Resident 

ERYTHROPOIESIS-STIMULATING AGENT (ESA) CLINIC:  REASSESS, INITIATE, EXPAND

Jessica Waletich, Kiyomi Yamaguchi, Jacqueline Joss,

IRB approval is not needed

Erythropoetin Stimulating Agents (ESAs) are frequently used in patients with non-dialysis chronic kidney disease (ND-CKD) to improve quality of life and lower the need for transfusions. The pharmacist-managed ESA clinic at Good Samaritan Regional Medical Center was assessed in regard to appropriate anemia management and Centers for Medicare and Medicaid Services (CMS) criteria for reimbursement, with a plan to expand this clinic to the other four hospitals in the health system. Release of the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) trial in October 2009, which indicated an increase in cerebrovascular accidents with ESAs vs placebo, led to the decision to also evaluate clinic data for achieved hemoglobin, as well as a review of currently available published data to determine the risk benefit ratio in this population.  A retrospective chart review was completed of twenty three ND-CKD patients with anemia being treated with ESA therapy between April 2009 and September 2009. The protocol and collaborative practice agreement was reviewed for revision based on our interpretation of the TREAT trial. Expansion of the clinic to other sites is anticipated in April 2009 which will include the development of a formal training program for participating pharmacists. Results from the chart reviews, conclusions from the literature evaluation, improvements made to the protocol, and initiation of pharmacist administration of medication and formal pharmacy ESA training will be discussed.

Implementation and Evaluation of a Pharmacy-Delivered Group Tobacco Cessation Program

Korin Richardson, Deborah Sanchez, Amy Watson.

IRB approved.

This will be a longitudinal, single center, evaluative, prospective study.  The sample size will be approximately 20 patients. The cessation clinic shall follow the American Lung Associations: Freedom from Smoking Program, and will be facilitated by two trained pharmacists. Educational materials from a variety of evidence based tobacco cessation programs shall also be integrated into the 7 week, 8 session tobacco cessation class.  The primary objective: effectiveness of the class shall be gauged via quit rates at 3 and 6 months for patients who completed the cessation program.  Secondary outcomes of the study include: improvement in quality of life, patient satisfaction with the class, and healthcare provider satisfaction with the referral process for the class.  This study will include patients aged 18 to 90 years old, who currently identify themselves as tobacco users and are willing to attend the tobacco cessation clinic. Data will be collected prospectively through self reported data obtained through surveys and the Short Form 12.  Quit Rate shall be analyzed via telephone survey at 3 and 6 months post clinic.  Improvement in general health shall be analyzed via comparison of Short Form 12 surveys pre and post clinic, where scale scores shall be obtained to determine changes in quality of life.  Patient and healthcare provider satisfaction shall be analyzed with a general satisfaction survey at the end of the 7 week class.  Full results, will be discussed and presented. 

OPTIMIZATION OF GENTAMICIN DOSING IN NEONATES AND DEVELOPMENT OF A DOSING PER PHARMACY GUIDELINE

Sarah Adams, Kimberly Schulz 

IRB approval pending.

This project optimizes the gentamicin dosing guideline in neonates through the implemention of a pharmacist managed monitoring plan in which doses will be monitored and adjusted in a consistent fashion to prevent toxicity and maximize efficacy. An assessment of the pharmacokinetic data produced by gentamicin dosing in neonates at our institution was performed to determine if an alternative dosing regimen would be more appropriate. A literature search and query of the American College of Clinical Pharmacy’s pediatric listserv was subsequently conducted to evaluate alternative dosing strategies at other institutions. After completion of this project and implementation of the new dosing guideline, pharmacists will be provided with the authority to order the appropriate labs for therapeutic monitoring of gentamicin including peaks, troughs, and renal function tests, as deemed necessary. All pediatric pharmacists will undergo training and subsequent competency assessment in the pharmacokinetic analysis of appropriate gentamicin dosing in the neonate.  The goal of this project is to provide consistency in the dosing regimen of gentamicin throughout our institution by maximizing therapeutic efficacy and minimizing toxicity in the neonatal population. 

IMPLEMENTATION OF A CLINICAL SCORING TOOL TO ASSIST PHARMACISTS WITH PATIENT PRIORITIZATION

Katherine Miller, Neil Edillo, Joseph Bubalo

IRB approval pending.

The object of this study is to develop, implement, and assess the utility of a clinical scoring tool in OHSU’s electronic health record to assist pharmacists with patient prioritization to improve pharmacist efficiency and documentation of clinical interventions.  A group of clinical pharmacists with varied backgrounds and clinical experience have developed criteria to create a clinical scoring tool.  The clinical scoring tool prioritizes patients based on specific clinical characteristics, including lab values and medication orders, which are assigned a score.  A group of pharmacists will pilot the clinical scoring tool to assess the validity of the tool.  These pharmacists will be asked to prioritize their patient load on a given day based on the clinical characteristics they feel are most pertinent, which will be compared to the prioritization given to the patients by the clinical scoring tool in order to validate the process.  All pharmacists will be invited to complete a survey evaluating their ability to efficiently evaluate the patients on their units, their time management, and their job satisfaction prior to and post implementation of the clinical scoring tool.  The results of the survey and validation process will be discussed. 

ANALYSIS OF END TIDAL CO2 MONITORING: OPPORTUNITY TO IMPROVE PATIENT CONTROLLED ANALGESIA

Katherine Palmer, Kate Farthing

IRB approval received.

The primary objective of this project is to improve post-operative patient safety with patient controlled analgesia (PCA) pump use through monitoring of end tidal CO2 levels with a new Alaris Smart Pump module and device.  Oversedation is a patient safety issue often associated with post-operative patients and the initiation of a PCA pump for pain control, which may result in rapid response team calls for patient intervention.  The new PCA pump module and device measures indicators of oversedation, including the amount of CO2 exhaled by patients as well as their respiratory rate.  When the end tidal CO2 and the respiratory rate drop below the programmed threshold, the pump sets off an alarm to alert the nurse and prevents additional medication from being administered to the patient.  The new PCA pumps were piloted in post-operative patients managed on two nursing units.  The number of rapid response team calls and naloxone use during the three months prior to implementation of the pilot will be compared to those parameters throughout the three months following implementation of the pilot.  The results of the pilot intervention and the role of end tidal CO2 monitoring will be discussed.

DEVELOPMENT OF A PHARMACIST MANAGED PNEUMOCOCCAL VACCINATION PROGRAM: A PILOT STUDY 

Mallory Heath, Jessica Steffl

IRB approval pending.

The objective of the study is to determine the utility of pharmacist involvement in screening, ordering, and monitoring of pneumococcal vaccination through a pilot study.  When collaborating with a quality specialist within the institution, it was discovered that The Joint Commission core measure for pneumococcal screen and vaccination is not currently being achieved.  It is hypothesized that pharmacists’ contribution will lead to an increase in pneumococcal vaccination rates for those patients in whom the vaccine is indicated.  The adult general medicine clinical pharmacist will utilize the pneumococcal vaccine order set in the electronic health record to ensure the patients on the general medicine inpatient units covered by this pharmacist are screened daily for eligibility.  If the vaccine is indicated, the pharmacist will contact the provider for a vaccine order.  Finally, the pharmacist will work as a team with nursing to ensure the vaccine is administered prior to discharge.  The pneumococcal vaccination rates from the pilot study will be compared to vaccination rates from last year when a pharmacist was not involved in the vaccination screening process.  The results of the pilot study and impact of pharmacists on the pneumococcal vaccine process will be discussed.  

Andrew Gibler, PharmD

Analysis of a Standardized Opiate and Benzodiazepine Wean Protocol in the Pediatric Intensive Care Unit

Andrew Gibler 

IRB approved.

An analysis of the efficacy and safety of a new opiate and benzodiazepine wean protocol implemented at Legacy Emanuel Children’s Hospital pediatric intensive care unit will be performed by comparing the medical records of 30 patients before protocol implementation to 30 patients after protocol implementation. Efficacy will be assessed by comparing total doses and duration of opiate and benzodiazepine therapy used during the taper process before and after implementation of the protocol. Safety will be assessed by comparing the use of naloxone, flumazenil and intervention by the Rapid Response Team before and after implementation of the protocol. The Withdrawal Assessment Tool will be utilized in these patients. A two sample t-test will be performed in the data analysis comparing total doses and duration of opiate and benzodiazepine therapy. A p-value of 0.05 or less will be considered statistically significant. Safety parameters will be directly compared. In addition, the average score from the Withdrawal Assessment Tool will be calculated as a way to assess what percentage of patients were considered to exhibit withdrawal symptoms during the taper process. Results will be discussed.

Pharmacy Intervention on Antimicrobial Management of Critically Ill Patients

Immanuel Ijo, Jeffrey Carwithen, Deborah Sanchez, Jeff Feyerharm

Objectives

• Define the characteristics of antimicrobial therapy in the critical care setting.
• Describe pharmacy-driven antimicrobial stewardship program developed to improve outcomes in critically ill patients.
• Report specific types of pharmacy antimicrobial intervention in the critical care setting, including dose optimization, drug discontinuation or addition, intravenous to oral conversion and streamlining.
• Outline antimicrobial cost and clinical outcomes following pharmacy antimicrobial interventions in the critical care setting.
• Recommend appropriate alternatives to the proposed pharmacy-driven antimicrobial stewardship program in the critical care setting.

Katie Foster, PharmD

EVALUATING THE QUALITY OF CARE AND COST EFFECTIVENESS OF PHARMACIST LED DIABETES EDUCATION

Katherine Foster, Jacqueline Joss, Glenna Hughes

IRB notified, approval not needed.

Community Outreach, Inc. provides the opportunity for uninsured patients to receive medical care at clinics in Linn and Benton Counties in Oregon.  Samaritan Health Services supports these services financially, as well as supports the volunteer involvement of physicians, pharmacists, and nurses.  At the clinic in Corvallis, Oregon, pharmacists have been managing diabetic patients and providing education while working alongside physicians and physician assistants for the past six years.  In close collaboration with the physicians, pharmacists make recommendations for medication adjustments and laboratory monitoring to provide continuity of care for such a transient population.  To evaluate the care provided by the pharmacists, a retrospective chart review of 18 patients was conducted and compared with 18 patients receiving usual care at the clinic in Corvallis or at another location in Lebanon, Oregon.  Cardiovascular risk reduction and number needed to treat will be determined utilizing the UKPDS Risk Engine and compared between the two patient groups.  Cost effectiveness of supporting these services will be evaluated utilizing the number needed to treat and the health-systems financial considerations.  Results and conclusions will be presented.

CHRONIC PAIN MANAGEMENT COMPETENCY-BASED TRAINING PROGRAM FOR PHARMACISTS

Corinne Gavrun, Lou Ann Thorsness, Yvonne Breaker Rice, Nancy Louie Lee, Tanya Ramsey. 

IRB not needed.

Kaiser Permanente Northwest launched an initiative to further improve chronic non-malignant pain management. A new clinical pharmacy service has been implemented in collaboration with the Pain Management Clinic and Primary Care. The goal of the service is to support primary care in the management of chronic non-malignant pain and utilization of opioids while ensuring patient safety, optimizing outcomes, and reducing costs. This project was designed to assess the baseline confidence and competency of the pharmacists new to chronic non-malignant pain management and to administer a competency-based training program. Pre- and post-training surveys and tests were administered to capture demographic data and to assess changes in confidence and competency. A baseline for confidence and competency has been established. 5 pharmacists completed the pre-training survey and test. A post-training test score of 80% or better is required for successful completion of the training program and receipt of CE credits. The training program and results will be discussed.

Providence Health Plans

Beaverton, OR

MTM 2010: IMPLEMENTATION OF CMS PROGRAM REQUIREMENTS IN THE HEALTH PLAN SETTING

Vafa Mahboubi, James Slater.

IRB approved.

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Part D sponsors to provide Medication Therapy Management (MTM) services to targeted eligible beneficiaries that are designed to ensure that covered Part D drugs are used appropriately.  The program must be developed in cooperation with licensed and practicing pharmacists and physicians, and be furnished by qualified providers.  In the 2010 CMS call letter to plan sponsors, CMS details changes to MTM services offered, which includes expanded access and more specific requirements associated with interventions and outcomes reporting.  The objective of this study is to design and pilot the Providence Health Plans (PHP) MTM program on a cohort of members eligible for MTM services in 2009 and predicted to meet criteria for 2010.  Piloting the program will allow PHP to optimize the process of administering the MTM benefit in order to be compliant with CMS 2010 requirements, and develop a protocol for MTM pharmacists to follow when performing MTM services.  This will also allow PHP to assess the capabilities of existing software utilized by the health plan to provide clinical services, and identify the need to purchase third party MTM software to assist in improving the quality of care provided.  The MTM program will focus on safe drug utilization, opportunities to reduce the member's prescription drug cost burden, and identify opportunities to improve medication use for the optimal treatment of identified chronic disease states. Results will be discussed.

IMPLEMENTATION AND EVALUATION OF A PHARMACY RENAL DOSING PROGRAM

Amanda Bringe, Deborah Sanchez, and Tom Wavrin. 

IRB approved 

Many commonly prescribed medications require dose adjustment for patients with renal impairment.  A standardized pharmacy renal dosing program was developed at a 378 bed regional hospital.  The rationale for this project was to assure medications are appropriately dosed for patients throughout their hospitalization.  This study focuses only on antimicrobial medications in patients with renal impairment defined as a creatinine clearance of less than or equal to 50 mL/min.    The study will select five antibiotics and follow for three days after a pharmacy dose adjustment recommendation is instituted.  Each day the WBC, temperature, and cultures will be monitored to ensure patient is showing signs of improvement despite the change in dosage of antimicrobial medication.  This protocol will help to develop a standardized process in the future for renal adjustments among the pharmacists.  Results and conclusion will be presented.  

Techniques to Reduce Inappropriate Use of Proton Pump Inhibitors

Laura Atack, Pharm.D., Patricia Chandler RPh, Eric Pfeifer Pharm.D., Pete Tamis Pharm.D.,

The use of proton pump inhibitors (PPIs) in the hospital setting has increased substantially in recent years.  Literature has identified potential safety concerns regarding osteoporosis, infection, and drug interactions.  The objective of this project is to reduce unnecessary use of PPIs in hospitalized patients.  An initial retrospective medication use evaluation (MUE) was completed assessing appropriateness of PPI therapy (N=70).  Results demonstrated 42 patients (60%) who received a PPI did not have a documented indication, 15 (21.4%) had a history of osteoporosis, 3 (4.3%) had documented Clostridium difficile during hospitalization, 7 (10%) were on a thienopyridine during admission and 19 (27.1%) were discharged home on a PPI without a documented indication.  GI prophylaxis recommendations have been revised after communicating MUE results to the medical staff and Pharmacy and Therapeutics Committee.  The recommendations will be applied to pre-printed order sets and, in the future, will be incorporated into Computerized Physician Order Entry (CPOE).  An order for a PPI will require a documented indication and intended duration of treatment.  Education to physicians will include an evidence based review of PPIs and H2 receptor antagonists for GI prophylaxis.  Following implementation, a follow up MUE will be done to assess changes in PPI use.  Results from the follow up MUE and conclusions will be discussed.

INTRAVENOUS VANCOMYCIN DOSING IN MORBIDLY OBESE PATIENTS

Sarah McDaniel, Tom Christian, Kimberly Russell, John Bury.

IRB approval received. 

Although intravenous vancomycin dosing and kinetics have been studied extensively, limited and conflicting data exists regarding optimum dosing in morbidly obese patients.  A medication use evaluation (MUE) conducted at Southwest Washington Medical Center (SWMC) in 2008-2009 indicated that SWMC’s vancomycin protocol was not used consistently for morbidly obese patients.  Moreover, although these patients received lower doses than current guidelines recommend, vancomycin troughs were supratherapeutic (average 28.3 mcg/mL; 24% therapeutic troughs).  The primary objective of this project is to improve the safety and efficacy of intravenous vancomycin usage in morbidly obese patients at SWMC by standardizing dosing and achieving target trough levels.  SWMC’s vancomycin protocol has been updated to include specific dosing parameters for morbidly obese patients.  Patients are included if their BMI is greater than or equal to 40.  Patients are excluded if they are under 18, pregnant, or on dialysis.  Included patients receive weight based vancomycin dosing using corrected body weight rather than total body weight.  The MUE will be repeated to assess protocol adherence and resulting vancomycin troughs.  Full results will be discussed. 

DEVELOPING A PROGRESSIVE INTERNSHIP PROGRAM IN COLLABORATION WITH SCHOOLS OF PHARMACY

Jill Rosa. Providence St. Vincent Medical Center, Portland, OR (jill.rosa@providence.org)

IRB Approval not needed-no human subject data.

EVALUATING AND IMPROVING APPROPRIATE PRESCRIBING OF OPIOIDS IN THE ELDERLY.

Jia Jan Fu, Kristen Wilson, S. Pat McClure, Brian Galbreth, Southwest Washington Medical Center, Vancouver, WA (lfu@swmedicalcenter.org),

IRB approval received.  

 The Institute for Safe Medication Practices lists opioids as a high alert drug class due to the heightened risk of significant patient harm when used in error. Literature suggests that, in particular, elderly patients are at a higher risk of side effects due to age related changes in drug clearance and increased sensitivity to centrally acting medications. Advanced age is also a recognized risk factor for respiratory depression, which is a preventable adverse effect of opioids. As elderly patients are at a greater risk for adverse events related to opioid therapy, the intent of this project is to describe the current prescribing and administration practices regarding opioids in the elderly and identify areas for improvement at Southwest Washington Medical Center. To accomplish this, a medication use evaluation (MUE) was performed on 50 elderly inpatients (defined as ≥70 years old) who received opioid(s) during hospitalization. Data regarding age, sex, weight, admitting diagnosis, home medication list, prescribed opioids, dose, route, administration, and concurrent administration of anticholinergic medications was collected via retrospective chart review. The adverse events examined in this MUE included respiratory depression, falls, and naloxone use. Full results, including steps being taken to improve patient safety, are to be discussed.

H1N1 INFLUENZA CHARACTERIZATION AND NEURAMINIDASE INHIBITOR USE.

Jessica Hunt. 

In 2009, greater than 99% of circulating influenza viruses identified were of the H1N1 strain. On June 11, 2009 the World Health Organization declared the first phase 6 global influenza pandemic of the century. While H1N1 infection has resulted in significant patient morbidity and mortality, information on the clinical illness associated with H1N1 infection and optimal approaches to treatment are still emerging.  The pandemic calls for further evaluation of the clinical characteristics of H1N1 infection and risk factors for increased severity of illness with the hope of improving treatment of H1N1 infection in the future. A descriptive epidemiologic study was performed to characterize H1N1 infection and use of neuraminidase inhibitors in hospitalized patients.  This study describes the occurrence of laboratory confirmed H1N1 and assesses utilization of neuraminidase inhibitor therapy.  A retrospective medical record review was performed on a subset of patients at least 18 years of age hospitalized at Providence St. Vincent Medical Center and Providence Portland Medical Center for at least 24 hours who tested positive for the H1N1 virus during the months of September 2009 through December 2009. Data was collected to characterize H1N1 influenza cases including patient demographics, underlying co-morbidities, severity of illness, complications potentially related to H1N1 infection, neuraminidase inhibitor therapy, and patient outcome. Results will be discussed.

IMPLEMENTATION OF AN ENDOCRINOLOGIST PHARMACIST COLLABORATIVE FOR OUTPATIENT DIABETES MANAGEMENT.

Katrina Ho, J. Chow, S. Sherington, C. Wong.

IRB approval is received.

As an integral part of the healthcare team, pharmacists are ideally positioned to provide diabetes mellitus (DM) management. The purpose of this project is to incorporate pharmacy services into the outpatient setting utilizing a collaborative drug therapy management (CDTM) through a pilot implementation. The goal is to increase patients’ access to follow up care and to determine feasibility of an endocrinologist pharmacist collaborative service. The initial target populations will be patients discharged from the hospital in need of short term follow up care and established clinic patients requiring medication related visits. Types of interventions, impact on patient care, patient volume, and cost will be evaluated. Data will be collected prospectively during pilot service implementation. Descriptive statistics will be utilized in the data analysis. Full results, including all patients seen and managed by a pharmacist, will be discussed. 

EXPANDED PHARMACIST ROLE IN A PILOT TOBACCO CESSATION PROGRAM WITHIN AN INTEGRATED HEALTHCARE SYSTEM

Daniel Christian, Tanya Ramsey, Nancy Louie Lee. 

IRB not needed.

Tobacco cessation has been an ongoing area of focus and a priority HEDIS measure for Kaiser Permanente Northwest.  The region’s early 2009 tobacco cessation HEDIS results identified this as an area for improvement.  A survey of physicians revealed dissatisfaction and confusion with the current tobacco cessation program.  This project was designed to increase physician satisfaction with the tobacco cessation program and improve “advice given to quit” to tobacco using patients as measured by HEDIS performance. The pilot program utilized a written protocol, a simplified referral process, and automatic electronic system messaging. The new process also included a three phase pharmacy approach: medication initiation, two week tolerance check, and a three month follow up. Enrollment began January 1, 2010 and ended February 28, 2010 at one of the region’s medical offices. Surveys were issued to participating physicians before and after implementation of the new program to determine satisfaction.  Referrals made during the pilot were compared to referrals during the same time the previous year. This was used to measure if patients received “advice to quit” in accordance with the HEDIS measure for tobacco cessation. The results will be discussed.

EVALUATION OF A PHARMACIST’S ROLE IN MEDICATION RELATED FALL RISK REDUCTION

Tomaz Sousa, Steve Stoner. 

IRB approved.

The Joint Commission NPSG 9 requires an evaluation of the effectiveness of a fall risk reduction program. Certain medication classes have been implicated in increasing the risk of patient falls. Providence Health and Services has implemented an electronic nursing fall risk assessment and delirium pre-printed order set, which includes an order for a pharmacy consultation to assess medication related risks. In spite of these changes, there has been only a modest decline in fall rates and few pharmacy consults. As a result, an electronic alert process and falls risk assessment algorithm were created to automatically generate requests for pharmacy consultation. The purpose of this study is to evaluate the impact of the electronically generated fall risk report and pharmacy consultation on patient's risk to fall. The study is a matched observational trial evaluating an intervention group against historic controls. The study primary end point is the total number of pharmacist interventions generated on patients assessed as being at high risk of falls. The secondary endpoint evaluates the overall fall rate between the interventional and control groups. Results will be discussed. 

IMPACT OF REPLACEMENT FLUID CHOICE AND DIALYSIS RATE ON OUTCOMES AND COST IN CONTINUOUS RENAL REPLACEMENT THERAPY

Jesse Bierman, Josh Curry, Ali Olyaei

IRB approval pending.

Continuous renal replacement therapy (CRRT) is a dialysis modality used in the intensive care unit for patients who require dialysis but are hemodynamically unstable and unable to tolerate intermittent dialysis. Our institution changed the replacement fluid for CRRT from custom made by the pharmacy to a commercially available, pre-made replacement solution to improve efficiency, reduce waste, and minimize the potential for medication errors.   We also changed the dialysis rate of CRRT from a standard flat rate for all patients to a custom rate based on the patient weight following publication of recent clinical trials.  The objective of this study is to assess the impact of replacement fluid choice and dialysis rate in CRRT on patient outcomes and cost of therapy.  A retrospective chart review will be undertaken for all adult patients who received CRRT from March 2008 through December 2009.  Data collection will include baseline data and indicators of mortality, duration of CRRT, renal recovery, and CRRT solution use.  Cost analysis will be obtained through pharmacy purchasing records and patient chart review. Results including mortality and cost data will be presented.

IMPLEMENTATION AND OUTCOMES OF A PHARMACIST MANAGED WEIGHT BASED ANTIMICROBIAL DOSING PROTOCOL.

Lindsie Froehlich

IRB approval pending.            

Obesity is recognized by the World Health Organization to be a worldwide pandemic, now encompassing more than one third of adults in the United States.  An increasing amount of literature suggests the need to optimize antimicrobial use in obese patients through dose escalation, and evidence indicates that the outcome of infections is worse in the obese population.  The current study will investigate the design, implementation, and outcomes analysis of a weight-based antimicrobial dosing protocol managed by pharmacists within a 260 bed teaching hospital.   The study includes all patients ≥ 18 years of age, receiving any one of the antimicrobials included in the protocol intravenously, weighing more than the prespecified weight (kg) deemed appropriate for dosage adjustment, and not requiring dialysis.  Data will be collected retrospectively using both paper and electronic medical records, as well as pharmacist monitoring sheets.The primary outcome is number of interventions by the pharmacist post-protocol implementation.  Secondary outcomes to be analyzed include length of stay and improvement of infection in patients with sepsis and pseudomonal infections both pre- and post-protocol implementation.  Compliance with the protocol and number of patients receiving subtherapeutic dosing will be measured post-protocol implementation.    Additional subgroup analyses will breakdown the aforementioned outcomes by specific nursing unit and antimicrobial to identify any potential outliers.  Full results will be discussed.

THERAPEUTIC DRUG MONITORING OF MYCOPHENOLATE MOFETIL IN PATIENTS UNDERGOING  KIDNEY TRANSPLANTATION: A PROSPECTIVE PHARMACOKINETIC STUDY

Ahmed Zikri

IRB approval received.

Mycophenolate Mofetil (MMF) is an immunosuppressant used to prevent rejection in kidney transplant patients. The standard dose of MMF is 1000 mg twice daily. Recent studies have shown that therapeutic drug monitoring (TDM) of MMF via measuring AUC in these patients could significantly decrease risk of rejection as well as toxicity. The two main methods used to measure AUC of MMF are multilinear regression (MLR) equations and Bayesian kinetics (BK). Currently, Legacy Transplant Clinic doesn’t perform TDM for MMF. One of the objectives of this study is to evaluate which method of calculating AUC for both brand and generic form of MMF will best fit our patient population. We also hypothesized that performing TDM of MMF will decrease acute rejection and risk of toxicity. In this study, we conducted TDM of brand name MMF (Cellcept) in 30 patients receiving kidney transplantation. A set of three blood samples was drawn at specified times on days 7, 30 and 60 post-transplantation. X patients were switched over to generic MMF for one week and another set of blood sample was drawn on day 67. AUC values were measured using both MLR equations and Bayesian kinetics. The dose of MMF was adjusted based on AUC data as well as signs of acute rejection or toxicity as determined by treating nephrologist. Data was then compared to data from a control group of 30 transplant patients who received the standard dose of MMF.  Complete results of the study will be discussed later.

EVALUATING PRESCRIPTION SYNCHRONIZATION AND MEDICATION MANAGEMENT IN A COMMUNITY PHARMACY

Tara Schmidt, Stacy Ramirez, Jennifer Davis, Richard McLeod. 

IRB approval received.

This study demonstrated additional ways to expand medication management services while evaluating the resulting benefits of synchronizing prescriptions using an appointment based care model in a community pharmacy.  Economic, clinical, and customer satisfaction outcomes relating to the patient and pharmacy were evaluated. In a community pharmacy setting, patients with five or more routine medications per month were offered enrollment. Patients’ prescriptions were migrated to a single fill day per month using an appointment based model.  Medication management services were conducted upon enrollment and via phone call two weeks before their upcoming fill day to review pertinent topics and ensure the patient’s medication profile remained unchanged. In addition, targeted medication management services were provided when prescriptions were picked up each month.  Baseline and 4 month data collection included customer satisfaction survey results, customer service measures (average wait time, ready when promised, partial fills, out of stock fills), clinical outcomes (blood pressure, blood glucose, cholesterol), prescription adherence, and clinical interventions made.  A total of 10 patients were enrolled in this study.  Patients enrolled filled an average of 9.7 prescriptions per month.  In total, 29 clinical interventions had been made at the 2 month interim, generating an average of 2.9 interventions per patient.  Full results from the 4 month study will be discussed. 

QUANTIFICATION OF ALUMINUM REDUCTION IN PARENTERAL NUTRITION SOLUTIONS FOR NEONATAL PATIENTS

Brian Melhart, Annie Migaki, Robert Huston.

IRB not needed-no human subject data.

Total parenteral nutrition (TPN) solutions are used in the neonatal population when oral intake is not possible. Calcium and phosphate supplementation is especially important for normal bone and skeletal development.  Due to contamination during manufacturing, high levels of aluminum are found in calcium gluconate and potassium phosphate, the primary salts traditionally used for calcium and phosphate supplementation in TPN solutions. Previous studies have associated aluminum exposure during long-term parenteral feeding with impaired neurological development. The NICU at St. Vincent’s Medical Center in Portland, Oregon has stopped using calcium gluconate and potassium phosphate and changed to calcium chloride and sodium phosphate which have markedly lower levels of aluminum. The purpose of this study was to determine the actual aluminum content in neonatal TPN solutions, to quantify the reduction in aluminum exposure achieved by using ingredients with lower aluminum content, and to compare results to the predicted aluminum content based on manufacturer’s data. The NICU’s standard formulation using calcium chloride and sodium phosphate was compared to three other formulations for comparison. The first formulation for comparison was identical to the standard formulation except cysteine was added, the second formulation used calcium gluconate instead of calcium chloride, and the third formulation used calcium gluconate and potassium phosphate. Full results to be discussed.