Ben Chiarolanza, PharmD Background: Medication discrepancies at discharge from the hospital have been associated with adverse drug events (ADEs). Clinical pharmacist involvement with medication reconciliation at discharge has been associated with a decrease in medication discrepancies and ADEs. In January 2023, a new process was implemented for clinical pharmacists to prospectively evaluate high-impact discharge prescriptions prior to outpatient pharmacy electronic transmission. The medications initially considered for review encompassed pediatric prescriptions (for individuals under 18 years of age), insulins, oral anticoagulants, and antimicrobials. The purpose of this study is to determine the impact of prospective review of discharge prescriptions on medication safety. Percentage of CABG and/or Valvular Surgery Patients Discharged on Amiodarone Cassandra Dilibero, PharmD Background: Post-operative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery, with the highest incidence 48 to 72 hours post-operation. The 2023 AHA/ACC/HRS guideline on atrial fibrillation (AF) recommend beta-blockers as first-line therapy for the treatment of POAF, unless contraindicated. . Despite these recommendations and significant adverse effects of amiodarone, patients are still regularly initiated on amiodarone for management of POAF. Furthermore, amiodarone initiated while inpatient may be unnecessarily continued upon discharge. Apixaban dosing in non-valvular atrial fibrillation patients with elevated serum creatinine Ivana Ganeva, PharmD Background: Current guidelines recommend dose reduction in patients with at least 2 of the following criteria: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine (Scr) ≥ 1.5 mg/dL.1-2 The use of reduced dose apixaban for non-valvular atrial fibrillation (NVAF) has been seen in common practice in patients with elevated serum creatinine levels. However, data is limited on patients that only meet Scr ≥ 1.5 mg/dL criteria and patients undergoing hemodialysis. This study aims to assess the clinical outcomes for patients with NVAF on apixaban with Scr ≥1.5 mg/dL. It also further compares the impact of reduced dose apixaban in patients on hemodialysis. Jordan-Nichole Manno, PharmD Background: Urinary tract infections (UTIs) are a frequent diagnosis made in the emergency department (ED). Solely, in the United States more than 2 million ED visits are attributable to UTIs annually. However, antibiotics for UTIs are often inappropriately prescribed in the ED. Sub-therapeutic and/or supra-therapeutic treatment can lead to resistant urinary isolates, recurrent infections, or treatment failure. Beta-lactam antibiotics are commonly used for UTI treatment despite lack of guideline support. This lack of support can be attributed to outdated guidelines and possible increase in resistance to first line agents with a need for alternative agents. The main purpose of this research is to aid in quality improvement of outpatient antibiotic prescribing for UTIs in the emergency departments across three Dignity Health St. Rose Dominican campuses. Necessity of ED-Based Outpatient Infusion Services as a Stewardship Program Benjamin Mossholder, PharmD Background: Infusion centers provide longitudinal chronic disease management of numerous conditions. Emergency departments have experienced patient visits for receipt of normally infusion-center based care. The purpose of this study was to assess the necessity and feasibility of implementing an outpatient infusion service within the emergency department (ED) for when the institution’s outpatient infusion center is unavailable. hemodialysis. |