratio, 1.37; 95% confidence interval, 0.72-2.85; P=0.347). Bleeding event rates were similar across groups (log-rank P=0.816). CONCLUSIONS: Implementing CYP2C19 genotype-guided DAPT is feasible and sustainable in a real-world setting but challenging to maintain at a consistently high level of fidelity. The higher risk of major adverse cardiovascular or cerebrovascular associated with clopidogrel use in CYP2C19 LOF allele carriers suggests that use of genotype-guided DAPT in practice may improve clinical outcomes.