Preeyaporn Sarangarm

Impact of Pharmacist Discharge Medication Therapy Counseling and Disease State Education Pharmacist Assisting at Routine Medical Discharge (Project PhARMD)

Many patients experience adverse events after discharge; numerous are medication related and preventable. The objective of this study is to evaluate the impact of pharmacist medication counseling and disease education at discharge. Pharmacist Assisting at Routine Medical Discharge is a prospective study of English- or Spanish-speaking adults discharged from internal medicine. Control patients received usual hospital discharge care; intervention patients received usual care with discharge counseling and a follow-up phone call. Evaluated outcomes included the following: 30-day hospital reutilization (combined readmissions/emergency department visits), pharmacist interventions, predictors for hospital utilization, patient satisfaction, and primary medication adherence. In all, 279 patients were enrolled: 139 in the control and 140 in the intervention group. Pharmacists made 198 interventions. The rate of hospital reutilization was 20.7% and similar between the intervention and control groups. Patients receiving the pharmacist intervention demonstrated improved primary medication adherence and increased patient satisfaction. Pharmacist-provided discharge counseling resulted in medication interventions, improved patient satisfaction, and increased medication adherence.

On-site pharmacists in the ED improve medical errors

OBJECTIVE The objective of the study was to compare errors in the emergency department (ED) with pharmacists present (PPs) for resuscitations and traumas vs with pharmacists absent (PAs). Our hypothesis was that errors would be significantly fewer during PP than PA times. We also hypothesized that times with PP would affect patients greater when disposition was to more critical areas (intensive care unit, or ICUs). METHODS The study was conducted during a 3-month period in 2009 in a level 1 trauma center with an emergency medicine residency. This was a cross-sectional cohort study comparing a prospective analysis of patients during the time (10 hour/day) with PP and a retrospective review of the time on the same days (14 hours/day) with PA. Demographics of age, race, and sex were recorded. Patient disposition was either ICU, operating room, non-ICU wards, observation unit, or discharge. Main outcome was errors recorded including medications given but not ordered, medication ordered but not given, and time delays for medications. For demographics and prevalence, descriptive statistics and percentages were used. Percent differences and 95% confidence intervals (CIs) and χ2 were derived. Logistic regression used predictor variables of age, race, sex, disposition, and presence or absence of pharmacists. An a priori power analysis was performed. The study was powered at 80% with 186 subjects per group (PP vs PA), to find a difference of 20% between the 2 groups in percent of medical errors. RESULTS There were 694 patients included in the 3-month period. A total of 242 presented during PP times and 452 during PA times. There were 383 (55%) male, 301 (43%) female, and 10 (2%) unknown sex. Mean age was 45±18 years in PP group and 48±20 years in PA group (P, nonsignificant). There was no difference in ethnicity between groups. There were 6 (3%) patients with errors recorded during PP times and 137 (30%) with errors recorded during PA times (difference, 27%; 95% CI, 23-32). Controlling for age, race, sex, and disposition, medical errors were 13.5 times more likely during PA than during PP times (adjusted odds ratio, 13.5; 95% CI, 5.7-31.9). CONCLUSION With pharmacists absent, over 13 times more errors are recorded in our ED than with pharmacists present. An on-site pharmacist in the ED may be helpful in reducing medical errors.

The effect of prenatal alcohol co-exposure on neonatal abstinence syndrome in infants born to mothers in opioid maintenance treatment

Abstract Objective: This study examined the effects of prenatal alcohol exposure (PAE) on the incidence and severity of neonatal abstinence syndrome (NAS). Study design: For this pilot study, 70 pregnant women on opioid maintenance therapy (OMT) were recruited from a perinatal substance abuse clinic. Subjects were categorized into three study groups based on the timing of alcohol use during pregnancy as assessed by repeated self-reported measures and a comprehensive panel of ethanol biomarkers. NAS outcomes included: duration of hospital stay, the need for pharmacological treatment of NAS, newborn age at the initiation of NAS treatment, duration of treatment and cumulative methadone dose administered. Results: The study included a large proportion of ethnic minorities (81.4% Hispanic, 5.7% American Indian), women with less than a high school education (52.2%) and unplanned pregnancy (82.9%). In multivariate analysis, PAE was not associated with NAS outcomes; however, one newborn diagnosed with fetal alcohol syndrome (FAS) demonstrated much more severe NAS compared to other PAE infants. Interestingly, 3rd trimester PAE was associated with a higher prevalence of microcephaly (62.5%) compared to the PAE abstaining group (36.8%; p = 0.08). Conclusion: In this study, PAE was not associated with NAS severity; however, further examination in a larger study is needed.

Effect of Intravenous Acetaminophen on Postoperative Opioid Consumption in Adult Orthopedic Surgery Patients.

Background Postoperative pain is managed with opioids, which are associated with adverse effects. The efficacy of intravenous (IV) acetaminophen in reducing opioid consumption has been studied with inconsistent results. The primary outcome of this study was to assess the effect of IV acetaminophen on opioid consumption 24 hours postoperatively. Secondary outcomes included the opiate consumption at 48 hours after the operation, opioid-related side effects 72 hours after the operation, discharge disposition, and length of stay. Methods This was an IRB-approved, retrospective cohort study including adult patients who underwent an elective total knee arthroplasty (TKA). Patients were stratified into IV and no IV acetaminophen groups; patients who had received at least one dose of IV acetaminophen were included in the IV acetaminophen group. Total opioids were collected, converted to morphine equivalents, and compared between groups. Patients were excluded for alcohol abuse, substance abuse treatment, non-elective TKA, or medication mischarting. Results Of the 161 patients evaluated, 148 patients were included: 86 in the IV acetaminophen and 62 in the no IV acetaminophen group. There were no differences in mean morphine equivalents between groups postoperatively at 24 hours (54.2 ± 35.9 mg vs 45.4 ± 30.2 mg; p = .12) and 48 hours (99.2 ± 68.7 mg vs 79.5 ± 49.1 mg; p = .06). There were no differences in secondary outcomes (administration of bowel regimen medications, antiemetics, naloxone, discharge disposition, or length of stay) between the groups. Conclusion The use of IV acetaminophen was not associated with a decrease in opiate use, opiate-related side effects, or any secondary outcomes in patients who underwent TKA.

Impact of an emergency medicine pharmacist on antibiotic dosing adjustment

OBJECTIVE Overall medication-related errors in the emergency department (ED) are 13.5 times more likely to occur in the absence of an emergency medicine pharmacist (EMP). Although the effectiveness of pharmacist-driven renal dosing adjustment has been studied in the intensive care unit, data are lacking in the ED setting. The aim of our study was to evaluate the appropriateness of antibiotic dosing when an EMP is physically present in the ED compared to when absent. METHODS This was a retrospective cohort study of patients treated in a level I trauma center with 75 adult and 12 pediatric beds and an annual census of 90000 patients. The study period was from March 1 to September 30, 2014. An EMP was physically present in the ED from 11:00 to 01:30 and absent from 01:31 to 10:59. Male and female patients 18years and older were considered for inclusion if cefazolin, cefepime, ciprofloxacin, piperacillin-tazobactam, or vancomycin was ordered. The primary outcome was the composite rate of correct antibiotic dose and frequency. Statistics included a multivariable logistic regression using age, sex, presence of EMP, and creatinine clearance as independent predictors of correct antibiotic use. RESULTS A total 210 cases were randomly chosen for evaluation, half during times when EMPs were present and half when they were absent. There were 130 males (62%) with an overall mean age of 54±18years. Overall, 178 (85%) of 210 of the antibiotic orders were appropriate, with 95% appropriate when an EMP was present compared to 74% when an EMP was absent (odds ratio, 6.9; 95% confidence interval, 2.5-18.8). In a logistic regression model, antibiotic appropriateness was independently associated with the presence of the EMP and creatinine clearance. CONCLUSION Antibiotics that require renal and/or weight dosing adjustment are 6.5 times more likely to be appropriate in the ED when an EMP is present. Prevalence of antibiotic dosing error is related to both the presence of EMPs and the degree of renal impairment.

Fixed dose 4-factor prothrombin complex concentrate for the emergent reversal of warfarin: a retrospective analysis

Published literature suggests that a fixed-dose 4-factor prothrombin complex concentrate (4FPCC) may be efficacious in managing warfarin-associated hemorrhage, however the ideal dose is still unclear. The purpose of this evaluation was to determine the efficacy of fixed-dose 4FPCC in reducing the International Normalized Ratio (INR) to ≤ 1.5 among warfarin patients with need for urgent or emergent anticoagulation reversal. Starting October 2016, our institution changed from standard 4FPCC FDA-labeled dosing based on the patient’s presenting INR and weight, to a fixed-dose of 1500 units for all patients requiring urgent or emergent warfarin reversal. We conducted a retrospective evaluation, after implementation, with the primary outcome being the proportion of patients who achieved an INR ≤ 1.5 with a single fixed-dose of 1500 units of 4FPCC. Secondary outcomes assessed included: medication turnaround times, attainment of target INR ≤ 2 or clinical hemostasis (as judged by the prescribing provider), use of rescue doses, thrombotic events, and cost savings. A total of 37 patients were included in the analysis. Almost 75% of patients achieved an INR ≤ 1.5 after a single fixed dose of 1500 units, and 100% of patients achieved an INR ≤ 2. The median pre- and post-dose INRs were 3.06 and 1.32 respectively. Based on this evaluation, the administration of a fixed dose of 1500 units 4FPCC, was shown to be effective in adequately reversing the INR in the majority of patients with minimal thrombotic risks.

Breadth of Statistical Training Among Pharmacy Residency Programs Across the United States

Background: Pharmacy residents’ knowledge of biostatistics is a self-identified deficit. Objective: To describe statistical training practices across postgraduate year 1 (PGY1) pharmacy residency programs and correlate training practices with residency program directors’ (RPDs) confidence in their residents’ statistical abilities. Methods: A 13-item survey was sent to PGY1 RPDs and included questions regarding respondents’ institution, program characteristics, type and amount of statistical training offered and desired, as well as performance of statistics, resident project publication rates, and RPDs’ confidence in residents’ statistical abilities. Results: Of the 1054 RPDs invited to participate in the survey, 202 (19.7%) surveys were completed. Nearly 25% of PGY1 pharmacy residency programs in this sample offered no statistical training to their residents. The most common types of training were study design considerations/selecting statistical tests (64.9%), descriptive statistics (59.9%), and database development/data manipulation (46.6%). The majority (60.9%) of RPDs had low confidence in their residents’ abilities to perform their own statistical analysis. After adjusting for significant covariates, residents receiving complex statistical training (odds ratio [OR]: 6.76; 95% confidence interval [CI]: 2.7-24.9) and a publication rate >50% (OR: 5.63; 95% CI: 1.61-19.69) were associated with higher RPD confidence in residents’ abilities to perform statistical analyses. Conclusion: The sample of programs in this survey indicates that statistical training for many residents may be limited, and many RPDs are not confident in their residents’ abilities to perform statistical analysis of research projects. Statistical training and opportunities to enhance research skills may be an area for future growth in pharmacy residency training programs.

Levetiracetam in toxic seizures

Abstract Background/Objectives: The use of levetiracetam (LEV) in the management of drug-induced seizures has not been systematically investigated. Repetitive and continuous seizures that do not respond to benzodiazepines require second line therapy. Levetiracetam has a unique receptor binding site, rapid absorption, no known cardiac effects at therapeutic doses, and is theoretically a good candidate for use in drug-induced seizures. We evaluate the safety of LEV and its association with seizure cessation in this retrospective chart review of patients who received LEV as a control agent in drug-induced seizures. Methods: We identified the medical records of patients presenting to an urban, level 1 trauma center between 1 January 2010 and 31 May 2015 by ICD-9 codes based on the following: (1) a poisoning diagnosis, (2) a seizure diagnosis, and (3) administration of LEV. We included patients with a drug-induced seizure based on history, electroencephalogram results, blood alcohol concentrations, urine drug screens, and adequate documentation. We excluded patients with alcohol withdrawal, anoxic brain injury, subtherapeutic concentrations of other antiepileptics, hypoglycemia, and pseudoseizures. Primary outcomes of interest included cessation of active seizures or the prevention of seizure recurrence. We assessed safety by the presence or absence of adverse drug effects (ADE) attributed to the administration of LEV. Results: Thirty-four patients met inclusion and exclusion criteria. Half of the study cohort (17) presented with generalized tonic-clonic seizures (TCS); half (17) presented in generalized convulsive status epilepticus (GCSE). Six patients in GCSE received LEV during their seizures; 2 also received fosphenytoin. One improved immediately following LEV administration, and the remaining 5 had seizure control. Eleven GCSE patients (65%) remained seizure free after LEV therapy. The patients with TCS (17) received LEV after seizure(s) control. Sixteen (94%) were seizure-free during their hospital course. We found no adverse drug effects. In total, 27 of 34 patients (79%) had a return to baseline neurological and physical health. Six had long-term sequelae; none of which are known LEV side-effects. We identified 46 toxic substances and 22 known seizurogenic agents (48%). The median length of stay was 3.7 days (0.4–96), and the median duration of in-hospital LEV therapy was 1.6 days (0–49). Conclusions: Levetiracetam used as a second-line agent was associated with control of drug-induced seizures and prevention of seizure recurrence without obvious adverse effects. A prospective study is needed to confirm these results.

Cultivating statistical knowledge in pharmacy residents’ research

Research skills to evaluate practice, review data, and assimilate scientific evidence to improve patient care or the medication-use system are requirements for completion of a postgraduate year 1 ASHP-accredited residency.[1][1] However, most pharmacy school graduates have limited experience with

Collaborating on a residency research project.

The purpose of pharmacy residency projects is to develop residents’ ability to identify and formulate research questions, develop a project proposal with sound methods, present results to their peers, and prepare a manuscript for publication. Due to limited time and a lack of research experience,