Category: Original  Research Poster Award Winner

Title: Clinical impact of rapid testing on gram negative bacteremia: A retrospective chart review

Gram-negative bloodstream infections have been associated with poor patient outcomes including increased mortality.  Rapid identification of microorganisms and resistance markers are valuable tools when it comes to targeting antimicrobial therapy. Molecular tests, used in conjunction with gram stain results, have the potential to reduce the time to organism identification and time to effective antibiotics.  The objective of this study is to assess the impact of Verigene BC-GN on antimicrobial therapy-related outcomes. The primary outcome is time to first antibiotic intervention and time to most targeted therapy for gram-negative bloodstream infections pre- and post-implementation of rapid pathogen identification technology. Secondary outcomes include length of stay, use of antibiotics, 30-day readmission rate and mortality rate.

Methods: 

This is a retrospective, single-center, cohort study assessing patients 18-89 years of age with gram-negative bacteremia from July 1st, 2018 to July 31st, 2020. The control group will consist of patients with a positive blood culture caused by a gram-negative pathogen from July 1st, 2018 to May 31st, 2019; prior to the implementation of Verigene assays. These patients will be compared to positive blood cultures from August 1st, 2019 to July 31st, 2020; post implementation of Verigene assays at Memorial Medical Center (MMC). Subjects will be excluded from review if they were transferred to MMC from outlying hospital due to need for higher level of care, deceased/hospice care at time of positive blood culture result, secondary infections with differing cultures/susceptibilities or on additional antimicrobial therapy for concurrent infection with no cultures/sensitivities available.  

Results: Research in Progress

Conclusions: Research in Progress

Submitting Author: Shelby Lynn Dial, PharmD, PGY-1 Pharmacy Practice Resident

Organization: Memorial Medical Center

Co-authors: Julie Downen, Pharm.D., BCPS, BCIDP, CLSSBB, Memorial Medical Center; Maithili Deshpande, PhD, Southern Illinois University Edwardsville

Category: Encore Poster Award Winner

Title: Impact of an Embedded Pharmacist on Diabetes Control in a Primary Care Practice

In June 2019, 42% of patients with diabetes in Northwestern Medicine Regional Medical Group Wheaton Internal Medicine (IM) practice had a baseline glycated hemoglobin (HgbA1c) of >7.0%. The American Diabetes Association (ADA) goal for most adults with diabetes is an HgbA1c of < 7.0%. Diabetes is the 7th leading cause of death in the United States and uncontrolled diabetes can lead to major health complications. The UK Prospective Diabetes Study (UKPDS) found that every 1% reduction in HgbA1c was associated with a 37% decrease in microvascular disease and a 14% reduction in myocardial infarction (MI).  Management of diabetes in primary care is complex and requires a multidisciplinary care team approach.  For our project, we wanted to see if an embedded pharmacist in the Wheaton Internal primary care practice could reduce HgbA1c values by at least 0.5% in 30% of patients with diabetes with HgbA1c >7% by the end of fiscal year 2020.  As a secondary outcome, we evaluated the impact of pharmacist services on provider burnout and patient satisfaction.   

Methods: 

We introduced a full-time embedded pharmacist to the care team at Wheaton IM to provide services to all patients with diabetes with an HgbA1c >7% via a signed collaborative practice agreement with all six providers in the practice.  The clinical pharmacist recorded all medication interventions per patient.  The project team used this intervention log as a basis to create automated reports on HgbA1c reduction and emergency department/hospitalization avoidance.  In addition, we established pharmacist follow up criteria, identifying frequency of follow up for medication titration and various education needs  

Results: 80.5% of patients with diabetes at the Wheaton IM practice decreased their HgbA1c by ≥0.5% after a clinical pharmacist was added to the patient care team. The most common pharmacist interventions included ensuring that the patient was on appropriate drug therapy, able to obtain their medications, and had access to proper disease state education.  Additionally, this project led to a 38.6% decrease in provider burnout score, while achieving a 96.4% average patient satisfaction score.  Lastly, a reduction in preventable diabetes-related emergency department visits of 95.1% and hospitalizations of 97.3% resulted in $85,965 in cost avoidance to Northwestern Medicine.   

Conclusions: Adding a clinical pharmacist to the patient care team improved clinical outcomes, reduced health care spending, increased patient access to care, and reduced provider burnout.  The keys to success were clearly defined pharmacist services, management of patient drug therapy, essential disease state education, establishment of patient follow-up criteria, and reduced demands on physician time.  Next steps include implementing billing for pharmacist services and growing the program to include pharmacist presence in additional primary care practices.

Submitting Author: Imran Khan, PharmD, Clinical Pharmacist, Ambulatory Care Management

Organization: Northwestern Medicine Physician Network

Co-author: Therese Castrogiovanni, Pharm.D, CDCES, RMG Wheaton Internal Medicine.

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Category: Student Poster Award Winner

Title: Rocuronium vs succinylcholine in the traumatically injured brain: a prospective, pilot study

Purpose: 

The purpose of this study was to assess the safety between two common paralytics, administered during rapid sequence intubation (RSI), in patients presenting with an acute traumatic brain injury (TBI) in the emergency department (ED). In these patients, RSI is implemented to protect a patient’s compromised airway. Following pharmacologic induction of a RSI, patients’ muscle tone is inhibited with rapid-onset, relatively short-acting paralytics such as rocuronium or succinylcholine. A retrospective study using rocuronium for RSI demonstrated mortality benefit in these patients. This prospective study compared the safety outcomes in similar patients who underwent RSI with either rocuronium or succinylcholine.  

Methods: 

Patients were identified for study inclusion between September 1, 2018 and June 30, 2020. The study population consisted of acute TBI patients who presented to the ED and required RSI using the paralytics succinylcholine or rocuronium. Demographics recorded include age, sex, race, severity of the TBI, and presenting Glasgow Coma Scale (GCS). Patients were excluded from the study if they were under the age of 18, a surgical airway was placed, patient was pregnant at time of study, cardiac arrest occurred prior to intubation, or intubation was attempted prior to arrival. The primary clinical outcome evaluated was the incidence of in-hospital mortality. The secondary outcomes measured both hospital and intensive care unit (ICU) length of stay (LOS), respectively. A sample size of 200 was calculated to detect a 20% difference in mortality.   

Results: Presented at the Spring Meeting 

Submitting Author: Nadine Alwawi, PharmD Candidate

Organization: Rosalind Franklin University of Medicine and Science

Co-authors: Lauren Stambolic, PharmD, Advocate Christ Medical Center; Marc McDowell, PharmD, BCPS, Advocate Christ Medical Center; Sabrin Jaber, PharmD, Stanford University Medical Center; Brook Walsh, PharmD, Little Company of Mary Hospital; Ellen Omi, MD, Advocate Christ Medical Center; Robert Mokszycki, PharmD, BCPS, University of Massachusetts.

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Category: Original Research 

Title: Evaluation of Bolus vs. Continuous Infusion Neuromuscular Blocking Agents in the Management of Severe Acute Respiratory Distress Syndrome

Purpose: 

Acute respiratory distress syndrome (ARDS) is characterized by pulmonary edema, reduced lung compliance, and acute hypoxemia following lung insult.  The primary management of ARDS is lung protective ventilation to reduce the risk of barotrauma and volutrauma and exacerbation of lung injury.  Neuromuscular blocking agents (NMBA) are often considered in patients with ARDS to manage ventilator dyssynchrony.  Prior to March 2020 at Rush University Medical Center, continuous NMBA infusions were administered at a flat infusion rate according to the ACURASYS trial.  Due to the large number of patients with COVID-19 infection who progressed to severe ARDS, NMBA dosing was re-evaluated to manage drug supply and prevent prolonged paralysis.  NMBA order sets were updated to encourage initial intermittent bolus NMBA administration for ventilator dyssynchrony followed by a weight-based infusion for persistent or recurrent dyssynchrony.  This MUE was designed to evaluate the use of bolus and weight-based continuous infusion NMBAs used in the management of ARDS associated ventilator dyssynchrony in COVID-19 positive patients.  

Methods: 

COVID-19 positive patients with orders for cisatracurium or rocuronium and a diagnosis of ARDS from March 1, 2020 through May 1, 2020 were identified for inclusion.  Patients were included if they received at least one dose of either cisatracurium or rocuronium for ventilator dyssynchrony, define as a respiratory rate of at least 5 breaths per minute above the desired ventilator rate.  Patients were evaluated for improvement in ventilator dyssynchrony by an improvement in respiratory rate, defined as a reduction of at least five breaths per minute; decreased peak inspiratory pressure, defined as a decrease in the peak inspiratory pressure of at least 5 cm H2O; or an improvement in the PaO2:FiO2 of at least 20 mmHg.  Respiratory rate, ventilator rate, and peak inspiratory pressure were assessed by the most recent values available prior to NMBA administration and by the first result available at least 1 hour after administration.  PaO2:FiO2 was assessed by arterial blood gas within 4 hours before and after NMBA administration.  Duration and average rate of infusions were utilized to determine overall exposure in patients who received infusions. 

Results:
Fifty-five patients had orders placed for either cisatracurium or rocuronium during the evaluation period.  Three patients were excluded because they did not receive a dose of either cisatracurium or rocuronium and one patient was excluded because their encounter occurred at an outside facility.  Patients were separated into the initial bolus group, those who received a bolus with at least one-hour separation from any subsequent infusion, and initial infusion group, those who received either no bolus or had les than one-hour separation between initial bolus and initiation of infusion. The overall response rate was 74.3% and 56.3% in the initial bolus and initial infusion groups respectively.  In the initial bolus group, 57.1% of patients required a continuous NMBA infusion, and in the initial infusion group 68.8% of patients received at least one bolus.  The median and mean overall cisatracurium exposure was 145 mg and 594 mg in the initial bolus group and 704 mg and 750 mg in the initial infusion group.  Both strategies resulted in lower cumulative exposure of 1800 mg for the historic flat infusion rate. 4. 

Conclusions:
Patients who received an initial bolus NMBA did not have less improvement in ventilator dyssynchrony compared to patients who received an initial infusion.  Cumulative exposure associated with an initial bolus regimen was lower when compared to an initial infusion regimen.  An initial bolus NMBA strategy may prove beneficial in reducing overall NMBA use in the management of ARDS, especially in the event of future drug shortages.

Submitting Author: Caleb McLeod, PharmD, PGY-1 Pharmacy Practice Resident

Organization: Rush University Medical Center

Co-author: Georgeanna Rechner-Neven, PharmD, BCPS, BCCCP, Rush University Medical Center.