Evaluation of a Clinical Pharmacist Specialist Transition of Care Pathway to Manage Heart Failure Readmissions During a Provider Shortage.

BACKGROUND: Evidence supports scheduling early follow-up after heart failure (HF) hospitalization with a provider capable of managing hypervolemia. Often this service is provided by cardiologists or specialty nurse practitioners. Continuity or "familiar" providers may be better positioned to identify decompensating HF in patients who have advanced HF and/or multiple complicating medical problems. The objective of this study was to evaluate whether a clinical pharmacy specialist (CPS) service, covering the role of a "familiar" provider in an advanced HF specialty clinic (AHFC) during a staffing shortage, may prevent readmission metrics from worsening. METHODS: We evaluated the entire, eligible concurrent cohorts, representing 175 AHFC-CPS and 273 control patient-admissions, respectively. Study- and disease-specific predictors for readmission were assessed. A matched cohort of 202 patient-admissions (101 AHFC-CPS:101 NO-CPS) were evaluated. RESULTS: Subjects were predominantly white, elderly males. While overall "clinic [performance] profiling" outcomes for readmissions (p = 0.43) and mortality (p = 0.66) did not statistically differ between the AHFC-CPS and NO-CPS groups, an imbalance in severity of illness persisted. A survival curve and analysis were constructed, and the hazard ratio for all-cause mortality was 0.69 (p = 0.033). CONCLUSIONS: This retrospective project supports the premise that AHFC-CPS intervention may be a suitable alternative to maintain the volume status for AHFC patients during a staffing short-fall. More work needs to be done to determine intervention effect size, predictors for readmission, specifically in advanced cardiovascular disease, and to evaluate CPS opportunities in the provision of independent HF care, particularly for patients with advanced HF.

Impaired Absorption of Extended-Release Potassium Chloride in a Patient With a High-Output Ileostomy.

BACKGROUND: Best practices in the management of ileostomies include use of immediate release (IR) medications and elimination of enteric coated and prokinetic agents. Extended-release (ER) potassium chloride is designed for postpyloric release rather than colonic absorption and is postulated to be an appropriate option for potassium repletion in this patient subset. CASE: We present a patient with an ileostomy who received intravenous ER and IR oral potassium chloride supplementation following diverting loop ileostomy. Clinical responsiveness to ER potassium chloride was poor; 15 to 40 mEq was required to replace 0.1 mEq/L of potassium. However, upon transition to IR potassium chloride, only 6.67 mEq was required to replace 0.1 mEq/L of potassium. CONCLUSIONS: Our experience in this case suggests that patients with surgical alterations to their gastrointestinal tracts who fail to have expected rises in serum potassium levels may benefit from early conversion to IR potassium chloride.

COVID-19 and Venous Thromboembolism Pharmacologic Thromboprophylaxis.

BACKGROUND: Coagulopathy has emerged as a hallmark issue of the coronavirus 2019 (COVID-19). Medical facilities are faced with the challenge of developing institutional thromboprophylaxis protocols; however, due to the novelty of the disease, there is a dearth of high-quality, prospective evidence for decision making. OBSERVATIONS: The US National Institutes of Health along with 4 leading societies in the fields of thrombosis and hemostasis have published guidance based on expert consensus that helps provide a framework for local policy development. While there is agreement in a few areas, there are notable and sometimes considerable differences in recommendations that facilities should discuss when developing local guidance. CONCLUSIONS: This document aims to streamline and simplify the available guidance so health care providers can readily identify consensus and divergence of COVID-19 thromboprophylaxis recommendations. Additionally, the authors provide and briefly highlight the COVID-19 thromboprophylaxis protocol of the US Department of Veterans Affairs Tennessee Valley Healthcare System in Nashville and Murfreesboro to serve as an example of a guideline-directed approach for order-set development.

Aerosolization of COVID-19 and Contamination Risks During Respiratory Treatments.

BACKGROUND: Aerosolized medications are frequently administered across the health care continuum to acutely ill patients. During viral pandemics, the World Health Organization and the Centers for Disease Control and Prevention advise the application of airborne precautions when performing aerosol-generating medical procedures, such as aerosolized medications. OBSERVATIONS: Appropriate personal protective equipment (PPE), including fit-tested particulate respirators should be worn when administering nebulized medications to patients. These PPEs have been in short supply in the US during early phases of the COVID-19 pandemic, which is increasing the risk faced by health care workers (HCWs) who are treating patients using aerosolized medications. Despite taking appropriate precautions, HCWs are becoming infected with COVID-19. This may be related to secondary exposure related to viral longevity in fugitive emissions and viability on fomites. CONCLUSIONS: We have expanded on non-US public health recommendations to provide guidance to frontline HCWs to enhance collaboration between clinicians, who are often siloed in their clinical practices, and ultimately to protect the federal workforce, which cannot sustain a significant loss of frontline HCWs.

Oral Liquid Potassium Chloride Dosing Pathway in a Tertiary Care Veteran Affairs Academic Medical Center.

Hypokalemia, defined as a serum potassium (K) concentration of <3.5 mEq/L, is an electrolyte imbalance commonly found in hospitalized patients. Hypokalemia is associated with potentially severe complications, including arrhythmias, which necessitate careful monitoring and repletion with potassium. In the inpatient setting, serum K may be repleted via intravenous or oral routes, with oral administration preferred. Potassium chloride (KCl) for oral administration is widely available in both immediate as well as an extended release formulations. Immediate release liquid KCl is optimal for inpatient use since it demonstrates rapid absorption and subsequent increase in serum K levels. However, acquisition costs for unit dose oral liquid KCl have prompted some institutions to implement guidance for appropriate use of KCl oral liquid. In this article, we describe the creation of a clinical pathway for ordering of oral immediate release KCl for inpatients at a tertiary Veterans Affairs Academic Medical Center.

Venous Thromboembolism Prophylaxis in Acutely Ill Veterans With Respiratory Disease.

This observational study assessed the rate and appropriateness of pharmacologic venous thromboembolism prophylaxis in veterans with pulmonary disease who were admitted to the hospital for a nonsurgical stay.

Designing a resident research program.

PURPOSE: The development of a resident research program and the role of the residency research advisory board (RRAB) in the program are described. SUMMARY: Over the past decade, there have been numerous barriers to successfully implementing a residency research program. An RRAB was subsequently developed to assist with research mentoring to help prepare residents to incorporate research into future positions. Within this board, one clinical pharmacy practitioner or preceptor serves as the research coordinator and acts as chair and liaison to the institutional review board (IRB) and research and development (R&D) committee. All members of the RRAB function as research experts in various aspects of the research process. The RRAB comprises three members to navigate IRB and R&D paperwork, generate and develop research ideas, create relationships with institutional research committees, educate pharmacy residents in a consistent manner on research methods in a longitudinal fashion, provide mentorship to preceptors, and facilitate service-related communication on our research timelines, plans, local and distant presentations, and other related efforts. The development of the resident research program and the RRAB have resulted in an improvement in the level of research conducted by our residents and preceptors. Due to the support of the RRAB, residents are submitting and presenting posters at local, state, and national meetings as well as submitting manuscripts to and publishing manuscripts in health care journals. CONCLUSION: Development of an RRAB increased residents' manuscript publication and poster presentation rates and facilitated the research process.

The pharmacokinetics and pharmacodynamics of valsartan in the post-myocardial infarction population.

INTRODUCTION: The most common risk factors for heart failure are hypertension and myocardial infarction. Angiotensin receptor blockers (ARBs) attenuate the deleterious effects of angiotensin II. Valsartan is a once or twice daily ARB that is FDA-approved for hypertension, LV dysfunction post-myocardial infarction and congestive heart failure as both an adjunct in ACE-inhibitor tolerant, and alternative in ACE-I intolerant patients. AREAS COVERED: This article presents a comprehensive review of the literature regarding the pharmacokinetics and pharmacodynamics of valsartan, with particular attention paid to the post-myocardial infarction population. EXPERT OPINION: Valsartan is a safe, well-tolerated and readily titratable ARB. In addition to its vasodilatory effects there are pleotropic effects associated with the ARB such as modulation of a number of neurohormonal regulators, cytokines and small molecules. Given the clear evidence-based benefits above and beyond its hypertensive properties, it has the potential, if priced appropriately, to grow in its impact as a pharmacotherapeutic long after its patent expires.

Role of aggressive LDL reduction in patients with coronary heart disease.

The aim of the present study was to integrate research evidence with the care of the patient with coronary heart disease (CHD) and place into perspective the importance of intensive statin therapy. We reviewed five major trials and select related post hoc analyses that examined the beneficial effects from intensive low-density lipoprotein (LDL) reduction on combined morbidity and mortality end points in patients with stabilized CHD and those with recent acute coronary syndrome.Accumulating evidence since the publication of the pivotal Heart Protection Study and Adult Treatment Panel III supports a more intensive LDL reduction than that recommended in the 2004 Adult Treatment Panel III update. An LDL reduction of 49% from baseline in statin-naïve patients with stable CHD or a 41% to 44% reduction in LDL from postadmission values in patients with acute coronary syndrome improves composite morbidity and mortality end points.Current evidence suggests that a more intensive LDL reduction of approximately 45% to 50% from a patient's baseline in acute and stable CHD is warranted. The decrease in recurrent events associated with the use of statin regimens that can achieve this degree of reduction in LDL may offer a financial incentive for managed care healthcare systems; however, statin therapy should be selected upon careful consideration of both dose and agent.

The clinical pharmacology of eplerenone.

Eplerenone is an aldosterone receptor antagonist indicated for the treatment of hypertension and congestive heart failure. Eplerenone contains an epoxy group, which offers greater mineralocorticoid receptor specificity. It is an effective antihypertensive that has been shown to reduce morbidity and mortality in individuals with left ventricular dysfunction post myocardial infarction. Studies are continuing to determine whether the benefit of mineralocorticoid receptor blockade in advanced congestive heart failure is also observed when eplerenone treatment is initiated in earlier stages of the disease. The most common side effect is hyperkalemia necessitating close monitoring in individuals with diabetes and proteinuria, heart failure or in those who are taking moderate CYP450 3A4 inhibitors. It is category B in pregnancy.