Non-trauma uses of viscoelastic hemostatic assays in critical care: A narrative review and primer for pharmacists

Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic tests of whole blood that provide real-time analyses of coagulation. TEG and ROTEM are often used to guide blood product administration in the trauma and surgical settings. These tests are increasingly being explored for their use in other disease states encountered in critically ill patients and in the management of antithrombotic medications. As the medication experts, pharmacists should be familiar with how to interpret and apply viscoelastic tests to disease state and medication management. The purpose of this narrative review is to provide a primer for pharmacists on viscoelastic tests and their interpretation and to explore non-trauma indications for viscoelastic testing in critical care. Literature evaluating the use of TEG and ROTEM for patients with acute and chronic liver disease, ischemic and hemorrhagic stroke, myocardial infarction, cardiac arrest, coronavirus disease 2019, and extracorporeal membrane oxygenation are described. Current applications of viscoelastic tests by pharmacists and potential future roles of critical care pharmacists in expanding the use of viscoelastic tests are summarized.Copyright © 2023 The Authors. JACCP: Journal of the American College of Clinical Pharmacy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.

Pandemic related mental health

OnTrackNY is a nationally recognized Coordinated Specialty Care model disseminated across New York state for young people experiencing early non-affective psychosis. OnTrackNY is a network of 22 teams located in licensed outpatient clinics, serving over 2500 individuals. OnTrackNY offers medication management, case management, individual and group cognitive behaviourally oriented therapy, family support and psychoeducation, supported employment and education, and peer support services. Teams receive training for implementation through an intermediary organization called OnTrack Central. OnTrackNY was selected as a regional hub of the National Institute of Mental Health Early Psychosis Intervention Network (EPINET), a national learning healthcare system (LHS) for young adults with early psychosis. This symposium will present the different ways in which EPINET OnTrackNY implemented systematic communitybased participatory processes to ensure robust stakeholder involvement to improve the quality of OnTrackNY care. Florence will present results of an assessment of stakeholder feedback experiences used to develop strategies for assertive outreach and engagement of program participants, families and providers. Bello will present on mechanisms for integrating of co-creation principles to design, develop and execute quality improvement projects in EPINET OnTrackNY. Stefancic will present on quality improvement projects that used rapid cycle qualitative methods, tools, and strategies to build team capacity and flexibility to respond to an LHS. Montague will present adaptations to OnTrackNY services during the COVID-19 pandemic using an implementation science framework. Finally, Patel will lead a discussion on the implications of involving individuals with lived experiences in all phases of the process to maximize learning in an LHS.

Comprehensive medication management services provided via telehealth or hybrid models: A scoping review

Comprehensive medication management (CMM) is increasingly provided by health care teams through telehealth or hybrid modalities. The purpose of this scoping literature review was to assess the published literature and examine the economic, clinical, and humanistic outcomes of CMM services provided by pharmacists via telehealth or hybrid modalities. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. Randomized controlled trials (RCTs) and observational studies were included if they: reported on economic, clinical, or humanistic outcomes;were conducted via telehealth or hybrid modalities;included a pharmacist on their interprofessional team;and evaluated CMM services. The search was conducted between January 1, 2000, and September 28, 2021. The search strategy was adapted for use in Medline (PubMed);Embase;Cochrane;Cumulative Index to Nursing and Allied Health Literature;PsychINFO;International Pharmaceutical s;Scopus;and grey literature. Four reviewers extracted data using a screening tool developed for this study and reviewed for risk of bias. Authors screened 3500 articles, from which 11 studies met the inclusion criteria (9 observational studies, 2 RCTs). In seven studies, clinical outcomes improved with telehealth CMM interventions compared to either usual care, face-to-face CMM, or educational controls, as shown by the statistically significant changes in chronic disease clinical outcomes. Two studies evaluated and found increased patient and provider satisfaction. One study described a source of revenue for a telehealth CMM service. Overall, study results indicate that telehealth CMM services, in select cases, may be associated with improved clinical outcomes, but the methods of the included studies were not homogenous enough to conclude that telehealth or hybrid modalities were superior to in-person CMM. To understand the full impact on the Quadruple Aim, additional research is needed to investigate the financial outcomes of CMM conducted using telehealth or hybrid technologies.Copyright © 2022 Pharmacotherapy Publications, Inc.

Medicines management of long-term conditions during the COVID19 pandemic: a narrative systematic review

Introduction: Due to lockdown measures associated with the COVID 19 pandemic (1), there were substantial changes to healthcare delivery, including the suspension of face-to-face medical appointments, expansion of telehealth and changes to medication protocols.(2) It is important to learn from the successes and challenges of this period to ensure we adapt and improve how we support people to take medicines in the future. Aim(s): We sought to conduct a systematic review to explore the different approaches used to deliver medicines management services for people living with long term conditions (LTCs) during the pandemic and identify strategies that could be integrated into standard care. Method(s): We conducted a systematic review across 3 large databases: MEDLINE (OVID), EMBASE (OVID) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Our research question and search strategy was developed using the PICO framework (Population: adults with LTCs, Intervention: medicines management during the COVID 19 pandemic;no comparison group. Outcome(s): any aspect relating to medicines management. Search terms relating to 'long term conditions', 'medication management' and 'COVID-19' were used. One reviewer (LM) screened all titles, s, and full texts. We included studies discussing medication management of LTCs, in patients of all ages and healthcare settings, throughout the pandemic. Primary literature sources, feasibility studies and case studies, were included. We excluded studies solely focusing on disease monitoring, or the treatment of COVID/ 'long Covid'. One reviewer performed a thematic analysis, synthesising the findings into themes and sub-themes, which were discussed with a further reviewer (CT). A critical appraisal was performed using the Critical Appraisal Skills Programme checklists. Result(s): The search returned 2365 results. After deduplication, articles were removed at the title (n=1070) (n=813) and full text (n=232) stages. 31 studies were included. Studies were conducted in India (n=6), US (n=5), international (n=4), France (n=2), Italy (n=2), and one each from China, Japan, Jordan, Mexico, Morocco, Nigeria, Romania, Saudi Arabia, Spain, UK, UK and US, and location not specified. Most studies (n=17) employed subjective methods of data collection (surveys/ questionnaires). We identified 6 themes. These were: changes in consultation type, for instance using teleconsultations and smartphone apps to monitor glucose control and diabetic management. Studies described temporary changes to treatment protocols e.g., using oral chemotherapy to reduce the need for in-person appointments and reduce the infection risk associated with intravenous administration. Control of certain conditions for example epilepsy was reduced in some studies. Patients missed doses due to drug shortages associated with disruptions in the medication supply chain, particularly in low-income countries. Finally, we identified prescribing trend changes in certain classes of medicines (e.g. reduced biologic usage due to immunosuppression risk) and an increase in patients self-medicating conditions including anxiety and depression, with associated safety risks. Conclusion(s): This review suggested that certain medical conditions such as diabetes and hypertension were more suited to remote monitoring with technological interventions such as smartphone apps. While other conditions e.g., cancer and epilepsy, demonstrated a greater need for in-person care. Countries of lower socioeconomic status were disproportionately affected by the pandemic.

Pay attention to the medication safety of patients during the period of coronavirus disease 2019 epidemic prevention.

The coronavirus disease 2019 (COVID-19) epidemic is facing the most critical situation. As of January 11, 2021, there have been nearly 90 million confirmed cases worldwide and nearly 2 million deaths. The local epidemic situation in China is sporadic and locally clustered, and the situation of epidemic prevention is difficult and complicated. In this situation, there are many problems in medication safety of patients, such as safety issues in off-label medication and compassionate medication of COVID-19 treatment, safety problems in the combination use of drugs for COVID-19 and drugs for other diseases, monitoring of adverse drug reactions in COVID-19 treatment, the safety issues in self-purchased drugs for prevention and treatment of COVID-19, and the medication safety in patients with other diseases during the epidemic. Therefore, it is necessary to pay more attention to the medication safety of patients to fight the epidemic scientifically and to win a greater victory in the fight against the COVID-19 epidemic at a smaller price.Copyright © 2021 Chinese Medical Association

Low dose vs high dose tocilizumab in COVID-19 patients with hypoxemic respiratory failure.

PURPOSE: Tocilizumab has been shown to decrease mortality when used concomitantly with steroids in COVID-19 with 8 mg/kg (max 800 mg) being the standard dose. Our study sought to assess whether a low dose (400 mg) shows similar benefit compared to a high dose for COVID patients concurrently on the same median dose of steroids. MATERIALS/METHODS: A retrospective, multihospital observational study of COVID-19 patients who received tocilizumab in conjunction with steroids between March 2020 and August 2021 was conducted. RESULTS: A total of 407 patients were analyzed with low dose group being significantly more ill at baseline as a higher percentage of patients received vasopressors, were admitted to the ICU and on mechanical ventilation. In the propensity-matched analysis, both groups receiving a median dexamethasone equivalent dose of 10 mg showed no difference in 28-day mortality (p = 0.613). The high dose group had a higher rate of fungal and viral infections. CONCLUSION: Compared to low dose tocilizumab, the high dose did not provide additional efficacy and mortality benefit but resulted in higher fungal and viral infections. This study illustrates that low dose tocilizumab can be an alternative to high dose during a drug shortage of tocilizumab without compensating for efficacy and safety, conserving resources for more patients.

Urate-lowering therapy adherence and the association with medication beliefs, self-efficacy, depression, anxiety, and COVID-19 pandemic-related concern in Chinese gout patients

Background: Under the current situation of COVID-19 pandemic, more medical resources are assigned to the prevention and control of the pandemic, while relatively less attention is paid to patients with chronic diseases. Previous studies reported that COVID-19 deaths were mainly observed among male patients with multiple comorbidities, and the major comorbidities were hypertension, diabetes, coronary heart disease, cerebral infarction, and chronic bronchitis, all of which are chronic diseases. As one of the most common chronic diseases that occurs in male, no report regarding how COVID-19 impacts gout patients psychologically due to the general susceptibility, their mental state and willingness to adhere to ULT treatment and the actual ULT adherence so far. This study aims to assess urate-lowering therapy adherence and the relationship with medication beliefs, self-efficacy, depression, anxiety, and COVID-19 pandemic-related concern in Chinese gout patients during the COVID-19 outbreak. Method(s): The cross-sectional study employed a total of 101 gout patients receiving urate-lowering therapy to evaluate adherence, medication beliefs, self-efficacy, depression, anxiety, and COVID-19 pandemic-related concern via a mobile app-based questionnaire. Statistical analysis was performed using SPSS 22.0. Result(s): 101 valid responses were included in the statistical analysis. Patients' adherence rate to urate-lowering therapy during the COVID-19 outbreak was 22.8%, higher than that in normal periods (9.6%). Compared with adherent groups, non-adherent gout patients had shorter disease duration, lower self-efficacy, lower Necessity about urate-lowering therapy score, higher Concerns about urate-lowering therapy score, and smaller Necessity-Concerns differential. Depression and anxiety rates (3.0% and 5.0%, respectively) during the COVID-19 break were lower than that in normal periods. Additionally, depression, anxiety, as well as COVID-19 pandemic-related concern (27.7%) were not related to ULT adherence. Conclusion(s): Adherence rate to urate-lowering therapy in Chinese gout patients during the COVID-19 outbreak was 13.2%, higher than normal times, but still very poor. Except for a little concern about being more susceptible to the virus, patients' mental state is relatively good. While the country puts great efforts in COVID-19 prevention and control, attention must also be paid to the medication management of patients with chronic diseases such as gout.

Tele-Critical Care Pharmacist Interventions before and after an Emergency Prescribing Protocol

INTRODUCTION: Prior to the COVID-19 pandemic, telecritical care (TCC) pharmacists evaluated patients at multiple ICUs across this healthcare system using clinical decision support (CDSS) alerts for abnormal laboratory values. To increase provider capacity for higher acuity activities, a critical care pharmacist emergency protocol (CCPEP) was enacted, allowing TCC pharmacists to manage therapy in multiple domains. The purpose of this review was to characterize TCC pharmacist interventions prior to and after CCPEP implementation. METHOD(S): This multi-center, multi-ICU, retrospective observational quality improvement project evaluated TCC pharmacist interventions documented from September 1, 2019, through November 30, 2019 (pre-CCPEP) compared with September 1, 2020, through November 30, 2020 (post- CCPEP). Descriptive statistics were reported. RESULT(S): In the pre-CCPEP period, 1448 interventions were performed in 655 unique patients (mean 2.2 interventions/patient) across 10 ICUs as compared to 2115 interventions in 861 unique patients (mean 2.5 interventions/ patient) across 8 ICUs post-CCPEP, a 46.1% increase in the total number of interventions. Glycemic control interventions decreased from 38.7% to 26.4% of interventions, while medication management interventions increased from 28.3% to 41.3% from the pre- to post-CCPEP period, respectively. In medication management, sedation and analgesia interventions increased from 57 (13.9%) in the pre- CCPEP period to 251 (28.8%) in the post-CCPEP period, cardiovascular medication recommendations decreased from 60 (14.6%) to 50 (5.7%), and gastrointestinal agent recommendations increased from 8 (2%) to 68 (7.8%). Electrolyte management, venous thromboembolism prophylaxis, and stress ulcer prophylaxis intervention rates remained similar. CONCLUSION(S): Implementation of a CCPEP facilitated more interventions by TCC pharmacists than CDSS review alone, especially in general medication management. Increased sedation and analgesia interventions in the post-CCPEP period suggest enhanced complexity of recommendations. More patients were intervened on in the post-CCPEP period with more interventions per patient, which may be due to increased census and acuity in addition to the CCPEP. Future directions include pursuing clinical pharmacist practitioner status in the TCC space.

Clinical Pharmacy Services Enhanced by Electronic Health Record (EHR) Access: An Innovation Narrative.

BACKGROUND: Patient care in the community pharmacy setting is often hindered due to limited access to adequate patient health information (PHI). Various studies suggest that lack of access to PHI is a main reason for delay in pharmaceutical care, medication dispensing errors, and lacking interprofessional relationships between prescribers and pharmacists. Literature has shown that interprofessional collaboration and improved access to PHI can improve transitions of care and communication for pharmacists, but literature is sparse on implementation of electronic health record (HER) access within independent community pharmacies. METHODS: This observational study follows implementation of HER access into a rural community pharmacy to enhance common clinical services carried out by pharmacy staff. Metrics include number of enhanced consultations by pharmacy staff, type of consultations provided, potential reimbursement, decreased need to follow up with other providers, potential for decreased time to treatment or refills, and aspects of EHR most utilized during search. RESULTS: Two-hundred sixty three patients' profiles were assessed, with 164 (62.4%) deemed appropriate for EHR access and searching. Most interventions made were related to cardiovascular, endocrinologic, neuropsychiatric, and COVID-19 therapy medications. CONCLUSION: EHR access in community pharmacy has the potential to improve both the quality and availability of clinical patient interventions through enhanced knowledge of PHI.

Managing Medications During a Pandemic: A Mixed-Methods Study of Perception of Adult Kidney Transplant Recipients and Those Waiting for a Kidney Transplant

Purpose: Patients interact with healthcare providers (HCP) and pharmacists to manage medications. Little is known about the impact of COVID-19 on medication management. The purpose of this study was to describe medication management, HCP/pharmacist interactions, and adherence, including initiation, implementation and persistence, during the COVID-19 pandemic in kidney transplant (KT) patients and those on the KT wait list. Method(s): The IRB determined this study was exempt. Using a mixed methods design, 340 adults at a transplant center in the midwestern US were recruited. The Managing Medications in the Midst of a Pandemic Survey measured HCP/pharmacy encounters and medication management. The Basel assessment of adherence to medications scale measured medication adherence. Result(s): The sample average age was 58.2 years, 61% male, and 86% White. During the COVID-19 pandemic, 90% had/were currently practicing socially distancing, 87% had /were currently wearing a face mask when out in public, 19% had/were currently diagnosed with COVID-19, and 84% received the vaccine. Additional survey results include: Medication management: 82% percent plan/organize their own medications. Healthcare team interactions: 98% talked with their HCP since the beginning of social distancing;13% delayed seeing a HCP because of COVID-19 concerns. Pharmacy interactions: 11% changed their method of obtaining medications from pharmacy due to social distancing and 3.5% delayed refilling medications. Medication adherence-Initiation: 2.5% were prescribed a new medication but did not begin taking it. Medication adherence-Implementation: in the 4 weeks prior to the survey, 19% missed a dose, 6.7% skipped a dose, 16% took a medication more than 2-hour time difference from the prescribed time, and 2.5% altered prescribed amount. Medication adherence- Persistence: 3.4% stopped taking a prescribed medication without a doctor's order during the pandemic. Conclusion(s): A majority of the patients waiting for a KT and KT patients acted to prevent COVID-19 but some still contracted the virus. The pandemic changed medication management interactions with HCP and pharmacists. Adherence implementation problems were nearly 20%. Findings are relevant to transplant HCP and pharmacists, who must support patients attempting to manage and adhere to prescribed medications during the pandemic.

HYDROXYCHLOROQUINE CAN BREAK YOUR HEART

SESSION TITLE: The Cardiac Intensivist 2 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Hydroxychloroquine and chloroquine are medications derived from aminoquinoline. They are disease-modifying antirheumatic drugs used in the treatment of systemic lupus erythematosus (SLE). Although well tolerated, they do have side effects such as retinopathy, vacuolar myopathy, neuropathy, and as seen in our patient, cardiotoxicity. CASE PRESENTATION: Patient is a 48 year old female with a past medical history significant for chronic kidney disease secondary to autosomal dominant polycystic kidney disease, SLE on hydroxychloroquine who presented to the emergency department complaining of weakness. On arrival the patient was found to be in cardiogenic shock. Her transthoracic echocardiogram revealed a reduced ejection fraction of 37% and a large pericardial effusion concerning for tamponade physiology. Her COVID-19 PCR test was positive. She was taken for emergent pericardiocentesis which revealed 300cc of exudative fluid. Patient’s right heart catheterization revealed mean pulmonary capillary wedge pressure of 23 mmHg, pulmonary artery pressures of 44 mmHg/24 mmHg, mean 31mmHg, cardiac index 1.1L/min/m² by thermodilution, 1.7 L/min/m² by Fick. Following right heart catheterization and intra aortic balloon pump placement, the patient was admitted to the medical intensive care unit (MICU) and placed on intravenous inotropic and vasopressor support. Shortly after arrival to the MICU, patient had an increase in vasopressor requirements. Bedside ultrasound revealed cardiac tamponade. Patient had approximately 400cc of bloody pericardial fluid removed from her pericardial drain. The decision was made for emergent venoarterial extracorporeal membrane oxygenation (ECMO) to be initiated. Endomyocardial biopsy was performed which revealed vacuolization in the cytoplasm of several myocytes as well as lymphocytes in the interstitium of the endocardium. The vacuoles found in the cardiac myocytes were PAS positive. These biopsy results are consistent with hydroxychloroquine cardiotoxicity. The patient’s hydroxychloroquine was discontinued. In addition to hemodynamic support, she also received intravenous immunoglobuluin and systemic steroids. After a prolonged hospitalization she was successfully discharged. DISCUSSION: Cardiotoxicity is a rare adverse reaction seen with hydroxychloroquine. A 2018 systematic review revealed 127 cases of cardiac toxicity associated with the use of hydroxychloroquine or chloroquine. Most patients had been treated with the medication for a prolonged period of time and the toxicity is dose dependent. The mechanism behind hydroxychloroquine and chloroquine induced cardiomyopathy is believed to be secondary to lysosomal dysfunction as a result of toxic phospholipid accumulation in cardiomyocytes. CONCLUSIONS: In patients with new onset cardiomyopathy, a detailed medication reconciliation should be conducted to evaluate for toxins such as hydroxychloroquine and chloroquine. Reference #1: Della Porta, A., Bornstein, K., Coye, A., Montrief, T., Long, B., & Parris, M. A. (2020). Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians. The American Journal of Emergency Medicine. Reference #2: Abbi, B., Patel, S., Kumthekar, A., Schwartz, D., & Blanco, I. (2020). A Case of Cardiomyopathy With Long-term Hydroxychloroquine Use. JCR: Journal of Clinical Rheumatology, 26(8), e300. Reference #3: Chatre, C., Roubille, F., Vernhet, H., Jorgensen, C., & Pers, Y. M. (2018). Cardiac complications attributed to chloroquine and hydroxychloroquine: a systematic review of the literature. Drug safety, 41(10), 919-931. DISCLOSURES: no disclosure on file for Joseph Adams;no disclosure on file for Suliman Alradawi;No relevant relationships by George Kalapurakal No relevant relationships by Mohammed Siddiqui

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill.

BACKGROUND: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. METHODS: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. RESULTS: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06-1.19), 1.17 (1.1-1.24), and 1.21 (1.14-1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75-0.97] vs. 0.88 [0.76-0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71-0.93) and 0.87 (0.77-0.96), respectively. CONCLUSION: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.

Telepharmacy at Mental Health Services: A new approach to medication therapy management during COVID-19

Service or Program: The number of COVID-19 infections have increased dramatically since March 2020 in Qatar. Measures have been taken to minimize the risk of exposure to COVID-19 including medication home delivery by postal service and by using telemedicine at The Mental Health Service (MHS), a tertiary care hospital in Qatar. In order to continue patients' access to care during the pandemic, the Medication Therapy Management (MTM) clinic at MHS would like to utilize clinical pharmacists to offer patient counseling, medication reviews, and develop medication action plans with the patients via telepharmacy. Justification/Documentation: Patients for whom counseling is essential to ensure positive outcomes of therapy were identified;patients on lithium or clozapine (phase 1), patient on newly prescribed psychotropics or on antipsychotic polypharmacy (phase 2), females on valproate in childbearing age (phase 3). The aim of this quality improvement (QI) project was to improve the number of patients currently receiving MTM service from baseline (90) by 20% by September 2020, 50% by December 2020 and 80% by March 2021. Outcome measure included percentage increase in patients from baseline who are receiving telepharmacy service, process measures included the percentage compliance of filling the Moresky Medication Adherence Scale-4 by the pharmacist, the percentage of referrals to other MHS services, balance measures were patient/caregivers and staff satisfaction. The improvement in outcome measure was successfully achieved in each phase;phase 1 - 28%, phase 2 - 82%, phase 3 - 127%. QI tools were used as appropriate. Adaptability: This service was intended to be provided by clinical pharmacists to adult patients registered under MHS. Similar service can easily be adapted to another setting by clinical pharmacists using comparable strategies and measures. Significance: The lessons learnt from this QI project will help in increasing patients' access to care, promote better utilization of resources, and allow better communication and management of patients.

2022 ACCP Virtual Poster Symposium

The proceedings contain 127 papers. The topics discussed include: utility, safety, and necessity of as needed electrolyte replacement orders: a multi-center medication use evaluation;perceptions of inpatient internal medicine pharmacists at a large quaternary academic medical center;comparative analysis of pharmacologic treatments for new onset insomnia in hospitalized adult patients;venous thromboembolism prophylaxis with enoxaparin versus unfractionated heparin in patients with low body weight;efficacy of apixaban loading doses post parenteral anticoagulation for venous thromboembolism;real-world impact of continuous glucose monitoring in non-insulin treated type 2 diabetes;expanding the scope at medication management service clinics through a patient recruitment initiative;impact of clinic-provided home blood pressure monitors during COVID-19 pandemic on blood pressure in underserved adults over 50 years old;and PCMH pharmacist impact of quality care measures for patients with uncontrolled type 2 diabetes (T2D).

PHARMACIST INTERVENTION IN SMOKING CESSATION: REALITY OR JUST “BLOWING SMOKING”

BACKGROUND: To extend the reach of primary care physicians, Collaborative Practice Agreements (CPA) and Pharmacist Clinician Licenses (PCL) have emerged as possible solutions to allow clinical pharmacists acting under a protocol to perform specific patient care functions, such as smoking cessation counseling. While studies have supported the efficacy of this approach, few data are available on the frequency of their use. METHODS: A list of pharmacies in the state of New Jersey (NJ) and New Mexico (NM) was obtained through the GoodRx Gold membership program list, which included 1,396 pharmacies in New Jersey and 151 in New Mexico. We randomly selected 113 pharmacies in New Jersey, which we contacted between December 2020 to March 2021. From New Mexico, we randomly selected 104 pharmacies, which we contacted between February 2021 and December 2021. Our interviewer-administered survey, which was designed to assess practice in 2019 (pre-pandemic), included questions on the presence of a CPA or PCL and the counseling provided (duration, frequency and type of counseling). RESULTS: In NJ, 83/113 (73%) pharmacies completed the survey, 17 declined to participate and awaiting reply from 13. Only 8/83 pharmacies reported having a CPA in place. One pharmacy had a CPA plan for diabetes medication management pre-pandemic but plans were postponed due to COVID-19. Another pharmacy stated that they had a CPA but declined any further participation in the survey. Of the remaining pharmacies participating in CPAs, 5 had agreements with physicians and 1 with nurse practitioner along with physician assistant. Three pharmacies provided smoking cessation counseling, two provided other counseling services and 1 solely provided naloxone treatment. Among the pharmacies participating in CPAs, they estimated completing 15-30 counseling interventions during 2019, with interventions ranging 5 minutes to 15 minutes. The pharmacies that provided smoking cessation counseling estimated less than 15 interventions in 2019, ranging from 5 minutes to 30 minutes. In NM, 61/104 (59%) pharmacies contacted, 24 declined to participate and awaiting reply from 19. Of the 61 pharmacies that participated, 7 had a PCL while the other 54 pharmacies did not. Of the pharmacies with PCLs, 4 declined further participation in the survey and of the remaining 3 pharmacies, 1 included smoking cessation counseling. Among the pharmacies recorded in the survey as participating in PCLs, they estimated 15 to 30 interventions during 2019 with interventions ranging 5 minutes to 15 minutes. The pharmacy that provided smoking cessation counseling estimated less than 15 interventions per year ranging from 15 minutes to 20 minutes. CONCLUSIONS: Pharmacists are effective at providing lifestyle counseling and legal agreements exist to support their doing so. We found that this potential remains vastly underutilized. Future studies should further examine barriers to having pharmacists deliver lifestyle counseling and test interventions to increase it.

AN INITIATIVE TO DECREASE 30-DAY HOSPITAL READMISSION RATES AT AN URBAN ACADEMIC SAFETY-NET HOSPITAL THROUGH A RESIDENT-LED TRANSITIONS-OF-CARE CLINIC

STATEMENT OF PROBLEM/QUESTION: The transition between hospital discharge and primary care follow-up is a vulnerable period for patients that can result in adverse health outcomes and preventable hospital readmissions. The COVID-19 pandemic has exacerbated this transitional period, as many patients have forgone their routine healthcare visits, lost touch with their primary care providers (PCPs), and lacked a point of contact for their health needs after leaving the hospital. DESCRIPTION OF PROGRAM/INTERVENTION: We launched a postdischarge Transitions in Care Management (TCM) clinic to serve patients discharged from NYU Langone Hospital Brooklyn, an urban safety net academic hospital that serves a racially diverse and socioeconomically vulnerable population in Southwest Brooklyn. From October 2020 to October 2021, TCM visits were offered to patients prior to discharge from the general medicine service at NYU Langone Brooklyn who did not have a primary care provider or who could not get an appointment with their PCP within 10 days of discharge. Patients were given the option of in-person visits or virtual visits. TCM visits were scheduled with residents within 2 weeks of patient discharge. Questions at the TCM visit focused on scheduled speciality appointments, any discrepancy in medications prescribed at discharge, or if the patient was connected to additional community resources. MEASURES OF SUCCESS: The primary outcome was the 30-day readmission rate for patients referred to TCM compared to all patients discharged from the general medicine unit. FINDINGS TO DATE: From October 2020 through October 2021, there were a total of 357 TCM visits out of a total 806 referrals placed (44% completion rate). There was a reduction in 30-day hospital readmission rate for patients who completed a TCM visit compared with those who were not referred (5% vs 15.9%;p < 0.001). There was also a reduction in readmission rate for those who were referred but did not complete their TCM visit compared to those who were not referred (8.4% vs. 15.9%;p < 0.001). Of the completed visits, 172 were in-person, 138 were virtual, and 47 were over the telephone. Patients were also more likely to show up to their virtual visits than their in-person visits (30% no-show rate for in-person vs. 12% no-show rate for virtual). KEY LESSONS FOR DISSEMINATION: Thirty-day hospital readmission rate was lower for patients seen as part of the resident-run TCM clinic at a safety net academic medical center. Interestingly, patients referred but who did not complete TCM visits still had a decreased readmission rate compared to those who were not referred, suggesting that there may be an inherent difference in these two patient groups. Future studies will examine the differences between these groups, and analyze the factors that influence TCM referral and visit completion. Future studies will also analyze how the medium of visit (virtual vs. in-person) and specific interventions during the TCM visits (medication reconciliation, specialty appointments, community resources) influenced patients' transition in care.

ADDRESSING HEALTHCARE INEQUITIES THROUGH IMPLEMENTATION OF THE NYC PUBLIC HEALTH CORPS COMMUNITY HEALTH WORKER PROGRAM IN A LARGE URBAN SAFETY NET SYSTEM

STATEMENT OF PROBLEM/QUESTION: The Covid-19 pandemic disproportionally affected low-income and Black and Latinx New Yorkers, led to disengagement from primary care, increased social needs, and worsened chronic diseases. DESCRIPTION OF PROGRAM/INTERVENTION: Community Health Workers (CHWs) are front line public health workers who are trusted members of and/or have a close understanding of the community served. Integrating CHWs into clinical teams can help to bridge gaps between the healthcare system and a patient's community. In 2021, NYC Health + Hospitals (NYC H+H) established a branch of the NYC Public Health Corps, comprised of over 200 CHWs and program staff in multiple care settings to address the health inequities exacerbated by the pandemic. CHWs are embedded in and hired by clinics while a centralized team coordinates training, program models, data/documentation tools and coaching by a team of CHW coaches. CHWs in adult primary care implement a model informed by the UPenn IMPaCT program in which CHWs provide tailored social support, advocacy and navigation to help patients achieve health goals. (Kangovi et al 2014, 2017, 2018). CHWs work intensively with patients who have 2+ chronic conditions over 3 months on a set of patient-driven goals. Goals fall into four categories: social needs, medical system navigation, medication management, and chronic disease risk factors. CHWs are provided guides and training on how to address specific patient goals. MEASURES OF SUCCESS: Initial measures include: 1. Launch success (# CHWs hired, development of documentation workflows). 2. Implementation of program model (# patients enrolled, goals identified). Long-term measures of success will include a cost effectiveness analysis. FINDINGS TO DATE: Between August and December 2021, approximately 200 CHWs were hired to staff 17 different clinical sites. 147 CHWs were hired for adult primary care and 58 have begun working with patients. All CHWs have completed IMPaCT and supplemental training. All CHWs document in the EMR using a specific build. 924 patients have been outreached, 365 enrolled, and 54 completed the program to-date. CHW median caseload is 7 with a goal to ramp up to 20. CHWs address an average of 5 goals per patient. The most common goals are primary care engagement, medication management, health insurance gaps/medical bills, and food insecurity. 60% of patients identified at least one social need to work on with the CHWs. KEY LESSONS FOR DISSEMINATION: 1. H+H was able to quickly build one of the largest CHW workforces in the country in response to patient needs elevated by the pandemic and availability of public funding by embedding CHW teams in clinics with central program support, increasing the likelihood of sustainability over time. 2. The development of a structured CHW program supported by training, coaching and documentation tools to address the most common issues affecting patient ability to manage health and wellbeing including social needs was critical in supporting this new workforce while allowing for flexibility to meet individual patient needs.