Development and implementation of an in-hospital pharmacist emergency response simulation training curriculum.

BACKGROUND: Medical simulation is an effective educational tool used to increase confidence, improve knowledge, and refine skills when responding to high-acuity situations. Despite established roles of the pharmacist on the hospital code team, most institutions lack formalized pharmacist training for code team responses. OBJECTIVE: This pre-post analysis aimed to evaluate the impact of a didactic and simulation-based code response training for pharmacists on self-perceived improvement and preparedness when responding to in-hospital medical emergencies. METHODS: An emergency response curriculum (ERC) was developed for pharmacists and pharmacy residents at our institution. The curriculum, led by 4 lead clinical pharmacy specialists, included a 60-minute didactic code competency lecture followed by 2 medical emergency simulations and a debrief after each scenario. After completion of the simulation portion of the ERC, participants were given a survey to complete that assessed their confidence using a 5-point Likert scale (1 = very unconfident to 5 = very confident) in completing the course objectives before and after the ERC. RESULTS: Seventy-two pharmacists completed the ERC and 60 completed the postcourse survey. Of those who completed the postcourse survey, 70% were pharmacy residents. Using a 5-point Likert scale (1 = very unconfident to 5 = very confident), median participant confidence rose from 3 (interquartile range [IQR] 2-4) before the session to 4 (IQR 3-5) after the session (P < 0.001). Of the participants, 95% believed the ERC training should be required annually or multiple times a year and 100% of respondents felt the ERC training was beneficial. CONCLUSION: Development of a pharmacist ERC including didactic and simulation-based learning improved the confidence and preparedness of pharmacists when participating as members of the hospital code team. Future studies should continue to evaluate pharmacist training and curriculum development in code team responses.

Comparison of Early Versus Late Adjunctive Vasopressin and Corticosteroids in Patients With Septic Shock.

BACKGROUND: Vasopressin (VP) and hydrocortisone (HC) have been shown to improve outcomes in patients with septic shock. However, there is very little literature addressing the impact of the timing of the combination. OBJECTIVE: This study was conducted to evaluate the impact of early versus late initiation of both VP and HC on time to shock reversal in septic shock patients. METHODS: This was a retrospective study conducted at a tertiary academic medical center. Data were collected from system-generated reports, which were used to identify patients with septic shock who were admitted to an intensive care unit (ICU) and received both VP and HC. The primary endpoint was time to shock reversal. Patients were divided into the "early" group if both VP and HC were initiated within 12 hours of vasopressor initiation or into the "late" group if either VP or HC (or both agents) were initiated after 12 hours of vasopressor initiation. RESULTS: A total of 122 patients were included in the analysis. Early initiation was associated with a shorter time to shock reversal (34 hours vs 65 hours; P = 0.012) compared to late initiation. There were no differences in ICU length of stay, mortality, the number patients requiring renal replacement therapy, or the duration of mechanical ventilation in either group. CONCLUSION AND RELEVANCE: Our study addressed a major gap in the literature and suggests that adding the combination of VP and HC within 12 hours of septic shock may be associated with improved patient outcomes.

Prevalence, risk factors, and outcomes associated with delayed second doses of antibiotics in sepsis at a large academic medical center.

Objective: To evaluate the prevalence, risk factors, and clinical impact of delays in second doses of antibiotics in patients with sepsis. Design: Single-center, retrospective, observational study. Setting: Large teaching hospital. Patients: Adult patients who triggered an electronic sepsis alert in the emergency department (ED), received ≥2 doses of vancomycin or an antipseudomonal beta-lactam, and were discharged with an ICD-10 sepsis code. Methods: We assessed the prevalence of delays in second doses of antibiotics by ≥25% of the recommended dose interval and conducted multivariate regression analyses to assess for risk factors for delays and in-hospital mortality. Results: The cohort included 449 patients, of whom 123 (27.4%) had delays in second doses. In-hospital death occurred in 31 patients (25.2%) in the delayed group and 71 (21.8%) in the non-delayed group (p = 0.44). On multivariate analysis, only location in a non-ED unit at the time second doses were due was associated with delays (OR 2.75, 95% CI 1.20-6.32). In the mortality model, significant risk factors included malignant tumor, respiratory infection, and elevated Sequential Organ Failure Assessment (SOFA) score but not delayed second antibiotic doses (OR 1.19, 95% CI 0.69-2.05). In a subgroup analysis, delayed second doses were associated with higher mortality in patients admitted to non-intensive care units (ICUs) (OR 4.10, 95% CI 1.32-12.79). Conclusions: Over a quarter of patients with sepsis experienced delays in second doses of antibiotics. Delays in second antibiotic doses were not associated with higher mortality overall, but an association was observed among patients admitted to non-ICUs.

Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization.

BACKGROUND: Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed. OBJECTIVES: The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF). METHODS: In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee. RESULTS: Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups. CONCLUSIONS: Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.

Evaluation of Dexmedetomidine as an Adjunct to Phenobarbital for Alcohol Withdrawal in Critically Ill Patients.

INTRODUCTION: Dexmedetomidine (DEX) is commonly used with benzodiazepines for the management of alcohol withdrawal syndrome (AWS), but limited data exist regarding its use with phenobarbital (PHB). This analysis evaluated the utility of DEX in addition to PHB for AWS in adult patients admitted to the intensive care unit (ICU). METHODS: This was a single-center, retrospective cohort analysis of critically ill adult patients who received PHB plus either DEX or different adjunctive therapies (NO-DEX) for AWS between 2018 and 2021. Patients were excluded if they had underlying altered mental status or seizure disorder unrelated to AWS or received PHB at outside hospitals. Coarsened exact matching (CEM) was performed to match patients on baseline characteristics in a 1:1 ratio. The primary outcome was ICU length of stay (LOS). A multivariate linear regression analysis was performed to assess the effects of DEX on ICU LOS when accounting for confounders. Secondary outcomes included days with delirium and incidence of mechanical ventilation after PHB administration. RESULTS: Of the 606 encounters evaluated, 197 met criteria for inclusion. After CEM, 56 encounters remained in each group for analysis. The median ICU LOS was 97.2 [50.1:139.5] hours for the DEX group and 47.5 [28.8:88.1] hours for the NO-DEX group (P = .002). The multivariate linear regression analysis showed the use of DEX (P = .008) was independently associated with an increased ICU LOS by 49.8 h. The DEX group had higher rates of total delirium days (208 vs 143 days, P < .001) and a higher incidence of mechanical ventilation after PHB administration (32% vs 9%, P < .001). CONCLUSION: This analysis suggests the use of adjunctive DEX with PHB for AWS was associated with a prolonged ICU LOS. Additional studies are needed to further understand the role of adjunctive DEX in the treatment of AWS in critically ill patients.

Naloxone Versus Methylnaltrexone for Opioid-Induced Constipation in Critically Ill Patients.

BACKGROUND: Opioid-induced constipation (OIC) may occur in up to 81% of critically ill patients and can lead to many complications. Opioid antagonists are a reasonable approach and may be used for managing OIC. OBJECTIVE: The purpose of this study was to assess the efficacy of enteral naloxone (NLX) versus subcutaneous methylnaltrexone (MNTX) for the management of OIC in critically ill patients. METHODS: A retrospective analysis was conducted on adult patients who received NLX or MNTX and a continuous opioid infusion for at least 48 hours. The primary end point was time to resolution of constipation, defined as hours to first bowel movement (BM) after the first dose of an opioid antagonist. Reversal of analgesia was assessed by comparing the total number of morphine milligram equivalents (MME) 24 hours preopioid and postopioid antagonist administration. Univariate and multivariate analyses were conducted to assess treatment response within 48 hours. RESULTS: Baseline characteristics were similar between patients receiving NTX (n = 89) and MNTX (n = 71). However, the time to the first BM with NLX was 18 hours compared with 41 hours with MNTX (P = 0.004). There was no difference in MME requirements 24 hours pre/post NLX or MNTX administration. Naloxone administration was identified as a statistically significant predictor of BM within 48 hours (odds ratio [OR] = 2.68 [1.33-5.38]). CONCLUSION AND RELEVANCE: The time to first BM was shorter with enteral NLX. Both NLX and MNTX appear to be effective for the management of OIC without causing reversal of analgesia. Future controlled, prospective trials comparing these agents are warranted.

Evaluation of Rocuronium Continuous Infusion in Critically Ill Patients During the COVID-19 Pandemic and Drug Shortages.

Background: Limited data exist to support the use of rocuronium continuous infusions in the intensive care unit (ICU). Objective: To evaluate the dosing and monitoring of adult patients who received rocuronium for hypoxemic respiratory failure during the Coronavirus Disease 2019 (COVID-19) pandemic. Methods: This was a retrospective, single-center study from March 1, 2020 to May 31, 2020. We identified all adult patients admitted to any ICU who received rocuronium via continuous infusion. Patients were excluded if they received rocuronium for <6 hours. The main outcome of this study was to determine the median rocuronium maintenance continuous infusion rate in the ICU. Secondary outcomes of this study included the initial continuous infusion rate, duration of therapy, cumulative dose, frequency and median of rocuronium boluses, time to resolution of neuromuscular blockade, and the relationship between the hourly administration rates of rocuronium and train-of-four (TOF) assessments. Results: Seventy-one patients and 97 paralytic infusions were included. Fifty-nine patients (83%) were positive for SARS CoV-2. Of the 97 rocuronium infusions, the median dose at initiation was 3 (3-5) mcg/kg/min and duration of infusion was 45 (23.6-92.5) hours. The median continuous infusion maintenance rate was 4.3 (2.8-7.2) mcg/kg/min. There was a negligible correlation between the dose of rocuronium and the TOF results (r = .04). A total of 1775 TOFs were assessed, of which 46.2% were over-paralyzed, 35.7% well-paralyzed, and 18.1% under-paralyzed. Conclusions: The initial and maintenance infusion doses in our analysis were lower than what have been previously referenced.

Safety and efficacy of transitioning from intravenous to subcutaneous insulin in critically ill patients.

Background Intravenous (IV) insulin is commonly used for the management of hyperglycemia in critically ill patients. However, an assessment of real-world practices for the transition process from IV to Subcutaneous (SC) is lacking. Objective The objective of this study was to describe the real-world practice during insulin transition from IV to SC in intensive care unit (ICU) patients. Setting ICUs at a tertiary medical center. Methods This was a retrospective cohort study. Data were obtained from electronic medical records for all ICU patients for whom insulin infusions were ordered between Nov 2017-2018. Adult ICU patients were included if they were transitioned to a SC insulin regimen after spending at least 6 h on IV insulin infusion. Data collected include blood glucose readings, transition percentage, and the type of insulin regimen used after transition. Main outcome measure Assessment of the transition percentage and dysglycemic events during the insulin transition process from IV to SC. Results Two hundred patients with 4702 blood glucose checks were included. Of the included patients, 65% (130/200) were transitioned to a basal insulin-containing regimen. The median transition percentage in those patients was 45% [IQR: 28 - 69]. In the overall cohort, the number of patients who developed moderate and severe hypoglycemia was significantly higher prior to transition, while hyperglycemia was significantly higher after insulin transition. Conclusion We observed that patients were converted to SC therapy using a lower transition percentage than previously described. More data are needed to optimize the transition process in critically ill patients.

Evaluating the Safety of Continuous Infusion Lidocaine for Postoperative Pain.

OBJECTIVES: The aim was to evaluate the safety of intravenous lidocaine for postoperative pain and the impact on opioid requirements and pain scores. MATERIALS AND METHODS: This was a single-center, retrospective, single-arm analysis of adult patients who received intravenous lidocaine for postoperative pain from January 2016 to December 2019. Patients were excluded if they received lidocaine for any indication other than pain or if lidocaine was only given intraoperatively. The primary outcome of this analysis was to determine the incidence of adverse effects (AEs) and the reason for discontinuation of lidocaine. Secondary outcomes included median daily pain scores (visual analog scale and Critical-Care Pain Observation Tool) and opioid consumption (daily morphine milligram equivalents) 24 hours before infusion and during day 1. RESULTS: A total of 452 patients were evaluated of which 298 (65.9%) patients met inclusion criteria. Of the 154 patients excluded, 153 did not receive lidocaine postoperatively. The median duration of infusion was 34 [20:48] hours with a median initial and maintenance rate of 1 mg/kg/h dosed on ideal body weight. In our analysis, 174 (58.4%) patients had a documented AE during infusion and 38 (12.8%) had lidocaine discontinued because of an AE. The most common AE was nausea in 62 (20.8%) patients and the most common reason for discontinuation was confusion in 8 (2.7%) patients. Daily morphine milligram equivalents (P<0.001) and visual analog scale (P<0.001) significantly decreased when comparing 24 hours before infusion and day 1. CONCLUSION: Although a majority of patients receiving lidocaine for postoperative pain experienced an AE, this did not result in discontinuation in most patients.

Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study.

AIMS: Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. METHODS AND RESULTS: Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, ß-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events. CONCLUSIONS: Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.

Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon.

BACKGROUND: An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. OBJECTIVE: To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). METHODS: This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. RESULTS: No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. CONCLUSION AND RELEVANCE: Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.

Evaluation of Hypertriglyceridemia in Critically Ill Patients With Coronavirus Disease 2019 Receiving Propofol.

OBJECTIVES: To report the prevalence of, and evaluate risk factors for, the development of hypertriglyceridemia (defined as a serum triglyceride level of > 400 mg/dL) in patients with coronavirus disease 2019 who received propofol. DESIGN: Single-center, retrospective, observational analysis. SETTING: Brigham and Women's Hospital, a tertiary academic medical center in Boston, MA. PATIENTS: All ICU patients who with coronavirus disease 19 who received propofol between March 1, 2020, and April 20, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The major outcome of this analysis was to report the prevalence of, and risk factors for, the development of hypertriglyceridemia in patients with coronavirus disease 19 who received propofol. Minor outcomes included the development of acute pancreatitis and description of propofol metrics. Of the 106 patients that were included, 60 (56.6%) developed hypertriglyceridemia, with a median time to development of 46 hours. A total of five patients had clinical suspicion of acute pancreatitis, with one patient having confirmatory imaging. There was no difference in the dose or duration of propofol in patients who developed hypertriglyceridemia compared with those who did not. In the patients who developed hypertriglyceridemia, 35 patients (58.5%) continued receiving propofol for a median duration of 105 hours. Patients who developed hypertriglyceridemia had elevated levels of inflammatory markers. CONCLUSIONS: Hypertriglyceridemia was commonly observed in critically ill patients with coronavirus disease 2019 who received propofol. Neither the cumulative dose nor duration of propofol were identified as a risk factor for the development of hypertriglyceridemia. Due to the incidence of hypertriglyceridemia in this patient population, monitoring of serum triglyceride levels should be done frequently in patients who require more than 24 hours of propofol. Many patients who developed hypertriglyceridemia were able to continue propofol in our analysis after reducing the dose.

Safety of Intravenous Olanzapine Administration at a Tertiary Academic Medical Center.

BACKGROUND: Although approved by the Food and Drug Administration for intramuscular administration only, analyses have described the administration of intravenous push (IVP) olanzapine, particularly for acute agitation. The safety and efficacy of IVP olanzapine has mostly been limited to emergency department patients. OBJECTIVE: To evaluate the safety of IVP olanzapine administration in the inpatient setting. METHODS: This single-center, retrospective analysis was conducted between July 1, 2018, and December 31, 2019, at Brigham and Women's Hospital in Boston, Massachusetts. Adult patients who received at least 1 dose of IVP olanzapine were included in the analysis. Safety endpoints analyzed included the following adverse drug events (ADEs): hypotension, bradycardia, cardiac arrhythmias, extrapyramidal adverse effects, and respiratory depressive events. Data on IV site reactions, including phlebitis and infiltration, were also collected. RESULTS: A total of 1,247 IVP administrations of olanzapine were identified across 252 patients. Two or more doses were received by 159 patients (63.1%). Most administrations (66%) took place in intensive care units, with 33% administered on general medicine wards. Overall, 104 administrations (8.3%) were associated with at least 1 ADE. Hypotension and bradycardia occurred in 62 (5.2%) and 16 (1.3%) administrations, respectively. Phlebitis occurred with 8 administrations (1.4%). All other adverse events were rare (<1%). CONCLUSION AND RELEVANCE: Hypotension, the most commonly noted ADE, occurred more frequently than in previous studies. IVP olanzapine appears to be a safe route of administration in hospitalized patients, including those receiving multiple doses. Further studies are required to evaluate the effect of IV olanzapine on hemodynamics.

The Incidence of Propofol-Induced Hypertriglyceridemia and Identification of Associated Risk Factors.

OBJECTIVES: The objective of this study was to describe the incidence of propofol-induced hypertriglyceridemia and the risk factors associated with hypertriglyceridemia in mechanically ventilated ICU patients while receiving propofol. DESIGN: This was a single-center case-control study. SETTING: Brigham and Women's Hospital, a tertiary academic medical center in Boston, MA. SUBJECTS: Adult ICU patients who received continuous infusion propofol for at least 24 hours from May 1, 2019, to December 31, 2019, were included. Patients were excluded if they were diagnosed with acute pancreatitis upon admission or did not have any serum triglyceride levels evaluated during propofol administration. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The major outcome was the incidence and risk factors associated with the development of propofol-induced hypertriglyceridemia, defined as triglyceride level greater than or equal to 400 mg/dL. Minor outcomes included the prevalence of acute pancreatitis. A hybrid multivariate logistic regression analysis was used to evaluate the relation between individual risk factors and the dependent variable of hypertriglyceridemia. During the study period, 552 patients were evaluated for inclusion, of which 136 were included in the final analysis. A total of 38 patients (27.9%) developed hypertriglyceridemia with a median time to hypertriglyceridemia of 47 hours. The only significant independent risk factor for development of hypertriglyceridemia identified was the cumulative propofol dose (odds ratio, 1.04; 95% CI, 1.01-1.08; p = 0.016). Two of the 38 hypertriglyceridemia patients (5.3%) were diagnosed with acute pancreatitis. CONCLUSIONS: In our analysis, approximately one third of patients developed hypertriglyceridemia with cumulative propofol dose identified as a significant predictor of the development of hypertriglyceridemia. Despite a high incidence of hypertriglyceridemia, a significant number of patients continued propofol therapy, and a relatively low prevalence of pancreatitis was observed. Future analyses are warranted to further investigate these results.

Comparison of Positive Inotropic Agents in the Management of Acute Decompensated Heart Failure.

Current guidelines recommend the consideration of positive inotropes in patients with acute decompensated heart failure (ADHF) who have low cardiac index and evidence of systemic hypoperfusion or congestion. However, there is no evidence detailing the first line agent for the management of ADHF. The purpose of this study was to compare the safety and efficacy of dobutamine to milrinone for the treatment of ADHF. This was a single-center, retrospective study at a tertiary academic medical center, approved by Partner's Health Care Institutional Review Board. Patients included in this study were those admitted with ADHF who received dobutamine or milrinone from June 2015 to July 2017. A total of 95 dobutamine and 40 milrinone patients were included in the analysis. Median hospital length of stay was 12 days in the dobutamine group versus 10 days in the milrinone group (P = 0.34). Rehospitalization within 30 days occurred in 29.5% of patients in the dobutamine group versus 17.5% of patients in the milrinone group (P = 0.15). Median intensive care unit length of stay was 4.5 days in the dobutamine group versus 10 days in the milrinone group (P < 0.01). All other minor end points including all-cause mortality, progression to renal failure within 72 hours, rehospitalization in 90 days, and urine output within 72 hours of therapy were not found to be statistically significant. In addition, a post hoc analysis compared major and minor outcomes between milrinone and dobutamine using linear and logistic regression with adjustment for baseline characteristics. There were not any statistically significant findings in the post hoc analysis. Overall, there were no statistically significant differences in outcomes between the 2 groups other than longer intensive care unit length of stay in the milrinone group.

Evaluation of a Clinical Pharmacist-Led Automated Dispensing Cabinet Stewardship Program at a Tertiary Academic Medical Center.

BACKGROUND: There is little guidance regarding the best methodology or frequency to optimize automated dispensing cabinets. Clinical pharmacists are in the unique position to make decisions regarding automated dispensing cabinet inventory to best serve their specific patient population. OBJECTIVE: The purpose of this evaluation was to determine if automated dispensing cabinet optimization by clinical pharmacists would affect the number of dispenses from central pharmacy, number of stockouts, and inventory cost. METHODS: A retrospective analysis was completed to evaluate the quantity of medications dispensed from a central pharmacy department over 2 separate 2-month periods, with optimization of automated dispensing cabinets occurring in between. The differences in quantity of medications dispensed and redispensed, as well as the number of stockouts and inventory cost on all automated dispensing cabinets, were compared pre- and postintervention. RESULTS: There were 1132 medication additions, 262 medication removals, and 167 medication par level adjustments. Medications dispensed from central pharmacy were decreased by 12% from the preintervention group to the postintervention group. The number of stockouts per cabinet per day also decreased from 0.75 to 0.61 in the pre- and postintervention groups, respectively. The inventory-at-par cost level was decreased by 15%. CONCLUSION AND RELEVANCE: Automated dispensing cabinet optimization by clinical pharmacists led to increased medication availability on inpatient units and decreased the number of dispenses from central pharmacy. Simple yet meaningful interventions can be taken to improve multiple medication distribution metrics simultaneously.

Evaluation of the Effect of Apixaban on INR in the Inpatient Population.

Direct oral anticoagulants (DOACs), particularly direct factor Xa inhibitors, have been associated with prolongation of the prothrombin time and the international normalized ratio (INR). Although DOACs do not require monitoring, elevations in the INR have been reported in in vitro and observational studies. The literature surrounding the extent of elevation and the clinical significance is limited. The objective of this study was to quantify the degree of INR elevation in hospitalized patients receiving apixaban. This was a single-center, retrospective, observational analysis of adult patients who received at least 1 dose of apixaban during their hospital admission and had at least 1 INR sample collected prior to and following administration. The major end point of this study was to characterize the effect of apixaban on the INR by determining the percentage of patients with an INR higher than our laboratory defined normal (defined as INR > 1.1). Minor end point outcomes included the incidence of an INR increase >0.3 from baseline INR and additional patient-specific factors that may influence INR elevation. Seventy-nine patients were included in the analysis. On day 1 of therapy, the median (interquartile range, IQR) INR was 1.4 (1.3:1.6) with 84.5% of patients having an elevated INR. The median (IQR) INR increased to 1.5 (1.4:1.6) and 1.7 (1.5:1.9) on day 4 and day 7, respectively. Of patients whose INR increased by more than 0.3, the median (IQR) change in INR from baseline was 0.5 (0.4:0.6). Apixaban is associated with a notable increase in INR in hospitalized patients, although it is not clear the clinical impact of the increase. Although literature does not support monitoring INR as a marker of apixaban activity, it is important for clinicians to understand the association apixaban has on the INR to avoid inappropriate interpretation of routine coagulation assays.

The Role of Double and Triple Therapy with Direct Oral Anticoagulants in Coronary Artery Disease, Peripheral Artery Disease, and Stroke.

PURPOSE: Combining antiplatelet and anticoagulant therapy is often necessary in clinical practice. However, there is limited literature on tolerability and efficacy for triple therapy with the newer direct oral anticoagulants (DOACs). The objective of this study is to characterize the discharge prescribing practice of double versus triple antithrombotic therapy with a DOAC at a large, tertiary academic medical center. METHODS: In this retrospective, cross-sectional, observational study, patients were identified if they had received any combination of a DOAC, aspirin, and a P2Y12 inhibitor during an admission at our institution from June 1, 2015, to May 31, 2016. Patients were included in the analysis if they had any indication for anticoagulation and antiplatelet therapies and were discharged from the hospital with prescriptions for a DOAC and single or dual antiplatelet agents (aspirin and/or P2Y12 inhibitor). Patients were excluded if they had an unclear indication for antiplatelet therapy. Patient characteristics and 6-month efficacy and tolerability outcomes were collected via review of the electronic medical record. FINDINGS: A total of 367 patients were included in this analysis. Most patients at our institution who required both antiplatelet and anticoagulant agents were discharged on a regimen of aspirin and a DOAC. Patients across all groups most commonly received antiplatelet therapy for coronary artery disease and acute coronary syndrome-related events, whereas they received anticoagulation for stroke prophylaxis in atrial fibrillation. Within 6 months of discharge, there were 16 bleeding-related readmissions in the DOAC-aspirin group, 1 in the DOAC-P2Y12 group, and 0 in the triple therapy group. IMPLICATIONS: This analysis found that varying combinations of antiplatelet agents and anticoagulants are used, depending on clinical indications. Further studies are needed that focus on patients with indications for dual antiplatelet therapy and anticoagulation to compare double and triple therapy strategies for efficacy and bleeding risk.