Pharmacist Involvement in a Community Paramedicine Team.

BACKGROUND: Hospital readmissions have recently gained scrutiny by health systems as a result of their high costs of care and potential for financial penalty in hospital reimbursement. Mobile-integrated health and community paramedicine (MIH-CP) programs have expanded to serve patients at high risk of hospital readmission. Pharmacists have also improved clinical outcomes for patients during in-home visits. However, pharmacists working with a MIH-CP program have not been previously described. This project utilized a novel multidisciplinary Community Paramedicine Team (CPT) consisting of a pharmacist, paramedic, and social worker to target patients with heart failure at high risk of readmission to assist with coordination of care and education. OBJECTIVES: This article describes the development of the CPT, delineation of CPT member responsibilities, and outcomes from pilot visits. METHODS: The CPT visited eligible patients in their homes to provide services. Patients with heart failure who were readmitted within 30 days were eligible for a home visit. RESULTS: A total of 6 patients were seen during the pilot, and 2 additional patients were seen after the pilot. CONCLUSION: Imbedding a pharmacist into a CPT provides a unique expansion of pharmacy services and a novel approach to address hospital readmissions.

Residency scramble: program directors' experiences with the Pharmacy Online Residency Centralized Application Service.

PURPOSE: Residency program directors' perceptions of the scramble process in 2013 using the Pharmacy Online Residency Centralized Application Service (PhORCAS) were evaluated. METHODS: After the ASHP Resident Matching Program ("Match") results were released in 2013, programs were asked to not extend offers to applicants until the following Monday, allowing a week for programs and applicants to evaluate their options and make the best decisions. A survey consisting of open-ended and structured response questions was sent electronically to 1905 program directors. Adherence to the recommended one-week moratorium before extending an offer to applicants for unmatched positions was also assessed. RESULTS: A total of 531 completed surveys were returned (28.2% response rate). Programs with 119 of the 133 unmatched postgraduate year 1 positions were represented in the results. The ma jority of directors were satisfied with the use of PhORCAS overall, rating it easier (60.3%) or at least the same (24.8%) as processes used in the past. Programs with unmatched positions thought using PhORCAS made it easier to fill positions (64.5%). Sixty percent of program directors contacted applicants the week after the Match. Most directors (79%) followed the recommendation of waiting until April 1 or later to make offers; however, 49% thought others did not follow the guidelines. Program directors offered many concerns about the stressful nature of the scramble process and offered several recommendations for improvement. CONCLUSION: Residency program directors found that the use of PhORCAS and guidelines from the ASHP Commission on Credentialing improved the scramble process and facilitated the filling of unmatched residency positions.

Vibration enhances clearance of solutes with varying molecular weights during in vitro hemodialysis.

This proof of concept pilot study was performed to determine whether vibration can increase solute clearance when applied to an in vitro dialysis model. Urea, creatinine, gentamicin, and vancomycin transmembrane clearances were calculated at a blood flow rate of 200 ml/min, dialysate flow rates of 2 and 8 L/hr, and no concurrent ultrafiltration at various vibration intensities. Dialyzer integrity was determined by measuring transmembrane pressure, filter drop pressure, and albumin clearance, and by visually inspecting the dialysate. Comparing the highest vibration modality with no vibration, the median percentage increase in urea, creatinine, gentamicin, and vancomycin clearance was 18% (all p < 0.005). The transmembrane clearance of albumin was negligible for all experiments. When measuring transmembrane pressure and filter drop pressure, no significant differences were found between nonvibration and vibration dialysis. The addition of vibration during dialysis increased transmembrane clearance for solutes with molecular weights of 60-1450 Daltons.

Age-related differences in propofol dosing for procedural sedation in the Emergency Department.

BACKGROUND: Propofol dose requirements may differ in the elderly due to age-related changes in pharmacokinetic or pharmacodynamic variables. OBJECTIVE: The objective of this study was to determine the effect of patient age on propofol dose required for procedural sedation in the Emergency Department (ED). METHODS: This was a retrospective cohort study conducted in a tertiary hospital ED. Adult patients who underwent procedural sedation in the ED using propofol were grouped a priori by age into three categories: 18-40 years, 41-64 years, and ≥65 years. The median induction dose and total dose of propofol required for the procedure was compared between the three age group categories. Multivariate linear regression analyses were used to adjust for confounders. RESULTS: A total of 170 patients were included in the final analyses: 18-40 years (n = 66), 41-64 years (n = 59), and ≥65 years (n = 45). The median induction dose was 1.4, 1, and 0.9 mg/kg, respectively; and the median total propofol dose was 2, 1.7, and 1.2 mg/kg, respectively. The ≥65 year-old group required significantly less propofol (mg/kg) for induction (compared to the 18-40-year-old group) and for the entire procedure (compared to all other groups) (p < 0.001). In the multivariate linear regression analyses, patient age was negatively predictive of induction dose (coefficient -0.011, 95% confidence interval [CI] -0.017 to -0.005) and total dose (coefficient -0.014, 95% CI -0.022-0.007) after adjusting for confounders. CONCLUSION: Elderly patients may require lower doses of propofol for procedural sedation in the ED, compared to younger adults.

Evaluation of discontinuation of atypical antipsychotics prescribed for ICU delirium.

A number of trials suggest that short-term use of atypical antipsychotics may be useful in the treatment of delirium associated with critical illness. However, long-term use of such agents for this indication has not been studied and may be associated with risks of adverse effects as well as unnecessary health care costs. A retrospective study of prescribing patterns of atypical antipsychotics initiated for the treatment of intensive care unit (ICU) delirium was performed to identify whether these agents were being discontinued prior to or upon hospital discharge. Of the 59 patients who met inclusion criteria and survived to hospital discharge, 28 (47%) were continued on the atypical antipsychotic upon discharge from the medical ICU. For those continued on the agent, 20 patients (71.4%) were prescribed continued therapy as an outpatient. Inpatient costs for atypical antipsychotics during the 9-month study period were increased by approximately $888. Annual cost of the medication as outpatient therapy is assessed at approximately $45,107. Although short-term trials of atypical antipsychotics may be useful for ICU delirium, caution is advised regarding potential adverse effects and added health care costs when use is prolonged.

Induction dose of propofol for pediatric patients undergoing procedural sedation in the emergency department.

OBJECTIVE: This study aimed to determine if patient age is an independent predictor of the propofol dose required for the induction of sedation in pediatric patients for procedures performed in the emergency department (ED). METHODS: This is a retrospective study conducted in an academic, tertiary ED between May 2005 and October 2009. Medical records of patients younger than 18 years who received propofol for procedural sedation were evaluated. Data collected included patient demographics, procedure type, propofol doses administered, time to sedation induction, pain scores before procedure, opioid administration, and adverse effects. Factors predictive of propofol induction dose were analyzed using linear regression analyses. RESULTS: Eighty-eight patients were included in the final analyses. The mean age was 11 years (range, 1-17 years), and 75% were male. The mean induction dose required was 2.1 ± 1.3 mg/kg using a median of 3 boluses (interquartile range, 2-4). The mean time to induction was 3.9 ± 4.2 minutes. In the linear regression analyses (R = 0.07), patient age was inversely predictive of the induction dose (in milligram per kilogram) of propofol (coefficient = -0.074; P = 0.013). Sex, race, procedure type, pain score before procedure, and opioid administration were not predictive of induction dose. Transient respiratory depression occurred in 13.6% and hypotension occurred in 8% of patients, without further complications. CONCLUSIONS: In pediatric patients undergoing procedural sedation in the ED, age is an independent predictor of the dose of propofol required for induction of sedation. Therefore, younger patients may require higher doses by body weight (in milligram per kilogram).

Characteristics of postgraduate year 1 pharmacy residency programs at academic medical centers.

PURPOSE: The training components and other characteristics of postgraduate year 1 (PGY1) pharmacy residency programs at a sample of academic medical centers were evaluated. SUMMARY: A questionnaire was sent via e-mail to the directors of 98 PGY1 residency programs at academic medical centers in the University HealthSystem Consortium (UHC) to elicit benchmarking data on issues such as recruitment, learning experiences, resident staffing requirements, resident research projects and professional presentations, opportunities for resident participation in teaching activities, and requirements for faculty service as preceptors; 72 program directors responded to the survey. The residency programs represented in the survey reported an average of approximately 14 applicants for each available position in 2010 and an average of about five candidate interviews per available position. The survey results indicated wide variation in the learning experiences offered by PGY1 programs (the most commonly reported rotations were in administration, critical care, internal medicine, ambulatory care, and drug information), with a high degree of individualization of elective rotations. Almost all programs had a mandatory staffing component, typically requiring 4-10 hours of service weekly. CONCLUSION: Results of this survey indicate that there is a large amount of variation in the components of PGY1 pharmacy residency programs among UHC academic medical centers. The majority of respondents reported no change in the number of residency positions offered within the past two years, but they reported an increase in the number of applications from 2009 to 2010.

The role of the emergency pharmacist in trauma resuscitation.

The clinical pharmacist in the emergency department is now commonly incorporated as a member of the emergency department trauma team. As such, the emergency pharmacist needs to have detailed knowledge of the pharmacotherapy of resuscitation and be able to apply the skills needed to function as a valuable member of this team. In addition to the traditional skills of the discipline of clinical pharmacy, the emergency pharmacist must be familiar with the intricacies of treating life-threatening injuries in an emergent setting and be able to anticipate the direction of the patient's care. The ability to provide valuable pharmacological interventions throughout the resuscitation and stabilization process requires familiarity with the process of resuscitation, including rapid sequence induction, analgesia and sedation, seizure prophylaxis, appropriate antibiotic and tetanus prophylaxis, intracranial pressure control, hemodynamic stabilization, and any other specific drug therapy that the clinical situation demands. This article discusses the aforementioned pharmacotherapeutic topics and describes the role of the Emergency Pharmacist on the ED trauma team.