Implementation of a Heparin Infusion Calculator in the Electronic Health Record System as a Risk-Mitigation Strategy in a Community Teaching Hospital Emergency Department.

INTRODUCTION: According to the Institute for Safe Medication Practices, unfractionated heparin is a high-risk medication due to the potential for medication errors and adverse events. Unfractionated heparin is often started in the emergency department for patients with acute coronary syndromes or coagulopathies. Risk-mitigation strategies should be implemented to ensure appropriate initiation and monitoring of this high-risk medication. In 2019, an unfractionated heparin calculator was built into the electronic health record at a community medical center. The purpose of this study was to evaluate the impact of the calculator as a risk-mitigation strategy. METHODS: Patients ≥18 years old admitted between January 1, 2020, and December 31, 2020, were included if they were administered an unfractionated heparin infusion in the emergency department. Patient encounters were excluded if unfractionated heparin order was discontinued before administration. Patient encounters were classified into the unfractionated heparin calculator arm if the unfractionated heparin calculator was used to determine initial dosing, and the remaining patient encounters were classified into the unfractionated heparin no calculator arm. Unfractionated heparin orders were reviewed if a baseline activated partial thromboplastin time was collected and if the correct initial bolus dose and infusion rate were administered. The primary objective is to determine whether the use of unfractionated heparin initiation calculator reduced the rate of medication administration errors. Medication administration errors are defined as baseline activated partial thromboplastin time not collected or incorrectly collected or the administration of incorrect initial bolus dose and infusion rate. RESULTS: A total of 356 patient encounters with unfractionated heparin orders were included in the primary analysis. There were 13.9% errors (39 of 279) present when the calculator was used and 23.3% (18 of 77) when the calculator was not used (P = .046). There was 86% correct administration of heparin (240 of 279) when the calculator was used and 76% correct administrations (59 of 77) when the calculator was not used. DISCUSSION: The use of the unfractionated heparin infusion calculator in the emergency department led to decrease in medication administration errors. This is the first study to evaluate the integration of an unfractionated heparin calculator into the electronic health record.

Impact of a COPD care bundle on hospital readmission rates.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality worldwide and contributes considerably to morbidity and health care costs. In October 2014, the Centers for Medicare and Medicaid Services introduced financial penalties followed by bundled payments for care improvement initiatives in patients hospitalized with COPD. OBJECTIVES: This study seeks to evaluate whether an evidence-based interprofessional COPD care bundle focused on inpatient, transitional, and outpatient care would reduce hospital readmission rates. METHODS: A pre- and postintervention analysis comparing readmission rates after a hospitalization for COPD in subjects who received standard of care versus an interprofessional team-led COPD care bundle was conducted. The primary outcome was 30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-cause readmissions, escalation of pharmacotherapy, interprofessional interventions, and hospital length of stay. RESULTS: A total of 189 subjects were included in the control arm and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%, P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P = 0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists consulted with 68.5% of subjects and assisted with access to outpatient medications in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P < 0.001) than the control arm. CONCLUSIONS: An interprofessional team-led COPD care bundle resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90 days.

A Review of the Efficacy and Safety of Genvoya® (Elvitegravir, Cobicistat, Emtricitabine, and Tenofovir Alafenamide) in the Management of HIV-1 Infection.

INTRODUCTION: This review evaluates the efficacy and safety of Genvoya® (elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide [EVG/c/TAF/FTC]), a single-tablet regimen used for the management of HIV-1 infection. Phase II and III randomized clinical trials evaluate the efficacy and safety of EVG/c/TAF/FTC and tenofovir disoproxil fumerate (TDF)-containing arms; renal impairment, bone mineral density, metabolic effects, and other adverse events are topics explored within this review. METHODS: A MEDLINE with full text and PubMed literature search was conducted for the past 5 years, up to April 2016. RESULTS: Virologic suppression was similar between the EVG/c/TAF/FTC and TDF-containing groups (<50 copies/mL) at week 48. The bone mineral density in the hip and spine showed a significant reduction in the TDF-containing groups. The glomerular filtration rate increased in patients in the EVG/c/TAF/FTC arm and there were significant differences in total proteinuria, albuminuria, and tubular proteinuria in patients switching to EVG/c/TAF/FTC. The most common adverse events were diarrhea, nausea, and headache. DISCUSSION: The coformulated Genvoya regimen is well tolerated and effective in treatment-naive and virologically suppressed patients. Data seem to suggest it may also be effective and safe in patients with mild to moderate renal impairment. The lower-dosed single-tablet regimen has significantly reduced bone and renal side effects.