Impact of a patient risk scoring tool pilot on prioritization of pharmacy-conducted medication histories.

BACKGROUND: Approximately 50-70% of patients have at least one medication discrepancy in their initial medication history. These discrepancies can lead to errors on admission and discharge orders and have the potential to cause patient harm and incur added costs associated with increased length of stay and readmission rates. Several studies have demonstrated improved medication history accuracy with pharmacy-conducted services, but variations in practice exist due to challenges with workflow and resources. OBJECTIVE: This study aims to assess the impact of implementing a patient risk scoring tool for the prioritization of medication history review by pharmacy staff. METHODS: This quasi-experimental, single-center study was conducted at a 948-bed academic medical center as a pilot study with the medication history team which consists of pharmacists and technicians in the emergency department (ED). The endpoints assessed included pharmacy completion rate of patients in the high-risk category, overall pharmacy conducted medication history rate, and the proportion of medication discrepancies identified after reconciliation. RESULTS: The number of medication histories completed by pharmacy (n=849) decreased by 5.7% in the post-intervention period (P=0.002). Between the pre- and post-intervention period, there were less low risk patients being captured by pharmacy (89.7% to 59.9%, respectively). There was also an increase in the number of medium-risk (Δ=25.4%) and high-risk patients (Δ=4.4%) being captured by pharmacy staff (P<0.017, α=0.017). CONCLUSION: Use of a risk scoring tool allowed pharmacy staff to prioritize workflow and capture more high-risk patients.

Impact of a passive clinical decision support tool on potentially inappropriate medications (PIM) use in older adult patients.

BACKGROUND: Medication related clinical decision support (CDS) interventions may improve patient safety. In older patient populations, there has been effort placed in reducing exposure to potentially inappropriate medications (PIMs). After years of reducing exposure of older adults in our hospitals to PIMs through multi-component interventions, our system chose to expand the scope and attempt a new strategy to lessen alert burden for providers and pharmacists. Based on the American Geriatric Society Beers Criteria and internal data, a passive CDS approach, termed "geriatric context" was established to recommend appropriate medication selection including lower dosage amounts and frequency of administration in older adults. METHODS: Retrospective descriptive study examining change in a pre and post implementation analysis of medication usage patterns between two 9-month time periods in 2019 and 2021 in patients age ≥65 years across an 8-hospital health system. The primary endpoint is the percentage of each medication intervened with an ordered dose and frequency outside of alignment with recommended context parameters. Secondary endpoints include total daily dose (TDD) and average dose (AD) per patient of the individual PIMs. Exploratory endpoints include frequency of active alerts fired by the CPOE and overridden by providers. RESULTS: A total of 62,738 older adult hospital admissions are included in the overall study period, with 32,969 pre-implementation and 29,769 post-implementation. Haloperidol showed the greatest reduction in inappropriate doses from 41.5% to 21.4% (p < 0.001) of orders, followed by reduction in inappropriate frequencies in orders for diphenhydramine from 57.2% to 39.7% (p < 0.001). Secondary endpoints showed favorable reductions across 11 of the 16 medications in both TDD and AD administered. Exploratory analysis with select medications showed reductions in frequency of alerts fired and overridden. CONCLUSIONS: Utilization of a passive CDS positively influences prescribing patterns for older adults and reduces the alert burden to ordering providers.

Analysis of Direct Oral Anticoagulant Therapy With Concomitant Use of Interacting Antiretroviral Agents.

Background: A theoretical interaction exists between human immunodeficiency virus (HIV) antiretroviral (ARV) agents and direct oral anticoagulants (DOACs), although the clinical significance is unclear. Objective: This study aimed to assess characteristics, prescribing patterns, and outcomes associated with concomitant therapy. Methods: A single-center, retrospective review was performed on patients older than 18 years prescribed a DOAC for any indication with concurrent interacting ARV(s) from June 2016 through June 2019. The primary endpoint was to assess prescribing and population characteristics. Secondary endpoints were to evaluate safety outcomes, DOAC level monitoring, readmissions, outpatient follow-up, and DOAC modification interventions. Results: Thirty-six patients (72 hospital admissions) were identified. The most common DOAC was apixaban (83.3%) and ARV was ritonavir (50%). Of the 72 encounters, 26 (36.1%) DOACs were dosed appropriately per guideline recommendations. Twenty pharmacy interventions for therapy modification were recognized. Eleven (30.6%) patients experienced bleeding and 2 (5.6%) thrombosis. Of the adverse events, all patients had renal impairment. Conclusions: As DOAC utilization grows, increasing use in HIV could be expected. More frequent adjustment or avoidance is recommended per guidelines. Our data suggest the majority of patients receive CYP3A4-inhibiting regimens. Caution should be employed with renal insufficiencies. Further studies are warranted to assess safety and efficacy within this population.

Alteplase for the treatment of midline catheter occlusions: a retrospective, single-cohort descriptive study.

BACKGROUND: Despite the increasing popularity of midline catheters, data on the use of alteplase for restoring midline catheter patency is scarce. AIMS: This study aimed to evaluate off-label use of alteplase for midline catheter occlusions. METHOD: Adults who received alteplase into a midline catheter between January 2015 and May 2018 within a multi-hospital health system were included in this study. The primary outcome was restoration of infusion or withdrawal function from at least one lumen of a treated midline catheter. FINDINGS: Following alteplase administration, withdrawal function was restored in 47% (25/53) of occlusion events, infusion function was restored in 65% (11/17) of complete occlusion events, and infusion or withdrawal function was restored in 58% (31/53) of occlusion events. Only 34% (17/50) of catheters were replaced because of malfunction. Local bleeding was documented in 9% (n=5) of occlusion events after alteplase administration. CONCLUSION: Most midline catheter occlusions treated with alteplase demonstrated restoration of infusion or withdrawal function.

Impact of Recent Acute Kidney Injury on Creatinine Clearance Estimation in Critically Ill Patients Undergoing Cardiac Surgery.

Acute kidney injury (AKI), often present in critically ill patients and patients with cardiac dysfunction, may alter estimates of renal function. The impact of recent AKI on the accuracy of the Cockcroft-Gault creatinine clearance equation (CG-CrCl) before cardiac surgery is unknown. This single-center, retrospective study included patients who underwent cardiac surgery from 1 January 2006 through 30 June 2012 and whose 24-hour urine creatinine clearance (24hr-CrCl) was measured in the intensive care unit before surgery. We evaluated CG-CrCl accuracy by calculating absolute differences between 24hr-CrCl and CG-CrCl estimates. Clinical impact was signified by discrepancies in United States Food and Drug Administration (FDA) renal impairment stage indicated by 24hr-CrCl versus CG-CrCl estimates. Acute kidney injury was evaluated by using Kidney Disease: Improving Global Outcomes criteria. Of 161 patients, 93 (58%) had recent AKI: stage 1, 31 (33%); stage 2, 39 (42%); and stage 3, 23 (25%). In mL/min, the CG-CrCl overestimated 24hr-CrCl (absolute difference: total, -10 ± 25; no AKI, -7 ± 26; stage 1, -8 ± 17; stage 2, -16 ± 28; and stage 3, -10 ± 26; P=0.29). Renal impairment stages assigned by CG-CrCl did not match 24hr-CrCl in 70 (43%) of the 161 patients, especially those with recent AKI: no AKI, 24/68 (35%); stage 1, 13/31 (42%); stage 2, 23/39 (59%); and stage 3, 10/23 (43%). The CG-CrCl consistently overestimated 24hr-CrCl in critically ill patients before cardiac surgery. Clinicians should use the CG-CrCl cautiously when estimating renal function and medication dosages in this population.

Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system.

PURPOSE: To describe the development of a multidisciplinary anticoagulant safety taskforce (ASTF) to address anticoagulation-related issues across the medication-use system. SUMMARY: Oral and parenteral anticoagulants have been classified as high-alert medications because of their potential for harm. Errors at the point of prescribing, monitoring, and administering therapy have been noted in safety literature. Our hospital system, which includes 1 academic medical center, 6 community hospitals, and 1 long-term care facility, designed a multidisciplinary ASTF to address anticoagulation-related issues. The ASTF used the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy as the primary tool for reviewing current practices, performing gap analyses, and identifying our greatest areas of opportunity. The top 8 best practice elements related to anticoagulant use were identified for initial efforts of ASTF activity. Meetings were led by a medication safety pharmacist who reviewed process opportunities and actions to address gaps. The hospital chief quality and patient safety officer and the vice president of quality were the executive sponsors of the ASTF. Key stakeholders such as the medication safety committee chair and the president of the medical staff were instrumental in leading the initiative. Recommendations from the ASTF were reviewed and approved by the system medication safety committee and the system pharmacy and therapeutics committee to support system-wide implementation. The ASTF accomplished more than initially planned within its first year. Error mitigation occurred through policy revisions, order set development and modification, and implementation of practice changes to comply with each best practice. The ISMP antithrombotic self-assessment score improved from 67% to 87%, surpassing the initially targeted score of 75%. To overcome implementation barriers with the electronic health record, we enlisted support from our informatics leadership to leverage information technology. Overall, the success of the taskforce was attributed to the teamwork and leadership of key individuals within the organization. CONCLUSION: Leveraging interest from key stakeholders across multiple disciplines with an established assessment tool was key in developing a productive and successful ASTF. The group came together to evaluate anticoagulant-related issues and implement sustainable changes to decrease anticoagulation error potential.

Evaluation of Neuromuscular Blockade Reversal on Postoperative Mechanical Ventilation Time in a Cardiovascular Surgery Population.

OBJECTIVE: To report on postoperative outcomes related to the administration of neostigmine for reversal of nondepolarizing neuromuscular blocking agents in cardiovascular surgery patients, with a specific focus on the duration of postoperative mechanical ventilation as the primary endpoint. DESIGN: A retrospective cohort study design was followed to achieve the study objectives. SETTING: This was a single-center, chart review study conducted at a large academic medical center of adult patients post-cardiovascular surgery. PARTICIPANTS: Patients were included if they had received a bolus dose of perioperative nondepolarizing neuromuscular blocking agent and underwent one of the targeted cardiovascular surgeries. INTERVENTIONS: Final analysis comprised of 175 patients, 95 of whom received neostigmine and 80 who did not receive neostigmine. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the duration of postoperative mechanical ventilation. When controlling for all covariates, neostigmine use was associated with a 0.34-hour reduction (∼20.4 min) in duration of mechanical ventilation (parameter estimate: 0.66, 95% confidence interval 0.49-0.89; p = 0.0071). More patients who received neostigmine met the early extubation benchmark of less than 6 hours (55 v 34 patients; p = 0.04). Finally, neostigmine use was not found to be associated with increased risk of respiratory complications or postoperative nausea and/or vomiting. CONCLUSIONS: The use of neostigmine was found to have a protective effect on the duration of postoperative mechanical ventilation without increasing the risk of adverse complications.

Evaluation of heparin induced thrombocytopenia using probability scores in a mechanical circulatory support population.

Patients on mechanical circulatory support (MCS) devices carry a high risk for thrombocytopenia and due to the routine use of heparin, heparin induced thrombocytopenia (HIT) is frequently suspected. HIT Expert Panel (HEP) and 4T scoring tools have been validated in the general medicine population to assess the probability of HIT diagnosis, however, these tests have not been validated for use in patients requiring MCS support. The objective of this study was to assess the association of 4T and HEP scores to available assess HIT diagnostic tests in patients requiring MCS. We conducted a retrospective review of patients requiring MCS who had heparin PF4 antibody optical density and/or serotonin release assay results reported. A 4T and HEP score at the time of heparin antibody ordering was calculated. Utilizing previously described ranges for HIT diagnostic tests, patients were categorized into two HIT probability categories: probable and not probable. Descriptive statistics were used for the 4T and HEP scores in both HIT probability categories and t-test and receiver operating characteristic (ROC) analysis were used to determine the association and agreement between each scoring tool and HIT probability. Eighty-five patients were identified who had HIT diagnostic tests ordered while on MCS; 7 patients were classified as HIT probable and 78 patients were classified as HIT not probable. Based on ROC analysis, 4T score and HEP score had an AUC of 0.88 (± 0.06) and 0.96 (± 0.02), respectively demonstrating high predictability of HIT. Utilizing sensitivity and specificity analysis through ROC curves, a cut off score of 3 for 4T score and 1 for HEP score was established. Based on our analysis, both 4T and HEP scores have high predictability of HIT in the mechanical circulatory support population.

Postoperative antimicrobials after lung transplantation and the development of multidrug-resistant bacterial and Clostridium difficile infections: an analysis of 500 non-cystic fibrosis lung transplant patients.

BACKGROUND: Broad-spectrum antimicrobials are given prophylactically post-transplant, although these agents are a risk factor for multidrug-resistant (MDR) infections and Clostridium difficile infection (CDI). This study aimed to determine whether an association exists between the duration of antimicrobials given early post-transplant and the development of MDR infections or CDI. METHODS: A single-center retrospective analysis was performed on lung transplants from September 2009 to August 2014. Patients were excluded for cystic fibrosis (CF) or postoperative survival less than 30 d. Qualifying infections were defined as any new positive MDR bacterial culture or C. difficile assay from postoperative day 7-90 d after a broad-spectrum antimicrobial. RESULTS: A total of 500 patients, 61% male, were identified, median age of 62 yr. MDR infections occurred in 169 (34%) and CDI in 31 (6%). Non-ICU days were associated with a decreased risk of MDR/CDI (OR 0.891, p = 0.0002), and duration of Gram-positive antimicrobials (OR 1.073, p = 0.0219) was associated with an increased risk. CONCLUSIONS: One-third (34%) of non-CF lung transplants develop MDR infections and 6% develop CDI within 90 d of postoperative antimicrobials. The duration of Gram-positive antimicrobials may increase the risk of MDR/CDI, while early transfer from the ICU may have a protective effect.

Comparison of anti-Xa and activated partial thromboplastin time monitoring for heparin dosing in patients with cirrhosis.

BACKGROUND: Cirrhosis of the liver results in complex hemostatic changes that place patients at risk for both bleeding and thrombotic events. This study evaluates the adverse effects of anticoagulation with unfractionated heparin among patients with cirrhosis and analyzes the discrepancy between anti-Xa and activated partial thromboplastin time (aPTT) values for heparin monitoring among cirrhotics. METHODS: Patients with cirrhosis receiving unfractionated heparin were matched 2:1 to patients without evidence of cirrhosis anticoagulated with unfractioned heparin. Markers of bleeding events including blood product administration and use of heparin reversal were analyzed between groups. Patients from both groups with aPTT and anti-Xa values obtained at the same time were also analyzed. RESULTS: A higher incidence of blood product administration or use of heparin reversal was observed among patients with cirrhosis [35/105 (33.3%) versus 37/210 (17.6%), P = 0.002]. This finding was consistent among those receiving anticoagulation through an established anti-Xa-based heparin dosing protocol [23/62 (37.1%) versus 25/124 (20.2%), P = 0.013]. A decrease in hemoglobin greater than 2 g/dL or a platelet decrease 50% or greater from baseline was also more frequently identified among cirrhotics when receiving heparin therapy [20/105 (19%) versus 23/210 (11%), P = 0.049 and 21/105 (20%) versus 12/210 (6%), P < 0.001, respectively]. A total of 88 correlated anti-Xa and aPTT values from 35 patients with cirrhosis demonstrated supratherapeutic aPTT values for anti-Xa levels within the therapeutic range (P < 0.001). This discrepancy was not observed among controls. CONCLUSIONS: A greater use of blood products among the cirrhotic population may indicate potential bleeding events on therapy. A discrepancy in correlated anti-Xa and aPTT values among patients with cirrhosis may explain the propensity for adverse effects. Further study is required to identify effective heparin anticoagulation monitoring strategies in liver disease.

A new epoprostenol formulation for the treatment of pulmonary arterial hypertension.

PURPOSE: The pharmacology and pharmacokinetics of a novel formulation of epoprostenol for the treatment of pulmonary arterial hypertension (PAH) are reviewed, with guidance on addressing a number of important safety considerations. SUMMARY: Epoprostenol is a direct vasodilator of the pulmonary and systemic vasculature indicated for improving exercise capacity in patients with PAH. Veletri, a recently approved formulation of epoprostenol for continuous i.v. infusion, offers increased stability relative to other available epoprostenol products. Therefore, the use of Veletri can lessen the therapy burden associated with the other available formulation of the drug by allowing for the advance preparation of infusion pump cassettes (at certain concentrations) and administration at room temperature without the need for cooling with ice packs. Sterility, however, is of concern with outpatient preparation of epoprostenol-containing cassettes stored for the maximum duration according to stability guidelines. All epoprostenol infusions are classified as high-risk therapies due to complex dosing, the drug's short half-life, and the potential for life-threatening rebound PAH with abrupt discontinuation. Adverse effects reported in ≥10% of participants in clinical trials of Veletri included flushing (58%), headache (49%), nausea or vomiting (32%), hypotension (16%), chest pain (11%), and anxiety, nervousness, or agitation (11%). As with other epoprostenol formulations, the use of Veletri requires an evaluation of health-system medication-use practices to ensure patient safety. CONCLUSION: Veletri provides an epoprostenol therapy option that reduces some of the inconveniences of the other formulation. Drug stability is dependent on cassette concentrations, which may be limited by sterility concerns with outpatient preparation. Use of this new agent within the health system requires an evaluation of practices to ensure patient safety.

A label-free immunoassay based upon localized surface plasmon resonance of gold nanorods.

Robust gold nanorod substrates were fabricated for refractive index sensing based on localized surface plasmon resonance (LSPR). The substrate sensitivity was 170 nm/RIU with a figure of merit of 1.3. To monitor biomolecular interactions, the nanorod surfaces were covered with a self-assembled monolayer and conjugated to antibodies by carbodiimide cross-linking. Interactions with a specific secondary antibody were monitored through shifts in the LSPR spectral extinction peak. The resulting binding rates and equilibrium constant were in good agreement with literature values for an antibody-antigen system. The nanorod LSPR sensors were also shown to be sensitive and specific. These results demonstrate that given a sufficiently stable nanoparticle substrate with a well defined chemical interface, LSPR sensing yields similar results to the surface plasmon resonance technique, yet with much simpler instrumentation.