Impact of an inpatient pharmacist-driven renal dosing policy on order verification time and patient safety.

Research regarding pharmacist-driven renal dosing policies has focused on cost savings or prevention of adverse drug events. However, little is known about how these policies influence time from order signature to order verification or how this efficiency may reduce the incidence of adverse outcomes. Objectives: The primary endpoint compared time from prescriber electronic order signature to pharmacist electronic order verification between pre- and post-renal dosing policy implementation. The secondary endpoint evaluated electrocardiogram QTc prolongation attributed to fluconazole accumulation in renal impairment. Methods: This retrospective analysis included adults with a creatine clearance ⩽50 mL/min who received at least two inpatient doses from a 34-medication renal dosing protocol between January-February 2020 and April-May 2020. Results: 502 patients met eligibility for the primary outcome. The pre- and post-policy cohorts shared similar baseline characteristics. Time from order signature to verification was 9 and 8 min in the pre- and post-policy groups, respectively (p = 0.0861). In all, 56 patients met inclusion criteria for the secondary outcome. The QTc interval during fluconazole increased relative to baseline in 3 of 7 (43%) pre-policy and 4 of 5 (80%) post-policy. The QTc interval exceeded 500 ms in two patients, both in the post-policy cohort. Conclusions: There was no difference in order signature to verification time. Post-policy fluconazole renal adjustment did not reduce QTc prolongation.

The impact of pain management changes to an inpatient general admission electronic order-set.

BACKGROUND: Opioids pose many risks, and standardized ordering processes need to be created. In May 2020, our institution implemented pain management changes to the inpatient general admission electronic order-set and increased provider education on pain management prescribing. OBJECTIVES: This study aimed to investigate the impact of pain management changes to the inpatient general admission electronic order-set on opioid prescribing. METHODS: Data were collected by retrospective chart review of 376 patients who were admitted using the inpatient general admission electronic order-set at 8 hospital locations within an integrated health system. Two cohorts were identified for comparison: patients admitted pre-electronic order-set change (n = 183; August 2019) and patients admitted post-electronic order-set change (n = 193; August 2020). The primary end points were the amount of intravenous (IV) opioids received measured in morphine milligram equivalents (MME), the quantification of opioids received for pain management, and the oral MME prescribed on discharge. RESULTS: There was no statistically significant difference in the use of IV opioids. There was, however, a statistically significant difference between the IV MME 24 to 48 hours with median 0 (interquartile range [IQR] 0, 6) and 0 (IQR 0, 0) for pre- and post-electronic order-set implementation, respectively (P = 0.003). Oxycodone was more frequently prescribed in the postimplementation cohort-55 patients (29%) compared with the 31 (17%) in the preimplementation cohort (P = 0.008). Tramadol was prescribed less frequently in the postimplementation cohort (n = 12 [6%]) than in preimplementation cohort (n = 28 [15%]) (P = 0.004). There was no statistically significant difference in the oral MME prescribed on discharge (P = 0.833). CONCLUSION: Changes to the inpatient general admission electronic order-set had relatively little impact on the prescribing of opioids. Further electronic order-set changes or other methodologies should be explored to affect inpatient opioid use.

Racial Variations in Emergency Department Management of Chest Pain in a Community-based Setting.

INTRODUCTION: Chest pain is one of the most common chief presenting complaints occurring in most Emergency Departments. The HEART score is a validated risk stratification tool commonly used to evaluate chest pain. Prior research has demonstrated the existence of complex racial variations in health care, specifically in what tests are ordered (or accepted by patients) during evaluation and treatment of cardiac disease. The authors hypothesized that chest pain management (i.e., disposition to hospital/observation unit and rates of stress testing) patterns and longitudinal outcomes (i.e., death and 30-day readmission) would occur differently in African Americans despite systematic use of the HEART score. METHODS: Funded by the Statewide Campus System, this study was comprised of a retrospective chart review of a sample of eligible patients presenting with chest pain to the authors' 345-bed community-based Michigan hospital. RESULTS: Of the 1,412 eligible sample patients, 886 (63%) reported their racial affiliation as White, 473 (33%) African-American, and 53 (4%) "Other". The average HEART score in Whites was 3.92 (SD = 1.89) compared to 3.31 (SD = 1.79) in African-Americans, (p < 0.01, 95% CI: 0.40-0.82). However, White patients' odds of admission to observation or inpatient was 1.49 times higher (95% CI: 1.04 - 2.15), with every unit increase in HEART score increasing the odds ratio of admission by 3.24 times (95% CI: 2.79 - 3.76). White patients were also 2.37 times more likely to receive (or accept) stress tests than African American patients (95% CI: 1.41 - 3.88). Only five (0.01%) of 458 White patients with HEART score between 4 and 6 experienced 30-day readmission or death whereas seven (0.04%) of 193 African-American patients experienced these outcomes (p = 0.04 with OR 3.40, 95% CI: 1.07 - 10.9). CONCLUSIONS: Although the authors were unable to precisely distinguish the provider (e.g., desire to order testing) and patient-driven (e.g., desire to accept testing) factors likely to contribute to measured differences, these results suggest continued complex racial variations concerning hospital admission and stress testing in chest pain patients. Further studies are needed to analyze potential systems or subject-level factors influencing the multi-dimensional phenomenon of chest pain management across racial affiliation.

Incidence of Fever Associated With Dexmedetomidine in the Adult Intensive Care Unit.

BACKGROUND: Published literature has described the temporal relationship of dexmedetomidine with elevated temperatures, but there is limited data to quantify the incidence of fever in ICU patients receiving dexmedetomidine. OBJECTIVE: The primary objective of this study was to estimate the incidence of temperature greater than or equal to 38.5°C in ICU patients receiving dexmedetomidine. METHODS: This was a retrospective cohort study of ICU patients who received dexmedetomidine with a propensity-matched subgroup analysis comparing dexmedetomidine fever patients to non-fever patients. Patients 18 years of age and older admitted between November 2017 and August 2018 who received continuous dexmedetomidine for 6 or more hours were eligible for inclusion. Included patients with a temperature of great than or equal to 38.5°C while receiving dexmedetomidine were established as having dexmedetomidine-related fever. RESULTS: Of 882 eligible ICU patients, 404 dexmedetomidine patients were included in the study. Sixty-one patients (15.1%) met the definition for the primary endpoint. Forty-two patients who received dexmedetomidine but experienced no fever were matched for multivariate analysis. The fever group received a higher mean maximum infusion rate (0.98 µg/kg/h ± 0.43 vs. 0.68 µg/kg/h ± 0.42, P < 0.001) and a longer median duration of dexmedetomidine (43.0 hours [range 7-711] vs. 24.3 hours [6-148], P = 0.001) compared to the non-fever group. CONCLUSION: Fever greater than 38.5°C was observed in 15.1% of ICU patients while receiving dexmedetomidine. Prospective studies are warranted to validate these findings.

Factor VIII Inhibitor Bypassing Activity (FEIBA) Reversal for Apixaban and Rivaroxaban in Patients With Acute Intracranial and Nonintracranial Hemorrhage.

BACKGROUND: The clinical use of factor VIII inhibitor bypassing activity (FEIBA) for factor Xa (FXa) inhibitor reversal is derived from small studies with notable variation in patient eligibility for use, dosage regimens, concurrent supportive care, and outcome measures. Consequently, additional effectiveness and safety data are warranted to expand the literature evaluating FEIBA for FXa inhibitor reversal. OBJECTIVE: This study sought to determine the incidence of observed effective hemostasis within 24 hours of post-FEIBA® administration as well as in-hospital and 30-day post-discharge incidences of thromboembolic event (TEE) and mortality between apixaban and rivaroxaban in the intracranial hemorrhage (ICH) and non-ICH populations. METHODS: This case series evaluated patients between January 1, 2014 through July 1, 2019 who received at least one FEIBA® dose for apixaban or rivaroxaban reversal secondary to acute ICH or non-ICH. Patient demographics, FEIBA® dosages, adjunct treatments, effectiveness, and safety outcomes were retrospectively collected from electronic medical record review. Modified hemostasis outcomes, adapted from criteria previously published by Sarode et al., TEE, and mortality between apixaban and rivaroxaban in the ICH and non-ICH populations were evaluated. RESULTS: Among the 104 patients evaluated, 62 received apixaban and 42 rivaroxaban. Thirty apixaban and 25 rivaroxaban users experienced ICH, whereas 32 apixaban and 17 rivaroxaban users experienced non-ICH. Among the combined ICH and non-ICH populations, effective hemostasis occurred in 89%, TEE in 8%, and mortality in 13%. No statistically significant differences were observed within ICH and non-ICH populations receiving apixaban or rivaroxaban regarding effective hemostasis, TEE, or mortality. CONCLUSION AND RELEVANCE: The combined ICH and non-ICH overall rates of effective hemostasis, TEE, and mortality were comparable to preexisting studies of FEIBA for factor Xa inhibitor reversal. The limitations inherent to the study design warrant a randomized controlled trial with an active comparator to confirm these observations.