Venous Thromboembolism Prophylaxis Compliance Before and After Electronic Health Record Implementation

Background: Adherence to American College of Chest Physicians (CHEST) and National Comprehensive Cancer Network (NCCN) guidelines for venous thromboembolism (VTE) prophylaxis helps avoid thromboembolic complications during hospitalization. Electronic health records (EHR) have the potential to make an impact on guideline adherence, but data are lacking. Objectives: To determine compliance with VTE prophylaxis guidelines in internal medicine and oncology populations and to determine whether EHR implementation had any effect on the rate and appropriateness of prophylaxis practices. Methods: A retrospective chart review was conducted on medical and oncology patients admitted to the hospital for a 2-month period pre-EHR and post-EHR implementation. Risk assessment tools were available pre and post, however they were not mandatory. The rate of VTE prophylaxis was compared between the 2 time periods, with appropriateness assessed in a subgroup of participants without prophylaxis. Results: A total of 2,423 patients on the oncology and internal medicine floors were identified during the pre-EHR (n = 1,171) and post-EHR (n = 1,252) time periods. Patients in the post-EHR group were less likely to be prescribed prophylaxis as compared to those in the pre-EHR group (43% vs 50%; P = .001). In the patients audited for proper prophylaxis use (n = 750), significantly more patients in the post-EHR group had risk factors (84% vs 53%; P \u3c .001) and contraindications (23% vs 8%; P = .001) than in the pre-EHR group. Noncompliance to prophylaxis in patients who were candidates (positive risk factors without contraindications) occurred more often in the post-EHR group (51% vs 39%; P \u3c .001). Conclusion: Implementation of an EHR was associated with an increase in the documentation of risk factors and contraindications; however, there was a significant decrease in VTE prophylaxis utilization after EHR implementation

Geriatric Medication Therapy: Weighing the Evidence versus Best Practice

Goals: The goal of this article is to provide a review of available evidence for safe prescribing in older adults and recommend medication therapies based on anticipated pharmacokinetic/physiologic changes in this population

Ceftriaxone Potentiates Warfarin Activity Greater Than Other Antibiotics in the Treatment of Urinary Tract Infections

Background: The cephalosporin class has been associated with an increased risk of bleeding among elderly patients receiving warfarin. Urinary tract infections (UTI) are the most prevalent infection in elderly patients. Objective: To determine the extent of interaction between antibiotics used in the treatment of UTI, particularly specific cephalosporins and warfarin. Methods: A retrospective chart review was conducted on chronic warfarin patients with a diagnosis of UTI treated with ceftriaxone, a first-generation cephalosporin, penicillin, or ciprofloxacin. The primary outcome was the comparison of the extent of international normalized ratio (INR) change from baseline between each antibiotic group. Results: The ceftriaxone group was found to have a statistically significant higher peak INR value compared to all other studied antibiotics (ceftriaxone: 3.56, first-generation cephalosporins: 2.66, penicillins: 2.98, ciprofloxacin: 2.3; P = .004), a statistically significant greater extent of change in INR value (+1.19, +0.66, +0.8, +0.275; P = .006), and a statistically significant greater percentage change in INR value when compared to ciprofloxacin (54.4% vs 12.7%; P = .037). Conclusion: Ceftriaxone interacts with warfarin to increase a patient’s INR value more than other commonly administered antibiotics for UTI treatment. Other antibiotics should be preferred for UTI treatment in patients on warfarin

Ascorbic Acid for the Treatment of Rasburicase induced Methemoglobinemia in the Setting of Acute Renal Failure

Purpose A case of apparent rasburicase-induced methemoglobinemia and acute kidney injury treated with i.v. ascorbic acid because of suspected glucose-6-phosphate dehydrogenase (G6PD) deficiency is reported. Summary A 46-year-old African-American man with a recent diagnosis of multiple myeloma and renal insufficiency was admitted to the hospital with a cough, hemoptysis, and fatigue. His medical history included hypertrophic cardiomyopathy, ventricular tachycardia, attention deficit/hyperactivity disorder, and pleural effusion. No treatments for multiple myeloma were started before hospital admission. Levofloxacin 750 mg orally daily for possible pneumonia, lenalidomide 10 mg orally daily, and dexamethasone 20 mg orally weekly were administered. Plasmapheresis was also initiated. Laboratory test results revealed sustained hyperuricemia, which was believed to be due in part to tumor lysis, and a single dose of rasburicase 6 mg i.v. was administered. Subsequently, the patient experienced a decrease in oxygen saturation. Methemoglobinemia was suspected, and the patient’s methemoglobin fraction was found to be 14.5%. The patient developed worsening shortness of breath and a drop in hemoglobin concentration, consistent with methemoglobinemia and hemolysis. Ascorbic acid 5 g i.v. every 6 hours was initiated for a total of six doses. Because the patient was assumed to have G6PD deficiency, which was later confirmed, methylene blue was avoided. Within 24 hours, the patient’s oxygen saturation values and symptoms improved. Conclusion A patient with apparent rasburicase-induced methemoglobinemia and acute kidney injury was treated with i.v. ascorbic acid (5 g every six hours for six doses) because of the possibility, later proved, that he had G6PD deficiency. The methemoglobinemia resolved without worsening of renal function

Hypertension Management: Making Sense of Guidelines and Therapy Options for the Elderly

Goal: The goal of this activity is to increase the awareness of the pharmacist on the complications surrounding hypertension management in the elderly individual, clarify the differences in current guideline recommendations, and aid in making the most appropriate drug therapy decisions regarding the management of hypertension

Assessing the Accuracy and Quality of Medication History Collection: Effect of Implementation of Electronic Health Record

Abstract from 2013 ACCP Annual Meeting, Alburquerque, New Mexico

Geriatric and Student Perceptions following Student-led Educational Sessions

Objective: The objective of this study was to measure the effect of student-led educational events on geriatric patient and student participant perceptions in a community setting. Methods: Students led three events at a senior community center, focusing on learning and memory, sleep hygiene, and arthritis pain. The participants were geriatric patients who themselves were providers of support to homebound peers (“clients”) through an independently organized program. Geriatric participants completed pre- and post-event surveys to measure changes in familiarity with the topics. Student participants also completed pre- and post-event surveys that tracked changes in their comfort in working with the geriatric population. Results: Each event demonstrated at least one positive finding for geriatric patients and/or their clients. Students reported increased comfort in working with and teaching the geriatric population following the first and third events, but not the second. Conclusion: Student-led educational sessions can improve perceived health-related knowledge of geriatric participants while simultaneously exposing students to the geriatric patient population. Overall, both students and geriatric participants benefited from these events. Practice Implications: Incorporation of single, student-led educational events could be mutually beneficial to students and the elderly population in the community and easily incorporated into any healthcare curriculum. Funding:This work was supported by a Butler University Innovation Fund Grant. Treatment of Human Subjects: IRB review/approval required and obtained   Type: Original Researc

Acid Suppression Therapy in the Hospital Setting: an Evaluation of the Appropriateness of Stress Ulcer Prophylaxis [abstract]

Abstract from the 2014 ACCP Annual Meeting: PURPOSE: Prevention of stress ulcer prophylaxis (SUP) through gastric acid suppressive therapy (AST) is common practice in the hospital setting. Despite published guidelines and recommendations describing indications for SUP, AST with proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs) is often prescribed inappropriately and is inadvertently continued at discharge. AST has been associated with infectious complications and adverse effects which may complicate disease state management and require need for medical management. We evaluated the utilization of AST and appropriateness of SUP prescribing at a community teaching hospital. METHODS: Utilizing our electronic medical records, we prospectively evaluated the use of AST in our intensive care units (ICUs) and on our internal medicine units for 3 months. Data collected included AST medication, SUP indication, home AST, and whether AST was continued at discharge. RESULTS: 445 patients were included in our evaluation and 56% had AST listed as a home medication. SUP accounted for 88% (n=391) of AST prescriptions. PPIs were prescribed more often than H2RAs (61 vs 39%), and IV administration was slightly preferred over oral (56 vs 44%). SUP was inappropriate in 61% of the prescriptions (n=239) and was more likely to occur outside of the ICUs (88% vs 17%). When groups were adjusted for home AST therapy (n=176), inappropriate rates were similar (86 vs 20%). 26% of SUP prescriptions were inappropriately continued at discharge. CONCLUSION: Inappropriate prescribing of AST for SUP, particularly outside of the ICUs, is common. Of concern is the continuation of AST and the infectious and metabolic risks associated with AST. Our findings suggest a process improvement plan is needed to help the clinician with appropriate SUP prescribing. In order to avoid inadvertent continuation of therapy at discharge, this plan will need to include facilitation of appropriate medication reconciliation at time of transfer and discharge

Impact of Evidence Based Guidelines for Management of Clostridium Difficile Infection [abstract]

Abstract from the 2015 ACCP Virtual Poster Symposium, May 18-19: OBJECTIVES: To determine the impact of an evidence-based guideline established for the treatment of Clostridium difficile infection (CDI) at a community teaching hospital. Endpoints included length of stay (LOS) after diagnosis, mortality, direct cost, and 30-day readmission rates. METHODS: Relevant literature was reviewed by internal medicine physicians, residents, and pharmacists to develop an internal treatment guideline for the classification and management of CDI. The guideline follows the Infectious Disease Society of America/ Society for Healthcare Epidemiology of America 2010 recommendations. The hospital guideline was provided to physicians and medical residents via email, an internal website, a resident pharmacotherapy handbook, and as a formal presentation during a noon conference. A retrospective chart review was conducted to identify LOS, mortality, direct cost, and readmission rates, as well identify physician adherence to the guideline provided. RESULTS: Seventy-nine patients were evaluated and it was found that guideline-based therapy (n = 31) was associated with a shorter LOS (7.45 days vs 7.9 days), decreased mortality (3.2% vs 6.3%), and a reduction in 30-day hospital readmission (29% vs 38%). However, guideline-based therapy was associated with a mean higher cost ($17,141 vs$12,787). None of these results achieved statistical significance. Although education was provided and access to the guideline was readily available, adherence by physicians and residents to the guideline-based therapy only occurred in 45% of patients. CONCLUSIONS: Implementation of guideline-based therapy for CDI may result in a reduction in LOS, 30-day hospital readmission, and mortality. Surprisingly a reduction in cost was not noted in the guideline-based therapy. Barriers to physician adherence still seem to exist despite seemingly adequate education and availability of the guidelines. Perhaps periodically revisiting education and adding requirements for ordering medications could improve adherence. Additionally, higher adherence rates may provide more definitive data for potential significanc