438: SAFETY AND EFFICACY OF CEFEPIME INTRAVENOUS PUSH VERSUS PIGGYBACK IN GRAM-NEGATIVE BACTEREMIA

Introduction: Gram-negative infections including bacteremia are a major cause of inpatient mortality. Optimizing management is key to improving outcomes. Beta-lactams exhibit optimal antibacterial effects based on the time free concentrations exceed an organism’s minimum inhibitory concentration. Limited data exists assessing outcomes using beta-lactams as intravenous push (IVP) compared to intravenous piggyback (IVPB) in serious infections. This study’s purpose was to compare safety and efficacy of cefepime administered IVP versus IVPB in gram-negative bacteremia. Methods: This was an IRB-approved, retrospective cohort of patients hospitalized January 2014 to December 2021 and administered cefepime for \u3e48 hours for gram-negative bacteremia involving Pseudomonas aeruginosa or AmpC beta-lactamase producing bacteria. Two groups were included: one of patients who received cefepime IVPB and the second of patients who received cefepime IVP. The primary outcome was a desirability of outcome ranking (DOOR) on a five-point ordinal scale including clinical cure (no recurrent bacteremia of initial pathogen, antibiotic escalation, or 30-day in-hospital mortality) and neurologic adverse effects during cefepime treatment up to 30 days inpatient or at discharge. Secondary outcomes included antibiotic escalation, time to defervescence, vasopressor use, and in-hospital mortality. A sample of 127 patients per group provided 80% power. Data was analyzed using measures of central tendency and variability, chi-square, student’s T test, and Mann-Whitney U. Results: A total 254 patients were included with 127 per group. DOOR with clinical cure was similar between the IVPB and IVP groups (105 (82.7%) vs. 104 (81.9%); P=0.656). Escalation of therapy was the most common reason for clinical failure in both the IVPB and IVP groups (17 (13.4%) vs. 18 (14.2%); P=0.856). More patients in the IVP group required vasopressors (13 (10.2%) vs. 28 (22.0%); P=0.011). No difference was found in time to defervescence or in-hospital mortality. Conclusions: When compared to cefepime IVPB in gram-negative bacteremia, treatment with IVP showed no significant difference in instances of clinical cure or adverse effects. Further research in a more severely ill population is needed to evaluate safety and efficacy of cefepime IVPB versus IVP

COMPARING NERVE BLOCK PAIN PUMPS TO STANDARD OF CARE IN PATIENTS FOLLOWING CARDIOTHORACIC SURGERY

INTRODUCTION: Post-operative pain management following cardiothoracic surgery (CTS) can be challenging. Although opioids are commonly prescribed, multimodal strategies are used to decrease opioid consumption. One strategy includes the use of local anesthetics via peripheral nerve block pain pumps (PNBPP). However, literature in CTS patients is limited and conflicting. This study evaluated the efficacy and safety of PNBPP in patients following CTS. METHODS: This was a quasi-experimental study that included adult patients admitted to the cardiac intensive care unit following CTS. The intervention group included those who received PNBPP and they were compared to a group that received standard of care (SOC). The primary endpoint was the total oral morphine milligram equivalents (MMEs) used in the four days following surgery. Secondary endpoints included adverse events, incidence of post-operative ileus, time to first bowel movement, pain scores, length of stay and cost of intervention. Statistical analysis was performed with Chi-square, Fisher\u27s exact, Mann-Whitney U and t-tests where appropriate (IBM SPSS Statistics Software version 28.0.1.1). A sample size of 126 was calculated to detect a 50% reduction in opioid consumption with an alpha of 0.05 and power of 80%. RESULTS: Baseline characteristics were similar between groups with a median age of 60 and 63 in the PNBPP and SOC groups, respectively. The majority of patients were male and had a coronary artery bypass graft performed. Median oral MMEs was 375 (IQR: 268.5, 457.5) in the SOC group compared to 304.5 (IQR: 240, 416) in the PNBPP group (p-value 0.189). When comparing the SOC and PNBPP groups, incidence of post-operative ileus was 2 (3.2%) and 12 (19%) (p-value 0.005) with median time in hours to first bowel movement of 68.38 (IQR: 50.31, 85.50) and 66.11 (IQR: 50.28, 76.13) (p-value 0.336). There was no significant difference between groups in pain scores or length of stay. Median cost (USD) of PNBPP therapy was $125 in those that received an electronic pump and$3,138 in those that received an elastomeric pump. CONCLUSIONS: Addition of PNBPP post-CTS did not significantly reduce opioid consumption compared to SOC. Larger studies are needed to better define the role of PNBPP in post-operative pain management following CTS

Project #37: Management Guidelines for Patients with COVID-19: Rapid Cycle Improvement

Project’s purpose is to rapidly devise, continually improve, educate, and implement a live and changing COVID-19 management guideline based upon emerging best available evidence. This project also aims to optimize the care of patients with COVID-19 and improve patient outcomes.https://scholarlycommons.henryford.com/qualityexpo2022/1004/thumbnail.jp

An electronic tool for health systems to assess and communicate discharge medication access

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: The purpose of this study was to describe how the discharge medication cost inquiry (DMCI) consult order and workflow were created and used to communicate transition of care needs and medication access barriers before discharge. SUMMARY: Health-system pharmacists collaborated with the information technology department to develop the DMCI consult order and workflow. This institutional review board-approved retrospective case study evaluated use of the DMCI consult order throughout the health system. Outcomes that could not be retrieved electronically were collected for every third patient encounter using manual chart review. The DMCI consult order was used at each hospital in the health system. Physicians placed the most DMCI consult orders; however, pharmacists at the large academic tertiary hospital utilized the DMCI consult order the most. The DMCI consult order was sent most frequently for anticoagulants. Although most medications were covered by insurance, the tool and workflow identified barriers to medication access. Almost 90% of the patients with a DMCI consult order had at least one prescription generated on discharge. CONCLUSION: The DMCI consult order is a novel electronic tool to aid in communicating discharge medication needs. When incorporated into care transition planning, the DMCI consult order and workflow provide a model to ensure patients have access to medications. It can also be used to document and evaluate the role of pharmacy in transitions of care in the health system

Sustainable Naloxone Education and Distribution From an Urban Emergency Department

Study Objectives: The opioid epidemic was declared a national emergency in 2017. Naloxone can rapidly reverse fatal overdose and evidence shows reduced mortality when naloxone is available in the community. The optimal naloxone distribution methods are yet to be established. We aim to determine the feasibility and sustainability of instituting a program which provides naloxone in hand to at-risk patients in a high-volume, urban emergency department (ED). Secondary objectives are to describe patient receptiveness to receiving naloxone at ED discharge, medication cost and 30 day follow up. Methods: Our study included a convenience sample of patients who presented to the ED between October 2018 and May 2019 who exhibited improvement in mental status after administration of naloxone, either in the ED or via emergency medical services, and who were anticipated to be discharged home from the ED. Enrollment was limited to the outpatient pharmacy work hours: Monday to Friday 7am to 6pm. Eligible patients were identified by ED personnel and were engaged by the ED naloxone educator 1-2 hours prior to anticipated discharge. Patients were asked if they were interested in receiving the naloxone and the administration instructions. If the patient was agreeable to others receiving education with them, others were invited to participate. If no one was available, teach back occurred to ensure the patient could teach others after discharge. The outpatient pharmacy delivered a 2-dose package of 4mg naloxone nasal spray as prescribed by the ED provider prior to discharge. Uninsured patients had medication cost covered by the ED medical needs fund. The pharmacy provided additional financial assistance for those with copays. The ED naloxone educator provided the naloxone administration education along with an informational packet on community resources and follow-up care. Patients were called in follow-up at least 30 days after the date of visit. Results: A total of 30 patients were approached between October 2018 and May 2019, and 27 (90%) patients were successfully enrolled in the study. The cohort was predominantly African American (75%) with a median age of 54 years and male sex (74%). 24/27 (89%) of patients were insured and 20/24 (83%) insured patients had zero copay for naloxone nasal spray. One of 18 (6%) eligible patients for 30 day follow up was successfully contacted. 4/18 (22%) patients who were agreeable to receive naloxone declined to give contact information for 30-day follow-up. The study was initiated as a 1-month pilot and was continued after ED administration noted minimal interference to ED workflow. Conclusion: Utilization of existing ED systems can allow for a sustainable model of naloxone provision and administration instruction. Most patients in the study had zero copay and were receptive to education. Follow-up in this patient population was relatively unsuccessful. Identifying patients nearing the end of an observation period with an anticipated discharge home can allow for naloxone distribution to cause minimal disruption to workflow in a busy ED. This model of naloxone provision can be sustainable without external funding and provides a method to receive prescribed medications while in the ED. Further studies are needed to demonstrate sustainable naloxone distribution

Improving transitions of care for critically ill adult patients on pulmonary arterial hypertension medications

PURPOSE: The purpose of this report is to describe the activities of critical care and ambulatory care pharmacists in a multidisciplinary transitions-of-care (TOC) service for critically ill patients with pulmonary arterial hypertension (PAH) receiving PAH medications. SUMMARY: Initiation of medications for treatment of PAH involves complex medication access steps. In the ambulatory care setting, multidisciplinary teams often have a process for completing these steps to ensure access to PAH medications. Patients with PAH are frequently admitted to an intensive care unit (ICU), and their home PAH medications are continued and/or new medications are initiated in the ICU setting. Inpatient multidisciplinary teams are often unfamiliar with the medication access steps unique to PAH medications. The coordination and completion of medication access steps in the inpatient setting is critical to ensure access to medications at discharge and prevent delays in care. A PAH-specific TOC bundle for patients prescribed a PAH medication who are admitted to the ICU was developed by a multidisciplinary team at an academic teaching hospital. The service involves a critical care pharmacist completing a PAH medication history, assessing for PAH medication access barriers, and referring patients to an ambulatory care pharmacist for postdischarge telephone follow-up. In collaboration with the PAH multidisciplinary team, a standardized workflow to be initiated by the critical care pharmacist was developed to streamline completion of PAH medication access steps. Within 3 days of hospital discharge, the ambulatory care pharmacist calls referred patients to ensure access to PAH medications, provide disease state and medication education, and request that the patient schedule a follow-up office visit to take place within 14 days of discharge. CONCLUSION: Collaboration by a PAH multidisciplinary team, critical care pharmacist, and ambulatory care pharmacist can improve TOC related to PAH medication access for patients with PAH. The PAH TOC bundle serves as a model that may be transferable to other health centers

Clinical characteristics and predictors of survival in adults with coronavirus disease 2019 receiving tocilizumab

Coronavirus disease 2019 (COVID-19) can progress to cytokine storm that is associated with organ dysfunction and death. The purpose of the present study is to determine clinical characteristics associated with 28 day in-hospital survival in patients with coronavirus disease 2019 (COVID-19) that received tocilizumab. This was a retrospective observational cohort study conducted at a five hospital health system in Michigan, United States. Adult patients with confirmed COVID-19 that were admitted to the hospital and received tocilizumab for cytokine storm from March 1, 2020 through April 3, 2020 were included. Patients were grouped into survivors and non-survivors based on 28 day in-hospital mortality. Study day 0 was defined as the day tocilizumab was administered. Factors independently associated with in-hospital survival at 28 days after tocilizumab administration were assessed. Epidemiologic, demographic, laboratory, prognostic scores, treatment, and outcome data were collected and analyzed. Clinical response was collected and defined as a decline of two levels on a six-point ordinal scale of clinical status or discharged alive from the hospital. Of the 81 patients included, the median age was 64 (58-71) years and 56 (69.1%) were male. The 28 day in-hospital mortality was 43.2%. There were 46 (56.8%) patients in the survivors and 35 (43.2%) in the non-survivors group. On study day 0 no differences were noted in demographics, clinical characteristics, severity of illness scores, or treatments received between survivors and non-survivors. C-reactive protein was significantly higher in the non-survivors compared to survivors. Compared to non-survivors, recipients of tocilizumab within 12 days of symptom onset was independently associated with survival (adjusted OR: 0.296, 95% CI: 0.098-0.889). SOFA score ≥8 on day 0 was independently associated with mortality (adjusted OR: 2.842, 95% CI: 1.042-7.753). Clinical response occurred more commonly in survivors than non-survivors (80.4% vs. 5.7%; p \u3c 0.001). Improvements in the six-point ordinal scale and SOFA score were observed in survivors after tocilizumab. Early receipt of tocilizumab in patients with severe COVID-19 was an independent predictor for in-hospital survival at 28 days

Evaluating the impact of severe sepsis 3-hour bundle compliance on 28-day in-hospital mortality: A propensity adjusted, nested case-control study

OBJECTIVES: The Centers for Medicare and Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) assesses antibiotic administration, lactate measurement, and blood culture collection within 3 h of severe sepsis onset. The impact of the SEP-1 3-hour bundle among patients with severe sepsis is not extensively described. This investigation aimed to describe the impact of 3-hour bundle compliance on 28-day in-hospital mortality in patients with severe sepsis. STUDY DESIGN: This was a retrospective, propensity adjusted, nested case-control study assessing the impact of compliance with a 3-hour sepsis bundle among patients with severe sepsis. SETTING: This study was conducted at a large, academic, tertiary care medical center in Detroit, Michigan from July 1, 2017 to December 31, 2019. PATIENTS: Cases were defined as those suffering 28-day in-hospital mortality. Controls were defined as those surviving at or discharged by 28 days. Patients were separated based on 3-hour bundle compliance or noncompliance. Nested and overall cohorts were assessed. Severe sepsis time zero was manually validated. Patients with shock, requiring vasopressors within 8 h of time zero, or those not meeting SEP-1 inclusion criteria were excluded. INTERVENTION: The primary outcome was the propensity adjusted odds of 28-day in-hospital mortality among 3-hour bundle compliant versus noncompliant patients. Secondary outcomes included mortality for individual bundle element compliance, progression to septic shock, and predictors of mortality according to logistic regression. RESULTS: A total of 325 compliant and 325 noncompliant patients were included. The median Sequential Organ Failure Assessment (SOFA) score was three in each group. There was no difference in propensity adjusted odds of mortality among those compliant versus noncompliant with the 3-hour bundle (odds-ratio [OR] 1.039; 95% CI: 0.721-1.497; p = 0.838) or with individual bundle elements. SOFA score and female sex were predictors of mortality. CONCLUSIONS: Three-hour bundle compliance did not impact 28-day in-hospital mortality in patients with severe sepsis. Further research is needed to understand the impact of 3-hour bundle compliance on mortality in severe sepsis