2011PresentationAbstracts

A1 InfectiousDisease

OUTPATIENT PARENTERAL ANTIMICROBIAL THERAPY OF SELECTED GRAM-POSITIVE AGENTS: IMPACT ON CLINICAL OUTCOMES (A1), Tiffany Bach. Western University College of Pharmacy, Pomona, CA (tbach@westernu.edu) IRB Approval Pending The objective of this study is to delineate the clinical outcomes associated with the use of selected intravenous Gram-positive agents in an outpatient setting. A retrospective cohort study of adult patients who have received vancomycin, telavancin, and daptomycin as outpatient parenteral antimicrobial therapy (OPAT) will be conducted. The St. Joseph Home Health medical records will be used to screen for patients who have received the study agents as OPAT for the study period March 2010 through February 2011. Patients who have received vancomycin, telavancin, and daptomycin as OPAT, age 18 or older, and in receipt of the study agents for > 72 hours will be considered. Chart reviews will be performed to abstract pertinent demographics, laboratory, and clinical data using a standardized data collection form. Outcome measures include clinical response, incidence of nephrotoxicity, and infectious complications requiring surgical intervention, change in antimicrobial therapy, or re-admission for acute care. Continuous data will be compared between the three study groups (telavancin, daptomycin, and vancomycin) using one-way analysis of covariance (ANOVA) and Kruskal-Wallis test where appropriate. Discrete data will be compared between the three study groups using chi-squared test. Results and conclusion will be presented.

CLINICAL OUTCOMES OF MRSA BACTEREMIA TREATED WITH VANCOMYCIN: ASSESSING THE UTILITY OF VANCOMYCIN TROUGHS AND AUC/MICS (A1). Erin Bailey. Donald Alexander. University of Utah Hospital, Salt Lake City, UT (erin.bailey@hsc.utah.edu) IRB approved. The objective of this study was to evaluate the utility of trough concentrations and 24 hour AUC to MIC values for predicting clinical efficacy and safety outcomes of vancomycin for the treatment of MRSA bacteremia. The study was a retrospective case series. The primary outcome was to determine the 30 day overall response rates from the first day of MRSA bacteremia, while analyzing the utilities of vancomycin troughs and 24 hour AUC to MIC values as quality surrogates for clinical outcomes. The secondary outcome was to evaluate the time to nephrotoxic events occurring from the start of treatment. Data was collected from a period of two years. Patients aged 18 years or older with positive blood cultures for MRSA were included. Patients were excluded if they had multiple infections, renal impairment, or received the first dose of vancomycin beyond 48 hours of blood culture collection. Significant associations between variables and clinical outcomes were statistically assessed. Associations found were evaluated for quantitative breakpoints. Results and conclusions will be presented.

ASSESSING COMPLIANCE WITH INFECTIOUS DISEASE SOCIETY OF AMERICA (IDSA) GUIDELINES FOR CATHETER-RELATED BLOODSTREAM INFECTIONS (A1). Jeremy Bair. Intermountain Medical Center, Murray, UT. (Jeremy.Bair@imail.org) IRB approved. The purpose of this study is to assess whether catheter-related blood stream infections at Intermountain Medical Center are treated in accordance with the updated 2009 Infectious Disease Society of America (IDSA) guidelines. This study is a retrospective chart review of adult patients at a tertiary medical center. The study included adult patients who had a positive blood culture and a diagnosis of a catheter-related blood stream infection admitted between July 1, 2009, and June 30, 2010. Patients were excluded if they were <18 years old, pregnant, had urosepsis, defined as a positive urine culture drawn within 48 hours prior to or with blood cultures that grew the same organism, and had positive bloodstream cultures within 48 hours of abdominal surgery. Charts were reviewed for compliance with the IDSA guidelines for catheter-related blood stream infections for proper empirical anti-infective coverage, narrowing coverage after cultures and susceptibilities were reported, and proper duration of antiinfective therapy. The primary endpoint is the percentage of patients with catheter-related blood stream infections

who were treated in accordance with the IDSA guidelines for catheter-related blood stream infections. The secondary endpoints are the number of patients with infective endocarditis, septic shock requiring vasopressors, mortality, the percentage of patients treated appropriately in the ICU versus the medicine floors, and patient length of stay. Results and conclusions will be presented.

IMPROVING ANTIBIOTIC USE IN PATIENTS WITH CELLULITIS VIA THE IMPLEMENTATION OF AN ANTIBIOTIC STEWARDSHIP PROGRAM (A1), Beth Becker. Good Samaritan Regional Medical Center, Corvallis, OR (bbecker@samhealth.org) IRB approval not needed. The study objective is to evaluate the impact of an antimicrobial stewardship program, which was implemented in September 2010 at Good Samaritan Regional Medical Center. All consecutive recommendations to improve antibiotic utilization made by our team between September 2010 and March 2011 will be described. We will also further quantify and qualify all accepted recommendations. Criteria for selection of patients for review by the pharmacist include: failure of current therapy, dose optimization, culture & sensitivity data, candidates for de-escalation, intravenous to oral switch, toxicity/side effects, and inappropriate indication. Patients already being consulted by the infectious disease physicians or post operative surgery patients on prophylaxis antibiotics are not included in the stewardship program. A subgroup analysis focusing on cellulitis patients will be used to further quantify the impact of the stewardship program by assessing the volume of selected intravenous antimicrobial use in patients hospitalized pre and post implementation of the antimicrobial stewardship program. The density of antimicrobial use will be calculated as doses administered per 1000 patient days. Continuous data will be analyzed using unpaired t tests, and categorical data will be assessed using the Pearson X2 test. Results and conclusions will be presented.

CHARACTERIZATION OF RISK FACTORS FOR FLUOROQUINOLONE-RESISTANT ESCHERICHIA COLI URINARY TRACT INFECTIONS (A1), Yuli Chang, Robert Tindula Long Beach Memorial Medical Center, Long Beach, CA (ychang2@memorialcare.org) IRB Approval Pending. Urinary tract infection (UTI) is one of the most common indications for antibiotic therapy for adults. Escherichia coli is responsible for more than seventy-five percent of uncomplicated cystitis and pyelonephritis cases. Fluoroquinolones are suggested for empiric therapy when the local sensitivity pattern suggests uropathogen resistance rates exceeding ten to twenty percent against trimethoprim/sulfamethoxazole. However, the expansive use of fluoroquinolones has led to selective pressure, resulting in emergence and rapid development of resistant bacteria. The increasing prevalence of infections caused by antibiotic-resistant bacteria makes the empiric treatment of UTIs more difficult. Our study objectives are to (1) identify and evaluate risk factors associated with fluoroquinolone-resistant E. coli urinary tract infection, (2) determine if our antibiogram data for overall E. coli resistance correlates with the sensitivity pattern of E. coli causing UTI, and (3) determine whether duplicate isolates are affecting our sensitivity patterns. A retrospective cohort study was conducted in patients greater than 18 years old with a urine culture positive for E. coli growth. The study included patients admitted to the hospital between January to December 2010 and evaluated antibiotic use characteristics and other potential risk factors

for fluoroquinolone-resistant E. coli acquisition. Results and conclusions will be presented.

CLINICAL OUTCOMES OF HOME INFUSION PATIENTS ON PARENTAL ANTIBIOTICS AT THE UNIVERSITY OF WASHINGTON MEDICAL CENTER (A1), Ilan Chao, Rupali Jain, Diane Matsuwaka. UW, Seattle, WA (ichao@uw.edu). IRB approval received. Outpatient parental antibiotic therapy (OPAT) is utilized among an increasing number of patients due to benefits of a shorter hospital stay, decreased cost, and improved quality of life for patients. There are concerns with OPAT because antibiotics are administered without close monitoring which could lead to poor outcomes when compared to inpatient administration of antibiotics. In 2006, the Pharmacy and Therapeutics Committee (P&T) at University of Washington Medical Center (UWMC) approved monitoring guidelines to ensure adequate monitoring. The objective of this study is to evaluate the safety and effectiveness of the home parental antibiotic therapy by examining the compliance with the institutions monitoring plan for OPAT. A retrospective chart review was conducted on patients greater than 18 years old who were discharged on home infusion of either vancomycin, colistin, or an aminoglycoside between July 1, 2009 and June 30, 2010. Secondary endpoints evaluated will be readmission due to new or progressive infection and/or antibiotic related toxicity. Patients were excluded if they were not followed up by UWMC providers. Cystic fibrosis patients on aminoglycoside were also excluded due to their atypical pharmacokinetics and dosing. Results will help the hospital assess whether the current standard guidelines need to be reinforced or revised. The results and conclusion will be presented.

CLINICAL OUTCOMES IN DIABETIC PATIENTS WITH LOWER LIMB OSTEOMYELITIS (A1), Tiffany Cheung, Michael Ascari, Gary Segal, David Gray. VA Healthcare System, Long Beach, CA. (tiffany.cheung@va.gov) IRB approved. Many diabetics present with non-healing lower limb infections progressing to osteomyelitis. Treatment commonly includes medical management with a prolonged course (6 or more weeks) of antibiotics, but studies examining long-term clinical outcomes such as rate of amputation in diabetic osteomyelitis are limited. The primary objective of this study is to characterize the clinical outcomes in diabetic Veterans who received IV antibiotic therapy to treat lower-limb osteomyelitis. Data from the VISN 22 Data Warehouse was utilized to identify diabetic patients diagnosed with osteomyelitis secondary to lowerlimb infection. Other data collected and analyzed include: baseline characteristics, pertinent labs, co-morbidities, and surgical procedures. Patients with trauma, history of arthroplasty, hematogenous osteomyelitis, or prosthetic joint infections were excluded. The primary outcomes are amputation and time to amputation after a course of IV antibiotic therapy. Secondary outcomes include changes in baseline labs and subsequent amputation over the follow-up period. Descriptive and inferential statistics will be performed as appropriate.

THE EFFECT OF EXTENDED INFUSION OF PIPERACILLIN-TAZOBACTAM ON PATIENT OUTCOMES AND ITS COLLATERAL EFFECTS IN A VETERAN POPULATION (A1), Yih-Ming Chi, Macy Ho. VA Healthcare System, Long Beach, CA (yih.chi@va.gov) IRB approved. Extended infusion piperacillin-tazobactam (EI-PT) 3.375g every 8 hours (4-hour infusion) has been demonstrated to improve clinical outcomes in critically ill patients with Pseudomonas aeruginosa infections compared to traditional intermittent infusion piperacillintazobactam (TI-PT) 3.375g every 6 hours (30-minute infusion). Piperacillin-tazobactam is the second most prescribed IV antibiotic at VA Long Beach Healthcare System. On October 1, 2009, our institution converted to EI-PT dosing for all patients except those with severe renal impairment or on hemodialysis and with a diagnosis of osteomyelitis, meningitis, or endocarditis. The objective of this retrospective cohort study is to compare patient outcomes in patients who received EI-PT with those in patients who received TI-PT. Outcome measures include 14-day mortality, length of hospital stay, time to normalization of WBC, and time to normalization of temperature. In addition, effects on antibiogram and potential cost savings will be examined. Data collection will be conducted via chart reviews utilizing the computerized patient record system. Paired t-test,

McNemars test, and Wilcoxon signed rank will be performed for statistical analysis as necessary. Full results and conclusion will be presented.

COMPLICATED STAPHYLOCOCCUS AUREUS INFECTION OUTCOMES FOLLOWING EMPIRIC VANCOMYCIN DOSING (A1). Jesse Cook. Saint Alphonsus Regional Medical Center, Boise, ID (cojesse@sarmc.org) IRB pending. Vancomycin is a glycopeptide antibiotic indicated for use in the treatment of serious gram positive infections involving MRSA. In 2009, a consensus review performed by the ASHP, the IDSA, and the Society of Infectious Diseases Pharmacists, provided recommendations for optimal dosing and trough concentrations of vancomycin. While commonly used vancomycin dosing regimens administered on an intermittent basis are sufficient in the treatment of susceptible staphylococci and streptococci, such dosing is unlikely to provide total trough serum concentrations for the treatment of complicated infections with isolates having higher MICs. With the increasing emergence of VISA and VRSA, vancomycin's role as a primary agent in treating MRSA necessitates institutional guidance to minimize potential vancomycin antibiotic resistance and ensure quality outcomes. The purpose of this study was to evaluate conformity with the 2009 consensus review and outcomes of empiric vancomycin dosing in a community hospital setting. All patients who received the treatment drug for a complicated infection (endocarditis, osteomyelitis, meningitis, or hospitalacquired pneumonia) or presumed complicated infection from January 1, 2010 to December 31, 2010 were included in the study. Data specific to patient demographics, therapeutic indication, dosing regimen, therapeutic

monitoring, and clinical outcomes were collected and assessed. Results and conclusions will be presented.

VORICONAZOLE ANTIFUNGAL SERUM LEVELS AND OBESITY: A RETROSPECTIVE CHART REVIEW (A1), Samantha Davies-Vorbrodt, James Ito, Sanjeet Dadwal, Jane Kriengkauykiat. City of Hope, Duarte, CA (svorbrodt@coh.org) IRB approval received. The study objective was to determine voriconazole antifungal serum levels achieved in patients, stratified by BMI, in order to identify a relationship between the antifungal dose and corresponding serum concentrations achieved in obese patients. The ultimate goal of this study was to provide recommendations for voriconazole dosing adjustments, in the above mentioned patient population, in order to achieve desired serum concentrations. All patients (regardless of weight, age, and underlying oncological disease state) receiving voriconazole who had voriconazole serum concentrations on file at City of Hope between 2005 to 2010 were identified via retrospective chart review and were included in the study. A standardized data collection sheet was utilized for each patient case that included all necessary information gathered for the study analyses (including, but not limited to, age, height, and weight of the patient, antifungal medication and dosing of the antifungal, serum drug levels along with date and time of the level, if the antifungal was initiated for prophylaxis versus treatment of a fungal infection, the probability of infection, other antifungals used concurrently, concurrent use of drugs that interact with the azole, and response to treatment). Patients who did not have voriconazole serum levels on file between 2005 to 2010 were excluded from the study. Appropriate statistical tests were applied to the data obtained based on the observations. Results and

conclusions will be presented.

ROLE OF ANTIBIOTIC IMPREGNATED CATHETERS IN THE PREVENTION OF CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS (A1). Jessica De Giacomo. University of Southern California School of Pharmacy- USC University Hospital, Los Angeles, CA (jdegiaco@usc.edu) IRB approved. Central line catheters are an essential feature of modern patient management in a majority of hospitalized patients who are critically ill requiring repeated vascular access. Despite the many advantages, its potential source of bloodstream infections is a major and potentially lifethreatening complication. Therefore, treating and potentially preventing central line associated bloodstream infections would substantially reduce morbidity and healthcare costs. The aim of this study is to determine if the use of antibiotic impregnated catheters reduce the incidence of central line associated bloodstream infections, and if this will be a cost effective and cost beneficial alternative for USC-University Hospital. This study is a retrospective chart review gathering all necessary data of patients admitted to the surgical CT floors of USCUniversity Hospital and LAC-USC County Hospital. 140 patients from each site, in which a central line was placed, will be included. Patients will be followed from the day of central line insertion to discharge, or incidence of central line associated bloodstream infection, whichever comes first. Data sets gathered at USC-University Hospital and LAC-USC County Hospital will be analyzed with the use of fisher exact test. Cost benefit and cost effective analysis will also be performed. Results and conclusions will be presented.

INCIDENCE OF EXCESSIVE ANTIBIOTIC USE FOR VENTILATOR ASSOCIATED PNEUMONIA AND IDENTIFICATION OF TARGETS FOR INTERVENTION AT AN ACADEMIC MEDICAL CENTER (A1). Monica Donnelley, Cinda Christensen, Brett Heintz, UC Davis Medical Center, Sacramento, CA (monica.donnelley@ucdmc.ucdavis.edu.com) IRB approved. The objective of this study is to ascertain the incidence of excessive antibiotic exposure for the treatment of ventilator associate pneumonia (VAP), and to identify areas of intervention. This study will review the duration of treatment and whether it complies with current American Thoracic Society and Infectious Diseases Society of America guidelines. This is an investigator initiated, singlecenter, retrospective chart review. Subjects were identified from electronic medical records by using the ICD-9 code for VAP (ICD-9 = 997.31). 112 adult patients during a one year time period met inclusion criteria. Detailed demographic, microbiologic, antimicrobial utilization and clinical data will be collected retrospectively, including time on ventilator, assessment of early vs. late-onset VAP, clinical pulmonary infection scores (CPIS), C. difficile infections, development of new and/or resistant pathogens, and mortality. Appropriate antibiotic de-escalation and development of complications associated with prolonged therapy will also be evaluated. Last, it will be noted if Infectious Disease Consult Service was involved in the patients care. In addition to descriptive statistics, binary logistic and multivariate stepwise regression analyses will be performed to identify predictors of treatment outcomes.

Odds ratios, corresponding confidence intervals and pvalues will be determined. Results and conclusions will be presented.

EVALUATING THE IMPACT OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM IN A COMMUNITY HOSPITAL SETTING (A1). Aprille Espinueva. Sharp Memorial Hospital, San Diego, CA (aprille.espinueva@sharp.com) IRB approved. The study objective was to determine whether the implementation of an antimicrobial stewardship program improves the quality of antibiotic prescribing and optimizes clinical outcomes. Compliance with known indicators of appropriate antimicrobial prescribing (a care bundle) in a historic control group versus an interventional cohort was measured. Stewardship pharmacists completed interventions via prospective audit and feedback, suggested changes to empirical and definitive antimicrobials, and monitored patients cultures and antimicrobial therapy daily. Interventions targeted the following quality indicators:(1) Documentation of indication for antibiotic therapy (2) Collection of appropriate culture specimens according to national and institutional guidelines (3) Appropriate empirical and definitive selection of a fluoroquinolone for the given indication (4) Appropriate de-escalation to a more narrow spectrum antimicrobial agent or fluoroquinolone discontinuation. Orders were also evaluated for correct dosing and route of administration. After infectious disease MD review, intervention notes were left in the progress note section of the patients medical chart with recommendations. Inclusion criteria was patients 18 years old or older, and admitted to the ICU with new orders to begin a fluoroquinolone. Patients transferred from other acute care facilities or prescribed a

fluoroquinolone for surgical prophylaxis were excluded. Results and conclusions will be presented.

DURATION OF VANCOMYCIN THERAPY IN PATIENTS FOUND TO BE COLONIZED WITH MRSA. Marguerite Esquibel, Tiffany Goolsby, Susan Kellie, NMVAHCS, Albuquerque, NM (Marguerite.Esquibel@va.gov). IRB approved Nosocomial pneumonia is associated with high mortality and morbidity. Appropriate initial therapy, duration of therapy and appropriate dose are key factors for an optimal outcome in patients with nosocomial pneumonia. In addition to resistant gram negative organisms, MRSA is of particular concern in nosocomial pneumonia. At the NMVAHCS patients nasal cavities are swabbed to determine if they are colonized with MRSA; a positive nasal swab does not mean that the patient has an active infection. The objective of the study was to determine the duration of vancomycin therapy in patients with nosocomial pneumonia who were and were not colonized with MRSA. A retrospective chart review was performed on all veterans who were started on vancomycin from July 2009 to June 2010 using information from the order entry systems (Vista, CPRS) to provide a list of patients that received vancomycin. Patients were then separated into 2 groups: nasal swab positive (group 1) and negative (group 2). A second was generated by extracting patients that were diagnosed with HAP, using ICD 9 codes. Patients were excluded from the study if they developed necrotizing pneumonia, empyema, if they had an adverse reaction to vancomycin or if the patient

received vancomycin for an infection other than nosocomial pneumonia. The results of the study could help reduce unnecessary prescribing of vancomycin in patients with pneumonia. Results and conclusions will be presented.

EVALUATION OF TREATMENT OUTCOMES IN ASTHMA AND CYSTIC FIBROSIS PATIENTS WITH ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA) (A1). Allison M. George, Dima Ezmigna, Mark A. Brown, Hanna Phan. University Medical Center, Tucson, AZ. (george@pharmacy.arizona.edu) IRB approved. The purpose of this longitudinal, descriptive cohort study is to describe trends of treatment and patient outcomes in adult and pediatric patients with asthma and/or cystic fibrosis and allergic bronchopulmonary aspergillosis (ABPA). All patients one year and older with asthma and/or cystic fibrosis and a history of ABPA admitted from August 1, 2006 through December 31, 2010 at University Medical Center will be included in the study. Data to be collected includes demographic information, ABPA treatment, sputum cultures, radiologic studies, laboratory data, clinical outcomes, and complications of treatment or disease. Statistical analyses will be conducted with STATA version 11.1 software. Descriptive statistics will be used to assess treatment trends. Baseline demographics and incidence of adverse drug events between groups will be assessed using Chi-square test. Outcomes such as changes in FEV1, serum IgE, and other measured variables will be assessed using a student t-test. The results will be discussed.

A RETROSPECTIVE CASE CONTROL STUDY OF VANCOMYCIN DOSING IN OBESE POPULATIONS (A1), Jason Gerstner, Mike Stander, Adam Porath, Jessica Thompson. Renown Regional Medical Center, Reno, Nevada (jgerstner@renown.org) IRB approval received. The objective of this study was to determine if obesity affected vancomycin dosing. A retrospective sample was taken of patients that were on vancomycin for a total of 72 hours, were greater than 18 years of age, had a BUN of <25mg/dL, serum creatinine <1.3mg/dL, and a trough drawn 72 hours after the start of vancomycin. These sample patients were then evaluated for cases. Cases were defined as individuals with a vancomycin maintenance dose < 30 mg/kg/day after 72 hours of therapy. These cases were then matched with two controls by age within 5 years, gender, race, concurrent nephrotoxins, contrast dye exposure within 72 hours, serum creatinine within 0.1mg/dL, and a trough level within 4mg/L after 72 hours of therapy. The cases and controls were then examined for the following variables: BMI, CHF, DM, location, albumin, chronic hepatic disease, and renal transplant. A univariate analysis was then performed between cases and controls to determine any difference. Categorical data was evaluated via chi-squared test. Wilcoxon rank sum was used to evaluate continuous variables, and multivariate logistic regression was used to evaluate independent risk factors. Results and conclusions will be presented.

EFFECT OF EXTENDED CARBAPENEM INFUSIONS ON BETA-LACTAM RESISTANCE OF KEY GRAMNEGATIVE ORGANISMS (A1). Annette Cordova. Shawn Giess. St. Josephs Hospital and Medical Center, Phoenix, AZ (shawn.giess@chw.edu) IRB approved. The study purpose was to assess the effect on the antibiotic resistance in Pseudomonas aeruginosa and Acinetobacter baumannii after conversion to extended doripenem infusions. All adult medical and intensive care unit patients with positive culture results for P. aeruginosa and A. baumanii drawn at least 48 hours after hospital admission were included. Potential culture sources were blood, cerebrospinal fluid, sputum, bronchial wash, body fluid and urine. Antibiotic susceptibility was assessed using the geometric mean, median, and mode minimum inhibitory concentrations (MIC). The study period was a time series consisting of the five months prior to July 2010 compared to the five months subsequent to July 2010 when hospital-wide conversion to extended doripenem infusions occurred. The primary endpoint is the comparison of MIC data for Pseudomonas cultures with doripenem, imipenem, cefepime, pip/tazo, and aztreonam prior to and after the conversion. For Acinetobacter species, amp/sulb replaced aztreonam in the primary analysis. Antibiotics assessed for the secondary endpoint will consist of the same comparison with non-beta-lactam antibiotics: levofloxacin, amikacin, gentamicin, and tobramycin. Exclusion criteria included a diagnosis of cystic fibrosis, pregnancy, and those who were severely immunocompromised. Only the first positive culture for each patient was included in the analysis. Results and conclusions will be presented.

EVALUATING THE NEED FOR VANCOMYCIN DOSING STANDARDIZATION TO IMPROVE PATIENT CARE IN A PRIVATE TEACHING HOSPITAL (A1), Hardeep Gill, Brian Benz. California Pacific Medical Center, San Francisco, CA (gillhk@sutterhealth.org). IRB approval pending. The Infectious Disease Society of America has established target vancomycin trough levels for optimizing vancomycin dosing for the treatment of gram-positive infections. California Pacific Medical Center is a private, non-profit, teaching hospital that is investigating the feasibility of a vancomycin dosing and management protocol. The objective of this study is to evaluate current physician practices for vancomycin dosing strategy, time to therapeutic trough level, appropriateness of laboratory monitoring, and to identify physician educational needs for optimizing treatment with vancomycin. Charts will be reviewed prospectively for data collection. Results will be analyzed for baseline physician prescribing habits, time to therapeutic trough level (with or without pharmacy intervention), the incidence of sub-therapeutic treatment regimens, and inappropriate laboratory drug level orders. Results will be discussed and recommendations will be offered for improving vancomycin dosing practices in concert with the Antibiotic Subcommittee

AN EPIDEMIOLOGICAL ANALYSIS OF POTENTIAL KLEBSIELLA PNEUMONIAE CARBAPENEMASE (KPC)-PRODUCING ISOLATES AT A TEACHING HOSPITAL (A1). Gregory Glenn. Kimberly Leuthner. University Medical Center, Las Vegas, NV (Gregory.Glenn@umcsn.com) IRB approved. Resistance to antibiotics is a problem of increasing importance for clinicians around the world. As pathogens become resistant to powerful, broad spectrum antibiotics, physicians are left with few treatment options. With the recent reports of metalo-beta-lactamase and carbapenemase producing organisms, increasing concerns of Gram negative resistance has been the topic of many discussions at our institution. The objective of this study is to identify suspected KPC-producing isolates and describe characteristics which may predispose patients to infection by these organisms. Suspected KPC-producing isolates were identified from April 2007 to October 2010 utilizing a retrospective chart review. A suspected KPC-producing isolate was defined as any Enterobacteriaceae resistant to beta-lactam antibiotics, including at least one carbapenem. Patients were included only on initial isolation of the organism, regardless of culture results on subsequent admissions. Data collected will include demographics, comorbidities, and known risk factors for multidrug resistant infections. Results and conclusions will be presented.

IMPLEMENTATION AND OUTCOMES OF A FUNCTIONAL ANTIMICROBIAL STEWARDSHIP PROGRAM (A1), Sydney Holt, Scott Mambourg. VA Sierra Nevada Healthcare System, Reno, NV (sydney.holt@va.gov) IRB approval pending. The study objective is to improve overall patient outcomes and safety, decrease local resistance rates, and decrease antimicrobial cost. Clinical decision support algorithms with empiric recommendations were developed for common disease states including cellulitis, diabetic foot ulcers, intraabdominal infections, pneumonia, and urinary tract infections. Biweekly rounds are conducted with the infectious disease pharmacist(s) and physician. All patients currently undergoing treatment with a trigger drug (ceftazidime, ciprofloxacin, daptomycin, linezolid, meropenem, piperacillin/tazobactam, tigecycline, tobramycin, voriconazole) are assessed. Patients are reviewed for appropriateness of therapy, deescalation, dose optimization based on age, weight, or renal function and intravenous to oral conversions. Recommendations are documented in the computerized patient record using a documentation tool created through the program and verbally communicated to the medical team. Patients with active infectious disease consultation are excluded. Deidentified patient information is recorded to determine acceptance of recommendations and for retrospective data collection. Antibiotic utilization and cost data will be assessed from calculated defined daily doses. Resistance patterns following facility restrictions will be analyzed. Results and conclusions to be presented.

RETROSPECTIVE EVALUATION OF THE INCIDENCE OF NEPHROTOXICITY ASSOCIATED WITH HIGH LOADING DOSES AND STANDARD DOSES OF INTRAVENOUS VANCOMYCIN (A1), David Hwang, Travis Dick, Elizabeth Sebranek Evans, Paul Wohlt. Intermountain Healthcare, Salt Lake City, UT (david.hwang@imail.org) IRB approval received. The study objective was to determine if administration of higher loading doses of intravenous (IV) vancomycin led to increased rates of nephrotoxicity. This retrospective analysis compared rates of adverse events in subjects that received IV vancomycin loading doses greater than or equal to 25 mg/kg to those whose first dose of vancomycin was between 15 and 24 mg/kg. All adults ages 18 years or older who received IV vancomycin while admitted as an inpatient at Intermountain Medical Center from October 29, 2007 to May 31, 2010 were included in this study. Subjects are ineligible if they were less than 18 years old at the time of admission or were pregnant during their hospital stay. Subjects who received their first dose of IV vancomycin in the emergency department, operating room, or an outside facility were not included. Subjects who required hemodialysis prior to initiation of therapy were also excluded. The primary endpoint of this study examined the rate of new-onset nephrotoxicity, as defined by the RIFLE criteria, within the first 48 hours after initiation of IV vancomycin therapy. Secondary endpoints examined the frequency of red man syndrome and the incidence of supratherapeutic IV vancomycin trough concentrations. Forthcoming results and conclusions from this study will be presented.

EVALUATING OUTCOMES OF INPATIENT ANTIBIOTIC DOSING PRACTICES FOR PATIENTS ON CVVH AND CVVHDF (A1). Nina Imura, Megan McMurray, Jeannie Chan. Harborview Medical Center, Seattle, WA (ninayee@uw.edu) IRB approved. Various guidelines for antibiotic dosing for patients on continuous renal replacement therapy (CRRT) are based on filtration rates of 1-2 L/h. Since March 2008, new filtration systems, filter types and faster filtration rates have been implemented at Harborview Medical Center. It is unclear whether antibiotic dosing strategies for patients on continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodiafiltration (CVVHDF) have been adjusted to account for these system changes. Currently, no clinical guidelines are available within the institution to assist providers in the dosing of antibiotics for patients on CRRT. This single center, retrospective observational study will evaluate whether the current practice for dosing antibiotics for inpatients on CVVH and CVVHDF is adequate for the rates and types of filtration systems used and determine the impact on infection related outcomes (i.e., clinical efficacy, hospital readmission and survival at discharge). Inclusion criteria are patients with age greater than 18 admitted to the intensive care unit and receiving concurrent CRRT and antibiotic therapy during the two year period between March 2008 to March 2010. Patients were excluded if on continuous venovenous hemodialysis (CVVHD) or hemodialysis (HD). Results and discussion will be presented.

OUTCOMES OF CYTOMEGALOVIRUS INFECTION TREATED WITH ALTERNATING GANCICLOVIR AND FOSCARNET (A1), Helen Jo, Jane Kriengkauykiat, James Ito, Chatchada Karanes, Sanjeet Dadwal. City of Hope Medical Center, Duarte, CA (hjo@coh.org) IRB approval received. Management of cytomegalovirus (CMV) in hematopoietic stem cell transplant (HSCT) recipients is frequently complicated by drug-related toxicities associated with ganciclovir (G) and foscarnet (F). Alternating combination therapy (ACT) with G and F can be used to minimize toxicity. We reviewed clinical features/ outcomes of CMV infections treated with ACT in HSCT recipients. Retrospective chart review of HSCT recipients with CMV viremia treated with ACT from July 2005 to June 2010. Inclusion criteria: ACT treatment duration 72 hours, age 18 years (y). 35 patients identified; 6 did not meet criteria. 30 cases treated with ACT were identified. At the end of therapy (EOT), 21 had complete response (polymerase chain reaction (PCR) 0 copies/mL at EOT or maintained PCR 0 copies/mL throughout treatment), 4 partial (<1 log change in PCR) decrease, 1 partial increase, and 2 failed therapy ( 1.0 log PCR increase); 2 did not have sufficient data. Median time to clear CMV viremia was 15d (days). 6 stopped ACT due to drug-related toxicities (5 bone marrow suppression; 1 renal insufficiency) and 5 due to persistent viremia without any log increase. 1 relapse occurred within 60d of completing ACT. There were 2 CMV-related deaths within 90d of completing ACT. ACT may be a viable alternative in HSCT patients at risk for drug-related

toxicities or those responding poorly to single-agent antiviral therapy.

CLINICAL SIGNIFICANCE OF SWITCHING CONVENTIONAL EIA WITH PCR FOR SUSPECTED C. DIFFICILE ASSOCIATED DIARHHEA (A1), Steven Johnson, Romney Humphries. Ronald Reagan UCLA Medical Center, Los Angeles, CA (swjohnson@mednet.ucla.edu) IRB approval pending. The pathogenicity of Clostridium difficile is closely related to the production of toxins A and B. Rapid enzyme immunoassays (EIAs) for C. difficile toxin have become the default test for C. difficile despite their poor sensitivity and specificity. Physician mistrust of negative EIAs has led to excessive retesting, inappropriate and prolonged antibiotic treatment and isolation of patients. Recently, a C. difficile PCR stool assay was initiated at the Ronald Reagan UCLA Medical Center. The new assay is associated with higher specificity and sensitivity and a more rapid turnaround time. The purpose of this retrospective study is to evaluate the transition from the EIA to PCR stool test. Methods include data collection to generate a database of all requests for stool C. difficile EIA in February 2010. Data will also be obtained prospectively for the same time period in 2011 for stool C. difficile PCR. Outcome measures to be evaluated between the two time periods include: patient demographics, service patient location, number of requests per patient, antibiotic utilization, and incidence of secondary VRE and fungal infections. Results and conclusion will be presented.

EFFECT OF IMPLEMENTING AN ELECTRONIC ORDER MENU FOR TRIMETHOPRIM SULFAMETHOXAZOLE ON PRESCRIBER ORDERING BEHAVIOR AND ADVERSE EVENTS (A1). Tina Khadem. Kimberly MacKay. Portland VA Medical Center, Portland, OR (Tina.Khadem2@va.gov) IRB approved. The primary objective of this retrospective chart review was to determine the effectiveness of the drug order menu on decreasing the percent of prescribing for those with one or more contraindications or two or more precautions to the drug, and also for those without current serum potassium and serum creatinine lab values. Secondary objectives were to determine if the number of hospitalizations for hyperkalemia and acute renal insufficiency, and the number of adverse drug events associated with the drug have decreased since implementing the order menu. This single center, retrospective chart review targeted a sample size of 240 veteran outpatients, 120 patients in each arm, who received oral trimethoprim sulfamethoxazole therapy before and after the implementation of the order menu, excluding a grace period from September 1, 2009 to December 31, 2009. Patients less than 65 years of age or on dialysis were excluded from the study. Nominal data will be compared both pre and post intervention, using Chi squared analysis. Results and conclusions will be presented.

SAFETY AND CLINICAL OUTCOMES OF DAPTOMYCIN IN THE MANAGEMENT OF GRAMPOSITIVE INFECTIONS IN OBESE ADULT PATIENTS (A1), Alice Khong, Monica Ludwick, Romic Eskandarian. Glendale Adventist Medical Center, Glendale, CA (Khongah@ah.org) IRB: Not needed. The purpose of this study is to evaluate the safety and clinical outcomes of daptomycin in obese patients (BMI >30). This retrospective chart review was conducted at a 450-bed private acute care hospital. Patients at least 18 years of age, who received daptomycin for at least 7 days as treatment of gram-positive infections during a 3-year period were included. Safety and clinical outcomes will be analyzed. We identified 237 patients who received at least 7 days of daptomycin during the study period. The percentage of patients with elevations of CPK above 397 was 4.6% (11/237). Of these 11 patients, 5 had BMI > 30 kg/m2 and 6 had BMI <30 kg/m2. Of the 11 patients with a CPK > 397 units/L (upper limit of normal) we identified 2 patients with CPK increases due to daptomycin, both patients had a BMI over 30 kg/m2, 89.5 kg and 215 kg, respectively. This represents 0.8% (2/237) of the patients studied. Of the 11 patients, 6/11 (55%) had CPK > 397 units/L that were not considered daptomycin related, since their CPK increases occurred prior to daptomycin was administered. For 3 daptomycin non-related cases, CPK increase occurred > 30 days after daptomycin was discontinued

Overall daptomycin use was safe in the management of gram positive infections in our patient population where 35% of patients had a BMI of at least 30 kg/m2. Of 237 patients, we found 2 patients had CPK elevations probably due to daptomycin. However, further studies are needed to evaluate the effects of obesity on CPK elevation.

CLINICAL SIGNIFICANCE OF COAGULASENEGATIVE STAPHYLOCOCCAL (CoNS) POSITIVE BLOOD CULTURE AND DEVELOPMENT OF CLINICAL CRITERIA FOR TREATMENT (A1). Jihye Kim, Cinda Christensen, Stuart Cohen, Archana Maniar, Hien Nguyen, UC Davis Medical Center, Sacramento, CA (jihye.kim@ucdmc.ucdavis.edu) IRB approved. Coagulase-negative staphylococci (CoNS) are the most frequently isolated bacteria from blood cultures. Although CoNS can be the cause of true bloodstream infection, they are the most common contaminants of blood cultures. No gold standard algorithm is available to help differentiate between CoNS bacteremia and contamination. The purpose of this study is to determine the incidence of patients given unnecessary antibiotics for likely contamination due to CoNS. The secondary objective is to test the usefulness of a published algorithm for determining true CoNS bacteremia versus contamination. This is a retrospective, single-center chart review of all patients with positive blood culture for CoNS between September 2009 and September 2010 at UCDMC. Inclusion criteria for this study are age 18 years or older with positive blood culture for CoNS. Patients with other concomitant infections that required antibiotic treatment with activity against CoNS, incomplete medical records, or who expired < 24 hours of initial positive blood culture are excluded from this study. An expert panel of infectious disease physicians will be reviewing the applicability of a potentially revised algorithm. Results and conclusions will be discussed.

EVALUATION OF BROAD SPECTRUM ANTIBIOTIC USE AND THE IMPLEMENTATION OF ANTIMICROBIAL STEWARDSHIP STRATEGIES FOR IMPROVING OUTCOMES (A1), Kaitlin Knudson. Central Washington Hospital, Wenatchee, WA (kaitlin.knudson@cwhs.com) IRB approved. The health systems electronic medical record system was used to identify patients who, over a 30 day period of time, had orders for four broad spectrum antibiotics (vancomycin, piperacillin tazobactam, meropenem and levofloxacin). Each patients antibiotic regimen was classified as appropriate versus not appropriate according to the following criteria: 1) Antibiotic use had an indication 2) Antibiotic was being given for and indication based on current evidence based medicine or package insert 3) Antibiotic dose was appropriate for the indication 4) Antibiotic was switched, deescalated, or discontinued based on culture and sensitivity results 5) Antibiotic was discontinued based on clinical improvement 6) Antibiotic was given for an appropriate duration based on evidence based medicine or package insert 7) Antibiotic dose was based on patient specific parameters (age, weight, height, renal function, etc.) and 8) Antibiotic choice was based on patients current known allergies. Following identification of appropriate versus not appropriate use, findings will be used to develop strategies for implementation of pertinent antimicrobial stewardship program interventions. Results and conclusions will be presented.

IMPACT OF PROCALCITONIN USE ON ANTIBIOTIC USAGE IN PNEUMONIA PATIENTS (A1). Janet Kook, Stephanie Chao, Philip Robinson, Nicola Cooper, Zerline Cruz, Bhavi Shah, Jennifer Le. Hoag Hospital, Newport Beach, CA (Janet.Kook@hoag.org) IRB not needed. Procalcitonin (PCT) is a peptide precursor of calcitonin that becomes significantly elevated in response to bacterial infections. This assay is a useful biomarker in guiding antibiotic therapy, and particularly in ruling out non-bacterial infections. The recent acquisition of the PCT assay at Hoag Hospital provides clinicians with a helpful prognostic tool when attempting to differentiate bacterial pneumonia from other clinically similar presentations such as COPD exacerbation or viral pneumonia. Use of the PCT assay at Hoag Hospital has increased; however, the outcome data has not been assessed. This study is a retrospective cohort analysis. The objective of this study is to evaluate the use of PCT in pneumonia patients to assist in the appropriate use of antibiotics. This will be assessed by comparing the duration of antibiotic therapy between pneumonia patients with PCT levels to pneumonia patients without PCT levels. Data presented will include antibiotic days and cost of antibiotic therapy for the treatment of pneumonia. Results will be discussed.

VANCOMYCIN RESISTANT ENTEROCOCCUS (VRE) BACTEREMIA IN THE BONE MARROW TRANSPLANT POPULATION (AT A TERTIARY CARE ACADEMIC MEDICAL CENTER) (A1), Emanuel Kwahk, Charles James, Randy Taplitz. UC San Diego Medical Center, San Diego, CA (ekwahk@ucsd.edu) IRB approval pending. The study object is to examine trends of VRE bacteremia in bone marrow transplant patients at a tertiary academic medical center. A retrospective review of inpatients receiving bone marrow transplants from 2005 to 2010 will be performed. An estimated 700 patients will be reviewed. Data will be collected including demographic information, oncologic diagnosis, chemotherapeutic regimen, history of bacteremia in the early post-transplant period, length of hospital stay, and mortality. For those patients who developed VRE bacteremia, additional information including antibiotic treatment and microbiological data will be collected. Patients with prior documented history of positive VRE cultures will be identified. Rates of VRE bacteremia for patients with prior colonization will be calculated. Data including incidence of VRE bacteremia, mortality, and length of hospital stay will be compared by year. Demographic and other data from the above sets that correlate to development of VRE bacteremia will be identified. Results, conclusions, and recommendations for further study will be presented.

EVALUATION OF BETA-LACTAM VS. NON BETALACTAM USE IN UNCOMPLICATED CELLULITIS AND/OR ABSCESS (A1) Diane Lieu, PGY1 Pharmacy Practice Resident, VA San Diego Healthcare System, San Diego, CA (diane.lieu@va.gov) IRB approved The study objective was to evaluate if a difference in failure rates for patients prescribed beta-lactam vs. non beta-lactams antibiotics with MRSA coverage for uncomplicated cellulitis with or without abscess in the outpatient setting or emergency department exists. A retrospective chart review using data from January 1 to December 31, 2010 was done at VA San Diego. Inclusion criteria consisted of ICD 9 codes for cellulitis and/or abscess, and if they were prescribed one of the following antibiotics: cephalexin, dicloxacillin, amoxicillin/clavulanate, trimethoprim/sulfamethoxazole, clindamycin or a tetracycline. Patients who received any IV/IM/PO antibiotics or had previous hospitalization within 1 month prior to oral antibiotic prescription, required surgical intervention, had no antibiotic prescribed, lived in group homes, were diagnosed with complicated cellulitis or diabetic foot ulcers, had miscoded ICD 9 codes, or were prescribed combination antibiotics in the same class were excluded. Treatment failure was defined as: addition/substitution of another antibiotic, refill or increased dosage of antibiotic prescription, hospital admission or surgical intervention after antibiotic

prescription, or no improvement noted in the chart. The sample population was comprised of 1451 patients recognized as having ICD9 codes for cellulitis. Chi- square and student t-tests will be used to analyze data. Results and conclusions will be presented.

EFFICACYANDSAFETYOFSIXMONTHS450MGVERSUS900MG VALGANCICLOVIRTOPREVENTCYTOMEGALOVIRUSINHIGH RISKRENALTRANSPLANTPATIENTS(A1).KevinLor.AshleyFeist. UCSDMedicalCenter,SanDiego,CA(kwlor@ucsd.edu)IRB approved. Thestudyobjectivewastocomparetheefficacyand safetyofsixmonthsofeither450mg/dayor900mg/dayof valganciclovir(VGC)inrenaltransplantpatients.AlthoughVGC 900mg/dayfor200dayshasprovenefficacyinpreventionof cytomegalovirus(CMV)disease,somecentersuse450mg/day basedonpharmacokineticdataandreportedsuccess.Thiswas aretrospective,multicenteredstudyofninenationwide hospitals.AllsubjectswereCMVdonorseropositive,recipient seronegativerenaltransplantpatientsthatalsoreceivedanti thymocyteglobulinorinterleukin2receptorantagonistsfor inductionfromAugust2001toDecember2009.Theprimary outcomemeasurewasprevalenceofCMVdiseaseatoneyear. SecondaryoutcomemeasureswereadverseeffectsofVGC, potentialconfounders,andriskfactorsforCMVdisease. StatisticalanalysiswasdescriptiveandinferentialusingFisher's exacttest,chisquaredtest,andmultipleregressionanalysis. Patientdemographicsandtransplantcharacteristicswere comparable.Theuseofantithymocyteglobulinwasnot significantlydifferentbetweenthetwogroups.Therewasno differenceofCMVratein450mggroup(n=130)comparedto 900mggroup(n=109),14.6%vs.24.3%(p=0.068NS).Therates ofearlyVGCdiscontinuationduetomyelosuppressionwere alsonotsignificantlydifferent.Either450mgor900mgofVGC couldbereasonableoptionstopreventCMV.Furtherresults willbepresentedanddiscussed.

APPROPRIATENESS OF DOSING BEFORE AND AFTER IMPLEMENTATION OF EXTENDED INFUSION PIPERACILLIN/TAZOBACTAM (A1). Nicole Lu, Staci Anderson, Marisa Mendez. Community Medical Centers, Fresno, CA (nlu2@community medical.org) IRB approved. The study objectives were to evaluate changes in the following areas, before and after implementation of the extended infusion administration of piperacillin/tazobactam in critically ill patients: appropriateness of dosing based on the patients renal function, MIC of select enterobacteriaceae organisms, mortality rates, length of stay in the intensive care unit and step down units (ICU/SDU), and cost savings. Piperacillin/tazobactam given as an extended infusion was implemented in the ICU/SDU at Community Regional Medical Center on 11/30/09. A retrospective chart review was conducted from 11/30/08 to 11/30/10 to evaluate for differences in the objectives as listed above. Patients 18 years and older receiving piperacillin/tazobactam in the ICU/SDU were included. Patients were excluded if they received piperacillin/tazobactam for empiric coverage with negative culture results or only had Gram positive organisms isolated. Two groups were analyzed: intermittent dosing and extended infusion dosing groups. The results from the two groups were compared using the Students t test. Results and conclusions will be presented.

ANTIMICROBIAL STEWARDSHIP PILOT PROGRAM (A1). Brittany Marshall. Dianna Gatto. Multicare Good Samaritan Hospital, Puyallup, WA (brittany.marshall@multicare.org) IRB approval exempt. The study objective is to pilot an antimicrobial stewardship program. A retrospective chart review was conducted to assess need for the program. Based on chart review data, a proposal was developed with hospital administration to pilot the implementation of a stewardship program. The pilot stewardship team consists of the pharmacy resident and infectious disease physician. During the pilot, the resident will conduct a daily prospective audit of all patients receiving selected antimicrobial agents, including piperacillin/tazobactam, imipenem, ciprofloxacin, levofloxacin, moxifloxacin, vancomycin, and linezolid. This information will be presented to the infectious disease physician during a daily meeting to discuss audited patients and potential interventions. The attending physician will then be contacted to discuss therapy recommendations. The number of accepted and rejected recommendations will be tracked, as well as the total number patients reviewed by the team. Estimated cost savings will be tracked. Results and conclusions will be presented.

PROSPECTIVE EVALUATION OF PERSISTENTLY POSITIVE MRSA BLOOD CULTURES FOR THE PRESENCE OF SUBPOPULATIONS WITH REDUCED SUSCEPTIBILITY TO VANCOMYCIN (A1), Courtney McKinney, D Nix. University of Arizona, Tucson, AZ (courtbmck@gmail.com) IRB approved. The primary objective of this study was to determine if methicillin resistant Staphylococcus aureus (MRSA) with reduced susceptibility to vancomycin is associated with persistently positive blood cultures using direct culture in vancomycin containing growth media. Patients with persistent MRSA bacteremia while on vancomycin therapy at a tertiary care, academic medical center during a 6 month period were prospectively enrolled in this study. Patients receiving antimicrobials other than vancomycin during the 5 days prior to collection of the index blood culture were excluded. MRSA blood isolates from eligible patients were directly plated onto brain heart infusion agar containing vancomycin concentrations of 0, 2, 4 and 6 mcg/ml. After incubation for 24 hours at 37 degrees Celsius, colony growth was recorded using a semiquantitative approach. Representative colonies from the plate with the highest concentration of vancomycin on which growth was evident were grown on fresh media and subjected to standard identification and broth microdilution MIC testing. Data analysis was descriptive only. Results and conclusions will be presented.

ANALYSIS OF CATHETER ASSOCIATED BACTERURIA MANAGEMENT AFTER PHARMACIST EDUCATIONAL INTERVENTION (A1). Rina Mehta, Nancy Nguyen, Russell Ryono. Veterans Affairs Palo Alto Health Care System (VAPAHCS), Palo Alto, CA (rina.mehta@va.gov) IRB not needed. Catheter associated bacteruria is among the most commonly observed in long term care patients, but less than one quarter of these patients actually develop urinary tract infection symptoms. Catheter associated asymptomatic bacteruria (CA ASB) does not warrant treatment, yet in clinical practice patients are often given antibiotics. The objective of this study is to compare the proportion of patients with CA ASB that are treated with antibiotics before and after educational intervention by a pharmacist. This retrospective study will include all inpatients in long term care facility wards at VAPAHCS with urine cultures collected during 7/1/10 to 9/30/10 and 3/1/11 to 4/30/11. Patients treated for a documented non urinary source of infection will be excluded. Electronic medical records will be used to gather data on lab results, pharmacy records, and clinical symptoms. In addition, the proportion of patients with catheters changed prior to urine cultures drawn, bacteria susceptible to empiric therapy, and documentation of urinary tract infection symptoms in the electronic charts will be analyzed before and after educational intervention. VAPAHCS long term care providers will be educated on treatment guidelines and antimicrobial stewardship. Subsequent analysis will be conducted to evaluate changes in prescribing practices. Results and conclusions will be presented.

APPROPRIATEUSEOFEMPIRICVANCOMYCINFORCOMMUNITY ACQUIREDCELLULITIS(A1),ChristieMock,ChrisTaylor.Phoenix VAHealthCareSystem,Phoenix,AZ(christina.mock@va.gov) IRBapprovalreceived. Theprimaryobjectivewastoretrospectivelyevaluateif vancomycinhasbeenappropriatelyusedinpatientsadmitted withcellulitis.AllpatientsadmittedtothePhoenixVAHealth CareSystemwiththeprimarydiagnosisofcellulitisfrom October1,2008toOctober30,2010wereevaluatedfor inclusion.Patientswereexcludediftheymetcriteriaforhealth careassociatedmethicillinresistantStaphylococcusaureus,met systemicinflammatoryresponsesyndromecriteria,were immunosuppressed,hadotherindicationsforvancomycin,or werelessthanorequalto18yearsofage.Appropriateor inappropriatevancomycinprescribingwasdeterminedbasedon clinicalpresentationcollectedfrompatientcharts.Four secondaryobjectiveswerealsoevaluated.First,theprevalence ofriskfactorsforcommunityacquiredStaphylococcusaureus infections(particularlycommunityacquiredmethicillinresistant Staphylococcusaureus)wasevaluated.Second,empiric antibioticsadministeredwereevaluated.Third,patientswith abscesswereassessedtodetermineifincisionanddrainagewas performed.Lastly,patientswereevaluatedtodetermineif cultureswereobtainedandifantibioticregimenswere appropriatelyadjusted.Chisquaredanalysiswillbeusedto evaluatetheprimaryendpoint.Descriptivestatisticswillbe usedtoassessthesecondaryendpoints.Resultsandconclusions willbepresented.

EVALUATION OF IMPLEMENTING AN ORDER SET TO IMPROVE PROPER AND COST-EFFECTIVE USE OF LINEZOLID (A1), Jeffrey Moghina, Cheryl Bauzon, Dan Neal. Veterans Affairs Roseburg Healthcare System, Roseburg, OR. (Jeffrey.moghina@va.gov) IRB approval pending. Methicillin resistant staphylococcus aureus (MRSA) treatment is a growing portion of antibiotic use by healthcare systems. This has important implications on cost to the system and development of new drug resistance. Linezolid (Zyvox) is a relatively recent addition to the handful of antibiotics that cover MRSA. Linezolid's well known efficacy on MRSA has led to increased use before other agents even though its cost is substantially higher than several other medication options. A drug utilization evaluation from September 17, 2009 to March 30, 2010 was performed via retrospective chart review at the VA Roseburg Healthcare System. Results showed fifteen of nineteen patients at the institution did not meet criteria for use. The study objective is to determine if implementation of a linezolid electronic order set will improve appropriate and cost-effective prescribing of linezolid. All data will be retrieved retrospectively through electronic medical record chart review. The study period will cover the first 3 months after implementation. Patients will be included in the study if they were prescribed linezolid. The results of the study have yet to be completed and will be discussed at a future presentation.

ANTIMICROBIAL SELECTION AND ITS IMPACT ON THE INCIDENCE OF CLOSTRIDIUM DIFFICILE INFECTION (A1), Michael Montoya. Palomar Medical Center, Escondido, CA (Michael.montoya@pph.org) IRB Approval is received. The study objective was to determine which antimicrobials place patients at a higher risk for Clostridium difficile associated diarrhea and which interventions can reduce their risk. All patients with diarrhea and a positive toxin assay for Clostridium difficile for three months were included in the study. Patients were broken down into either community acquired infection or healthcare associated infection based on symptom onset, antibiotic usage prior to admission and where the patient was admitted from. Physicians were educated on antimicrobials that place patients at higher risk for Clostridium difficile associated diarrhea and alternative agents to use. Physician education consisted of in-service presentations, posters, Medical Grand Rounds, and an article in the physician newsletter highlighting the initial results of this study and alternative antimicrobial regimens. Baseline data consisted of 40 patients with Clostridium difficile associated diarrhea. After implementation of educational programs a repeat sample of patients will be reviewed to determine effectiveness of the physician education. Results and conclusions will be presented.

INVASIVE ENTEROBACTER SP. INFECTIONS - IS TREATMENT WITH A THIRD GENERATION CEPHALOSPORINS ASSOCIATED WITH TREATMENT FAILURE? (A1), Manasa Murthy, Cinda Christensen, UC Davis Medical Center, Sacramento, CA (manasa.murthy@ucdmc.ucdavis.edu) IRB approved. The objective of this study is to determine the frequency and outcomes associated with the use of thirdgeneration cephalosporins versus other antimicrobial agents in the setting of invasive Enterobacter sp. infections. This study is a single-center, retrospective chart review analyzing a minimum of 100 patients diagnosed with invasive Enterobacter sp. infections at UCDMC. Patients were selected from a microbiology lab report identifying positive Enterobacter sp. cultures from May 2008September 2010. Patients greater than two months of age deemed to have monomicrobial, invasive Enterobacter sp. infections were included in the study. Exclusion criteria included incomplete medical records, superficial infections, polymicrobial infections, and patients who did not receive antimicrobial therapy. Study outcomes include 30-day mortality, clinical or microbiological cure, infection recurrence, susceptibility changes, and development of C. difficile. Predictors of treatment failure including appropriateness of dosing, immunocompetancy status and site of infection will be reviewed. Results and conclusions will be presented.

THE EFFECT OF EARLY ANTIBIOTIC ADMINISTRATION ON LENGTH OF STAY IN PATIENTS DIAGNOSED WITH COMMUNITYACQUIRED PNEUMONIA IN THE HOSPITAL AT VALLHS (A1), Juleann Mutka, Tony Chau. VA Loma Linda Healthcare System, Loma Linda, CA (Juleann.Mutka@va.gov) IRB approved. The study objective is to determine the average length of stay (LOS) in the hospital for patients that receive their first antibiotic dose within 4 hours after being diagnosed with CAP. Other objectives are to evaluate the average LOS of patients who received the first antibiotic dose within 2 hours, 6 hours, and beyond 6 hours. This is a retrospective chart review study evaluating patients admitted into VA Loma Linda Medical Center with CAP and looking at the time to first antibiotic dose and their length of stay. Eligible patients were 18 years or older with a confirmed primary diagnoses of CAP (based on ICD-9) from 7/1/2007 - 7/1/2010. In addition to evaluating LOS, other covariance such as age, sex, comorbidities, and nosocomial infections are also included in the analysis. Factors that could have contributed to the delay of the first dose administered were also be evaluated. The results and conclusions will be presented.

CUMULATIVE INTRAVENOUS LIPID EMULSION INFUSION AND INFECTION RISK (A1) Ana Negrete, Mark Decerbo, Meghan Jeffres, Sean Barclay. UMCSN, Las Vegas, NV (ana.negrete@umcsn.com) IRB Approved. In vitro, fatty acids have been associated with decreased immune function, including reduced migration, phagocytic activity, and reactivity of neutrophils, macrophages, and lymphocytes. In vivo, IV lipid receipt has been associated with higher infection rates, ventilator days, and length of ICU stay. An internal pilot study revealed cumulative grams of IV lipids as an independent predictor of infection in patients on parenteral nutrition (PN). However, days of lipid receipt was also increased in the infected cohort, obscuring whether infection risk is independently related to cumulative lipid dose, or simply a factor of PN duration. The objective of this study is to evaluate rate of bloodstream infections (BSI) in patients receiving PN, and at fixed time intervals of PN receipt, compare cumulative administered lipid in patients developing BSI as compared to those who do not. Adult patients admitted to a tertiary care hospital from 2009 to 2010 receiving a minimum of 3 days of PN were retrospectively identified. At days 3, 7, 10, 14, 21, and 28 of PN therapy, patients were evaluated for BSI, and cumulative amounts of infused lipid from both PN and

propofol were calculated. Total grams in patients developing BSI were compared to those in the uninfected cohort in order to determine if development of a BSI was associated with a higher cumulative amount. Patients with a documented BSI prior to PN initiation or antimicrobial use at baseline or in the absence of positive blood cultures were excluded. Results and Conclusion: To be presented

IMPLEMENTATION AND STANDARDIZATION OF ANTIMICROBIAL STEWARDSHIP PROGRAMS THROUGHOUT A HEALTH SYSTEM (A1), Jenni Nelson, Steve Stoner. Providence Health and Services, Oregon (jenni.nelson@providence.org). This project entails developing tools and gathering resources for implementation of successful antimicrobial stewardship programs (ASP) in eight hospitals across a health system. The Providence health system in Oregon consists of two tertiary, two critical access and four community/rural hospitals. Development of a business plan to gain administrative support as well as infectious disease physician buy in was the first step. Subsequent steps included updating and approval of antimicrobial criteria for use guidelines and creation of education/training modules followed by an exam for clinical pharmacists competency. Effective clinical surveillance programs will be determined to aid pharmacists in which patients to focus on during their shift. Another vital aspect of implementation is meeting with pharmacy managers and clinical coordinators at each individual hospital to determine the different barriers that need to be overcome to start a successful service in their hospital. Infectious Disease Physician oversight to the smaller and rural hospitals remains a challenge at this time, however interventions regarding appropriate use of antibiotics can be made by pharmacists when use of these new tools occurs. Data will compare antimicrobial cost between a Providence hospital with a current ASP and one without as well as measure pharmacists pretests versus posttests when completing the education/training modules.

RISK FACTORS, SEVERITY, AND CLINICAL OUTCOMES OF CLOSTRIDIUM DIFFICILE INFECTION IN HEMATOPOIETIC STEM CELL TRANSPLANT RECIPIENTS (A2), Lynn Nelson, Charles James, Randy Taplitz. UC San Diego Medical Center, San Diego, CA (lcnelson@ucsd.edu) IRB approval pending. The primary objective of this study was to contrast clinical symptomatology, outcomes, risk factors, and treatment strategies of Clostridium difficile infection in hematopoietic stem cell transplant (HSCT) recipients versus non transplant patients. Data were collected retrospectively from January 1st, 2009 to December 31st, 2010 utilizing the pharmacy and laboratory information computer systems. The case group included patients carrying a diagnosis of Clostridium difficile infection with previously documented HSCT. The control group was identified utilizing the same criteria with no prior history of HSCT. Enrollment for each arm was anticipated to include 80 patients. Patients were excluded if they were diagnosed and treated for Clostridium difficile infection in the outpatient setting, or if they were under 18 years of age. Severity of Clostridium difficile infection (based on established grading criteria) and associated recurrence were collected for comparison between the two groups. T-tests and chi-square tests will be used to compare continuous and categorical variables between groups, respectively. Results and conclusion will be presented.

EVALUATION OF EMPIRIC FLUOROQUINOLONE USE IN A COMMUNITY HOSPITAL. Amie Nguyen, Maggie Brownell. Scripps Memorial Hospital La Jolla, La Jolla, CA (nguyen.amie@scrippshealth.org) IRB approved. Fluoroquinolones have been widely used because of their broad spectrum activity, favorable safety profile and comparable intravenous and oral bioavailability. Scripps Memorial Hospital La Jolla (SMHLJ) has shown an increase in the utilization of fluoroquinolones (levofloxacin being the most prescribed) from 2004-2008 and concurrent decreased isolate susceptibility (particularly with Escherichia coli, Proteus mirabilis and Pseudomonas aeroginosa) to levofloxacin over the past 10 years. In our study, we assess whether empiric levofloxacin use at SMHLJ is justified based on definitive cultures and sensitivities. Additionally, we determine whether or not de-escalation occurred once cultures and sensitivities were available. This is a retrospective and concurrent study evaluating adult inpatients on oral or IV levofloxacin with positive cultures. Analysis of descriptive data will be performed. Results and conclusions will be presented.

AN INTEGRATIVE APPROACH TO THE TREATMENT OF CHRONIC HCV IN CO-INFECTED PATIENTS WITH HIV (A1). Michael North, Karla Thornton, Paulina Deming, Renee Mercier. University of New Mexico Hospital, Albuquerque, NM (mnorth@salud.unm.edu) IRB approval is received. The study objective was to determine if an HIV clinic which uses an integrated approach to treating HCV, without a referral to a gastroenterologist, will treat a greater number of patients with HCV and whether sustained virologic response (SVR) rates will be improved compared to other clinic data published in the literature. The study will include adult patients with confirmed HIV infection and at least one positive HCV RNA. Patients treated at the Truman Street HIV clinic in Albuquerque, NM between 2003 and 2010 will be included. Approximately 213 HIV/HCV patients were seen at the HIV clinic during this time period and approximately 35 patients received at least one dose of HCV treatment. Data to be collected include patient demographics, use of HAART, laboratory data including HIV and HCV viral loads, and CD4 counts. The reasons why patients were ineligible for treatment and reasons for not treating treatment-eligible patients will also be recorded. If applicable, data on the HCV treatment course will be collected including adverse events during treatment, the reasons for discontinuing treatment, type and dose of interferon, and the dosage of ribavirin administered. SVR rates from this study will be compared to the reported rates from non-integrated clinics found in the literature. Results and conclusions will be presented.

INFECTION RATES IN PATIENTS WITH RA, CROHNS DISEASE OR ANKYLOSING SPONDYLITIS RECEIVING TNF ALPHA ANTAGONIST (A1), Eddu OparieAddoh, Dustine Whiteman, Phoenix VA hospital, Phoenix, AZ (eddu.oparieaddoh@va.gov) IRB approved

The study objective is to compare the infection rates one year before to one year after initiating tumor necrosis factor alpha (tnf alpha) antagonists in patients with rheumatoid arthritis (ra), Crohns disease (cd) or ankylosing spondylitis (as). The secondary objectives will stratify the infection rates by patient characteristics such as indication for tnf alpha antagonist therapy, specific tnf alpha antagonist regimen, and documentation of prescreening for tuberculosis (tb). This is an observational, retrospective study. Patients prescribed tnf alpha antagonists for rheumatoid arthritis (ra), Crohns disease (cd) or ankylosing spondylitis (as) between 10/1/2006 and 9/30/2010 may be included in this study. Patient charts will be reviewed for the 1 year prior to the initiation a tnf alpha antagonist. The same patients records will then be reviewed for the 1 year after the initiation of tnf alpha antagonist. Clinical and demographic data will be extracted from patient charts: age, gender, race/ethnicity, social security number (ssn), name of tnf alpha antagonist medication, date tnf alpha antagonist was initiated, documentation of infections for which the patient was either hospitalized or treated with an antibacterial, antifungal or antiviral drug (including date of diagnosis of infection, type of infection, and antimicrobial medications used to treat infection), indication for tnf alpha antagonist, and history of placement of purified protein derivative (ppd) to screen for tb.

EXPANSION OF ANTIMICROBIAL STEWARDSHIP: THE IMPACT OF A 72 HOUR REVIEW OF IV ANTIBIOTICS WITHIN THE ICU (A1). Tom Richardson. Neil Massoud. Steve Wimer. St. Joseph Medical Center, Bellingham, WA (trichardson3@peacehealth.org) IRB exempt. The objective of this study is to evaluate the impact of a 72 hour review of intravenous antibiotics by a pharmacist, by measure of days to de-escalation or discontinuation. ICU pharmacists and pharmacy residents will prospectively evaluate intravenous antibiotics ordered during the first 72 hours for appropriateness. Patients reaching 72 hours of antibiotic therapy will be presented during ICU rounds with a recommendation to continue, deescalate, or discontinue antibiotics. Patients reaching the 72 hour mark for antibiotic usage will be identified using the hospitals database extracting program. The intervention group will be evaluated prospectively, ending when 100 patients have been included into the study. Patients in the comparator group will be retrospectively evaluated prior to initiation of the intervention; data from the last 100 patients admitted to the ICU that received intravenous antibiotics. The following data will be collected: number of days to deescalation or discontinuation, percentage of patients who had de-escalation or discontinuation, specific type of antibiotic(s) initially prescribed, antibiotic(s) used in deescalation, cost savings analysis, initial indication for

antibiotic prescription, and the reason for de-escalation or discontinuation. The results will be discussed with a presentation of data specifics.

CREATION AND EVALUATION OF AN ADULT ANTIBIOTIC ORDER FORM COMPARING THE APPROPRIATE USE OF ANTIBIOTICS (A1), Aleesha Richman, Dustin Waters. McKay Dee Hospital/Intermountain Healthcare, Ogden, UT (Aleesha.Richman@imail.org) IRB approval received. It has been well documented across the nation that due to the inappropriate use of antibiotics, hospitals are experiencing resistant pathogens, increased costs for treatment of infections, increased patient mortality and longer hospital stays for patients. The purpose of this study is to evaluate the effectiveness of an adult antibiotic order form at prescribing appropriate antibiotics. Appropriate use is defined by the drug, dose, schedule, and duration of therapy based on current guidelines. This study will include patients 18 years and older who are empirically being treated for an indication on the order form. The indications include: HCAP/VAP, intraabdominal infections, skin and soft tissue infections, UTI, meningitis, and febrile neutropenia. A calculated percentage will be compared between the use of the order form and those prescriptions written from the order form. An antibiotic order form has been placed in all admit packets on the medical, intermediate care and cardiovascular units making it more accessible to prescribers. The form will also be available in the ICU and ED. Implementation of the order form began in February 2011 and data will be collected and determined as appropriate or inappropriate as defined above by two clinical pharmacists. Results and conclusions will be presented.

DEVELOPING AND IMPLEMENTING AN AMINOGLYCOSIDE DOSING AND MONITORING PROTOCOL FOR ADULT PATIENTS (A1). Andrea Rieland. San Joaquin General Hospital, French Camp, CA (alesher@sjgh.org) IRB approval is received. Due to a combination of increasing resistance among gram negative bacilli and the lack of development of new antibiotics, clinicians have been compelled to use older classes of antibiotics, such as the aminoglycosides. This class of medications is notoriously difficult to use due to a narrow therapeutic index and the need for pharmacokinetic monitoring. The objective of the current study was to determine the impact of a pharmacist-driven aminoglycoside dosing and monitoring protocol. A six month retrospective study was conducted and included all adult patients who received more than one dose of gentamicin, tobramycin, or amikacin. The appropriateness of therapy was determined based on indication, dose and time to serum level. The six month prospective arm was compared with that of the retrospective arm to determine if a difference exists between physician driven and pharmacist driven aminoglycoside dosing and monitoring. Results will be presented.

ANTIBIOTIC USE IN HOSPITALIZED PATIENTS ADMITTED FROM A LONG-TERM CARE FACILITY WITH HEALTHCARE-ASSOCIATED PNEUMONIA (A1). Clare Rupprecht. V. Venugopalan. K. Johnson. Hollywood Presbyterian Med Ctr, Los Angeles, CA (crupprec@gmail.com) IRB pending. The purpose of this retrospective study was to determine the clinical outcomes of adherence to American Thoracic Society/Infectious Diseases Society of America empiric antimicrobial guidelines for healthcare-associated pneumonia (HCAP) in patients presenting to a community acute care hospital in southern California from a long-term care facility. Study subjects were identified using discharge diagnosis codes for pneumonia. Patients were included if they were at least 18 years old and admitted from a long-term care facility. Patients were categorized into two groups according to the empiric antimicrobial therapy received: HCAP guideline concordant treatment, or guideline non-concordant treatment. The primary endpoint was time to clinical stability. Secondary endpoints included inpatient mortality, length of stay, and cost of hospital stay. The results will be analyzed using descriptive statistics and multivariate regression. Results and conclusions will be presented.

EVALUATION OF TROUGH LEVELS AND NEPHROTOXICITY WITH A CLINICAL PHARMACIST VANCOMYCIN PROTOCOL (A1). Gavin Sakamoto. Kaiser Permanente Hawaii Moanalua Medical Center, Honolulu, HI (gavin.t.sakamoto@kp.org) IRB approval is not needed. Vancomycin provides gram positive bacterial coverage and is the mainstay of treatment for MRSA. Development of resistance to vancomycin has led to new recommendations for increased target vancomycin trough levels. However, uncertainty remains whether the attainment of higher target trough levels is associated with increased nephrotoxicity. The study objectives are to determine if the initiation of a newly implemented Clinical Pharmacist Vancomycin Protocol (CPVP) and dosing calculator achieved goal trough levels at an acceptable rate and led to changes in nephrotoxicity rates. A retrospective chart review was performed on patients receiving vancomycin from January 2010 to April 2011 to compare rates of targeted vancomycin trough levels and nephrotoxicity pre and post CPVP implementation. Inclusion criteria were adult patients, dosed per pharmacy, treated for a minimum of three days with properly drawn vancomycin trough levels. Exclusion criteria were patients less than 18 years of age, patients undergoing intermittent hemodialysis or continuous renal replacement therapy, pregnancy, acute renal failure, and critical care unit patients. Results will be presented.

MULTIDISCIPLINARY MANAGEMENT OF LEVOFLOXACIN THERAPY (A1), Wendy Satterwhite, Anthony Scriver. The Medical Center of Aurora, Aurora, CO (wendy.satterwhite@healthonecares.com) IRB approval received. Levofloxacin is a concentration dependent antibiotic that is widely used in the United States for the treatment of common infections as well as coverage for Pseudomonas aeruginosa. This study proposes that pharmacist mediated education to physicians involving sequential therapy and appropriate renal adjustment can be successfully implemented in order to streamline levofloxacin use without compromising patient care. For phase 1, data was collected retrospectively during the first quarter of 2010 using the pharmacy and medical record systems at The Medical Center of Aurora on adult patients over the age of 18 who were initially prescribed levofloxacin IV. Education on levofloxacin dosing and adjustment will then be provided to physicians and pharmacists in order to collect phase 2 data during the first quarter of 2011. The primary endpoints include determining the efficacy of this new levofloxacin management protocol, as well as including a cost effectiveness analysis to determine the savings per patient when therapy is appropriately switched from intravenous to oral levofloxacin. The secondary endpoints include total duration of IV therapy between the control and study group, as well as the incidence of adverse side effects associated with levofloxacin therapy. Data and complete results will be discussed.

IMPLEMENTATION AND ASSESSMENT OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM (A1). Jennifer Schneider. MultiCare Health System. Tacoma, WA (Jennifer.Schneider@multicare.org). IRB exempt The Joint Commissions National Patient Safety Goal 7 is to reduce the risk of health care associated infections including the prevention of multi drug resistant organism infections. The Infectious Disease Society of America along with the American Society of Health System Pharmacists recognize that the combination of effective antimicrobial stewardship along with a comprehensive infection control program limit the emergence and transmission of antimicrobial resistant bacteria. The objective of this study is to implement an antimicrobial stewardship program and assess its outcomes at a 400 bed private, nonprofit tertiary hospital. A baseline retrospective audit from October to November 2010 was conducted to assess current antibiotic prescribing. A multidisciplinary team reviewed the audit results to assess opportunities to improve antibiotic use. Inclusion criteria, patients admitted to the hospital for greater than 48 hours, patients 18 years of age or older, and patients with an order for one or more of the following antibiotics, linezolid, daptomycin, vancomycin, levofloxacin, ceftriaxone, piperacillin and tazobactam, and imipenem and cilastatin. Primary endpoints include appropriate empiric antibiotic selection, appropriate de escalation of therapy including intravenous to oral conversion, appropriate duration of therapy, and dose optimization. Secondary endpoints include decrease in adverse effects and cost associated with

antibiotics. A repeat audit will be conducted to assess the effectiveness of the antimicrobial stewardship program.

EFAVIRENZ USE IN PATIENTS WITH ESTABLISHED PSYCHIATRIC DISEASE (A1). Patrick Shin. Thuong Tran. Wayman Lee. Christopher Graber. Veteran Affairs Greater Los Angeles Healthcare System. Los Angeles, CA (pshin@usc.edu) IRB pending. HIV patients with psychiatric disease are believed to have greater risk on efavirenz for neuropsychiatric adverse events due to case reports of severe psychiatric decompensation in patients who have efavirenz as a part of their combination antiretroviral therapy. Neuropsychiatric adverse events are a common problem with efavirenz treatment with an estimated 50% experiencing some form of it. Our study objective, therefore, was to determine the duration of efavirenz as a part of combination antiretroviral therapy in HIV patients at the Veteran Affairs Greater Los Angeles Healthcare System with underlying psychiatric disease or a history of alcohol or recreational drug abuse. The primary outcome of interest was days of treatment with efavirenz prior to discontinuation due to these adverse events, and the secondary outcomes were other reasons for discontinuation such as non-neuropsychiatric adverse events, noncompliance, or virologic failure as well as how the providers treated the neuropsychiatric adverse events in these patients. For the primary outcome, patient days on efavirenz were determined and if the drug was discontinued, the reason for discontinuation was documented. A time-to-event analysis will be used to evaluate our primary outcome. Results and conclusions will be presented.

ANTIMICROBIAL PRESCRIBING AND STREPTOCOCCUS PNEUMONIAE NONSUSCEPTIBILITY AT ALASKA NATIVE MEDICAL CENTER (A1), Ryan Stevens. Alaska Native Medical Center, Anchorage, AK (rwstevens@anthc.org) IRB approval received. The objective of this study was to determine if population-based antimicrobial prescribing was associated with nonsusceptibility in Streptococcus pneumoniae causing invasive disease in Alaska Native patients between 1992 and 2009. Isolate nonsusceptibility data for Anchorage was gathered from cases reported to the Centers for Disease Control and Prevention, Arctic Investigations Program. Antimicrobial data were gathered from the electronic patient management system and included all prescriptions dispensed to Alaska Native patients from outpatient pharmacies at Alaska Native Medical Center. Vaccine (PCV7) serotypes were excluded from analysis due to small numbers of isolates in the latter part of the study period. Over the study period, trimethoprim/sulfamethoxazole nonsusceptibility in Alaska Native patients age five or greater increased in nonPCV7 serotypes (0% to 12%, p<0.05). This increase in nonsusceptibility was accompanied by an increase in trimethoprim/sulfamethoxazole prescribing (43/1000/year in 1993 to 108/1000/year in 2009, p<0.001). Similarly, erythromycin nonsusceptibility in nonPCV7 serotypes increased in Alaska Native patients age five or greater (0% to 7%, p= 0.087). Prescribing rates also increased for macrolide antibiotics (46/1000/year in 1992 to 84/1000/year in 2009, p<0.05). Increased prescribing of

trimethoprim/sulfamethoxazole and macrolides in Alaska Native patients age five or greater was associated with increased nonsusceptibility to these antibiotics between 1992 and 2009.

EFFICACY OF PIPERACILLIN/TAZOBACTAM EXTENDED INFUSION AGAINST GRAM NEGATIVE BACTERIAL INFECTIONS (A1), Paul Takamoto, Denise Bragg, Deepak Sisodiya. Stanford Hospital and Clinics, Palo Alto, CA (PTakamoto@stanfordmed.org) IRB approved. The purpose of this retrospective, single center, chart analysis study is to compare the clinical efficacy of extended infusion (4 hour) protocol versus conventional infusion (30 minute) of piperacillin/tazobactam in critically ill patients. Patients were identified through the Stanford Hospital and Clinics computer system (EPIC) based on piperacillin/tazobactam orders placed for ICU patients since the implementation in November 2008. Comparison of outcome from conventional and extended infusion strategies included a one year pre and one year post implementation period. The patients included in the study were: over 18 years old, stayed for more than 48 hours in the ICU (excluding CCU), had absolute neutrophil count greater than 1000 cells per cubic millimeter, positive gram negative bacterial culture sensitive to piperacillin/tazobactam, received piperacillin/tazobactam within first 72 hours of documented gram negative infection, and received piperacillin/tazoabctam for more than 48 hours. The primary endpoint will measure 14 day mortality and length of total hospital stay. Secondary outcomes will include duration of piperacillin/tazobactam therapy, primary ICU service, duration of ventilation, primary site of infection, minimum inhibitory concentration of cultured organism, and concurrent antibiotic therapy. The results and conclusion of the study will be presented.

EVALUATING PHARMACOKINETIC AND PHARMACODYNAMIC TARGET ATTAINMENT IN ANTIBIOTIC DOSING REGIMENS: A RETROSPECTIVE STUDY, (A1), Conan MacDougall, Nathan Tang. UC San Francisco Medical Center, San Francisco, CA (Nathan.tang@ucsf.edu) IRB approved. The study objectives are to determine the pharmacodynamic (PD) and pharmacokinetic (PK) target attainment in patients treated with common antibiotic dosing regimens, evaluate the relationship between target attainment and process of care variables, and evaluate the relationship between target attainment and clinical outcomes. Inclusion criteria include adult patients with documented non-urinary tract infections caused by Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), or Acinetobacter baumannii. Other inclusion criteria include patients treated with a stable dose of intravenous vancomycin, piperacillin and tazobactam, cefepime, or meropenem for at least 48 hours. Qualifying patients will be identified through hospital microbiology records. For patients meeting study criteria, estimated PK and PD target attainment will be calculated based on patient specific factors, such as age, gender, creatinine clearance, antibiotic dose, and minimum inhibitory concentration (MIC) of the infecting organism. The PK and PD target variables will be calculated for each patient using standard PK techniques and summarized using descriptive statistics. The relationship between process of care variables and target attainment will be analyzed using linear or logistic regression, as appropriate. The relationship between target attainment and clinical

outcomes will be investigated using linear or logistic regression, as appropriate. Results and conclusions will be presented.

A SNAPSHOT OF ANTIBIOTIC USE AT THE VETERANS AFFAIRS GREATER LOS ANGELES HEALTHCARE SYSTEMS (A1), Hoang Truong, Wayman Lee, Thuong Tran, Christopher Graber, Andrew Lai. Veterans Affairs Greater Los Angeles Healthcare Systems, Los Angeles, CA (hoang.truong@va.gov) IRB approved. Since the advent of antimicrobials, clinicians have overused and misused antimicrobials which have lead to an increase in resistance. Reports have estimated that 50% of antimicrobial use is inappropriate. Current data anticipates that newly developed antimicrobials will not come to market for more than 10 years from now. As a result, there are serious concerns for the lack of treatment options due to the increase in resistance and slow development of antimicrobials. The development of treatment guidelines and antimicrobial restrictions were developed to address these issues. However, the uses of antibiotics have not been assessed. The purpose of the study was to evaluate the antibiotic usage at the Veterans Affairs Greater Los Angeles and therefore potentially identify areas that can be improved to optimize the appropriateness of antibiotic usage. An observational chart review, of all patients receiving intravenous antimicrobials at the Greater Los Angeles Veterans Affairs Health System were reviewed at two different periods throughout the year. The first reviewed period was January, 2010 and the second was July 2010. Patients were excluded if they were taking oral or intramuscular administering antibiotics, taking antibiotics initiated by non-VA providers, receiving outpatient parenteral antibiotics, and receiving only 1 dose

of antibiotic based on a single admission during the review period. Results and conclusion will be presented.

EVALUATION OF ANTIBIOTIC TREATMENT FOR COMPLICATED URINARY TRACT INFECTIONS (A1). Hoainam Vo. Scripps Memorial Hospital La Jolla, La Jolla, CA (vo.hoainam@scrippshealth.org) IRB approved. The objective of this study was to identify common microorganisms causing complicated urinary tract infections in patients presenting to Scripps Memorial Hospital La Jolla and to evaluate appropriateness of antibiotic use, differentiating between community acquired versus healthcare acquired, and catheter associated versus noncatheter associated urinary tract infections. This was a concurrent, single center review of electronic and nonelectronic medical records. The information collected included demographics, diagnosis, signs and symptoms of infection, related past medical history, history of UTI, recent antibiotic use, allergies, antibiotic administration, laboratory results, microbiology results, presence of a catheter prior to admission, length of hospitalization, and length of antibiotic use. Inclusion criteria consisted of adults admitted with a UTI diagnosis defined by positive urinalysis, positive urine culture, and at least one clinical symptom of a UTI. Excluded patients were those with negative urinalysis or urine culture results, those who did not receive antibiotics, a UTI that developed during current hospitalization, concurrent antibiotics for indications other than a UTI, and those who were pregnant and/or lactating. An empiric antibiotic regimen for community acquired and healthcare acquired complicated UTIs will be designed to maximize the likelihood of effective antibiotic therapy. The results and conclusions will be presented.

EFFECTIVENESS OF ONCE DAILY VS TWICE DAILY RALTEGRAVIR ADMINISTRATION IN TREATMENT EXPIRIENCED, HIV POSITIVE PATIENTS (A1). Joy Vongspanich, Patricia Poole. Center for AIDS Research and Education Services (CARES) Clinic, Sacramento, Ca. (jvongspanich@ucdmc.ucdavis.edu) IRB approved. Raltegravir is an integrase inhibitor recommended by the Department of Health and Human Services (DHHS) guidelines as a first line option in treatment nave patients. Approved dosing of raltegravir is one 400 mg tablet orally, twice a day. As the intra-nuclear elimination half life of raltegravir is 29 hours; it is thought that once daily dosing of raltegravir should be clinically possible. A retrospective, observational study was conducted at The Center for AIDS Research and Education Services Clinic (CARES Clinic) in Sacramento, Ca to compare the effectiveness of once daily raltegravir regimens against approved twice daily dosing. Patients were included if they received 3 months of raltegravir therapy, were treatment experienced and had follow up lab results. Data is being collected using both the electronic health record and the HBS Pharmacy system. Data collection is ongoing and results will be discussed.

IMPACTOFDEPRESSIONONTHESUSTAINEDVIRALRESPONSE OFINTERFERONTREATMENTWITHHEPATITISC(A1),Robin Wackernah,SusiePark.LosAngelesCountyandUSCMedical Center,LosAngeles,CA(wackerna@usc.edu)IRBapproved. Thestudyobjectivewastodeterminethesustained viralresponseinpatientswithcomorbiddepression.Achart reviewofpatientswithhepatitisCviruswhoweretreatedwith peginterferonalfaandribavirinwithandwithoutdepression werecomparedforsustainedviralresponseingenotypes1,4 and6versus2and3.ThePatientHealthQuestionnaire9was usedtodeterminebaselinedepressionorinterferoninduced depressionalongwithastructuredclinicalinterviewfollowing theDiagnosticandStatisticalManualIVTRguidelinesfor depression.Laboratoryresultsat42weeksposttreatment wererecordedtodetermineifsustainedviralresponsewas achieved.Age,gender,weight,andinitialviralloadwerealso comparedasknownpredictorsofpoorresponse.Sixtynine patientscompletedtreatmentandwereincludedinthefinal analysis.Fifteendiscontinuedtreatmentearlyduetoadverse sideeffectsand12werelosttofollowup.Sustainedviral responsewasachievedby55%ofpatients,64%neverhad depression,22%hadbaselinedepression,and15%had interferoninduceddepression.Sixtypercenthadgenotypes1, 4or6and40%hadgenotypes2or4.Conclusionstotheresults willbepresented.

BLOODSTREAM INFECTIONS CAUSED BY ESBL PRODUCING E. COLI AND KLEBSIELLA SPECIES: ANTIMICROBIAL SELECTION AND PATIENT OUTCOMES (A1). Brian Werth, Scott Souza. The Queens Medical Center, Honolulu, HI. (bwerth@queens.org). IRB approved. Bacteremia with extended spectrum beta-lactamase producing E. coli and Klebsiella species (ESBL-EK) is a growing public health threat worldwide and has been associated with mortality rates up to 2.5 times higher than non-ESBL controls. There is currently little data to guide therapy for the treatment of serious infections caused by ESBL-EK. Limited data and expert opinion suggests that carbapenems are the agents of choice for treating these infections regardless of in vitro sensitivity to other agents. There have been no studies evaluating factors that may influence antimicrobial selection. The objective of this study is to describe and summarize the clinical characteristics and treatment course of patients admitted to The Queens Medical Center (QMC) with bacteremia caused by ESBL-EK. This is a retrospective, observational study of hospitalized adult patients at QMC. Adult inpatients with at least one blood culture positive for ESBL-EK between 2/1/2006 and 12/31/2010 are eligible for inclusion. Data will be collected regarding patients underlying illness, severity of illness, antimicrobial sensitivity reports, and antimicrobial selection for empiric and definitive therapy. Patient outcome data will also be collected including 14 and 21 day hospital mortality and length of stay. Preliminary results will be presented.

DEVELOPMENT, IMPLEMENTATION, AND ASSESSMENT OF AN EXTENDED-INFUSION PIPERACILLIN-TAZOBACTAM DOSING PROTOCOL (A1), Joshua Wiegel, Jerusha Taylor. Oregon Health & Science University, Portland, OR (wiegel@ohsu.edu) IRB approval received. Objective: To assess feasibility and implement a hospital-wide extended-infusion piperacillin-tazobactam dosing protocol after conducting a pilot protocol in the medical intensive care unit. Methods: Published literature was compiled to develop a protocol for the implementation of extended-infusion piperacillin-tazobactam. Education was provided to nursing, pharmacy, and physician staff. A one month pilot period was conducted in the adult medical intensive care unit, where all orders for piperacillintazobactam were transitioned to the extended-infusion protocol for all patients except those with the following: morbid obesity (BMI > 40 kg/m2); congestive heart failure; neutropenia (WBC < 4,000 cells/mm3); history of solid organ or bone marrow transplant; receiving continuous renal replacement therapy (e.g. CRRT); documented allergy to penicillins; documented infection with an organism resistant to piperacillin-tazobactam. The data from the pilot period will be presented to the pharmacy and therapeutics committee for a proposal for hospital-wide implementation, projected to start June 1, 2011. Results pending. Results of published literature on outcomes associated with the use of extended-infusion piperacillintazobactam will be discussed in addition to results from the one month data collection period, including barriers to implementation.

RETROSPECTIVE ANALYSIS OF ANTIMICROBIAL USE AFTER IMPLEMENTATION OF A MODIFIED ANTIMICROBIAL RESTRICTION POLICY (A1), Amanda Wight, Nancy Nguyen. VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA (Amanda.Wight@va.gov) IRB approval not needed. In 2007, the antimicrobial formulary and restrictions at VAPAHCS were updated as steps towards implementing a formal antimicrobial stewardship program (ASP), including Infectious Disease (ID) approval for use of restricted agents. However, provider adherence to the antimicrobial restriction policy is less than optimal. In 2010, a review of meropenem use showed that 27% of orders did not have documented ID approval and the start of the new medical resident year was associated with an increase in meropenem use from an average of 7.6 to 15 orders per month. We sought to improve the ASP through implementation of a modified antimicrobial restriction policy and provider education regarding these changes. This retrospective analysis will evaluate the impact of these interventions on restricted antimicrobial prescribing patterns for the 3 months pre and post intervention (9/1/10 to 2/28/11). All hospitalized patients receiving restricted antimicrobials will be included. Review of restricted agents will include meropenem, levofloxacin, imipenem/cilastatin, and linezolid. Outcomes of the project will include: (a) comparison of the number of patients on restricted antimicrobials pre and post intervention; (b) the number of restricted antimicrobial approvals leading to ID consults; and (c) comparison of prescribing patterns during ID on service and on call hours. Results will be discussed.

A COMPARISON IN THE INCIDENCE OF CATHETERRELATED INFECTIONS: SODIUM CITRATE 4% LOCKS VS. HEPARIN LOCKS (EXTENSION STUDY) (A1), Eva Wong, Calantha Yon, Chai L. Low. VA San Diego Healthcare System, San Diego, CA (eva.wong@va.gov) IRB approved. The use of heparin as a catheter-locking solution is a commonly accepted practice in the hemodialysis patients with tunneled catheters. Sodium citrate is equally effective in maintaining catheter patency and preventing thrombosis. In addition, it may offer potential antimicrobial benefits. Our study objective is to determine the difference in the incidence of catheter-related infections with sodium citrate locks in comparison to standard heparin locks in hemodialysis patients at the VA San Diego Medical Center. In this retrospective, case-controlled cohort study, the incidence of infections during the heparin study period from July 2008 July 2009 and the citrate study period from September 2009 September 2010 will be investigated. Patients 18 years of age or older with a permanent catheter indicated for chronic hemodialysis were included in this study. Exclusion criteria included presence of arteriovenous fistula or graft access and documented heparin or citrate allergy. The primary endpoint will be the incidence of catheter-related infections. Secondary endpoints are incidence of hospitalizations and 6-month mortality. Data will be analyzed using parametric and nonparametric statistical tests as appropriate. Results and conclusion will be presented.

INSTITUTIONAL EVALUATION OF TIME TO APPROPRIATE ANTIBIOTIC ADMINISTRATION IN SEPTIC PATIENTS (A1). Lisa Yacko. Kevin Kaucher. Mike Doody. Denver Health Medical Center, Denver, CO (lisa.yacko@dhha.org) IRB approved. The objective of this evaluation is to determine and describe our adherence to the 2008 Surviving Sepsis Campaign guidelines regarding appropriate antibiotic administration in patients who present to the emergency department with sepsis, severe sepsis or septic shock. This is a retrospective, observational review of patients 18 to 89 years old admitted from the emergency department to the MICU with a diagnosis of sepsis, severe sepsis, or septic shock from January 1, 2009 to December 31, 2009. Patient demographics, antibiotics given, time of antibiotic administration in reference to time of admission to the emergency department and suspected sources of infection will be determined based on data collection and analysis. 226 patients met criteria for the dates listed. Possible pharmacist interventions to improve time to antibiotic administration and appropriateness of antibiotic selection will be presented with complete results and conclusions.

EVALUATION OF THE CLINICAL IMPLICATIONS OF EXTENDED VS. TRADITIONAL ZOSYN DOSING IN ICU PATIENTS (A1), Russell Yee. Kaiser Permanente Diablo Service Area, Walnut Creek, CA. (Russell.S.Yee@kp.org) IRB approved. This retrospective study evaluates the clinical effectiveness of Zosyn in the ICU when administered via extended interval dosing as opposed to traditional dosing. Extended infusion (EI) dosing is infused over 4 hours, while traditional infusion (TI) is infused over 30 minutes. In July 2010, Kaiser Permanente Diablo Service Area began implementation of extended interval Zosyn dosing based on evidence that extended interval dosing might provide greater time above minimum inhibitory concentration, thus improving bactericidal activity. This retrospective study includes ICU patients who were admitted between Nov 2009 and Feb 2011. There are two arms in this study: the extended interval dosing arm and the traditional dosing arm. Patients included in the study must be 18 years of age or older and have been treated with Zosyn for at least 24 hours for suspected gram negative infection in the ICU. The primary outcome evaluated is median length of stay in the ICU. Secondary endpoints include: survival (as measured by 14 and 30 day mortality rates), duration of therapy, and spend per adjusted patient discharge. The results and conclusion of this study will determine whether the use of extended interval Zosyn dosing reduces length of stay in the ICU. Results will be presented.

IMPACT OF VANCOMYCIN MONITORING ON PATIENT OUTCOMES AT A VA MEDICAL CENTER (A1), Kateryna Yenina. Adam Chiappini. Kristina De Los Santos. Southern Arizona VA Healthcare System, Tucson, AZ (Kateryna.Yenina@va.gov) IRB approved. The primary goal of this study was to determine whether obtaining vancomycin levels improves patient outcomes. The secondary aim of this study was to observe the impact of monitoring on safety and to determine whether IDSA guidelines on monitoring are followed at SAVAHCS. This was a historical prospective case-control cohort study. Adult patients (18-89 years old) who received vancomycin treatment for more than three days from February 10, 2010 to July 10, 2010 were included. Patients who had vancomycin levels monitored (cases) were matched with controls based on age, sex, weight (BMI), and renal function. Patients on dialysis prior to the study or who were receiving vancomycin for post-surgical prophylaxis were excluded. The primary outcome was treatment failure within 30 days of vancomycin treatment. Treatment failure was defined as death, repeat positive cultures with 7 days of vancomycin treatment, recurrence of infection within 30 days, or change to another MRSA specific antibiotic anytime during hospitalization. Secondary outcomes included individual components of the primary outcome, acute renal insufficiency length of vancomycin therapy, vancomycin dose category (high, medium, low dose), and length of hospital stay. Observational outcomes evaluated included percent of vancomycin levels in goal range, and percent of patients in

each group that received a loading dose. Results and conclusions will be presented.

SUSTAINING JUDICIOUS USE OF ANTIBIOTICS IN A COMMUNITY HOSPITAL (A1), Kristine Yi, Katherine Lee, Harriet Catania. St. Joseph's Medical Center, Stockton, CA (kyung.yi@chw.edu) IRB approval pending. Judicious use of antibiotics is important to optimize their effectiveness, minimize drug related adverse events, and reduce costs while containing bacterial resistance and improving patient outcomes. In an effort to promote the appropriate use of antibiotics, an Antibiotic Stewardship Committee (ASC) was formed at St. Joseph's Medical Center last year. In the 4th quarter of 2010, comparative data across our health system showed our hospital's carbapenem use was more than twice the system average based on cost per adjusted patient day. The objective of this project is to identify opportunities for improving use of antibiotics under the supervision of the ASC. Drug utilization evaluations were performed on five frequently prescribed broad spectrum antibiotics: doripenem, ertapenem, piperacillin/tazobactam, linezolid and daptomycin. Based on theses results, strategies were developed to encourage optimal use of doripenem, including educating frequent prescribers on optimal use, developing standardized communication forms, and reevaluating or deescalating therapies. Implementing a continuous infusion protocol of piperacillin/tazobactam was developed as an alternative to doripenem. The results including length of stay, duration of therapy, and acceptance rate of interventions will be discussed.

EVALUATION OF VANCOMYCIN USE IN A PEDIATRIC POPULATION AND IMPACT OF A PHARMACIST MANAGED VANCOMYCIN DOSING PROTOCOL (A1). Kennda Zoffka-Zimmerman. Swedish Medical Center, Seattle, WA (Kennda.ZoffkaZimmerman@swedish.org) IRB approval pending. The study objective was to determine if implementation of a pharmacist managed vancomycin dosing protocol based on current, evidence-based practices would improve the dosing patterns and attainment of goal troughs in a pediatric population. Goal troughs were determined using the 2011 IDSA guidelines for MRSA in adults and children, and dosing recommendations were derived from recent primary literature. Retrospective data were gathered for patients newborn up to 18 years of age for the one-year period from October 2009 through September 2010 and were compared to prospective data gathered for a 10-week period after implementation of the pharmacist managed protocol in February 2011. Patients receiving less than two vancomycin doses were excluded from the analysis. Results and conclusions will be presented.

A2 Oncology

A RETROSPECTIVE REVIEW OF ADHERENCE AND ADVERSE EFFECTS WITH ORAL CAPECITABINE OR 5 FLOUROURACIL IN COLORECTAL CANCER (A2), Lorinda Anderson. Glenna Hughes. Good Samaritan Medical Center, Corvallis, OR (loanderson@samhealth.org) IRB approved. The objective of this study is to determine factors contributing to patient adherence with oral capecitabine compared to a control group receiving 5 flourouracil. Patients with stage II or III colorectal cancer and who were prescribed either capecitabine or 5 flourouracil monotherapy between March 2005 and March 2010 were included. A chart review was conducted to determine documented side effects, treatment modifications, hospitalizations, and any mention of adherence. This information was supplemented with a patient telephone interview to further assess adherence since this is rarely documented in charts. Other information obtained from these interviews include treatment factors considered when deciding on therapy, whether patients felt they were adequately educated on their chemotherapy choices, and any reported side effects. A parallel study is being conducted by another investigator assessing the overall cost differences between the two treatments in the same population. Results and conclusion will be presented.

COMPARISON OF CLOSED SYSTEM DRUG TRANSFER DEVICES (CSTD) USING TECHNETIUM 99 (TC99M) AS A RADIOACTIVE TRACER (A2). Lorena Bagain. Erik DeFreitas. Tripler Army Medical Center, Honolulu, HI (lorena.r.bagain@us.army.mil) Pending IRB approval. Unintentional exposure to cytotoxic chemotherapeutic agents has long posed an occupational health hazard despite the precautionary measures that have been developed. Thus, there is a need to develop techniques and equipment to limit or eliminate these risks. One method recommended by the American Society of Health System Pharmacists and the National Institute of Safety and Health is the use of CSTDs. As institutions have adopted their use, commercially-available systems have been marketed but limited studies have been publicly available to assess relative efficacy. This experimental study will recruit IVcertified pharmacy technicians and pharmacists to test three CSTDs that are currently marketed: PhaSeal, Tevadapter, and CLAVE/Spiros. A radioactive tracer, Tc99m, will be utilized to quantify possible leakage upon manipulation of these systems. Radioactivity of the disposable underpads lining the work, gloves used by the participants, and wipe samples at the point of entry between vial adapters and syringe adapters will be measured. Data collected will be compared among the systems with statistical significance of p0.05 assessed through analysis of variance (ANOVA). The preliminary results of this study will be discussed. The views expressed in this abstract are those of the author and do not reflect the official policy or position of

the Department of the Army, Department of Defense, or the U.S. Government.

INFLIXIMAB IN THE TREATMENT OF ACUTE STEROID REFRACTORY GRAFT-VERSUS-HOST DISEASE (GVHD) IN PEDIATRIC BONE MARROW PATIENTS (A2), Sarah Balzar, Adam Brothers, Bee Chua. UW Medicine, Seattle Cancer Care Alliance, Seattle, WA (balzar@u.washington.edu) IRB approved. This study is designed to evaluate the impact of infliximab therapy on acute steroid refractory GVHD in pediatric patients through analysis of the degree of their symptomatic response. Secondary endpoints include infections and concurrent GVHD treatments. This single center retrospective chart review will include patients treated at the Seattle Cancer Care Alliance (SCCA) and Seattle Childrens Hospital between January 1, 2001 and October 31, 2010 who received treatment with infliximab for GVHD after transplant on a pediatric protocol. Review of SCCA/ Seattle Childrens Hospital medical records will provide: diagnosis, age, gender, type of transplant, organ involved in GVHD, other treatments used to treat GVHD, number of doses and dose utilized of infliximab, response as defined by organ system, day post transplant treatment was initiated, prophylactic antibiotics/antifungal therapy patient received, concurrent infections and treatments utilized, type of nutrition patient received throughout treatment and incidence of GVHD relapse. GVHD will be assessed on day of diagnosis and weekly thereafter. Responses will be reported as complete response, partial response, or no response. The results and conclusions will be presented.

USE OF BENDAMUSTINE, RITUXIMAB, OFATUMUMAB, AND SARGRAMOSTIM TO ERADICATE MINIMUM RESIDUAL DISEASE IN POOR PROGNOSTIC CLL (A2), Lisa Carlson, Elber Camacho, Craig Elg. Desert Regional Medical Center, Palm Springs, CA (lisa.carlson@tenethealth.com) IRB approval not needed. Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in adults. Disease activity can range from indolent to rapidly progressing. The introduction of new therapeutics as well as diagnostic tools has opened new perspectives for the management of CLL. The improvement in identification of poor prognostic factors in CLL has led to a need for therapeutic regimens that are effective in this difficult to treat patient population. In addition, the approval of new cytotoxic as well as biologic agents has improved the clinicians likelihood of eradicating minimal residual disease (MRD) in CLL patients. The elimination of MRD has been shown to be an important factor in improving overall survival in CLL patients. At present, there are no reports showing meaningful elimination of MRD in patients with poor prognostic factors. This case report will explore a yet to be reported regimen of combined chemoimmunotherapy and its ability to eradicate MRD in a group of poor prognostic CLL patients.

PATIENT CHARACTERISTICS RELATED TO RITUXIMAB INFUSION REACTIONS AND EVALUATION OF AN INPATIENT RAPID INFUSION PROTOCOL IN HEMATOLOGIC MALIGNANCIES (A2), Jessica Duman, Jeff Kaiser, Cindy L OBryant, Jennifer Tobin. University of Colorado Denver School of Pharmacy, Aurora, CO (jessica.duman@ucdenver.edu) IRB approval received. Attempts to identify patients who are likely to experience infusion reactions with rituximab have met with limited success. The primary objective of this study is to evaluate patient characteristics that may predispose individuals to infusion reactions while being treated with rituximab. Secondary objectives include evaluation of the incidence and severity of infusion reactions in hematologic malignancy inpatients receiving the rapid (90 minute) rituximab infusion rate at University of Colorado Hospital (UCH) when given according to the standard order set for rituximab. Pharmacy maintained paper and electronic medical records will be retrospectively reviewed to identify approximately 30 hematologic malignancy inpatients who were previously treated with rituximab. This data set will serve as a historical control and help to expand the sample size of the study. In addition, a prospective population will be identified and will include all new hematologic malignancy inpatients treated at UCH with rituximab as part of usual medical management over a period of approximately 3 months. Patient characteristics will be evaluated using descriptive statistics. Results and conclusions will be presented.

EFFECTS OF RITUXIMAB ON THROMBOCYTOPENIA DUE TO GRAFT VERSUS HOST DISEASE POST ALLOGENEIC STEM CELL TRANSPLANT (A2), Atefeh Fahimi, Joan Morris, Bill Brown. Loma Linda University Medical Center, Loma Linda, CA (afahimi@llu.edu) IRB approval pending. Thrombocytopenia is often a severe complication of chronic graft versus host disease (GVHD) in allogeneic hematopoietic stem cell transplant (allo-HSCT). Current studies show efficacy of antiCD20 (rituximab) for autoimmune thrombocytopenia lending support to its possible use in thrombocytopenia due to refractory GVHD. This retrospective chart review evaluates the effects of rituximab on platelet counts following allo-HSCT. The inclusion criteria are: (1) patients less than or equal to 21 years of age who underwent allo-HSCT at Loma Linda University Medical Center between January 2005 and January 2011, and (2) diagnosis of GVHD with thrombocytopenia post transplant. Subjects are divided into to those who received rituximab (treatment) and those who did not (control). The primary endpoints include: (A) the effects of rituximab on platelet count and (B) the time and number of rituximab doses to platelet restoration. Secondary endpoints include the number of platelet transfusions received and the prevalence of opportunistic infections in the two groups. The results will be discussed.

EVALUATION OF RASBURICASE AND ALLOPURINOL IN THE MANAGEMENT OF HYPERURICEMIA IN THE SETTING OF TUMOR LYSIS SYNDROME (A2) Sunny Gascon. Samit Patel. Ann Le. Yi An (Anne) Chen. Maggie Cudny. Stanford Hospital and Clinics, Palo Alto, CA (sgascon@stanfordmed.org) Institutional Review Board approval not needed given the retrospective nature. Hyperuricemia associated with tumor lysis syndrome in the treatment of malignancies is effectively managed with hydration, allopurinol and rasburicase. The objectives of this study are to examine the clinical efficacy and economic impacts of single, reduced dose rasburicase in the setting of hyperuricemia. The hospitals electronic medical record system was used to identify adult patients that received allopurinol or rasburicase from 2008 to 2010 for the management of tumor lysis syndrome. Collected data includes age, gender, height, weight, WBC, uric acid, potassium, phosphate, LDH, serum creatinine, malignancy type, and treatment regimen. All data were confidentially maintained to protect personal health information. This retrospective study examined changes in uric acid levels and other tumor lysis markers at baseline and at several time points post-treatment to evaluate the clinical efficacy of single, reduced dose (0.075mg/kg) rasburicase. The current average wholesale price for rasburicase was obtained to evaluate economic impacts of single, reduced dose rasburicase. Based upon the results of this retrospective study, a prospective study will then be conducted at a future date to evaluate hospital use of reduced dose rasburicase. The findings of this study will be used to amend current hospital guidelines intended for use at the physicians discretion. Study design, data collection and analysis were conducted by pharmacists at the Stanford University Hospital and Clinics. Results and conclusions will be presented.

OUTCOMESANALYSISOFANOUTPATIENTGRANULOCYTE COLONYSTIMULATINGFACTORMEDICATIONUSEEVALUATION ATAVETERANSAFFAIRSMEDICALCENTER(A2),Jerrelee Hollings,JosephineTefferi.VASouthernNevadaHealthcare System,LasVegas,NV(jerrelee.hollings@va.gov)IRBapproval pending. Cancerpatientsreceivingchemotherapyoftenreceive filgrastimfortheprophylaxisandtreatmentofneutropenia. Thisstudywascompletedtoevaluatetheuseoffilgrastim.Two patientpopulationswillbediscussed:patientsgivenfilgrastim asprophylaxisortreatment.Prescriptionsforfilgrastimfrom June,2010throughOctober,2010accordingtotheVeterans HealthInformationSystemsandTechnologyArchitecturewillbe queried.Adatacollectionsheetwillbekeptalongwithpatient identifiersinaseparatepasswordprotectedfilewithinthe encryptedharddrivewithrestrictedaccesstotheprimary investigators.Alinkagelogwillbecreatedfordatacollection andwillbekeptuntilJune30,2011.Itwillthenbedestroyedby theInformationSecurityOfficer.Patientchartswillbereviewed byaccessingtheComputerizedPatientRecordSystemto identifythesex,age,numberofwhitebloodcellcolony stimulatingfactortreatments,lengthoftreatment,adverse effects,febrileneutropeniarisklevelofchemotherapy accordingtotheNationalComprehensiveCancerNetwork guidelinefortheuseofhematopoieticcolonystimulating factorstypeofcancer,cancerstage,currentandpast chemotherapyregiments,previouscancertypesand treatments,hospitalizations,dateofadmission,reasonfor admission,lengthofstay.Resultsandconclusionwillbe discussed.

META-ANALYSIS OF CYTOMEGALOVIRUS (CMV) PROPHYLAXIS IN CMV SEROPOSITIVE PATIENTS AFTER ALLOGENEIC BONE MARROW TRANSPLANT (A2). Miryoung Kim. Joseph Guglielmo. Lisa Bero. UCSF Medical Center, San Francisco, CA (miryoung.kim@ucsf.edu) IRB not needed. The role of antiviral prophylaxis for CMV in allogeneic bone marrow transplant has not been clearly established. The study objective was to evaluate the efficacy of CMV prophylaxis in CMV seropositive patients after allogeneic bone marrow transplant to prevent CMV disease, and infection. We performed a meta-analysis of randomized controlled trials comparing ganciclovir with placebo, no treatment or other agents. We searched CENTRAL (The Cochrane library) and PubMed with no date restrictions. Terms searched include cytomegalovirus, prophylaxis, allogeneic bone marrow transplant, and neutropenia. Two reviewers independently appraised the trials for risk of bias and extracted data. The primary measured outcomes were incidence of CMV disease, infection, and antigenemia. Additional outcome measures included toxicity of prophylactic treatment including neutropenia/ absolute neutrophil count (ANC), thrombocytopenia and overall survival. We calculated the relative risk for each outcome from included trials with 95% CI using Review Manager (RevMan). We will use random-effects model (DerSimonian and Laird) to account for any heterogeneity. We analyzed heterogeneity of the trials by calculating 2 test and I2 test. Results and conclusions will be presented.

A RETROSPECTIVE REVIEW OF AMIFOSTINE USE AS A RADIOPROTECTIVE AGENT IN VETERAN PATIENTS RECEIVING RADIATION THERAPY FOR HEAD AND NECK MALIGNANCIES (A2). Robert Lawson, Rusty Crawford. SAVAHCS, Tucson, AZ (robert.lawson2@va.gov) IRB approved. The research includes patients of SAVAHCS diagnosed with head and neck cancer who received open label amifostine concurrently with radiotherapy prior to May 15, 2010 at University Medical Center (UMC) in Tucson, Arizona. A retrospective chart review was performed to retrieve data from radiation oncology progress notes at UMC. Severity of radiation-induced xerostomia will be classified into four grades using Common Terminology Criteria for Adverse Effects (CTCAE). A grade 0 indicates no symptoms; grade 1 indicates symptomatic, dry or thick saliva; grade 2 indicates symptomatic and significant oral intake alteration; and grade 3 indicates symptoms leading to inability to adequately aliment orally. Initiation of amifostine is considered day zero, with subsequent administration counted from this date. SAVAHCS medical records were reviewed for the addition of alternate medications, if any, for treating symptoms of xerostomia not prevented by the administration of amifostine. Xerostomia scoring will be based on the need for additional medications for symptom control. The follow up period includes three months beyond the final treatment with amifostine. The primary outcome measure will be efficacy of amifostine in preventing xerostomia as measured by the CTCAE

modified criteria grading. The secondary outcome measure will be an assessment of the safety and tolerability of amifostine administration in this group. Results and conclusions will be presented.

INFLUENCE OF OBESITY ON EFFICACY AND TOXICITY OF INDUCTION CHEMOTHERAPY IN PATIENTS WITH NEWLY DIAGNOSED ACUTE MYELOID LEUKEMIA (A2). Andrew Lin, Amy McQuary, Mary Chi, Elihu Estey. University of Washington Medical Center, Seattle, WA (alin01@u.washington.edu) IRB approved. The primary outcome to be examined by this retrospective chart review is to investigate the impact of obesity on the percentage of patients with newly diagnosed AML achieving complete remission (CR). Secondary outcomes are to describe the length of CR, mortality, and safety as described by the incidence of grade 3 to 4 hematologic and nonhematologic toxic effects. UWMCs medical and pharmacy records will be utilized to identify patients, from January 2006 to January 2010, with newly diagnosed AML who received 7+3 (cytarabine in combination with daunorubicin or idarubicin) as induction therapy. Data collected will include: patient demographics (age, height, weight, etc.); karyotype (i.e. intermediate, favorable, or unfavorable); molecular genetics (i.e. FLT3ITD mutation); dates, type, and number of chemotherapy doses planned and administered; previous hematologic malignancy/disease; CR rate; length of survival, and evaluation for grade 3 to 4 hematologic and nonhematologic toxicities. Multivariate analysis will be utilized to determine the impact of each independent data point, in particular focusing on the impact of obesity on achievement of CR, mortality and several other secondary endpoints. Results and conclusions will be presented.

EVALUATION OF THE ROLE OF APREPITANT IN PREVENTING CHEMOTHERAPY INDUCED NAUSEA AND VOMITING IN PATIENTS RECEIVING HIGHDOSE CISPLATIN (A2). Yenni Lin. Kaiser Permanente Medical Care Program, Fontana, CA (yenni.x.lin@kp.org) IRB approved. The study objective was to evaluate the efficacy of aprepitant in comparison to the standard antiemesis regimen of a serotonin antagonist and a corticosteroid in preventing chemotherapy induced nausea and vomiting in patients receiving highly emetogenic regimen. This is a multicenter, retrospective data analysis with the study period from October 1, 2008 to September 30, 2010. Patients were included if they were 18 years and above, received the first cycle of cisplatin dosed at 50 milligrams per meter square or greater, had not received any chemotherapy prior to this regimen, and were monitored by the oncology pharmacists. Patients were excluded if they had allergies or contraindications to corticosteroids or serotonin antagonists. For each group, the number of patients who were hospitalized with the primary diagnosis of nausea and vomiting within 96 hours of the first cycle of cisplatin, the number of emergency room visits for nausea and vomiting within 96 hours of the first cycle of cisplatin, and the number of patients who were managed successfully by outpatient rescue antiemesis treatments were measured and compared. In addition, risk factors were characterized to identify patients who may benefit from aprepitant therapy. The endpoints were compared using a chi-square test. Results and conclusions will be presented.

ANTIEMETIC EFFECTS OF DRONABINOL IN CHEMOTHERAPY INDUCED NAUSEA AND VOMITING (A2). Steven Ng. Andrew Lowe. Arrowhead Regional Medical Center, Colton, CA (steven.ng@armc.sbcounty.gov) IRB approved. The objective of the study was to investigate the antiemetic effects of dronabinol in chemotherapy induced nausea and vomiting. Retrospective and prospective data collection was done on all patients who received highly emetogenic chemotherapy regimens at Arrowhead Regional Medical Center. Data on patients who received chemotherapy with and without dronabinol will be collected and reviewed. Patients currently receiving chemotherapy and dronabinol will be assessed for nausea and vomiting. Specific data elements include: patient identifiers, date of chemotherapy, medications used, antiemetics used, cost, payer, and outcome of therapy. Results and conclusions will be presented.

INCIDENCE OF SECONDARY ADRENAL INSUFFICIENCY IN ALLOGENEIC HEMATOPOEITIC STEM CELL (HSCT) PATIENTS (A2) Laura Ng, Joal Mayor, Paul Carpenter. UW Medicine, Seattle, WA (lauraln@u.washington.edu) IRB Approval is received Graft-versus-host-disease (GVHD) is a common complication of allogeneic hematopoietic stem cell transplantation (HSCT). Glucocorticosteroids are the most common therapeutic intervention used to treat GVHD. Patients are often treated with glucocorticosteroids for prolonged periods and therefore are at risk of developing adverse sequelae, including, but not limited to, metabolic disorders, infectious complications and secondary malignancies. Given these risks, patients are tapered off steroids following successful treatment of GVHD. As a result of chronic steroid exposure, patients are at risk of developing secondary adrenal insufficiency (AI). Currently, there is limited data available regarding the prevalence of secondary AI in allogeneic HSCT patients. The objective of this study is to examine the incidence of secondary AI in this patient population. Allogeneic pediatric and adult HSCT patients with GVHD who received a high dose cosyntropin stimulation test during the time period of January 1, 2004 through December 31, 2009 will be identified. The following demographic information will be collected: age, diagnosis, conditioning regimen, and stem cell source. Information regarding GVHD management and steroid use will also be collected. Secondary AI management and outcome information including cosyntropin levels as well as hydrocortisone dose

and frequency will also be collected. Results to be presented.

DEVELOPMENT AND IMPLEMENTATION OF A STANDARDIZED INTRAVENOUS IMMUNE GLOBULIN ORDER SET (A2), Tuan Nguyen. Highline Medical Center, Burien, WA (tunguyen@highlinemedical.org) IRB not needed. The study objective is to standardize the use of intravenous immune globulin at medical center through the implementation of a common order set. A retrospective analysis of past immune globulin usage was done by reviewing patient charts spanning a period of 22 months. The collected data revealed areas for improvement in the administration of immune globulin at the institution. The areas identified for improvement include consistent dose rounding, maximum dose titration, assessment for supportive medications, and monitoring for adverse effects. Further collaboration with stakeholders like physicians, nurses, and pharmacists help to develop a common order set to address deficiencies of current practice and present the standard order set to Pharmacy and Therapeutics Committee for approval. Results and conclusion will be presented.

ROLE OF INTRAPERITONEAL (IP) CHEMOTHERAPY IN RECURRENT ADVANCED EPITHELIAL OVARIAN CANCER: A RETROSPECTIVE STUDY (A2), Tina Nguyen, Ashley Tran, Ernest Han. City of Hope, Duarte, CA (tinanguyen@coh.org) IRB approval received. In this study we examined the feasibility of IP chemotherapy for treatment of recurrent epithelial ovarian cancer. IP chemotherapy has demonstrated concentrated drug delivery to tumor sites in Phase I studies and therefore may have use against recurrent disease for which there is currently no effective treatment. A retrospective chart review was performed on 30 patients diagnosed with recurrent ovarian cancer treated at City of Hope using IP chemotherapy regimens between 1995 and 2008. All treatment regimens used either cisplatin or carboplatin as the IP agent. Patients were included if they had histologic verification of malignancy at the time of diagnosis regardless of prior treatment history or performance status. Response rates and progression free and overall survival were determined. Tolerability to IP chemotherapy (e.g. adverse events, side effects) was also examined. Data was analyzed using appropriate statistical tests. Conclusion: Results and conclusions will be reported at the upcoming meeting.

ADHERENCE TO NCCN GUIDELINES FOR GCSF USE AS PART OF HIGH RISK CHEMOTHERAPY REGIMENS: A MEDICATION USE EVALUATION PROJECT (A2), Anh Nguyen, Katherine Medley, Pieter Helmons. UCSD Medical Center, San Diego, CA (atn033@ucsd.edu). IRB approved. The risk for developing febrile neutropenia is dependent on the chemotherapy regimen, patient specific variables, and the treatment intent. The National Comprehensive Cancer Network (NCCN) updated their guidelines on the use of myeloid growth factors (GCSF and Peg GCSF) to prevent chemotherapy induced febrile neutropenia in 2009 and recommend prophylactic myeloid growth factor use in patients with a 20% risk of febrile neutropenia. The primary objective of this retrospective study is to determine the baseline rate of adherence to the NCCN guidelines in patients receiving high risk chemotherapy (CHOP/RCHOP, ACT, RICE, topotecan, paclitaxel) at our institutions cancer center. Adherence to guidelines will be determined by time to initiation of GCSF therapy after high risk chemotherapy. The secondary objective is to measure appropriate use of GCSF therapy and the incidence of dose reduction or dose delay as a results of neutropenia in these patients. Variables used to determine appropriate use of GCSF are dose and duration of therapy. Data between April 2009 and August 2010 will be collected on eligible patients by chart review. The results and conclusions will be presented.

EVALUATION OF APPROPRIATE GRANULOCYTE COLONY STIMULATING FACTOR USE IN PATIENTS WITH FEBRILE NEUTROPENIA (A2). Cham Nguyen, Shanna Block, Pieter Helmons. UC San Diego Medical Center (UCSDMC), San Diego, CA (cpn005@ucsd.edu) IRB approved The primary objective of this retrospective medication utilization evaluation is to determine the frequency of inappropriate use of granulocyte colony stimulating factor (GCSF) in patients admitted for febrile neutropenia (FN). Inappropriate use is defined as: (1) GCSF use in patients admitted for FN who did not receive prophylactic GCSF and/or do not have risk factors for an infection-associated complication as defined by National Comprehensive Cancer Network (NCCN) guideline; (2) GCSF given to patients admitted for FN who received outpatient prophylaxis with the long acting GCSF analogue. The secondary objective is to determine if NCCN guidelines for prophylactic therapy with GCSF prior to start of chemotherapy were followed in patients admitted for FN. Records were reviewed from 4/2009 to 9/2010 for patients hospitalized for FN after receiving outpatient chemotherapy. Patients were identified based on diagnosis codes of neutropenia and fever. Inclusion criteria were cancer patients admitted to UCSDMC for FN due to myelosuppressive chemotherapy for non-myeloid malignancy. Results and conclusion will be presented.

EVALUATION OF PATIENTS, SAFETY, AND FINANCIAL IMPLICATIONS OF SIPULEUCEL T FOR TREATMENT OF METASTATIC CASTRATE RESISTANT PROSTATE CANCER AT USC (A2), Stacy Pak. USC/Norris Cancer Hospital, Los Angeles, CA (pak.stacy@gmail.com) IRB pending. Sipuleucel T is an immunotherapy approved for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant prostate cancer based on the IMPACT trial. There are limited data in the use of Sipuleucel T in patients outside clinical trials and those with history of chemotherapy, opioid use or visceral metastases. The study objective is to evaluate patients, safety, and financial implications of Sipuleucel T usage at USC/Norris Cancer Center and Hospital. A retrospective chart review was performed on 34 patients who received at least one Sipuleucel T infusion between June 2010 and February 2011 at USC/Norris Cancer Center and Hospital. A prospective log was used to track patients with electronic medical records to correlate clinical variables for all patients. Financial data were obtained from USC authorization department. Results will be presented and a descriptive analysis will be performed. Results and conclusions will be presented upon data collection.

EVALUATION OF THE ROLE OF UGT1A1 GENOTYPE TESTING IN COLORECTAL CANCER PATIENTS ADMINISTERED IRINOTECAN AND THE OCCURRENCE OF GRADE 3 AND 4 NEUTROPENIA (A2). Sushma M. Patel. Kaiser Permanente Medical Care Program, Oakland, CA (sushma.m.patel@kp.org) IRB approved. A retrospective cohort developed from the Kaiser Permanente California regions electronic databases from November 1, 2005 to July 1, 2010 will be used to assess the prevalence of UGT1A1 genetic testing in patients diagnosed with colorectal cancer initiated on a colorectal cancer chemotherapy including irinotecan as part of the regimen. An assessment of whether testing for UGT1A1 genetic polymorphisms affected the overall occurrence of severe grade 3 and 4 neutropenia compared to those patients who did not get tested will be reported. There were 680 patients included in the study. A secondary objective will assess whether initial irinotecan dose reduction in patients with genotypes UGT1A1*28 (TA7/7) homozygous and UGT1A1*28 (TA 6/7) heterozygous affects the incidence of grade 3 and 4 neutropenia compared to the wild-type UGT1A1*1 (TA 6/6). Multivariate logistic regression and Cox Proportional Hazard will be used to determine if initial UGT1A1 genotyping in patients initiated on irinotecan therapy is beneficial in reducing the incidence of severe grade 3 and 4 neutropenia and whether dose reduction reduces the risk of neutropenia while controlling for confounders. Results and conclusions will be presented.

INCIDENCE AND CHARACTERIZATION OF BENDAMUSTINE INFUSION REACTIONS: A SINGLE CENTER EXPERIENCE (A2), Ashli Rasmussen, Myke Green, Christopher Campen. University Medical Center, Tucson, AZ (arasmuss@pharmacy.arizona.edu) IRB approved. Infusion reactions in up to 25% of patients treated with bendamustine have been reported in clinical trials. Due to frequent co-administration with rituximab, the true incidence and characterization of reactions to bendamustine is unknown. The purpose of this retrospective chart review is to determine the incidence of bendamustine infusion reactions; subsequently, each reaction will then be characterized and graded by the investigators according to the Common Terminology Criteria for Adverse Events (CTCAE V4.0). All charts of patients receiving at least one infusion of bendamustine at a single institution from October 1, 2008 thru July 31, 2010 were reviewed to determine whether or not the patient experienced a reaction from the infusion. Physician and nursing notes regarding each infusion were evaluated by the researchers for any notation signifying a reaction to the infusion. The study included 37 patients with a total of 209 infusions. Results and conclusions will be presented.

RETROSPECTIVE EVALUATION OF THERAPEUTIC DRUG MONITORING OF POSACONAZOLE (A2), Karen Slezak. Rupali Jain. UW Medicine, Seattle, WA (kslezak@uw.edu) IRB approval received. Therapeutic drug monitoring of posaconazole has been proposed as a method to ensure therapeutic concentrations and reduce the incidence of clinical failure. The primary objective of this study is to determine the percentage of patients on posaconazole with therapeutic drug monitoring who have a therapeutic first level, defined as a trough concentration >700 ng/mL at steady state. Additional objectives include the correlation between dose and trough level, the percentage of patients with therapeutic drug monitoring, median time to achieve a therapeutic level, relationship between level and clinical outcome in patients with documented invasive fungal infections, impact of medications and nutritional status on trough level, side effects, and clinical outcomes in patients with versus those without therapeutic drug monitoring. Subjects for this study will be identified using pharmacy and lab medicine records to search for patients dispensed posaconazole or with a posaconazole level between January 1st 2007 and November 1st 2010. The following data will be collected through chart review of the electronic medical record: patient age, sex, indication for posaconazole, concurrent disease states, medication list, drug levels, liver function, nutritional status, mucositis, diarrhea or other GI tract abnormality, adverse events, microbiology data, response to posaconazole treatment, and incidence of breakthrough infections. Data collection and evaluation are ongoing and preliminary results will be presented.

FACTORS AFFECTING CLINICAL RESPONSE TO TYROSINE KINASE INHIBITORS IN CHRONIC MYELOID LEUKEMIA (A2), David Stenehjem, Diana Brixner. Huntsman Cancer Hospital, Salt Lake City, UT (david.stenehjem@hsc.utah.edu) IRB approval received. The primary objective of this study is to determine if clinical response to the tyrosine kinase inhibitors (TKIs) imatinib, dasatinib, or nilotinib is affected by CYP450 drug-drug or drug-transporter interactions, the use of acid suppression therapy, or certain baseline demographic factors. Secondary objectives include analyzing the TKI discontinuation rate and incidence of side effects in patients with interacting drugs. This study will employ an observational, cohort design. Patients will be identified from the Enterprise Data Warehouse. Patients will be included in the analysis of the primary and secondary endpoints if they have an ICD-9 diagnosis of CML with at least one encounter in the database and were prescribed a TKI. Patients will be categorized according to baseline characteristics at the time of diagnosis, disease severity, and treatment response. Multivariate linear or logistic regression models will be developed to examine the associations between clinical outcomes and baseline demographics; concomitant CYP3A4 or P-gp inhibitor or inducer use; and use of acid suppression therapy. Results to be presented.

EVALUATIONOFRENALTOXICITYOFCISPLATINADMIXEDIN NORMALSALINECOMPAREDTOMANNITOLANDHYPERTONIC SALINE.MattTaliaferro,JessieModlin,RobertMancini.St. LukesHealthSystem(A2).taliafem@slhs.org.IRBnotneeded. Cisplatinisanephrotoxicchemotherapeuticagentused totreatmanytypesofcancers.Theconcomitantuseof hydrationregimensalongwithdiuresishasbeenusedtoavoid thepotentialnephrotoxicityassociatedwithcisplatin.Today, thereareawidevarietyofhydrationregimensusedforthe administrationofcisplatin.Debatesurroundstheuseof hypertonicsalineandmannitolrelatingtotheirrolein preventionofnephrotoxicityfromcisplatin.Anextensive literaturesearchwasperformedregardinghydrationregimens anddiuresistosupporttheuseofhypertonicsalineand mannitol.Theliteratureevaluatedgavelittlesupporttothe superiorityofhypertonicsalineandmannitolcomparedto hydrationwithnormalsaline.AtSt.LukesHealthSystemthe proposalwasmadeandacceptedtoswitchtheadmixtureof cisplatinfromhypertonicsalineandmannitoltonormalsaline. Aspartoftheproposal,pharmacywillmonitorpatients receivingcisplatinforchangesinrenalfunction,determinedby serumcreatinine,andcomparetosimilarresultstakenbefore thechangewasimplemented.Datawillbecollectedand analyzedfortwelveweeks.Resultsandconclusionwillbe presented.

A RETROSPECTIVE ANALYSIS OF ANTIBIOTIC PROPHYLAXIS IN AFEBRILE, NEUTROPENIC PATIENTS (A2). Christine Tieu, Tiffany Dea. VA Medical Center, San Francisco, CA (christine.tieu@va.gov) IRB approved. Patients treated with high intensity chemotherapy are at risk for prolonged and profound neutropenia. Recent national infectious diseases guidelines recommend consideration of antibiotic prophylaxis in these high risk patients. The goal of this retrospective study is to assess the efficacy of antibacterial prophylaxis in afebrile neutropenic patients receiving chemotherapy. Patients will be included if they received treatment with high intensity inpatient chemotherapy for non Hodgkins lymphoma, acute leukemia, or high grade myeloma during the period of July 1, 2000 through June 30, 2010. The incidence of febrile neutropenia in patients who received prophylaxis will be compared to those who did not during the first cycle of chemotherapy. We will also evaluate the incidence of bacterial infections, sepsis, ICU admissions, prolonged hospitalizations, and death. Data collected will include patient demographics, cancer diagnosis, chemotherapy regimen, absolute neutrophil count, duration of neutropenia, prophylactic antibiotic agent, febrile neutropenic episodes, and length of hospitalization. Results and conclusions will be presented.

TREATMENT OUTCOMES WITH THE USE OF RITUXIMAB IN THE MANAGEMENT OF IDIOPATHIC THROMBOCYTOPENIC PURPURA (A2), Ngoctran Tran, Andrea Iannucci, Jerry Powell. UC Davis Health System, Sacramento, CA (ngoctran.tran@ucdmc.ucdavis.edu) IRB approval received. The study objective is to quantify the rate and duration of response to rituximab in patients with idiopathic thrombocytopenic purpura in comparison to other treatment options. Retrospective review of medical records of all patients with International Classification of Disease 9 codes for idiopathic thrombocytopenic purpura from September 2005 to September 2010 will be done. Data such as date of diagnosis, platelet counts, demographic, duration of thrombocytopenia prior to treatment and history of treatment for idiopathic thrombocytopenic purpura will be collected. Patients will be included if they were age 18 years or older at diagnosis and were treated for idiopathic thrombocytopenic purpura from September 2005 to September 2010. Patients will be excluded if their medical records were incomplete. Patients will be stratified according to previous treatments received. Response rate will be determined based on rise of platelet above 50,000 cells per milliliter following the treatment. Duration of response will be assessed based on the number of days the platelet count was maintained above 50,000 cells per milliliter without platelet transfusion or further treatment excluding maintenance steroid. Data collection and analysis are in progress. Results and conclusions will be presented.

INCIDENCE OF TOXICITIES USING COCKCROFT GAULT AND MODIFIED COCKCROFT GAULT EQUATIONS TO CALCULATE CARBOPLATIN DOSAGE IN OBESE AND OVERWEIGHT PATIENTS (A2). Ha Trinh. Kaiser Permanente Medical Care Program, Fontana, CA (ha.b.trinh@kp.org) IRB approved Cockcroft Gault (CG) and Modified Cockcroft Gault (MCG) equations use ideal body weight and adjusted body weight, respectively. However, since there is no consensus that body weight should be adjusted for overweight and obese patients, there is a concern that the use of adjusted body weight in MCG equation may overestimate the carboplatin dosage and may result in an increase risk for toxicity. The objective of this study will be to assess the incidence of carboplatin toxicities when using CG and MCG to calculate the carboplatin dosage in overweight and obese patients. This is a multicenter, retrospective study. Data will be extracted from preexisting electronic charts from January 1, 2009 to December 31, 2010. Patients will be included in the study if they meet all of the following criteria: age 18 years or older, body mass index greater than or equal to 25 and on carboplatin-containing regimen. Patients will be excluded if another equation was used to calculate the carboplatin dosage. Primary endpoints will assess the number of patients with toxicities, up to 6 cycles. Secondary endpoints will assess the incidence of each toxicity and the number of patients that required carboplatin dose adjustment for each toxicity. Results and conclusions will be presented.

HEMODIALYSIS RATES WITH AND WITHOUT RASBURICASE ADMINISTRATION FOR TUMOR LYSIS SYNDROME (A2), Kali Williams; Tricia Jeppson; Jeff Gilreath; Dan Sageser (kali.williams@hci.utah.edu). Huntsman Cancer Institute, Salt Lake City UT. IRB approval received. Tumor lysis syndrome (TLS) is an oncologic emergency and can be a serious complication of chemotherapy. It results in hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. Hyperuricemia is responsible for a majority of the clinical manifestations, namely urate nephropathy and renal failure. Rasburicase is a recombinant urate oxidase enzyme that rapidly reduces serum uric acid levels. All studies of rasburicase report effectiveness by 1/*0measuring a secondary endpoint, uric acid lowering, however, the clinical implications of rasburicase administration, namely decreased dialysis rates, remain to be shown. The primary objective of this restrospective cohort study is to determine if rasburicase administration for the treatment of TLS in patients receiving chemotherapy for the treatment of leukemias and non-Hodgkins lymphomas decreases the use of dialysis compared to patients who received standard treatment including allopurinol. Secondary objectives are to characterize the number of high risk features in each group, determine the proportion of patients in both cohorts who have acute renal failure, and determine the reason for dialysis in those receiving rasburicase. Two retrospective cohorts of patients were compared to determine if rasburicase with allopurinol significantly decreases dialysis rates compared to allopurinol alone.

IMPACT OF RELATIVE DOSE INTENSITY ON RESPONSE RATES OF VETERAN PATIENTS RECEIVING PRIMARY CHEMOTHERAPY FOR ADVANCED NON-SMALL CELL LUNG CANCER (A2), Laura Yarbro, Russell Crawford. Southern Arizona VA Healthcare System, Tucson, AZ (laura.yarbro2@va.gov) IRB Approved. The study objective was to determine response rates of patients with advanced non-small cell lung cancer based on their ability to maintain their relative dose intensity. These patients are treated with the intent to prevent disease progression, not cure. The relative dose intensity tool measures the variation of actual dosing compared to recommended guideline doses. Achieving relative dose intensities less than 80% is felt to potentially diminish the efficacy of these treatments. A retrospective chart review of the Veterans Affairs EMR Computerized Patient Record System and individual oncology charts was performed to identify eligible patients who received at least one platinum containing doublet treatment regimen. Acceptable regimens included either cisplatin or carboplatin with paclitaxel, docetaxel, gemcitabine or pemetrexed. Exclusion criteria included previous chemotherapy for advanced disease and concurrent lung radiation or resection. A relative dose intensity was calculated for each cycle to identify achievement of 80% or greater. Patients were then divided into two groups based on relative dose intensity to evaluate response rates, time to treatment failure, and indications for reductions. Results and conclusions will be presented.

A3 CardiovascularCare

PRESCRIBING PATTERNS OF STATIN-BASED COMBINATIONS THAT ARE HIGH RISK FOR MYOPATHY (A3). Julie Alford, Joseph Saseen, Kavita Nair. University of Colorado School of Pharmacy, Aurora, Colorado. (julie.alford@ucdenver.edu) IRB approved. The objective of this retrospective observational database study was to describe prescribing adherence to manufacturer recommended dose restrictions for 3hydroxyl-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) when used concomitantly with fibrates, HIV protease inhibitors, verpamil, diltiazem, amiodarone, macrolides and cyclosporine. Data were collected using claims data covering 17 million commercially insured lives to identify prescribing patters from across the United States for the treatment of dyslipidemia. The database utilized includes medical and pharmacy administrative claims files. Patients aged greater than or equal to 18 years of age up to 89 years of age who received 2 or more prescriptions including one lipidlowering drugstatin and one concomitant druga known to increase risk of myopathy interacting medication between January 1, 2003 and June 30, 2009 were included in the study. Diagnosis codes (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9]) related to cholesterol, kidney, liver, osteoporosis, heart failure, diabetes, coronary artery disease, hypertension, hypothyroidism, and vitamin D deficiency were included to

describe the patient demographics. Initial analysis has identified 15,677 patients meeting criteria and receiving a combination that is high risk for myopathy over the study duration. Descriptive statistics were will be used to analyze these data. The Rresults will be discussed.

ELECTRONIC ORDER SET IMPLEMENTATION OF SULFAMETHOXAZOLE/TRIMETHOPRIM FOR PATIENTS ON WARFARIN THERAPY (A3). Kristin Diaz . Cheryl Bauzon. Veterans Affairs Roseburg Healthcare System, Roseburg, OR (kristin.diaz@va.gov) IRB approval pending. At our institution, sulfamethoxazole/trimethoprim (SMZ/TMP) is often prescribed for patients on warfarin. Warfarin and SMZ/TMP is a well-documented severely interacting drug-drug interaction with warfarin causing which can lead to supratherapeutic INRs. A majority of time, our anticoagulation pharmacists are not alerted for warfarin dosage adjustments when SMZ/TMP is prescribed and if they are alerted, physicians are receptive of alternative antibiotics recommendations with less drug interactions. The study objective is to implement an electronic order set that gives providers alternatives to SMZ/TMP for patients on warfarin therapy who need a course of antibiotics and alerts the anticoagulation pharmacist when this medication is prescribed. This in turn, allows the pharmacists to monitor the patients more closely as needed, decreasing the risk of critical INRs and bleeding. The pPrescribing of SMZ/TMP for warfarin patients before and after the implementation of the electronic order set will be analyzed in retrospective chart review. Results of this electronic order set is pending.

IMPROVING PERFORMANCE IN TREATMENT OF HEART FAILURE (A3) Linzi Allen, Tamara Close, Daniel Diggins. Phoenix Indian Medical Center, Phoenix, AZ (Linzi.allen@ihs.gov) IRB not neededperformance improvement project. The performance improvement project objective was to evaluate the compliance with guidelines and CMS measures for treatment of heart failure (HF) since HF is a complex disease that can be costly to treat, and significantly impact quality of life. The medical records will be retrospectively reviewed to identify patients with HF diagnosis who have undergone hospitalization during the date range of July 2009 to July 2010. The records will be analyzed to identify performance on quality measures for heart failure patient hospitalization. Data collected will be what is needed to assess compliance with measures as well as beta blocker or spironolactone therapy. All data will be recorded without patient identifiers. This data will be used to educate the medical teams about compliance with these measures and impact on patient care. Existing hospital admission standard orders for HF will be revised and a universal HF discharge sheet will be developed to assist in documentation of measure-specific activities. The discharge sheet will be used by a pharmacist when discharge medication counseling occurs to ensure that the patient is given all information needed to comply with measures, and to document necessary information. After education of the medical teams and implementation of the admission and discharge sheets occurs a reevaluation of performance will be done to assess effectiveness of this

performance improvement project. Results and discussion will be presented.

IMPACT OF A NEWLY ESTABLISHED DISEASE STATE MANAGEMENT CLINIC IN A RURAL NATIVE AMERICAN HOSPITAL (A3). Golden Berrett. Rowdy Atkinson. Whiteriver Indian Hospital, Whiteriver, AZ (golden.berrett@ihs.gov) IRB not needed-no human subject data. The objective of this presentation is to describe establishment of a pharmacist operated disease state management clinic and to assess the efficacy and safety of the clinic. A pharmacist submitted the project to the hospital's governing board and received approval. Patients with diabetes mellitus, hypertension, and/or dyslipidemia were recruited into the clinic after obtaining primary care provider approval. Patients meet with the clinic pharmacist between primary care provider follow up visits. The clinic is designed to improve patient outcomes. This is accomplished by optimizing therapeutic regimens according to current evidence and guidelines. The clinic is also intended to alleviate the patient burden on medical staff while increasing patient access to healthcare. Clinical laboratory data will be compared from first to last visit of the study period and between patients seen in the clinic and a random group of those within the healthcare system not seen by the clinic. Patient home monitoring data, quality of life and satisfaction, medication compliance, and adverse drug events will be compared between the first and last visit. Results and conclusion will be presented.

COMPARISON OF BLEEDING EVENTS OF BIVALIRUDIN AND GLYCOPROTEIN (GP) IIB/IIIA INHIBITORS (A3). Mike Brown. Intermountain Healthcare, Salt Lake City, UT (Michael.Brown2@imail.org) IRB approved We performed a retrospective analysis comparing the minor bleeding events associated with bivalirudin compared to GP IIb/IIIa inhibitors to determine which treatment option is associated with fewer bleeding events. We also evaluated the subjects age, weight, history of bleed, concomitant antiplatelet, anticoagulant, and nonsteroidal anti-inflammatory drugs, renal function, and the dosing of the study drugs to determine if any one of these covariates contributed to a higher risk of bleeding when treated with bivalirudin compared to a GP IIb/IIIa inhibitor. Subjects receiving bivalirudin or a GP IIb/IIIa inhibitor at Intermountain Medical Center from October 29, 2007 to August 1, 2010 were analyzed through data extraction and chart review from the time of drug administration to hospital discharge. To limit confounding blood loss due to procedures, we also performed a subgroup analysis using data from those patients who received one stent or less. Results and conclusions are pending.

APPROPRIATENESS OF ARGATROBAN USAGE AFTER PROTOCOL IMPLEMENTATION (A3), Sarah Camponovo, Tina Chan. Presbyterian Healthcare Services, Albuquerque, NM (scamponov@phs.org) IRB approval received. The objective of this study is to assess and compare usage from before and after implementation of an argatroban protocol. All adult patients who received argatroban between August 2009 and August 2010 were identified, and patient chart and laboratory data were retrospectively evaluated. In order to determine the appropriateness of argatroban usage the following data were collected: starting dose, time to first PTT after argatroban initiation, and the percentage of PTTs in the therapeutic range. Warfarin starting dose, platelet count on the day of warfarin initiation, and days of overlapping argatroban and warfarin therapy, were collected to determine the appropriateness of conversion to warfarin from argatroban. Additional data collection included the number of argatroban orders that utilized the written protocol for initial orders and for dosing adjustments. Bleeding or thrombotic adverse events that occurred during argatroban therapy were also collected. Results and conclusions will be presented.

EVALUATING THE DEVELOPMENT OF ACUTE AND CHRONIC HYPONATREMIA AND ITS INFLUENCE ON TREATMENT OUTCOMES IN ACUTE HEART FAILURE (A3). Diana Cao, Tien Ng. LAC+USC Medical Center, Los Angeles, CA (xuancao@usc.edu) IRB approved. The primary objective of this study is to describe the incidence and iatrogenic risk factors for acute (developed in hospital) and chronic (present on admission) hyponatremia in acute heart failure patients, and evaluate their individual influence on clinical outcomes and treatment responses. Aim #1 of the study is to delineate the incidence of hyponatremia in acute heart failure. Aim #2 is to evaluate the association of hyponatremia on clinical outcomes and treatment response. This will be a retrospective cohort study in hospitalized patients who were treated with intravenous loop diuretics for a minimum of 48 hours. For aim #1, incidence of chronic and acute hyponatremia will be described. Hyponatremia will be stratified by severity: serum sodium concentration between 130 to <135 mEq/L, 125 to < 130 mEq/L, 120 to < 125 mEq/L, and < 120 mEq/L. For Aim #2, patients will be categorized into one of the following three cohorts: 1) normonatremic throughout hospitalization, 2) chronic hyponatremia, and 3) acute hyponatremia. Efficacy endpoints will include assessment of diuretic response and ability to initiate angiotensin converting enzyme inhibitors on discharge. Safety endpoints will include length of stay, in-hospital mortality, as well as assessment of hemodynamics, overdiuresis, and requirement of renal

replacement therapy or intravenous inotropes and vasopressors. Results and conclusion will be presented.

IMPACT OF PHARMACIST DIRECTED INPATIENT COUMADIN EDUCATION (A3). Benjamin Chun, William Richelieu, John Anderson. Presbyterian Intercommunity Hospital, Whittier, CA. (bchun@pih.net). Warfarin continues to be the predominant drug for long-term systemic anticoagulation. However, due to lack of patient understanding about warfarin and its many interactions, there continues to be inadequate maintenance of therapy and increased risk of thromboembolism and bleeding. The study objective is to determine if inpatient education for patients new to warfarin therapy would: improve patient understanding of warfarin (i.e. drug and food interactions), improve the time to (TTR) and time in therapeutic range, and have improved overall satisfaction of their warfarin therapy compared to new patients directly referred from physician offices. Inpatients at Presbyterian Intercommunity Hospital that have recently started on warfarin will be educated prior to discharge about warfarin, how to take the medication, drug/drug and drug/food interactions as well as how warfarin is monitored. An oral anticoagulation knowledge (OAK) test will be administered to patients referred to the PIH outpatient coumadin clinic. Differences in scores, as well as TTR will be compared to patients that were educated in the inpatient setting compared with patients that were directly referred from physician offices and did not receive prior education about warfarin. Results will be presented and discussed.

EVALUATION OF THIENOPYRIDINE USE WITH A CLINICAL DECISION SUPPORT TOOL IN PCI (A3), Kate Conway, Melanie Townsend, Susan Keys, Ngan Vi Bellew, Briah Rah. Billings Clinic, Billings, MT (kconway@billingsclinic.org) IRB approved. This prospective, randomized, open-label study analyzed patients undergoing urgent or elective percutaneous coronary intervention (PCI) for UA, NSTEMI, or STEMI for the appropriate use of the thienopyridines clopidogrel and prasugrel. Proper use was defined as the correct loading and maintenance doses, timing of dosing, exclusion due to contraindications, and concurrent use of aspirin. The intervention data was compared to a historical control, and drug selection was based on physician discretion. A clinical decision support tool consisting of four questions directed toward the proper use of prasugrel was created within the automated dispensing machines located in the cardiac catheterization laboratory in order to assist with proper utilization of the medication. The primary endpoint was the appropriate use of thienopyridines during PCI. Secondary outcomes included occurrence of major and minor bleeding, thrombotic events, stent occlusion, and PCI related readmission within 30 days of the procedure. Adult patients with an acute coronary syndrome (ACS) who underwent urgent or elective PCI and received a thienopyridine for the procedure were included. Patients less than 18 years of age and pregnant females were excluded. Preplanned subgroups included low risk patients versus moderate to high risk patients and those receiving clopidogrel versus prasugrel. Within the ACS PCI group,

data was further compared as STEMI versus UA or NSTEMI. Results and conclusions will be presented.

EVALUATION OF ANTI-FACTOR XA LEVELS IN MEDICALLY-ILL OBESE MALE PATIENTS RECEIVING ENOXAPARIN FOR VTE PROPHYLAXIS (A3), Lauren Corcoran, James
Adair, Holly Fleming, Michael Sanchez. NMVAHCS, Albuquerque, NM (Lauren.Corcoran@va.gov) IRB approved. Venous Thromboembolism (VTE) prophylaxis using enoxaparin has become a standard of care in todays medical practice. Obese patients are at a higher risk for VTE than non-obese patients and there have been conflicting results with regards to the relationship between anti-factor Xa and BMI. The primary objective of this study is to evaluate the relationship between anti-factor Xa and BMI. A prospective observational study was conducted to collect anti-factor Xa levels in medically-ill, male patients with BMI > 25 kg/m2 who received fixed doses of enoxaparin 40 mg SC daily while admitted to NMVAHCS from January 1, 2011 to March 31, 2011. Anti-factor Xa levels will be correlated with BMI to determine if patients are receiving appropriate VTE prophylaxis. Data will be analyzed for the percentage of VTE events, bleeding events, and thrombocytopenia. If significant, the results of this study could support weight based dosing of enoxaparin for VTE prophylaxis and be clinically significant. Results and conclusions will be presented upon completion of data collection.

HEPARIN ACTIVITY LEVEL (HAL) VERSUS ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) FOR THERAPEUTIC MONITORING OF UNFRACTIONATED HEPARIN (A3), Jennifer Curello, Mark Klanjac, Alfred Hurt. Stanford University Medical Center, Stanford, CA (JCurello@stanfordmed.org) IRB approval is not needed. The purpose of this study is to determine if there is a statistically significant discordance between the aPTT and the HAL in patients receiving heparin drips and if there is, to determine if this discordance is associated with an increased risk of bleeding. The electronic medical record will be utilized to identify all patients who, over an 18 month period of time, received heparin drips and had both the HAL and aPTT drawn for monitoring. For this retrospective chart review, data points collected will include the aPTT and HAL values in addition to all other labs pertinent to monitoring heparin therapy. Medication profiles and physician progress notes will be reviewed for any administration of blood products, protamine, or any other documentation of an active bleed. The primary endpoint of this study is the occurrence of a discordant HAL and aPTT. The secondary endpoint is bleeding in the context of a therapeutic HAL and supratherapeutic aPTT, defined as an aPTT greater than 110 seconds. Once all the data is collected, the investigators will determine if there is a statistically significant discordance between HAL and aPTT in patients receiving heparin infusions and if so, attempt to determine if a correlation exists between the discordance and increased risk for bleeding. Results and conclusions will be presented.

IMPACT OF A HEART FAILURE POST-DISCHARGE MANAGEMENT CLINIC ON HOSPITAL READMISSION RATES (A3). Noelle de Leon, Cynthia Jackevicius, Freny Mody. Western University of Health Sciences, Pomona, CA (ndeleon@westernu.edu). IRB approved. Heart failure (HF) is one of the most frequent discharge diagnoses and is a common cause for hospital readmission. Specialized clinics that manage patients following HF hospitalization have demonstrated significant reductions in readmission rates and improved patient adherence to evidence-based HF therapies. The VA Greater Los Angeles Healthcare System established the Heart Failure Post-Discharge Management (HF-PDM) clinic in July 2010 to provide comprehensive care for patients who are discharged from the hospital with a primary HF diagnosis. Patients are seen by various providers within one to two weeks after their HF hospitalization discharge for six clinic visits spanning ten weeks. This retrospective study will assess the efficacy of the clinic through chart review of patients who received care in the clinic compared with historical controls. The primary outcome of this study is to assess the impact of the HF-PDM clinic on readmission 90 days following discharge from the index hospitalization. Secondary outcomes include patient adherence to the evidence-based HF medications by calculating the proportion of days covered, and titration efficacy at 90 days in a subgroup of patients with left ventricular systolic dysfunction to determine whether patients achieved target doses of their evidence-based HF medications. Results will be presented.

IMPACT OF ONCE DAILY VERSUS TWICE DAILY ANTIHYPERTENSIVE MEDICATION REGIMEN ON AMBULATORY BLOOD PRESSURE MONITORING PARAMETERS. Josh Elston, Tony Eid, Anthony Dargush, Sachin Shah. Travis AFB and Thomas J Long School of Pharmacy and Health Sciences, University of the Pacific. Fairfield, CA. joshua.elston.1@us.af.mil. IRB approval received.

The objective of this study was to evaluate if increasing the dosing frequency of once daily antihypertensive medications from one to two times per day without increasing the total daily dose would promote blood pressure reductions. This was a before and after study design where patients on a once daily antihypertensive dosing algorithm were switched to a twice daily dosing algorithm without a corresponding increase in total daily dose. The primary outcome was the change in average daily systolic and diastolic blood pressure. Patients currently enrolled in the metabolic clinic at David Grant Medical Center, taking one of the four study medications (lisinopril, telmisartan, amlodipine/benazepril, telmisartan/HCTZ), and above the age of 18 years were included. Patients were excluded if they had a recent blood pressure medication change, in hypertensive crisis, having congestive heart failure, end stage renal disease, pregnant or planning to become pregnant, or having previously failed the respective twice daily dosing regimen or were taking more than one of the study drugs at inclusion. After

baseline office and 24-hour ambulatory blood pressure measurement, one of the patients anti-hypertensive medications dosing frequency was changed from once to twice daily without a dose increase for a period of 14 days. Office and ambulatory blood pressure monitoring was performed again at day 14. A paired t-test was performed for all continuous data. Compliance was assessed via pill counting. Results are pending. This study may provide an alternate dosing mechanism for blood pressure reduction in difficult to treat patients.

ASSESSMENT OF PATIENT MEDICATION ADHERENCE USING PHARMACY REFILL DATA IN PATIENTS WITH CARDIOVASCULAR AND CEREBROVASCULAR RISKS (A3), Melissa Fung. Alameda County Medical Center, Oakland, CA (mfung@acmedctr.org) IRB approval pending. Patients with coronary and other vascular diseases need to be on chronic medications to slow the atherosclerotic process and to prevent cardiac and cerebrovascular events. However, adherence to medications among patients with chronic disorders is a common problem. The World Health Organization estimates that 50% of all patients do not take their medications as prescribed. Within Alameda County Medical Center, patients at Highland hospital receive their medications from the Highland outpatient pharmacy, whereas patients at the free standing clinics receive their medications from contracted retail pharmacies. Two preliminary studies showed a discrepancy in refill adherence rates between the two patient populations. The primary objective of this study is to verify that a difference in refill adherence rates exists. Medication adherence to ACEIs or ARBs and lipid lowering agents will be evaluated using the medication possession ratio (MPR), an accepted method to calculate refill adherence from administrative data. The secondary endpoint is to explore factors including patient demographics and pharmacy services that potentially impact patient adherence. Results and conclusions will be presented.

ANTIPLATELET OR ANTICOAGULATION THERAPY FOR CERVICAL ARTERY DISSECTION (A3), Sanaz Ghaffarian, Benson Sederholm, Jana Wold. University of Utah Hospitals and Clinics, Salt Lake City, UT (sanaz.ghaffarian@hsc.utah.edu) IRB approval received. Cervical artery dissection involves the tearing of the inner layer of an artery located in the neck. Penetration of blood through the tear can result in hemostasis and thrombus formation, which may lead to distal embolism and ischemic stroke. Current guidelines include initial treatment of stroke and secondary stroke prevention with antiplatelet or anticoagulation therapy. To date, there is no clear consensus as to which therapy is superior. The objective of this study is to investigate the use of antiplatelet or anticoagulation therapy for secondary stroke prevention in patients admitted to the University of Utah Hospital with cervical artery dissection. The study is a retrospective chart review. Patients age 18 or older, with a diagnosis of first cervical artery dissection between August 1, 2007 and July 31, 2010, who received at least one dose of either an antiplatelet agent or anticoagulant, were included. The primary outcome measure is the percentage of patients receiving antiplatelet or anticoagulation therapy for secondary stroke prevention. Secondary outcomes include the duration of treatment; time from admission to start of maintenance treatment; hospital length of stay; and rate of symptomatic intracranial hemorrhage, major extracranial bleeding, or recurrent ischemic event within three months after discharge. Results will be presented.

CHARACTERIZATION OF PATIENTS WITH DIASTOLIC DYSFUNCTION HEART FAILURE (A3). Brooke Glasmann, Sarah Anderson, Joel Marrs. Denver Health Medical Center, Denver, CO (brooke.glasmann@dhha.org) IRB approved. The purpose of this retrospective observational study is to establish common clinical characteristics and demographics of patients with diastolic dysfunction heart failure (DHF). Secondary outcomes are to determine the primary reasons for hospital admission; the rate of hospital readmission at 30, 90 and 180 days post heart failure admission; rehospitalization due to acute decompensated heart failure; and common medication therapies used in the treatment. Inclusion criteria are age greater than or equal to 18 years old and age less than or equal to 89 years old with a diagnosis of DHF and an ejection fraction of greater than or equal to 45%. Descriptive statistics will be used to summarize patient characteristics and medical treatment during hospitalization. Correlational analyses will be used to determine if an association exists between DHF and the variables of age, comorbidities and medication therapies. Results and conclusion will be presented.

INCIDENCE OF NEW ONSET ATRIAL FIBRILLATION IN POST CARDIAC SURGERY PATIENTS WITH AND WITOUT USE OF A PROPHYLACTIC ORDERS SET (A3), James Hall, Patricia Montgomery, Mercy General Hospital, Sacramento, CA (James.Hall@chw.edu) IRB approved The objective of this retrospective study is to observe if there is a significant difference in the incidence of new onset atrial fibrillation in post cardiac surgery patients receiving prophylaxis as specified by a new order set. The prophylaxis orders include post-operative intravenous magnesium and oral metoprolol; in addition, intravenous plus oral amiodarone is administered to prespecified high-risk patients. The study includes all cardiac surgery patients over the age of 19 years for six months prior to and three months following implementation of the prophylaxis orders. Exclusion criteria include previous atrial fibrillation being currently treated, implanted defibrillator, or hemodynamically unstable patients. Data collected includes age, sex, beta-blocker use prior to surgery, type of cardiac surgery, preexisting conditions such as hypertension, diabetes, and renal failure, smoking status, number of doses of each medication administered and development of atrial fibrillation post cardiac surgery. The incidence of postoperative atrial fibrillation between the two groups will be compared using a Yates Continuity Correction. Preliminary results and conclusions will be presented.

PRESCRIBING TRENDS FOR THE TREATMENT OF RESISTANT HYPERTENSION (A3), Michele Hanselin, Joseph Saseen, Kavita Nair. University of Colorado School of Pharmacy, Aurora, CO (michele.hanselin@ucdenver.edu) IRB approval exempt. Resistant hypertension is defined as persistent elevations in blood pressure above goal despite the use of three or more antihypertensive medications from different classes at optimal doses, one preferably being a diuretic. Resistant hypertension also includes patients at goal blood pressure on four antihypertensive medications from different classes. The study objective is to describe prescribing trends for the treatment of resistant hypertension, and to determine the rate of appropriate prescribing based on 2008 American Heart Association treatment recommendations for patients with resistant hypertension. The recommendations support the use of chlorthalidone and spironolactone for the treatment of resistant hypertension. This retrospective cohort database study will be performed to identify prescribing trends for the treatment of resistant hypertension using claims data covering 17 million commercially insured lives across the United States. Inclusion criteria are patients with 4 or more concurrent antihypertensive medications, age18 to 89 years, greater than 12 months consecutive plan enrollment, and an ICD9 for hypertension. The primary endpoint is to describe prescribing patterns for the treatment of resistant hypertension including the percent use of individual antihypertensive classes. Secondary endpoints include percent use of fixed dose combinations, spironolactone, chlorthalidone, and unapproved or unsupported

antihypertensive combinations. Results and conclusion will be presented.

EVIDENCE BASED UTILIZATION OF AMIODARONE FOR NEW ONSET ATRIAL FIBRILLATION (EVIL) STUDY( A3), Jayme Hara, Sean Barclay, Meghan Jeffres. University Medical Center of Southern Nevada, Las Vegas, NV (jayme.hara@umcsn.com) IRB approved. Atrial fibrillation is the most common arrhythmia encountered in clinical practice. Prior to the AFFIRM trial, rhythm control was the preferred treatment strategy for most practitioners. Theoretically, the restoration and maintenance of normal sinus rhythm should improve hemodynamics, increase quality of life, and reduce the risk of thromboembolism. Unfortunately the anti-arrhythmics currently available have limited efficacy at maintaining normal sinus rhythm coupled with frequent and sometimes life-threatening adverse effects. The purpose of this study is to evaluate the prescribing trends of amiodarone for new onset atrial fibrillation, assess the appropriateness based on available evidence, and determine patient characteristics associated with inappropriate amiodarone use. This is a retrospective study of adult patients discharged on oral amiodarone for new onset atrial fibrillation. Patients with a past medical history of arrhythmia, prior use of amiodarone, cardiac surgery or ventricular arrhythmia during the current admission were excluded. The results and conclusion will be presented.

EVALUATION OF ADHERENCE TO THIENOPYRIDINES AFTER DISCHARGE (A3), Heather Hatch, Linda Tyler, Rodney Badger, Shannon Ludwig, Amy Beal Cook. University of Utah Hospital. Salt Lake City, UT (heather.hatch@hsc.utah.edu) IRB approval pending. The study objective was to evaluate patient adherence to thienopyridines after percutaneous coronary intervention, determine reasons for non adherence, and identify areas for improvement in the discharge process that will facilitate greater patient adherence. This was a descriptive study. Patients were screened for participation if they received a coronary artery stent and were discharged with a new prescription for clopidogrel or prasugrel. Inclusion criteria were age greater than 18 and an active telephone number. Patients were excluded if they declined participation, did not speak English, were unable to complete the questionnaire, were discharged to a long term care facility, or took clopidogrel or prasugrel prior to admission. Patients were called 3 to 5 days after discharge. A standardized questionnaire was used to determine thienopyridine adherence and assess potential barriers to adherence. Barriers assessed included financial concerns, logistical problems getting to a pharmacy, poor understanding of the medication and the reason it was prescribed, lack of education about the medication prior to discharge, problems taking the medication such as side effects or difficulty remembering doses, patient education level, and patient pill burden. Results and conclusions will be presented.

EXTENDED CLOPIDOGREL THERAPY VERSUS STANDARD THERAPY FOR VERY LATE STENT THROMBOSIS IN PATIENTS RECEIVEING AN EVEROLIMUS ELUTING STENT (A3). Matthew Higley. Intermountain Healthcare, Salt Lake City, UT (matt.higley@imail.org) IRB approved. The purpose of this study is to compare the incidence of the combined endpoint of death from any cause or hospital readmission due to cardiac causes in patients who received an everolimus eluting stent and discontinued their clopidogrel therapy at the recommended time of 1 year (standard therapy) versus patients who continued clopidogrel beyond 1 year (extended therapy.) This study is retrospectively-chosen hypothesis evaluated in a prospectively followed observational cohort of subjects. A Kaplan Meier curve will be constructed to look for an increase in primary events within the first 3 months after patients should have stopped their clopidogrel dose at 1 year.Subjects will then be divided into those who had greater than or equal to 80 percent compliance with prescription fills for clopidogrel during the first year after everolimus eluting stent placement and then discontinued clopidogrel after 1 year versus those who had greater than or equal to 80 percent compliance with prescription fills for clopidogrel for the first year after everolimus eluting stent placement and continued to fill clopidogrel after the first year. We will use a Cox regression analysis to evaluate the effect of time on treatment with clopidogrel while taking into consideration covariates. Results and conclusions will be presented.

ESTABLISHMENT OF A POST-PROCEDURAL WARFARIN DOSING PROTOCOL (A3). Kimberly Jacques, Arthur Allen, Scott Mambourg. VA Sierra Nevada Health Care System, Reno, NV (kimberly.jacques@va.gov) IRB pending. The study objectives are to develop a safe and effective post-procedure dose loading protocol that improves time to a therapeutic INR after interruption in anticoagulation therapy and reduces peri-procedural thrombotic complications (tracked with the proprietary VA anticoagulation software). Patients on warfarin requiring full INR reversal prior to their procedure without lowmolecular weight heparin bridge will have an INR recorded prior to interruption. The following patients will be excluded: time in therapeutic range less than 40%, with recent (within 6 months) bleeding or thromobotic event, and procedures with high bleed risk including those involving the CNS. Those included will then be randomized on a walk-in basis to one of three groups: a control group (Study Group 1) which is restarted on their previously established dose, Study Group 2 who will have their dose increased by 50% for three days then resume their maintenance dose, and Study Group 3 who will have their dose doubled for three days, then resume their maintenance dose. Data will be analyzed using a Cox regression of a Kaplan-Meier survival analysis to determine median time to therapeutic INR. Other data to be gathered include the number of bleeding/thrombotic complications, number of critical INRs (INR greater than 4.5), and the number of patients requiring vitamin K or FFP for reversal. Results and conclusions will be presented.

PATIENT SELF-MANAGEMENT OF WARFARIN. AN EDUCATIONAL PROGRAM FOR A PROSPECTIVE PILOT STUDY (A3). Kathleen M. Jenner, Daniel M. Witt. Kaiser Permanente Colorado, Aurora, CO. (kathleen.m.jenner@kp.org) IRB approval received. Patient self-management of warfarin using point-ofcare INR monitors appears to improve the therapeutic outcomes of warfarin, but feasibility and cost may be prohibitive. The purpose of this study was to determine the feasibility of patient self-management of warfarin using veinipuncture INR results released through a secure website. The study objectives were to develop an anticoagulation patient self-management training and assessment program and a patient-friendly warfarin-dosing algorithm; to train enrolled patients in warfarin selfmanagement; to describe patient characteristics of those who do and do not successfully complete the program; and to assess and compare patient self-management competency test scores before vs. after training program. Patients with atrial fibrillation, INR targets of 2-3, and receiving warfarin 5 mg tablets were identified and recruited for enrollment. Consented patients received warfarin self-management training via a tailored PowerPoint presentation and correlating handouts. To date 28 patients have been enrolled and 27 patients have completed both pre- and post-competency tests. 53.6% of the population was male and the mean age of patients was 70.9 years. Mean pre-training competency test score was 48.6% and mean post-training score was 85.7%. 92.6% (25/27) of patients earned a passing score (70%) on the

post-competency test and continued on to patient selfmanagement of warfarin. Final data will be presented.

EFFECT OF PHARMACIST INTERVENTION IN 30DAY HEART FAILURE READMISSION RATES (A3), Helen Kim. Providence Tarzana Medical Center, Tarzana, CA (helen.kim@providence.org) IRB exempt. Heart failure is the most common diagnosis leading to hospitalizations for Medicare beneficiaries. In the past decade, the mean length-of-stay for heart failure patients decreased from 8.8 to 6.3 days. In contrast, the 30-day readmission rate increased from 17 to 20%. A regional initiative called ProvRED (Providence ReEngineered Discharge) was developed at our hospital to evaluate and optimize discharge planning for heart failure patients. This initiative was an adjunct to the current Joint Commission heart failure core measure guideline. ProvRED is primarily driven by case management and nursing at our institution, a 240-bed acute care community hospital. The purpose of this initiative is to educate patients regarding their disease state and to promote follow-up care post-discharge. The ProvRED initiative compliance rate is currently less than 40%. Our aim was to determine if pharmacist involvement in the ProvRED team can increase compliance with the initiative, reduce heart failure readmission, and further improve heart failure core measure compliance.

A RETROSPECTIVE ANALYSIS OF PATIENTS CONVERTED FROM EZETIMIBE/SIMVASTATIN TO SIMVASTATIN (A3), Mira Kim. Kaiser Permanente Medical Care Program, San Rafael, CA (mira.x.kim@kp.org) IRB exempted. Evidence regarding the cardiovascular benefit of ezetimibe is currently under debate. Kaiser Permanente has implemented a new lipid management guideline to support the use of simvastatin alone as the lipid-lowering drug of choice for the management of dyslipidemia and cardiovascular risk. Kaiser Permanente clinical pharmacists review patients on the combination ezetimibe/simvastatin (Vytorin) and provide recommendations to adjust therapy to simvastatin monotherapy at either the current simvastatin dose or at an increased dose. The purpose of this study is to evaluate the impact of a therapeutic conversion from ezetimibe/simvastatin to simvastatin in maintaining or reaching the low-density lipoprotein cholesterol goal. A retrospective chart review was performed from October 2009 to October 2010 at Kaiser Permanente San Rafael, Santa Rosa, San Francisco and Vallejo Medical Center. The study population included adults who were prescribed ezetimibe/simvastatin who also had laboratory values collected within a year prior and 8 to 12 weeks after the change to simvastatin. Patients who had no baseline or follow-up laboratory values and those with a history of liver disease or rhabdomyolysis were excluded. Collected data included low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), alanine aminotransferase (ALT), and creatine

kinase (CK), if available. Results and conclusion will be presented.

COMPARISON OF EFFICAY AND TOLERABILY BETWEEN NIACIN EXTENDED-RELEASE (ER) AND SLO-NIACIN (A3), Won-Sahn Lau, Yong Moon, David Gray. VA Healthcare System, Long Beach, CA (wonsahn.lau@va.gov) IRB approved Dyslipidemia is highly correlated with coronary heart disease, which is the leading cause of death in the United States. Niacin can decrease LDL cholesterol and triglycerides as well as increase HDL cholesterol. While there are several prescription and non-prescription niacin products, they all differ in efficacy, toxicity and metabolism. At the VA Long Beach, a conversion from niacin extended-release to slo-niacin is currently underway. The primary objective of this study is to assess the efficacy and tolerability in patients that were switched from niacin extended release to slo-niacin. This will be a retrospective cohort study of pharmacy records and laboratory results from the VA Desert Pacific Health care Network Data Warehouse. The following pre and post-conversion data will be collected and analyzed. Clinical endpoints will include: change in serum creatinine, ALT/AST, fasting lipid panel including HDL, LDL, Triglycerides and total cholesterol, and reported niacin adverse side effects. Descriptive statistics and other applicable statistical tests will be performed. Final results and conclusion will be presented

AMINO TERMINAL PRO BNP AS A GUIDE FOR THE TITRATION OF BETA BLOCKERS IN PATIENTS WITH ACUTE DEPCOMPENSATED HEART FAILURE (A3). Norela Ocampo. Rebecca Cheung. LLU Medical Center. Loma Linda, Ca (nvocampo@llu.edu) IRB approved. Natriuretic peptides have been used as diagnostic tools for the assessment as well as prognostic markers for acute decompensated heart failure (HF). Beta-blockers (BBs) have been shown to decrease the risk of morbidity and mortality in patients with HF and reduced LVF. However, its use is controversial in patients with acute symptoms. Current guidelines suggest the use of BBs in patients who have been stabilized on diuretics, vasoactive agents and inotropes. The objective of this study is to establish a guide for the level of pro-BNP at which BBs may be titrated. The computer system at Loma Linda University Medical Center will be utilized to generate a list of patients on BBs and will be matched with patients who were admitted with the diagnosis of HF from January 1, 2010 through July 1, 2010. Inclusion criteria will include patients who are: 18 years and older with a diagnosis of heart failure on admission, EF< 45%, and on BBs during clinical stay. Data collected include: age, gender, ethnicity, medications used for heart failure, medical history, length of hospital stay, pro-BNP on admission and on subsequent days, other cardiac markers, vital signs, and any pertinent laboratory values. Results and conclusion will be presented.

RETROSPECTIVECHARTREVIEWOFPHARMACIST INTERVENTIONOFSTATINFIBRATECOMBINATIONATTHEVA SOUTHERNNVHEALTHCARESYSTEM(A3),MeetaPatel, JoahnnaPaderna.VASouthernNVHealthcareSystem,Las Vegas,NV(Joahnna.Paderna@va.gov)IRBapprovalpending. Hyperlipidemiaischaracterizedbyelevated concentrationsofcirculatinglipids,increasingtheriskof atherosclerosisandheartdisease.Highconcentrationsoftotal andlowdensitylipoprotein(LDL)cholesterolaswellaslow concentrationsofhighdensitylipoprotein(HDL)cholesterol predictcardiovascularriskinbothmenandwomen.Clinical trialsshowthatLDLloweringtherapyreducestheriskfor coronaryheartdisease(CHD).HMGCoAreductaseinhibitors (statins)arefirstlineagentsinthetreatmentofelevatedLDL cholesterol.Fibratesarehighlyeffectiveatimprovinglipid levels;however,thereisalackofevidenceforaddedbenefiton overallhealthoutcomewhentheseagentsareaddedtostatin therapyandmaycauseharmthroughincreasedmuscletoxicity. Theprimaryobjectiveofthisstudyistoevaluateprovider prescribinghabitsofstatinfibratecombinationsinresponseto pharmacistinterventionsattheVASNHS.Thisstudywillretrieve andreviewpatientrecordsfromtheVeteransAffairs(VA) computersystems:VeteransHealthInformationSystemsand TechnologyArchitecture(VistA)andComputerizedPatient RecordSystem(CPRS).Allpatientsrequiringpharmacist interventionbetween5/1/10to5/31/10willbeincludedinthis study.Datacollectionwillinclude:patientname,socialsecurity number,LipidClinicnotewiththefollowingsubject,Statinand FibrateUseEvaluation.Resultsandconclusionwillbe presented.

ADHERENCE TO DUAL ANTIPLATELET THERAPY (ADAPT) AND CARDIAC STENT OUTCOMES: A RETROSPECTIVE ANALYSIS (A3). Stephen Perona. Southern Arizona VA Health Care System, Tucson, AZ (stephen.perona@va.gov) IRB approved We sought to determine the impact of adherence to clopidogrel on cardiovascular outcomes and bleeding risk in patients following drug eluting stent placement. This was a retrospective review of patients at a single center with one or more drug eluting stent(s) placed between January 2004 and December 2008. Patient characteristics, coronary stent information, and cardiovascular outcomes were collected during the one year period immediately following stent placement. Cardiovascular outcomes were adjudicated by physicians with specialty training in cardiology. A pharmacist reviewed clopidogrel refill information and classified patients as adherent or non-adherent using the medication refill adherence method. The incidence of a composite cardiovascular endpoint and bleeding were compared between the two groups. Results and conclusion will be presented.

FREQUENCY OF AMINOPHYLLINE USE FOR REVERSAL OF DIPYRIDAMOLE AND REGADENOSON INDUCED SIDE EFFECTS DURING STRESS MYOCARDIAL PERFUSION IMAGING (MPI) (A3), Lisa Perry, Mei Tse, Ronald Brown. Portland Veterans Affairs Medical Center, Portland, OR (Lisa.Perry4@va.gov) IRB approved. The objective of this retrospective chart review is to compare the incidence of adverse drug events associated with both dipyridamole and regadenoson and to report the frequency of use of aminophylline for reversal of these drug effects. This study will include 140 veteran patients who received cardiac radionucleotide imaging with regadenoson (Lexiscan) or dipyridamole (Persantine) for stress myocardial perfusion imaging to evaluate the presence of coronary artery disease. The health systems electronic medical record system, computerized patient record system (CPRS) and Vista, will be used to identify 140 veterans who were at least 18 years of age and had received dipyridamole or regadenoson for stress myocardial perfusion imaging. The following data will be collected: patient age, gender, weight, height, race, heart rate, blood pressure, concomitant medications (theophylline, methylxanthines, and beta-blockers), nicotine products (patch, gum, lozenge, inhaler, and nasal spray), nicotine use (cigarettes and chewing tobacco), reported adverse events, receipt of regadenoson or dipyridamole and dose, and receipt of aminophylline and dose. Results and conclusions will be presented.

EVALUATION OF HOSPITALIZATIONS ASSOCIATED WITH THIAZIDE-ASSOCIATED HYPONATREMIA (A3). Divaker Rastogi, Mitchell A. Pelter, Robert L. Deamer. Kaiser Permanente Medical Care Program, Woodland Hills, CA (Divaker.X.Rastogi@kp.org) IRB Approved. National guidelines place thiazides as first line agents in the treatment of hypertension, primarily because of their unsurpassed efficacy in reducing cardiovascular complications in numerous outcome trials, such as ALLHAT. Thiazide-associated hyponatremia (HTAH) is not well investigated, despite its high frequency in hospitalized patients, and association with increased morbidity and mortality. The objective of the current trial is to determine specific risk factors for HTAH. The current trial is a retrospective, case-controlled study from 2001 to 2010 in which patients were identified using ICD-9 codes from a large, healthcare system database. Cases were defined as patients hospitalized with hyponatremia while being concurrently treated with thiazide diuretics. Five controls were matched to each case based upon date of initial thiazide prescription. Subjects were excluded if diagnosed with: SIADH or causes of SIADH, including medication-induced causes; kidney disease; liver disease; congestive heart failure; and ascites. Logistic regression was used to determine an association between HTAH and variables potentially related to this condition, including: age, gender, weight, ethnicity, concurrent medications, and intercurrent conditions. Odds ratios of risk factors for cases and controls were compared, with a p-value less than 0.05 considered statistically significant.

INCIDENCE OF CONTRAST INDUCED NEPHROPATHY IN PCI PATIENTS RECEIVING IODIXANOL VERSUS IOPAMIDOL (A3), Renee Rife, Denise Erickson. Banner Heart Hospital, Mesa, AZ (renee.rife@bannerhealth.com) IRB approval pending. The purpose of this study is to compare the incidence of contrast induced nephropathy based on the type of contrast received in patients with renal insufficiency undergoing percutaneous coronary intervention (PCI). Contrast induced nephropathy will be defined as a 25 percent or greater decrease in creatinine clearance after receiving contrast. Study data will be obtained from an electronic medical database and paper charts. All PCI patients with baseline renal insufficiency receiving iodixanol or iopamidol during their procedure at Banner Heart Hospital from September 2009 through November 2010 are eligible for inclusion. Renal insufficiency will be defined as a creatinine clearance less than 60 mL/min, calculated using ideal bodyweight. Patients will be excluded if they receive an alternate contrast agent, have incomplete lab data, have end stage renal disease requiring dialysis, or patients presenting with cardiogenic shock prior to PCI. Demographic data to be collected will include; patient age, serum creatinine before and after PCI, and calculated creatinine clearance and MDRD before and after PCI. The primary outcome of the study is the incidence of contrast induced nephropathy in patients receiving iodixanol versus iopamidol. Nominal data will be evaluated with a Fishers exact test. Results of the study and statistical analysis will be presented.

WARFARIN SELF-MANAGEMENT UTILIZING VENIPUNCTURE INR PILOT STUDY(A3) Brandon Simmons, Daniel M. Witt. Kaiser Permanente Colorado (KPCO), Denver, CO (Brandon.x.simmons@kp.org) IRB approval has been received. In multiple disease states, including diabetes mellitus and asthma, patient outcomes have improved with medication self-management. Warfarin self-management utilizing point-of-care international normalized ratio (INR) devices and weekly INR testing is more costly than less frequent laboratory INR monitoring using venipuncture. We conducted a prospective, one arm, open label study in patients with atrial fibrilation using 5mg warfarin tablets to examine the feasibility of self management using traditional lab venipuncture INRs reported directly to patients through Kaiser Permanentes unique, secure internet messaging site. Consenting patients attended a self management training class. Those who demonstrated proficiency in self management at the end of the class managed their own warfarin therapy for three months with oversight from their anticoagulation pharmacist. Study variables included time in the therapeutic INR range, missed INR appointments, occurrence of extreme INR values, need for patient safety interventions, and episodes of major bleeding and thrombosis. Preliminary data including baseline demographics will be presented.

A RETROSPECTIVE ANALYSIS OF MODIFICATIONS TO EXISTING DUAL ANTIPLATELET AND STATIN PHARMACOTHERAPY AFTER A NONPRIMARY ACS EVENT (A3). Tiffany Stevens, Lindsay Huxtable. Phoenix VA Hospital, Phoenix, AZ (Tiffany.Stevens@va.gov) IRB approval received. The primary objective was to determine if modifications were made to baseline dual antiplatelet therapy in patients who had a non primary acute coronary syndrome event. All patients at the Phoenix VA Healthcare System that had a primary acute coronary syndrome event after August 2001, a subsequent non primary acute coronary syndrome event between March and September 2010, and documented use of dual antiplatelet therapy at the time of the non primary event were evaluated for inclusion. Patients were excluded if they had a contraindication to antiplatelet therapy or a major documented bleeding event. Secondary objectives include evaluation of statin pharmacotherapy before and after the non primary acute coronary syndrome event and the impact of platelet function testing on modifications to antiplatelet therapy in those patients in whom testing was performed. Data was extracted from a retrospective chart review and primary outcome analysis was performed using the Chi Square test of independence. Results and conclusions will be presented.

PRASUGREL (EFFIENT) USE IN AN ACADEMIC MEDICAL CENTER: A REAL WORLD PERSPECTIVE (A3), Christine Tran, Douglas Humber, UCSD Medical Center, San Diego, CA (cttran@ucsd.edu) IRB approval pending. The study objective was to determine the appropriateness of prasugrel use at UCSD Medical Center, as defined by use that matches the FDA black box warning criteria for use. The study included all nonpregnant patients age > 18 years who received prasugrel between October 1, 2009 and December 31, 2010. Patients receiving prasugrel were identified using the prasugrel drug code in UCSDs inpatient and outpatient electronic medical records database. Demographic information included age, weight, indication for prasugrel, prior use of clopidogrel, if any, P2Y12 platelet function assay results, baseline labs, past medical history pertinent to ischemic or bleeding outcomes (e.g., history of stroke), and concurrent medications that could increase risk of bleeding. The primary outcome was the number of patients prescribed prasugrel with adherence to FDA recommended criteria for use (e.g., age < 75 years, > 60 kg, no history of stroke or transient ischemic attack, no active bleeding, and a percutaneous coronary intervention (PCI). Secondary outcomes included the number of patients prescribed prasugrel for off-label uses (e.g., non-acute coronary syndrome (ACS) or ACS without planned PCI) and hospital readmissions for bleeding events and/or restenosis. Results and conclusions will be presented.

DETERMINING THE OPTIMAL VITAMIN K DOSE NEEDED TO REVERSE ANTICOAGULATION BASED ON THE INR AND WEEKLY WARFARIN DOSE (A3), Laura Tsu, William Dager. UC Davis Medical Center, Sacramento, CA. (laura.tsu@ucdmc.ucdavis.edu) IRB approval received. Vitamin K is a common reversal agent used in patients receiving warfarin who require a lowering of the intensity of anticoagulation and to decrease the risk of related bleeding complications. The optimal dose of vitamin K to lower the international normalized ratio (INR) into a safe range, without causing excessive or prolonged reversal once therapy is reinitiated is unclear. Resistance to reinstating warfarin can cause increased use of bridging agents and possibly prolong hospitalization until target INR is reached. Currently, data describing the optimal dose of vitamin K for a given INR and home warfarin requirements to achieve a targeted INR reduction is limited. This retrospective analysis of patients at UC Davis Medical Center who were treated with vitamin K for reversal of warfarin from February 2008 through November 2010 aims to create a vitamin K dosing guideline based on the patients weekly warfarin requirement and initial INR as an aid to guide dosing decisions. Data collection includes warfarin dosing history, dose and route of vitamin K administered, INR at baseline and within 48 hours after vitamin K administration, and use of alternative reversal agents and bridging agents. Results will be discussed.

MANAGEMENT OF ATRIAL FIBRILLATION IN TRAUMA PATIENTS AT A LARGE ACADEMIC MEDICAL CENTER (A3). Shannon VonMuenster, Jeremiah Duby. UC Davis Medical Center, Sacramento, CA (shannonvonmuenster@gmail.com) IRB approved. The purpose of this study is to identify the occurrence rate, to characterize the population, and to describe the effects of medical management of atrial fibrillation (AF) in critically ill trauma patients. 2,591 consecutive patients admitted to a trauma intensive care unit (ICU) from February 2008 November 2010 were identified using the UCDMC Trauma Registry and will be screened for a rhythm of AF. A retrospective chart review of the electronic medical record was used to collect patient demographic data (e.g. age, sex, injury severity score, type of injury), risk factors for AF (e.g. history of AF, heart disease, heart rate on admission, BMI) and for venous thromboembolism (VTE), fluid status (e.g. fluid inputs and outputs, central venous pressure), medication use (e.g. ratecontrol agents, anticoagulants, diuretics), hemodynamic response (e.g. heart rate, blood pressure, rhythm), adverse effects (e.g. bradycardia, hypotension, rescue medication), and related clinical outcomes (e.g. clinical VTE event, myocardial infarction, ICU length of stay, AF at discharge, discharge on rate-control or anticoagulant medications for AF). Data was recorded in Microsoft Access and Excel and primarily analyzed with descriptive statistics. Binary

logistic and multivariate stepwise regression analyses will be performed to identify predictors of treatment outcomes, including AF. Results and conclusions will be presented.

IDENTIFYING FACTORS ASSOCIATED WITH RESISTANCE TO DARBEPOETIN IN CHRONIC HEMODIALYSIS PATIENTS (A3) Nathan Votroubek, Heather Nyman, Alfred Cheung, Srini Beddhu, Brad Baird. University of Utah Hospitals and Clinics, Salt Lake City, UT (nathan.votroubek@hsc.utah.edu) IRB approval received. Anemia is pervasive in chronic hemodialysis patients. Darbepoetin, an erythropoiesis stimulating agent, is commonly used to treat anemia in this population. Recent data have suggested a link between increased doses of erythropoiesis stimulating agents and increased risk of cardiovascular events. The objective of this study was to evaluate the relationship between clinical factors and darbepoetin dose requirements in chronic hemodialysis patients. In this prospective, cross sectional study, 20 adult chronic hemodialysis patients requiring either 0.45 micrograms per kilogram per week of darbepoetin or greater than1.5 micrograms per kilogram per week of darbepoetin were enrolled. Patients with known causes of increased darbepoetin requirements were excluded from enrollment. This included patients with iron deficiency, hemolytic anemia, cancer and chronic bleeding. Laboratory tests, a physical exam, patient interview, and a medication history were conducted for each patient monthly for 4 months. An analysis was conducted to determine if an association exists between any of these factors and resistance to darbepoetin. Results and conclusions will be presented.

PILOT PROJECT FOR A PHARMACY-MANAGED HEART FAILURE MEDICATION EDUCATION AND DISCHARGE INSTRUCTION PROGAM (A3), Bruce Warden, John Mackay. Oregon Health & Science University, Portland, OR (wardenb@ohsu.edu) IRB approval received. The quality improvement project objective was to determine if pharmacists involvement in the delivery of medication education and discharge instructions at the time of discharge can increase The Joint Commission Core Measures (discharge instructions, ACEI/ARB prescribing at discharge) to exceed the UHC targets and reduce heart failure readmission rates at our institution. All patients on the cardiology unit with left ventricular systolic dysfunction admitted for heart failure exacerbation as their primary diagnosis were included. The pharmacist coordinated with the primary team and performed medication reconciliation. Both initially and at discharge, the pharmacist provided verbal and written education on heart failure pathophysiology, activity level, diet, medications, weight monitoring, what to do if symptoms worsen and follow-up appointments. A customized medication list with appropriate follow-up and contact information was given upon discharge. During the hospitalization, the pharmacist assisted with medication selection, dosing and monitoring parameters. All care was documented in a consult note within the EHR. Patient satisfaction data was collected at discharge and will be analyzed for project improvement. The pharmacist also provided telephone follow-up at one week and one month intervals following discharge. Time involvement and the

number and type of pharmacy interventions were recorded during the duration of the project. Results and conclusions will be presented.

RETROSPECTIVE ANALYSIS OF SAFETY AND EFFECTIVENESS OF ENDOTHELIN RECEPTOR ANTAGONISTS FOR TREATMENT OF PULMONARY ARTERIAL HYPERTENSION (A3). Heather Wong. UCSF Medical Center, San Francisco, CA (heather.wong@ucsf.edu) IRB approved. Endothelin Receptor Antagonists (ERAs) like bosentan and ambrisentan are commonly used to treat Pulmonary Arterial Hypertension (PAH) but are available on a limited distribution basis due to the potential for fetal harm and hepatotoxicity. The study objective was to evaluate the safe use of ERAs as determined by Risk Evaluation and Mitigation Strategies (REMS) criteria for baseline and monthly liver and pregnancy tests and to determine correlations with clinical improvements in PAH symptoms measured by New York Heart Association (NYHA) functional class. Inclusion criteria were age greater than 18 years, diagnosis of PAH, and initiation of ERA at UCSF Medical Center inpatient or outpatient between January 1, 2008 and December 31, 2010. Patients were excluded if they were initiated on an ERA before the study period or if they began a study drug outside of UCSF Medical Center. A total of 108 patients were initiated on bosentan and 35 on ambrisentan during the study period. Results and conclusions will be presented.

INPATIENT ACE-INHIBITOR UPTITRATION AND LENGTH OF HOSPITALIZATION AMONG PATIENTS ADMITTED FOR ACUTE DECOMPENSATED HEARTFAILURE (A3) Shirley Wong, Rebecca Cheung, Jun Chiong. Loma Linda University Medical Center, Loma Linda, CA (slwong@llu.edu). IRB approved. The objective of this study is to assess the impact of inpatient ACE-inhibitor uptitration on hospital length of stay and readmission rates. The recent HFSA 2010 practice guidelines recommend that all patients with reduced LVEF be discharged at near optimal doses of ACE-inhibitors. At these doses, ACE-inhibitors beneficially alter the progression of heart failure, prevent readmissions and reduce mortality. Unfortunately, only 54% of patients who are candidates for an ACE-inhibitor are actually prescribed an ACE-inhibitor at discharge. Outpatient efforts to manage chronic heart failure therapy are only marginally successful. Currently, research on the outcomes of inpatient ACE-inhibitor uptitration is limited. This is a retrospective, single-centered, observational study of acute decompensated heart failure (ADHF) patients admitted to Loma Linda University from January 1 to June 30, 2010. Patients were included in the study if they were 18 years and older with an EF< 40% or diagnosed systolic heart failure, and on a home ACE-inhibitor or received one during hospitalization. Patients were excluded if they were allergic or intolerant to an ACE-inhibitor. Length of hospitalization and readmission will be collected from medical records and analyzed with ANOVA. Results and conclusions will be discussed.

IMPACT OF CYP2C9 AND VKORC1 POLYMORPHISMS ON WARFARIN DOSAGE REQUIREMENTS IN AN ETHNICALLY DIVERSE POPULATION (A3). Brian Yamada. University of Southern California School of Pharmacy, Los Angeles, CA (brian.yamada@usc.edu) IRB approved. The objective of this study is to determine the frequency of polymorphisms in Cytochrome P450 2C9 (CYP2C9 and Vitamin K Epoxide Reductase Complex 1 (VKORC1) in an ethnically diverse population and to relate this information to average warfarin dose requirements (AvgWDR). This is a retrospective study involving patients from two pharmacist-managed anticoagulation clinics in Los Angeles. Inclusion criteria included age greater than 18 years and warfarin therapy for at least fourteen days. Exclusion criteria excluded patients who are not followed by an anticoagulation clinic, who do not have relevant data readily available, or who have a prognosis that predicted a poor outcome. Following informed consent, blood samples will be collected and genotyped for CYP2C9 and VKORC1 polymorphisms. Relevant patient data including primary indication for warfarin therapy, co-morbid conditions, ethnicity, age, concomitant medications, and AvgWDR will be collected and analyzed. Additionally, observed AvgWDR will be compared to predicted warfarin dose requirements using a well-referenced warfarin dosing calculator available on-line. Results and conclusions will be presented.

INCIDENCE OF UPPER AND LOWER EXTREMITY VEIN THROMBOSIS FOLLOWING RECOMBINANT ACTIVATED FACTOR VII ADMINISTRATION: A RETROSPECTIVE STUDY IN PATIENTS UNDERGOING CARDIAC SURGERY (A3), Olga Zaitseva, Kaman Chung, Nicola DAttellis. Cedars-Sinai Medical Center, Los Angeles, CA (olga.zaitseva@cshs.org) IRB approved. The objective was to investigate the safety of offlabel use of rFVIIa in patients with refractory bleeding during or after cardiac surgery. All patients who underwent cardiac surgery and received at least one dose of rFVIIa from March 2007 through March 2009 were included in the study. Patients were selected from a pharmacy medication database that was then cross-referenced with the surgical records. Pre-operative, intra-operative, and post-operative data were collected via chart reviews. The primary outcome measure evaluated was the overall incidence of upper and lower extremity vein thrombosis within seven days of rFVIIa administration. Secondary outcome measures included the incidence of thrombosis in relation to rFVIIa dose, patient co-morbidities, incidence of MI, and the appropriateness of DVT prophylaxis after the surgery. Data is currently being collected and the results and conclusions will be presented. Once data has been analyzed, the dosing of rFVIIa sufficient to reverse bleeding and minimizing risk for clotting can be evaluated and contribute to implementing an institutional guideline on the use of rFVIIa in this patient population.

A4 GastrointestinalCare

EVALUATION OF PROTON PUMP INHIBITOR USE AND IMPLEMENTATION OF STRATEGIES TO REDUCE USE WITHOUT INDICATION (A4). David Ackiss. Central Washington Hospital, Wenatchee, WA (david.ackiss@cwhs.com) IRB approved. The objective of this project is to determine the overall rate of proton pump inhibitor (PPI) use and develop a plan to reduce inappropriate use of PPIs for stress ulcer prophylaxis. The electronic medical record was used to identify patients with orders for PPIs over a thirty day period. The indication for the PPI was then ascertained and classified. The following information was also collected when available: reason for admission, relevant outpatient medications, relevant inpatient medications, medical diagnoses, relevant laboratory values, pertinent information from history and physical, pertinent information from progress notes, and demographic parameters. Appropriate indications are based on the agents package insert, published indications by the United States Food and Drug Administration, and clinical guidelines. Use is also considered appropriate if the patient was taking a PPI prior to admission to the hospital. Use is considered inappropriate if the patient has no approved indication for PPI therapy. Education will be presented to providers and information will be made available in the hospitals pharmacy newsletter about appropriate PPI use. After the initial review period, the investigators will conduct a second review of patients who have orders for PPIs. The rate of inappropriate use of PPIs will be analyzed and compared. Results and conclusions will be presented.

EXTENDED INFUSION N-ACETYLCYSTEINE: EFFECTS ON LIVER ENZYMES IN PATIENTS WITH ACETAMINOPHEN TOXICITY (ENAC STUDY) (A4). Francisca Akoh. Jamie King. Michelle Manley. University Medical Center, Las Vegas, NV (Francisca.Akoh@umcsn.com) IRB approved. Prolonged infusion of N-acetylcysteine is commonly used in severe cases of acetaminophen toxicity. Length of therapy is generally guided by abnormalities in liver enzymes. Studies have yielded conflicting results on the efficacy of this practice, and there are no guidelines on duration of therapy or dosing. The objective of this study is to determine the time until resolution of elevated liver enzymes in patients presenting with acetaminophen toxicity who were treated with an extended infusion of Nacetylcysteine (> 21 hours). This is a retrospective study evaluating patients treated from June 2006 to June 2010. Patients 18 years of age and older were identified through the pharmacy database and included if they received more than 300mg/kg of N-acetylcysteine infused over a period longer than 21 hours. At least 2 sets of liver enzymes were required for inclusion. Data will be analyzed for effects on liver enzymes and INR. Results and conclusions will be presented.

A PROSPECTIVE COMPARISON OF COMMERCIAL STANDARDIZED, PARENTERAL NUTRITION FORMULATIONS TO INDIVIDUALIZED PARENTERAL NUTRITION FORMULATIONS (A4), Jennifer Baggs, C. Rollins. University of Arizona, Tucson, AZ (baggs@pharmacy.arizona.edu) IRB approved. The use of standardized, commercially-available PN products in lieu of customized PN solutions has become of particular interest, especially during times in which limitations in market supplies of intravenous (IV) macronutrients (i.e. amino acid solutions) may limit the feasibility of customized PN administration. Proposed benefits of standardized PN include decreased risk of errors, cost-effectiveness related to decreased labor costs, and decreased potential for microbiological contamination, but have not been clearly demonstrated in clinical trials. The potential disadvantage of standardized PN is the inability of available products to meet the needs of a diverse patient population. Therefore, the purpose of this study is to evaluate the appropriateness and safety of a standardized, commercially-available PN formulation as compared to an individualized PN formulation in hospitalized patients. In this prospective observational analysis, medical records of all adult patients receiving standardized commercially-available or individualized PN who meet study criteria will be evaluated. Data collection will include patient demographics and nutrition support data. The results and conclusions will be presented.

A RETROSPECTIVE STUDY TO COMPARE STANDARDIZED VS. INDIVIDUALIZED PARENTERAL NUTRITION FORMULATIONS IN CRITICALLY ILL PATIENTS (A4),Sara Bliss, University of Arizona, Tucson, AZ (bliss@pharmacy.arizona.edu) IRB approved. The purpose of the study is to compare the ability of standardized, commercially available parenteral nutrition (PN) formulations and individualized PN formulations to meet nutrient requirements in critically ill patients. A retrospective chart review of up to 100 patients who received individualized PN while in the surgical/trauma or medical ICUs between January 2005 and December 2009 will be conducted. A comparison will be done to determine the ability of standardized, commercially available PN products to fulfill patient-specific caloric, protein, and fluid requirements within 25% of estimated goals. Each component will be analyzed individually. Results and conclusions will be presented.

DEVELOPMENT AND IMPLEMENTATION OF STRESS ULCER PROPHYLAXIS GUIDELINES (A4), Mary Esquibel, Kim Neff, Denis McCarthy, Beverly Dinsdale. NM VA Health Care Center, Albuquerque, NM (Mary.Esquibel@va.gov) IRB approval not needed-no human subject data. The practice of stress ulcer prophylaxis has become increasingly more common. Although the ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis are available, many patients are inappropriately initiated on stress ulcer prophylaxis. Results of a residency project conducted last year suggest that stress ulcer prophylaxis is also being inappropriately used at the New Mexico Veterans Affairs Health Care System. The objective of this project was to develop and implement local guidelines to help guide providers in the appropriate use of stress ulcer prophylaxis. After an extensive literature search, and in collaboration with the Chief of Gastroenterology, local guidelines were developed. The proposed guidelines were presented and approved by the local Pharmacy and Therapeutics Committee. A computerized template is currently being developed as a resource for providers to use upon admission of a patient to help guide them in determining if stress ulcer prophylaxis is warranted. Inservices will be provided to educate providers on the appropriate use of stress ulcer prophylaxis, the newly developed guidelines, and the use of the computerized template. The development and implementation process of the local guidelines will be discussed.

APPROPRIATE USE OF STRESS ULCER PROPHYLAXIS IN THE MEDICAL PATIENT (A4): A RETROSPECTIVE STUDY. Catherine Gannon. Anthony Scriver. Joseph Forrester. The Medical Center of Aurora, Aurora, CO (Catherine.Gannon@healthONEcares.com) IRB approved. The objective of the study was to determine appropriateness of stress ulcer prophylaxis in patients on a medical floor. Those discharged on continued therapy for stress ulcer prophylaxis were also identified. The study consisted of two different one month phases. The electronic medical record system was used to collect data and determine appropriate use of stress ulcer prophylaxis in both phases. Following phase 1, education was provided to physicians and pharmacists on indentifying appropriate criteria for stress ulcer prophylaxis. After education was provided, data for phase 2 was collected. Results of appropriate prescribing between the two phases were then compared. Inclusion criteria included any adult patient that received either a proton pump inhibitor or histamine H2 blocker. Those taking a proton pump inhibitor or histamine H2 blocker prior to hospital admission, diagnosis of gastroesophageal reflux disease, or active GI bleed or ulcer were excluded. The ASHP therapeutic guidelines on stress ulcer prophylaxis were used to determine the appropriate criteria for the use of stress ulcer prophylaxis. Results and conclusions will be presented.

EFFECT OF PHARMACIST-IMPLEMENTED USE CRITERIA ON THE INPATIENT UTILIZATION OF PROTON PUMP INHIBITORS AND STRESS ULCER PROPHYLAXIS (A4). Susan Krueger. Mercy San Juan Medical Center, Carmichael, CA (Susan.Krueger@chw.edu) IRB approved. The study objective is to determine if implementation of a new stress ulcer prophylaxis (SUP) policy will improve appropriate management of SUP in the facility. The policy allows pharmacists to complete therapeutic interchanges or discontinue inappropriate medications based on guidelines. The guidelines designate famotidine as the facility medication of choice for stress ulcer prophylaxis and provide criteria for the appropriate use of proton pump inhibitors. The study includes two periods, one before and one following the implementation of the policy. Each study period is three and a half months in duration. Patients will meet inclusion criteria if they are over 18, have a length of stay of at least three days and receive at least one dose of acid-suppressing medication (including proton pump inhibitors, H2 receptor antagonists and sucralfate). Data collection will include drug class used, indication, patients with positive C. difficile tests, pharmacy interventions, patients discharged on acidsuppression therapy and class of drug on discharge orders. All patients with positive C.difficile toxin tests in both groups will be assessed for use of acid suppression therapy. Chi square analysis will be used to compare appropriate use before and after implementation of the policy. Results and conclusions will be presented.

LOW VOLUME TPN SOLUTIONS IN ICU PATIENTS (A4), Denise Kwong, April Fong, Jeffrey Inokuchi. Stanford Hospital and Clinics, Palo Alto, CA (DKwong@stanfordmed.org) IRB approved. Formulations for Total Parenteral Nutrition (TPN) with different final volumes are compounded using commercially available amino acid, dextrose, and lipid solutions depending on the stock solution concentration for each macronutrient. For patients with fluid restrictions, maximum concentration TPN is traditionally compounded by reducing caloric intake and/or varying macronutrient composition. Alternatively, more concentrated stock solutions could be used to compound a low volume TPN bag that is isocaloric without compromising the compositional ratio for each ingredient. Minimizing incidental volume found within a TPN solution could potentially be beneficial for critically ill patients in the Intensive Care Unit (ICU) who may be volume restricted. The objective of this study is to see if the amount of fluid given through TPN affects overall patient outcome. Study participant eligibility criteria include patients admitted to the ICU who are indicated and prescribed TPN. Exclusion criteria include patients who do not have central venous access. Study participants are initiated on low volume TPN per protocol. This study involves a chart review of participants who received low volume TPN versus traditional and high concentration TPN compounded with

OUTCOMES OF PARENTERAL NUTRITIONASSOCIATED CHOLESTASIS IN CHILDREN: A RETROSPECTIVE ANALYSIS (A4). Christian Larsen, Mark MacKay. Primary Childrens Medical Center, Salt Lake City, UT (christian.larsen2@imail.org) IRB approved. The objective of this retrospective analysis is to determine the outcomes (i.e., morbidity, mortality) of parenteral nutrition-associated cholestasis (PNAC) in pediatric patients receiving long-term ( 2 weeks) total parenteral nutrition (TPN) in a large, non-profit, community-owned pediatric hospital. This retrospective, observational study will utilize data obtained from the electronic database of a large pediatric hospital. Pediatric patients ( 18 y/o) receiving TPN 2 weeks with an average conjugated bilirubin concentration 2 mg/dL between March 2007 and November 2010 will be eligible for inclusion. Patients receiving TPN < 2 weeks or patients diagnosed with cholestasis prior to initiating TPN therapy will be excluded. The primary outcome measure of this analysis is to determine the incidence of morbidity (e.g., liver failure, transplant) and mortality related to an average conjugated bilirubin concentration 2 mg/dL in pediatric patients with PNAC. In addition, the following secondary outcome measures will be explored: disease states/conditions associated with increased conjugated bilirubin levels; conjugated bilirubin levels at which there an increase in morbidity/mortality; relationship between

age and conjugated bilirubin levels; correlation between glucose infusion, fat dosage, and time on TPN with conjugated bilirubin levels; and the role of ursodiol in the treatment of cholestasis. Results and conclusions will be presented.

EVALUATION OF BRAND TO GENERIC TACROLIMUS CONVERSION IN AN INTEGRATED HEALTH CARE SYSTEM (A4). Lynda Nguyen. Michele Spence. Kaiser Permanente Drug Information Services, Downey, CA (Lynda.M.Nguyen@kp.org) IRB approved. Kaiser Permanente renal, bone marrow, and heart transplant patients were converted to generic (Sandoz) tacrolimus starting in October 2010. Since tacrolimus has a narrow therapeutic index, physicians may be concerned about converting patients due to any difference in bioequivalence. This project is a retrospective analysis to evaluate the conversion from brand to generic tacrolimus. The study objectives were to compare tacrolimus trough levels and serum creatinine before and after the conversion, to examine the rate of patients switching back to brand tacrolimus after the conversion, and to report cost savings. Patients served as their own controls for the comparison of tacrolimus trough and serum creatinine levels from up to six months before the conversion and three months after the conversion. The study period was 9 months. Inclusion criteria were: continuous enrollment in Kaiser Permanente during the study period; at least 6 months of continuous tacrolimus therapy prior to the conversion; a minimum of three months of follow-up after the conversion; at least two stable tacrolimus troughs within six months prior to the conversion; and a diagnosis of renal, bone marrow, or heart transplant. The serum creatinine and troughs were compared using paired t-tests. Results and conclusions will be presented.

standard stock solutions. The primary outcome is volume savings. Other monitoring parameters include nutritional status, TPN rate, total fluids, duration of TPN, nitrogen balance, daily delivered calories broken down by component, and adverse effects from TPN. Results and conclusions will be presented.

A5 NeuroPsychorPain ManagementAgents

THE IMPACT OF ANTIDEPRESSANT MEDICATIONS ON THE DAILY OPIOID DOSE REQUIREMENT IN CHRONIC NON MALIGNANT PAIN. (A5) Pietra Adams. Steve Echaves. Debbie Lu. Tristan Lindfelt. Wilson Ly. Linda Banares. Paul Perry. Touro University, Vallejo, CA (pietra.adams@tu.edu) IRB Approval Exempt. It is hypothesized that patients with chronic pain require a lower daily dose of an opioid if they are concomitantly receiving a tricyclic antidepressant (TCA), a serotonin norepinephrine reuptake inhibitor (SNRI), or a selective serotonin reuptake inhibitor (SSRI). The study population consists of patients diagnosed with chronic pain syndrome treated between 1/1/2008 and 12/31/10 via a medication agreement at a San Francisco General Hospital primary care clinic. The primary endpoint is the average daily opioid dose between two groups of patients: 1) those receiving an opioid plus a TCA, SSRI, or SNRI, versus 2) those receiving only an opioid. The secondary endpoints are the differences in the mean and median of opioid doses between these two groups, stratified as low, medium, high, and very high. Student t-test will be utilized to assess whether the difference between the mean opioid doses of the two groups is significant with an alpha of 0.05. A 2 x 4 contingency table analysis will be used to contrast the proportion of patients on four opioid dose categories. Multivariate linear regression analysis will be utilized to determine the association between TCA/SSRI/SNRI utilization and average daily opioid dose and to assess whether the concomitant use of these agents affect the opioid dose escalations. Results of the study are pending.

EVALUATION OF RELATIONSHIP BETWEEN AGE OF PARKINSON'S DISEASE ONSET AND LEVODOPA DOSE REQUIRED FOR SYMPTOMATIC BENEFIT (A6), Evan Baker, Lisa Proffitt, Linda Poon, Graham Glass. VA Medical Center, San Francisco, CA (evan.baker@va.gov) IRB approved. Levodopa is the most effective medication for treating the motor symptoms of Parkinson's Disease (PD). The goal of this study is to determine if a relationship exists between the age of onset of PD and the dosage of levodopa required for initial improvement of motor symptoms. Approximately one hundred patients from a previous study conducted at the San Francisco Veterans Affairs Medical Center were included in this study. Patients were stratified into 2 groups: monotherapy (levodopa was the only medication for PD) or adjunct therapy (levodopa was added to an existing PD medication regimen). A retrospective chart review was conducted. Data collection included age and date of PD onset, date levodopa therapy initiated, date symptom improvement first reported and levodopa dose, and side effects reported during levodopa therapy. Mean dosage of levodopa that provided an initial improvement in motor symptoms will be calculated for each age group, and either a t test or ANOVA will be used to determine if significant differences exist between mean dosages for each age group. The results and conclusions will be discussed.

ADHERENCE TO SELECTIVE SEROTONIN REUPTAKE INHIBITORS IN IRAQ AND AFGHANISTAN VETERANS WITH MENTAL HEALTH DISORDERS(A5), Andrew Barrett. Phoenix VA Medical Center, Phoenix, AZ (Andrew.Barrett@va.gov) IRB approved. The study objective is to evaluate the benefit of clinical pharmacy intervention on SSRI adherence rates in veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). In this comparative, retrospective, chart-based review, OEF/OIF veterans who were prescribed and received at least one SSRI between January 1, 2009 and December 31,2009 for the treatment of PTSD or other anxiety disorders, major depression, or adjustment disorder were included. Veterans who were receiving concomitant care outside the Veterans Affairs system or who had bipolar disorder or psychotic disorders were excluded. Subjects were grouped based on whether or not clinical pharmacy services were provided. Adherence rates were calculated using the medication possession ratio (MPR) and differences between groups were evaluated with the Chi-square test. Results and conclusions will be presented.

STANDARDIZING TREATMENT WITH LITHIUM THERAPY IN A 33 BED INPATIENT PSYCHIATRIC UNIT BY IMPLEMENTING A PHARMACY LITHIUM PROTOCOL (A5), Tyson Bigelow, Katie Chiu. McKay Dee Hospital, Ogden, UT (Tyson.Bigelow@imail.org) IRB approved. Bipolar disorder is a severe chronic psychiatric disorder and is associated with a significant social and economic burden. Lithium therapy has been a mainstay in treating bipolar disorder for decades because of its proven efficacy. Within the 33 bed McKay Dee Hospital Behavioral Health Unit, lithium therapy is used extensively for treating bipolar disorder and augmenting major depressive disorder. However, much variability has existed regarding lithium utilization due to weaknesses in continuity of care resulting from staffing variability, and due to lack of standardization regarding lithium use. This has often resulted in variability regarding lithium dosing, monitoring, and assessing for drug interactions. The purpose of this study was to standardize the way in which lithium therapy is initiated and monitored in a 33 bed psychiatric unit by implementing a pharmacy lithium dosing protocol, and to assess the efficacy of this protocol. This prospective analysis assessed the efficacy of the lithium protocol by analyzing the percentage of patients with serum lithium levels within therapeutic range on day four of therapy. These results were compared to the percentage of therapeutic lithium levels in non protocol patients treated with lithium therapy since October 1, 2010. The lithium protocol was initiated on January 7, 2011. Patients included for analysis were those 18 years of age or

older admitted to the behavioral health unit for treatment of bipolar disorder, major depressive disorder, or augmentation with lithium. Patients excluded from analysis were those with renal dysfunction, severe debilitation, dehydration, or sodium depletion. The primary endpoint of the study was the percentage of patients with therapeutic serum lithium levels at goal on day four of therapy. These results were also compared to the percentage of therapeutic day four lithium levels in non protocol patients treated since October 1, 2010. Secondary endpoints included utilization of the protocol by physicians, the number of patients to whom drugs known to interact with lithium were administered or prescribed, and the percentage of non protocol patients that received different initial lithium doses than would have been calculated by pharmacy. Results and conclusions will be presented.

DEVELOPMENT AND IMPLEMENTATION OF A KETAMINE INFUSION PROTOCOL IN POST OPERATIVE PAIN MANAGEMENT (A5). Dana Bowers. Julie McCoy. Jillian Myers. Providence St. Peter Hospital, Olympia, WA (dana.bowers@providence.org) Institutional Privacy Board approval pending. Ketamine, a NMDA (N methyl D asparatate) receptor antagonist, may improve post operative pain management and reduce adverse effects associated with opioid use. Acute, post operative pain management with opioids may be limited by adverse effects such as sedation, respiratory depression, nausea, and vomiting. Ketamine, a general anesthetic agent, utilized at low doses exerts analgesic or antihyperalgesic effects. When used in combination with other opioids, ketamine has been associated with better pain relief and an opioid sparing effect. The primary objective of this project was to develop, implement, and evaluate post operative pain management with a ketamine infusion protocol. Medical records of patients included in the protocol were retrospectively reviewed for opioid use, length of stay, components of pain management, and adverse effects. Results and conclusions will be presented.

EFFECTS OF TRAZODONE ON THE STANDARDIZED FIELD SOBRIETY TESTS (A5). Quang Bui. Eric Ip. Mitchell Barnett. Roger Wright. Melissa Serino. Amin Kazani. Paul Perry. Touro University, Vallejo, CA (quang.bui@tu.edu) IRB approved. Utilizing validated assessment tools that include oral fluid test, blood test, breath sample, driver simulators, and closed driving courses, the National Roadside Survey concludes that drugs besides alcohol can significantly impair driving. The standardized field sobriety test (SFST) has not been used to assess driving performance effects of central nervous depressants, such as trazodone, a commonly prescribed agent for depression and insomnia. The study objective is to investigate the effects of trazodone on the SFST. It was hypothesized that the two hour post exposure SFST response to trazodone is similar to a 0.08% blood alcohol concentration (BAC). A randomized, double-blind, controlled study of 45 healthy subjects was conducted. Subjects were assigned in a 2:1 ratio to receive either a one time oral dose of trazodone 100mg or acetaminophen 650mg respectively. Eligible participants included males and females not currently taking any medications known to cause psychomotor effects. Three common components of the SFST, the horizontal gaze nystagmus, the walk and turn, and one leg stand, were administered. Performance assessments before and two hour post trazodone or acetaminophen were collected and analyzed. The primary outcome is the proportion of subjects who passed the SFST. Results will also be contrasted to those of the National Highway Traffic

Safety administration effects of 0.08% BAC. Results and conclusions will be presented.

EFFECTS OF ANTIPSYCHOTICS ON INCIDENCE RATES OF THE DIFFERENT CARDIOMETABOLIC PARAMETERS (A5). Suk Chan.Sarah Popish.Amy Furman.Kristina Ward. Dept of Veterans Affairs, Northern California Healthcare System. Martinez, CA(SukChan@VA.gov) IRB approved. The primary objective of this study is to compare incidences of abnormal cardiometabolic parameters between patients on various antipsychotic regimens; secondarily, we will examine the monitoring rate of cardiometabolic parameters in these patients. This study is a retrospective analysis of electronic data extracted from the Veteran Integrated Service Networks Pharmacy Benefits Management Data Mart. Cardiometabolic parameters examined are BMI, BP, HDL, triglyceride, and plasma glucose or HgbA1C. Patients must be newly started with at least one active antipsychotic prescription between January 1, 2003 and January 1, 2009, have a medication procession ratio above 80 percent, have baseline values of studied parameters within one year prior to antipsychotic initiation, and have follow up values obtained at least 8 weeks to 1 year after antipsychotic initiation. Patients with missing values of studied parameters as described above are considered nonmonitored. Patients with a previous record of antipsychotic use are excluded in this study. We will stratify data by antipsychotics prescribed, antipsychotic regimens, concomitant medications impacting cardiometabolic parameters, and monitoring rate

to determine if there are significant differences between these parameters. Statistical analysis will be performed using the computer program, Sigma Stat. Results and conclusions will be presented.

IMPLEMENTATION OF AN ORDER SET TO INCREASE APPROPRIATE PRESCRIBING OF TRANSDERMAL FENTANYL (A5). Karla Choy, Dan Neal. Veterans Affairs Roseburg Healthcare System, Roseburg, OR (karla.choy@va.gov) IRB approval pending. Transdermal fentanyl has specific criteria for use set forth by the Veterans Health Administration Pharmacy Benefits Management Service and the Medical Advisory Panel. The objective of this study is to increase appropriate prescribing of transdermal fentanyl through implementation of an electronic order set. A drug utilization evaluation was performed via retrospective chart review for the period of February 2010 to May 2010. During this time, thirteen of twenty four patients initiated on transdermal fentanyl at our institution did not meet criteria for use. In attempt to resolve this issue, an order set that guides providers through these criteria was implemented in our computerized provider order entry system. This order set also records data entered by the provider on criteria for use that the patient has met. Data is currently being collected to gauge the efficacy of this order set, and any missing data will be obtained through retrospective chart review. A follow up drug utilization evaluation will be performed to assess for any change in the rate of appropriate prescribing after implementation of the order set. The results are pending and will be discussed.

CONTINUOUS FEMORAL NERVE BLOCK VERSUS SINGLE-INJECTION FEMORAL NERVE BLOCK ON POST OPERATIVE PAIN AND REHABILITATION AFTER TOTAL KNEE ARTHROPLASTY (A5). Mo Cui. Sharp Healthcare System, San Diego, CA (mo.cui@sharp.com) IRB approved. The study objective is to compare various aspects of post operative patient care at two San Diego community hospitals, using continuous femoral nerve blocks (cFNB) which is the standard of care at Sharp Coronado Hospital (SCOR), and single injection femoral nerve block (sFNB), which is the standard of care at Sharp Memorial Hospital (SMH), in the management of patients after unilateral total knee arthroplasty (TKA). 50 consecutive patients of two orthopedic surgeons of Sharp Healthcare, who are undergoing unilateral primary TKA at either SCOR or SMH over a period of 5 months, will be studied. Post operative data will include visual analog pain scores (VAS, at rest and during activity), amount of pain medications used post operatively (daily and total), range of leg motion, distance ambulated, observations of nausea, vomiting, constipation, length of hospital stay, quadriceps weakness, major falls, curb and stairs, patient demographics, and complications. Inclusion criteria includes age greater than 18 years, primary TKA and use of femoral nerve block. Exclusion criteria includes revision TKA, allergies to any of the protocol medications and opioid tolerant patients. Results and conclusions will be presented.

EFFECT OF CONTINUOUS INFUSION KETOROLAC TROMETHAMINE ON PAIN PERCEPTION AND NARCOTIC USE (A5). Caitlin Downer. Andrew Lowe. Arrowhead Regional Medical Center, Colton, CA (Caitlin.Downer@armc.sbcounty.gov) IRB approved. The study objective was to investigate the effect of a low dose continuous infusion of ketorolac tromethamine on pain perception and opiate use. Surgical patients between the ages of 18 and 60 were included in the study. Patients were excluded if they had coexisting medical conditions. Each patient was randomized to receive a continuous infusion of ketorolac tromethamine 120 mg in 500 ml normal saline, or normal saline, each infusing at 10 ml/hr. Continuous infusion was started at the end of the surgical procedure. Each patient was started on PCA with morphine or hydromorphone without a basal rate. Bolus doses of opioids were ordered for breakthrough pain. Pain was assessed daily using a visual analogue scale. The number of times the patients pressed the PCA button and the number of doses administered were recorded. PCA was discontinued after 48 hours and oral analgesia was started. Results and conclusions will be presented.

RETROSPECTIVE ANALYSIS OF THE USE OF DEXMEDETOMIDINE IN THE MANAGEMENT OF ALCOHOL WITHDRAWAL (A5). Anna Gandelman. Swedish Medical Center, Seattle, WA (anna.gandelman@swedish.org) IRB approval pending. The objective of this retrospective study was to characterize the use of dexmedetomidine in patients admitted to the intensive care unit alcohol withdrawal treatment. Primary benchmarks were rates of intubation, use of restraints, and the number of days in the ICU. Secondary benchmarks included mean RASS or CIWA scales, and use of additional sedatives as needed to further control symptoms. Inclusion criteria were patients admitted to Swedish Medical Center between November 2008 and November 2010 with alcohol withdrawal (diagnosis code: 291). Patients were included only if they received dexmedetomidine as an adjunct to manage alcohol withdrawal symptoms in addition to lorazepam infusion or lorazepam as needed (per Swedish alcohol withdrawal protocol). Patients were excluded if they received midazolam concomitantly within the time period of dexmedetomidine or lorazepam. Results and conclusions will be presented.

A RETROSPECTIVE CHART REVIEW EVALUATING THE OUTCOMES OF COMBINATION THERAPY IN PATIENTS WITH POST-TRAUMATIC STRESS DISORDER (A5), Melat Garedew, Nahed Bahlawan. Naval Hospital Camp Pendleton, Oceanside, CA (mgaredew@ucsd.edu) IRB pending. PTSD is a mental disorder with complex set of symptoms. Treatment of PTSD patients may involve multiple psychotherapeutic and psychopharmacological approaches. Although SSRIs are considered an effective first line treatment in PTSD patients, there are certain sets of patients that do not respond to SSRIs alone. These treatment-resistant PTSD patients cannot be treated algorithmically. Hence combination therapy is favored in these patients. However, its important to note that undesirable side-effects from combination therapy may decrease tolerability leading to decreased adherence to medication regimens. The objective of this study is to evaluate the potential adverse outcomes of combination therapy with psychotropic drugs in PTSD patients. Study investigators will perform a retrospective electronic chart review of patients with PTSD and receiving treatment at the United States Marine Corps Wounded Warrior Battalion West Camp Pendleton. Results and conclusion will be presented.

AN EVALUATION OF THE EFFICACY AND SAFETY OF A FORMULARY CONVERSION FROM OXYCODONE CR TO ALTERNATIVE OPIOIDS (A5), Emilie Goldsberry, Kristina De Los Santos. Southern AZ VA Health-Care System, Tucson, AZ (emilie.goldsberry2@va.gov) IRB approved. The purpose of this study was to evaluate whether a pharmacist guided versus provider guided conversion from oxycodone CR to alternative opioid medications increased failure rates and examine the overall safety and efficacy of such a conversion. This was a historical prospective cohort study conducted by reviewing electronic medical records at the Southern AZ VA Health-Care System. The cohort included all patients converted from oxycodone CR to alternative opioid medications from September 2008 through May 2009. The primary outcome was a comparison of failure rates in pharmacist versus provider guided conversion from oxycodone CR to alternative opioid medications measured at six months following conversion. Secondary outcomes included observing the primary outcome by provider type, observing whether patients that did not fail were stabilized on a dose, determining conversion ratios used, evaluating reasons for discontinuation including adverse drug reactions, and determining the overall success rate of the conversion. The primary endpoint was compared using chi square analysis. Chi square analysis was also used to compare pharmacist versus physician and pharmacist versus nurse practitioner failure rates. Other secondary outcomes were observational and reported as rates or percentages. Results and conclusions will be presented.

ARE PROVIDERS DOCUMENTING THE EFFICACY OF ARIPIPRAZOLE FOR ADJUNCTIVE TREATMENT OF MAJOR DEPRESSIVE DISORDER AFTER 3 MONTHS OF TREATMENT? (A5). Michelle Gouker. VA Puget Sound Healthcare System, Seattle, WA (michelle.gouker2@va.gov) IRB not needed. The study objective is to determine whether patients that are receiving aripiprazole for adjunctive therapy for depression are being assessed after 12 weeks of therapy. Patients will be searched for retrospectively from 2008 to present in the VA Puget Sound Healthcare System. Patients will be included if they are taking aripiprazole </=15mg daily for the treatment of MDD and aripiprazole is being used as augmentation of an antidepressant (SSRI or SNRI). Exclusion criteria include a diagnosis of schizophrenia, schizo-affective disorder or bipolar disorder and if currently taking bupropion or quetiapine >/=150mg/day. The primary endpoint will be documentation of response in the medical chart note at or before 12 weeks after dose titration to a maximum aripiprazole dose of 15mg daily. Secondary endpoints will include the discontinuation rate in those subjects that are determined to non- responders at 12 weeks of treatment; number of patients found to be responders at 12 weeks after maximum dose in titration and the maximum dose used before discontinuation. Results and conclusions will be presented

ATYPICAL ANTIPSYCHOTIC POLYPHARMACY: ARE SAFETY AND ECONOMIC CONCERNS A REASON TO AVOID COMBINATION THERAPY (A5). Rebecca Graham, Jonathan Lacro, Josephine Tran. VA San Diego Healthcare System, San Diego, CA (rebecca.graham2@va.gov) IRB approved. The study objective was to compare the safety and cost of care in Veterans diagnosed with schizophrenia or schizoaffective disorder prescribed atypical antipsychotic monotherapy versus polypharmacy. A retrospective cohort database analysis of computerized medical records (October 2004 and August 2010) in our healthcare system was performed. Veterans receiving concurrent prescriptions for two different oral atypical antipsychotics were classified as receiving atypical polypharmacy. Demographic (age, sex, race, diagnosis), medication (drug name, dose, start and stop dates), safety (measures of new onset or abnormal changes in extrapyramidal symptoms, diabetes, hyperlipidemia, weight, and laboratory indices) and healthcare utilization data variables were collected. Our statistical plan includes performing regression analyses to determine differences between our Veteran groups. While we are in the process of data validation, the mean (SD) age of the Veterans is 55.3 (12.0) years, of whom the majority are male. The mean HbA1C and total cholesterol for the Veterans who received polypharmacy were 6.43% and 188.03 mg/dL respectively compared to 6.5% and 185.42 mg/dL for the Veterans who received monotherapy. Other data will be presented, but our robust dataset will allow us to describe the prevalence of and address the safety and

economic impact of atypical antipsychotic polypharmacy in our setting.

EFFECT OF BODY MASS INDEX ON ANALGESIC RESPONSE TO MORPHINE (A5). Karen Holmes. University Medical Center, Tucson, AZ (holmes@pharmacy.arizona.edu) IRB approved. The study objective was to determine if analgesic response following a single dose of intravenous morphine changes as a function of body mass index. This retrospective cohort study included patients who received a 4mg bolus dose of intravenous morphine as their first analgesic in the emergency department of a trauma center. Patients with chronic opioid use or alcohol/illicit drug abuse were excluded. Patients with known renal or hepatic disease were also excluded. One hundred consecutive patients in three body mass index categories were included: 18.5-29.9 kg/m2, 30-39.9 kg/m2, and >/=40 kg/m2. Initial pain scores and post-morphine pain scores were recorded from patients medical records. If significant differences are found, multiple regression analysis will be used to explore potential relationships between the analgesic response and patient specific factors such as age or sex. Results and conclusions will be presented.

CONVERSION FROM BRAND-NAME TO GENERIC CLOZAPINE IN VETERANS INTEGRATED SERVICE NETWORK 22 (A5). Thomas Hong, Kirby Lim, Monica Yee, and Wayman Lee. Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA (thomas.hong@va.gov) IRB approved. The study objective was to evaluate the effect and tolerability of a switch from brand-name to generic clozapine in a veteran population in Veterans Integrated Service Network 22 (VISN 22). This project was a retrospective chart review that included all patients in VISN 22 with a diagnosis of schizophrenia (with or without subtype) or schizoaffective disorder based on ICD-9-CM codes. Patients must have had a trial of brand-name clozapine for at least 8 weeks before conversion to generic clozapine in 2007. Data regarding clozapine regimens, concomitant psychiatric prescriptions, metabolic parameters, generic tolerability, psychiatric hospitalizations, and discontinuation rates was collected from patients charts for up to 1 year before and 1 year after the conversion from Clozaril to generic clozapine. Evaluating the generic conversion from brand to generic clozapine has never been conducted in a veteran population. This project aims to evaluate the use of generic clozapine and whether the switch to the generic clozapine affects clinical outcomes such as psychiatric admissions, discontinuation rates, and generic tolerability. Results from this study could change prescribing patterns within VISN 22 and improve patient care in this veteran population. Results and conclusions will be presented.

EVALUATION OF PATTERNS OF USAGE OF TRIPTANS IN THE MANAGEMENT OF HEADACHE IN THE VETERAN POPULATION WITH AND WITHOUT TRAUMATIC BRAIN INJURY (A5). Christopher Ivie, Sunita Dergalust, Layla Rakei-Milani,Viet-Huong Nguyen. Veterans Affairs Greater Los Angeles Healthcare Systems, Los Angeles, CA(Christopher.Ivie@va.gov) IRB approved. Headache is the most common complaint following head injury, and is commonly referred to as a post traumatic headache (PTH). Headache occurrence in these individuals has been estimated between 3090%. It has many of the clinical features that are characterized as primary headache syndrome. PTHs that arise from trauma injuries to the neck or from a whiplash type injury are commonly referred to as a Traumatic Brain Injury (TBI). Previous studies have shown that veterans with TBIs were more likely to have headache, features of migraine, more severe pain, more frequent headaches, post-traumatic stress disorder, and impaired sleep with nightmares. This issue is especially relevant to the veteran population because PTH is a very complicated and controversial disorder to treat and manage. Currently there is no standard of practice to treat such patients with PTH. Treatment becomes difficult because the balance between abortive therapies and prophylaxis becomes challenging due to risk of medication overuse. This study was a retrospective quality assurance chart review of patients who were on triptans from July 1, 2005 to June 30, 2009. Refill history was reviewed to assess the use of triptans

among veterans with and without TBI. The use of prophylactic medications was also assessed. Results and conclusions will be presented.

METABOLIC EVENTS WITH COMBINATION SECOND GENERATION ANTIPSYCHOTIC THERAPY IN A VETERAN POPULATION (A5) Chantrelle Johnson. Kristyn Straw. Southern Arizona VA Healthcare System, Tucson, AZ (chantrelle.johnson@va.gov) IRB approved The study objective was to determine if second generation antipsychotic (SGA) combination therapy results in an increase incidence or worsening of preexisting metabolic side effects in those treated with SGA combination therapy vs. SGA monotherapy in Veterans treated at Southern Arizona VA Healthcare System (SAVAHCS). This is a historical prospective cohort design, using a review of electronic medical records at SAVAHCS. Male and female Veterans, 18-89 years old are selected based on use of SGA combination therapy or SGA monotherapy between July 31, 2003 and July 31, 2009. Participants must have one SGA fill within 45 days of the first prescription.The combination therapy group will include Veterans taking two or more SGA longer than one month, followed from the time a second SGA is added to therapy for up to one year. The monotherapy group includes subjects who received a new prescription for a single SGA during the selection period. Subjects who meet these search criteria will have their electronic medical records reviewed to determine inclusion criteria. Exclusion criteria will include subjects that have documented dementia, treatment with first generation antipsychotics prior to the start of the study period, did not have a subsequent fill within 45 days, those transferred in from outside SAVAHCS already on a SGA, and/or subjects who

received a SGA from an outside source. Results and conclusions will be presented.

EVALUATION OF DELIRIUM RISK FACTORS IN PATIENTS FOLLOWING ABDOMINAL TRANSPLANT (A5), Pargol Khorsandi, Erin Knox, Vickie Yang. USC University Hospital, Los Angeles, CA (pkhorsan@usc.edu) IRB approval received. Post operative delirium is a serious life threatening complication that has been associated with increased morbidity, mortality, cost and hospital stay. Furthermore, post operative delirium is also associated with a need for long term care, a decline in functional status after discharge and higher rates of major complications. While studies have been conducted looking at delirium in a variety of post operative settings, few have specifically examined patients who have undergone abdominal transplants (liver, kidney or both). The aim of this study is to determine risk factors associated with the development of delirium in the immediate period post abdominal transplant. This study is a single site, retrospective chart review. The 150 most recent patients post abdominal transplant who met study criteria were screened. Subjects with delirium were compared to those without delirium using a logistic multivariate analysis model. The characteristics compared included age, gender, alcohol use, smoking history, positive blood cultures, intraoperative blood loss, intraoperative hypoxia, hyponatremia, hypoglycemia, number of offending agents received, post operative hypoxia, ICU length of stay, immunosuppressant drug level, requirement of additional steroid bolus, and ammonia level. Results and conclusions will be presented.

EFFICACY OF COMBINATION SECOND GENERATION ANTIPSYCHOTIC THERAPY IN A VETERAN POPULATION (A5). Eric Kowalek. Kristen Allison. Kristyn Straw. Alicia Newkirk. Southern Arizona VA, Tucson, AZ (Eric.Kowalek@va.gov) IRB approved. The objective of this study was to determine if second generation antipsychotic (SGA) combination therapy was more efficacious than SGA monotherapy in Veteran patients being treated at Southern Arizona VA Healthcare System (SAVAHCS). Male and female Veterans, 18 to 89 years old were selected based on use of SGA combination therapy or SGA monotherapy between July 31, 2003 and July 31, 2009. Participants must have had at least one SGA fill within 45 days of the first prescription to exclude those who were being tapered from one antipsychotic to another. The combination therapy group included Veterans taking two or more SGA for greater than one month. Participants in the combination therapy group were followed from the time a second SGA was added to their regimen up to one year. The monotherapy group included subjects who received a new prescription for a single SGA during the above time period. Subjects who met these search criteria had their electronic medical records reviewed to determine if inclusion criteria were met. Exclusion criteria included patients that had a documented diagnosis of dementia (ICD-9 code 294.8), had been treated with first generation antipsychotics prior to the start of the study period, did not have a subsequent fill within 45 days, those transferred in from outside SAVAHCS already on a SGA, and/or subjects who

received a SGA from an outside source. Results and conclusions are pending.

MEDICATION USE AND ADHERENCE PREVALENCE IN PATIENTS WITH POST TRAUMATIC STRESS DISORDER (A5), Jennifer Kryskalla, Joy Meier, Amy Furman. VA Northern California Health Care System, Martinez, CA, US (jennifer.kryskalla@va.gov) IRB approved. The study objective was to evaluate PTSD pharmacotherapy and the relationship between medication regimen and adherence. The Department of Veterans Affairs VISN 21 (the Veterans Integrated Service Network) includes health care systems in Northern Nevada, Northern and Central California, and the Pacific Islands. VISN 21 Veterans with a PTSD diagnosis and an active prescription for an SSRI, prazosin, atypical antipsychotic, benzodiazepine, or mood stabilizer were included in the study. Prescription data extracted from the VISN 21 PBM Data Mart were used to determine prescribed medication combinations and to calculate medication possession ratio (MPR), an indicator of medication adherence. Study metrics including number of prescriptions, MPR, and concomitant medications will be displayed in an online clinical dashboard for health care provider use. Statistical analysis will be performed using SigmaStat. Results and conclusions will be presented.

IMPACT OF INTRA-OPERATIVE ANTI-EMETIC ON THE USE OF RESCUE ANTI-EMETICS FOR POSTOPERATIVE NAUSEA AND VOMITING IN HIGH RISK SURGICAL PATIENTS (A5). Alexis Lee. Fountain Valley Regional Hospital, Fountain Valley, CA (alexis.lee@tenethealth.com) IRB not needed. Despite published consensus guidelines and effort advocated for the prevention of postoperative nausea and vomiting (PONV), it continues to be a common problem in surgical patients. Personal risk factors and anesthetic agents administered are associated with increased risks of PONV. The objective of this study is to assess adequacy of intraoperative interventions for the prevention of PONV at Fountain Valley Regional Hospital. A retrospective audit from April to December 2010 was conducted to collect patient specific risk factors, anesthetic agents, intraoperative antiemetic use and needs for rescue antiemetic postoperatively. The primary end point was to determine the incidence of PONV. Guideline compliance for the prevention and management of PONV by current anesthesiology practice was evaluated as a secondary end point. Surgical patients with risk factors and general anesthetic interventions are at high risk for PONV without appropriate antiemetic management. Results and conclusions will be presented.

IMPACT OF ANTIPSYCHOTIC REGIMENS AFTER PSYCHIATRIC HOSPITALIZATION (A5). Olivia Ng, Paul Lofholm, Mitchell Barnett. Touro University, Vallejo, CA. Marin Community Mental Health Clinic, Greenbrae, CA. (olivia.ng@tu.edu) IRB approved. The study objective was to determine if acute psychiatric hospitalization contributed to antipsychotic polypharmacy and if polypharmacy was addressed by the mental health provider in the outpatient follow-up visit. A retrospective review of patient data was done at Marin Community Mental Health clinic. Inclusion criteria included patients at least 18 years old with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder. Patients must have been discharged with at least one antipsychotic and seen by a mental health provider within 90 days of hospital discharge. A comparison of psychotropic medications prior to hospitalization and at discharge will be analyzed using a repeated measures ANOVA design. Results and conclusions will be presented.

RETROSPECTIVE CHART REVIEW OF THE EFFICACY AND TOLERABILITY OF ZONISAMIDE IN PATIENTS WITH NEUROPATHIC PAIN (A5). Elizabeth OBrien. Gifford Hoyer. SAVAHCS, Tucson, US (Elizabeth.OBrien@va.gov) IRB approved. The patient population for this single center, retrospective chart review was comprised entirely of patients who received treatment at the Southern Arizona VA Health Care System between 8/1/04 to 8/1/10. Patients who received a new prescription for zonisamide and who had a diagnosis of neuropathic pain based on ICD-9 code were included, and were followed for one year from the date of initial prescription. Up to 100 charts were reviewed. The primary outcome was documentation of improvement in pain symptoms found in the electronic medical record. Secondary outcomes included change in pain score and adverse effects associated with zonisamide. Other data collected included age, sex, co-morbid conditions, patient adherence, number of patients who discontinued treatment, adverse effects and other medications for neuropathic pain used prior to initiation of zonisamide. Additionally the service responsible for prescribing zonisamide was noted, as was the starting dose, maximal dose, dose at stabilization, and time to titration. Data was evaluated using descriptive statistics. Results and conclusions will be presented.

EFFECTS OF OXYCODONE CR AND TRANSDERMAL FENTANYL ON QTc INTERVAL (A5) Kathryn Patrick, P.David Pacheco, Patricia Pade. New Mexico VA Health Care System, Albuquerque, NM (Kathryn.patrick@va.gov) IRB approval pending. Chronic pain afflicts several million people worldwide and the use of opioid agonists to treat chronic pain continues to increase. It is well known that some opioids, such as high dose methadone, are capable of altering cardiac electrophysiology, indicated by an increased QTc interval. The NMVAHCS currently treats hundreds of chronic pain patients with methadone, oxycodone, fentanyl and morphine. Recently, high dose oxycodone was implicated as having the capability to increase the QTc interval. It is becoming increasingly evident that more studies are required to determine the cardiac effects of opioid-agonists. This study will be a retrospective chart review comprised of patients that have been on long term oxycodone CR or transdermal fentanyl to determine if they experience EKG changes during treatment. Electronic databases available through the NMVAHCS will be used to query a random group of patients on oxycodone CR or transdermal fentanyl. A manual chart review will be conducted to determine if there are EKG recordings that meet our inclusion criteria. All patient information will be de-identified. Findings will be presented at Western States Conference in Pacific Grove California May, 2011. If findings of this study show EKG changes with oxycodone or transdermal fentanyl, future endeavors can be pursued. Prospective studies comparing agents could be conducted or educational in-services can be provided to physicians regarding safe medication practices.

ANALYSIS OF HOSPITALIZATION RATES AND LENGTHS OF STAY BEFORE AND AFTER THE INITIATION OF CLOZAPINE (A5), Lorraine Sam, Jennifer A. Rosen. VA Long Beach Healthcare System, Long Beach, CA (lorraine.sam@va.gov) IRB approval received. The primary objective of this study is to analyze psychiatric hospitalization rates and total lengths of stay in patients prior to, and following, initiation of clozapine treatment. Subjects diagnosed with schizophrenia or schizoaffective disorder who were initiated on clozapine with history available one year before and one year after initiation will be included in the study. Data collected
include age, gender, diagnosis, clozapine maintenance dose, concurrent psychiatric medications, psychiatric comorbidities, and reasons for discontinuation of treatment. Outcome

measures will be calculated based on differences in psychiatric hospitalization rates and total bed days before and after initiation of clozapine. A regression analysis will also be performed to look at trends between psychiatric comorbidities, psychiatric medications, and hospital admissions. Results and conclusions will be presented.

LONG TERM COMPARATIVE EFFECTIVENESS AND SAFETY OF DULOXETINE VS. VENLAFAXINE XR IN VETERANS WITH MAJOR DEPRESSIVE DISORDER (A5), Whitney Shields, Pamela Youngberg, Jeannie Lee. Tucson VA, Tucson, AZ (whitney.shields@va.gov) IRB approved. This was a historical prospective cohort study evaluating patients with a diagnosis of major depressive disorder using the ICD9 296.2 or 296.3 coding. Patients initially prescribed duloxetine or venlafaxine XR for depression between December 1, 2005 and December 1, 2009 were screened for inclusion. The primary endpoint of this study was effectiveness, which was assessed by a review of the patients medical record, inspecting progress notes within 6 months of initial prescription of duloxetine or venlafaxine XR to determine if an improvement in symptoms of depression was documented. In order to assess long term effectiveness, the study investigators evaluated the patients electronic medication profile to measure refill history and determine the total number of months patients continued receiving the study agents. The secondary endpoint of this study was to establish the long term safety of duloxetine or venlafaxine XR by examining the reasons for discontinuation of the study agent. Descriptive statistics was used to analyze demographic data, whereas the statistical differences in the primary and secondary objectives were analyzed using t-test, chi-square test and logistic regression. Results and conclusions will be presented.

PRESCRIPTION NARCOTIC USE IN LONG BEACH VETERANS AFFAIRS OUTPATIENTS(A5) Patrick Tokuyama, Nathaniel Meridor, James Rick, Michael Juzba. VA Healthcare System, Long Beach, CA (Patrick.Tokuyama@va.gov) IRB approved. Opiate use across the nation has risen and with an increased risk for adverse drug events, drug interactions, morbidity, and mortality. Evaluating opiate utilization in non malignant pain syndromes and characterizing any morbidity associated with specific narcotics, their dosage or a specific diagnosis may improve current pain management practices, outcomes, and decrease healthcare costs. The primary objective of this study is to evaluate the use of chronically prescribed opiates in outpatients and to characterize the patient population using these drugs. The VISN 22 Data Warehouse was used to extract data regarding patients with a pain related diagnosis as specified by an ICD9 code and a 180 day supply of prescription opiates on or after January 1, 2008 to January 1, 2010. Descriptive statistics as well as statistical analyses such as t tests, chi squared tests, linear or logarithmic regressions will be performed as appropriate. The results of this study will be presented.

EFFECT OF CHOLINESTERASE INHIBITORS ON HEART RATE IN THE ELDERLY POPULATION AT THE VETERANS AFFAIRS GREATER LOS ANGELES HEALTHCARE SYSTEM (A5). Anahit Trdatyan. VA Greater Los Angeles Healthcare System, Los Angeles, CA (Trdatyan@usc.edu) IRB approved. Cholinesterase inhibitors (ChE-Is) are commonly used to treat dementia. These drugs increase cholinergic transmission and may provoke adverse effects in some patients because cholinergic effects are not limited to the central nervous system. Labeling for all ChE-Is warns that this class of medication can slow heart rate and may induce syncope. However, existing data on whether cholinesterase inhibitors can induce bradycardia is insufficient and conflicting. The purpose of this study was to evaluate the association between the use of ChE-Is and their effect on heart rate. A retrospective analysis was conducted of individuals with dementia who received a new prescription for a ChE-I at the VA Greater Los Angeles Healthcare System from September 31, 2003 to September 31, 2008. The difference in mean heart rate for patients before and after the start of ChE-I therapy was calculated along with the incidence of new onset bradycardia. The incidence of heart rate-related outcomes was also compared before and after the start of therapy. In addition, change in heart rate was stratified according to various risk factors, including the concomitant use of certain medications such as betablockers and comorbid conditions. Data and results will be presented.

A RETROSPECTIVE ANALYSIS OF SUBANESTHETIC INTRAVENOUS KETAMINE INFUSIONS FOR ACUTE CHRONIC PAIN (A5) Catherine Ubaldo. Naval Medical Center, San Diego, CA (catherine.ubaldo@med.navy.mil) IRB approval received. Chronic pain is associated with central sensitization and the wind up phenomenon which results in hyperalgesia and allodynia. Evidence supports the involvement and upregulation of the N methyl D aspartate (NMDA) receptor in central sensitization. Ketamine is a NMDA antagonist which has been evaluated and utilized off label using subanesthetic intravenous ketamine infusions and has demonstrated to improve pain scores, quality of life, and is an effective adjuvant analgesic to opioids in patients with acute chronic pain. Given the limited evidence regarding the long term utility and safety of subanesthetic ketamine infusions, the primary objective of this study is to evaluate the effectiveness and tolerability of subanesthetic intravenous ketamine infusions for the treatment of acute chronic pain. A retrospective electronic chart audit will be performed to determine patient demographics, pain diagnosis, ketamine dosages, analgesic relief, opioid requirements prior to and post ketamine infusions, and adverse effects. The effectiveness of ketamine will be assessed using the numerical pain scale and improvement in quality of life after each ketamine infusion. Patients will be included in the study if they received intravenous

subanesthetic ketamine infusions from approximately March 2008 to December 2010 at Naval Medical Center San Diegos Pain Clinic. Results and conclusions will be presented.

IMPLEMENTATION OF A MULTIDISCRIPLINARY CHRONIC PAIN MANAGEMENT CLINIC IN A SMALL RURAL HOSPITAL (A5), Hillary Volsteadt. Whiteriver Indian Hospital, Whiteriver, AZ (hillary.volsteadt@ihs.gov) IRB approval is not needed-no human subject data. A chronic pain management clinic has been established to focus on individualized care for complex patients that require a multi-modal approach. The primary responsibilities are comprehensive pain assessment, coordination of nonpharmacologic services and treatments, pain agreements, urinalysis interpretation, and management of pharmacologic treatment. The project team consists of two pharmacists and a primary care physician. Potential enrollees are patients diagnosed with chronic pain lasting more than three months. Exclusion criteria are the presence of acute or malignant pain, age under 18 years, and pregnancy. Comprehensive assessments focus on pain levels, functional status, appropriateness of pharmacologic therapy, and opiate abuse or addiction potential. Individualized treatment plans designed by the project team may include modification of pain agreements and pharmacologic therapy, as well as coordination of physical therapy, acupuncture, osteopathic manipulative treatment and behavioral health services. Coordination of care is conducted on a biweekly or monthly basis via telephone or clinic visits in order to provide continuous assessment and evaluation of pain control. Outcome measures for effectiveness of the project are the evaluation of pharmacologic and non-pharmacologic treatment utilization according to evidence-based guidelines, as well as reported

pain, quality of life, and emergency room visits for acute pain exacerbations.

ASSOCIATION BETWEEN OLANZAPINE USE AND BENZODIAZEPINE AND OPIOID REQUIREMENTS IN CHILDREN WITH ICU DELIRIUM (A5). Tien Vu. Children's Hospital Los Angeles, Los Angeles, CA (tivu@chla.usc.edu) IRB approval pending. The study objective was to determine if the addition of olanzapine reduced benzodiazepine and opioid requirements in mechanically ventilated pediatric patients diagnosed with ICU delirium. This was a retrospective analysis of patients admitted to the PICU or CTICU at Childrens Hospital Los Angeles from June 1, 2009 through May 31, 2010. Inclusion criteria were diagnosis of delirium by the psychiatric consult team, mechanical ventilation, and initial treatment with scheduled benzodiazepine(s) and/or opioid(s). Exclusion criteria were treatment with antipsychotics other than olanzapine. These patients were stratified into two groups: 1) patients who did not receive olanzapine, and 2) patients who received olanzapine. Data was collected on patient's age, weight, date of mechanical ventilation, date started on olanzapine, and Axis III diagnosis (acute medical condition). Total daily doses of olanzapine, daily equivalent doses of benzodiazepines (lorazepam equivalents), and daily equivalent doses of opioids (morphine equivalents) were collected. A comparison of the total daily equivalent doses of benzodiazepines and opioids was made between the two groups. Analysis included adjusting for underlying causes of delirium, length of stay in the ICU, total daily doses of olanzapine (mg/kg), and concomitant use of either dexmedetomidine or clonidine. Results and conclusions will be presented.

ASSESSMENT OF PROPHYLACTIC CLOZAPINE LEVELS IN STABLE OUTPATIENTS WITH SCHIZOPHRENIA (A5), Courtney Wilborn et al. Touro University California College of Pharmacy, Vallejo, CA (courtney.wilborn@tu.edu) IRB approved. Therapeutic clozapine plasma levels are established for the treatment of acutely ill patients diagnosed with schizophrenia. However, there are no data describing what clozapine concentrations are effective among stable outpatients. The objective of this study was to determine the range of clozapine plasma levels and doses that resulted in a 24-item Brief Psychiatric Rating Scale (BPRS) score of 48. Patients (n=33) being treated with clozapine monotherapy on a stable dose of clozapine for a minimum of 10 days were recruited from a private psychiatric practice. Demographic data included age, sex, substance abuse history, smoking status, BMI, diagnosis, polypharmacy status and race. For determining the range of optimum clozapine plasma levels, receiver operator curve and contingency tables analyses were used. Linear regression analysis determined whether a correlation existed between clozapine dose and BPRS score. To determine if any demographic independent variables correlate with the clozapine serum concentration, multiple linear regression analysis was employed. Results will be reported.

OUTCOMES IN VA PATIENTS TAKING CLOZAPINE (A5), Ariane Wilson, Rachel Grande, Randell Miyahara. VA Palo Alto Health Care System, Palo Alto, CA (ariane.wilson@va.gov) IRB approval not needed. Schizophrenia is a thought disorder characterized by persistent delusions, hallucinations and disorganization coupled with social and occupational dysfunction. The mainstay of treatment is antipsychotic medication, but many patients try and fail multiple agents due to lack of efficacy or intolerable side effects. Clozapine is an efficacious atypical antipsychotic often avoided due to serious side effects. Although some data exists regarding clinical outcomes with clozapine, few studies focus on qualitative outcomes. The objective of this study is to examine clinical, economic and humanistic outcomes associated with clozapine therapy. Patient hospitalization and global assessment of function (GAF) data prior to initiation of clozapine will be compared against similar data obtained after clozapine therapy is begun. Cost of clozapine therapy, hospitalization rates and GAF scores will be examined. Patients included in this study will be over 18 years of age, receive at least 6 months of clozapine therapy, and receive clozapine for an indication approved by VA clozapine use guidelines. Patients excluded from the study lack at least 6 months of hospitalization data prior to initiation of clozapine. Data analyzed in this study will provide baseline information used in ongoing quality improvement of VA Palo Alto clozapine use. Resulting data will be analyzed using paired t tests for interval data and non parametric McNemar's test for nominal data. Results and conclusions will be presented.

PATIENT POPULATION WITH ANTIPSYCHOTIC POLYPHARMACY IN A COUNTY MENTAL HEALTH PROGRAM (A5), Betsy Yuan, UC San Francisco Medical Center, San Francisco, CA (betsy.yuan@ucsf.edu) IRB approved. The purpose of this study was to evaluate the rate and rationale for the use of antipsychotic polypharmacy, defined as the concurrent use of two or more antipsychotics. Patients were retrospectively identified using an electronic prescription database from a large urban mental plan in San Francisco, California. Data regarding patient demographics, prescribed antipsychotics, Axis I and II diagnoses, Brief Psychiatric Rating Scale score, and documented reasons for antipsychotic polypharmacy were compiled from electronic medical records. Collected data will be used to characterize patients receiving more than one antipsychotic. Descriptive statistics will be used in data analysis. Final results will be presented and discussed.

A CROSS COUNTRY STUDY OF THE EFFECT OF DIBENZODIAZEPINES: CLOZAPINE, QUETIAPINE AND OLANZEPINE ON THYROID FUNCTION IN PATIENTS WITH SCHIZOPHRENIA Xiaojuan Yuan[1], Wei Guo[2], Zhimin Wang[2], G.S.Shankar[1] Western University of Health Sciences, Pomona,CA, 2.Anding Hospital, Beijing, China (carolyuan@yahoo.com). IRB approved. Thyroid plays important role in disease states such as schizophrenia and mood disorders. Atypical antipsychotics including dibenzodiazepines (DBZD) often are used as the first line agents to treat schizophrenia (SP) or schizoaffective (SA) disorders. Many published case reports describe that DBZD decrease thyroid hormone and complicate treatment with poor prognosis. Primary objective is to look at the extent of hypothyroidism with DBZD with non-dibenzodiazepine (NDBZD) antipsychotics. Secondary objective is to compare the degree of hypothyroidism among the three drugs within the DBZD class. Retrospective chart review for this study is from two psychiatric hospitals. We expect sample size of 110 patients. Patients in the DBZD group are on at least one of the three DBZD. Patients in the comparison arm are on at least one NDBZD medication. We exclude any patient who is on any medications other than DBZD that will affect the thyroid function. We will evaluate hospital dietary plans to make sure a balanced diet is given to

patient since this is a cross-country study. Every patient selected to be in the study must have a normal baseline TSH and TT4 or FT4 and FT3 on file, and levels at 6 to 12 weeks from baseline. We predict low thyroid function in patients treated with DBZD.

A6 DiabetesCare

SAFTEY AND EFFECTIVENESS OF AN INSULIN INFUSION PROTOCOL (A6). Lauren Bodhaine, Caitlin Cameron. Maricopa Medical Center, Phoenix, AZ. (lauren.bodhaine@mihs.org) IRB approved. The objective of this study was to evaluate and validate an insulin infusion protocol for management of hyperglycemia in critically ill patients at Maricopa Medical Center. Adult patients 18 years and older admitted to the MICU, SICU, or CICU on an insulin infusion for 12 hours or longer were included in this retrospective, observational chart review after being identified through a computer generated report. Patients were excluded if they were pregnant or had diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome. The primary outcome measured was percentage of point of care blood glucose readings within the target range of 130 to 160 milligrams per deciliter. Secondary outcomes included mean blood glucose, time from initial insulin bolus to first glucose reading within target range, time within range, percentage of glucose readings in the following ranges: 70 to 129 milligrams per deciliter, 160 to 180 milligrams per deciliter, total number and rate of episodes of hyperglycemia (181 to 300 milligrams per deciliter), severe hyperglycemia (greater than 300 milligrams per deciliter), hypoglycemia (50 to 69 milligrams per deciliter), and severe hypoglycemia (less than 50 milligrams per deciliter), and nursing compliance with the protocol as measured by the percentage of rate adjustments per protocol. Results and conclusions will be presented.

IMPACT OF HIGH INTENSITY DIABETES CLINIC IN PATIENTS WITH POORLY CONTROLLED TYPE 2 DIABETES MELLITUS (A6), Kelsey Bohling. Phoenix VA Health Care System, Phoenix, AZ (kelsey.bohling@va.gov) IRB approval received The objective is to investigate the clinical differences observed after patients were enrolled in a multidisciplinary high intensity diabetes management (HIDM) clinic at the Phoenix VA Health Care System. This is a comparative, observational retrospective study in which data will be collected through patient chart review to evaluate the HIDM prescriber adherence to the ADA guidelines regarding lipid lowering agents (specifically statins), angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), and aspirin therapy by comparing patients pharmacotherapy at baseline to post enrollment in HIDM. Percent change in blood pressure (BP), percent change in low density lipoprotein (LDL), and the degree of micro and macroalbuminuria before and after HIDM enrollment will also be compared. Additional comparisons will assess percent of patients pre enrollment and post enrollment in HIDM who meet the following clinical quality measures: Healthcare Effectiveness Data and Information Set (HEDIS) measure for BP of less than 140/90, HEDIS measure for LDL less than 100, and American Diabetes Association BP goal of less than 130/80. HIDM clinic patients will be included in the study if they are 18-75 years old, and have completed the third of four HIDM clinic visits with at least one follow up A1C drawn. The results will be discussed at the Western States Conference.

INTRODUCTION OF GENERIC TACROLIMUS AND THE INCIDENCE OF ACUTE GRAFT REJECTION IN KIDNEY TRANSPLANT PATIENTS. Ryan Bolonesi. Scott Evans. Yasir Qazi. University of Southern California, University Hospital, Los Angeles, CA. (bolonesi@usc.edu) IRB-Divisional Review. In August 2009 a generic equivalent of tacrolimus, an immunosuppressive drug, was approved by the FDA. These drugs have a narrow therapeutic index, and are classified as critical dose drugs (CDDs). These CDDs do not receive any testing or evaluation in transplant patients before being approved. The objective of this study is to retrospectively compare rates of kidney transplant rejection 1 year post transplant between patients who received proprietary tacrolimus (Prograf), or the generic equivalent, as part of the immunosuppression regimen. This is a single center retrospective chart review of kidney transplant recipients between March 1st 2008 and February 28th, 2010. The primary endpoint of the study is the incidence of kidney graft rejection in patients who received proprietary verses generic tacrolimus. Statistical analysis will be performed using a logistic regression model with binary variables. Results and conclusions will be presented.

THE INCIDENCE OF FRACTURES IN VETERAN PATIENTS ON THIAZOLIDINEDIONES (A6). Susie Chin. Wayman Lee. Thu Nguyen. Diane Valdez. Veterans Affairs, Greater Los Angeles, Los Angeles, CA. (susie.chin@va.gov) IRB approved. Prospective studies suggest there is increased bone mineral density loss in type 2 diabetic women within the first couple years of thiazolidinedione use. Currently there is a need to perform studies in men to evaluate if the risk is indeed gender related. The study objective was to determine if thiazolidinediones, such as pioglitazone or rosiglitazone, increased the risk of fractures within the first two years of use. Patients were selected for this study if they started pioglitazone or rosiglitazone during June 1, 1999 to September 31, 2008. A retrospective chart review was performed to gather deidentified patient data to assess the incidence of fractures. Data such as weight, history of bone disease, and use of bisphosphonates was collected to ensure other confounding factors, which may affect the risk of fractures, was accounted for. All pertinent data, such as documented occurrence of fracture, was collected over two time periods with patients serving as their own controls. Data two years prior to thiazolidinedione use will be compared to data two years after the initiation of the thiazolidinedione. Results and conclusions will be presented.

USE OF U-500 INSULIN IN RESISTANT TYPE II DIABETIC PATIENTS IN THE OUTPATIENT SETTING (A6), Joanne Chong. Kern Medical Center, Bakersfield, CA (chongj@kernmedctr.com) IRB approval pending. The primary study objective was to determine the safety and efficacy of U-500 insulin in uncontrolled type II diabetic patients. Fiscal outcomes of conversion to U-500 insulin were reviewed as a secondary study objective. All type II diabetic patients on U-500 insulin who were seen at Sagebrush Diabetes Clinic or KMC Medicine Clinic were reviewed retrospectively from 12/2007 to 01/2011. Total daily insulin usage and A1c at baseline prior to conversion were compared to post conversion values. All hypoglycemic events following conversion were noted and evaluated to determine safety profile. Medications for glycemic control were compared prior to and following conversion to U-500 insulin in order to determine fiscal outcomes. Inclusion criteria encompassed all type II diabetic patients over the age of 18 on U-500 insulin for a minimum of 3 months. All type I diabetics, pregnant type II diabetics, and any study subjects without post conversion follow up labs were excluded. Results and conclusions will be presented.

BASAL INSULIN OPTIMIZATION AND THIAZOLIDINEDIONE REDUCTION: RESULTS OF A PHARMACIST INITIATED MEDICATION CONVERSION (A6), Megan Chynoweth. Kaiser Permanente, Bakersfield, CA (megan.x.chynoweth@kp.org) IRB approval received. Thiazolidinediones (TZDs) are associated with side effects including edema, weight gain, and increased cardiovascular risk, and are available as brand only medications. Insulin, a more affordable medication, can reduce HbA1c to a greater degree than TZDs, thus enabling more patients to achieve glycemic goals. Furthermore, insulin has a well established safety profile and is preferred over TZDs therapy. In an effort to optimize therapeutic outcomes and minimize healthcare costs in type 2 diabetes (T2DM) patients, Kaiser Permanente Kern County developed a pharmacist run medication conversion program. Patients with uncontrolled T2DM, defined as a HbA1c greater than or equal to 7.5 mg/dl, currently taking a TZD and NPH only insulin were enrolled. The TZD was discontinued and insulin titrated. The objectives of this retrospective study are 1) determine the benefits and outcomes of a pharmacist run medication conversion initiative; 2) determine if the outcome measures collected are appropriate and effective. Fasting blood glucose is the primary outcome measure. Secondary outcomes include patients weight, HbA1c, number of hypoglycemic episodes, and average monthly copayments for diabetes medications. Data will be collected from electronic medical records and dispensing history databases. The results and conclusions will be discussed.

ASSESSMENT OF A PROACTIVE INSULIN PROTOCOL FOR NON-CRITICALLY ILL, ADULT PATIENTS IN A TERTIARY CARE, COMMUNITYBASED TEACHING HOSPITAL (A6) Megan Evans. Providence Sacred Heart Medical Center Spokane, WA (megan.evans@providence.org) IRB exempt Objective: A new, proactive insulin protocol was implemented in the fall of 2010. The protocol begins with a non-aggressive insulin sliding scale; if the patient has two or more blood glucose readings greater than 180 mg/dL on that scale, then the basal/bolus/corrective phase of the protocol is initiated. This project assesses the effectiveness and safety of the protocol in maintaining blood glucose between 100-180 mg/dL, and identifies barriers to implementation/adherence. Methods: The electronic medical record system will be used to identify patients who were initiated on the insulin protocol. Frequency of blood glucose readings within the following ranges will be described for each phase of the protocol (page 1 only, algorithm A, algorithm B, algorithm C, tube-fed/regular insulin, and additional/other proactive therapies): 20-39 mg/dL, 40-59 mg/dL, 60-69 mg/dL, 70-79 mg/dL, 80-99 mg/dL, 100-179 mg/dL, 180-199 mg/dL, 200-219 mg/dL, 220-240 mg/dL, and > 241 mg/dL. Thorough assessment of all hypoglycemic events will be carried out and attributable causes will be identified. Protocol compliance will be assessed to identify barriers to implementation. This assessment will be performed immediately after protocol implementation and again several months later. Results/conclusion: The results will be discussed.

EVALUATION OF A UTILIZATION MANAGEMENT PROGRAM TO OPTIMIZE THE APPROPRIATE USE OF INSULIN NPH (A6). Brandy Fouts. Terry Richardson. Vivien Chan. Jim Carlson. Group Health Cooperative, Tukwila, WA (fouts.b@ghc.org) IRB approval not needed. When used in patients with type 2 diabetes, insulin glargine provides modest clinical benefits at a higher cost compared to insulin NPH. As an integrated health plan and delivery system, Group Health has a unique opportunity to manage this medication use. The study objective is to evaluate the impact of a three part utilization management program on prescribing patterns of insulin glargine and insulin NPH within an integrated system. The three part program consists of (1) educational tools developed through interprofessional collaboration and systemically deployed by clinical pharmacists to provide consistent messaging to prescribers regarding evidence-based data for basal insulin products, (2) assessment of eligibility for drug conversion by clinical pharmacists, and (3) the evaluation and improvement of care transition points within the delivery system using Lean Processes for continual improvement. Claims data will be used to determine the percentage of patients initiating insulin therapy on insulin NPH and overall market share of insulin glargine and insulin NPH. Data will be analyzed at baseline and three months post program implementation. Impact on utilization patterns will be presented.

HYPERGLYCEMIA MANAGEMENT IN ACUTE MEDICINE PATIENTS (A6). Alisa Hughes-Stricklett, Chad Nelson, VA-SLC Healthcare System, Salt Lake City, UT (Alisa.Hughes-Stricklett@va.gov) IRB Approved. The purpose of this study was to determine the effectiveness of a newly implemented hyperglycemia protocol compared to regular insulin sliding scale to control blood glucose in hospitalized medical patients. The research design was a retrospective chart review. All patients admitted to the acute medicine ward with a prior diagnosis of diabetes and who received insulin were included. The control group was drawn from admissions between January and July 2010 and the protocol group from October 2010 and March 2011. The primary outcome was a comparison of average daily glucose in patients prescribed regular insulin sliding scale or insulin per protocol containing two of three insulin components: basal, prandial, or correction factor insulin. Secondary outcomes included average fasting glucose, proportion of fasting and random blood glucose values within target range, episodes of hypoglycemia or severe hyperglycemia, and length of hospital stay. Results and conclusions will be presented.

RELATIONSHIP BETWEEN PERI-OPERATIVE GLYCEMIC CONTROL AND DELAYED GRAFT FUNCTION IN KIDNEY TRANSPLANT PATIENTS (A6), Laura Lafranchise, Michael L. Misel. UCSD Medical Center, San Diego, CA (llafranchise@ucsd.edu) IRB approval received. The study objective was to determine if tighter control of blood glucose levels within the first five days post transplant correlated with a lower incidence of delayed graft function in kidney transplant patients. Data were collected and analyzed from patients charts retrospectively to evaluate adult patients who underwent kidney transplantation at University of California, San Diego Medical Center between January 2008 and December 2009. Exclusion criteria included: patients less than 18 years old, a history of previous transplant, and a combined kidney/liver or kidney/pancreas transplant. The information collected may help decide whether better glucose control is needed to improve early kidney allograft function for the purpose of maximizing kidney allograft longevity. The results will be discussed.

SEASONAL HEMOGLOBIN A1C VARIATIONS IN A DESERT CLIMATE (A6). Michael Man. Todd Rowland. Michelle Wilhardt. Phoenix VA Health Care System, Phoenix, AZ (Michael.Man@va.gov) IRB approval pending. The study objective was to determine if there are seasonal variations of hemoglobin A1C in patients with type 2 diabetes who live in the hot desert climate of central Arizona. A retrospective database study was performed on A1C lab tests collected at the Phoenix VA Health Care System between 10/1/2005 and 9/30/2010. Data extraction from the medical record was performed utilizing both local and centralized database query techniques. Data validation was performed by comparing query results to the electronic medical chart for a subset of patients. The primary result is a descriptive characterization of mean A1C values during hot months (when the mean maximum temperature is above 90 degrees Fahrenheit) and cool months (when the mean maximum temperature is below 90 degrees Fahrenheit), and a quantification of the difference. Secondary results include stratification of these variations by patient characteristics, including gender, race/ethnicity, age, body mass index, and A1C range. Additionally, secondary data analysis includes a comparison of month-to-month A1C fluctuations to determine if a difference in mean A1C values exists during specific months of the year. Results and conclusions will be presented.

IMPLEMENTATION AND EVALUATION OF A GLUCOSE MANAGEMENT TEAM IN THE LABOR AND DELIVERY DEPARTMENT (A6). Claire Nguyen. Presbyterian Intercommunity Hospital. Whittier, CA (cnguyen1@pih.net) IRB not needed. Elevated maternal blood glucose levels during the intrapartum period has been established as a cause of complications to the fetus, the neonate, and to the mother. Multiple studies have established that with tight glycemic control, these complications can be reduced. The objective of this study was to design and implement a glucose management team in the labor and delivery department. The team will consist of a pharmacist, an endocrinologist, and a diabetes educator. A literature search was performed in order to verify the appropriate target blood glucose levels, types and doses of insulin to recommend in this population, and the timing of blood glucose levels for monitoring. The team compiled an order set that is considerate of the current American Diabetes Association target blood glucose levels for gestational diabetes, as well as the American College of Obstetrician and Gynecology guidelines. The order set was added to the electronic computer ordering system and made available to all physicians in the hospital. The order set has the option for the physician to indicate if he or she wishes to consult the glucose management team. Data on the patients under the care of the glucose management team will be collected. The description of the program design and implementation, and the evaluation of the patient data will be presented.

A RETROSPECTIVE ANALYSIS OF HYPOGLYCEMIC EVENTS AT TWO ACADEMIC MEDICAL CENTERS (A6), Neil Patel, Kevin Box. UC San Diego Medical Center, San Diego, CA (nhpatel@ucsd.edu) IRB approval pending. The objective of this retrospective study was to characterize contributing factors of hypoglycemic events in patients who experienced a point of care blood glucose value <70 mg/dL during their hospitalization between November 2010 and January 2011 at two UC San Diego Medical Centers. Patients included in this study were either male or female, at least 12 years of age, and of all ethnic backgrounds. Neonatal patients and patients who were hypoglycemic upon hospital admission were excluded. Investigators have access to data of approximately 200 patients who experienced a hypoglycemic episode. The following primary outcomes were assessed as possible risk factors for hypoglycemia: (1) concurrent disease states (2) concurrent medications that may precipitate hypoglycemia. Secondary outcomes included: (1) utilization of rescue interventions, (2) compliance with the institutional hypoglycemia protocol, (3) adjustments of medication regimens that control blood glucose. Data was collected retrospectively by reviewing electronic and paper medical records and will be summarized using descriptive statistics. Results and conclusion will be presented.

GLYBURIDE VS. GLIPIZIDE: A COMPARISON OF GLYCEMIC CONTROL IN A SELECTED VETERAN POPULATION (A6). Bharti Sharma, Anne Lubischer. Portland VA Medical Center, Portland, OR (Bharti.Sharma@va.gov) IRB approval received. The study objective was to determine if a select group of patients who were switched from glyburide to glipizide due to safety concerns maintained A1c values comparable to those prior to the switch. Patients with active prescriptions for glyburide who were 65 years of age or older with estimated GFR of 50ml per min or less were switched to glipizide to reduce risk of hypoglycemia. Primary endpoint of the study is A1c. Secondary endpoints include weight, percent of patients reaching goal A1c of less than 7 percent, changes in dose of glipizide or other anti diabetic agents, addition or discontinuation of other anti diabetic agents. Safety endpoints include documented blood glucose values of less than 60mg/dL, symptoms of hypoglycemia and decrease in glipizide dose. Descriptive statistics will be used to describe patient demographics. Continuous variables will be compared using the paired t test for normally distributed variables and the Mann Whitney U test for non normally distributed variables. The Chi square test or the Fisher exact test will be used to compare categorical variables. Data from 70 patients is needed to detect a significant change in A1c. Each patient will serve as his or her own control. Patients who were less than 65 years of age, had recently expired glyburide prescriptions or did not have baseline or follow up A1c values were excluded from the study. Results and conclusions will be presented.

FAILURE MODE EFFECTIVE ANALYSIS: HYPOGLYCEMIC EVENTS IN AN INPATIENT POPULATION (A6). Huyentran Tran. Desert Regional Medical Center, Palm Springs, CA (huyentran.tran@tenethealth.com). IRB not needed. An ongoing analysis of the utilization of hypoglycemic rescue agents demonstrated an opportunity for preventing hypoglycemic events in our general adult medical population. Cerner analytic reports identifying treatment of hypoglycemic episodes were utilized to review current practice patterns in glycemic management and the utilization of antidiabetic agents. Hypoglycemic events were defined as mild (blood glucose 60 to 70 mg/dL), moderate (blood glucose 50 to 60 mg/dL), or severe (blood glucose less than 50 mg/dL). In 2010, we identified 540 patients who had 1137 hypoglycemic events, or approximately 95 incidents per month. The majority of episodes (75 percent) occurred between midnight and 10:00 a.m. An interdisciplinary team was formed with the immediate goals of decreasing the number of hypoglycemic incidents by fifty percent while understanding the complexities in our care process contributing to increased untoward events. Our focus is to identify preventable causes of hypoglycemic events in order to develop sustainable clinical practice changes. Results and implemented methodology will be presented and discussed.

IMPACT OF HIGH INTENSITY DIABETES CLINIC IN PATIENTS WITH POORLY CONTROLLED TYPE 2 DIABETES MELLITUS (A6), Alexandra Vu. Phoenix VA Health Care System, Phoenix, AZ (Alexandra.Vu2@va.gov) IRB approved The study objective was to investigate the clinical differences observed after patients were enrolled in a multidisciplinary high intensity diabetes management (HIDM) clinic. These patients could enroll in HIDM clinic if they met the following criteria: diagnosis of type 2 diabetes, A1C greater than 9%, already on insulin, and seen by Endocrinology or the diabetes nurse case manager at least once. Each visit consisted of appointments with a nurse diabetes educator, nutritionist, pharmacist, nurse practitioner/endocrinologist, and a psychologist. HIDM clinic patients are scheduled for four visits before being returned to usual care. Patients were included if they were 18-75 years old, enrolled in the HIDM clinic and have completed the third of four HIDM clinic visits with at least one follow up A1C drawn prior to September 14, 2010. The primary clinical outcome will compare the percent change in glycosylated hemoglobin (A1C) before and after HIDM clinic enrollment. Secondary outcomes include percentage of patients achieving A1C < 9% and A1C<7% as well as change in weight, insulin dose and diabetes related hospital admissions or emergency room visits. Descriptive statistics, student's t-test, and McNemar test will be used. Results and conclusion will be presented.

THE IMPLEMENTATION OF A SUBCUTANEOUS INSULIN ORDER SET AND DOSING GUIDELINE ON NON CRITICAL CARE HOSPITALIZED PATIENTS (A6), Scott Yost, Gerry Migaki, Providence St. Vincent Medical Center, Portland, OR (scott.yost@providence.org) IRB approved. The primary objective of this project is to reduce adverse events and decrease potential medication errors associated with insulin administration. Following ISMP recommendations, a standard adult subcutaneous insulin order set and dosing guideline was developed and implemented at Providence St. Vincent Medical Center in non critically ill patients. A study was conducted to examine the outcomes of the project. One hundred patients were analyzed before the subcutaneous insulin order set and dosing guideline implementation and compared to one hundred post implementation patients. Patient data was retrospectively analyzed using the assistance of a subcutaneous insulin report. All of the patients analyzed were in patients on either the sixth seventh eighth or ninth floors at Providence St. Vincent Medical Center. Patient demographic information along with blood glucose measurements and the amount and type of subcutaneous insulin used during hospitalization was collected. The primary outcomes of the study are the mean daily blood glucose, rates of hypoglycemia, and rates of severe hypoglycemia. The results and conclusion of the study will be presented.

B1 AmbulatoryCare

EVALUATION OF U500 INSULIN SAFETY AND EFFICACY AFTER IMPLEMENTATION OF SAFETY MEASURES (B1). Sean Akamine, Howard Mun. Department of Veterans Affairs Puget Sound, Seattle, WA (Sean.Akamine@va.gov) IRB approval pending. The objective of this study is to describe the safety and efficacy of U500 insulin before and after the implementation of the Veterans Affairs National Patient Safety Guidelines. This retrospective chart review will obtain aggregate, demographic, and clinical data from the Computerized Patient Record System. Patients enrolled in the Veterans Affairs Puget Sound ambulatory care clinic with a prescription for U500 insulin filled between September 1, 2007 and December 1, 2010 will be included in the analysis. Primary endpoints will evaluate episodes of hypoglycemia, episodes of symptomatic hypoglycemia, and emergency department visits or admissions related to hypoglycemia prior to and after the implementation of safety guidelines. The secondary endpoint will evaluate diabetes goal attainment with the use of U500 insulin. Data will be statistically evaluated through chi squared and paired t analysis. Results and conclusions will be presented.

A PHARMACY RESIDENT MANAGED PAIN CLINIC: IMPACT ON PATIENT REPORTED PAIN SCORES (B1), Eric Andersen, Paul Otto, Abril Atherton. VA Pocatello Outpatient Clinic, Pocatello, ID (eric.andersen@va.gov) IRB approval pending. Chronic pain management is an important and growing need in the VA healthcare system. Clinical pharmacists with their expertise in pharmacotherapy and drug therapy monitoring provide a unique perspective and have ability to effectively manage chronic pain. To better meet the needs of its veterans, the Pocatello VA clinic initiated a schedule II opioid renewal clinic in 2001. The pain clinic manages two types of patients, those not yet stable who are actively followed by a pharmacy resident, and stable patients on voice mail opioid renewal. Patients managed by the pharmacy resident are called monthly to assess compliance, analgesia, side effects and degree of satisfaction. The resident makes dose adjustments as needed and manages side effects. This information is extensively documented in the electronic medical record. Objective: To describe and evaluate outcomes in a pharmacy resident run pain management clinic at a VA outpatient clinic in Pocatello, Idaho. Methods: A retrospective chart review will be conducted for patients with pain management agreements signed between January 1, 2009 and November 30, 2010 and currently followed by the pharmacy resident. Data will be collected on average pain scores, patient satisfaction, adverse effects and documentation of bowel regimen. A telephone satisfaction survey of all patients currently in the pain management

program will also be conducted. Descriptive statistics will be performed. Results and conclusions to be presented.

PERCEIVED VALUE OF A PHARMACIST-MANAGED REFILL PROGRAM AS PART OF A PATIENTCENTERED MEDICAL HOME (B1). Carmela Andrada, Steven Erickson, Annie Lam. Valley View Clinical Pharmacists, Monroe, WA (candrada@uw.edu) IRB approved. A majority of the physicians in the Washington Providence Medical Group perform their own refill authorizations. The purpose of this study is to gather physicians' opinions regarding current medication refill authorization practices and perceived benefit of a pharmacist-managed refill authorization program. An initial email was sent to physicians in the Washington Providence Medical Group, notifying them of the purpose of the study and to encourage participation in a survey. Participation was completely voluntary and anonymous. The survey was designed to measure the physicians' estimated amount of refills they authorize daily, amount of physician effort required, and if they would find this pharmacy service valuable (e.g. allow more time to see patients, increase office visits, or help remind physicians to follow-up with patients regarding labs, medication issues, and their disease states). Surveys were available to the providers at a physician meeting and through electronic and interoffice mail. Surveys were returned to the investigator through interoffice mail. Results of the survey will be used to determine if a pharmacist-managed refill authorization program is a value-added service and should be implemented in all primary care clinics in the Providence Medical Group network. Results and conclusions will be presented.

ESTIMATED COST AVOIDANCE ASSOCIATED WITH A PHARMACIST LED DIABETES INTENSE MEDICAL MANAGEMENT CLINIC (B1). Anisa Arjmand, JD Hirsch, CM Morello. VA San Diego Healthcare System, San Diego, CA (Anisa.Arjmand@va.gov) IRB approved. Diabetes mellitus imposes a substantial economic burden on society. Studies show that improving glycemic control reduces direct medical costs associated with diabetes care. In May 2009, a pharmacist led Diabetes Intense Medical Management (DIMM) clinic was initiated in collaboration with an endocrinologist at the VA San Diego Healthcare System (VASDHS) in order to optimize metabolic outcomes through diabetes education and medication therapy management. A retrospective cohort will be used to estimate the direct medical costs avoided from the perspective of a healthcare system as a result of improvement in glycemic control. Study population consists of 37 patients who will have received 6 months of care by January 2011 and an equal number of comparator group patients with uncontrolled diabetes (matched by HbA1c). Primary endpoint will be the estimated 3 year direct medical costs avoided due to change in HbA1c in DIMM clinic patients in comparison to the comparator group patients after 6 months of treatment. Two published regression equations will be used to estimate the relationship between HbA1c levels and direct medical costs for baseline and 6 month HbA1c values in order to estimate cost difference due to changes in HbA1c between baseline and 6 months thereafter. T tests will be used to determine the mean medical cost difference between the DIMM clinic

and comparator group. Results and conclusions will be presented.

IMPACT OF A PHARMACIST RUN MEDICARE PART D CLINIC ON PATIENT COST SAVINGS AND MEDICATION THERAPY MANAGEMENT (MTM) AT A COUNTY HOSPITAL (B1). Saduf Ashfaq. San Joaquin General Hospital, French Camp, CA (sashfaq@sjgh.org) IRB approval is received. With the immense number of advertisements in the community and the constantly changing formularies of Part D plans, Medicare patients are generally confused about which plan would best fit their needs. Although there is a Plan Finder Tool on the Medicare website, it can be complex and difficult to use, especially for the elderly Medicare population. The objective of this study was to determine if pharmacists can significantly reduce medication costs and optimize medication treatment by evaluating patients Medicare Part D plans and offering Medication Therapy Management (MTM) services. In order to obtain patient referrals, informational brochures were distributed to various ambulatory clinics, staff, and related offices. Short presentations were given to physicians at repeated intervals to ensure that all rotating practitioners were aware of the project. At each patient visit, Medicares online Plan Finder Tool was used to evaluate various Part D plans for coverage and cost of therapy. In addition, MTM services were provided. Patients were asked to fill out a questionnaire regarding their visit. The number and types of interventions, cost savings, and patient satisfaction were measured. Results will be presented.

MEDICATION RECONCILIATION IN PRIMARY CARE PRACTICES (B1). Andrea Backes, Trina Huynh, Grace Kuo. UC San Diego Health System, San Diego, CA (ackwan@ucsd.edu) IRB approved. The study objective was to determine the frequency and type of medication discrepancies in primary care clinics. This prospective cross sectional observational study was conducted using purposive sampling at four primary care clinics. Trained research assistants recruited 120 patients (30 from each of the 4 clinics) in the waiting room, explained the study, and asked if eligible patients were interested in participating. Written informed consent was obtained from patients and clinic staff. The research assistants shadowed patients and observed clinic encounters related to medication reviews. The research assistants interviewed patients about their medication use and their experience with the medication review process in the clinic. Patients were asked to recall their medication names, dosages, and frequencies. After the visit, the research assistants reviewed medications listed in patients charts. Patients self reported medication use information was compared with their chart records (name, dosage, frequency). We defined medication discrepancy as any difference between medications recorded in the chart and medications reported by patients. All data analyses were performed using Stata. Data analyses included descriptive analyses of patient demographics, frequency and type of medication discrepancies, and regression analyses to assess factors associated with such discrepancies. Results and conclusions will be presented.

IMPLEMENTATION OF A COLLABORATIVE DISPENSING WORKFLOW FOR ORAL AGENTS USED TO TREAT CANCER (B1) Nicholas D. Baker, Kaiser Permanente Central Valley Service Area, Modesto, CA (nicholas.d.baker@kp.org) IRB Exempt. The last ten years has seen a surge in the development of oral anti-neoplastic agents. Community pharmacists are increasingly being asked to deliver consultations on these agents, but may lack the specialized knowledge. This project involved a redesign of workflow that aligned the oncologist, oncology pharmacist, and outpatient pharmacists in a medication regimen evaluation process. The objective was to increase the number of referrals submitted by oncologists to oncology pharmacists for evaluation of oral chemotherapy regimens prior to dispensing. In addition, pre and post surveys were administered to determine training opportunities and the impact of training on outpatient pharmacists knowledge and confidence level. The project was piloted at Kaiser Permanentes medical offices and pharmacies in Stockton over a three month period. A formal referral process was initiated for patients prescribed oral chemotherapy, followed by a standardized evaluation of the patients medication profile by the oncology pharmacist. Outpatient pharmacists received specialized training on oral chemotherapy and were given a pocket card to facilitate the consultations. Referral rates pre and post implementation of

workflow changes were compared through Chi Square analysis. Descriptive statistics were used to evaluate outpatient pharmacists knowledge and confidence level. Secondary endpoints included pharmacist interventions and intervention acceptance rate. Results will be discussed.

IMPACT OF PATIENT EDUCATION ON PRIMARY NON-ADHERENCE IN A COMMUNITY HEALTH CENTER (B1), Amber Burdeau, Monica Serrano, Annie Lam, HealthPoint, Kent, WA (aburdeau@healthpointchc.org) IRB approval received. Primary non-adherence, defined as patients failing to pickup a prescribed medication from a pharmacy, is a prevalent medication use problem. This study is conducted in a 340b community health center pharmacy serving indigent patients to (1) identify the types of prescription drugs and patient demographics that are associated with primary non-adherence, (2) assess the effects of patient education on primary non-adherence rates, (3) calculate pre-intervention revenue loss due to non-redeemed prescription drugs, and (4) calculate the impact of educational intervention on pharmacy prescription revenue during the study period.. Non-redeemed prescription records are identified and reviewed retrospectively during August through October 2010, and prospectively in March through April 2011with clinic-provided patient educational information regarding pharmacy services and refill policy are available for all patients during February 2010. The demographics, social, and economic status of patients with non-redeemed prescriptions, and the associated prescription revenue are collected from electronic medical and pharmacy records, as well as drug name, drug class, prescription transmission date/time, and indication of prescriptions for pharmacotherapy. Primary non-adherence rates pre and post educational intervention will be analyzed using Students T-test for unequal variances, with p=0.05.

Descriptive statistics will be used to analyze other data. Results and conclusion will be presented.

IMPACT OF PHARMACISTS ON THE ECONOMIC AND CLINICAL OUTCOMES OF PATIENTS ENROLLED IN THE INTENSIVE PRIMARY CARE PROGRAM (B1), William Chan. Virginia Mason Medical Center, Seattle, WA (William.chan@vmmc.org) IRB approval pending. Virginia Mason collaborated with a local health plan and a major employer to conduct a trial of the intensive outpatient care pilot program, which showed a 20% decrease in health care costs of the pilot participants versus the control group. The program was subsequently implemented and expanded to include more patients and a broader interdisciplinary team. The purpose of this project is to determine the impact of team member interventions on the clinical and economic outcomes of patients enrolled in the program. Enrolled patients are required to have a pharmacist review of the medication profile within 60 days. In this observational study, pharmacist medication therapy management plans will be evaluated for the number and type of interventions. Intervention categories can include the following: untreated therapeutic indication, optimal drug use, nonadherence, drug monitoring, drug interactions, subtherapeutic dose, supradose, renal function, adverse side effects, and no therapeutic indication. Economic outcomes will be assessed based on drug cost savings as well as potential cost savings due to the prevention of adverse drug reactions. Clinical outcomes will be evaluated based on the improvement of indirect metrics. Pharmacist opportunities to improve patient care in the program will also be explored. Results and conclusions of overall impact on indirect metrics and economic outcomes will be presented.

THERAPEUTIC INERTIA AMONG OLDER HYPERTENSION PATIENTS IN AN ACADEMIC MEDICAL CENTER (B1), Kelly Chang, May Mak, Steve Chen. USC School of Pharmacy, Los Angeles, CA (kellycha@usc.edu) IRB approved The study objective is to evaluate the prevalence of therapeutic inertia (TI) among geriatric patients with hypertension who receive care at an academic ambulatory health center. Therapeutic inertia is defined as the absence of treatment modification for patients with blood pressure readings persistently above goal. The study is a retrospective chart review over a 2 year period. Subjects greater than 55 years of age with a diagnosis of hypertension are included in the study. Those with less than 3 clinic visits will be excluded from the study. A survey will be given to physicians of the study subjects to describe treatment strategies and possible reasons for unmet blood pressure goals. The primary endpoint is to calculate a therapeutic inertia score to evaluate TI's effect on blood pressure control. The TI score is calculated by the number of visits with increased blood pressure subtracted by the number of visits with medication changes, all divided by the total number of visits. Secondary outcomes are to compare TI rates between geriatricians and general practitioners, and to describe reasons for the prevalence of TI as perceived by physicians. Results and conclusions will be presented.

IMPLEMENTATION OF A PHARMACIST-MANAGED PSYCHIATRIC SERVICE IN AN OUTPATIENT SETTING (B1). Deempal Chaudhari. Kaiser Permanente Santa Clara Medical Care Center, Santa Clara, CA (Deempal.E.Chaudhari@kp.org), IRB Exemption Received. Outpatient psychiatry is an area of medicine that has recently incorporated the use of psychiatric pharmacists. The addition of a psychiatric pharmacist has shown to improve drug therapy, reduce cost and adverse effects of therapy. A competent and qualified pharmacist can potentially provide value to the health care system by optimizing medication therapy outcomes. The objective of this study is to design and implement an ambulatory care service which will incorporate the roles of pharmacists in an outpatient psychiatric facility. Methods will include: design a business plan to hire a psychiatric pharmacist, create a protocol for pharmacists to provide medication management to psychiatric patients, establish clinical guidelines and a treatment algorithm based on national standards of care for patients with psychiatric conditions, and finalize the workflow for a new pharmacy service. Once this service is fully implemented, quality assurance parameters such as reduction of adverse event, number of physician office visits, ED visits, hospitalization and improvement in HEDIS scores for depression will be assessed. Results and conclusions will be discussed.

DO PATIENTS MAINTAIN LDL GOAL ONE YEAR POST DISCHARGE FROM CLINICAL PHARMACISTMANAGED CLINIC (B1)?, Diana Chen, Phillip Ng. VA Loma Linda Healthcare System, Loma Linda, CA (Diana.Chen2@va.gov) IRB approved. The study objective was to examine the percentage of patients that were able to maintain LDL control 12 months post discharge from clinical pharmacist managed lipid clinics. Chart review was conducted for all patients who were discharged from pharmacist managed clinics in VA Loma Linda Healthcare System between March 1, 2006 and December 1, 2009. 2,000 patients were screened in Computerized Patient Record System and 400 patients were enrolled in the study. Relevant lipid parameters such as LDL, HDL, TG, and TC was collected upon discharge, at 3 months, 6 months, 9 months, 12 months post discharge, and up to 18 months post discharge. LDL was also collected prior to enrollment into the pharmacist managed lipid clinics for subgroup analysis. Results and conclusion will be presented.

DEVELOPMENT AND IMPLEMENTATION OF A PATIENT SATISFACTION SURVEY FOR AMBULATORY CARE SERVICES: A MTM PILOT (B1) Jennifer Chiok. Kaiser Permanente San Mateo Area, Redwood City, CA. (jennifer.x.chiok@kp.org) IRB approval not needed. Although ambulatory care pharmacy services are well established at Kaiser Permanente, an ongoing process to effectively capture patients perceived value and satisfaction with ambulatory care pharmacists is not in place. The objective of this pilot study is to develop a patient satisfaction survey tool and process that can be used to measure ongoing quality of service in the Northern California Kaiser Permanente Medication Therapy Management (MTM) program. A survey tool was developed with questions divided into five categories, including informativeness, care experience, convenience and access, confidence in care, and overall satisfaction. The ongoing process involved mailing surveys to eligible patients within two weeks of a comprehensive medication review provided by a MTM pharmacist. Patients were given the option to complete the survey online or by mail. Surveys were distributed from January 2011 to March 2011. The results of the surveys will be used to develop a scorecard on service performance for individual and area pharmacists. Results and analysis will be presented.

ROLE OF A PHARMACIST-MANAGED REFILL PROGRAM AS PART OF A PATIENT-CENTERED MEDICAL HOME (B1). Katherine Choiniere, Steven Erickson, Annie Lam. Valley View Clinical Pharmacists, Monroe, WA (wallerk@uw.edu) IRB approved. The purpose of this study was to provide evidence that will describe and quantify the contributions of a pharmacist-managed refill authorization service to a patient-centered medical home. Pharmacists at two internal medicine clinics within the Providence Medical Group in Washington currently authorize non-controlled medication refill requests on behalf of prescribing physicians under a state-authorized collaborative practice agreement. Over a period of one month, data were collected for all refills authorized by the pharmacists. Data included patient's diagnosis, refill approval or denial, and pharmacists' interventions (e.g., request for a follow-up visit or labs, or therapeutic substitution made). After the data collection period, patient charts were examined to determine if requested follow-up visits and/or labs were agreed upon and/or ordered/completed by the prescribing physician. Results of the study will focus on percentage of pharmacist recommendations that were accepted or completed. Results and conclusion will be presented.

PROPOSAL FOR THE ADDITION OF A PHARMACIST TO AN AMBULATORY CARE ONCOLOGY CENTER, (B1), Shawna Cook. Benefis Health System, Great Falls, MT. (cook.shawna@gmail.com) IRB approval not needed no human subject data. The objective of this study was to review the available literature to determine the feasibility of adding a pharmacist to the care team at an ambulatory care oncology center. To determine the unique contributions a pharmacist can provide to this particular setting, the practice site was visited. The final step in determining how a pharmacist can be incorporated into the setting was through conducting interviews with current staff. The results of the site visit and staff interviews will also be discussed.

PHARMACIST MANAGED COLLABORATIVE PRACTICE FOR ORAL CHEMOTHERAPY (B1). Amber Diaz, Semra Stanley, Trish Mayhew, Meggan Smith. Southwest Washington Medical Center, Vancouver, WA (adiaz@swmedicalcenter.org) IRB approval received. The study objective was to evaluate the feasibility of extending clinical oncology pharmacy services at the Southwest Washington Regional Cancer Center to manage oral chemotherapeutic agents with the goal to improve patient safety and provide quality care. Clinical pharmacy services were utilized to provide initial patient education upon receiving oral chemotherapy, to provide follow-up care, and to provide appropriate laboratory, adverse effect, and drug interaction monitoring. Monitoring and clinical management was provided by a pharmacist operating under a collaborative practice agreement. Efficacy outcome measures included the following: 1) number and type of pharmacist interventions 2) cost-effectiveness of implementing the service 3) physician satisfaction with service. Results and conclusions will be discussed.

OUTCOMES OF A PHARMACIST IN A PATIENT CENTERED MEDICAL HOME CLINIC (PCMH) (B1). Kimberly Dong, Jonathan Wong, Randell Miyahara. Veterans Affairs Palo Alto Health Care System (VAPAHCS), Palo Alto, CA (kim.dong@va.gov) IRB pending. The PCMH model was developed in the 1960s as a way to ensure patient centered, physician guided care under a team of collaborative health care professionals. Implementing the PCMH model, referred to as Patient Aligned Care Teams (PACT) in the VA System, has the potential to improve the quality of the health care system. This model was recently implemented at the VAPAHCS but its effectiveness has not been evaluated. The objective of this retrospective study is to assess the outcomes of a clinical pharmacist who manages patients with diabetes, hyperlipidemia, hypertension, or a combination of the above conditions, in the PACT clinic at the VAPAHCS. Baseline data for patients referred to the clinical pharmacist will be compared to a snapshot of data collected at a maximum of four months later after enrollment into the clinic to determine the patients progress toward their goal metrics. Patients are excluded if they were not referred to the clinical pharmacist or if they were followed for less than one month for hypertension and two months for diabetes or hyperlipidemia, respectively. Paired t tests will be used to analyze continuous data and the Chi square test will be used to describe nominal data. Results and conclusions will be presented.

PLANNING AND DESIGN OF THE PHARMACISTMANAGED COMPONENT OF A MULTIDISCIPLINARY DIABETES CLINIC (B1). Pierre-Alex Duvivier. Adams Solola. TCRHCC, Tuba City, AZ (Pierre-Alex.Duvivier@tchealth.org) IRB approval is not needed-no human subject data. The purpose of the study is to establish a diabetes clinic in a rural Native American population. This study aims first to develop the initial steps for organizing and designing a pharmacy managed diabetes clinic under a collaborative practice agreement between pharmacy and the prescribers in the facility, then to implement these steps. This clinic will treat newly diagnosed patients with type 2 diabetes. In the beginning, this project will be presented to the Tuba City Regional Health Care Corporation (TCRHCC) Diabetes Advisory Committee, the Medical Executive Committee, the Pharmacy and Therapeutics Committee, and others for approval. A protocol will be designed for the clinic. This protocol will combine attributes of the facility, the patient population, and components from programs elsewhere that are similar to the concept that is planned for this facility. Upon review of the protocol by the several hospital committees mentioned above, the protocol will be modified based on feedback from the different committees prior to seeking final approval. Once the protocol is approved, patient encounter forms, EHR templates, guidelines, and training will be developed for the pharmacist providers of the diabetes clinic.

IMPACT OF A PHARMACIST MANAGED REFILL CLINIC ON PATIENT CARE AND COST SAVINGS (B1), Natalie Fan. Alameda County Medical Center, Oakland, CA (nfan@acmedctr.org) IRB approval pending. Alameda County Medical Center receives a high volume of refill requests from patients and neighboring pharmacies. Previously, the adult medicine refill clinic staffed a part time physician, a physician assistant, a medical assistant, and a clerk. At that time, the average turnaround time was about 14 days. Patients thus presented to the Emergency Department or Urgent Care for medication refills. A pharmacist managed refill clinic will possibly benefit patients, providers, and the hospital. The primary objective is to evaluate the interventions pharmacists make within the clinic. The pharmacist will authorize refills for chronic medications within 72 hours, arrange for primary care follow up appointments, order appropriate labs, initiate prior authorizations, and ensure that patient receives the appropriate medications. The following interventions will be measured through i2iTracks, a population health management system. i2iTracks will also be used to maintain an updated medication list for each patient. The secondary objective is to assess the potential cost savings. Implementation of a pharmacist driven refill clinic will potentially alleviate provider burden so that more time is dedicated to reimbursed visits, and improve the quality of patient care.

IMPACT OF PHARMACISTS INTERVENTIONS IN PATIENTS ON VERAPAMIL/DILTIAZEM AND HIGHER THAN RECOMMENDED SIMVASTATIN DOSES TO MINIMIZE RHABDOMYOLYSIS RISK (B1), Nancy Fong. Kaiser Permanente Medical Care Program, West Los Angeles, CA (nancy.x.fong@kp.org) IRB approved. Reported rates of fatal rhabdomyolysis are 0.12 for every one million prescriptions of simvastatin. Although the incidence is low, the Food and Drug Administration (FDA) has released a drug safety communication concerning an increased risk for myopathy and rhabdomyolysis in combining high-dose simvastatin with certain CYP3A4 inhibitors, such as verapamil and diltiazem. The recommended maximum dose of simvastatin is 20 mg for patients on verapamil and 40 mg for patients on diltiazem. The objective of this project was to evaluate the implementation of a pharmacist clinical intervention program developed to reduce the number of patients on the combinations of these medications exceeding the maximum recommended doses. Clinical decision-making materials were developed, in collaboration with physicians, to switch patients to safer alternatives. Eligible patients were identified via prescription dispensing histories and chart reviews. The impact of pharmacists clinical interventions was evaluated by a comparison of the pre and post number of patients successfully switched, and the types of interventions made. Changes in blood pressure, heart rate, liver function tests, and/or lipid panel were evaluated as secondary goals. Results will be presented and discussed.

IMPACT OF VISITING FRIENDS AND RELATIVES (VFR) TRAVEL ON CHRONIC DISEASE (B1) Holly Gurgle, Tiffany Erickson, David Roesel. UW Medicine, Seattle, WA (hollyeg@uw.edu) IRB approved. VFR travelers are individuals traveling internationally to visit friends and relatives in countries in which a gradient of epidemiologic risk exists between home and destination. As opposed to general tourism, VFR travel is often longer in duration and involves staying in local homes, having close contact with locals, consuming high risk foods and water, and traveling to rural or unsecure areas. VFR travelers have increased risk of travel related health problems but are less likely to seek travel counseling or be appropriately vaccinated. Increasingly, pharmacists practicing in the ambulatory setting are providing travel health consultations as part of their primary care services. Travel health consultations often focus on infectious disease prevention but current evidence suggests that travelers are far more likely to succumb to the same illnesses, complications, and acute events as they would in the USA. Little is known about the impact of travel on chronic disease in VFR travelers. The objective of this study is to determine if there is a change in chronic disease markers amongst VFR travelers. This study is a retrospective, chart review of outpatients receiving travel health counseling in the International Medicine Clinic at Harborview Medical Center, a primary care clinic for immigrants and refugees. Data collected includes: markers of chronic diseases, descriptions of travel consultation and travel, and documented health problems. Results and conclusions will be presented.

IMPACT OF A MEDICATION RECONCILIATION SERVICE PERFORMED BY VOLUNTEER STUDENTS ON PATIENT SAFETY IN A UNIVERSITYAFFILIATED COMMUNITY CLINICS NETWORK (B1), Song Yun Han. USC School of Pharmacy, Los Angeles, CA (songyhan@usc.edu) IRB approval pending. The study objective was to develop and implement a system for identifying and clarifying the significance of adverse drug events (ADEs) and potential adverse drug events (pADEs) among patients who receive care through a network of university-affiliated safety net clinics. ADE and pADE tracking was integrated into a form and computer database used to document pharmacist interventions. Taxonomy from the National Coordinating Council for Medication Error Reporting and Prevention was incorporated to categorize ADEs and pADEs, and each pADE was rated as mild, moderate, or severe depending on the potential harm avoided. Volunteer pharmacy students from all levels were recruited and trained on how to conduct a medication reconciliation, including screening for ADEs and pADEs. Trained pharmacy students were assigned to specific clinics for continuity and supervised by clinical pharmacists, with the goal of providing medication reconciliation and safety screening for every patient receiving care at the clinics. A report summarizing the types of ADEs and pADEs detected, the severity of pADEs avoided, and the most severe ADEs and pADEs identified and resolved will be compiled at 3-month intervals and shared with medical staff. Results and conclusions will be presented.

THE ROLE OF CLINICAL PHARMACISTS IN A HIV CARE TEAM: A RETROSPECTIVE REVIEW (B1). Cathy Hau. Kirsten Balano. University of California at San Francisco, San Francisco, CA (Cathy.Hau@ucsf.edu) IRB Approved. The objective of this study is to describe the clinical interventions and patient population that are being served by pharmacists in the HIV clinics at the Sonoma County and to define a subpopulation of HIV patients whom pharmacists intervention will be the most beneficial for their disease state management. The study is conducted as a non randomized, retrospective database review that utilizes the Sonoma County HIV patient database to compare baseline demographic data for HIV patients with or without pharmacists follow up. This is a clinical database containing approximately 500 patients, with demographic information, antiretroviral history, problem lists, CD4, and HIV viral load data being maintained by physicians in order to monitor patient care. In addition, medication lists, and clinical pharmacy interventions are entered into the database. Using data from January 2009 to December 2010, we compare clinical characteristics between patients who received pharmacists care and those who did not. Patients with incomplete information in the database will be excluded from the study. We will also evaluate the types of pharmacist interventions provided. Ultimately, we plan to

generate a set of clinical parameters that warrant pharmacists interventions. These parameters will be utilized by the Sonoma County HIV Healthcare Network to standardize referral to HIV pharmacists and to standardize the interventions provided. Results and conclusions will be presented.

IMPLEMENTATION OF A PHARMACIST DIRECTED DIABETES MANAGEMENT CLINIC (B1). Kelly Hegarty. Tricia Patterson. Banner Baywood Medical Center, Mesa, AZ (kelly.hegarty@bannerhealth.com) IRB approval pending. The purpose of this project is to develop and implement an outpatient, pharmacist driven diabetes clinic with a focus on education and medication management at a community hospital. Initial clinic appointments will be scheduled per physician orders upon hospital discharge or by community physician referrals. Targeted patients for enrollment will include those with poorly controlled diabetes, new diagnosis of diabetes, or new start insulin. Questionnaires will then be used to evaluate the impact of the education program, its ability to improve patient understanding, and patient satisfaction. A retrospective chart review will be used to compare Hemoglobin A1C levels at baseline and at three month intervals after initial enrollment. The study period for the questionnaires will be four weeks. Inclusion criteria for data analysis will be age greater than 18 and enrollment in the clinic. Patients who do not wish to participate or who do not complete all questionnaires will be the excluded from the study. Data collection is ongoing. Preliminary results and conclusions will be presented.

DEFINING THE ROLE OF A PHARMACIST IN A HIV/AIDS PATIENT CENTERED MEDICAL HOME MODEL (B1), Paulin Heng, Kaiser Permanente Medical Care Program, Los Angeles, CA (paulin.x.heng@kp.org) IRB approved. The patient-centered medical home model is a team-based approach to primary care services and consists of the following core principles: whole person orientation, coordinated care, enhanced access to care, ongoing relationships between patients and providers, and quality and safety. At Kaiser Permanente Los Angeles, ambulatory care pharmacy services for HIV/AIDS patients are provided in a novel and unique setting that incorporates the medical home model. HIV physician specialists, pharmacist, nurses, care coordinator, and social worker work together in the same clinic to provide comprehensive care management for HIV/AIDS and non-HIV/AIDS conditions. The primary objective of this study is to define and evaluate the roles of the HIV pharmacist within a HIV/AIDS medical home through analysis of the types of clinical interventions made. Patient chart reviews were conducted to identify, categorize and quantify the types of interventions made by the pharmacist. This information was then used to create a comprehensive description of the HIV pharmacist's role within the medical home. Secondary outcomes looked at antiretroviral medication adherence and hospital readmission rate for any medical condition. Data for frequency of CD4+ testing, percentage of patient with controlled HIV RNA load and metabolic outcomes were also collected. Results and conclusions will be presented and discussed.

EVALUATION OF PERIPROCEDURAL ANTICOAGULATION IN PATIENTS UNDERGOING ATRIAL FIBRILLATION ABLATION (B1). Sara Hiller. Sara R. Vazquez. Amanda Walker. University of Utah Health Care, Salt Lake City, UT (sara.hiller@hsc.utah.edu) IRB approval received. Currently, controversy surrounds periprocedural anticoagulation of AF ablation. Although there is general agreement that anticoagulation is needed, recommendations from consensus guidelines differ on type and duration of anticoagulation. For patients undergoing AF ablation at the University of Utah Health Care, the method of periprocedural anticoagulation varies. The objective of this study was to retrospectively evaluate patient care and outcomes resulting from differences in periprocedural anticoagulation in patients undergoing AF ablation. Patients were included if they had an AF diagnosis, underwent radiofrequency catheter ablation at our institution between July 1, 2009 and June 30, 2010, had warfarin therapy managed by the University of Utah Thrombosis Service, were at least 18 years old, and had follow up documentation for at least six months after ablation. The primary outcomes were to define variable methods of anticoagulation before and after AF ablation. This data will include percent of INRs in the goal range before and after ablation. The secondary outcomes were to evaluate the safety and efficacy of the variable methods of anticoagulation at our institution. The results will be used to build a protocol to standardize the periprocedural anticoagulation management of this patient population. Results will be discussed.

COMPARISON OF ORAL AND INJECTABLE ANTICOAGULATION FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS AFTER MAJOR ORTHOPEDIC SURGERY (B1), Charlene Joe. Kaiser Permanente East Bay, Oakland, CA (Charlene.x.joe@kp.org) IRB approved. The study objective was to determine whether oral or injectable anticoagulant should be recommended for venous thromboembolism prophylaxis in post orthopedic surgery patients to optimize clinical outcomes and cost effectiveness. This retrospective study included Kaiser Permanente patients age 18 years or older who underwent major orthopedic surgery and were referred to Kaiser Permanente Oakland Anticoagulation Clinic for venous thromboembolism prophylaxis in 2009. The exclusion criteria included patients with an admitting diagnosis of venous thromboembolism, active bleeding, congenital bleeding/clotting disorders, and hemorrhagic stroke, or on either warfarin, enoxaparin, or fondaparinux within the past three months. For data analysis, patients were divided into one of three arms: on warfarin, enoxaparin, or fondaparinux. The primary endpoints looked at the frequency of DVT/PE events, bleeding complications, and cost between anticoagulants. To further analyze cost, an analysis was completed incorporating the following: readmission rates, number of hospital days, number of emergency room visits, number of pharmacist telephone visits, number of clinic visits, number of INR/CBC labs done within three weeks duration of therapy, cost of each blood draw, cost of a nurse visit, and cost of the medication. Secondary endpoints evaluated include:

mortality, mean number of hospital days, median/mean time to reach INR goal, and time in therapeutic range for warfarin patients. Results and conclusion will be presented.

CLINICAL OUTCOMES OF A PHARMACISTMANAGED DIABETES MELLITUS CLINIC (B1). Jay Joson. Ryan Gates. Kern Medical Center, Bakersfield, CA (josonj@kernmedctr.com) IRB pending. The study follows patients from previous studies at Kern Medical Center, analyzing long-term (greater than 6 months) clinical outcomes, as well as new patients. The primary endpoint was hemoglobin A1c level. Secondary endpoints included blood pressure, lipids, microalbumin-tocreatinine ratio, calcidiol level, and diabetes-related emergency department visits and hospital admissions. A retrospective study of data from January 2007 to February 2011 was researched. Inclusion criteria included: age over 18, A1c over 7%, 2+ clinic visits, 1+ follow-up lab results. Exclusion criteria included: age less than 18, A1c less than or equal to 7%, non-adherence to clinic visits or labs, and pregnancy. Results and conclusions will be presented.

DRUG-RELATED ISSUES IDENTIFIED IN PHARMACIST-DELIVERED COMPREHENSIVE MEDICATION REVIEWS (B1), Jina Jung, Danmy Loi, Jennifer Shin, Karen Stockl, Lihua Zhang. Prescription Solutions, Irvine, CA (jina.jung@prescriptionsolutions.com) IRB approved. In an effort to improve medication use and optimize therapeutic outcomes, Prescription Solutions, a national PBM, has implemented the comprehensive medication review (CMR) program as part of the Medication Therapy Management (MTM) program. Medicare Part D members who are eligible for the MTM program were offered a telephonic CMR conducted by a pharmacist. Although studies have shown improved outcomes as a result of MTM interventions, there is limited outcomes data supporting the effectiveness of telephonic CMRs run by pharmacists. The primary objective of this study is to assess the prevalence and resolution rates of medication therapy issues identified during a CMR. In addition, demographics and characteristics of CMR participants will be examined to detect attributes that may result in higher resolution rates for the identified issues. A retrospective, observational cohort analysis of patients identified for the MTM program during 2010 will be conducted using electronic pharmacy claims and patient reported data. Demographics and characteristics of CMR enrollees will be compared to nonenrollees. Among the CMR enrollees, the most common medication therapy issues and their resolution rates will be reported for the total population as well as those with specific medical conditions. The evaluation of

this study is currently underway. Results of the study will be available for presentation and discussion at the conference.

DEVELOPMENT OF PHARMACIST SERVICE FOR THE MANAGEMENT OF HYPERURICEMIA IN GOUT PATIENTS (B1), Jean Kao, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (jean.x.kao@kp.org) IRB exemption received. Gout is the most common inflammatory arthritis in the United States, affecting about 6.1 million Americans and comprising about 3.9 million of ambulatory care visits yearly. The disease is characterized by supersaturation of serum uric acid and the subsequent deposition of urate crystals in the joints. Hyperuricemia is a primary risk factor for gout. Therefore, the reduction of serum uric acid is a key treatment objective to decrease the likelihood of recurrent gout attacks. However, patients are often lost to follow up after initial management and do not initiate uric acid lowering therapy. Adherence with lab tests and medications has also been identified as obstacles to appropriate management of hyperuricemia. The objective of this project is to develop an ambulatory care pharmacy service at KP Santa Clara Medical Center to improve management of hyperuricemia in gout patients. Key steps include development of a pharmacy practice protocol, outreach to solicit patient referrals from rheumatology and primary care physicians, and pilot of the clinical service by an ambulatory care pharmacist. Future assessment will include data collection on serum uric acid, frequency of gout flares, physician office and ED visits secondary to acute attacks, and additional healthcare expenses. An analysis of the development and implementation of this novel clinical pharmacy service will be presented.

PHARMACIST COLLABORATIVE PRACTICE FOR THE MANAGEMENT OF DIABETES MELLITUS AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN A HEART FAILURE CLINIC (B1). Kayla Kent. Kristin Peterson. FHS, Tacoma, WA (kaylakent@fhshealth.org) IRB approval not needed. The objective of this project was to create, implement, and evaluate the effectiveness of collaborative practice agreements and protocols for pharmacist driven diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) management in a heart failure clinic. Data from the Franciscan Health Systems (FHS) Heart Failure clinic has shown a correlation between uncontrolled DM and heart failure readmissions. Collaborative practice agreements and protocols were approved by the Washington State Board of Pharmacy. Patients with uncontrolled DM or COPD were referred by the primary provider at FHS Heart Failure clinic for pharmacist disease state management. Patient appointments were conducted by the pharmacist from January 2011 to April 2011. The primary study objectives were reduction in heart failure related emergency department visits and hospital readmissions at Saint Joseph Medical Center, as well as reduction in COPD exacerbation emergency department visits and hospital readmissions at Saint Joseph Medical Center. Secondary outcomes addressed blood glucose measurements, HgbA1C, and medication adherence, as well as provider and patient satisfaction. Results and conclusions will be presented.

DEVELOPING A PROTOCOL TO REDUCE THE RELATIVE RISK OF MUSCLE RELATED ADVERSE EVENTS IN PATIENTS ON A HIGHLY INTERACTIVE STATIN AND GEMFIBROZIL (B1). Abraham Kim. Kaiser Permanente Medical Care Program, Los Angeles, CA (abraham.k.kim@kp.org) IRB approved. Due to a higher risk of muscle related adverse events such as myalgias and rhabdomyolysis with the concurrent use of highly interactive statins and gemfibrozil, the manufacturers and the FDA have made recommendations on the maximum dosage of such statins (lovastatin 20 mg, simvastatin 10 mg, rosuvastatin 10 mg) when taken with gemfibrozil. Despite the safety alert in the computer physician order entry and outpatient pharmacy computer systems when these combinations are prescribed or dispensed, there are still patients who are on both medications. The study objective was to determine the number of patients on this particular combination and identify what types of opportunities exist in optimizing their lipid therapy and minimizing the interaction based on a developed algorithm. A retrospective chart review was conducted to identify patients who filled a highly interactive statin and gemfibrozil between January 1, 2010 and September 30, 2010. Exclusion criteria include pregnancy, HIV, patient on dialysis, history of transplant or no longer on an interactive statin or gemfibrozil. These patients were categorized into either "therapy already optimized" or "potential for further optimization" and the recommended action based on the algorithm was documented. Results and conclusions to be presented.

IMPLEMENTATION AND EVALUATION OF A MULTIDISCIPLINARY ASTHMA QUALITY IMPROVEMENT PROGRAM FOR A HOMELESS POPULATION (B1). Melissa Kim. University of Southern California, Los Angeles, CA (melissa.kim@usc.edu) IRB pending. Multiple barriers such as low health literacy and substandard living conditions make asthma control for homeless patients uniquely challenging. The objective of this study is to describe the implementation of a multidisciplinary asthma quality improvement (QI) program for homeless patients and identify variables associated with attainment of asthma treatment goals. Clinical pharmacists led the development of the QI program which consisted of evaluations / screenings, services, interventions, and core drug therapies for all patients with asthma. Physicians, medical assistants, social work, and clinical pharmacy all had distinct direct patient care and documentation responsibilities. In addition, the pharmacists were responsible for entering all asthma measures into a database and reporting findings to the clinic quality improvement committee. Asthma measures, consistent with current national guidelines and the National Quality Foundation, include process measures (e.g., enrollment in an asthma education class, ) and clinical outcome measures (e.g., Asthma Control Test scores, attainment of Well-Controlled status). A multivariate

analysis will be conducted to identify variables that are strongly associated with attainment of asthma treatment goals. Results and conclusions will be presented.

OUTCOMES ESTABLISHING A PHARMACIST-RUN EPO STIMULATING AGENT CLINIC IN NON DIALYSIS CHRONIC KIDNEY DISEASE PATIENTS (B1). William Kuykendall, Linda Banares. San Francisco General Hospital, San Francisco, CA (william.kuykendall@tu.edu) IRB exempt. Anemia associated with chronic kidney disease is related to increased morbidity and mortality and decreased quality of life. Patients with chronic kidney disease often have a deficiency in erythropoietin. Erythropoietin stimulating agents (ESAs) are used in patients with chronic kidney disease to help stimulate red blood cell maturation and to increase quality of life. Pharmacists at San Francisco General Hospital (SFGH) recently developed a collaborative practice protocol for managing anemia in non-dialysis chronic kidney disease (ND-CKD) patients. Goals of this pharmacist-run clinic are to maintain therapeutic hemoglobin, ferritin, and TSAT levels while minimizing fluctuations with Hgb and educating patients on ESA therapy. The objective of this study is to determine the therapeutic and safety outcomes of this pharmacist-run clinic. The study will compare therapeutic maintenance of patients pre- and post-implementation of the ESA pharmacist-run clinic. The following data will be collected: patient age, gender, ethnicity, SBP, DBP, CBC, Hgb, Hct, ferritin, TSAT, medications, comorbidities, and reported adverse events. Multivariant regression analysis will be utilized to describe the outcomes of this study. Results and conclusions will be presented.

EVALUATING TREATMENT PRACTICES FOR PATIENTS WITH ISCHEMIC STROKE (B1), Lisa Lash, Kari Olson, Kaiser Permanente Colorado, Denver, CO (Lisa.J.Lash@kp.org) IRB approval received. Treatment guidelines for ischemic stroke are widely available, yet studies indicate they are inconsistently applied in clinical practice. The objective of this study was to evaluate treatment patterns for patients with ischemic stroke according to national clinical practice guidelines. This was a cross sectional study of patients who were 18 to 85 years of age, members of Kaiser Permanente Colorado for at least 6 months, and had a validated ischemic stroke diagnosis. Patients with transient ischemic attack or intracranial or subarachnoid hemorrhage were excluded. Patient demographics, comorbidity, vital sign, fasting lipid profile, and medication (lipid lowering, antihypertensive, and antiplatelet therapy) data within 365 days but most proximal to December 31, 2010 were administratively identified. Patients were considered to be taking evidence based medications if the day supply overlapped December 31, 2010. Goal LDL was defined as less than 100 mg/dL and goal blood pressure was defined as less than 130/80 mmHg. Factors associated with attaining lipid and blood pressure goals among these patients will be determined. Descriptive statistics, t-tests, Pearsons chi square test, and multivariate logistic regression were used in data analysis. Preliminary results and conclusions will be presented.

INITIATION AND ASSESSMENT OF PHARMACY MANAGED AMBULATORY REFILL AUTHORIZATION WITHIN AN INTEGRATED HEALTH SYSTEM (B1) Christopher Ledeboer. MultiCare Health System, Tacoma, WA (Christopher.Ledeboer@multicare.org). IRB approval not needed. Refill requests present a significant disruption to ambulatory clinics with increased physician and nurse workload. In addition, delays in refill authorization interrupt the continuity of patient care. Pharmacists are an important resource for medication knowledge and can be used to determine the appropriateness of drug therapy. The objective of this pilot project is to create, implement, and evaluate the impact of pharmacy managed refill authorization. A collaborative practice agreement was established with three primary care providers based out of the MultiCare Gig Harbor Clinic for pharmacy managed refill authorization for six weeks during February to March 2011. An internal protocol was developed to streamline the refill authorization process utilizing smart tools built within the electronic chart. Pharmacists were trained and completed a refill authorization competency prior to the pilot. Primary endpoints include comparison of refill request response time between pharmacist and physician management, physician time saved, and pharmacist time to authorize refills. Secondary endpoints include quality measures determined by pharmacist interventions, volume of requests, and the amount of months authorized. Results and conclusions will be presented.

MEDICATION THERAPY MANAGEMENT OUTCOMES IN ASTHMA CONTROL (B1). Alana Lee Providence Health Plans, Beaverton, OR (won.lee@providence.org) IRB approval pending. The study objective is to track and measure possible clinical outcomes of medication therapy management (MTM) program and pharmacists interventions in a subset of MTM eligible patients. Patients with uncontrolled asthma were identified by either inpatient or ER visit related to asthma or medication ratio of inhaled corticosteroid and inhaled short acting bronchodilator. Routine MTM reviews were conducted for these patients. For the patients who have completed the MTM review, data will be collected to compare the level of asthma control before and after MTM interventions. Data to be compared are the average number of short acting bronchodilator inhaler per month, the average medication ratio of inhaled corticosteroid and inhaled short acting bronchodilator, average number of long acting beta agonist use per month, average number of anticholinergic use per month, rate of oral steroid use, rate of hospital or ER visit as well as the number of recommendations made to and accepted by the providers. The impact of MTM interventions will be assessed by paired t tests of these data. Results and conclusions will be presented.

DEVELOPMENT OF A PROTOCOL INCORPORATING STUDENT VOLUNTEERS TO COLLECT AND REPORT DRUG THERAPY INTERVENTIONS AND SAFETY DATA FOR UNIVERSITY-AFFILIATED COMMUNITY CLINICS (B1). Boram Lee. USC School of Pharmacy, Los Angeles, CA (Boram.Lee@usc.edu) IRB approval pending. The study objective was to develop and implement a system for identifying and tracking interventions made by pharmacists to assure the safe and optimal use of medications in university-affiliated community clinics. Nationally-recognized tools and resources were used to develop categories of drug-related problems, including medication safety issues, that pharmacists frequently identify and resolve. A documentation form and computer database program were created that incorporated these elements. Due to time constraints, clinical pharmacists working in the community clinics were unable to screen for drug-related problems among all patients receiving care at the clinics; as a result, volunteer pharmacy students from all levels were recruited and trained on how to conduct a medication reconciliation and document findings in the computer database. Trained pharmacy students, under the supervision of a clinical pharmacist, were assigned to specific clinics for continuity and a protocol was developed at each clinic to integrate medication reconciliation into patient flow, usually immediately prior to provider

appointments. Data regarding the types of drug-related problems identified and actions taken to resolve these will be evaluated at 3-month intervals and shared with medical staff. Results and conclusions will be presented.

IDENTIFYING AND MANAGING BARRIERS TO ADHERENCE TO LOWER BLOOD PRESSURE IN A PHARMACIST MANAGED HYPERTENSION CLINIC (B1), Daniel Louie, Teresa Kwong, University of California Davis Medical Center, Sacramento, CA (daniel.louie@ucdmc.ucdavis.edu) IRB pending. The objective of this retrospective and prospective chart review is to identify specific barriers to blood pressure control and the specific intervention to break those barriers at UC Davis Medical Center (UCDMC) Hypertension Clinic. Subjects at least 18 years of age and managed by the UCDMC Hypertension Clinic between January 2007 and April 2011were included. Patients lost to follow up or did not keep appointments were excluded. Specific barriers (insurance/cost, education, age, and transportation) to reach blood pressure goal and specific interventions of pharmacists were identified. Blood pressures with pulse were assessed. Other outcomes measured include improvement in blood pressure, defined as 10 point reductions in systolic and five point reductions in diastolic readings, number of follow up appointments required to achieve to goal or improvement, and proteinuria. Baseline characteristics were also collected to stratify the patient population. Results and conclusions will be presented.

EVALUATING A TRANSITIONAL CARE PHARMACIST PROGRAMS IMPACT ON REDUCING HOSPITAL READMISSION RATES AND INCREASING MULTIDISCIPLINARY COORDINATION (B1), Sunita Madadi. Kaiser Permanente Medical Center, Sacramento, CA (sunita.x.madadi@kp.org) IRB not needed. Studies have shown that nearly half of all patients discharged home after an inpatient encounter experience an adverse drug event (ADE), medication dispensing error, polypharmacy, serious drug interaction, or improper follow up. It has been shown that integration of a pharmacist in the discharge process improves patient care. The objective of this project is to demonstrate the value of the Transitional Care Pharmacist (TCP) program in improving compliance, decreasing the hospital readmission rate, and increasing patient satisfaction. In this study, a TCP reviews medications to identify any potential adverse drug reactions or medication discrepancies and educates patients on their medications prior to discharge. This integrated workflow results in a seamless transition in pharmaceutical care. This program is in place on the medical/surgical hospital floor, Monday through Friday between 9:30am and 6pm. Patients discharged outside these hours or during weekends or holidays were excluded, as well as patients under the age of 18 and patients discharged to a SNF. All TCP discharges completed between December 2009 through July 2010 were evaluated to determine the types of interventions made, to compare 30 day readmission rates pre- and post-TCP implementation, and to estimate potential cost savings associated with trends in 30 day

readmission rates and prevention of ADEs and medication discrepancies. Results will be used to justify the need for a TCP program.

DEVELOPMENT OF A BUSINESS PLAN FOR A SPECIALTY PHARMACY AT COMMUNITY HOSPITAL (B1), Ellen Maddox, Southwest Washington Medical Center, Vancouver, WA (ejmaddox@swmedicalcenter.org) IRB approval is received. The purpose of this project was to assess the financial and operational feasibility of a self-affiliated specialty pharmacy at Southwest Washington Medical Center (SWMC). A preliminary specialty drug formulary based on patient usage and external specialty pharmaceutical outsourcing was developed. Current health plan utilization was determined through pharmacy claim reports for benefit eligible SWMC employees and dependants over the past fiscal year. A cost-analysis comparison of the current drug reimbursement processes to a self-affiliated specialty pharmacy model was the primary means of assessing cost-feasibility. A formal business plan was designed, which includes: market assessment, drug formulary, current health plan usage, strategic planning, cost-analysis, and step-by-step action plan and timeline for implementation. The primary efficacy outcome measures were: 1) annual cost-savings for drug reimbursement through the PHSW specialty pharmacy model and 2) expanded access to specialty drugs for health plan members. The results of the project will be discussed.

CONSULTANT VS COLLABORATIVE PRACTICE AGREEMENT AMBULATORY CARE PHARMACIST MODELS FOR CMS SPECIAL NEEDS PLAN PATIENTS (B1), Erin Matsushita. Kaiser Permanente Medical Care Program, Baldwin Park, CA (erin.a.matsushita@kp.org) IRB approval received. As part of the Medicare Modernization Act of 2003, Special Needs Plans (SNP) were developed for MedicareMedicaid, dual-eligible patients which include coordinated care by an interdisciplinary team. Beginning January 2010, Kaiser Permanente (KP) implemented the SNP model of care which includes an annual review by a team comprised of a physician, pharmacist, nurse, and social worker that addresses medical and social needs in collaboration with the patients primary care physician. The study objective was to compare two models of ambulatory care pharmacists involved with SNP care for KP Southern California by assessing the role and interventions of a consultant versus a collaborative practice agreement model. The consultant model involves a pharmacist performing a medication review through electronic chart review over a limited number of hours. In comparison, the collaborative practice agreement model allows the pharmacist time to perform a comprehensive medication review, including patient interview and medication adjustments as appropriate. A productivity database was developed to collect the recommendations and interventions of pharmacists in each practice setting. A retrospective analysis from October 2010 to January 2011 will help describe the impact of ambulatory care pharmacists within SNP care. Results and conclusions will be presented.

EVALUATION OF A PHARMACIST RUN, TELEPHONE PAIN ASSESSMENT PROGRAM FOR CHRONIC PAIN PATIENTS (B1), Timothy Millar, Louise Wu, Tracy Lin. San Francisco VA Medical Center, San Francisco, CA (Timothy.Millar@va.gov) IRB approval received. The study objective was to describe the results of a telephone pain assessment program and to make recommendations for program development. This pilot program targets chronic pain patients on stable narcotic regimens that have not recently seen their primary care providers. The pain management pharmacist calls these patients and asks a standard set of questions to assess patient knowledge of their pain regimen, adequacy of pain control, impact of pain on function and emotional well being, and adverse drug effects related to pain medications. The pharmacist then evaluates patient responses, recommends follow up if needed, and records the phone encounter as a note in the medical record. The present study is a six month retrospective chart review of these telephone pain assessment notes. Specific outcomes include average pain scores, average impact of pain on daily function and emotional well being, proportion of patients able to correctly recall their pain regimen, proportion of patients experiencing adverse drug effects, proportion of patients recommended for follow up, and average time spent per phone call by the pain management pharmacist. Results will be discussed.

PATIENT PROGRESS UNDER PHARMACISTMANAGED DIABETES CARE IN A COMMUNITY CLINIC (B1), Emily Min. Alvin Goo. Carrie Yuan. University of Washington Medical Center, Seattle, WA (emilykm@uw.edu) IRB approved. This study aims to describe and quantify the effects of pharmacist intervention on diabetic patients over a two year period. Pharmacists in the Family Medicine Clinic at Harborview Medical Center participate in the collaborative management of complex diabetic patients. A retrospective chart review was performed on approximately 100 of these patients. The study population included patients with type II diabetes seen by clinic pharmacists at least twice between 2008 and 2009. Pregnant women and patients less than 18 years old were excluded. Key diabetic health markers, such as hemoglobin A1C, are collected at baseline and at the end of the study period. Additionally, changes in medication regimens are characterized. Finally, patient demographics are analyzed for correlation with diabetic outcomes. Results and conclusions will be presented.

A PAIN PLAN: RETROSPECTIVE ANALYSIS OF INDIVIDUALIZED EXTENDED RELEASE OXYCODONE (OXYCODONE ER) CONVERSION PLANS COMPLETED BY PHARMACISTS (B1). Tien Nguyen, Sophia Ho, Alex Cao. Kaiser Permanente Fontana Medical Center, Fotana, CA (tien.t.nguyen@kp.org) IRB approved. Oxycodone ER is a schedule II prescription narcotic that is highly abused and has a high street value. Oxycodone ER use is rising to epidemic proportions, leading to an increase in addiction and fatal overdoses. Recognizing its growing use and abuse in the community, the pharmacy department at the Kaiser Permanente Fontana Medical Center has piloted a pharmacist managed conversion service in which pharmacists develop and present Individualized Oxycodone ER Conversion (IOC) plans to prescribers in an effort to assist in identifying chronic oxycodone ER users and provide alternative narcotic analgesic agents for chronic pain management. This study will measure the impact of the IOC plans at 1, 3, and 6 months post delivery to prescribers in the Family Medicine and Internal Medicine departments. Endpoints that will be analyzed and assessed include; time to conversion to alternative narcotic analgesic(s), alternative analgesic(s) used, prescriber and patient acceptance of alternative analgesic(s), and the number of referrals to the Integrated Pain Management Program at the Kaiser Permanente Fontana Medical Center. Documentation of any changes made to patients medication profile by the physician regarding pain management will be obtained through retrospective chart review. Additionally,

educational materials will be developed to help educate and increase awareness of affected physician departments and medical practice locations. Study results will be presented.

VALIDATING A PREDICTIVE MODEL FOR PRIORITIZING MEDICATION THERAPY MANAGEMENT ENROLLMENT (B1), Nikki Nunokawa. Kaiser Permanente San Jose Medical Center, San Jose, CA (Nikki.S.Nunokawa@kp.org) IRB approval received. A previous study (Wu et al) done at Kaiser Permanente San Jose Medical Center produced a predictive modeling tool that showed a correlation between a comorbidity index score and risk of hospitalization in its Medication Therapy Management (MTM) patient population. The objective of this retrospective study was to put this tool through a rigorous validation process. This study looked at additional MTM eligible patients in 2008 that were not hospitalized nor included in the Wu study. In total, the Wu study looked at 290 patients; a comparable number of patients were reviewed in this study. The validation process entailed reviewing demographic data, prescription history, and ICD-9 codes to score each patient. The scores were then inputted into an equation to generate a theoretical probability of hospitalization. The actual validation occurred through tracking of hospitalizations that occurred in the following year, 2009. An analysis using logistic regression was done to determine if there was a correlation between the probability of hospitalization and actual hospitalization. The predictive value of this tool enables providers to prioritize patient contact. This tool may also apply to a more general population of patients with chronic conditions. Final results to be presented and discussed.

PHARMACIST MEDICATION RECONCILIATION VIA VIDEO CONFERENCE FOR PATIENTS AFTER HOSPITAL DISCHARGE (B1) Ethel Odiakosa. Desert Regional Medical Center, Palm Springs, CA (ethel.odiakosa@tenethealth.com). IRB not needed. Drug discrepancies after acute care discharge are a national problem which may result in preventable hospital readmissions. A program was developed at Desert Oasis Healthcare to decrease medication discrepancies and preventable drug related hospital readmissions in elderly patients. In this program hospital case managers provide patient information to the ambulatory care pharmacist. The pharmacist, via video conference, conducts a medication therapy review within one week after discharge. During the review the pharmacist completes a medication reconciliation, reviews appropriateness of drug therapy and provides patient education about medications and basic self care. During the video conference an assistant will visit the home to help the patient gather medications for the interview. Drug discrepancies and recommendations are documented and sent to the primary care provider prior to the next physician office visit. Data collected includes the number of drug discrepancies discovered and hospital readmissions within 30 days after discharge. It is expected that this program will meet Medicare Advantage Special Needs Program requirements for medication reconciliation post discharge. The results will be discussed.

EVALUATION OF A PHARMACIST INITIATED FLUTICASONE/SALMETEROL STEP-DOWN PROGRAM IN NAPA SOLANO KAISER PERMANENTE AREA (B1), Lily Phuong. Kaiser Permanente Vallejo Medical Center, Vallejo, CA (Lily.x.phuong@kp.org) IRB Exempt. The use of long acting beta agonists (LABA) as monotherapy has been associated with increased risk of asthma-related death. In 2010, The Food and Drug Administration mandated labeling changes that recommend stepping down LABA use when asthma control has been achieved and maintained. Primary care pharmacists collaborated with providers in Kaiser Permanente NapaSolano Area to develop a fluticasone/salmeterol (F/S) StepDown Program to decrease unnecessary LABA use in patients with well-controlled asthma. The objective of the study was to evaluate the efficacy of the program in decreasing F/S use. The study period was one year. Participants included patients with asthma aged 18 to 50 years old who filled F/S between 2009 to 2010. Patients were excluded if there was any indication of uncontrolled asthma, asthma exacerbations, diagnosis of chronic obstructive respiratory disease, or were being followed by the Pulmonary care managers. The primary endpoint was to determine the rate of change in F/S use after implementing the step down program in 2010 compared to previous years. Secondary endpoints included identifying the patient population that could most successfully step down F/S use, reviewing the barriers to the program, evaluating the existing step-down process, and recommending a more effective method of decreasing F/S

use that can be applied to other medical centers. Results and conclusions will be presented.

EVALUATION OF A COLLABORATIVE PROCESS TO IMPROVE DIABETIC MEASURES AS PART OF A MEDICAL HOME (B1), Caroline Pitney, Alvin Goo, Jamie Mazon, University of Washington, Harborview Medical Center, Seattle, WA (carollp@uw.edu) IRB approval received. The project objective is to evaluate the effect of primary care providers, pharmacists, nurses, and medical assistants working together to implement a more formalized, systematic, collaborative approach to the management patients with diabetes in a family medicine clinic medical home model. The collaborative approach involves the implementation of team huddles in which diabetic patients are assessed for appropriate monitoring, screening, referrals, and opportunities for medication adjustments and follow up. Clinical pharmacy is participating in team huddles to provide medication recommendations and information relating to medication adherence. Pharmacy is also involved in the development of a diabetic patient registry. All diabetic patients 18 years or older, with at least two clinic visits after the start of the project are included in the pre and post analysis. The study period is for 7 months. The primary outcome measures, as defined by the Washington State Medical Home Collaborative, are the change in hemoglobin A1c, blood pressure and LDL. The secondary outcomes are change in status related to nephropathy screen or treatment, foot exams, eye exams, referral to the nutritionist, appropriate immunizations, aspirin usage, smoking status, and assessment of problems with medication adherence or misuse. Clinical pharmacy is also tracking patients who

receive two or more pharmacy visits to determine if pharmacy visits are of benefit. Results and conclusions will be presented.

IMPLEMENTATION OF MEDICATION THERAPY MANAGEMENT SERVICES IN A HEALTH SYSTEM OUTPATIENT CLINIC (B1), Sundari Poegoeh, Teresa Blanc, Kristin Peterson, Keith Sinay. Franciscan Health System, Tacoma, WA (sundaripoegoeh@fhshealth.org) IRB Approval Not Needed. Franciscan Health System currently has four pharmacist-run anticoagulation clinics that are trying to expand their clinical services by providing Medication Therapy Management (MTM). Pharmacists who provide MTM services in clinic settings or manage chronic disease states can improve patients quality of life, reduce hospitalization, and ultimately decrease healthcare costs. The objective of this project is to demonstrate the value of MTM services to the health system by identifying the number of therapy interventions per MTM visit, improving patients knowledge of their disease states and medication regimens, and by creating therapeutic care plans based on individualized patient needs. Patients diagnosed with at least one chronic health condition, patients with polypharmacy issues, patients with history of pooradherence to medication therapy, and patients who need reinforcement and education on medications and disease state management can self-refer or be referred by their providers for MTM services. The MTM services were delivered by utilizing the five core elements of MTM services model in pharmacy practice, which includes medication therapy review, personal medication record, medication-related action plan, intervention and/or referral, and documentation and follow up. Final results and

conclusions will be presented at the Western States Conference.

MEASURING THE IMPACT OF COLLABORATIVE EFFORTS TO MANAGE PATIENTS ON INSULIN PUMP THERAPY WITHIN A MEDICAL GROUP (B1), Silvia Rivas, Robert Schoenhaus. Sharp Rees-Stealy Medical Group, San Diego, CA (silvia.rivas@sharp.com). IRB approval pending. The objective of this study is to determine the impact of the collaboration between pharmacy benefits department personnel, diabetes nurse case managers and educators on the care of Type 1 diabetics on insulin pump therapy and/or Continuous Glucose Monitoring System. Clinical outcomes such as hemoglobin A1c, LDL cholesterol, blood pressure measurements, serum creatinine and microalbumin levels were compared before and after a multidisciplinary approach was implemented. Compliance rates of measures including nephrology screenings, endocrinology and diabetes education visits were evaluated, as well as trends of expenditures on diabetic supplies since this collaboration has been in place. Other data collected includes age, sex, ethnicity and medication profile information related to diabetes care. Retrospective data was collected for a one-year study period. The results and conclusions will be presented.

IMPLENTATION AND ASSESSMENT OF A MEDICARE PART D MEDICATION THERAPY MANAGEMENT PROGRAM AT A COMMUNITY HEALTH CENTER (B1), Lanae Salveson, Jaime Hornecker. Community Health Center of Central Wyoming, Casper, WY (lsalveson@chccw.org) IRB approved. The Community Health Center of Central Wyoming is a federally qualified health center that serves a population of patients with limited financial resources. Providers at the clinic recognize that even patients with Medicare coverage may still have difficulty affording their medications, as well as challenges in navigating the Medicare Part D system. The objectives of this study were to determine whether a pharmacist review of the patient medication profile and subsequent appointment would lead to cost-savings and increased understanding of the Medicare system and other available resources. Any patient with Medicare parts A and B was eligible to participate. Patients were referred for this service by their primary care physician or the in-house pharmacy, and were scheduled for a one-hour appointment with the pharmacist. Prior to the appointment, the pharmacist researched the patients financial status, determining eligibility for prescription savings programs and entered their medications into the Medicare website to compare drug plans based on their individual regimen. During the appointment the results were discussed with the patient and any additional applications were filed, therapeutic substitution suggestions were made to their provider, and all questions were answered. The average annual cost-

savings per patient to date has been $400. Remainder of results and conclusion will be presented.

VOCAL CORD DYSFUNCTION IN THE MILITARY POPULATION (B1). Dara Shin, Paige Shimamoto, Erik Osborn, Donald Helman. Tripler Army Medical Center, Honolulu, HI (dara.shin@us.army.mil). IRB Approval is not needed. Vocal cord dysfunction (VCD) is an upper respiratory tract condition in which the vocal cords close inappropriately, which limits airflow. VCD patients most often present with inspiratory stridor, which is mistakenly described as wheezing and they are often misdiagnosed for asthma. The cause of VCD is idiopathic and symptoms of VCD can be elicited by various factors such as temperature extremes, inhalation of irritants, gastroesophageal reflux disease, postnasal drip, or certain psychiatric conditions. VCD is of special interest in the military population because soldiers are often exposed to emotionally or physically stressful situations that may elicit VCD symptoms as a conversion reaction. As a result, active duty VCD patients may face negative consequences on medical grounds. Currently, the main treatment options for VCD are speech therapy and biofeedback training. Recently, there has been speculation that an inhalable anticholinergic agent may be used to treat VCD. The views expressed in this abstract are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

OUTCOMES OF A PHARMACIST MANAGED ERYTHROPOIETIN STIMULATING AGENT (ESA) CLINIC (B1), Tara Sim, Michelle S. Ho, Tracy Fang, Randell Miyahara. VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA (tara.sim@va.gov) IRB pending. Due to the potential dangers associated with inappropriate monitoring of ESAs, healthcare institutions have begun implementing pharmacist managed ESA clinics in an attempt to improve adherence to proper utilization of ESAs. In 2009, a pharmacist was hired to develop and manage an ESA clinic at VAPAHCS. An earlier review of the ESA clinic found that appropriate monitoring of hemoglobin (Hgb) levels and iron panels had improved within 3 months of implementation of the clinic. The objective of this study is to investigate the 1 year impact of the ESA pharmacists interventions on patients receiving an ESA. A retrospective chart review will be conducted to evaluate the long term clinical and economic outcomes of patients prior to their enrollment in clinic and after their enrollment in clinic. Patients will be included if they received an ESA for at least 6 months prior to enrollment, and were enrolled in clinic for at least 3 months. The primary clinical outcomes are: percentage of patients who attained target Hgb and iron levels, percentage of patients who had Hgb and iron levels monitored appropriately, and percentage of patients who had appropriate adjustment of ESA dose for high Hgb levels (Hgb greater than 12g/dL). The primary economic outcomes are: average monthly costs of ESA, iron supplementation, and laboratory testing. Results and conclusions will be presented.

CHARACTERIZING HEALTH LITERACY AND OUTCOMES IN KIDNEY TRANSPLANT RECIPIENTS (B1) Emilie Smith. Mike Misel. UCSD Medical Center, San Diego, CA (eas004@ucsd.edu) IRB Pending. The primary objective of this study is to characterize the relationship between health literacy, transplant knowledge, and graft function [serum creatinine, glomerular filtration rate (GFR)] after kidney transplantation. Health literacy will be assessed using Short Test of Functional Health Literacy (S-TOFHLA) and the Rapid Estimate of Adult Literacy in MedicineTransplantation (REALM-T). Multivariate regression analysis will be used to evaluate any correlation between health literacy levels and kidney allograft function. Data to be collected include age, gender, ethnicity, marital status, education, primary insurance, annual household income, primary language, use of computer, serum creatinine, glomerular filtration rate, donor status (living or deceased), extended criteria donor, delayed graft function, slow graft function, immunosuppressive drug levels, graft rejections, and hospitalizations for any cause. Numerical data will be analyzed using two sample t-test or Mann Whitney, categorical using chi-square, and linear regression analysis will be used to evaluate effects of different variables on serum creatinine and GFR. Results and conclusions to date will be presented.

A PROSPECTIVE STUDY EVALUATING A CLINICAL PHARMACIST MANAGING HIGH RISK DIABETIC PATIENTS IN A MEDICAL HOME SETTING (B1), LCDR Susan Sparks. Naval Medical Center (NMCSD), San Diego, CA (susan.sparks@med.navy.mil) IRB approval not needed. The medical home is a new model of healthcare delivery that provides comprehensive primary care. The objective of this study is to determine whether integrating a clinical pharmacist into a medical home setting to manage high risk diabetic patients with HbA1C > 7% and LDL > 100mg/dL has different outcomes than patients managed by a primary care provider. Patients were included if they were enrolled at one of NMCSDs largest outpatient clinics, 18 years of age, HbA1C level > 7%, and an LDL > 100mg/dL. Patients were excluded if they relocated, were seen by an endocrinologist, refused, or did not return phone call to schedule an appointment. Eligible patients were contacted by phone and scheduled for a one hour initial appointment with the clinical pharmacist. The pharmacist is credentialed to order labs, adjust, initiate or stop medication therapy, and order speciality consults if necessary (i.e. podiatry, nutrition, opthamology). At this initial visit, the pharmacist reviews labs, medications, and provides the patient with both verbal and written patient education about their disease state and their medications. Follow-up appointments are made based on the individual patients diabetes and lipid criteria. Analysis will be at 3, 6, and 12 months post-enrollment. Pre and post outcome data will be analyzed by the chi-square and paired student t tests. Results and conclusion are pending.

EVALUATION OF THE APPROPRIATE USE, SAFETY, AND EFFICACY OF VARENICLINE IN A VETERAN POPULATION (B1). Nydia Sta Maria. Kirby Lim. Wayman Lee. Veterans Affairs - Greater Los Angeles Healthcare System, Los Angeles, US (Nydia.Stamaria@va.gov) IRB pending. In July 2009, the Food and Drug Administration issued a boxed warning regarding the risk of serious neuropsychiatric events such as depression, suicidal ideation, and suicide attempt with varenicline use. After this warning, the Veterans Affairs - Greater Los Angeles Healthcare System (VA-GLAHS) created a smoking cessation treatment algorithm and restricted the use of varenicline by making it available only through prior authorizations. The study objective was to evaluate the appropriate use, safety, and efficacy of varenicline in the VA-GLAHS. This retrospective study included all patients who received varenicline from May 10, 2006 to December 31, 2009 in the VA-GLAHS. Initiation of therapy was determined appropriate through adherence to the VAGLAHS treatment algorithm. Smoking cessation clinic and primary care visit notes were reviewed to assess prior treatment attempts, adverse events, duration of varenicline therapy, and quit rates at 6 and 12 month follow-up post discharge from the smoking cessation clinics. Results and conclusions will be presented.

EFFICACY OF TELEPHONE MONITORING AND INTERVENTION TO ACHIEVE LDL GOAL IN ISCHEMIC HEART DISEASE PATIENTS (B1). Rebecca Stone, Bridget Kaufmann, Anne Lee. VA Puget Sound, Seattle, WA (rebecca.stone@va.gov) IRB approval received. The objective of this study is to evaluate the efficacy of a pharmacist initiated telephone monitoring practice to increase achievement of LDL cholesterol goal less than 100 mg/dL in patients with ischemic heart disease (IHD). Telephone clinic participants are patients currently enrolled in the VA Primary Care clinic, who have been diagnosed with IHD and have a current LDL greater than 100 mg/dL. Pharmacists initiate telephone contact with study patients to provide education, assess and modify lipid lowering therapy, and monitor labs for efficacy and safety until LDL goal is achieved. Primary Care providers and pharmacists work collaboratively via established clinical practice. Aggregate, demographic, and clinical data will be obtained from the Computerized Patient Record Medical Record System (CPRS) via prospective chart review. Clinical data to be collected includes medication therapy, ADR history, medication intervention, total cholesterol, triglycerides, HDL, and LDL values at baseline and lab recheck. Safety monitoring will include liver and renal function and creatinine phosphokinase as appropriate. The results to date will be discussed.

A RETROSPECTIVE ANALYSIS OF PHARMACIST INVOLVEMENT IN A DIABETIC DISEASE STATE MANAGEMENT PROGRAM ON A1c. (B1). Andrea Stump Mary Brubaker. North Country HealthCare, Flagstaff, AZ (andreanstump@yahoo.com). IRB Approval received. The study objective was to determine the impact on the A1c of adult Type 1 or Type 2 diabetic patients referred by their medical provider to the pharmacist run clinic. All patients were seen at North Country HealthCare, a community health center. The program consisted of patient education on SMBG and MNT. Drug therapy adjustments included oral medications and/or insulin to achieve a goal A1c of less than 7%. The A1c value was determined at baseline and 6 months to evaluate the outcome of the pharmacists involvement. Results and conclusions will be presented.

THE IMPACT OF PHARMACY SERVICES IN A NEPHROLOGY SPECIALTY CLINIC (B1). Lydia Sun, Kim Donnelly, Glenn Kuz. UW Medicine, Seattle, WA (lydsun@uw.edu) IRB waiver. The purpose of this study is to identify, measure, and describe a pharmacists interventions in a Nephrology Clinic. This data will be used to justify a clinical pharmacist position in the Nephrology Clinic. Patients with kidney disease require numerous medications to prevent both short and long term complications, and to manage complex comorbidities. Studies have shown that vigilant monitoring of patients by a pharmacist can result in cost savings and may decrease hospitalizations. Currently, clinical pharmacy services are not provided in the Nephrology Clinic at the University of Washington Medical Center (UWMC). A pharmacy resident will provide pharmacy services for four hours of the total of approximately 24 hours of nephrology clinic per week. The resident will perform medication therapy management based on a previously outlined problems approach. An intervention tracking database will be used to collect and analyze the following parameters: type of intervention (identification/prevention of adverse drug reaction, initiation/discontinuation of drug therapy, dose adjustment, change in monitoring plan, medication reconciliation, or patient/provider education), time resident spent on the intervention, and whether the intervention was accepted by

the nephrologist. In addition, a quarterly survey of providers in the nephrology clinic will assess perception of pharmacy services throughout the study. The results and outcomes of these activities will be presented.

EVALUATION OF THE IMPACT OF A CLINICAL PHARMACIST IN A PRIMACY CARE PATIENT CENTERED MEDICAL HOME PRACTICE (B1), Amy Tan, Kaiser Permanente Medical Care Program, Riverside, CA (amy.m.tan@kp.org) IRB approval received. Health care costs in the United States have been rising, partially attributed to the lack of emphasis in chronic disease management, preventative medication management, and transitions in care. The Patient Centered Medical Home is a patient care delivery concept that consists of a multidisciplinary primary care team that provides comprehensive patient centered health care and effective transitions in care, taking into consideration, the specific needs of the patient. The purpose of this study is to evaluate the impact of the clinical ambulatory care pharmacist in the Patient Centered Medical Home team on 1) reduction in 30-day readmission rates, 2) optimization of medication management, 3) demonstration of patient and physician satisfaction with the clinical pharmacists services, and 4) overall cost benefit to the organization. A retrospective study of electronic medical records and the pharmacist intervention tracking database will be reviewed from October 2010 through January 2011. Comparisons of the 30-day readmission rates for the pharmacist intervention group will be compared to a control group with no pharmacist intervention. A patient and physician satisfaction survey will be administered and the results will be discussed. An analysis of the readmission outcomes as well as an analysis of pharmacist interventions will also be presented.

CAN PATIENTS MAINTAIN THEIR A1C GOAL ONE YEAR POST DISCHARGE FROM A PHARMACIST MANAGED CLINIC? (B1). Ellen Tasaka, Yasmina Lee. VA Loma Linda Healthcare System, Loma Linda, CA (Ellen.Tasaka@VA.gov) IRB approved. The study objective was to determine the percent of patients that maintain their A1c goal (<8%) one year post discharge from the pharmacist managed clinics. This was a retrospective chart review using the computerized patient record system at VA Loma Linda Healthcare Systems to evaluate patients with uncontrolled diabetes that were discharged from a pharmacist managed clinic once they reached an A1c <8%. Data that was collected included baseline A1c upon enrollment in a pharmacist managed clinic as well as A1c values at discharge, 3 months, 6 months, 9 months, and 12 months post discharge from the clinic. The primary endpoint for this study was to look at the percentage of patients that maintain their A1c at goal one year post discharge. The results and conclusions will be presented.

ASSESSMENT OF THE RELATIONSHIP BETWEEN COLCHICINE THERAPY AND SERIOUS ADVERSE EVENTS (B1). Brittany Todd, Sarah Billups. Kaiser Permanente Colorado, Denver, CO (brittany.x.todd@kp.org) IRB approval received. Case reports of colchicine toxicity (including rhabdomyolysis and blood dyscrasias) lead to the FDA adding warnings to colchicine prescribing information in July 2009. The primary objective of this study was to assess the odds of exposure to colchicine therapy within 100 days prior to patients experiencing either an elevated creatine phosphokinase (CK) or a blood dyscrasia (cases) compared to control patients who received a health maintenance exam during the study period. For this casecontrol study, we identified patients with a CK > 2000 IU/L or a clinically significant blood dyscrasia, defined as thrombocytopenia (platelet < 50,000), neutropenia, aplastic anemia, or pancytopenia between 1/1/2006 and 6/30/2009. Cases were matched to controls up to 1:10 on age, gender, and event date. A Mantel-Haenszel chi-square test was used to determine the difference between cases and controls in their rate of exposure to colchicine in the previous 100 days. A conditional logistic regression model was used to determine independent predictors of being a case. The study identified 964 cases and 9007 controls. The primary outcome showed a significantly higher rate of exposure to colchicine prior to event date in cases versus controls (0.6% vs. 0.2%, p= 0.004). Patients with a confirmed elevation in CK or blood dyscrasia had a higher rate of previous exposure to colchicine compared to those who had a health maintenance exam. Further results will be presented.

IMPACT (IMPROVING PHARMACY ANTICOAGULATION IN A HEALTH CLINIC ON THE TULALIP TRIBES RESERVATION) (B1). Valerie Tran, Asaad Awan. Tulalip Clinical Pharmacy-U of WA, Tulalip, WA (vtran@tulaliptribes-nsn.gov) IRB approval pending. This is a preliminary evaluation of an established pharmacist-managed anticoagulation program in a tribal setting. Our two-year, unblinded, non-randomized study focuses on the following outcome measures: INR, factors contributing to INR stability, adherence, and patient satisfaction. Our primary aim is to compare the percentage of therapeutic-range INR results between the two arms (pharmacist-managed or usual physician care). We hypothesize that a higher percentage of therapeutic-range INR results will occur within the pharmacy arm due to appointment-based follow-up care, with pharmacistprovided education and intervention. The main outcome measure is the percentage of INRs within therapeutic range; additional measures will examine factors contributing to stabilized INR ranges and patient satisfaction. The final analysis will compare the two study arms for each measure. The study includes tribal members over 18, with preexisting conditions currently receiving anticoagulation therapy and excludes non-tribal members, children, and those unable to give informed consent. Indications include: DVT, PE, atrial fibrillation, and heart valve placement; goal INRs are based on indication. All INRs are measured by the clinic lab personnel. Care provision is unchanged from current practice: the pharmacy-managed anticoagulation arm is appointment-based, whereas the

physician arm is a walk-in based system. Results of this research will be presented upon conclusion.

DEEP VEIN THROMBOSIS: HOW PHYSICIANS DECIDE FOR WITHDRAWAL OR CONTINUED ANTICOAGULATION WHEN FIRST EPISODE TREATMENT PERIOD IS COMPLETE (B1), John Truong, Ruby Chang. VA Healthcare System, Long Beach, CA (john.truong@va.gov) IRB approved. Oral anticoagulant therapy is utilized to reduce the recurrence of deep vein thrombosis (DVT). Long term treatment is not only associated with an increased risk of bleeding complications, but also requires frequent laboratory monitoring and dose adjustments. It is recommended to stop oral anticoagulation when the benefit of reducing recurrent DVT no longer outweighs the risk for bleeding. The American College of Chest Physicians recommends varying lengths of anticoagulant therapy depending on etiology and patient risk factors for recurrent DVT. At VA Long Beach, the provider who initiates the oral anticoagulant recommends the duration of therapy. Once the initial duration of anticoagulant therapy is reached, the referring provider evaluates the benefit of clot prevention versus bleeding risk. The objectives of this study are to evaluate the providers rationale to continue anticoagulant therapy beyond the recommended duration of therapy and to determine if there are certain factor(s) that are associated with the decision to continue anticoagulant therapy indefinitely. The study will evaluate patients with first time DVT diagnosed from July 1, 2009 to July 31, 2010. Clinical endpoints will include the number of patients who withdrew versus continued anticoagulant therapy and the rationale for the clinical decision. Final results will be reported.

IMPROVING ANTICOAGULATION PATIENT SAFETY: ENHANCING CBC MONITORING AT VETERANS AFFAIRS SOUTHERN NEVADA HEALTHCARE SYSTEM WHO ARE RECEIVING WARFARIN (B1),Implementation of a Clinical Reminder to Monitor Patients Hemoglobin Who Are Currently Prescribed Warfarin in the Anticoagulation Clinic Roseann Visconti, Kyle Filby. VA Southern Nevada Health Care System, Las Vegas, NV (roseann.visconti@va.gov ) IRB approval pending. Warfarin is the most commonly prescribed oral anticoagulant; its prescribing information states that use of warfarin isthat its use is cautioned in patients with anemia. However, there is limited data supporting the need and frequency for routine hemoglobin monitoring in patients receiving warfarin. In the Veteran's Affairs Southern Nevada Healthcare systemSystem, any patient who is currently onreceives warfarin must have consults and all lab work processed through the be followed by the Anticoagulation clinicClinic for management. other VA hospitals in our VISN are monitoring hemoglobin in addition to monitoring patients INR levels. The VASNHS is currently has approximately 13% of patients lacking either baseline or annual hemoglobin monitoring. The primary objective is to improve CBC monitoring for all patients in the AC clinic receiving warfarin. The secondary objective is to evaluate the effectiveness of a clinical reminder. prospectiAll patients

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who receive warfarin through the Anticoagulation Clinic (for a period of 6 months or longer ask Joee for advice on this issue???) during the study period currently enrolled in the Anticoagulation clinic will be included in this study. This study will evaluate the percentage of patients receiving baseline CBC monitoring, as well as annual CBC monitoring for all patients receiving warfarin therapy. . will be included in this study. The implementation of a Clinical Reminder will be evaluated as to percentage of patients with a reminder that has been completed during the study period. Active enrollees will be evaluated monthly to compare the percentage of patients who have were? not receiveding annual hemoglobin monitoring versus those now receiving annual monitoring following implementation of a clinical reminder. (A lot needs to be added here: should discuss what information youre collecting, how youre planning to store/analyze etcData collection and analysis will be performed to collect therapy information including: indication, length of therapy and lab data for any patient not using VASNHS laboratories. Results and conclusion will be presented.

STATIN ADHERENCE RATES IN AN ALASKA NATIVE/AMERICAN INDIAN POPULATION WITH CORONARY ARTERY DISEASE (B1), David Webb, Mike Beiergrohslein, John McGilvray, Renee Robinson, Judy Rose. Southcentral Foundation, Anchorage, AK (dwebb@scf.cc) IRB approved. The study objective was to assess statin adherence rates for an Alaska Native/American Indian population in south central Alaska with a diagnosis of coronary artery disease and to compare this to a subset of published statin adherence rates. A retrospective review was performed of electronic health records using a proprietary data mining tool. Inclusion criteria were Alaska Native Medical Center patients between 18 and 75 years old, diagnosis of coronary artery disease, and prescribed a statin between October 1, 2009 and September 30, 2010. Coronary artery disease was defined by appropriate ICD-9 or CPT codes. Adherence was calculated using Proportion of Days Covered method. Adherence was defined as at least 80 percent of the proportion of days covered. The PubMed database was searched for comparison studies using the following search terms: proportion of days covered, PDC, adherence, compliance, statin, coronary disease, CAD. Comparison studies were chosen that reported results representing the majority of published works on adherence and were similar to this project. Adherence findings of males versus females as well as younger versus older demographics were compared using the chi-square test of proportions. Mean adherence findings were compared for the same groups using t tests. Results and conclusions will be presented.

COMPETENCY-BASED TRAINING FOR MEDICAL HOME PHARMACISTS IN AN INTEGRATED HEALTH CARE SYSTEM (B1). Tina Wong, Tanya Ramsey, Lisa Nakashimada, Nancy Louie Lee. Kaiser Permanente Northwest, Portland, Oregon (tina.t.wong@kp.org) IRB not needed. Kaiser Permanente Northwest began implementing patient-centered medical home pilots in two of their primary care medical offices with pharmacists starting in October 2010. These pharmacists will be involved in pharmacy drug cost savings, complex case management, and other clinical pharmacy services. The objective of this project was to assess baseline confidence and competency of the pharmacists in their practice areas and to administer a competency-based training program. Training modules will consist of diverse learning activities including didactic lectures, practical experience, and self-study time. Pre and post training surveys and knowledge tests will be administered to capture demographic data and to assess for changes in confidence and competency. Observational evaluations and quality assurance reviews will be utilized in areas requiring additional process assessments. The pharmacists will evaluate each training module and the overall program for continuous improvement. A total of 12 pharmacists participated in this training program. Results and conclusions will be presented.

VALIDATION OF ICD9 CODES TO IDENTIFY PATIENTS WITH STROKE (B1). Michele Wood, Kari Olson. Kaiser Permanente Colorado, Denver, CO (michele.x.wood@kp.org) IRB approved. The purpose of this study was to determine positive predictive values (PPVs) for ICD9 codes to develop a validated stroke registry. Patients with ICD9 codes (430 to 438) for ischemic stroke, intracranial hemorrhage, and/or subarachnoid hemorrhage between January 2001 and December 2009 were identified from any emergency room, hospital inpatient (primary or secondary discharge position) an/or outpatient visit using administrative claims data at Kaiser Permanente Colorado. Investigators developed a standardized chart abstract tool which was tested for interrater reliability and found to have a kappa score of greater than 0.8. Medical chart reviews were conducted using the chart abstract tool to determine whether patients had a stroke and the type of stroke patients experienced. PPVs for the individual ICD9 codes were calculated. A total of 4738 charts were reviewed of which 1933 (41%) patients had a confirmed stroke. The ICD9 codes with the lowest (<40%) PPVs were other and unspecified intracranial hemorrhage (432), transient cerebral ischemia (435), and other and ill defined cerebrovascular disease (437). Results indicate that stroke ICD9 codes lack consistent predictive value. Various patient and administrative characteristics will be evaluated individually and then combined to determine the most accurate coding structure for ischemic stroke. Final results and conclusions will be discussed.

DECENTRALIZATION OF THE PHARMACY NEW MEMBER PROGRAM (B1), Samar Yalda. Kaiser Permanente, San Diego, CA (samar.x.yalda@kp.org) IRB approved. At Kaiser Permanente, San Diego, new members are interviewed over the phone by a pharmacist prior to their first primary care physician appointment. This has helped new members transition to Kaiser Permanente through continuity of care with regard to medication therapy. The current new member pharmacist workflow is centralized and operates independently when compared to the integrated workflow of the decentralized pilot. The integrated model of the decentralized pilot facilitates greater interactions between pharmacists and other health care providers. In addition, the pharmacist is situated closer to the physician, providing an opportunity for a more efficient workflow. The hypothesis of this study is that the decentralized model will provide increased efficiency when compared to the centralized model, as measured by the number of patients contacted prior to the new member appointment. Inclusion criteria include new members within the Kaiser Permanente San Diego Area who are currently taking at least one prescription medication. Exclusion criteria include patients not currently taking prescription medications, cognitively impaired, or decline clinical pharmacy services. Data on the number of patients interviewed and percentage of medication recommendations accepted for both the centralized and decentralized New Member pharmacists will be compared from December 2010 to March 2011. The primary

outcomes will be compared using a two samples t test. Results and conclusions will be presented.

IMPLEMENTATION AND EVALUATION OF AN OUTPATIENT OPIOID TITRATION GUIDELINE (B1), Kristen Zak. Kaiser Permanente Greater Southern Alameda Area (GSAA), Union City, CA (kristen.n.zak@kp.org) IRB approval not needed. Chronic pain patients with uncontrolled pain, despite long-term use of high dose opiates, are a challenging population to manage. In order to provide the best care for these patients, it is imperative to optimize pain medications, yet the literature lacks specific recommendations. Medication management through opioid dose reduction or rotation may improve clinical outcomes, such as pain control and quality of life, in patients maintained on high dose opioid therapy. In this study, an opioid titration guideline was developed and implemented in collaboration with a multidisciplinary pain management team in the Chronic Pain Clinic. Patients aged 18 to 75 years old taking opioid medications exceeding 300mg per day of oral morphine equivalent with average pain scores of greater than or equal to 6 were included. Exclusion criteria included pregnancy, a diagnosis of opioid addiction, or a diagnosis of malignant pain. A retrospective chart review was conducted to analyze pain score, depression, and quality of life data before, during, and after utilization of the opioid titration guideline. Initial results of program implementation and evaluation will be presented.

B2 CommunityPractice

ATYPICAL ANTIPSYCHOTIC USE IN THE COMMUNITY: ARE PATIENTS MEETING METABOLIC GOALS? (B2). Ben Michaels. Stacy Ramirez. Jennifer Davis. Community Health Centers of Benton and Linn Counties, Corvallis-Monroe-Lebanon, Oregon (Benjamin.michaels@fredmeyer.com) IRB Approved. The study will evaluate adult patients on atypical antipsychotics and determine if their metabolic parameters are at goal. The primary objective will be to identify if these patients BMI, blood pressure, blood glucose, and LDL cholesterol meet established national guidelines. The secondary objective will look at correlations between prescribed medications and the rates at which patients meet established goals. The study will pull patient data from the Community Health Centers EMR. After these results are gathered, they will be compiled and examined to identify if these patients metabolic parameters are at goal: BMI <29, blood pressure <140/90mmHg, random blood glucose of <140mg/dL, and LDL cholesterol <160mg/dL. These goals are a joint compilation of the American Diabetes Association, AT-III, JNC-7, and NHLBI. The data gathered will be compared to the population of the clinic and analyzed for differences in percentage of patients at goal. Descriptive statistics (mean, median, mode, standard deviation) will be used for data analysis. A t-test and a chi squared test will compare the atypical antipsychotic group to the clinic control population. The results of this study will be used for additional targeted counseling and education. Results and conclusions will be presented.

RELATIONSHIP BETWEEN PATIENT BELIEFS ABOUT MEDICINES AND MEDICATION ADHERENCE IN THE RURAL POPULATION OF MAUI (B2), Amy Baker, Sheena Jolson, Les Krenk, Anita Ciarleglio. University of Hawaii at Hilo, Hilo, HI (AmyBaker@hawaii.edu) IRB approval pending. Patients will be recruited from each of four independent community pharmacies. These are located on the island of Maui in Kahului, Paia, Makawao and Haiku and represent a culturally and economically diverse population. The patients will be identified by pharmacy staff upon arrival to the pharmacy to pick up their prescription refills. Inclusion criteria are: age greater than 18; patients picking up medications for themselves; have refilled one or more medications at least two times at a participating pharmacy; and are comfortable speaking English. Patients who volunteer to take the survey will be directed to speak with one of the pharmacists in a private office, where an oral interview will be conducted. Validated surveys included will be the Beliefs about Medicines Questionnaire (BMQ) and the Morisky 8-item Medication Adherence Scale (MMAS-8), as well as a short survey of patient needs so that we may better tailor our services to the patients in the future. Outcomes measured will be self-reported medication adherence and beliefs about medicines, both in general and directly relating to the patients personal medications. Results and conclusions will be presented.

DEVELOPMENT AND IMPLEMENTATION OF AN AMBULATORY CLINICAL PHARMACIST IN AN OUTPATIENT PHARMACY SETTING (B1), Megan Buchanan, Valley Medical Center, Renton, WA (megan_buchanan@valleymed.org) IRB not needed-no human subject data. The objective of this project was to establish an ambulatory clinical pharmacist position at an outpatient pharmacy affiliated with a community hospital. Participation in 340B created the opportunity to utilize the savings as a source to fund an ambulatory clinical pharmacist. Development of the ambulatory clinical pharmacy practice model included communication with successful ambulatory care clinics, determination of the menu of services, approval of- and acquiring point of care testing devices, and creation of a business plan. The business plan included projection of the profit and loss margin, designation of billing codes, and estimation of both client volume and the budget within the outpatient pharmacy. Additionally, reimbursement was established for the new pharmacy service including contracts with local insurers. A collaborative drug therapy agreement was created and approved by both the facilitys P&T committee and the Washington State Board of Pharmacy. Implementation included meeting with prescribers within the facilitys clinic network, promotion through a local health fair, visits to the diabetes education center, and establishing relationships with the facilitys clinic network providers through providing services onsite at each clinic during strategic hours. The results will be discussed.

IMPLEMENTATION OF AN ONCOLOGY MEDICATION STEWARDSHIP PROGRAM (B2). Kristin Calabro. Michael Rupp. Kelly Kistler. The Apothecary Shops, Phoenix, AZ (kcalabro@theapothecaryshop.com) IRB approved. The purpose of this study is to evaluate a pharmacybased program to assist patients who are taking oral oncology medications to properly dispose of their unused medications upon discontinuation of therapy. The program targets patients taking Afinitor (everolimus), Gleevec (imantinib), Nexavar (sorafenib), Sutent (sunitinib), Tarceva (erlotinib), Temodar (temozolomide), Tykerb (lapatinib), Votrient (pazopanib), or Xeloda (capecitabine). Patients were recruited through The Apothecary Shops National Mail order facility using a mailed informational flyer, and during regularly scheduled refill and adherence calls. Call center technicians were trained to ask all patients who discontinued therapy if they had remaining medications that required disposal. If so, the patients were provided with program details and allowed to enroll via a customized website or directly with the call center technician over the telephone. Participating patients were mailed a Sharps TakeAway envelope which was subsequently tracked using the Sharps Tracer software. Data collected included the number and weight of envelopes received by Sharps which will be used to

estimate the amount of hazardous waste that was diverted from potential contamination of landfills and water supplies. Results and conclusions will be presented.

HIV CYCLE FILL PROGRAM: EVALUATION OF MEDICATION ADHERENCE, PATIENT COMPLIANCE, CLINICAL OUTCOMES, AND COST SAVINGS (B2). Carley Campion. Kaiser Permanente, Sacramento, CA (carley.m.campion@kp.org) IRB not needed. According to the CDC, one in every six newly diagnosed HIV patients experiences resistance to antiviral therapy. Non-adherence to antiviral therapy has been associated with a decrease in viral control. This study assesses the effectiveness of a cycle fill program for the HIV patient population through a pre versus post cycle fill data analysis. The cycle fill program is a pharmacy managed prescription refill program. Patients are enrolled based on the following inclusion criteria: specific Sacramento service area zip codes, current treatment with an antiviral regimen including Norvir and/or Atripla throughout the study period, and voluntary enrollment in the program. The study time frame is December 2008 through December 2010. The goals of this project are three fold. First, to demonstrate improvement in medication compliance leading to potential reduction in resistance to antivirals and fewer therapy changes. Second, to identify improved clinical outcomes seen through virologic suppression. Measures of improvement include an increase in CD4 count greater than 50 cell/uL per year and a decrease in viral load by 400 copies/mL within 6 months and 50 copies/mL within 1 year. Third, to recognize potential cost savings associated with a decrease in hospitalization trends. The end results will be used to

demonstrate the need for a pharmacy managed HIV cycle fill program.

IMPACT OF A POST DISCHARGE CONSULTATION AND FOLLOW UP MODEL IN THE OUTPATIENT PHARMACY SETTING ON MEDICATION RELATED READMISSIONS (B2), Michelle Candido. Kaiser Permanente, South Bay, CA (michelle.x.candido@kp.org) IRB approved. The 2010 Affordable Care Act involved a series of Medicare reforms that will improve the quality of care, develop new models of providing health care, and contain cost. One of the provisions implemented by the Centers of Medicare and Medicaid Services is the reduction of hospital reimbursement due to readmissions associated with heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PNA) diagnoses. Outpatient pharmacists can play a role during the discharge process, in regards to medication education, adherence and preventing adverse events. The purpose of this project is to evaluate the implementation of a hospital post discharge consultation and follow up model in the outpatient pharmacy setting, and the potential impact on overall re-admissions. This project targeted patients 65 years of age or older, who were discharged with any diagnosis of HF, all AMI or PNA patients. Outpatient pharmacists reviewed HF and AMI patient profiles for drug omissions, drug therapy duplications and drug-drug interactions, provided an expanded consultation during medication pick up, and provided a medication review by telephone 3 to 5 days post discharge. PNA patients received a telephone follow up if discharge medications were not picked up at the pharmacy. Results and conclusion will be discussed.

EVALUATION OF A TDAP IMMUNIZATION COCOONING CLINIC IN A HOSPITAL POSTPARTUM UNIT (B2), Sandra Chiang, Elizabeth Rosenblum, Jason Sauberan, Sarah McBane. UCSD Medical Center, San Diego, CA (swchiang@ucsd.edu) IRB approved. The study objective was to compare vaccination rates before and after implementation of a hospital-based Tdap vaccination service operated by pharmacists and physicians from August to December 2010. Targeted patients for the service were visiting fathers, caregiver and other household contacts greater than 7 years of age. Contacts that reported encephalopathy or seizure after a prior vaccination or a severe latex allergy were excluded from vaccination. Pregnant women and individuals of all races and ethnicities were eligible to receive the vaccine pursuant to recommendations from the California Department of Public Health and the Advisory Committee on Immunization Practices. Pharmacists operating under a collaborative practice protocol administered Tdap vaccines during 90-minute sessions six days per week in a clinic setting created on the hospital postpartum unit. Vaccine was provided by the California Department of Public Health with funding from the Federal American Recovery and Reinvestment Act. Data collected included the number of vaccines administered, subject age, relationship to newborn, race, and ethnicity. Descriptive and comparative statistics will be performed and results presented.

A CONSUMER SURVEY AT THE POINT OF DISPENSING TO ASSESS RECALL OF A PRINT AND VIDEO BOARD OF PHARMACY NOTICE TO CONSUMERS (B2). Anahita Dashtaei, Jeff Goad. University of Southern California, Los Angeles, CA. (Dashtaei@usc.edu). IRB approved. California law requires pharmacies to display a Notice to Consumers (NTC) poster informing consumers of their rights at an outpatient pharmacy. However, there is little evidence supporting the current method of NTC notification, especially since the public has become more accustomed to electronically delivered information. The objective of this study it to determine whether consumers recall of information presented in the NTC varies between poster and video modalities. A cross-sectional paper-based consumer survey will be available to consumers picking up new or refilled prescriptions at the pharmacy. Exclusion criteria include age less than 18 years, drive-thru and mail order consumers. Data will be collected from 91 pharmacies of the same grocery store chain. Participating pharmacies will show a video dramatization of the NTC in a continuous loop. The survey will be distributed during two one-month time periods. During period 1, the NTC poster alone will be displayed in the pharmacy. During period 2, the video will be shown in addition to the poster. Pharmacy layout and demographic information will be collected to ensure consistency of the NTC displays. Data from the survey will be analyzed using descriptive statistics

and chi-squared tests to compare recall of information during the two time periods. Other potential factors in a pharmacy that may affect information recall will also be described. Results and conclusions will be presented.

PHARMACIST INTERVENTIONS TO PREVENT ADVERSE DRUG EVENTS IN ELDERLY PATIENTS ON ANTI-HYPERTENSIVE THERAPIES (B2), Dyan Fleming. Kaiser Permanente- South Sacramento, CA (dyan.c.fleming@kp.org) IRB exempt. Adverse drug event data seems to indicate that patients aged 65 years and older are particularly susceptible to adverse events due to medications. The objective of this project is to evaluate opportunities for pharmacist interventions to prevent the occurrence of adverse drug events in the elderly patient population who receive specific anti-hypertensive medications, and who do not receive adequate lab monitoring. A randomized retrospective chart review of patients age 65 years and older who received a diuretic, ACE-inhibitor or a betablocker in an outpatient setting between January 1, 2009 and July 31, 2010 was performed. Patients were excluded from the data analysis if they did not meet the age criteria of their medication refill or laboratory test dates fell outside the predefined time parameter. A determination was made as to whether these patients had received serum creatinine laboratory monitoring within 12 months of the last date of refill for their antihypertensive medications. A data collection tool was developed to organize and analyze this information, and the data was analyzed to assess compliance with laboratory monitoring and dose adjustment guidelines in geriatric patients with some degree of renal dysfunction. Medication doses were reviewed for appropriate renal and/or geriatric dosage adjustments. Results and conclusions will be discussed.

DEVELOPMENT AND IMPLEMENTATION OF AN OUTPATIENT PHARMACY RENAL DOSE ADJUSTMENT CERTIFICATION PROGRAM (B2), Olivia Garnier, Kaiser Permanente Medical Care Program, Fremont, CA (Olivia.C.Garnier@kp.org) IRB approval not needed. A major concern with medication use in an older patient population is the occurrence of adverse drug events, especially those that are preventable. Because the outpatient pharmacist is the final check in the medication dispensing process, it is essential for the pharmacist to utilize available resources to effectively evaluate the safety of the medication to prevent potential adverse drug events for the specific patient. The objective of this project is to create a training program that will allow pharmacists to properly make dose adjustments based on renal function with the intent to pilot a renal dose adjustment service with the focus on sulfamethoxazole-trimethoprim. This program will train and assess outpatient pharmacists ability to calculate creatinine clearance using information from Kaiser Permanentes medical record system to promote appropriate medication dosing based on renal function. This study will take place in a single outpatient pharmacy located at Kaiser Permanente Fremont Medical Center. Pre and post training competency, pharmacists perception survey scores, and the number of missed dose adjustment opportunities will be analyzed. A detailed description of the process, methods, and findings will be presented.

IMPROVING PRESCRIPTION LABEL DIRECTIONS TO ENHANCE PATIENT COMPREHENSION (B2). Sevana Ghazarian, Brian Kawahara, Ranya Alwan. VA Loma Linda Health Care System, Loma Linda, US (Sevana.Ghazarian@va.gov) R&D approval pending. The study objective is to determine if the default wording of prescription labels are preferred by patients compared to an alternative. VA patients were surveyed anonymously over a four week period. The questionnaire contained four samples of prescription labels; each sample included a default and an alternative label based on the new California labeling regulations. The survey asked patients to choose the wording they prefer. A total of 400 patients were surveyed with 200 completed surveys used in the study for the results and conclusions presented.

ASSESSMENT OF AN INTERNET- BASED SEMINAR FOR BREAST CANCER PATIENTS TAKING XELODA (B2). Laura Hitchingham. Michael Rupp. Eric Sredzinski. The Apothecary Shop, Phoenix, AZ (lhitchingham@theapothecaryshop.com) IRB approved. The study objective was to evaluate the impact of an internet-based seminar on the knowledge and understanding as well as persistence of breast cancer patients taking Xeloda. During the initial fill of an oral oncology medication the pharmacist provides verbal counseling via the telephone. The internet-based seminar is a live, online, interactive educational presentation. Patients who have been taking Xeloda are given a link to the internet-based seminar where they can view a slide show presentation consisting of an overview of breast cancer, information on Xeloda, and how to manage adverse side effects. Patients are able to call in or listen via the audio on their computers. They can also interact using the chat function and/or type in questions. Improvement in patient knowledge and understanding is assessed by pre and post tests given in the beginning and end of the webinar. Additionally, persistence will be evaluated based on days on therapy over a six month period. Inclusion criteria included age greater than 18, diagnosis code of breast cancer, female, and patients taking Xeloda. Results and conclusions will be presented.

CHINESE HERBAL MEDICATION USE BY PATIENTS AT A SAN FRANCISCO CHINATOWN PUBLIC HEALTH CENTER (B2). Oliver Hsu. Cathi Dennehy. Lenny Chan. Candy Tsourounis. Albert Yu. UC San Francisco Medical Center, San Francisco, CA (oliver.hsu@ucsf.edu) IRB approved. The study objective was to assess the prevalence, indications, and types of Chinese herbal medications used by adults who were predominantly monolingual Chinese patients and who sought care at a Chinatown public health center in San Francisco. Data collection occurred over three months. Surveys were made available to patients in the clinic waiting room. Pharmacists at the clinic also aided in administration of the survey. Survey questions characterized the patient population and examined their Chinese herbal medication use in regards to frequency of administration, indication, types of products used, and perceptions versus Western medicine. If patients indicated they used Chinese herbal medications, they were asked to list their most commonly used products and the indication for use. Survey results will be analyzed using descriptive statistics such as frequency and mean. The results and conclusions will be discussed.

RELATIONSHIP BETWEEN LITERACY AND MEDICATION ADHERENCE IN RURAL PATIENTS (B2), Sheena Jolson, Amy Baker, Les Krenk, Anita Ciarleglio. University of Hawaii at Hilo, Hilo, HI (sjolson@hawaii.edu) IRB approval pending. The study objective is to determine the relationship between health literacy and self-reported medication adherence. Patients will be recruited from four geographically different independent pharmacies on the island of Maui. The pharmacies are located in the towns of Kahului, Paia, Makawao and Haiku, all owned by one pharmacist. Limited data exist on literacy level and adherence rates for patients in this region. Patients will be identified by pharmacy staff upon arrival to the pharmacy to pick up their prescription refills. Patients will complete an in-person interviewerassisted questionnaire that includes the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R), the Morisky 8-item Medication Adherence Scale (MMAS-8),and a short survey of patient needs so that we may better tailor our services to the patients in the future. The study period will be 2 months. Inclusion criteria will be age greater than 18; patients picking up medications for themselves; have refilled one or more medications at least two times at a participating pharmacy; and are comfortable speaking English. Results and conclusions will be presented.

EVALUATION OF OBSTACLES ENCOUNTERED AND OUTCOMES IN PATIENTS WHO DO NOT PICK UP MEDICATIONS (B2), Ann Ryvkin, Andrew Lowe. Arrowhead Regional Medical Center, Colton, CA (Ann.Ryvkin@armc.sbcounty.gov) IRB Approved. The aim of this project is to evaluate the reasons patients do not pick up their prescribed medications, and to determine the effect on their health outcome. This project will involve unclaimed prescriptions for 200 patients. Prescription medications that have not been picked up by patients will be reviewed, and the patients will be contacted to determine the reason. Each patients medical record will then be reviewed for outcome measures. The following data elements will be collected: diagnosis, clinic or emergency department setting, number of medications, payer, reason provided by the patient, number of subsequent physician visits or hospitalizations, disease state outcome, and cost. The data will be aggregated and stratified by diagnosis, medical care location, payer, and reason for not claiming prescriptions. The outcomes and cost of therapy will be evaluated and the results and conclusions will be presented.

EVEROLIMUS FOR CALCINEURIN INHIBITOR MINIMIZATION IN LUNG TRANSPLANT RECIPIENTS WITH CHRONIC RENAL INSUFFICIENCY (B2), Kelly Schoeppler, Ike Kim, Martin Zamora. University of Colorado Hospital, Aurora, CO (Kelly.Schoeppler@uch.edu) IRB approved. Everolimus (EVR) with calcineurin inhibitor minimization (CNImin) improves glomerular filtration rate (GFR) in thoracic tranplant recipients when started early post transplant. The primary objective of this study is to evaluate EVR with CNImin for improving GFR in LTX recipients. This study is a retrospective descriptive analysis of all LTX recipients who received EVR for CNImin at our center. The primary outcome measure was the difference between GFR at EVR initiation and after one month of therapy. Twenty nine LTX recipients with CRI who received EVR with CNImin for at least one month were included in this analysis. A statistically significant increase in GFR was observed among study subjects (54.3 SD of 20.2 vs. 41.6 SD of 15.7 ml/min, p less than 0.05). An increase in GFR was also observed in the recipients who were more than two years post LTX at the time of the intervention (53.6 SD of 22.5 vs. 39.7 SD of 15.8 ml/min, p less than 0.05, n equals 21). Two of six patients who developed new or worsening peripheral edema and one patient with accelerated HTN stopped EVR; three patients required changes to their antihypertensive medications. EVR exhibits short term efficacy and safety while minimizing CNIs in LTX recipients with CRI. Of note, LTX recipients who were more than two years post transplant at the time of the intervention demonstrated benefit from EVR with CNImin. Determining the continued efficacy and safety of EVR with CNImin requires a longer term analysis.

IMPROVING COMMUNITY PHARMACISTS KNOWLEDGE OF ACUTE PHARYNGITIS (B2). Jessica Sipe, Rachel Allen, Annie Lam. Bartell Drugs/University of Washington SOP, Seattle, WA (jsipe@bartelldrugs.com) IRB approval received. In addition to fulfilling licensing requirements, continuing education (CE) courses provide pharmacists the ability to enhance their professional skills, knowledge and competency. A recent search of numerous CE providers found no programs on sore throat, strep throat or pharyngitis; ailments often encountered in community pharmacy practice. In order to fill this void, we developed a CE program on acute pharyngitis. The purpose of this study was to evaluate this CE program, to assess its impact on pharmacists knowledge, confidence in patient counseling and overall satisfaction with the CE and the learning process. All pharmacists employed by Bartell Drugs were eligible for this study, which took place over a 6-week time period. Data was collected using a series of questionnaires and surveys with responses recorded either using a multiple-choice format or a 5-point Likert scale. Pharmacists knowledge about acute pharyngitis and their confidence in counseling on this condition were assessed initially. Participants were then invited to view a web-based CE program on acute pharyngitis. Immediately after the CE program, pharmacists were asked to complete another knowledge assessment and counseling confidence survey, as well as an overall CE evaluation. Study results will be presented and discussed.

PHARMACIST-RUN ADHD MEDICATION MANAGEMENT SERVICE ON A UNIVERSITY CAMPUS: STUDENT HEALTH PROVIDER SURVEY AND PROGRAM DEVELOPMENT (B2), Rachel Sperling, Jeff Goad. USC, Los Angeles, CA (rsperlin@usc.edu) IRB approved. The study objectives are to (1) assess student health providers need for and willingness to refer to a pharmacist-run Attention Deficit Hyperactivity Disorder (ADHD) medication management program; and (2) develop and implement a community pharmacy based ADHD clinic on a university campus. An anonymous webbased survey developed using commercial software will be sent out to providers at university health centers nationwide to identify current ADHD management practices and possible roles for pharmacists in the medication management of students with ADHD. Survey results will be analyzed using descriptive and inferential statistics. The general results of the survey together with input received from pharmacists and other providers at this institution will be used to develop and implement an ADHD medication management service at the campus community pharmacy. Patients will be referred to the service by student health providers based on specific criteria determined during program development. For each patient enrolled in the program, the pharmacists will assess symptom control, adverse effects, and adherence; adjust medications as necessary; manage side effects; and provide medication refills. Patient encounters will be documented in the university health centers electronic medical record system.

Survey results, program description, and conclusions will be presented.

KNOWLEDGE, ATTITUDES, AND PERCEIVED BARRIERS OF ELDERLY PATIENTS AND PHYSICIANS REGARDING SHINGLES AND SHINGLES VACCINE ADMINISTRATION (B2). Chairat Supsin. Western University of Health Sciences, Pomona, CA. (csupsin@westernu.edu) IRB approved. In the United States, approximately one million cases of herpes zoster infection (shingles) occur annually, predominantly in individuals 60 years of age and older. Although current Centers for Disease Control and Prevention guidelines recommend shingles vaccination in this population, national vaccination rates remain below 10%. To that end, Healthy People 2020 have set a goal for the administration rate of the shingles vaccine at 30%. The objective of this study was to assess the knowledge, attitudes, and perceived barriers to shingles and shingles vaccine administration in individuals 60 years of age and older and in physicians. Eligibility for participation included patients who have received the shingles vaccine, walk-in patients who have not received it but are indicated for it, and physicians who have previously prescribed the shingles vaccine. Currently, a cross sectional survey is being administered at an independent community pharmacy. Previously vaccinated patients and walk-in patients are being surveyed via telephone and in the pharmacy, respectively. Physicians are being surveyed via fax. Outcome measures for participants include their knowledge, attitudes, and perceived barriers to receiving the shingles vaccine. In addition, patient demographics will be assessed. Further, practice settings and the number of years in practice will be evaluated for physicians. All data

will be analyzed with an appropriate statistical program. Results and conclusions will be presented.

ADVANCING OUPATIENT PHARMACY CLINICAL SERVICES: EFFICACY OF OUTPATIENT PHARMACIST INTERVENTION IN ENHANCING LABORATORY MONITORING RATES (B2). Quynh-vi Trinh. Kaiser Permanente Medical Center, San Francisco, CA (Quynh-vi.X.Trinh@kp.org) IRB exempt. Kaiser Permanente San Francisco (KPSF) has been looking to expand outpatient pharmacy clinical services as part of organization-wide efforts to improve medication safety. To this end, KPSF aims to enhance laboratory monitoring rates by promoting the unique role of outpatient pharmacists at point-of-dispensing. This study was designed to determine the impact of a pharmacist consultation on the laboratory follow-up rate of patients on ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs) and/or diuretics with no recorded serum creatinine and/or potassium level in the past 12 months. Inclusion criteria were age greater than 18, medication compliance, English as the primary spoken language, and pharmacy walk-in as method of medication pick-up. Eligible patients were divided into two groups. Those in the control group received usual care with no additional counseling on laboratory test adherence. Those in the intervention group were identified for mandatory consultation using a note in their medication profile. Outpatient pharmacists were instructed to educate these patients on the importance of annual laboratory monitoring. A retrospective data analysis was used to compare laboratory completion rates between the two groups, with subgroup analyses by age, gender, laboratory value(s) and blood pressure control. Results and conclusion of this study are pending.

PHARMACIST PRESCRIPTION REFILL AUTHORIZATION PROGRAM (B2), Linda Truong, Jessica C. Song, Jennefer Yoon, June Vu, Phoebe Li, Narinder Singh. Santa Clara Valley Medical Center, San Jose, CA (linda.truong@hhs.sccgov.org) IRB approval not needed. Pharmacist authorized refill protocols have been used at several institutions but there is limited data regarding whether they are safe. Moreover, no published study has addressed the role of a pharmacist to perform therapeutic interchanges in addition to refill authorizations. This prospective study compares the times required to refill prescriptions before and after implementation of a refill authorization protocol in one primary care clinic. In addition, this study will determine the number of patients before and after protocol implementation with up-to-date laboratory monitoring for selected medications. Patients eligible for pharmacist authorized refills had to have at least two previous refills, their medication had to be for a chronic medical condition, and the prescription had to be by a participating physician. Protocol medications were chosen based on whether they can be safely monitored by a pharmacist, whether they require continuous therapy, as well as whether they legally could be refilled. The role of the refill authorization pharmacist was expanded to include the execution of therapeutic interchanges to penny-drugs during the refill authorization process, given the necessity for cost-saving measures at Santa Clara Valley Medical Center. The results, to be analyzed using the Student's ttest, Chi Square test or Fisher Exact Test, and descriptive statistics, will be presented.

B3 CriticalCare

ASSESSMENT OF DELIRIUM MONITORING AND TREATMENT IN THE ICU AT AN ACADEMIC MEDICAL CENTER (B3), Karen Anderson. UC San Diego Medical Center, San Diego, CA (k3anderson@ucsd.edu) IRB approval pending The purpose of this study is to conduct a retrospective medication use evaluation of CAM positive patients, including if they were treated, which agents were prescribed and if the treatment improved patient outcomes. A secondary objective of this study was to reinforce and assess the compliance of the CAM-ICU (Confusion Assessment Method for the Intensive Care Unity) test for delirium. To implement the CAM assessment, an in-service was performed in 2009 for nursing education committees, physicians, and pharmacists. Unit specific nurse educators modeled and led unit-specific education to fellow nursing staff. Follow-up bedside training and re-education was conducted by pharmacy staff in coordination with nurse educators in the fall of 2010. The initiation of delirium treatment and choice of agent was left to the discretion of the physician. A retrospective analysis was performed from November 1, 2010 to January 12, 2011 including collection of study endpoints such as ICU length of stay, days of mechanical ventilation, time to delirium resolution and ICU mortality. Results and conclusions will be discussed.

DELIRIUM MANAGEMENT BY PHARMACISTS IN A DIVERSE COMMUNITY HOSPITAL INTENSIVE CARE UNIT (B3), Sandra Bartlett, John Flanigan and James Adams. Exempla Good Samaritan Medical Center, Lafayette, CO (BartlettS@Exempla.org) IRB approved. Delirium is a brain dysfunction that affects consciousness and cognition. It is associated with increased mortality and is a predictor of significant cognitive impairment especially in patients surviving a critical illness. A collaborative protocol lead by pharmacists was introduced to enhance the quality of patient care. The protocol includes proactive assessments by pharmacists and nurses using the Confusion Assessment Method (CAM) for the intensive care unit (ICU) to identify delirium and an algorithm for delirium prevention and treatment. Environmental control and reorientation therapy is implemented by nurses to minimize the development of delirium while pharmacists review medication profiles to minimize the use of drugs associated with delirium. In addition, pharmacists order and dose antipsychotic medications to treat delirium according to the protocol. The primary objective of this descriptive pilot study is to compare the impact of the protocol implementation on the prevalence of delirium in a diverse community hospital ICU. Inclusion criteria for the study consist of patients age 18 or older. Patients excluded from the study are those who are moribund, comatose, have either stated allergies to or are currently taking haloperidol or olanzapine as home medication and those patients taking medications for dementia prior to admission. The descriptive patient statistics and study results will be presented.

EVALUATION OF THE TREATMENT OF ALCOHOL WITHDRAWAL SYNDROME IN CRITICALLY ILL PATIENTS (B3), Andrew Berry, Jeremiah Duby, UC Davis Medical Center, Sacramento, CA (andrew.berry@ucdmc.ucdavis.edu) IRB approved. The objective of this retrospective cohort study is to describe the management of alcohol withdrawal syndrome in critically ill patients at UC Davis Medical Center. Subjects were identified from electronic medical records by using the ICD-9 code for alcohol withdrawal (ICD-9 = 291.81). Patients at least 18 years of age that were admitted to an ICU between February 2008 and February 2010 were included. Patients with severe brain injury, denoted by persistent Glasgow Coma Scale (GCS) < 8, were excluded. Total daily use of sedatives, antipsychotics, and analgesics were recorded. Medication use was assessed until the patient expired, was discharged from the ICU, or for a maximum of 28 days. Baseline patient characteristics were also collected to determine severity of illness and severity of alcohol withdrawal in the study population. Study outcomes include length of stay in the ICU, days of continuous sedation, instances of over-sedation (Richmond Agitation Sedation Scale, or RASS -3), instances of agitation (RASS 2), time to resolution of agitation (RASS 0 to -2), presence of seizures, time on ventilator, and rate of nosocomial pneumonia. Other outcomes include markers of drug toxicity such as flumazenil use, metabolic acidosis, renal failure and anion gap >10. Detailed results and conclusions will be presented. Study results will be used to assess current practice, develop a protocol and order set, and produce educational materials.

PROGNOSTIC VALUE OF HEART RATE ABNORMALITIES IN HOSPITALIZED HYPOTENSIVE POISONED PATIENTS (B3). Elisabeth Birdsall. UCSF, San Francisco, CA (elisabeth.birdsall@ucsf.edu) IRB approved. The study objective was to evaluate the differences in treatment requirements, complications and health outcomes in hospitalized hypotensive poisoned patients according to whether they were bradycardic or tachycardic. The study was a retrospective review of records from the California Poison Control System (CPCS), San Francisco Division. CPCS receives calls for toxicological consults regarding poisoned patients from hospitals throughout California. Each patient case is followed up on a daily basis until it is determined that the effects of the toxin(s) have resolved at which point the case is closed. Each case is then coded for substances involved; signs and symptoms related to the poisoning; treatments given to the patient; and outcome at the time of case closing. For the purposes of this study, the records of all calls from January 1, 2000 through December 31, 2009 involving hospitalized patient cases coded with hypotension related to the poisoning were reviewed. Inclusion criteria were SBP less than 90 mmHg with a simultaneous numerical HR value documented in the record. Patients were separated into groups based on varying degrees HR abnormalities. Data of interest included patient demographics; substances responsible for the poisoning; complications/events; BP response to IV fluids; vasopressor requirement; intubation; and severity of health outcome. Results and conclusions will be discussed.

EFFICACY OF HYDROCORTISONE WITH VASOPRESSIN IN ADULT PATIENTS WITH SEPTIC SHOCK: A RANDOMIZED PILOT STUDY (B3), Karen Bronson. Legacy Health, Portland, OR (kbronson@lhs.org) IRB approval pending.
The objective of the project is to develop and implement a randomized controlled trial in the critical care setting. The purpose of the trial is to determine if adding corticosteroids to vasopressin will improve outcomes as measured by decreased ICU length of stay for patients with septic shock. The study will be a multi-center (within Legacy Health), prospective, randomized, double-blind trial enrolling patients who have septic shock and are dependant upon vasopressors; patients will be randomized to receive either vasopressin plus hydrocortisone or vasopressin plus placebo. Secondary outcomes will be hospital length of stay, improvement in organ dysfunction (as measured by the sequential organ dysfunction score) and days alive and free from support (ventilation, renal replacement therapy, and/or vasopressors). A total of 360 patients (180 in each treatment arm) will be enrolled in order to detect a 25% decrease in ICU length of stay, assuming a two-sided alpha error of 0.05 and a power of 50%. Enrollment will begin pending IRB approval; the enrollment period is estimated at 2.5 to 3 years. Enrolled patients will receive unblinded vasopressor agents and either blinded hydrocortisone 50 mg IV every 6 hours or a matched placebo. Results will be published upon study completion.

GLYCEMIC CONTROL IN INTENSIVE CARE UNIT PATIENTS WITH PROVISION OF PARENTERAL NUTRITION BY A NUTRITION AND METABOLIC SUPPORT SERVICE (B3). Zhiyu Chen. John Engelbert. Sharp Healthcare. San Diego, California, (zhiyu.chen@sharp.com) IRB approved. The study objective is to compare whether a nutrition and metabolic support service (NMSS) in Sharp Memorial Hospital (SMH) providing parenteral nutrition (PN) improved glycemic control in ICU patients, compared to individual practitioner prescribed PN service in Sharp Grossmont Hospital (SGH). At SMH, all PNs are provided by multidisciplinary NMSS. At SGH, PN regimen is provided by individual caring physician. The study is a retrospective analysis of glycemic control in ICU patients who received PN. The study period is 7 months. The inclusion criteria is age greater than 18, admitted into ICU and prescribed PN. The exclusion criteria are patients who received PN for less than 48 hours or patients who did not survive 72 hours after the initiation of PN. Patients demographic information, global assessment score (SGA), severity of illness (SI), indication for PN, duration of PN, daily Point-of-Care glucose level, laboratory venous glucose sample levels and electrolyte levels such as potassium, phosphate and magnesium are collected. Concurrent medications effecting glycemic control are reviewed as well. The mean blood glucose, the percentage of time patients experience hyperglycemia (greater than 180 mg per dL) or hypoglycemia (less than 60 mg per dL) are analyzed by the Chi-square test, student t-test and ANCOVA. Results and conclusion will be presented.

CLINICAL IMPACT OF AN ANTIBIOTIC SELECTION GUIDE ON THE TREATMENT OUTCOME OF SEPSIS (B3). Maggie Ching, Kenneth Woo, Katherine Yep, Gary Louie. California Pacific Medical Center, San Francisco, CA. (ChingM@sutterhealth.org) IRB approval is pending. Suboptimal selection and timing of administration of antimicrobial agents for the treatment of infections are possibly linked to the emergence of antibiotic resistance, increased length of hospital stay, and poor patient outcomes. An antimicrobial selection guide, intended to assist physicians in the ordering of empiric antibiotic regimen for different types of infections was adopted in October 2010 by the Pharmacy and Therapeutic Agents Committee. The study objective is to measure and evaluate compliance to the Guide to Initial Antibiotic Selection, timeliness of antibiotic administration and its impact on treatment outcome of sepsis. Patients in the sepsis tracking data prior to the implementation of the antibiotic guide are included as baseline comparison. These data are compared to sepsis patients admitted after the implementation of the antibiotic selection guide. Antibiotic regimens, timing of antibiotic administration, culture results, duration of antibiotics, and length of hospital and critical care unit stay were evaluated. Results and conclusion will be presented.

PHARMACIST INTERVENTION ON SEDATION MEDICATION THERAPY IN MECHANICALLY VENTILATED ADULTS (B3), Rebecca Cochrane. Asante Health System, Medford, OR (rcochrane@asante.org) IRB approval received. By improving sedation medication therapy at Rogue Valley Medical Center this project will attempt to increase patient safety and improve clinical outcomes. Pharmacist intervention(s) will improve sedation medication infusion rates and dosages as well as frequency of sedation vacations. First, current utilization of available protocols will be assessed through a retrospective chart analysis. Patients will be identified via the pharmacy drug database. The inclusion criteria will be: age greater than 18 years, mechanical ventilation, sedation with midazolam or propofol for greater than 12 hours. Patients will be excluded if they have unstable intracranial pressure, profound hemodynamic instability, on the hypothermia protocol, receiving neuromuscular blocking agent or a written hold order on sedation vacations. Data to be collected for analysis includes documentation of: sedation score, sedation vacation, and appropriate reduction of sedation medication infusion rate. The pharmacist intervention is to ask questions regarding sedation medication infusion rates, dosages, and sedation vacations during interdisciplinary rounds. The intervention period will be 4 weeks. After the intervention period, the same data will be collected to assess if the pharmacist intervention had an impact on sedation medication therapy. The number of pharmacist interventions will be recorded during the 4 week intervention period. Data collection is currently underway and analysis is pending. Results and conclusions will be presented.

FUROSEMIDE VERSUS A FUROSEMIDE/ALBUMIN COMBINATION ON URINE OUTPUT IN HYPOALBUMINEMIC CRITICALLY ILL PATIENTS (B3). Thitima Doungngern. University Medical Center, Tucson, AZ (doungnge@pharmacy.arizona.edu) IRB approved. This retrospective crossover study was designed to compare the diuretic effect of continuous furosemide infusion when co-administered with and without albumin in critically ill patients. Patients were included if admitted to the adult medical intensive care unit between Jan 1, 2007 and August 31, 2010 and prescribed continuous furosemide infusions both with and without continuous infusions of 25% albumin. Patients were excluded if they received either furosemide alone or combined furosemide-albumin for less than 6 hours, or had serum creatinine concentrations greater than 1.5 mg/dl. Furosemide and albumin doses, fluid intake, urine output, and demographic data were collected. Urine output and cumulative negative fluid balance between the two groups were compared. Simple regression analysis was used to investigate relationships between the dependent variable, urine output, and independent variables such as fluid input, severity of illness and serum albumin concentration. One hundred seventy patients were identified that received furosemide with and without albumin. Thirty-six of these patients received at least 6 hours of each regimen, but 5 additional patients were excluded due to serum creatinine concentrations greater than 1.5 mg/dl. Therefore, 31 patients were included in the final analysis. The results will be discussed.

IMPACT OF HIGH-FIDELITY SIMULATION TRAINING ON PHARMACIST COMPETENCY IN ACLS (B3), Amy Eng, Jennifer Namba, Kevin Box. UC San Diego Medical Center (UCSDMC), San Diego, CA (a1eng@ucsd.edu) IRB approval pending. To improve retention of knowledge and adherence to the 2010 Advanced Cardiovascular Life Support (ACLS) guidelines, high-fidelity simulation was implemented this year as an additional training tool for pharmacist residents at the UCSDMC. This study is a retrospective analysis of 12 pharmacist residents at the UCSDMC who participated in simulation-based ACLS training using a high-fidelity mannequin. Baseline knowledge of ACLS algorithms and medications, competency, and confidence were evaluated. The simulation course includes a didactic update of recent ACLS guidelines, a review of medication preparation and pertinent drip calculations, and participation in 3 simulated clinical scenarios. Three weeks after the simulated training session, the residents were assessed for enhancement of ACLS knowledge, competency, and confidence through a written exam, competency exercise, and confidence survey. All UCSDMC acute care PGY1 pharmacist residents who have completed simulation training were included. The Wilcoxon signed-rank test will be used to compare the preand post-simulation results. The significance level will be set at 0.05. Results will be presented.

PREVENTING ICU RELATED DELIRIUM IN OLDER ADULT PATIENTS (B3), Curtis Geier. Franciscan Health System, Tacoma, WA. (curtisgeier@fhshealth.org) IRB approval received. The objective of this trial is to determine if risperidone is effective in preventing delirium in older adults who are intubated and sedated. Patients between 50 and 80 years old who are mechanically ventilated and receiving sedation were randomized to receive risperidone 0.5mg by feeding tube daily for 5 days or no study drug. Exclusion criteria included any psychiatric or neurologic diagnosis that would preclude the use of Confusion Assessment Method for the Intensive Care Unit (CAMICU) or confound the diagnosis of delirium. A pharmacist then performed a CAM-ICU assessment each day for seven days. The primary study endpoint was incidence of delirium as measured by a positive CAM-ICU measurement assessed by a pharmacist. Secondary endpoints include duration of intubation, length of ICU stay, and adverse events. The validity of CAM-ICU assessments completed by nursing compared to those done by a pharmacist was also studied. The results and conclusion will be discussed.

MAINTENANCE OF RATE CONTROL IN ATRIAL FIBRILLATION PATIENTS CONVERTED FROM IV TO ORAL AMIODARONE: IS THERE A CLINICAL BENEFIT TO BRIDGING? (B3). Elizabeth Gramer. VA San Diego Healthcare System, San Diego, CA (Elizabeth.Gramer@va.gov) IRB approved. The study objective is to determine if bridging patients to oral amiodarone therapy plays a role in maintaining rate control when compared to those who are not bridged. There is currently very little literature on bridging patients with atrial fibrillation from intravenous (IV) to oral (PO) amiodarone. The practice of bridging patients to PO therapy at our institution is physicianspecific and can range from one hour to one day. A retrospective chart review from January 1, 2005 to January 1, 2011 was used to evaluate the success rate of those bridged to PO therapy versus those who were not bridged. Success was defined as maintaining a heart rate below 110 beats per minute and not requiring an amiodarone rebolus during the study period. Atrial fibrillation patients who were admitted to the ICU or DOU and given IV and PO amiodarone were included in the study. Patients who were being treated for ventricular arrhythmias or had any contraindications, such as 2nd or 3rd degree AV block or sinus bradycardia, were excluded. The success rates of the two groups were compared using a Chi-square analysis. Results and conclusions will be presented

DEVELOPMENT AND IMPLEMENTATION OF A MULTI-DISCIPLINARY PAIN AND SEDATION ASSESSMENT AND TREATMENT ALGORITHM IN THE ICU (B3). Beth Han. Janell Krack. Keely Sieg. Angela Stewart. Yakima Memorial Hospital, Yakima, WA (ElizabethHan@yvmh.org) IRB exempt. Most mechanically ventilated patients in the ICU experience some degree of pain and stress. Without proper assessment and treatment, there is an increased rate of mechanical ventilation, length of stay, mortality and inability to assess current cognitive status. Through implementation of a multi-disciplinary pain and sedation algorithm, ICU patient outcomes will improve. A retrospective chart review of mechanically ventilated patients admitted in 2009 will be conducted to determine use of the Richmond agitation and sedation scale (RASS) and pain scores. After development and implementation of the algorithm, a repeat chart review will be conducted from February through April 2011. Patients that are ventilated for less than 96 hours, are less than 18 years old, or are not on pain or sedation medications will be excluded from this study. Data will be collected on demographics, diagnosis, comorbidities, length of stay in the ICU, days on mechanical ventilation, days at goal sedation and pain levels. Each morning, nurses will awaken mechanically ventilated patients if they meet criteria and utilize the RASS and pain assessment scales. Pharmacists will provide education to the ICU nursing staff on the use of the sedation and pain algorithm. This team is composed of three pharmacists, ICU nursing staff and the pulmonary physician group. Results and conclusion will be presented.

SEPSIS QUALITY IMPROVEMENT THROUGH A BUNDLE PROTOCOL FOR EARLY GOAL DIRECTED THERAPY (B3), Elizabeth Hetrick, Christian Hamm, Duane Coffler, Tom Rowe. MultiCare Medical System, Tacoma, WA. (elizabeth.hetrick@multicare.org) IRB approval not required. Despite advances in care, sepsis remains a leading cause of morbidity and mortality. The Surviving Sepsis Campaign released revised guidelines in 2008 to direct evidence based management of early sepsis. The purpose of this investigation is to monitor compliance with early goal directed therapy targets for severe sepsis and septic shock and to identify areas that could be improved through pharmacy services. A retrospective chart review will be conducted. Inclusion criteria include patients aged 18 years and older admitted via the emergency department with severe sepsis or septic shock during the second and third quarters of 2010. Cases will be reviewed for compliance with the early goal directed therapy bundle. Primary endpoints include serum lactate drawn within one hour, fluid resuscitation directed by hemodynamic parameters, blood cultures drawn prior to antibiotic administration, antibiotics administered within 3 hours of presentation to the emergency department, broad spectrum antibiotic selection appropriate for suspected infectious source, and vasopressor administration directed by central venous pressure or venous oxygen saturation. Descriptive statistics will be used to analyze data with a goal of 100% compliance with guidelines. A multidisciplinary team will assess results and implement potential quality improvement strategies. Further data will be presented.

A RETROSPECTIVE ANALYSIS OF THE UTILIZATION OF INTRAVENOUS IRON, EPOETIN ALFA, AND PACKED RED BLOOD CELLS IN THE ADULT TRAUMA PATIENT POPULATION (B3), Josie Huerta, William Marcus, Adam Porath. Renown Regional Medical Center, Reno, NV (jhuerta2@renown.org) IRB approved. The study objective was to determine what effects the use of intravenous (IV) iron and epoetin alfa (Epo) had on the utilization of packed red blood cells (PRBCs). The electronic medical record system was used to identify patients who had been admitted to the Trauma Intensive Care Unit (TICU) for at least 48 hours and had received IV iron, Epo, and/or PRBCs. Identified patients were compared to a historical control group admitted to the TICU prior to the routine utilization of Epo. The study period was one year. Patients were excluded if they were younger than 18 years of age; pregnant; unable or unwilling to receive PRBCs; received recombinant human erythropoietin products in the last 30 days; and/or had a history of acute ischemic heart disease, hemophilia, sicklecell disease, and/or gastrointestinal bleed. The following data was collected: demographic data; the utilization of IV iron, Epo, and PRBCs; days receiving mechanical ventilation; TICU length of stay; hospital length of stay; in hospital mortality; and the occurrence of venous thromboembolism, transfusion related acute lung injury, and infection. Injury severity scores for all subjects included in the study were calculated. A historical analysis was performed to compare the percentage of patients receiving PRBCs from July 2006 to July 2007 versus July

2009 to July 2010. Results and conclusions will be presented.

RETROSPECTIVE EVALUATION OF BLEEDING RISK WITH LOW-MOLECULAR-WEIGHT-HEPARINS IN PATIENTS WITH RENAL DYSFUNCTION AND OBESITY IN VAGLA (B3). Eileen Jeong, Maria Longo, Wayman Lee. Veterans Affairs Greater Los Angeles Healthcare Systems, Los Angeles, CA (Eileen.Jeong@va.gov) IRB approved. The objective was to evaluate the bleeding risk in VA GLA veterans with renal dysfunction and/or obesity that were treated with low-molecular-weight heparins. Patients were reviewed between June 1, 2009 and August 31, 2010 with objectively confirmed diagnosis of acute coronary syndrome, atrial fibrillation, aortic valve and mitral valve surgery and deep vein thrombosis/pulmonary embolism on LMWH therapy with renal dysfunction and obesity. Patients were assessed from the time LMWHs are initiated to 1 week, at 1 month and 3 month on treatment. This study included all patients who have renal function of less than 60 ml/min or total body weight of greater than 120kg. The incidence of bleeding on enoxaparin or dalteparin was collected, and evaluated for possible risks that caused the bleeding. Based on the data analyzed, we developed an in house anti Xa level ordering criteria and a nomogram for dosing LMWHs in order to improve patient care. Results and conclusions will be presented.

EVALUATION OF STANDARDIZED INTRAVENOUS ANTIBIOTIC DESENSITIZATION PROTOCOLS IN AN ACADEMIC MEDICAL CENTER (B3) Genevieve Kautz Amy Go, Gerard Barber, Stephen Dreskin. University of Co Hospital, Aurora, CO (Genevieve.Kautz@gmail.com). IRB approved. Significant focus is dedicated to the appropriate use of antimicrobial therapy to optimize patient outcomes. Unfortunately, some patients may not receive an optimal agent due to IgE hypersentitivity to the agent. However, desensitization to the offending agent offers a potential treatment approach Desensitization is a process by which an offending agent is administered first as a low dose and then as increasingly higher doses at regularly timed intervals until a therapeutic dose is achieved. Preparing the orders and serial dilutions for desensitization to an agent is a time consuming and error prone process for physicians, pharmacists and nurses. In August 2010, the University of Colorado Hospital (UCH) instituted standardized desensitization protocols for nine intravenous antibiotics to help reduce errors and save time for health care providers. This observational, case-controlled study was performed to evaluate how the standardization of practices has impacted patient outcomes and time allocation for healthcare providers. The primary outcome was patient safety and tolerability measured by rates of reaction. Secondary outcomes included ICU length of stay, number of errors committed, number of successful desensitizations, and time saved by healthcare providers. Results and conclusions will be presented.

TREATMENT OF DIABETIC KETOACIDOSIS (DKA) USING THE TWO-BAG SYSTEM IN ADULT ICU PATIENTS (B3), Shannon Knutsen. Exempla Saint Joseph Hospital, Denver, CO (knutsens@exempla.org) IRB approval received. The American Diabetes Association recommends that treatment of DKA include IV fluids, insulin, potassium replacement and assessment of need for bicarbonate. Based on these guidelines a DKA protocol was established for Exempla Saint Joseph Hospital. Despite its ability to treat DKA patients, the protocol has been observed to have some shortcomings. This is a prospective, randomized open-label study comparing the current DKA protocol to the TwoBag System. The Two-Bag system consists of 2 fluid bags with equal electrolytes but different dextrose concentrations given simultaneously. This allows the amount of glucose and total fluid rate to be manipulated independently. The primary outcome is to determine if utilization of the Two-Bag system will result in a steadier rate of decline in serum glucose compared to the current DKA protocol. Patients are consented and randomized in a 1:1 ratio within two hours and treated for DKA with the Two-Bag system or the current DKA protocol. The titration of the Two-Bag fluid rate is different for each total infusion but standardized based on final dextrose concentration and serum glucose values. The results of this study will be presented.

A RETROSPECTIVE CHART REVIEW OF EXAMINING THE CLINICAL AND ECONOMIC IMPACT OF SWITCHING FROM ENOXAPARIN TO DALTEPARIN IN A HIGH RISK POPULATION (B3), Michael Li, Kenneth Jarman. UW Medicine, Seattle WA (mhli@uw.edu) IRB Approval received. In June 2010, University of Washington Medicine changed the preferred formulary low molecular weight heparin from enoxaparin to dalteparin. The purpose of this study is to determine whether this formulary switch is cost effective for venous thromboembolism prevention in a high risk population at Harborview Medical Center. This investigation is a retrospective chart review of critical care patients admitted to the trauma surgery service at HMC who received enoxaparin during a two month period in 2009 and dalteparin in the same period in 2010. The defined primary outcomes of this investigation are VTE (lower extremity deep vein thrombosis or pulmonary embolism), heparin-induced thrombocytopenia, and bleeding events defined as either a fifty percent drop in hematocrit in 24 hours, bleed requiring transfusion of two or more units of packed red blood cells, or a fatal bleeding event. Secondary outcomes of this analysis include percentage of time patients received the respective lowmolecular weight heparin during their hospitalization and overall costs related to VTE prophylaxis. Cost effectiveness of therapy will be determined by calculating the direct medication costs and indirect costs of treating adverse outcomes. The results of this analysis are pending and will be presented.

MEDICATION ERRORS INVOLVING SPECIAL ADMINISTRATION PROCEDURES IN THE INTESIVE CARE UNIT (B3), Aundrea Linn, Anna Kirejczyk, Mitchell Buckley. Banner Good Samaritan Medical Center, Phoenix, AZ (Aundrea.bell@bannerhealth.com). IRB approved. Medications errors are common and remain a concern in critically ill patients. The incidence of medication errors have been reported to occur in 19% of hospitalized patients. However, medication error rates in the intensive care unit (ICU) are almost twice that of patients on general medicine floors. Critically ill patients usually receive twice as many medications as patients on general medicine floors, thereby increasing the potential for medication error rates. Medication errors can occur throughout the medication use process. However, the administration stage has been associated with more errors compared to the prescribing, transcription and dispensing stages. The purpose of this study is to determine the rate of continuous infusion medication errors associated with special administration requirements within the intensive care unit such as appropriate filter use, frequent tube changes, protection from light, central line administration restrictions or specific storage temperatures. This study is a prospective, single-center, observational study in adult ICU patients. Patients will be included if they receive a medication that requires special administration. Results and conclusion will be presented.

PROPOFOL DOSING IN OBESE CRITICALLY ILL ADULT PATIENTS (B3). April Lott. Leigh Ann Mike. University of Washington Medicine, Seattle, US (Aprilrl@uw.edu) IRB approved The optimal dose strategy for dosing propofol in obese ICU patients is unknown. The study objectives were to: (i) evaluate the dosing weight for propofol that best correlates with achieving the target level of sedation in obese intensive care unit (ICU) patients; (ii) determine the incidence of propofol related infusion syndrome (PRIS). This was a retrospective cohort study involving obese ICU patients admitted to a tertiary academic medical center within a 16-month period. Adults with a BMI > 30 kg/m2 admitted to an ICU and received propofol for > 24 hours with documented sedation scores were included. Exclusion criteria included incomplete data, receiving propofol for indications other than ICU sedation, or in patients < 18 years of age. Demographic and clinical data, including time to initial goal Richmond Agitation Sedation Scale (RASS) score were collected. The diagnostic criteria for PRIS were based on published literature. Attainment of the target level of sedation was defined as having 2 consecutive RASS scores at goal. Linear regression will be performed to compare total, ideal, and adjusted body weight for attainment of target level sedation. Preliminary results (N=38) expressed as mean SD include: Age: 55 19 years, BMI 38.6 4.3 kg/m2, APACHE II 15 7, duration of mechanical ventilation 13 8 days, length of stay in ICU and hospital 8 8 and 30 23 days, respectively; average cumulative propofol dose 15 16 grams, time to goal

RASS 26 32 hours, time to goal RASS maintenance 32 39 hours. No patients experienced PRIS.

PHARMACISTS INSULIN MANAGEMENT IN AN INPATIENT SETTING (B3). Sarah Low, Highline Medical Center, Burien WA (salow@highlinemedical.org) IRB not needed no human subject data. The study objective is to determine if a systematic approach in pharmacists management of insulin infusion will improve patient outcomes in ICU patients. Medical records were requested for patients who were at Highline Medical Center and had the intensive insulin protocol physician initiated and managed by pharmacy. Demographics gathered include age, gender, weight, BMI, diabetes mellitus history, corticosteroid use, and home insulin dose. Furthermore, safety data gathered will include number of hypoglycemic episodes, infections in hospital, mortality during admit, length of stay, and time averaged glucose. The second phase will be to implement the new protocol and pharmacists' education. The second study period will have the same data points as the first study period to compare effectiveness and safety. The data comparison pre and post insulin infusion will be presented.

IMPLEMENTATION AND EVALUATION OF EARLY GOAL DIRECTED THERAPY IN SEPSIS (B3). Matthew Maglalang. Clayton Littell. Bret Gravatt. Brent Albertson. Providence Sacred Heart Medical Center, Spokane, WA (Matthew.Maglalang@providence.org) IRB exempt. Nationally, sepsis mortality rates have remained between 30 to 40 percent over the last three decades. When septic shock is present, 50 to 60 percent mortality is estimated. Medical centers that have implemented sepsis bundle protocols adapted from the Surviving Sepsis Campaign have shown decreased mortality. Studies have shown early goal directed therapy to result in absolute reductions in mortality as high as 16 percent. The project objective was to implement strategies aimed at identifying sepsis and severe sepsis in the emergency department (ED) within 30 minutes of patient assessment and decreasing baseline mortality by 10 percent. A multidisciplinary committee comprised of ED physicians, ICU intensivists, nursing, laboratory, pharmacy and other personnel were assigned to determine the best way to implement a standardized sepsis bundle for the ED and ICU. All early goal directed therapies were adopted from the Surviving Sepsis Campaign and incorporated into the sepsis bundle protocol. ICD 9 codes were used to identify all patients with sepsis and severe sepsis over a three month period. Time to antibiotics administration, correct antibiotic selection, time to fluid goals being met, length of stay in the ICU, and mortality were measured. The results were compared with retrospectively obtained data on patients treated before protocol implementation. Results and conclusions will be presented.

EVALUATION OF COMPLIANCE WITH DAILY INTERRUPTION OF SEDATION IN MECHANICALLY VENTILATED ICU PATIENTS (B3) Erica Martin. Saint Alphonsus Regional Medical Center, Boise, ID (Martiebu@sarmc.org) IRB approval pending. Infusions of sedatives and analgesics are widely used in mechanically ventilated patients in the intensive care unit (ICU). Continuous infusion may increase patient comfort and provide a constant level of sedation; however, excess sedation is associated with increased risk for ventilator associated pneumonia, and increased length of ICU and hospital stay. Studies have demonstrated that daily interruption of sedation can improve these outcomes. The objective of this review is to measure and compare the rate of compliance with daily interruption of sedation in the ICU before and after implementation of pharmacist led education of ICU staff and conversion to CPOE. Baseline compliance will be measured through a retrospective review of ICU patients on the sedation protocol from December 2009 to February 2010. Barriers to compliance will be identified by a committee of ICU physicians, nurses, respiratory therapists, pharmacists and managers. Educational materials will be developed by pharmacy and will be aimed at overcoming the barriers and improving compliance with the protocol. After presenting the education and converting to CPOE, the rate of compliance will again be measured for patients on the sedation protocol. Results and conclusions will be presented.

HYDROMORPHONE VERSUS FENTANYL CONTINUOUS INFUSIONS IN VENTILATED PATIENTS IN THE INTENSIVE CARE UNIT (B3), Lina Meng, Cherwyn Nguyen, Craig Sterling, Stanford Hospital & Clinics, Stanford, CA (LMeng@stanfordmed.org) IRB approved Fentanyl is a commonly used continuous intravenous (IV) infusion for analgesia in ventilated, critically ill patients. Its increased fat solubility, especially with prolonged use, can result in accumulation in peripheral tissue. Its elimination involves redistribution of the drug from peripheral tissue to systemic circulation, which occurs at an unknown rate. The subsequent impact on recovery time and extubation is not well studied. Hydromorphone lacks these properties. Our objectives were to 1) determine the effects of hydromorphone and fentanyl continuous IV infusion on return to normal neurological status and 2) to determine if hydromorphone is an acceptable alternative analgesic for continuous IV infusion in critically ill patients. A retrospective chart review was performed in adult patients of the Stanford Hospital & Clinics surgical, medical, and cardiovascular intensive care units (ICU) over a 1 year period. Two hundred patients were included in our analysis. Study endpoints included time between discontinuation of study drug and first spontaneous breathing trial (SBT), time until successful passing of SBT, time until following commands and eye opening, duration of ICU stay, and percent time in optimal sedation. These events will be analyzed using log rank test and Coxs proportional hazards model. Wilcoxons rank sum test will be used to analyze the effect of cumulative dose and passing of SBT. Results and conclusions will be presented.

DETERMINING OPTIMAL DOSING OF BIVALIRUDIN DURING EXTRACORPOREAL LIFE SUPPORT IN PEDIATRIC PATIENTS (B3), Erin Nagle, William Dager, Aaron Josh Roberts, UC Davis Medical Center, Sacramento, CA (erin.nagle@ucdmc.ucdavis.edu) IRB approved. The objective of this retrospective analysis is to assess the use of continuous infusion bivalirudin in pediatric patients maintained on extracorporeal life support (ECLS) refractory to unfractionated heparin (UFH). The analysis will explore dosing regimens used to achieve target anticoagulation goals with bivalirudin. Patients less than 18 years old on ECLS who received bivalirudin for anticoagulation between May 2006 and February 2011 were enrolled. Data extraction will include UFH and bivalirudin dosing requirements, activated partial thromboplastin times, activated clotting times, antithrombin and fibrinogen concentrations, blood product requirements, renal and liver function studies, extracorporeal circuit changes, and adverse effects including hemorrhage and thrombosis. Baseline characteristics and disease severity will be collected for each subject. Results and conclusions of the analysis will be presented.

VALIDATION OF A NEW INSULIN INFUSION PROTOCOL USING MODERATE BLOOD GLUCOSE CONTROL IN A MIXED ADULT INTENSIVE CARE UNIT (B3). Julie Nguyen, Christopher Tan. Tripler Army Medical Center, Honolulu, HI. (Julie.K.Nguyen@us.army.mil) IRB approved. The landmark Leuven trial, which demonstrated that intensive insulin therapy significantly reduced in hospital mortality, served as the foundation for the previous insulin infusion protocol targeting a blood glucose (BG) level of 80 to 140 mg/dL at Tripler Army Medical Center (TAMC). Recently, the NICE SUGAR trial revealed that tight glycemic control resulted in higher mortality in critically ill patients. As a result, a new protocol at TAMC was developed to target a moderate BG range of 100 to 150 mg/dL. The objective of this retrospective study is to examine the safety and efficacy of the new insulin protocol, as well as to compare it to the old protocol. Eligible patients include adults at least 18 years old who require insulin infusion for at least 24 hours. Patients with an admission diagnosis of diabetic ketoacidosis, hyperosmolar hyperglycemic state or pregnancy will be excluded. Endpoints include time to reach target range, percentage of BG within desired target range, mean BG after target has been achieved, ICU length of stay, readmissions to the ICU, number of hypoglycemic episodes and in hospital mortality. Preliminary results will be presented. The views expressed in this abstract are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

EVALUATING THE ECONOMIC IMPACT OF INADEQUATE CROTALIDAE POLYVALENT IMMUNE FAB (CROFAB) ANTIVENOM USE (B3), Tam Nguyen. Anh-Vuong Ly. Loma Linda University Medical Center, Loma Linda, CA. (TamNguyen@llu.edu) IRB approval received. Although snakebite envenomations rarely result in mortality, they are associated with significant morbidity ranging from severe pain to systemic complications such as coagulopathy, compartment syndrome, and hypovolemic shock. Currently, CroFab is the only available agent for rattlesnake envenomations in the United States. However, multiple issues complicate its use. Due to its high cost and rarity of use, other institutions may not always stock an adequate supply of Crofab. An inadequate loading dose of Crofab may lead to insufficient initial control of symptoms and result in adverse patient consequences and a significant financial burden for both the hospital and the patient. This study will include adult patients treated with Crofab at Loma Linda University Medical Center (LLUMC) from 2001 to 2010. The objective of this retrospective study is to evaluate the economic impact of patients transferred from other facilities who received an insufficient loading dose of Crofab or initial control of symptoms compared to those treated appropriately at LLUMC. The economic impact will include the adverse effects and treatment of complications of the snakebite due to inadequate initial control of symptoms. Results will be presented.

IMPACT OF A PHARMACIST IN THE EMERGENCY DEPARTMENT: A LOOK AT THE JOINT COMMISSION CORE MEASURES (B3), Thien-Kim Duc Nguyen, Kaiser Permanente San Diego Medical Center, CA, (thien-kim.d.nguyen@kp.org) IRB approval received. The Emergency Department (ED) is a fast-paced,high capacity work environment in which patient care is at an elevated risk for medication errors. In such a setting, a pharmacist would be an invaluable resource to the multidisciplinary ED staff by contributing worthwhile medication interventions. The purpose of this study is to implement pharmacy service in the ED. The impact of such a service shall be reflected on how the medical center performs on The Joint Commissions Core Measures of Stroke and Community Acquired Pneumonia (CAP). The aim of the pharmacy services in the ED will be to improve door-to-needle time (stroke core measure) and CAP antibiotic selection, blood cultures drawn before antibiotic initiation, and the percentage of initial CAP antibiotic administration within 6 hours of hospital arrival (CAP core measures). Data analysis of each Stroke and CAP Core Measure will compare pre-implementation to postimplementation data. The implementation date was November 30, 2010. Other ED Pharmacist responsibilities include: verifying medication orders, managing pharmacy protocols, replying to drug information requests from staff, participating in cardiopulmonary resuscitation emergency codes, and providing medication reconciliation in complicated patient cases. A description of the studys methods, final results, and conclusions will be presented.

DEVELOPMENT OF CLINICAL PHARMACY SERVICES IN AN EMERGENCY DEPARTMENT (B3). Viet Nguyen. Desert Regional Medical Center, Palm Springs, CA (viet.nguyen2@tenethealth.com) IRB not needed. The objective of this project is to create a position for a clinical pharmacist as an integral team member of an emergency department. The emergency department at Desert Regional Medical Center is a twenty seven bed twenty four hour, Level II Emergency Trauma Center which is in the process of transitioning to computerized clinician order entry. A review of the literature was conducted to determine what processes, procedures, and templates were created at institutions which had established new clinical pharmacy services in the emergency room and the cost justification used to support the addition of the services. The medical director of the hospital as well as the emergency room doctors and clinicians where surveyed and asked what they saw as the roles of a pharmacist in the emergency room. A proposal to fund a new position for an emergency room pharmacist was drafted and will be submitted to hospital administration. Results will be discussed at a future date and shall include the survey findings and the response of hospital administration as to whether a position for an emergency room pharmacist shall be created. Furthermore, metrics will be presented which can be used to document the cost savings and success associated with clinical pharmacy interventions in the emergency department.

EFFECTS OF STATINS ON VASOPRESSOR USE IN SEPTIC PATIENTS ON EARLY GOAL DIRECTED THERAPY (B3), Faaria Nusrat. Kaiser Permanente Medical Center, San Jose, CA (Faaria.X.Nusrat@kp.org) IRB approval received. Patients with infections who progress to severe sepsis with multiple organ failure and shock have a high mortality rate. They often require aggressive fluid resuscitation and vasoactive drugs in addition to antibiotics. Some studies have suggested that statins decrease the severity of sepsis. The objective of this project was to determine if statin use was associated with a decreased use of vasopressors, thus indicating a decreased incidence or severity of septic shock. Secondary measures included length of ICU and hospital stay. This study was a retrospective review of patients admitted with a diagnosis of severe sepsis who were placed on the early goal directed therapy protocol (EGDT). This protocol provides a structured and progressive treatment plan for sepsis and limits variability in disease severity among the study population. The patients were split into two groups based on whether or not they were exposed to statins. Baseline characteristics were collected for a logistic regression analysis to identify any differences between the two cohorts. Primary outcomes measured included initiation and amount of vasopressor used. Chi-squared analysis was used to establish the probability of statins affecting the use of vasoactive drugs. Results and conclusions are to be presented.

IMPROVING PHARMACOLOGIC MANAGEMENT OF SEVERE BLEEDING EPISODES (B3). Adam Petersen. Peace Health Southwest Medical Center, Vancouver, WA. (ajpeters@swmedicalcenter.org) IRB approved. The project objective was to increase appropriate use and safety of available blood factor derivatives and associated medications used to treat intractable hemorrhages. A retrospective chart review was completed to assess the use of factors VII (Novoseven), VIII, IX (Benefix) and Humate-P in the past 2.5 years at Peace Health Southwest Medical Center. The results were presented to the Pharmacy and Therapeutic Committee with suggested changes to current usage practices. In addition, prothrombin complex concentrate (PCC) products were reviewed for potential benefit of use. The current factor products Novoseven, factor VIII, Benefix and Humate-P were evaluated as well to determine the benefits of modification of these agents formulary status. New order sets were designed and the changes were presented to key stakeholders. Pharmacy and medical staff were educated on the use of the new guidelines to increase safety and improve outcomes. A prospective MUE is in progress to evaluate the appropriate and safe use of the new order sets. Results and conclusions will be presented.

EVALUATION OF THE EFFICACY AND SAFETY OF A DEXMEDETOMIDINE PROTOCOL (B3), Ann Marie B. Prazak, Nick Lonardo, Kyle Ludwig, Gabriele Baraghoshi, Peter Liu; University of Utah Hospitals & Clinics, Salt Lake City, UT (annmarie.prazak@hsc.utah.edu), IRB approval received. Dexmedetomidine (DXM) has a rapid distribution phase with a distribution (alpha) half-life of approximately 6 minutes and a terminal elimination (beta) half-life of approximately 2 hours. Approximately 20 to 30 minutes is required to achieve steady state of the distribution phase and 10 hours to reach the terminal steady state. Based on the pharmacokinetics of DXM, we have developed and implemented a DXM dosing protocol in the Surgical ICU (SICU). We collected data from one year prior to the protocol to establish an historical evaluation of DXM use in the SICU. We are evaluating the efficacy and safety of the protocol from January 2011 to April 2011. The primary outcomes of this study are the time to achieve target sedation score (Riker SAS = 4) and the percentage of time at the target sedation score (Riker SAS = 4) during DXM administration. The secondary outcomes are hypotension (MAP<60 mmHg) and bradycardia (BP<50 bpm) attributed to DXM that requires intervention (decrease infusion rate; stop infusion; administration of a rescue drug), and duration and cost of DXM infusion pre-protocol and postprotocol. Prospective data collection is ongoing, and results will be presented.

DEVELOPMENT AND IMPLEMENTATION OF AN EMERGENCY DEPARTMENT PHARMACIST ROLE IN A COMMUNITY BASED HOSPITAL (B3). Channa Richardson. Jami Shaffer. Larry Ishii. St Joseph Medical Center, Bellingham, WA (CRichardson@Peacehealth.org) IRB Approval not needed. The objective of this project is to describe the process of establishing a pharmacy service in the ED of a community based hospital. Initially the available literature was reviewed along with a site visit to another hospital with an ED pharmacist already established to gain sufficient background information. A three month pilot is now being conducted with a pharmacist present forty hours per week during peak hours in the ED. A survey of the ED staff will occur before and after the pilot to assess staff support and gather feedback. ED pharmacy services being provided include but are not limited to: drug information, therapeutic recommendations, order review, patient counseling, and staff education. Pharmacy specific intervention data is being collected to evaluate the pharmacists ability to improve patient care, medication safety, and cost savings in the ED. Data on ED specific performance measures such as time to appropriate medications given will also be evaluated. A business plan will be presented to hospital leadership for consideration of creating a more permanent pharmacy presence in the ED. The results will be discussed with a presentation of data specifics.

EVALUATION OF A SEDATION AND ANALGESIA PROTOCOL FOR MECHANICALLY VENTILATED PATIENTS IN THE ICU (B3). Erica Swanson, Susan Lee, Tanvi Shah. Department of Veterans Affairs Puget Sound, Seattle, WA (Erica.Swanson@va.gov) IRB approval pending. The purpose of this retrospective study is to review initiation, adherence, and efficacy of a nurse driven sedation and analgesia protocol. The protocol will be reviewed by the Pharmacy and Therapeutics Committee. Intensive care unit (ICU) nurses will undergo training for implementation of the protocol. All data will be collected through chart review of patients in the medical and surgical ICU. Inclusion criteria are ICU patients requiring mechanical ventilation. Exclusion criteria are patients ventilated for less than 24 hours, patients with loss of neurologic function, and patients receiving paralytic agents. Data collection from patient flow sheets will include appropriate and timely documentation of daily spontaneous awakening trials for eligible patients, Richmond Agitation Sedation Scale (RASS) scores, and Confusion Assessment Method (CAM) ICU scores. Appropriate usage and titration of both sedatives and analgesics (bolus or continuous infusion) to achieve goal RASS scores will be assessed. Results and conclusions will be presented and discussed.

ADJUSTED ENOXAPARIN DOSING FOR VENOUS THROMBOEMBOLISM PROPHYLAXIS IN TRAUMA PATIENTS (B3), Vy Tran, Kevin Box, Jim Lane, Justin Regner, UCSD Medical Center, San Diego, CA (t0t001@ucsd.edu) IRB pending. The primary study objective is to characterize the adequacy of enoxaparin dosing, based on anti-Xa concentrations, for VTE prevention in trauma patients. The secondary study objective is to characterize the frequency of VTE in trauma patients receiving enoxaparin for VTE prevention. A retrospective review of medical records will be conducted for trauma patients who received enoxaparin 48 hours or more. Inclusion criteria include patients with age 18 years and older, admitted through the trauma service, receiving prophylactic enoxaparin with proper anti-Xa levels drawn, and routine duplex screening. Peak and trough anti-XA levels, typically drawn after the third dose will be collected. Patients were excluded if they had VTE occurrence prior to the study, received not more than 3 doses of enoxaparin, contraindication to anticoagulation, or were pregnant. Primary outcome includes any VTE. Descriptive statistics will be used to present the data. The results and conclusion will be presented.

ETOMIDATE DOSING VARIABILITY BASED ON WEIGHT FOR RAPID SEQUENCE INTUBATION IN THE EMERGENCY DEPARTMENT (B3). Brittany Traylor. Asad Patanwala. Brian Erstad. The University of Arizona, Tucson, AZ (traylor@pharmacy.arizona.edu) IRB approval received. The purpose of this study is to determine if patients who weigh 100 kg were more likely to have received subtherapeutic doses of etomidate for rapid sequence intubation compared to patients who weigh <100 kg. This study is a retrospective cohort study of clinical data for adult patients brought to the University Medical Center emergency department between 07/01/08 and 7/31/10 who received etomidate for rapid sequence intubation. A total of 200 adult patients (100 in each group: <100 kg and 100 kg) will be included. Mean dose of etomidate will be compared between the groups using an unpaired students t-test. A regression analysis will be performed to adjust for covariates and for potential baseline differences between the two groups. The a priori alpha level used will be 0.05. Results and conclusion will be presented.

FACTOR IX COMPLEX CONCENTRATE (BEBULIN VH) USE FOR WARFARIN ASSOCIATED INTRACRANIAL HEMORRHAGE AT VIRGINIA MASON MEDICAL CENTER (B3). Emily Vigil. Virginia Mason Medical Center, Seattle, WA (emily.vigil@vmmc.org) IRB approved. The management of warfarin associated intracranial hemorrhage is changing; current guidelines suggest a variety of protocols combining prothrombin complex concentration, and or fresh frozen plasma and phytonadione. In July 2010, our institution incorporated Bebulin VH into the standard treatment protocol for patients diagnosed with warfarin associated intracranial hemorrhage. The objective of this study is to compare the outcomes of patients admitted with warfarin associated intracranial hemorrhage who received Bebulin VH according to the current protocol, to patients who received only thawed plasma and phytonadione. It is hypothesized that patients who received Bebulin VH have earlier INR normalization and improved survival at discharge. This retrospective review includes patients admitted with warfarin associated intracranial hemorrhage from January 2009 to March 2011. Baseline data, fluid overload complications, venous thromboembolism incidence rates, and other adverse drug reactions will be documented. Additional information to be collected includes: National Institute of Health Stroke Scale score, rate of INR correction, rate of in hospital rebleeding, required surgical interventions, length of hospital stay, discharge location, and survival at discharge, three months, and six months. Results and conclusions will be presented.

RETROSPECTIVE EVALUATION OF DEXMEDETOMIDINE USE IN VENTILLATED ICU PATIENTS IN THE SEDATION WEANING PHASE AT TWO TEACHING HOSPITALS (B3), Shannon Welch, Lynda Tanagi. University of Washington Medical Center, Seattle, WA (smwelch@uw.edu) IRB approved. Dexmedetomidine was added to the sedation and analgesia protocol at University of Washington Medical Center and Harborview Medical Center in June 2010 with use restricted to ventilated patients with hyperactive delirium in the sedation-weaning phase. The objective of this study is to evaluate the efficacy and safety of dexmedetomidine in adult medical and surgical ICU patients in the sedation-weaning phase. This is a retrospective, case-control, observational study of adult ventilated ICU patients prescribed dexmedetomidine between June 15 and November 15, 2010 compared to control patients receiving standard of care between January 1 and November 14, 2010. The primary endpoints of the study are successful extubation while on dexmedetomidine and reintubation at 24 hours. The secondary endpoints are ICU length of stay, duration of mechanical ventilation, time spent over-sedated (RASS < -2) or under-sedated (RASS > +2), delirium at dexmedetomidine initiation, occurrence of bradycardia (HR < 60) and occurrence of hypotension (SBP < 90). Data will be collected from the University of Washington Medical Center electronic medical record. Results and conclusions will be presented.

B4 GeneralClinical Practice

PROCESS IMPROVEMENT FOR DIAGNOSIS AND TREATMENT OF HEPARIN INDUCED THROMBOCYTOPENIA (B4). Marjan Bigverdi. Brent Albertson. Providence Sacred Heart Medical Center, Spokane, WA. (marjan.bigverdi@providence.org) IRB approval not needed. This project objective was to evaluate and improve our institutions HIT treatment protocol. A baseline use evaluation was conducted to assess the appropriateness of treatment of HIT, use of argatroban and transition to long term anticoagulants in our institution. This evaluation identified the following areas for improvement: dosing of direct thrombin inhibitors in special populations (renal and hepatic impairment), transition to warfarin, treating patients with prior history of HIT, and treatment of patients with low pre-test probability. Institution specific guidelines, based on current literature and physician leadership, were developed to include standards for clinical and laboratory diagnosis, surveillance via clinical decision support tools, initial therapy while lab results pending, transition to warfarin, and utilization of bivalirudin and fondaparinux. These guidelines will be implemented per institutional standards of practice. A pharmacist development training module, with focus on initiation, proper dosing and monitoring of agents as well as the transition to warfarin (when needed), is planned. Results and conclusions will be presented.

ANALYSIS OF PHARMACIST ORDER VERIFICATION USING A COMPUTERIZED PHYSICIAN ORDER ENTRY SYSTEM (B4) Margaret Hancuff. Robert Tindula. Lisa Veale. Miller Children's Hospital, Long Beach, CA (mhancuff@memorialcare.org) IRB approval is pending. The primary objective of this study is to analyze the process of pharmacist order verification using computerized physician order entry (CPOE) as a potential source of medication errors. The first part of the study will be a comparative descriptive analysis of pre and post implementation of a CPOE system and the effect on the verification process. The errors will be collected from an online database for neonatal and pediatric patients less than 21 years of age and hospitalized at a 332 bed community teaching hospital between January 1, 2007 and March 1, 2010. A retrospective analysis of pediatric medication errors which passed through pharmacist order verification and reached a patient will be done. The second part of the study will include an anonymous survey of current pharmacists who have extensive experience using this CPOE system. The responses from this survey will be used to perform a failure mode and effects analysis (FMEA). This may indicate what steps in the order verification process are most vulnerable to errors and identify potential improvements. Results and conclusions will be presented.

EVALUATION OF FENTANYL PATCH ORDERS IN AN ACADEMIC MEDICAL CENTER (B4). Judy Hsiao, Farivar Jahansouz, Krishma Dhillon, Pieter Helmons, JoAnna Lamott, Shobha Kolan, Rabia Atayee. UCSD Medical Center, San Diego, CA (jhsiao@mail.ucsd.edu) IRB approved. A retrospective data analysis was conducted to determine pharmacist adherence rate to the medical center documentation procedure for fentanyl patch orders, based upon the FDA boxed warning that restricts transdermal fentanyl use to patients who meet specific criteria for opioid tolerance. Quality of pharmacist documentation, defined in our study as completeness of notation, was also evaluated in order to identify ways to improve the existing notation system and facilitate the safe inpatient use of transdermal fentanyl. A total of 296 fentanyl patch orders prescribed at UC San Diego Medical Center between July 1st, 2009 and July 31st, 2010 were identified using the hospital pharmacy database. Sixty-four of these orders were new starts whereas 232 orders were continued outpatient regimens. Inpatients 18 years of age at the time of fentanyl patch initiation were eligible for study inclusion. Transdermal fentanyl orders were initially evaluated for pharmacist documentation of opioid tolerance assessment in the pharmacy electronic medical record (EMR) during order validation. Fentanyl patch orders were then evaluated based on the completeness of notation. Results and conclusions will be presented.

INAPPROPRIATE PRESCRIBING OF PROTON PUMP INHIBITORS IN HOSPITALIZED PATIENTS (B4) Ahmed Altyar. University Medical Center, Tucson, AZ (altyar@pharmacy.arizona.edu) IRB approved. This is a retrospective study designed to evaluate if proton pump inhibitor (PPI) therapy was indicated in hospitalized patients based on current guidelines and recommended indications. Patients were included if they were admitted to the adult medical service between July 1, 2009 and June 30, 2010 and received a newly-initiated oral PPI during hospitalization. Patients were excluded if they were transferred to any of the Intensive Care Units, pregnant, younger than 18 or received an intravenous PPI at any time during their hospital stay. Patients who met the inclusion and exclusion criteria were divided into two groups based on the presence or lack of a valid indication for PPI treatment. Information collected included demographic data, indications for PPI therapy, number of patients discharged on a PPI, and PPI-related complications. 400 patients charts were reviewed, and differences between patient groups will be tested for statistical significance using Chi-square analysis. Results will be presented.

EVALUATING VITAMIN D REPLETION REGIMENS AND THEIR RELATIONSHIP TO CHANGES IN VITAMIN D SERUM LEVELS IN VETERAN PATIENTS. Sheryl Aterrado, Gregory Ono, Shawn Kanehira-Mar, Joy Meier, Arthur Swislocki. Veterans Affairs Northern California Health Care System, Mather, CA (Sheryl.Aterrado@va.gov) IRB approved. Vitamin D receptors are found in numerous tissues, which when activated can work on DNA to produce a wide variety of effects. The use of vitamin D supplementation in patients has increased with recent studies linking benefits to cardiovascular disease, cancer, diabetes and many other disease states. Currently, there is no clear consensus on vitamin D repletion regimens and dosing. This study is a multicenter, retrospective data extraction and analysis between January 1, 2005 to December 31, 2010. Data extraction will be conducted using the Veterans Integrated Service Network of the Sierra Pacific (VISN 21) Pharmacy Benefits Management (PBM) Data Mart. The primary objective of this study is to evaluate vitamin D treatment regimens and their dose response relationship in repleting vitamin D serum levels. Secondary outcomes such as discontinuation rates, frequency of drawing labs to monitor vitamin D serum levels, and adherence will also be evaluated. Full results and conclusions will be presented.

IMPACT OF A MULTI-DISCIPLINARY TEAM ON COMPLIANCE WITH ACUTE ISCHEMIC STROKE CORE MEASURES AND MEANINGFUL USE CRITERIA (B4), Gregory Aung, Angela Stewart, Michael Sieg, Dennis Hoover

Memorial Hospital, Yakima, WA (gregoryaung@yvmh.org) IRB exempt This study investigates the difference in compliance with CMS and JACHO acute ischemic stroke core measures outcomes before and after the establishment of a multi-disciplinary stroke care team. Interventions performed by pharmacy include clinician and public education, revision of order sets, medication use evaluations, and concurrent patient care. This is a single site study with a pre-post quasi experimental design. Inclusion criteria include age 18 years or older and a discharge diagnosis of acute ischemic stroke. Exclusion criteria include age less than 18 years old, hospice or comfort care, hemorrhagic stroke, pregnancy, and TIA as a primary discharge diagnosis without diagnosis of acute ischemic stroke. Primary outcomes to be measured include the rates of compliance with the following core measures related to pharmacotherapy: DVT prophylaxis, use of antithrombotics, anticoagulation for atrial fibrillation and flutter, use of thrombolytics, and statin medications. The baseline retrospective arm had the following rates of compliance; 72%, 99%, 94%, 87%, and 75% respectively. Further results and conclusions will be presented.

IMPACT OF PHARMACIST INTERVENTIONS IN ENSURING OPTIMAL ASTHMA MEDICATIONS UPON EMERGENCY DEPARTMENT DISCHARGE (B4), Maria Florencia Barrio. Kaiser Permanente Medical Care Program, West Los Angeles, CA (Florencia.M.Barrio@kp.org) IRB approved. Emergency Department (ED) visits related to asthma exacerbations continue to be an extensive burden for both asthma patients and the health care system. Asthma ED visit rates at Kaiser Permanente (KP) West Los Angeles remain high despite attainment of national benchmark goals for the treatment of asthma. Recent KP Southern California data indicates that many patients seeking emergency asthma care could have been treated in the urgent care or other outpatient settings. However, for patients who visit the ED, opportunities exist to optimize medications and patient education. ED pharmacists are well positioned to assist in enhancing the patients care beyond stabilization of the acute issue by intervening prior to discharge. The objective of this study was to evaluate the implementation of an ED pharmacist checklist developed to help ensure optimal asthma medications are prescribed at discharge. Optimal asthma medication regimens were defined as those that included an inhaled-corticosteroid (ICS), a short-acting beta-agonist (SABA), and a systemic corticosteroid upon discharge from the ED. The impact of the pharmacists interventions was evaluated by a comparison of patients ED discharge asthma medications from 11/2009 through 2/2010 and post checklist implementation from 11/2010 through 2/2011. The primary

outcome of this study was optimal asthma medications upon ED discharge. Preliminary results will be discussed.

Quality Improvement of heparin continuous infusion management and the usage of the current PAMC preprinted order. (B4), Amanda Boo. Providence Alaska Medical Center, Anchorage, AK. (amanda.boo@providence.org) Exempt from IRB approval.

This retrospective review will evaluate how well the Adult Heparin Continuous Infusion Preprinted Order is followed at Providence Alaska Medical Center (PAMC). The PAMC pharmacy information system was used to identify 30 consecutive patients who have been prescribed a heparin continuous infusion. Excluded were patients less than 18 years old, over 90 years old, prisoners, and those prescribed heparin without the preprinted order. The following data was collected using the electronic medical record: age, weight, indication for heparin, doses, nursing unit where therapy occurred, times of boluses and dose changes, aPTT draw times and results, adverse effects potentially related to heparin (bleeding), hematocrit, hemoglobin, occurrence of thromboses and observations regarding protocol variances, reasons for them and affects on the patient. The results of this review will be used to determine variances between protocol-specified monitoring and dosage adjustments versus the actual activities that occurred. Evaluation of this data will determine what types of education, improvements, and protocol corrections are needed. An additional second phase follow up review will occur to evaluate the efficacy of these improvement measures. Results will be discussed.

EVALUATION OF PROCESS INDICATORS BETWEEN PHARMACIST AND NURSE MANAGEMENT OF INTRAVENOUS UNFRACTIONATED HEPARIN (B4), Kevin Brady. Kaiser Permanente, Downey, CA (kevin.m.brady@kp.org) IRB approval received. Individual patient response to unfractionated heparin is variable and unpredictable, and rigorous monitoring is essential to ensure effectiveness and safety of therapy. Previous studies have demonstrated benefit from pharmacist management of unfractionated heparin, but the apparent advantages may be largely driven by pharmacist use of weight-based dosing protocols. At Kaiser Permanente, anti-Xa levels are used to monitor unfractionated heparin by pharmacists per protocol in Southern California institutions and by nurses per protocol in Northern California institutions. A comparison of pharmacist versus nurse management of unfractionated heparin will be pursued to determine differences in process indicators. Retrospective chart review will be performed for adult patients receiving intravenous unfractionated heparin for acute myocardial infarction, deep vein thrombosis, or pulmonary embolism between January 1, 2009, and December 31, 2010. Primary outcome measures will include time to achieve therapeutic threshold, proportion of patients achieving therapeutic threshold within 24 hours, and proportion of anti-Xa levels within therapeutic range. Outcome measure comparisons will be made between the pharmacist per protocol group and the nurse per protocol group. A total of 6477 patients with mean (standard deviation) age of 67.5 (14.9) years will be analyzed. Results will be presented and discussed.

INITIATION AND ASSESSMENT OF PHARMACIST MANAGED UNFRACTIONATED HEPARIN THERAPY (B4), Kenny Bui. MultiCare Health System, Tacoma, WA (kenny.bui@multicare.org) IRB approval not needed. Reducing the likelihood of patient harm associated with the use of anticoagulant therapy is a National Patient Safety Goal. Anticoagulation with unfractionated heparin is driven by evidence based clinical practice guidelines however the complexity of managing the use of heparin often leaves patients suboptimally treated. As part of a patient safety initiative for 2010, a retrospective audit was performed on critical patients treated with heparin at a nonprofit, integrated health organization to assess adherence to the institutions current practice standard. Preliminary data and anecdotal concerns suggested that practice discrepancies existed. A multidisciplinary performance improvement team assembled to review audit data, identify improvement opportunities, and coordinate implementation of improvement strategies. The primary objective of this project is to reprogram heparin order sets within an electronic medical record to improve clarity and optimize the pharmacists role in heparin therapy management and to evaluate the impact of these changes. Pharmacists began to manage the prescribing of heparin in critical patients in December 2010. The primary endpoint is the reduction of supratherapeutic and subtherapeutic heparin activity levels. Secondary endpoints are the percent time within therapeutic range of heparin activity levels and the time to therapeutic range. Results will be presented.

CHARACTERIZING THE SCOPE OF INSULIN ASSOCIATED MEDICATION ERRORS IN A UNIVERSITY HOSPITAL (B4). Chris Burrell. Candy Tsourounis, Joe Guglielmo. UC San Francisco, San Francisco, CA. (christopher.burrell@ucsf.edu) IRB not needed Recent studies recommend the use of multiple methodologies in the identification of medication errors (ME) for high risk drugs. Using multiple methodologies results in identification of different MEs. Insulin is considered to be a high risk drug by ISMP. Objective: Our goal was to characterize the scope of insulin associated MEs. Methods: 1) quantitative and qualitative evaluation of appropriate use of subcutaneous insulin order form: (quantitative) case based questions used to determine nurses ability to correctly interpret the form; (qualitative) nursing comfort level in using the form. 2) chart review: reviewed subcutaneous insulin use in three general medical wards. Results: The order form evaluation demonstrated 52% of nurses would have administered an inappropriate amount of correctional insulin to NPO patients; 41% of nurses would have not given the correct dose to patients with glucose levels <100 mg/dL; 58% of nurses were not able to document the correct insulin administration protocol for patients with interpretations to their tube feeds. The chart review showed 32.3% of nurses do not document the correct timing of insulin administration and that the subcutaneous insulin order form for tube feed/TPN patients is incorrectly completed by prescribers 60% of the time. Conclusions: Use of multiple methodologies allows for a

more complete identification of MEs for insulin than found with a single method approach.

DEVELOPMENT AND IMPLEMENTATION OF A CONSULTATION SERVICE FOR PRADAXA (DABIGATRAN) (B4), Johnny Chau. Kaiser Permanente Medical Center, San Francisco, CA (Johnny.X.Chau@kp.org) IRB exempt. The study objective was to create and implement a consultation service for Pradaxa (dabigatran). Pradaxa is a novel oral anticoagulant with unknown long-term effects. Guidelines are under development within Kaiser Permanente, but no workflow process exists on how to utilize these guidelines locally at our site. A search was conducted for recommendations or guidelines for Pradaxa. The databases used for the literature review was PubMed, EBSCOHost and Web of Science. The implementation process will include: developing a workflow for providers to refer patients for consults, training anticoagulation pharmacists, educating providers of the new consultation service and to determine appropriate outcome measures. Outcome measures include: total number of patients on Pradaxa, total number of referrals to the consultation service, number of patients not referred to the consult service on Pradaxa, number of appropriate or inappropriate use of Pradaxa according to a regionally developed decision-support tool not routed to the consultation service. Inclusion criteria are patients are all patients on Pradaxa, atrial fibrillation (AF) patients currently on warfarin who are potential candidates to switch to Pradaxa, and AF patients wanting to start oral anticoagulation therapy. Exclusion criteria are patients currently on or candidates for oral anticoagulation therapy for an indication other than AF. Final results and conclusions will be presented.

PHARMACIST INVOLVEMENT IN PAIN MANAGEMENT IN AN INPATIENT SETTING (B4), Timothy Chiu, Kaiser Permanente Diablo Service Area, Martinez, CA (timothy.j.chiu@kp.org) IRB not needed-no human subject data. This retrospective study evaluates the effectiveness of the Inpatient Pharmacy Pain Management Program at Kaiser Permanente Walnut Creek. Patients often require pain relief during their hospital stay. Pharmacist-led pain management is relatively new to pharmacy, but not many studies have evaluated the effectiveness of such programs. This retrospective review includes patients who were admitted to the Walnut Creek Medical Center between January 2009 and December 2010. Patients in this study had a history of chronic pain, cancer related pain, were on comfort or palliative care, or were receiving multiple doses (greater than 3 doses per 24 hours) of opioids for breakthrough pain. Study patients were separated into two arms: 1) Patients who received care from the Inpatient Pharmacy Pain Management Program, between January 2010 and December 2010, and 2) Patients that did not receive care from the Pharmacy Pain Management Program, between January 2009 and December 2009. The primary outcomes were the pain scores of eligible patients and their length of stay. The secondary outcome was the pharmacist time to provide the pain management service. The results and conclusion of this study will evaluate if the Inpatient Pharmacy Pain Management Program improves patients overall pain scores and shortens length of stay, leading to lower overall cost. The results will be presented at a later date.

EVALUATION OF CLINICAL PHARMACY SERVICES IN THE EMERGENCY DEPARTMENT (B4), Erin Cutter, Kim Donnelly. University of Washington Medical Center, Seattle, WA (ecutter@uw.edu) IRB not needed-no human subject data. The fast paced environment of the ED creates the perfect set up for medication errors. Recent studies have shown that dedicated ED pharmacists can reduce medication errors by up to 90%, and provided a cost benefit to their institution. The University of Washington Medical Center is a 450 bed medical center with an ED providing an estimated 27,000 patient visits in 2010 resulting in approximately 60,000 medication orders. In October of 2010, clinical pharmacy services were implemented in the ED with coverage 10 hours a day, 7 days a week. The objective of this analysis is to identify pharmacist interventions preformed in the ED during the initial 3 months of implementation and how those interventions impact patient care and medication safety in the ED. Daily interventions were documented by the ED pharmacist and collected via an intervention tracking database. Data collected included type of intervention (therapeutic drug monitoring, identification/prevention of potential adverse drug events, drug information/recommendation, and initiation/changes of medications) as well as duration and acceptance of intervention. Cost-benefit analysis will be performed in order to demonstrate financial benefit to the institution. In addition, a survey will be given to ED staff 3 months after implementation to assess the perceived benefit of pharmacy services in the ED. The findings from this study will be presented.

COMPUTER-GUIDED IV INSULIN THERAPY IN THE CARDIOVASCULAR INTENSIVE CARE UNIT (B4). Dong Dao, Stephanie Chao, Nicola Cooper, Zerline Cruz, Bhavi Shah, Jennifer Le. Hoag Hospital, Newport Beach, CA (dong.dao@hoag.org) IRB approval not needed. Intravenous insulin therapy for treatment of hyperglycemia is often managed using standardized insulin algorithms on paper orders. However, these algorithms rely on a single blood glucose reading and do not consider patient-specific parameters such as insulin sensitivity or previous blood glucose responses. Computer-guided IV insulin therapy programs are able to customize patientspecific IV insulin regimens by factoring in previous glucose readings to formulate a patient-specific insulin resistance curve. The objective of this retrospective cohort study is to determine the efficacy and safety of hyperglycemia management in cardiovascular intensive care unit (CVICU) patients using a computer-guided IV insulin therapy program (EndoTool), versus historical CVICU patients initiated on a standardized paper algorithm. Data presented will include rates of hypo- and hyperglycemia, time to goal blood glucose range, duration within goal blood glucose range, and the rate of compliance with therapy protocols. The data will then be used to analyze the current efficacy of EndoTool and to determine its possible implementation in areas outside of the CVICU. Results and conclusions will be presented.

DEVELOPMENT, PILOTING, AND IMPLEMENTATION OF A BASAL/NUTRITIONAL/CORRECTIVE SUBCUTANEOUS INSULIN PROTOCOL (B4), Leanna Davis, Jamie Casanova, Mike Bonck. Franciscan Health System, Tacoma, WA (leannadavis@fhshealth.org). IRB approval not needed. The objective was to design and pilot a basal/nutritional/corrective subcutaneous insulin protocol on a general medical unit, assess its efficacy by comparing outcomes to current insulin prescribing practices, and implement usage of the final glycemic control protocol throughout the health system. The pilot subcutaneous insulin protocol was designed based on current practice guidelines. It was initiated on forty medical patients identified to have a history of diabetes mellitus, or no history with at least two hyperglycemic blood glucose values. Patients with a hypoglycemic episode in the last 24 hours, patients admitted for diabetic ketoacidosis or hyperglycemic hyperosmolar state, patients using insulin pumps, and pregnant patients were excluded. Control data were collected retrospectively on a similar inpatient population. The primary outcomes are percentage of mean daily blood glucose within the ADA goal range and number of monitored days with hypoglycemic episodes. Patients will be excluded from the data analysis if fewer than five blood glucose values were measured after protocol initiation. The data from the retrospective control group will be compared to those of the prospective basal/nutritional/corrective subcutaneous insulin protocol group using the student t-test for mean data and Fisher

exact test for proportional or percentage data. Results and conclusions will be presented.

ASSESSING VENOUS THROMBOEMBOLISM PROPHYLAXIS IN POST OPERATIVE VASCULAR AND GENERAL SURGERY PATIENTS (B4), Layla Derreja. Veterans Affairs Medical Center, San Francisco, CA (layla.derreja@va.gov) IRB approval pending. Patients who undergo surgical procedures are at increased risk of developing venous thromboembolisms (VTEs). Venous thromboembolisms are preventable diseases with the use of proper anticoagulation as defined by the American College of Chest Physicians (ACCP). The primary purpose of this study was to assess provider compliance rates with the ACCP guidelines when prescribing post operative VTE prophylaxis to vascular and general surgery patients. Secondarily, this study evaluated how many VTE events occurred within 30 days after surgery and assessed whether those events were associated with inappropriate prescribing of VTE prophylaxis. This was a retrospective analysis of VTE prophylaxis in patients at the San Francisco VA Medical Center (SFVAMC) who underwent general or vascular surgery between July 1, 2010 and December 31, 2010. Final results will be presented and discussed.

IMPROVING PATIENT SAFETY THROUGH DEVELOPMENT AND IMPLEMENTATION OF AN ELECTROLYTE MAINTENANCE PROTOCOL (B4). Stefanie Draper. Southwest Medical Center, Vancouver, WA (sdraper@swmedicalcenter.org) IRB approved. The objective of this study was to improve patient safety and pharmacist workflow by creating a single electrolyte dosing protocol incorporating both replacement and maintenance dosing for use by pharmacists throughout the institution. A medication use evaluation of an existing replacement protocol was performed in order to identify patients that would benefit from maintenance dosing. Results indicated that patients on IV fluids with poor oral intake and patients taking scheduled diuretics frequently required multiple potassium replacement doses. The protocol was modified to incorporate specific inclusion criteria enabling pharmacists to order potassium maintenance dosing. Patients receiving IV fluids as a primary source of intake and patients on scheduled diuretics were included. The revised protocol was approved by the required institutional committees, and education on changes to the protocol was provided to pharmacists. A follow up medication use evaluation was performed to assess the safety, efficacy, and impact on pharmacist workflow resulting from changes to the electrolyte dosing protocol. Results and conclusions will be presented.

EVALUATION OF PHARMACY-COMPLETED HOME MEDICATION RECONCILIATION FOR PATIENTS ADMITTED THROUGH THE EMERGENCY DEPARTMENT IN A RURAL HOSPITAL SETTING (B4), Dalari Fales. Providence St. Mary Medical Center, Walla Walla, WA (dalari.fales@providence.org) IRB approval waived. The study objective was to develop a process for pharmacy-completed home medication reconciliation, compare it to current procedures and evaluate the rate of errors/discrepancies between the two. A protocol was developed detailing the steps to be taken and specific questions to be asked while gathering the patients home medication history and information. It included methods of data collection such as verbal information from the patients, medications lists, old medical records and contacting the patients pharmacy to get the most current records. The study included patients admitted to the hospital from the emergency department who had medication reconciliation completed by the nurse. After completion of each medication reconciliation, errors/discrepancies were categorized into 10 different categories and documented. Necessary updates/corrections were then made to the patients home medication record. The study period was 7 months. Error data from all medication reconciliations completed by both a nurse and then again by a pharmacist will be analyzed and presented.

PILOT STUDY ON THE IMPACT OF A PHARMACIST FACILITATED TRANSITIONAL CARE INTERVENTION ON 30 DAY READMISSION RATES (B4). Rachel Feierabend, Providence Health and Services, Portland, OR (rachel.feierabend@providence.org) IRB approved. The objective of this study was to evaluate whether a pharmacist intervention, including postdischarge telephone follow up within 72 hours, could decrease readmission rates. A prospective cohort design was used to compare outcomes between patients who received a pharmacist transitional care intervention and patients who received usual postdischarge care. The primary outcome was unplanned hospital readmissions or emergency department visits within 30 days. Patients included were those discharged home from a Providence community hospital and determined to be at risk of readmission based on meeting one of the following criteria: diagnosis of CHF, COPD, seven or more maintenance medications, discharge on anticoagulants or antibiotics, or by referral from a hospitalist. The post discharge phone calls focused on assuring adherence to safe, effective, and affordable medication regimens in the immediate post discharge period. Interventions included clarifying medication regimens, screening for barriers to adherence and side effects, and providing medication counseling. If medication concerns were identified during the phone call, patients were referred to an outpatient clinical pharmacy specialist for additional follow up. Results and conclusions will be discussed.

PHARMACIST PROVIDED DISCHARGE MEDICATION RECONCILIATION TO IMPROVE CMS HF-1 CORE MEASURE COMPLIANCE (B4), Daniel Fleischman, Seth Meisner, and Cindy Wilson. Franciscan Health System, Tacoma, WA (danielfleischman@fhshealth.org) IRB approval not needed. The Centers for Medicare and Medicaid Services (CMS) first quality indicator for congestive heart failure (CHF), or HF-1, requires that CHF patients receive adequate discharge instructions which address each of the following six aspects: activity level, diet, discharge medication instruction, follow up appointment, weight monitoring, and what to do if symptoms worsen. St. Clare Hospital (SCH), affiliated with Franciscan Health System (FHS), is a 105-bed community hospital located in Lakewood, WA. Inadequate discharge medication instruction was associated with 100% of the HF-1 core measure noncompliance at SCH during the third quarter of fiscal year 2010. Adequate discharge medication instruction requires accurate medication reconciliation on discharge and documentation of this within the patients medical record and discharge summary dictation. In an effort to improve HF-1 compliance, a pharmacy resident completed discharge medication reconciliation, updated the patients medical record, and dictated a discharge medication list for identified CHF patients from January through March 2011. The primary objective was an improvement in HF-1 core measure compliance at SCH. Secondary objectives included assessment of

pharmaceutical care interventions, time of discharge, time to completion of medication reconciliation and dictation, and number of discharges per month. The results of this three month pilot project will be discussed at the Western States Conference in May 2011.

EFFECTS OF CALCINEURIN INHIBITOR FREE IMMUNOSUPPRESSION ON RENAL AND GRAFT FUNCTION IN POST CARDIAC TRANSPLANT PATIENTS. (B4) Nanette Gamazon, Robert Tan. Loma Linda University Medical Center, Loma Linda, CA (ngamazon@llu.edu) IRB approval pending. Calcineurin inhibitor (CNI) therapy is the basis of immunosuppresion in cardiac transplantation. While CNIs have increased graft survival after transplantation, the long term effect of CNI-induced nephrotoxicity remains a concern. After transplant, patients are routinely seen in clinic to assess tolerability of immunosuppresion medication(s) and to monitor graft function. This is a retrospective study on the effect of CNI free immunosuppression on renal and graft function in patients who received a cardiac transplant. The inclusion criteria are (1) cardiac transplant prior to 18 years of age between November 1985 and December 2010 and (2) discontinuation of tacrolimus or cyclosporine due to decline in renal function, post-transplant lymphoproliferative disorder, or other adverse reactions to CNIs. Patients who do not meet criteria as stated above were excluded from this study. After CNI discontinuation, patients were maintained on a CNI free immunosuppresive regimen. The primary outcome is change in renal function after conversion to CNI free immunosuppresion. Secondary outcomes include rejection rate, rejection grades, and time to rejection. The data will be analyzed and results will be presented.

STANDARDIZING EMPERIC ANTIMICROBIAL THERAPY IN TREATMENT OF URINARY TRACT INFECTIONS THROUGH PHARMACIST INTERVENTION IN THE EMERGENCY DEPARTMENT (B4). Kendra Gingerich. St. Patrick Hospital, Missoula, MT (kgingerich@saintpatrick.org) IRB approved. The objective of this study was to see whether or not standardization of empiric antimicrobial treatment through a pharmacist led algorithm decreased inappropriate antibiotic usage and improved overall patient outcomes in patients presenting to the ED with urinary tract infections. The study contained two distinct phases. The first phase collected data for seventy patients, who were then followed up by phone call to assess medication compliance, resolution of symptoms and possible medication side effects. Upon completion of the data collection from seventy patients in the first phase, an algorithm based upon current guidelines for empiric treatment of urinary tract infections, current facility antibiograms, and recommendations from infectious disease physicians was initiated in the emergency department. The study then moved on to the second phase where data was again collected for seventy more patients, with another follow up phone call to assess the same parameters as in phase one. The study period was approximately seven months. Inclusion criteria were all patients presenting to the emergency department with discharge diagnosis of cystitis or pyelonephritis. Exclusion criteria included patients with recurrent urinary tract infections, or those with chronic catheter placement. Results and conclusion to be presented.

DESCRIPTIVE CASE-SERIES OF MANAGEMENT OF HEPARIN-INDUCED THROMBOCYTOPENIA (B4). Mary Giouroukakis; Michelle Wheeler; Erin Fox; George Rodgers; Robert Pendleton. University of Utah Hospital, SLC, UT (Mary.Giouroukakis@hsc.utah.edu) IRB approved. Immune-mediated heparin-induced thrombocytopenia (HIT) is a potentially life-threatening reaction that occurs infrequently in patients who have received unfractionated heparin or low molecular weight heparin. The American College of Chest Physicians clinical practice guidelines recommend discontinuation of all heparin products and using an alternative, nonheparin anticoagulant in patients with strongly suspected or confirmed HIT (with or without thrombosis). The objective of this study was to evaluate the management of HIT at the University of Utah Hospital. The study was a descriptive case-series of current HIT therapy management in adult patients with a history of HIT, clinically suspected, or newly diagnosed HIT. Medical records were reviewed retrospectively over a 6 month period. Cancer patients were excluded. Results revealed variability in the management of HIT, including deviation from current clinical practice guidelines. Some deviations included warfarin monotherapy, continued heparin, or no alternative anticoagulants for patients with suspected HIT. Therefore, a need for an institutional guideline for HIT therapy management was identified, and guideline development is currently in progress.

PERCEIVED IMPACT OF EMERGENCY MEDICINE PHARMACISTS ON PHYSICIAN EDUCATION, A NATIONAL SURVEY OF PRACTICE TRENDS (B4), Maja Graonic. University of Arizona, Tucson, Arizona (graonic@pharmacy.arizona.edu) IRB approved The goal of this study is to assess pharmacy practice trends in the emergency department and emergency medicine physician resident perceptions on how pharmacy practice impacts their education. There are no current studies assessing the educational impact of interacting with a clinical pharmacist as perceived by emergency medicine physician residents. An assessment of practice styles and their respective perceived impact on education may aid in further development of clinical pharmacy practice in emergency departments with emergency medicine physician training programs. This goal of this study will be accomplished via online survey. A link to an online survey will be sent via electronic mail to emergency medicine pharmacy residency directors, who will complete a survey on pharmacy practice trends in their emergency department. Upon completion, the online survey will contain a body of text and a link to a second survey that the residency directors will be asked to send to their emergency medicine physician group via electronic mail. The second survey will address physician perceptions of emergency medicine pharmacy services. The surveys will be open for six weeks. Program directors of PGY2 pharmacy specialty residency programs in emergency medicine and their emergency medicine physician residency groups will be asked to participate. Inclusion criteria include emergency medicine physician residents and emergency medicine

pharmacy residency directors. Pharmacists and physicians who elect not to participate will be excluded from the analysis. The results and conclusion will be presented.

IMPACT OF HEPARIN MONITORING USING THE ANTIFACTOR XA ASSAY VERSUS APTT ON TIME TO FIRST THERAPEUTIC LEVEL (B4), Alexandra Grubbs. Denver VA Medical Center, Denver CO (Alexandra.Grubbs@va.gov) IRB approved. The activated partial thromboplastin time (aPTT) is the accepted standard for monitoring unfractionated heparin (UFH) therapy despite having several limitations. There are potential advantages of using the anti-Xa assay for monitoring UFH therapy, but there is limited published information regarding its use, safety and effectiveness. The study objective was to evaluate whether measurement of UFH therapy with the anti-Xa assay rather than the aPTT will result in faster achievement of therapeutic levels. In October 2009, the DVAMC revised the heparin monitoring protocol to replace the aPTT test with the anti-Xa assay. Data was collected retrospectively using the electronic health record. Inclusion criteria was age greater than or equal to 18 years, admission to the internal medicine service and initiation of UFH therapy for deep vein thrombosis, pulmonary embolism or acute coronary syndrome. Exclusion criteria was admission to the surgical or vascular service, use of non-standard therpaeutic goal ranges, pregnancy and UFH therapy lasting less than 24 hours. There were 2 cohort groups of patients on UFH therapy and 2 similar data colletion time periods: 4/1/09-9/30/09 for aPTT and 4/1/10-9/30/10 for anti-Xa. Descriptive statistics and statistical tests (paired t-test, the Fisher's exact test, and chi-square) will be utilized for the data analysis. Results and conclusions will be presented.

OPTIMIZING PHARMACIST INTERVENTION DOCUMENTATION, TRACKING, AND REPORTING WITHIN AN ELECTRONIC HEALTH RECORD (B4). Evelyn Handel, Majid Tanas, Neil Edillo, John Chang. Oregon Health & Science University Hospitals and Clinics, Portland, OR (handel@ohsu.edu) IRB approved. The objective of this project is to optimize the current tool for documenting pharmacist interventions within the electronic health record at OHSU (Epic) and to achieve a standardized process that can be incorporated into the daily workflow. The overall goal is to demonstrate the value of non-tangible services provided by inpatient and ambulatory pharmacists in order to retain and expand clinical pharmacy services. The project team interviewed pharmacists and administrators to determine their opinions and needs regarding the current utilization of the documentation tool. We revised the tool and developed a standard operating procedure to create a uniform documentation process. The project lead also serves as the chair of a newly created departmental committee, which was established to continually evaluate the quality of pharmacist documentation, oversee intervention management, and establish benchmarking standards. To assess the impact of the change, intervention data from three months pre- and post-implementation will be analyzed. Pharmacists will also be surveyed via an online tool regarding their perceptions of and familiarity with the documentation process before and after implementation. The impact of the optimization will be discussed, as well as the benefits to inpatient and ambulatory pharmacists and pharmacy administration.

INCREASED PATIENT/FAMILY INVOLVEMENT IN THE ADMISSION MEDICATION RECONCILIATION PROCESS: EFFECTS ON PATIENT SATISFACTION (B4). Laura Hanson. Tricia Rader. Tina Smith. Bill Wightkin. Scottsdale Healthcare, Scottsdale,AZ (LHanson@shc.org)IRB approved. The goal of this study was to assess the effect on patient satisfaction of a recently implemented process involving providing patients with a printed copy of the hospital home medication record for review and correction, if necessary. The process was initiated on two nursing units (intervention units). Remaining nursing units did not provide patients with a written home medication list (control units). Patient satisfaction with the medication reconciliation process was assessed via Likert scale surveys on both intervention and control units. All participants were also asked how many corrections they needed to make regarding their hospital home medication record. The primary objective of the study was to assess the impact on patient satisfaction when the level of involvement of the patient/patients family in the admission medication reconciliation process is increased. The secondary objective was to assess whether enhanced patient/family involvement leads to increased correction of errors in the hospital's record of a patient's home medication list. Likert scale data will be analyzed using the Whitney-Mann U test. The t-test will be used to assess whether a statistically significant difference exists with regard to number of interventions. Results and conclusion to be presented.

QUALITY IMPROVEMENT PROJECT FOR A NEWLY CREATED ANTIMICROBIAL STEWARDSHIP TEAM (B4), Andrew Harbison, Brent Albertson. Providence Sacred Heart Medical Center, Spokane, WA (Andrew.Harbison@providence.org) IRB exempt. The objective of this project was to identify opportunities to expand the role of the newly created antimicrobial stewardship pharmacist, and determine the effectiveness of a pharmacy based antimicrobial stewardship team on optimization of antimicrobial therapy. The first part of the project was to review recent medication use evaluations (MUEs) and previous quality improvement projects including imipenem/cilastin, aztreonam, micafungin, Clostridium difficile associated diarrhea therapy, and severe ICU related pneumonia. After sufficient time has passed, retrospective, follow up MUE projects were then conducted and compared to previous MUE data to determine the effectiveness and impact of the antimicrobial stewardship team. An institution specific Antimicrobial Guidebook was developed that includes formulary antimicrobials and comparable costs, empiric recommendations and dosing, adult/pediatric renal dose adjustments, IV to PO switch, adult/pediatric vancomycin and aminoglycoside dosing guidelines, aztreonam use guidelines, imipenem/cilastin use guidelines, and antifungal use guidelines. Preliminary results include development of an Antimicrobial Guidebook for distribution to hospital physicians and pharmacists. Other data, including results from follow up MUE projects, will presented.

EVALUATION OF PERFORMING SPUTUM CULTURES IN PATIENTS WITH HOSPITALIZED COMMUNITY-ACQUIRED PNEUMONIA (B4), Jiayi Huang. VA San Diego Healthcare System, San Diego, CA (jiayi.huang@va.gov) IRB approved. The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) communityacquired pneumonia (CAP) guideline encourages clinicians to obtain sputum samples for Gram stain and culture in hospitalized pneumonia patients. However, the usefulness of sputum cultures in the treatment of pneumonia remains controversial due to inconsistent yields. The objective of this study is to determine if sputum cultures, as a diagnostic tool, is associated with positive treatment outcomes at the VA San Diego Healthcare System. A retrospective chart review will be performed on CAP patients who required hospital admission between January 2007 to December 2010. The primary endpoint is the frequency of sputum samples collected within the first 48 hours of admission. Length of treatment stay, change in antibiotic regimen based on culture results and time from IV to oral antibiotics will also be determined in patients with sputum cultures compared to those without sputum cultures. Student t-test and Chi-square tests will be used to analyze the data. Currently, there are approximately 1,700 admissions based on ICD-9 codes for pneumonia. Results and conclusions will be presented.

INITIATION AND EVALUATION OF A PHARMACIST-MANAGED PROTOCOL FOR AUTOMATIC RENAL ADJUSTMENT AND IV TO PO CONVERSION (B4), Philip Huynh, Brenda Donehower. Valley Medical Center, Renton, WA (philip_huynh@valleymed.org) IRB is not needed. The project objective is to evaluate the cost-savings of automatic renal adjustments and IV to PO conversion by pharmacists. A prescriptive authority protocol, policy and procedure were developed, approved by Pharmacy and Therapeutics (P&T) committee, and implemented defining specific medications, clinical criteria, and monitoring guidelines for pharmacists to follow. A brief survey was conducted determining time spent to complete interventions. Automatically renally adjusted medications were performed by the pharmacist using prescriber order forms while medications authorized for IV to PO conversion were performed on an order set created and approved by the P&T committee. Candidates eligible for IV to PO conversion include patients older than 17 years of age, have a functioning GI tract, hemodynamically stable, afebrile for 24 hours, improving WBC, and no diagnosis of febrile neutropenia, meningitis, endocarditis, or bacteremia. Pharmacists recorded the number of daily interventions on a intervention spreadsheet. A pharmacy resident collected data from December 1st 2010 to February 28th 2011. Quantifi was utilized to tally interventions and analyze results to determine potential savings by proper renal dosing and IV to PO conversions in relation to time spent by pharmacists. Results will be presented and discussed.

DEVELOPMENT AND ASSESSMENT OF A PHARMACIST-LED VENOUS THROMBOEMBOLISM PROPHYLAXIS SCREENING TOOL IN A RURAL HOSPITAL (B4), John Jemison. Providence St Mary Medical Center, Walla Walla, WA (john.jemison@providence.org) IRB approval waived. Objective. To assess venous thromboembolism (VTE) prophylaxis utilization by physicians for hospitalized patients and the impact of pharmacist-led recommendations on current practice. Methods. A paperbased, pharmacist screening and assessment tool for VTE prophylaxis was designed and used over a 4 month period. Hospitalized patients were selected at random until 200 patients were identified and assessed for VTE prophylaxis utilization. The screening tool assessed risk factors for venous thromboembolism, stratified patients based on risk and contraindications, and provided recommendations, both pharmacologic and mechanical, for VTE prophylaxis. Results. Data will be collected and analyzed on risk factors, contraindications, risk stratification, utilization of VTE prophylaxis before pharmacist recommendation, and acceptance of pharmacist recommendations by providers. Conclusion. The data will be analyzed and presented to identify the most common risk factors and contraindications to VTE prophylaxis, how most patients are stratified, the current provider practice, and acceptance of pharmacists recommendations.

EVALUATING USE OF THE ROGUE VALLEY MEDICAL CENTER IV TO PO POLICY (B4), Michael Kasik, Asante Health System, Medford, OR (mkasik@asante.org) IRB approval received. The primary objective of this study was to evaluate the rate of IV to PO switches performed by pharmacists to gain baseline utilization data of the pharmacist driven IV to PO policy. A retrospective chart review from two different time frames was conducted; one from before the implementation of the IV to PO policy and one after. The goal number of subjects for each time period reviewed was 100. Inclusion criteria were age between 18 and 99 and having received one of the following IV medications: pantoprazole, famotidine, levofloxacin, ciprofloxacin, metronidazole, fluconazole, or linezolid. Exclusion criteria included patients admitted to ICU/CCU, Labor and Delivery, or Neurobehavioral unit, pregnant females, or patients that received one or more of the above medications but had a condition making them ineligible for IV to PO switch by a pharmacist. For patients meeting inclusion criteria, orders were reviewed to determine if and when the patient was switched from the above mentioned IV medication to the corresponding PO equivalent. Drug, dose, and length of IV treatment, as well as indication, were documented. For patients switched to PO, it was recorded as to whether the patient was switched by a pharmacist or physician. Data collection is currently underway and analysis is pending. Results and conclusions will be discussed.

EVALUATION OF HEPATIC MONITORING WITH LEFLUNOMIDE IN RHEUMATOID ARTHRITIS (B4). Joanne H. Kim. Wayman Lee. Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, US (Joanne.Kim@va.gov) IRB approved. The risk of severe liver injury with leflunomide was initially reported by the European Agency for the Evaluation of Medicinal Products (EMEA). The American College of Rheumatology (ACR) also acknowledged this risk with an announcement made on the organizations hotline in August 2001. It was suggested that the guidelines for prescribing and monitoring leflunomide may not have been completely adhered to. In July 2010, the FDA issued a Boxed Warning regarding the potential risk as well as how to avoid such liver injury. The study objective was to evaluate the adherence to the guidelines following the 2001 ACR report for monitoring frequency of liver enzymes and to assess for any evidence of liver injury related to the use of leflunomide. This retrospective study included all patients with an initial prescription of leflunomide from August 1, 2001 to June 30, 2009. A review of baseline and follow-up liver enzymes collected were used to evaluate adherence to the monitoring guidelines. Baseline levels and follow-up levels were considered from up to one year prior to and after the initial leflunomide therapy. It was also evaluated if the appropriate interventions were made accordingly based on lab values collected. Additional information such as demographic data and therapy issues related to rheumatoid arthritis treatment were also reviewed. Results will be presented and discussed.

ASSESSING BARRIERS TO SUCCESSFUL CHEMICAL PROPHYLAXIS AND COMPLIANCE WITH DURATION OF ANTICOAGULATION OVERLAP THERAPY (B4), Allison Komatsu, Sylvia Martin Stone. Cedars Sinai Medical Center, Los Angeles, CA (allison.komatsu@cshs.org) IRB approved. The Joint Commission Venous Thromboembolism (VTE) Core Measures require prophylaxis to prevent VTE and a 5 day overlap of oral and parenteral therapy for the treatment of VTE. Two studies were conducted to improve compliance with these measures. The first study included a retrospective analysis of patients with chemical prophylaxis orders who developed VTE while hospitalized. Prophylactic agents and potential barriers to administration of therapy were identified for each case. After identification of barriers (i.e., dose missed, patient refusing injections, newly diagnosed coagulopathy), specific healthcare provider follow up was performed highlighting optimal administration of prophylaxis. The second study addressed full duration of anticoagulation overlap therapy, which is essential to decreasing the risk of post thrombotic complications and rethrombosis. Both retrospective and prospective analyses were conducted to screen for completion of overlap therapy in those patients diagnosed with VTE. When the 5 days of overlap were not met or when the INR was less than 2, physician reminders were placed in the patient chart and prescribers were called to recommend completion of overlap therapy. Instances of prescriber noncompliance were addressed via medical staff follow up. Data collected will reflect the impact of these

interventions on optimization of chemical prophylaxis and anticoagulation overlap compliance. Results will be presented.

QUANTIFYING PATIENT CARE INTERVENTIONS BY PHARMACISTS AT DISCHARGE: PROJECT PHARMD (B4). Lisa Koselke, Patricia Marshik, Gretchen Ray. University of New Mexico Hospitals, Albuquerque, NM (lkoselke@salud.unm.edu) IRB Approval received. The objective of this study is to describe the quantity and type of patient care interventions that can be attributed to a pharmacist provided discharge medication reconciliation and counseling service, and to identify factors predicting the need for pharmacist intervention. In this single center prospective hospital based study, patients discharged from the internal medicine service between November 2010 and March 2011 that speak English or Spanish and are willing to participate will be screened for eligibility. Internal medicine teaching teams will be randomized to receive the pharmacist provided discharge services in addition to usual care, or usual care only. The services will consist of medication reconciliation, counseling, and a follow-up phone call 36 to 72 hours after discharge. Pharmacist interventions recommended will be recorded and categorized based on type of intervention. Patient demographics, disease severity measured using the Charlson comorbidity index, number of hospitalizations in the previous year, length of stay, and insurance status will be collected. The number and type of interventions recommended will be presented using descriptive statistics. Logistic regression will be used to identify patient-level factors predicting the need for pharmacist intervention. Full results and conclusions will be presented.

IDENTIFICATION OF CLINICAL CHARACTERISTICS AND OUTCOMES OF HOSPITALIZED PSYCHIATRIC PATIENTS WITH VENOUS THROMBOEMBOLISM. (B4) Kelly Krieger and Deborah Laird. Maricopa Integrated Health System, Phoenix, AZ (Kelly.Krieger@mihs.org) IRB Approved. In the United States, the annual incidence of venous thromboembolism (VTE) in the general population is 1 to 2 per 1000 people. In contrast, the incidence of hospital acquired VTE in patients without prophylaxis is 10 to 40% for general medical and surgical patients and up to 60% for major orthopedic surgery patients. Currently, there is limited data on the risk factors for VTE in the psychiatric population. Some studies indicate there may be an increased risk of VTE in psychiatric patients compared to the normal population. The objective of this retrospective study was to identify risk factors, clinical characteristics and outcomes of hospitalized psychiatric patients with VTE. Patients were selected retrospectively using International Classification of Diseases (Ninth Revision) codes (ICD 9) to identify patients with a psychiatric condition and a VTE. The study population consisted of sixty five individuals that were admitted to the Maricopa Integrated Health System from January 2006 to October 2010. A computerized chart review was completed on each patient in order to collect data. Patients with a history of VTE and those less than 18 years of age were excluded from the study. Results and conclusions will be presented.

ECONOMIC ANALYSIS OF KIDNEY TRANSPLANTATION IN HIGHLY SENSITIZED (HS) PATIENTS DESENSITIZED WITH IVIG AND RITUXIMAB COMPARED TO MAINTAINING ON HEMODIALYSIS: A SINGLE CENTER OUTCOMES (B4), Jennifer Kwon, Ashley Vo, Cedars-Sinai Medical Center, Los Angeles, CA (jennifer.kwon@cshs.org) IRB approved. Currently, ESRD patients wait an average of 6-8 years for kidney transplants. Wait-time has increased significantly, especially in patients who have preformed antibodies resulting from pregnancies, blood transfusions or previous transplants. Those with a panel-reactive antibody (PRA) of 80 percent or above, wait the longest. Data reported by the United States Renal Data System (USRDS) in 2007 shows that hemodialysis accounts for $19.4 billion of the total Medicare expenditures per year, that is roughly $78,000 per person. This study is a retrospective, observational study evaluating the costs of transplantation of HS patients after desensitization with IVIG and rituximab compared to cost of maintaining on hemodialysis. In addition, costs associated with the immunosuppressive agents as part of the post-transplant regimen are evaluated. A total of thirty patients, from July 2006 to September 2010, who received kidney transplantation after desensitization with IVIG and rituximab will be evaluated. Treatment for post-transplant complications, including rejection, infections, and patientgraft survival will also be evaluated. Data and results of this study will be presented in May 2011.

IDENTIFYING INCIDENCE AND PREVENTING MEDICATION-INDUCED HYPOGYCEMIA IN THE INPATIENT HOSPITAL SETTING. Angela Lam. Dianna Gatto. Lauren Roemer. Good Samaritan Hospital, Puyallup, WA. (angela.lam@multicare.org) IRB is not needed. The objective of this study is to implement strategies that prevent inpatient medication-induced hypoglycemia. A modified methodology from the Institute for Healthcare Improvement (IHI) Global Trigger Tool was used to identify medication-induced hypoglycemic events. Monthly hypoglycemic incidence and occurrence rate per 1000 discharges were reported. Retrospective chart reviews are concurrently being performed to identify problems with prescribing, dispensing, administration, and monitoring. Subjective staff feedback has also been solicited to identify additional areas of improvement. Next, modifications of work flow will be made according to the specific problems identified. These will include order set revisions and clinical education to physicians, nurses, pharmacists, and other pertinent healthcare providers. A pharmacy CE program on inpatient diabetes management will be delivered. In addition, there is an emphasis on patient education to encourage self-advocacy on glucose management. After the interventions, a retrospective chart review will be done to assess effectiveness. Results and conclusions will be presented.

HYPOGLYCEMIC EVENTS IN THE ACUTE CARE SETTING: CAUSES AND PREVENTION. (B4). Tina Le, Andrew Lowe. Arrowhead Regional Medical Center, Colton, CA Tina.Le@armc.sbcounty.gov) IRB approved The objective of the study is to examine the causes of hypoglycemia events occurring in patients being treated with antidiabetic agents in an acute care hospital, and to introduce process changes aimed at increasing safety. The study is a retrospective analysis of hypoglycemic events before and after process change. The following data elements are collected: patient age, sex, diagnoses, cause of hypoglycemia, antidiabetic regimen, treatment of hypoglycemia, dietary intake. Pregnancy, age less than 18, and acute hyperkalemia are exclusion criteria. Once causes of hypoglycemic episodes have been identified, drug dosing and monitoring process changes will be implemented. The incidence of hypoglycemic episodes following the implementation of changes will be evaluated. Results and conclusions will be presented.

EFFICACY OF HIGH-DOSE NUTRITIONAL VITAMIN D3 COMPARED TO PARACALCITOL IN DECREASING PTH LEVELS IN HEMODIALYSIS PATIENTS (B4). Tina Le, Andrew Lowe. Arrowhead Regional Medical Center, Colton, CA (Tina.Le@armc.sbcounty.gov) IRB approved The objective of the study is to compare the effects of high-dose oral cholecalciferol (vitamin D3) with IV paracalcitol on parathyroid hormone (PTH) levels after 3 months of therapy. The study is a retrospective review on vitamin-D deficient hemodialysis patients. More specifically, patients with serum 25(OH)D3 level < 75 mmol/L who have not received any vitamin D or cinacalcet supplementation for the past 6 months are included. Patients are excluded if they have one or more of the following: 1) uncontrolled hyperphosphataemia, 2) uncontrolled hypercalcaemia, 3) cinacalcet treament, 4) or history of parathyroidectomy. The primary outcome is PTH level reduction after 3 months. The secondary outcomes include 1) change in plasma 25(OH)D3 level from baseline after 3 months 2) change in alkaline phosphatase level after 3 months, and 3) correlated calcium and phosphate product after 3 months. Patients are retrospectively assigned to control and treatment group through matching with respect to ethnicity, age, and gender. Results and conclusions will be presented.

THE EFFICACY OF LOW MOLECULAR WEIGHT HEPARIN (LMWH) IN PREVENTING VENOUS THROMBOEMBOLISMS (VTE) IN CRITICALLY ILL AND OBESE POPULATIONS (B4). Helen Lee. Jason Madamba. Huntington Hospital, Pasadena, CA. (helen.lee@huntingtonhospital.com) IRB approved. Current venous thromboembolism (VTE) prophylaxis dose recommendations with low molecular weight heparin (LMWH) may not be sufficient for all types of patients. This study retrospectively examines patients receiving VTE prophylaxis that experience documented VTE with the hypothesis that critically ill and obese patients are at higher risk of VTE prophylaxis failure compared to non-critically-ill or non-obese medical/surgical patients. The hospitals electronic record will be used to identify patients who received appropriate VTE prophylaxis with enoxaparin. Data extracted will include patients demographics, critical care course, active problems, surgery data, laboratory values, duration of stay, time of VTE prophylaxis initiation from admission, and time to VTE from LMWH initiation. The primary outcome will be the incidence of VTE after appropriate enoxaparin prophylaxis dose was given in all study patients. The secondary outcomes will be the incidence of VTE in ICU patients on vasopressor support and the incidence of VTE in obese populations. Secondary safety analysis will be the incidence of bleeding. Positive Doppler or CT angiogram studies will be used to determine VTE incidence. This data will help clarify if current VTE prophylaxis is sufficient to prevent documented VTE at a community hospital. Results and conclusions will be presented.

DESCRIPTION OF CURRENT OSTEOPOROSIS MANAGEMENT IN PATIENTS USING MEDICATIONS ASSOCIATED WITH A HIGH RISK OF FRACTURES (B4), Rena Leong, Noelle Hasson. VA Palo Alto Health Care System, Palo Alto, CA (rena.leong@va.gov) IRB approval pending. Osteoporosis is a common chronic disease state with poor morbidity and mortality outcomes. Osteoporosis is associated with several risk factors, one being the use of medications that cause an increased risk of fractures, such as anticonvulsants, aromatase inhibitors, high dose glucocorticoids, and gonadotropin releasing hormone agonists. Iatrogenic osteoporosis is hypothesized to be overlooked and potentially undertreated. The objective of this study is to characterize the current practice of osteoporosis management in patients chronically using high fracture risk medications. Specifically, we will (a) determine the rate of screening; (b) determine the incidence of osteoporosis; (c) describe current osteoporosis treatment patterns; and (d) evaluate the incidence of fractures. Data collection from a regional data warehouse and retrospective chart review will be performed for patients that received an outpatient prescription for a medication associated with an increased risk of fractures between October 1, 2008 and September 30, 2010. Patients who did not fill this prescription during six out of the eight quarters and patients only receiving low doses of glucocorticoids (less an equivalent dose of prednisone 5mg per day) will be excluded. Results and conclusions will be presented.

IMPACT OF COMMUNITY PHARMACY RESIDENT'S INTERVENTIONS ON THE CLINICAL AND SERVICE OUTCOMES IN A PATIENT-CENTERED MEDICAL HOME (B4). Yushi Li, Marci Reynolds, Annie Lam. University of Washington School of Pharmacy-QFC, Seattle, WA (yushili@uw.edu) IRB approved. Pharmacy resident completed a 3-month medical home practice rotation at an internal medicine clinic. The study evaluated the impact of the resident's interventions on clinical outcomes in patients with hypertension, diabetes mellitus, hyperlipidemia, and chronic non-cancer pain and the clinics service outcomes. Clinical outcomes were improvements in clinical targets (BP, FLP, HgA1C, and pain scores) and medication use (dose, adherence, and number of medications per disease state). Retrospective review of electronic medical chart was performed to identify patients who were seen at least twice by the resident for disease state management and follow up care. Baseline data were taken from the visit prior to the initial visit with the resident for established patients and from the initial visit with the resident for new patients. Final data were taken from the follow up visit. Interventions are categorized as changes in medication selection, dosage, and patient education. Clinical targets from baseline and final visit were compared to determine whether interventions lead to changes in clinical outcomes. Service outcomes included monitoring (ordering of necessary laboratory tests) and documentation (medication reconciliation) of medication therapy. We hypothesized that the resident's interventions can positively impact both clinical and service outcomes. Results and conclusion will be presented.

EVALUATION OF PHENYTOIN UTILIZATION AND MANAGEMENT (B4), Aundrea Linn, Mitchell Buckley. Banner Good Samaritan Medical Center, Phoenix, AZ (Aundrea.bell@bannerhealth.com). IRB pending. Phenytoin is a common antiepileptic agent used for treatment of seizure disorders and prophylaxis following traumatic brain injury. However, phenytoin also requires strict serum level monitoring in order to maintain therapeutic benefit and avoid toxicity. Understanding phenytoins pharmacokinetics and potential interactions play an important role in maintaining phenytoin within its narrow therapeutic target range. The purpose of this review is to evaluate the phenytoin medication use process and patient outcomes. The goal is to discover opportunities in which pharmacists may intervene and aid in patient care, medication management monitoring and cost savings. This is a retrospective, single-center evaluation. Patients will be included if they received phenytoin during their hospitalization for either seizure disorder treatment or seizure prophylaxis following traumatic brain injury between April 2010 to October 2010. This review will assess appropriateness of loading and maintenance doses, duration of prophylaxis treatment, time of IV to PO conversion, therapeutic serum drug level attainment and potential drug interactions. Results and conclusion will be presented.

IMPLEMENTATION OF A COMPUTERIZED ANTIMICROBIAL DECISION MAKING SUPPORT SYSTEM (B4). Yi Yu Liu, Viral Kothary, Julie Evans, Sean McFarland, Deborah Bruno, Paul Goebel. VA Central California Healthcare System, Fresno, CA (yiyu.liu@va.gov) IRB approval pending. The study objective was to determine if a computerized antimicrobial decision support system will positively impact use of antimicrobials, clinical and financial outcomes. The clinical decision support algorithm was incorporated into CPRS, a computerized physician order entry, to assist providers in choosing the appropriate empirical treatments for the suspected or diagnosed infections. All patients admitted to the VA Central California Health Care System who received at least one dose of IV antibiotic for the indication of cellulitis, diabetic foot ulcers, intra-abdominal infections, urinary tract infection, and pneumonia were included in the study. The study excluded patients on active cancer treatment, end stage renal and liver disease, HIV and other immunosuppressive conditions and taking more than 20mg/day of steroid. The study period is 3 months prior and 3 months after implementation. Usage of the antibiotic order menu, appropriate empirical treatments, drugs and doses administered, length of stay, frequency of C. difficile testing and

diagnoses, clinical cure at 30 days and drug costs will be compared pre- and post- implementation. Statistical analysis using odds ratio test, proportion test, Mann-Whitney test and survival analysis will be performed for the appropriate variables. The Results and conclusions will be presented.

PATIENT SATISFACTION OF PHARMACIST DISCHARGE COUNSELING SERVICES: PROJECT PHARMD (B4), Matthew London, Lenka Hrebickova, Gretchen Ray. UNM Hospital, Albuquerque, NM (mlondon@salud.unm.edu) IRB approved. The discharge process for the patient can represent a confusing and stressful time in which they may be learning about new medications and disease states. Pharmacists are ideally suited to help facilitate good patient medication understanding during discharge and ease patient transitions from the hospital to the patients home. The objective of this study is to assess the effect of a pharmacist run discharge counseling service on patient satisfaction scores. Patient satisfaction scores are significant for many reasons including potential increases in profit share, reimbursement rates, employee satisfaction as well as potential reduction in malpractice suits. This is a single center prospective hospital based intervention study. The intervention group is comprised of three internal medicine teams assigned to receive discharge counseling by a pharmacy resident in addition to the usual discharge care. The comparator group is comprised of three internal medicine teams assigned to receive the usual discharge care. Patients being discharged are handed an envelope containing a cover letter and a satisfaction survey to be filled out prior to discharge from the hospital. Surveys are being administered in English and Spanish. Patients satisfaction will be assessed using a Likert response scale. Individual question responses and overall satisfaction will be analyzed using chi square test. The results will be discussed.

VENOM VARIABILITY AND HEALTH SEVERITY OUTCOMES IN CROTALUS SCUTULATUS SCUTULATUS FROM SOUTHERN ARIZONA (B4), Daniel Massey. Kelvin Richards. Ryan Curtis. UA Medical Center, Tucson, AZ (masseyd@pharmacy.arizona.edu) IRB approved. The study objective was to identify geographical variances in the Mohave rattlesnake venom and to see if these variances correlate with the clinical presentation of rattlesnake envenomations in Southern Arizona. Twenty one Mohave rattlesnakes were collected and milked for venom. The venom was analyzed for phenotypes using reverse phase high pressure liquid chromatography and for toxicity using LD50. In addition, specific clinical information was collected from the Arizona Poison and Drug Information Center in order to correlate venom potency and clinical outcomes. Results and conclusions will be presented.

A RETROSPECTIVE CASE CONTROL STUDY OF HOSPITAL READMISSIONS ON A GENERAL MEDICINE WARD (B4), Lauren Masuda, Scott Souza, Kathleen Baker. The Queens Medical Center, Honolulu, HI (laurenmasuda@gmail.com) IRB approval pending. A study of Medicare beneficiaries found that 19.6 percent of patients discharged were rehospitalized within 30 days. Medicare payments to hospitals are expected to be reduced by up to 1 percent for avoidable readmissions in the year 2013. The focus of this study is to test the association between a Chronic Disease Score and hospital readmission when patients were readmitted to The Queens Medical Center within 30 days of index admission for any cause. A case is defined as a patient on a general medicine ward that was readmitted within 30 days of the index admission. Controls will be age and gender matched on a 1:1 ratio. A total of 516 patients will be enrolled between January 1, 2009 and January 1, 2011. Other covariates that will be analyzed in association with readmission include primary diagnosis, age, ethnicity, financial class, length of stay, disposition status, number of hospitalizations the previous year, and number of medications. Variables will be analyzed using logistic regression. The information obtained from this study will be important to help identify those patients at high risk of readmission that may need additional monitoring, education, and follow-up prior to and post-discharge. The results and conclusion will be discussed.

SUCCESSFUL IMPLEMENTATION OF EMERGENCY DEPARTMENT PHARMACISTS AT UCSF: A ONE YEAR SURVEY (B4), Sijy Mathew, Zlatan Coralic. UCSF Medical Center, San Francisco, CA (sijy.mathew@ucsf.edu) IRB approved. The UCSF emergency department pharmacist (EDPh) program was started in November 2009 with the intent to provide clinical and distributive services during the busiest hours. The objective of this study was to determine the staff perceptions of the EDPh program one year after implementation. This is the first study designed to evaluate the effectiveness of EDPh services after only one year. All ED patient care staff was asked to complete a 25 item survey that was modeled after a previously published survey of a program more established than the EDPh program at UCSF. The questions focused on evaluating the necessity of the pharmacists in the ED and the benefit of their specific roles. The participants were also prompted to provide additional comments. The surveys were made available online for a period of two weeks. Those eligible to participate included physicians, medical residents, nurse practitioners, physicians assistants and nurses working in the ED. Data was analyzed using descriptive statistics and confidence intervals where appropriate. Results and conclusions will be presented.

AN EVALUATION OF VANCOMYCIN IN THE OBESE PATIENT POPULATION (B4), Julie McIndoo, Mitchell Buckley. Banner Good Samaritan Medical Center, Phoenix, AZ (Julie.McIndoo@bannerhealth.com) IRB approved. Vancomycin is a glycopeptide antibiotic commonly used in the management of serious gram-positive infections. However, the optimal dosing strategy for this antibiotic remains uncertain. The most commonly studied dosing regimen has been 1 gram every 12 hours. In the obese population, however, this regimen may be insufficient compared to individualized weight-based regimens (e.g. 15mg/kg every 12 hours) in achieving target serum concentrations. Obesity has several important implications which may impact dosing strategies, including increased volume of distribution and increased drug clearance. Few studies have specifically evaluated vancomycin in the obese population. Unfortunately, these studies have not consistently evaluated the relationship between vancomycin doses and predicted serum trough concentrations, or the incidence of nephrotoxicity. The purpose of this study is to evaluate vancomycin weightbased dosing regimens resulting in therapeutic serum trough concentrations, and the risk of nephrotoxicity. In this retrospective, observational study, both obese (101kg) and non-obese (<101kg) patients were included if they received 48 hours of vancomycin therapy and 1 serum trough level was drawn. Therapeutic trough concentrations were defined as 15-20mcg/mL, and nephrotoxicity was defined as an increase in SCr of >0.5 mg/dL, or an increase >50% over baseline, on 2 consecutive days following

therapy initiation. Results including patient data will be discussed.

IMPROVING RISK STRATIFICATION AND VTE PROPHYLAXIS IN GENERAL MEDICAL PATIENTS (B4). Charles McQuade, Bryan Rowe, Colleen Terriff. Deaconess Medical Center, Spokane, WA. (mcquadc@empirehealth.org) IRB approved. To identify missed prophylaxis opportunities and assess the impact on re-admission rates for venous thromboembolism (VTE), pharmacy drug charge codes were used to identify general medical patients 40 years of age and hospitalized for > 48 hours who did not receive VTE prophylaxis. Discharge coding (ICD-9) was used to identify general medical patients admitted for VTE-related events with hospitalizations occurring within the previous 90 days who did not receive appropriate VTE prophylaxis. A total of 2400 patients were identified, of whom 1035 (43%) with an average length of stay of 5.6 days, did not receive VTE prophylaxis. A random sample resulted in 95 patients, after removing patients receiving full dose anticoagulation 76 (80%) were eligible for chart review. Of the 76 patients 65 (86%) had 2 risk factors for VTE and failed to receive prophylaxis during hospitalization. Further data will be presented following the implementation of an automated VTE risk assessment tool. A concurrent audit will assess whether the tool will decrease missed prophylaxis opportunities or readmissions for VTE related events among general medical patients at risk for VTE.

USINGCAPILLARYZONEELECTROPHORESISTOEVALUATETHE STABILITYOFPROMETHAZINEHYDROCHLORIDEINNORMAL SALINE(B4),JedMilne,CortneyHebert,JaronHansen.Utah ValleyRegionalMedicalCenter,Provo,UT(jed.milne@imail.org) IRBapprovalnotneeded. Theobjectiveofthisstudyistodeterminethestability ofpromethazinewhendilutedwithnormalsalineto concentrationsof250mg/Land125mg/Landstoredformore than24hours.Thisisstrictlyadrugstabilitystudythatuses capillaryzoneelectrophoresistomeasurethestabilityof promethazinewhendilutedwithnormalsalinetoinitial concentrationsof250mg/Land125mg/L.Theconcentrationof promethazinewillbemeasuredevery12hoursandthe compatibilityofitsphysicalandchemicalpropertieswillbe examined.SolutionswillbepreparedinanInternational OrganizationforStandardization(ISO)class5environmentby drawingup25mgand12.5mgofpromethazineandcombining themwith100mlofnormalsaline.Thesolutionwillbestoredin polyvinylchloridebags.Thesamplebagswillbestoredunder refrigeration(5plusorminus3degreesCelsiuswithmonitoring fortemperaturediscrepancies)andprotectedfromlight.One millilitersampleswillbedrawnfromeachbagattwelvehour intervals.Allsampleswillbefrozenuntilcollectionhasbeen completed.Dataanalysiswillcommenceviacapillaryzone electrophoresisandwavelengthultravioletdetection.The concentrationsofmoleculeswillbedeterminedbyintegrating theareaundereachwavelengthpeak.Thepeaksontheinitial knownconcentrationsampleswillallowdevelopmentofa calibrationcurve.Resultsandconclusionwillbepresented.

APPLYING DOCUMENTATION OF PHARMACISTS INTERVENTIONS IN THE EMERGENCY DEPARTMENT (B4), Victor Monrreal Jr.. Sharp Healthcare System, San Diego, CA (victor.monrreal@sharp.com) IRB approval pending. The study objective is to quantify and analyze the emergency department (ED) pharmacists interventions at a large community hospital (Sharp Grossmont Hospital) in San Diego comparing the hours from 2400 to 1200, when a pharmacist is not present in the ED, to the hours of 1300 to 2400, when a pharmacist is present in the ED, and assess if pharmacist initiated clinical interventions will have an effect on medication intercepted errors. All ED pharmacists will document their interventions from 1300 to 2400. The main pharmacy will record interventions they encounter during order processing between the hours of 2400 to 1200. All interventions over a 3 month period will be included and divided into specified categories, ie ADE (adverse drug event), Alternative Drug Therapy, Allergy Screening, etc. Interventions will then be classified by medication stage defined by the California Department of Public Healths 11 medication stages. This methodology is traditionally used to assess, improve, and evaluate medication safety and identify actual or potential medication related errors. Results and conclusions will be presented.

EVALUATION OF AN INPATIENT PHARMACY MANAGED EDUCATION PROGRAM FOR PATIENTS INITIATED ON WARFARIN THERAPY. Jolene Morris. Kaiser Permanente, Fresno, CA (jolene.x.morris@kp.org) IRB exempt One of the Joint Commissions 2010 National Patient Safety Goals requires health systems to provide warfarin education to patients, including face-to-face interaction with a trained professional during a hospital stay. In 2009, the inpatient pharmacists at the Fresno Kaiser Medical Center began providing warfarin education to patients before discharge. Before this, education was provided after discharge by ambulatory care pharmacists only. Inpatient pharmacists are now required to provide warfarin education at the bedside of all hospitalized patients on warfarin. There are no studies that have examined the impact of an inpatient pharmacy managed warfarin education program on rate of re-hospitalizations and Time-to-Therapeutic Range (TTR). This study compared 30-day hospital re-admission rates due to thromboembolic or bleeding events as well as TTR before and after implementation of the inpatient warfarin education program. A secondary outcome of this study compared patient compliance with INR lab follow-ups as scheduled by the ambulatory care pharmacists during the 30-day post discharge period. Patients were excluded from the study if they were discharged to a skilled nursing facility or did not complete 30 days of warfarin therapy after discharge. A retrospective chart review of 200 patients was conducted to compare the rate of re-hospitalization, TTR, and compliance with scheduled INR lab draws during

the pre- education period and the post-education period. The results and conclusions will be discussed.

A QUALITY OF CARE AND WASTAGE MINIMIZATION ANALYSIS OF ADULT TOTAL PARENTERAL NUTRITION (B4), Niousha Nader, Rita Jue. Ronald Reagan UCLA Medical Center (RRUCLAMC), Los Angeles, CA (nnader@mednet.ucla.edu) IRB approval pending. Hospital pharmacy departments often evaluate medication usage and wastage in attempts to improve clinical performance and minimize costs. National drug shortages have added further rationale for these evaluations. Recently, amino acid shortages impacted the RRUCLAMC where a number of patients receive total parenteral nutrition (TPN). Although an established TPN per pharmacy protocol has helped standardize the hospitals TPN use in adult patients for many years, some excess use and wastage still occur for unclear reasons. The purpose of this study is to evaluate the appropriateness of TPN use and to determine the causes for TPN wastage throughout the hospital. Methods include an observational period with a prospective daily analysis of unused TPN bags returned to the pharmacy, as well as, random quality of care audits on active TPN orders. The reasons for TPN wastage will be categorized and evaluated. This study will help identify intervention methods that will assist in the reduction of future wastage. The impact of pharmacists on appropriate TPN use and minimization of wastage are also to be determined. The results will be discussed.

IMPACT OF THE NEW FORMULATION OF HEPARIN ON HEPARIN INFUSION RATES AND THE INCIDENCE OF HEMORRHAGIC OR THROMBOTIC EVENTS (B4), Kami Nakagiri, Lisa Tong. San Francisco VA Medical Center, San Francisco, CA (kami.nakagiri@va.gov) IRB approval is received. In October of 2009, the United States Food and Drug Administration (FDA) informed health care providers of a change in the United States Pharmacopeia (USP) standards for manufacturing heparin. With standardization, there was an estimated 10% decrease in potency of the new heparin formulation compared to the previous formulation. The objective of this study was to identify if there was a difference in potency with the change in heparin formulation which could determine if current recommended doses need to be adjusted, and if there is an increase of thrombosis or bleeding. This study is a retrospective chart review of hospitalized patients at SFVAMC who received a heparin infusion between February 15, 2010 and August 31, 2010. Heparin infusion rates of patients from February 15, 2010 to May 14, 2010 (old formulation) were compared to heparin infusion rates of patients from June 1, 2010 to August 31, 2010 (new formulation). Thrombosis and bleeding events will also be recorded during each time period and compared. The results will be discussed.

THE DEVELOPMENT AND IMPLEMENTATION OF AN INPATIENT PHARMACIST MANAGED PATIENT CONTROLLED ANALGESIA (PCA) SERVICE (B4), Khanh Nha Nguyen. Kaiser Permanente, Anaheim, CA (khanh.nha.nguyen@kp.org) IRB approval received. Patient controlled analgesia (PCA) is often utilized in postoperative patients because it allows patients to take an active role in managing their pain with self administration of intravenous analgesic medication. A pharmacist managed PCA service will allow pharmacists to initiate and adjust the appropriate opioid analgesic delivered by PCA to assist patients in achieving optimal pain relief. A pilot project was conducted at Kaiser Permanente, Anaheim to assess the impact of pharmacist intervention in providing safe and effective pain management during the postoperative recovery period. The first phase of this project consisted of creating and receiving approval for the pharmacist managed PCA protocol. The second phase involved the implementation and evaluation of the protocol. Retrospective chart reviews of adult patients that met the inclusion and exclusion criteria set forth by the protocol were conducted prior to and after the implementation of the protocol to compare patients perception of pain. The results of this project will be presented.

EVALUATIONOFWARFARINPROTOCOLTOASSESS ACHIEVEMENTOFTHEJOINTCOMMISSIONSNATIONAL PATIENTSAFETYGOALS(B4).DeannaNielsen.AsanteHealth System,Medford,OR(dnielsen@asante.org)IRBapproved. InresponsetoNationalPatientSafetyGoal03.05.01, RogueValleyMedicalCentercreatedandimplementedthe PharmacyProtocolforWarfarinManagement.Thisprotocol wasdesignedtoguidewarfarinmanagementconductedby pharmacists,whileimplementingtheobjectivesassociatedwith thisgoal,andtherebyimprovingpatientsafety.Thepurposeof thisstudyistoevaluatetheachievementofthepharmacy protocolinmeetingTheJointCommission'sNationalPatient SafetyGoalsatacommunityhospital.Toeffectivelyevaluate theachievementsofthewarfarinprotocol,performanceofthe protocolwillbeassessedthrougharetrospectivechartanalysis. Patientswillbeidentifiedusingacomputergenerated anticoagulationreportandthepharmacydrugdatabase.The followingdatawillbecollected:thepercentageofpatientswith abaselineINRpriortobeginningwarfarintherapy,the percentageofpatientsthathaveacurrentINRduringwarfarin therapy,thepercentageofpatientsthathavetheirfood,drug, andwarfarininteractionsassessedanddocumented,the percentageofpatientsthatreceivedwarfarineducation. Resultsandconclusionswillbepresented.

A COMPARATIVE STUDY OF INTRAVENOUS VERSUS ORAL N-ACETYLCYSTEINE FOR PREVENTION OF CONTRAST-INDUCED NEPHROPATHY (B4). Tess Nishida, Jessica Steffl, Ali Olyaei, Oregon Health and Science University, Portland, OR (nishida@ohsu.edu) IRB approved. The study objective is to compare the efficacy of the intravenous (IV) versus oral formulation of Nacetylcysteine (NAC) in preventing contrast-induced nephropathy (CIN) in patients receiving IV contrast. To date, studies on CIN prophylaxis have been small and have not directly compared the two drug formulations which have a significant cost difference. Many providers have been ordering IV NAC regardless of a patients ability to tolerate oral medications. A retrospective chart review evaluated all patients who received prophylactic NAC from June 1, 2010 to October 1, 2010. Patients who received at least one dose of NAC prior to IV contrast were included. Patients who received NAC for acetaminophen overdose or as a mucolytic agent were excluded. The definition of CIN is defined as an increase in Scr of either > 0.5 mg/dL or > 25% from baseline within 48 hours of IV contrast administration. Data collection included patient age, gender, history of diabetes or chronic kidney disease, other nephrotoxins, concurrent administration of IV sodium bicarbonate or normal saline, hypotension, current infection, worsening of heart failure, need for renal replacement therapy and mortality. Statistical tests performed include the Fishers exact test, students t-test, chi-squared test, Kaplan Meier curve, and multivariate logistic regression. Results and conclusions are pending.

EVALUATION OF EMPIRIC TREATMENT OF CELLULITIS IN THE COMMUNITY (B4), Hannah Oh, Terrill Tang, Linh Van, Roger Baxter. Kaiser Permanente Oakland Medical Center, Oakland, CA. (hannah.x.oh@kp.org) IRB approval received. The Infectious Diseases Society of America (IDSA) recommends coverage of Streptococcal species and Staphylococcus aureus in the management of cellulitis. With widespread emergence of community acquired methicillin-resistant S. aureus (CA-MRSA), clinical practice often seems to favor use of antimicrobials that also cover for CA-MRSA. Until the release of the IDSA guidelines for MRSA-associated infections in early 2011, the ideal empiric antimicrobial regimen for cellulitis had remained unclear. This retrospective, cohort study of adult patients seen in the emergency department (ED) or outpatient clinics within the Kaiser Permanente Northern California region between 2006 and 2009 assesses clinical effectiveness of current practice in empiric treatment of cellulitis, pre-dating publication of the new IDSA recommendations. Patients coded with an ICD-9 diagnosis of cellulitis were stratified by initial oral antibiotic(s) received. The primary outcome was failure of initial therapy defined as any one of the following: 1) oral or IV antibiotic(s) for cellulitis within 3 weeks following initial diagnosis; 2) hospitalization within 3 weeks of initial antibiotics with admission for diagnosis of cellulitis, fever, sepsis, abscess, osteomyelitis, or bacteremia; or 3) ED/clinic visits within 3 weeks of initial diagnosis. The results and conclusion will be discussed.

IMPLEMENTATION AND EVALUATION OF A PHARMACIST MANAGED INAPATIENT ANTICOAGULATION SERVICE (B4) Emily Oien. Intermountain Healthcare, Provo, UT. (emily.oien@imail.org) IRB approved. A pharmacist managed inpatient anticoagulation service was established at Utah Valley Regional Medical Center. The service is supported by the institutions medical executive committee and pharmacy and therapeutics committee. The service operates under a collaborative practice agreement, which was approved by the pharmacy and therapeutics committee, along with all policies, procedures and protocols. Pharmacists participating in the anticoagulation service are required to complete anticoagulation education and demonstration of competency by examination. The collaborative practice agreement has been made available to physicians following a presentation promoting the service at medical staff department meetings. A prospective, observational study will evaluate the quality of warfarin management by a pharmacist compared to physician management of warfarin. The primary outcome of the analysis will be days with INR within the predetermined therapeutic range. The secondary outcomes will include days with INR greater than 4, days to reach therapeutic range, length of stay following initiation of warfarin, number of vitamin K doses administered, reported adverse drug events, and number of physicians who have utilized the pharmacy managed anticoagulation service. Results and conclusions will be presented.

IMPLEMENTATION AND ANALYSIS OF AN ORAL UUNIT-DOSE SYSTEM (B4). Sarah Peitz. Providence Alaska Medical Center, Anchorage, AK (sarah.peitz@providence.org) IRB exempt. The Institute for Safe Medication Practices and the American Society of Health-System Pharmacists provide guidance regarding the way bulk drugs should be dispensed to patient care areas and advise that medications should be dispensed in unit-dose or unit-of-dose containers that are ready for immediate use. This is especially important in areas such as pediatrics where liquid drugs are commonly used. The objective of this study is to implement a hospital-wide program for unit-dosing oral liquid medications and then to evaluate the effect this program has on cost and on nursing satisfaction. Institutional Review Board exemption was obtained prior to initiation of the study. The first step in the project was to determine which oral medications used in the hospital are currently dispensed as a bulk liquid product. The proposed dispensing method of each was then chosen as unit-dose or unit-of-dose. Labels and labeling conventions were developed for the new system. Pharmacy workflow and staffing was evaluated and necessary changes made in order to accommodate this new procedure within the pharmacy. Pharmacy, nursing, and medical staff all received education regarding the unit-dose system, and February 15, 2011 was the date set for hospital-wide implementation. Before starting the unit-dose system an anonymous survey was distributed to nurses working in pediatrics and the NICU to assess their satisfaction with the current method of drug dispensing and to gain feedback regarding workflow. This will be repeated two months post implementation. Also, cost assessments will be performed analyzing several commonly used drugs before and after implementation of the unit dose system. Comparison of nurse satisfaction and costs will identify benefits and needed refinements of the new system. Results and conclusion will be presented.

TIMI-BLEEDS IN DOSE-ADJUSTED ENOXAPARIN (TIDE) (B4). Felix Pham, Tom Saito. Fountain Valley Regional Hospital, Fountain Valley, California, US (felix.pham@gmail.com) IRB approval pending. Fountain Valley Regional Hospital (FVRH) uses anti-Xa levels to assist in dose adjustments of enoxaparin in patients who are elderly, obese, or renally insufficient thus, ensuring therapeutic anticoagulation and minimizing bleeding events. However, a review of the literature suggests that there is no clear correlation between supratherapeutic anti-Xa levels and TIMI classified bleeds. Studies suggest that bleeding events associated with heparin use has been strongly associated with impaired renal function. The objective of this study is to determine which factors correlate with bleeding events in patients receiving therapeutic, pharmacy dose-adjusted enoxaparin for a thromboembolic event. A 90-day retrospective chart review was performed on patients who received therapeutic enoxaparin with at least one anti-Xa level. Patient information was extrapolated from archived data and analyzed for trends. The primary end point will determine bleeding etiologies in this patient population. Secondary end points will establish factors contributing to supratherapeutic anti-Xa levels and its relationship to bleeds. Data collection needs to be completed and analyzed before any conclusions can be discussed.

PHARMACIST DRIVEN HEPARIN PROTOCOL AND THE TIME TO APTT GOAL AT THE VAGLAHS (B4). Rosalin Preechakul. Veteran Affairs Greater Los Angeles Healthcare Systems, Los Angeles, CA. (Rosalin.Preechakul@va.gov) IRB approved Heparin is a heterogeneous product with a variable pharmacokinetics making it a challenge to dose and maintain patients at a therapeutic level. The original intravenous unfractionated heparin (IV UFH) guideline was developed in the early 1990's as a template to help facilitate anticoagulation. Later resident staffs observed an inconsistent approach to dosing and rate adjustment of IV UFH which led to the development of a pharmacist driven heparin protocol. The study objective was to evaluate the impact of the newly implemented pharmacist driven IV UFH protocol to help improve the quality of use and to better patient outcomes in the future. This was a retrospective chart review of hospitalized patients at the Veteran Affairs Greater Los Angeles Healthcare System from Aug12, 2008 through Aug 11, 2010 with documented use of unfractionated heparin. Primary outcome was the therapeutic and safety effects of IV UHF by measuring the activated partial thromboplastin time. Results and conclusions will be presented.

RENAL MONITORING IMPLEMENTATION IN A COMMUNITY HOSPITAL (B4), John Price. Lisa Keller. Yuma Regional Medical Center, Yuma, AZ (jeprice@yumaregional.org) IRB not needed-no human subject data. The study objective is to design and implement a pharmacist-based renal monitoring protocol. All adult patients with a serum creatinine of two or more are identified daily. The patient electronic medication administration record is reviewed for renally excreted drugs to make recommendations based upon the estimated creatinine clearance. These recommendations are communicated to the prescribing or attending physician by phone, notes, or direct communication. Once a recommendation is made on a patient, the pharmacist is to follow the patient until the serum creatinine is less than or equal to one for three consecutive levels, admission to the ICU, or discharge. During the month, five random days are evaluated to confirm appropriate and all possible recommendations are made. The study period is five months. Inclusion criteria are age greater than 17 and serum creatinine of 2 or more. Exclusion criteria are admission to the ICU or discharge before a recommendation is made. All renal monitoring forms are analyzed to determine the rate and frequency of acceptance of pharmacist recommendations and different medications. Results and conclusions will be presented.

EFFECTS OF PHARMACIST INTERVENTION ON MEDICATION SAFETY AND COMPLIANCE IN AN INDIAN COUNTRY CORRECTIONAL FACILITY (B1). Erin Ressler. Linda Crosby. Warm Springs Health and Wellness Center, Warm Springs, OR (Erin.Ressler@ihs.gov) IRB approved. The study objective was to determine the extent of improvement in the medication system at Warm Springs Adult Detention Center as a result of pharmacist led interventions and education of correction officers. Interventions consisted of redesigning all medication administration records, revising the medical services policy and procedure manual and re-implementing the use of bubble packaged medications. Education classes were conducted by a pharmacist and other health care professionals on topics including treatment of common disease states, appropriate use of over-the-counter and prescription medications, proper documentation and use of medication reference materials. Pre- and post-intervention data was collected from surveys of correction officers and reviews of inmates medication administration records. Survey data was used to determine changes in the officer's confidence regarding medication administration and attitudes concerning inmate medication use. Medication administration record data was used to determine a percent change of performance improvement in medication administration and documentation compliance. Results and conclusions will be presented.

COORDINATION OF CARE BETWEEN INPATIENT AND OUTPATIENT PHARMACY ANTICOAGULATION MONITORING (B4), Lindsey Rich. Kaiser Permanente Medical Care Program, Vallejo, CA (Lindsey.X.Rich@kp.org) IRB exempted. Omissions in hospital discharge documentation can have detrimental effects on patients receiving anticoagulation therapy. Previous research suggests a need for coordination during transitions of care to prevent communication deficits that lead to erroneous dosing, lack of monitoring, non-adherence, and drug interactions. Thus, examination into the potential benefits of inpatient pharmacists providing the coordination to outpatient clinics is warranted. In 2010, Kaiser Permanente Napa-Solano implemented a new workflow to transfer anticoagulation monitoring from inpatient pharmacists to the outpatient clinic when patients are discharged from the hospital. This retrospective chart review assessed whether the new procedures were followed with respect to warfarin-nave patients initiated on anticoagulation therapy prior to hospital discharge. The study evaluates the implementation of a coordinated anticoagulation service to increase communication and information transfer between pharmacists. The information collected included quantitative data for descriptive analysis, with the primary outcome measuring electronic notification between pharmacists about patients initiated on warfarin. Secondary outcomes include whether patient education about warfarin was performed prior to discharge, timeliness of electronic referral documentation, timeliness of follow-up laboratory monitoring, and frequency of readmission within 30 days

due to warfarin toxicity or thrombosis. Final results and conclusions will be presented.

EVALUATION AND OPTIMIZATION OF INPATIENT ANTICOAGULATION MANAGEMENT (B3) Justin Ross. Brent Albertson. Lance Muncey. Providence Sacred Heart Medical Center, Spokane, WA (Justin.Ross@providence.org) IRB exempt. Research has shown that utilization of pharmacy managed anticoagulation therapy when compared to physician guided therapy have been associated with improving overall patient care while reducing the cost of therapy. The objective of this project was to optimize clinical outcomes related to anticoagulation therapy. Initial focus was placed on utilization of warfarin per pharmacy management followed by a series of retrospective Medication Use Evaluations (MUE) around warfarin and unfractionated heparin. Areas of focus included application of guidelines to our patient populations, protocol compliance with dosing and monitoring, dose adjustments, time to achieve goal, and clinical outcomes. MUE data was then used to identify areas of improvement and strategies were implemented to optimize protocol performance. The second phase of this project involved an assessment of areas of additional pharmacy involvement as a means to improve anticoagulation therapy provided to our patients. The current role of the pharmacist in anticoagulation therapy management was assessed through the pharmacy documentation system. Areas for pharmacist intervention were then evaluated to improve the performance of existing protocols as identified in the MUEs. Additional areas focused on improving processes around continuity of care and utilization of clinical decision support software. Results and conclusions will be presented.

DOES INDUCTION THERAPY CONTRIBUTE TO THE INCIDENCE OF URINARY TRACT INFECTIONS IN ADULT RENAL TRANSPLANT RECIPIENTS? (B4) Tiffany Royer. Renee Weng. Clarence Foster. UC Irvine Medical Center, Orange, CA (troyer@uci.edu) IRB approval received. The introduction of powerful immunosuppressants have significantly improved the clinical outcomes of transplantation. However, the impact of these immunosuppressants on the risk of infectious complications is not fully understood. The most common infectious complication following renal transplantation is urinary tract infections, occurring in over one third of patients within the first 4 months. Induction immunosuppressants, such as Simulect or Thymoglobulin, induce a state of immunosuppression and decrease the risk of rejection. The selection of which induction agent to give is based on surgeon assessment of rejection risk; with Thymoglobulin reserved for higher risk patients due to its greater potency. A single center retrospective chart review of adult kidney transplant patients from July 2005 to July 2010 was conducted. Data collected include the patients age, gender, ethnicity, primary cause of renal failure, body mass index, length of hospitalization, history of diabetes, waitlist time, length of dialysis treatment, use of ureteral stents, duration of foley use, and which prophylactic antibiotics were given during the surgery. Primary objective is to compare the incidence of urinary tract infections in patients receiving Simulect versus Thymoglobulin. Secondary objectives include identifying possible risk factors for

developing urinary tract infections after transplant. Results and conclusions will be presented.

IMPACT OF A PHARMACIST FACILITATED DISCHARGE SERVICE ON PRIMARY MEDICATION ADHERENCE: PROJECT PHARMD (B4). Christian Sanchez, Melanie Dodd, Gretchen Ray. University of New Mexico Hospitals, Albuquerque, NM (COSanchez@salud.unm.edu) IRB approved. The study objective was to evaluate the impact of pharmacist medication therapy counseling and disease state education on primary medication adherence for patients discharged from an internal medicine service. Primary medication adherence is defined as the rate at which patients fill new prescriptions. This is a single center prospective hospital based intervention study. Patients discharged from the Internal Medicine service from November 2010 to February 2011 that speak English or Spanish and are willing to participate will be screened for eligibility. The intervention will consist of medication reconciliation, counseling, disease state education, and a follow-up phone call 36 to 72 hours after discharge. The patients in the control group will receive usual care, discharge instructions and/or counseling by a registered nurse. Data from the two groups will be compared to assess whether the intervention had an effect on rates of primary adherence. Rates of primary medication adherence will be calculated based on number of prescriptions written and number of prescriptions picked up from the hospital outpatient pharmacy in both the intervention and control group. Results to be presented and discussed.

IMPACT OF PHARMACIST DISCHARGE COUNSELING SERVICES ON 30 DAY HOSPITAL READMISSIONS AND ED VISITS: PROJECT PHARMD (B4), Preeyaporn Sarangarm, Rucha Bond, Gretchen Ray. UNM Hospital, Albuquerque, NM (psarangarm@salud.unm.edu) IRB approved. As many as 20% of patients experience an adverse event after hospital discharge, with an estimated 60% of those events deemed medication related and preventable. The objective of this study was to evaluate the impact of pharmacist medication therapy counseling and disease state education on a combined endpoint of 30 day post discharge rehospitalizations and ED visits for patients discharged from the Department of Internal Medicine at UNMH. Pharmacist Assisting at Routine Medical Discharge (Project PhARMD) is a single center prospective hospital based intervention study. Study recruitment occurred from November 2010 to February 2011. Patients discharged from six internal medicine teams, who spoke English or Spanish and were willing to participate were considered for study enrollment. Patients were enrolled into two study groups, an intervention or a control group, with each group comprised of three internal medicine teams. Patients in the control group received usual hospital discharge care, while patients in the intervention group received discharge counseling provided by a Pharmacy Practice Resident in addition to the usual care and a follow up phone call 36 to 72 hours post discharge. Descriptive statistics and multiple logistic regression with odds ratios were to compare rates of 30-day readmissions and ED visits between the two groups. Full results and conclusions will be presented.

ANTIMICROBIAL STEWARDSHIP: A NEW ROLE FOR PHARMACISTS IN THE EMERGENCY DEPARTMENT (B4). Lisa Serrano. Jill Terry. Annie Wong-Beringer. Huntington Hospital, Pasadena, CA. (lmaserrano@yahoo.com) IRB approved. Sepsis is a common ailment seen in patients presenting first to the Emergency Department (ED) and yields a role for a clinical pharmacist in assisting with early goal directed antimicrobial therapy. The objective of this retrospective cohort study is to determine the impact of an on-duty (MonFri 7:00am-5:30pm) ED Clinical Pharmacist in empiric antimicrobial selection for septic patients. Adult patients admitted to Huntington Hospital will be identified using the Surviving Sepsis Campaign 2008 Guidelines (SIRS Criteria), those receiving ED initiated antibiotic therapy, and had at least one culture specimen collected in the ED. Their health systems medical record will be reviewed over a period of one year and empiric antibiotics will be deemed clinically appropriate for those who have a culture positive result correlating with susceptibility patterns. For patients with a negative culture, clinically appropriate empiric antibiotics will be based on Huntington Hospitals approved guidelines on empiric antibiotic usage. Inappropriate use of antimicrobials will be identified as those with microbiology findings that do not support empiric selection, a clinical contraindication, or the wrong dose, route, or frequency of antibiotic was

prescribed. Outcome measures will include the percent of patients receiving clinically appropriate empiric antibiotic therapy in the ED, clinical response time, length of hospitalization, and in-hospital mortality. Results and conclusions will be presented.

IMPLEMENTATION OF A COMPREHENSIVE CLINCIAL PHARMACY PRACTICE MODEL (B4). Genesis Sezate. Mary Manning. Banner Baywood Medical Center, Mesa, AZ (genesis.sezate@bannerhealth.com) IRB exempt. The goal of ASHPs Pharmacy Practice Model Initiative (PPMI) is to foster the creation of an innovative hospital pharmacy practice model. The PPMI focused on developing a
practice model that optimizes the use of pharmacy resources for patient care-related services. Banner Baywood Medical Center is a 340 bed community hospital with a practice model consisting of centralized medication distribution and order verification with clinical pharmacy services provided by 5 Clinical Specialists. Existing clinical responsibilities include

pharmacy consults, patient chart review guided by a target medication list, and per protocol interventions. The objective of this study was to determine the impact of implementing a comprehensive clinical pharmacy practice model in line with ASHPs Pharmacy Practice Model Initiative on medication use based on several pre-specified outcomes. The outcomes included the number of pharmacy consults, per protocol interventions, Heart Failure Clinic referrals, and nurse satisfaction. The integrated pharmacy practice model was piloted on the telemetry floor for 4 weeks. One pharmacist was assigned to each of three units. The pharmacist was responsible for order verification, clinical pharmacy consults, medication reconciliation and

discharge instruction for patients classified as high risk, patient chart reviews and coordinating referrals to the medication management clinic. All patients admitted to the telemetry floor from January 10 to February 4 were included. Results and conclusions will be presented.

 AN EMERGENCY ROOM (ER) PHARMACISTS INTERVENTIONS AND RATE OF PROSPECTIVE ORDER REVIEW (B4), Stefany Shimada, Ethan Anderson, Randell Miyahara. VA Palo Alto Health Care System (VAPAHCS), Palo Alto, CA (StefanyM.Shimada@va.gov) IRB approval pending. Due to the urgent nature of ER medication orders, it is often difficult for centralized pharmacists to readily review all orders in a timely and prospective manner. In April 2010, a clinical pharmacist was deployed to the VAPAHCS ER to assume responsibility of medication management and ensure compliance with all Joint Commission medication management standards. Our ER relies on central pharmacists for medication review during the ER pharmacists off hours. During this time, most medications dispensed from automated dispensing machines are not reviewed by a pharmacist. This retrospective study will review data from August 23rd, 2010 to October 1, 2010. Data will be collected through chart review of patient records obtained from photocopied ER medication orders and administration records, medication dispensing reports, and faxed ER medication orders sent to inpatient pharmacy. Objectives of the study include: (a) to compare prospective medication order review rates during the ER clinical pharmacists shift versus the inpatient central pharmacists ER coverage shift hours; (b) to describe interventions made by the ER clinical pharmacist; and (c) to describe types of medications not prospectively reviewed by pharmacists. Results will be presented.

EVALUATION OF INPATIENT HEART FAILURE CARE AT DEACONESS MEDICAL CENTER (B4), Sharon Shiraga, Bryan Rowe, Colleen Terriff, Deaconess Medical Center, Spokane, WA (shirags@empirehealth.org) IRB approved. The study objective was to identify gaps in standard of care at Deaconess Medical Center (DMC) from admission to discharge. This project is a single centered, retrospective chart review involving ~230 patients. Patients were included in if they: (i) carried an ICD-9 code of CHF between June 2009 to July 2010; (ii) re-readmitted < 30 days after discharge from DMC. Patients were excluded if: (i) did not have an ICD-9 code of heart failure documented; (ii) they were re-admitted > 30 days after their initial discharge. Primary end points were when follow up was scheduled. The results will be discussed and other data will be presented.

ASSESSING PATIENT PREDICTORS FOR HOSPITAL READMISSIONS AND EMERGENCY DEPARTMENT VISITS WITHIN 30 DAYS POST DISCHARGE: PROJECT PHARMD (B4), Stanley Snowden, Gretchen Ray. UNM Hospital, Albuquerque, NM (ssnowden@salud.unm.edu) IRB approved. Transitional care including discharge medication counseling at the University of New Mexico Hospital is run by the nursing staff. A new discharge counseling service run by pharmacy practice residents will be piloted. The objective of this study is to identify patient predictors associated with hospital readmissions and emergency department visits within thirty days after initial hospital discharge following pharmacist discharge counseling. This study was approved by our Institutional Review Board. This is a single center, prospective cohort study. Patients discharged from the internal medicine service between November, 2010 and February, 2011 that speak either English or Spanish and are willing to participate will be included. Patients in the intervention group will receive discharge medication counseling and a follow up phone call 36-72 hours after they are discharged from the hospital in addition to usual care. The control group will receive usual care. The following data will be collected: age, gender, ethnicity, marital status, primary spoken language, disease severity using the Charlson Comorbidity Index, number of hospitalizations within the previous year, hospital length of stay, and insurance status. Logistic regression will be used to identify predictors. Full results and conclusions will be presented.

PILOT STUDY EVALUATING THE IMPACT OF PNAFISH TESTING FOR STAPYLOCOCCUS AUREUS ON ANTIBIOTIC USE (B4), Brandi Strauser, Christine Witherspoon, Ronald Rains, Paula Moyers. Memorial Health System, Colorado Springs, CO (brandi.strauser@memorialhealthsystem.com) IRB approved. The objective of this study is to evaluate whether PNA-FISH testing on blood cultures with gram positive cocci in clusters (GPCC) affects the use of antibiotics or associated costs at Memorial Health System. Adult inpatients, treated by intensivists, hospitalists, or infectious disease specialists with blood cultures positive for GPCC are eligible for enrollment. Patients less than 18 years old, pregnant patients, prisoners, patients with ANC less than 1000, and patients with permanent implanted devices where coagulase negative staphylococci are unlikely to be a contaminant will be excluded. Appropriate education regarding the use and application of the PNA-FISH test will be provided to the target physician group. On Mondays through Thursdays, the microbiology lab will perform PNA-FISH testing twice daily on blood cultures positive for GPCC from patients of the targeted physician group. Positive blood cultures from patients of the targeted physician group reported Friday through Sunday will serve as the matched control group. The responsible provider will be notified by the primary investigator of the PNAFISH results as soon as possible after the patients have been screened for exclusion criteria. Decisions regarding antibiotic therapy will be at the discretion of the provider. Results and conclusions will be presented.

DEVELOPING AND IMPLEMENTING DIABETES SCREENINGS FOR PATIENTS AND EMPLOYEES IN A COMMUNITY BASED HOSPITAL (B4). Christie Stuhmer, Christy Locke, Harriet Catania, St. Josephs Medical Center, Stockton, CA (Christie.Stuhmer@chw.edu) IRB Approval Pending Diabetes is a growing epidemic in the United States with than 18.8 million people diagnosed, an estimated 79 million that are prediabetic, and 7 million undiagnosed. Eight percent of the US population has diabetes. Numerous hospital admissions may be preventable by early detection and management of diabetes. Sustained hyperglycemia has a financial impact on the health care system; for every 1 unit increase in the hemoglobin A1c there is an increase in cost by 17.2 %. Preventing cardiovascular complications in diabetic patients may reduce health care costs; currently 48% of St Josephs Medical Center (SJMC) diabetic patients are on aspirin and statin therapy. This projects objective is to implement a diabetes screening process for patients and SJMC employees then to provide education on disease prevention and disease management to those with abnormal results. A point of care hemoglobin A1c test will be used as a screening tool. In an effort to reduce cardiovascular risk, patients will be evaluated for appropriate use of aspirin and statins. Physicians will be notified for A1c results greater than 6.5% in unrecognized diabetic patients. Physicians have the option to refer their patients to the St. Josephs Medical Center Disease Management program. Results and conclusions will be presented.

EVALUATING THE IMPACT OF A MEDICATION THERAPY MANAGEMENT PROGRAM PROVIDED BY A MEDICARE PART D SPONSOR (B4), Wendy Sui. Blue Shield of California, San Francisco, CA (wendy.sui@blueshieldca.com) IRB not applicable. The passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 required Medicare Part D plan sponsors to offer medication therapy management programs (MTMP) to eligible Medicare beneficiaries. This study evaluates the impact of a health plan sponsored MTMP on utilization, cost, clinical outcomes and medication adherence for participating beneficiaries. MTM services, including targeted clinical mailings and telephonic consultations with pharmacists, were provided to eligible Medicare members by a large California health plan. All eligible beneficiaries received customized monthly messages that identified potential gaps in care, preventive service opportunities and medication optimization. A subset of beneficiaries received pharmacist consultations to discuss medication-related issues, adherence and chronic disease management. Newly eligible Part D beneficiaries who met the MTMP 2010 criteria from January 1, 2010 to September 30, 2010 will be evaluated. The study will assess program outcomes during the 6month period following MTMP enrollment compared to a 6-month baseline period prior to enrollment. Data captured in a web-based MTM documentation tool, a clinical messaging system, and through medical and pharmacy claims will be used to evaluate the impact of MTM services. Results will be discussed when the study is presented.

EVALUATING THE IMPACT OF A STAFF DEVELOPMENT PROGRAM ON WARFARIN CRITICAL DRUG INTERACTIONS (B4). Elizabeth Surano, Audrey Lee, Maureen Boro. San Francisco Veterans Affairs Medical Center, San Francisco, CA (elizabeth.surano@va.gov) IRB approved. The objective of this study is to evaluate the impact of a warfarin critical drug drug interaction (DDI) pharmacist staff development program. The primary endpoint of this retrospective study is to compare the weekly rates of pharmacist documentation for warfarin critical DDIs before and after the program. A secondary endpoint is to determine if the pharmacists preferred method of learning affects their documentation of targeted warfarin DDIs. The program consists of management strategies for three targeted warfarin DDIs using 3 teaching methods: a computerized format, an oral presentation, and the combination of the two formats. Pharmacists will be asked to complete an anonymous post one month program evaluation. Warfarin critical DDIs meeting inclusion criteria will be collected for a 2 month period prior and after the program and for a 2 week period 3 months after the program. Each warfarin DDI will be matched with its corresponding pharmacy intervention and evaluated for the presence and appropriateness of documentation. The weekly rate of appropriate documentation will be determined for all warfarin DDIs and the 3 targeted warfarin DDIs before and after the program. Pharmacists' preferred method of learning will be compared to the appropriateness of pharmacist documentation for the

targeted warfarin DDIs. Results and conclusions will be presented and discussed.

DEVELOPMENT OF ESA GUIDELINES TO IMPROVE PATIENT SAFETY AND MEDICATION USE IN ADULT CKD PATIENTS (B4), Leanne Svoboda, Jess Steffl, Ali Olyaei. Oregon Health and Science University, Portland, OR (svobodal@ohsu.edu) IRB approval received. Anemia caused by chronic kidney disease (CKD) is associated with significant morbidity and mortality. The use of erythropoietin stimulating agents (ESAs) for the treatment of CKD caused anemia has improved patients quality of life but has also been associated with an increase risk of mortality when targeting a higher hemoglobin level. The main study objective is to evaluate pharmacists impact on the appropriate use of ESAs in patients with CKD. To assess this impact two months pre-implementation data and two months post-implementation data will be collected. Following this evaluation a pharmacy managed ESA dosing program will be implemented within the pharmacy department. Descriptive statistics will be used for comparing patient demographics. Study variables include: ESA used (darbepoetin or epoetin), dose (units/kg for epoetin or mcg/kg darbepoetin), indication, serum iron, serum ferritin, transferrin saturation (TSAT), route of administration, hemoglobin and hematocrit levels, transfusions, and adverse events (i.e. thrombosis). A cost savings analysis will also be conducted. Results are pending and the study conclusion will be presented at the 2011 Western States Conference.

PHARMACEUTICAL SERVICES AND MEDICATION SAFETY IN THE EMERGENCY DEPARTMENT (B4). Pamela Tien. Jason Ellison. Harriet Catania. St. Josephs Medical Center, Stockton, CA. (Pamela.Tien@chw.edu) IRB approval not required. At St. Josephs Medical Center, a dedicated pharmacist in the emergency department contributes to increased medication safety and is a valued resource to the ED staff. Current pharmacy services provided include completion of medication reconciliations, first dose review, and clinical interventions such as providing drug information, patient counseling and participating in code situations. In the last quarter of 2010, there were multiple changes within the institution that affected patient care and safety. Deployment of a hospital wide integrated hospital information system that included a fully functioning CPOE system identified several medication safety challenges in the ED. Such significant changes warranted a thorough analysis on medication safety and ultimately patient safety in the ED. The objective of this study is to assess how first dose review and medication accessibility and availability were affected before and after implementation of the CPOE system. This study also explores the possibility of a need for the expansion of pharmacy services within the ED. These objectives will be achieved through retrospective audits and surveying of the ED staff about pharmacy services within the ED. Result and conclusions will be presented.

DETERMINING AND EVALUATING BARRIERS TO ADHERENCE TO DISEASE-MODIFYING ANTIRHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS PATIENTS (B4), Peter Tran. Health Net, Rancho Cordova, CA (peter.tran@healthnet.com) IRB approval is not needed-no human subject data. The Centers for Medicare and Medicaid Services (CMS) use the Healthcare Effectiveness Data and Information Set (HEDIS) measures to assess the performance of managed care organizations on providing care to members. The measure Disease Modifying Antirheumatic Drug Therapy for Rheumatoid Arthritis is one dimension of care measured by HEDIS. This measure is defined as the percentage of members diagnosed with rheumatoid arthritis (RA) who were dispensed at least one ambulatory prescription for a disease-modifying antirheumatic drug (DMARD) within a measurement year. The objective of this study is to determine and measure the barriers to adherence to DMARDs among members with RA who were enrolled in Medicare Advantage plans in 2008 and 2009. Members with RA and deemed nonadherent were telephonically surveyed to determine causes of non-adherence. Results from the 2008 and 2009 measurement years are as follows. A total of 4,206 members met HEDIS measure eligibility. Males accounted for 21.6% (909 members) and females accounted for 78.4% (3,297 members) of the total population. The average age was 71.4 years. The average number of RA-related physician encounters per member was five. There were 3,205 (76.2%) members that received at least one ambulatory DMARD prescription and 1,001 (23.8%)

members that received zero ambulatory DMARD prescriptions within a measurement year. Survey results and conclusions are pending and will be presented.

COMPARISON OF TWO UNFRACTIONATED HEPARIN MONITORING PROTOCOLS: ONE UTILIZING THE APTT AND ONE UTILIZING AN ANTIFACTOR XA ASSAY (B4). Jeremy Vandiver. Tom Vondracek. Exempla Saint Joseph Hospital, Denver, CO. (vandiverj@exempla.org) IRB Approved. Intravenous unfractionated heparin (UFH) requires close monitoring due to marked interpatient variability. The activated partial thromboplastin time (aPTT) is the most common lab test to assess heparin activity. An alternative method to monitor UFH activity is to utilize an antifactor Xa assay, which is less impacted by physiological factors. In July of 2010, our institution began monitoring UFH with the anti-Xa assay in place of the aPTT. This study will retrospectively assess approximately 200 patients who were placed on an UFH infusion using the DVT/PE protocol at our institution over a 4 month period. Patients in the first two months (pre conversion) had their UFH monitored, and adjusted, based on the aPTT, while the patients in the second two months (post conversion) had their UFH monitored, and adjusted, based on an anti Xa assay. The goal of this study will be to assess if utilization of the anti Xa assay results in fewer lab draws, fewer UFH rate adjustments, more rapid achievement of goal levels, and greater time in goal range, as compared with the protocol that utilized the aPTT. Preliminary data from this study appears to support that the new protocol results in more rapid achievement of levels in goal range, greater time in goal range, and fewer lab draws and dose adjustments. Final results and conclusions will be presented.

ANTIFACTOR XA ASSAY VERSUS APTT MONITORING WITH CONTINUOUS HEPARIN INFUSION (B4), Kendra VanGrinsven, Kyle Townsend, Susan Keys, Jeffrey Ferber, Jacob Thiesse. Billings Clinic, Billings, MT (kvangrinsven@billingsclinic.org) IRB approval received. The objective of this prospective, randomized, single center study was to evaluate the efficacy and safety of continuous heparin infusions as assessed by heparin assays (antifactor Xa assays) versus activated partial thromboplastin times (aPTTs). All adult inpatients meeting study criteria who received continuous intravenous heparin infusion for at least 24 hours for the prophylaxis or treatment of arterial or venous thromboses were randomized to monitoring via heparin assays (HA) or aPTTs. Patients were excluded if heparin was interrupted for 6 consecutive hours or longer; if heparin was given for a duration of less than 24 hours; if the aPTT was elevated at baseline; or if the patients heparin dosing varied by greater than 10 percent from the organizations standard pharmacy directed heparin protocol. Pregnant females were also excluded. The primary outcome was the percentage of HA and aPTT values within the therapeutic range at 6 hours and 24 hours. Secondary outcomes included the mean time to reach the therapeutic range; number of monitoring tests performed per 24, 48 and 72 hours; percentage of monitoring tests in range; number of dosage changes per 24, 48 and 72 hours; dose of heparin administered per kg per hour; estimated cost of monitoring heparin at 24, 48 and 72 hours; and presence of any adverse events secondary to

heparin during the patients hospitalization. Results and conclusion will be presented.

A PROSPECTIVE ANALYSIS OF ANTIMICROBIAL UTILIZATION FOR THE DEVELOPMENT OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM (B4), Katie Vuong, Cathy Oliphant, Rob Wills. St. Luke's Regional Medical Center, Boise, ID (vuongk@slhs.org) IRB approval not needed. The objectives of this study are to measure baseline antimicrobial utilization compared to the effects of antimicrobial stewardship, focused to optimize antimicrobial use and promote multidisciplinary collaboration at a 400+ bed community hospital. Methods consisted of following adult patients on empiric broad spectrum antibiotics entering the medicine floors prospectively from admission and monitored daily until discharge. Definitive therapy will be assessed for appropriateness based on the patients' condition. Formal assessments are based on the disease state, past medical history, cultures & sensitivities, lab values, vital signs, imaging and days of therapy. Based on formal assessments, written interventions focusing on antibiotic de-escalation at 48 and 72 hours into therapy will be measured to establish metrics of the current practice at this institution. Interventions made after 72 hours of starting antimicrobial therapy are also included. "Pharmacy to dose" antimicrobial services are measured to determine the workload of the present state. The study is 4 weeks in duration, Monday through Friday. Inclusion criteria are patients who are on antibiotics. Surgical prophylactic uses of antibiotics that have defined stop dates are excluded. Results and conclusions will be presented.

EVALUATION OF MEDICATION RECONCILIATION UPON ADMISSION TO A CHILDRENS HOSPITAL (B4), Lynn Warner, Wenee Lopez, Samuel Lehman. Childrens Hospital Central California, Madera, CA (lwarner@childrenscentralcal.org) IRB approval pending. The objective of the study was to quantify the number of discrepancies during medication reconciliation. Secondary objectives included categorizing the types of errors, documenting the number of patients who did not have a completed medication reconciliation form, determine risk factors for having an error during medication reconciliation and determine pharmacist time required for medication reconciliation. All patients underwent the hospitals standard medication reconciliation process. Patients were then randomly selected for pharmacist interview of home medications. Pharmacist collected medication information was reconciled with staff collected medication information as well as physician admission orders. Discrepancies were documented, discussed, and resolved with the physician. Results and conclusions will be presented.

IMPLEMENTATION OF PHARMACY SERVICES IN AN URBAN COMMUNITY HOSPITAL (B4), Jacob White. Swedish Medical Center, Seattle, WA (jacob.white@swedish.org) IRB approval not needed. To determine the impact of a pharmacist in the Emergency Department, a six week pilot project was launched. A pharmacist was assigned to the Emergency Department for 26 eight hour shifts. A daily tally sheet recorded the type and number of interventions made. The interventions were stored in an online database along with notes on select interventions. Cost avoidance was calculated using previously published cost data in the literature. The emergency department staffs perceived benefit of pharmacist coverage was assessed by electronic surveys emailed out both pre and post intervention. During the intervention period, 316 interventions were made, the most common intervention being professional inquiries. Preliminary results from the post intervention survey show strong staff support in favor of pharmacist coverage in the Emergency Department. Complete results and conclusions will be presented.

IMPROVING VENOUS THROMBOEMBOLISM ASSESSMENT AND PROPHYLAXIS RATES (B4). Linda Wong. Brent Albertson. Lance Muncey. Providence Sacred Heart Medical Center, Spokane, WA (Linda.wong@providence.org) IRB exempt. An evaluation at our hospital showed venous thromboembolism (VTE) prophylaxis adherence rates can be improved compared to current guidelines for hospitalized patients. The goal of this project is to develop a standardized screening tool that can be used for all admitted patients. Retrospective data was collected to determine the current adherence rates for VTE prophylaxis and readmission rates related to VTE events to identify specific service lines to target for improvement. Historical rates of VTE prophylaxis at our institution for patients readmitted within 90 days for a VTE event ranged from 47 to 67 percent depending on the type of event that occurred. With mandatory implementation of this screening tool our institution could potentially decrease our rate of VTE events by at least 50 percent based on published data showing the possible impact of a mandatory assessment program. Preliminary data at our institution suggests the need for a comprehensive standardized screening tool that can apply to any patient type for ease of use and compliance. Areas for pharmacy involvement will be reviewed and explored. Once experience with the screening tool is gained, staff specific education modules will be developed and implemented to promote compliance and understanding. Results and conclusions will be presented.

EVALUATION OF A CLINICAL PHARMACIST IN MANAGING HYPERLIPIDEMIA THROUGH TELEPHONE APPOINTMENTS (B4), Jennifer Yang. San Francisco VA Medical Center, CA (jennifer.yang2@va.gov) IRB approval pending. Cardiovascular disease is one of the most common and costly diseases in America. Elevated low density lipoprotein (LDL) level is a risk factor in the development of coronary heart disease, yet studies show that it remains poorly controlled. In 2005, a protocol for Collaborative Drug Therapy Management by Clinical Pharmacists was implemented in the Primary Care clinics at our institution. Under this protocol, a clinical pharmacist is utilized as an alternative to a physician in providing care for patients with hypertension, diabetes, and/or hyperlipidemia. During patient visits, pharmacists provide education regarding non pharmacologic and medication therapies, monitor for adverse events, order pertinent labs, and titrate or renew medications to help patients achieve their specific target goals. Subsequently, pharmacist run telephone visits for lipid management were introduced to help increase patient satisfaction and improve convenience. However, there has been no formal assessment of effectiveness. The objective of this study is to examine the efficacy of this pharmacist run telephone clinic. A retrospective chart review of patients seen between March 2009 and March 2011 will be conducted in order to assess mean reduction of LDL, mean number of visits to reach the specified LDL goal, and the mean length of follow up time before LDL goal is achieved. Results and conclusions will be presented.

IMPACT OF PHARMACIST INTERVENTION DURING DISCHARGE MEDICATION RECONCILIATION (B4). Jenni Yea. Michael Marr. Julie McCoy. Providence St. Peter Hospital, Olympia, WA (Jenni.Yea@Providence.org) Institutional Privacy Board approval pending. According to The Joint Commission, medication errors are the most frequent causes of preventable harm. About 12 to 17% of patients experience adverse drug events after discharge. National Patient Safety Goal 8 specifies that all medications be accurately and completely reconciled across the continuum of care. The objective of this project is to assess the impact of pharmacist intervention in reducing errors upon discharge medication reconciliation on three cardiology units of Providence St. Peter Hospital. Discharge documents from the hospital system for 94 patients were retrospectively reviewed for medication errors from October through November 2010. A high risk criterion to target patients at risk of medication errors was subsequently developed. A flow diagram was created to incorporate pharmacists into the discharge medication reconciliation process. A pilot was implemented in January 2011, with a target goal to provide the second verification of discharge medications for two to four high risk patients every week day and to intervene when necessary. Patient demographics and medication errors will be collected. Retrospective review of a similar cohort of patients discharged from the cardiology unit without pharmacist intervention will be reviewed for medication errors. Data from both groups will be compared and final results will be presented.

SAFETY OF INTRAVENOUS KETOROLAC USE IN POST-OPERATIVE INFANTS UNDER SIX MONTHS OF AGE (B4). Jun Zhang. Wenee Lopez. Childrens Hospital Central California, Madera, US (JZhang@Childrenscentralcal.org) IRB approved. The purpose of this study was to investigate the safety of using intravenous ketorolac in patients less than six months of age. A retrospective chart review was performed on surgical receiving ketorolac who were admitted into Childrens Hospital Central California (CHCC) from Aug. 2009 to Jan. 2011. A control group of patients of similar age, diagnosis, and ketorolac administration was also identified. The BUN/Scr, Hgb, Hct, Plt and the urine output (UOP) before and after the ketorolac (or surgery for the second group) for both groups were obtained. The changes in these lab values were compared using the students t-test. Inclusion criteria for the cohorts are: less than 6 months of age, no prior history of renal disease, Scr0.6mg/dL and/or BUN 15mg/dL before the surgery, Hgb10g/dL and/or Hct29%, Plt 150 x 103/mm3 before surgery. Exclusion criteria include: post-operative stay<48 hours, hematologic abnormalities, on any gastric suppressive treatment before surgery, on anticoagulation therapy before and/or after surgery. Results and conclusions will be presented.

B5 LongTerm,Geriatric orHospiceCare

A RETROSPECTIVE REVIEW OF HYPERTENSION MANAGEMENT IN A GERIATRICS PRIMARY CARE CLINIC (B5), Simon Ahn, Bradley Williams, Steven Tam. UC Irvine Medical Center, Orange, CA (slahn@uci.edu) IRB approval pending. Objective: This study aims to review the current management of hypertension in older adults to determine how geriatricians manage the condition in relationship to JNC-7 guidelines, and if their goals and strategies differ for the oldest-old and the young-old patients. Methods: A retrospective chart review of newly-established patients will be conducted, dividing patients into three groups, young-old (65-74 years), middle-old (75-84 years) and oldest-old (>85 years). Subjects will be those who established as new patients in 2009, and were followed for at least one year. Based on initial visit blood pressure measurements, patients within each group will be further subdivided into two groups, at target, defined as <140/90mmHg or <130/80mmHg for diabetes or CKD, or above target. Progress notes of each patient will be reviewed. Changes in blood pressure, medications, complaints of adverse effects and reasons for the change will be recorded and tracked. Data collected will be compared within and between patients of the 3 groups. Results and conclusion will be presented.

PHARMACOTHERAPY AND FALLS: A RETROSPECTIVE EXAMINATION OF MEDICATION USE AND INTERVENTIONS IN A HOME BASED PRIMARY CARE POPULATION (B5), Megan Bulas. Denver VA Medical Center, Denver, CO (Megan.Bulas@va.gov) IRB approved. The primary objective of this study was to determine if implementation of formal pharmacist recommendations regarding fall-associated medications would increase medication interventions and minimize the number of falls that occur within the management of home based primary care providers. For the purposes of this study, a formal pharmacist recommendation was one that was documented in a patients electronic medical record by a pharmacist in a fall-associated medication review note. A note was written for each patient upon admitting into the program, discharging from a hospital, experiencing a fall, or quarterly pharmacist review. This analysis compared a cohort of patients in the program during the first six months after implementation of the recommendations to a cohort of patients in the program during the same six month time period a year earlier. Additional outcomes that were evaluated included the number of medications used without a documented indication, the number of medications inappropriately dosed based on indication and/or patient factors such as organ impairment, and percentage of falls resulting in injuries, death, or hospital admissions. The study period was a total of 12 months over 2 years. Data was collected retrospectively using the electronic health record. Descriptive statistics were utilized for the data analysis. Results and conclusions will be presented.

PREPARING FOR THE AGING AMERICA: PHARMACIST INTERVENTIONS TO MINIMIZE ADVERSE DRUG EVENTS IN THE ELDERLYPATIENT POPULATION (B5), Jua Choi, Rita Shane, Hai Tran. Cedars-Sinai Medical Center, Los Angeles, CA (jua.choi@cshs.org) IRB approved. The study objective was to reduce potential adverse drug events in elderly patients through pharmacist evaluation and intervention. A recent study identified risk factors that increase adverse drug events in the elderly patient populations which include: age greater than 65 years, use of greater than 5 medications, and greater than 4 chronic conditions. Hospitalists referred 30 consecutive patients greater than 65 years and receiving greater than 5 medications to the pharmacist. The patients were seen by the pharmacist within 24 hours of referral. The pharmacist evaluated the patients electronic medical record, medications prior to and during admission, vital signs, laboratory data, social history, drug allergies, and anthropometrics. Potentially harmful drugs in the elderly were analyzed using the modified Beers list. The pharmacist provided recommendations to the physicians to reduce potential adverse drug events and optimize therapeutic regimens. The primary outcome measures were number of potential adverse events identified and prevented. Exclusion criteria were patients with palliative or hospice care involvement. Results and conclusions will be presented.

DONT BREAK A LEG: PHARMACIST INTERVENTION TO REDUCE THE USE OF HIGH RISK MEDICATIONS IN THE ELDERLY WITH A HISTORY OF FALLS OR HIP FRACTURES (B5), Nicholas Ferrarella. Kaiser Permanente, Anaheim, CA (nicholas.c.ferrarella@kp.org) IRB approved. Accidental falls in the elderly can lead to serious health consequences, including hip fractures. Numerous medications can cause side effects that precipitate falls. Three high risk classes in particular are tricyclic antidepressants, antipsychotics, and sleep agents. The study objective was to evaluate the effectiveness of a pharmacist intervention process in reducing the inappropriate utilization of these three high risk classes in the elderly with a history of falls or a previous hip fracture. Patients with an underlying psychotic disorder, such as schizophrenia or bipolar disorder, were excluded. A pharmacist intervention process, which included the development of a physician memo and therapeutic substitution form, was implemented to notify primary care providers of their qualifying patients in an attempt to discontinue or change these high risk medications to safer alternatives. Educational presentations were provided at selected physician department meetings. Patients who had their medications converted or discontinued received a patient letter and a mandatory patient consultation. The total number of patients on high risk medications pre and post intervention was evaluated. The results and conclusion from this project will be presented.

FEASIBILITY, JUSTIFICATION, AND CLINICAL DEVELOPMENT OF A HOSPICE CARE PROGRAM (B5), Michael Filtz, Dan Sageser, Scott Silverstein, Leigh DeMarco, Stephanie Sanders, Steve Kirkegaard. U of Utah, SLC, UT (michael.filtz@hsc.utah.edu) IRB approved. Hospice provides palliative care to patients that are expected to live less than 6 months. The benefits of hospice are an increased quality of life, a reduction in pain and suffering, and possibly a longer life. The benefits of hospice to hospitals and institutions include cost savings, a better work environment and improved provider and patient satisfaction. There is a national effort to advance and expand hospice and palliative care. Results from a new hospice service proposal will be presented. Included in the proposal will be: 1. Hospice service survey from the Huntsman Cancer Institute and peer institutions. 2. Gap analysis of the services currently offered and the additional resources that will be needed. 3. Business plan pro forma. 4. Clinical algorithms for pain, sedation, bowel, nausea, and respiratory management. 5. Implementation phase plan.

DEVELOPMENT OF AN EXPERIENTIAL INTERDISCIPLINARY LEARNING PROGRAM FOR MEDICAL AND PHARMACY STUDENTS (B5). Melissa Kim. University of Southern California, Los Angeles, CA (melissa.kim@usc.edu) IRB pending. The objective of this study was to develop an experiential interdisciplinary learning program involving medical and pharmacy students, and to compare student perceptions of interdisciplinary collaboration before versus after participation. Medical and pharmacy school faculty were identified who had a shared interest in interdisciplinary learning. The faculty identified the geriatric population as an ideal target group due to the prevalence of multiple medications, diseases, and physicians. Relationships were established between the university and local continuing care retirement communities that would allow pairs of pharmacy and medical students to interact with independent-living seniors. Protocols and syllabi were developed that included the roles and objectives for pharmacy students and medical students; pharmacy students provided medication reconciliation while medical students applied basic testing such as home safety screening and mental status exams. In the pilot phase, students visited seniors only one time. Experience from the pilot phase will be used to develop a longitudinal experience for all medical and pharmacy

students in which each pair of students will visit assigned senior citizens at least four times over the course of a year. A validated survey measuring student perceptions of interdisciplinary collaboration will be administered before and after participation in the program. The results will be discussed.

EVALUATION OF A NEW PHARMACIST AND NURSE PRACTITIONER COLLABORATIVE PATIENT MANAGEMENT PROGRAM (B5). Pamela Lincoln. Jeff Goad. USC School of Pharmacy, Los Angeles, CA (plincoln@usc.edu) IRB approval pending. The objective of this study was to characterize the interventions made by a pharmacist remotely collaborating with nurse practitioners (NP) to manage a panel of Medicare beneficiaries living in nursing homes and assisted living facilities. Two NPs were selected for their willingness to collaborate with a pharmacist. The pharmacist established a procedure for routinely assessing medication profiles and intervening through the NP for 103 patients. The pharmacist provided an initial baseline assessment of the patients using complete medication lists, laboratory data as well as NP progress notes. All recommendations and interventions were documented by the NP in the patients medical record. Patients were followed up and those interventions were also documented. Data collected includes patient demographics, type(s) of intervention and NP acceptance of recommendation. A personal interview will be conducted for each participating NP at the conclusion of the program to gain their feedback on the program. Results and conclusions to be presented.

IMPACT OF A PHARMACIST PRACTICE PROTOCOL IN HOSPICE CARE (B5), Michelle Moon. Kaiser Permanente Medical Care Program, Redwood City, CA (michelle.e.moon@kp.org) IRB approval not needed. In 2008, 2.5 million Americans died from all causes and 900,000 of those received hospice care. The goal of hospice care is to provide the best quality of life and comfort for patients at the end of their lives including pain, symptom, psychological, and emotional support. Pharmacists especially can play a crucial role in the medication management of hospice patients. A new hospice pharmacist practice protocol was implemented at Kaiser Permanente Redwood City in March 2010. Under the protocol, pharmacists have authority to initiate and adjust medications within a wide range of therapeutic categories for hospice care. The objective of this study is to evaluate the impact of this newly established pharmacist protocol to the hospice care program by specifically looking at pharmacist interventions, time savings to the hospice staff, and drug cost savings. Pharmacist interventions will be evaluated by performing a retrospective chart review to compile and categorize all interventions performed. Time savings will be evaluated by measuring time spent on medication requests by the hospice staff and comparing results on days the pharmacist works and does not work. Drug cost savings will be evaluated by measuring interventions regarding appropriate day supply. Final results will be presented and may be used to support the expanded role of pharmacists in hospice care.

DOCUMENTATION OF HOME BASED PRIMARY CARE (HBPC) PHARMACIST INTERVENTIONS (B5). Kara Wong, Virginia Krause, Bridget Kaufmann. Department of Veterans Affairs Puget Sound, Seattle, WA (Kara.Wong3@va.gov) IRB approved. The objective of this study is to describe the HBPC patient population and the scope of the clinical pharmacist in the interdisciplinary team by exploring and documenting current HBPC pharmacist activities. Patients will be included in this study if they are enrolled in HBPC during the study period (June 2009 through September 2010) and receive the required medication reviews. Aggregate, demographic, and clinical data will be obtained from Computerized Patient Record System medical records via retrospective chart review. Primary endpoints include percent of accepted recommendations and medication appropriateness index scores upon program enrollment and 90 day review. Secondary endpoints include types of recommendations, recommendations by disease state, and disease-specific recommendations for diabetes management. The Students t-test or the 2-tailed Wilcoxon signed-rank test will be utilized for data analysis. Results and conclusions will be presented.

CLINICAL PHARMACIST MEDICATION REVIEWS: CONTRIBUTIONS TO MANAGEMENT OF HOME BASED PRIMARY CARE VETERANS (B5). Janine Wu. Jennifer Ho. Jaime Chew. Charles King. VA Northern California Health Care System, Mather, CA (Janine.Wu@va.gov) IRB approved. Clinical pharmacists play a key role as part of the home based primary care (HBPC) multidisciplinary team through conducting medication reviews of enrolled veterans. The study focuses on illustrating the significance of the clinical pharmacists involvement through assessment of the type and number of interventions recommended and determination of the acceptance rate of recommendations. Veterans enrolled into HBPC at McClellan and Martinez within the study time frame underwent retrospective CPRS chart review for tabulation of recommendations regarding efficacy of therapy, side effects of medications, monitoring labs, pharmacotherapy assessments, pharmacokinetic dose adjustments, elderly dose adjustments, and medication reconciliation. Acceptance rates of the recommendations were also determined and differentiated as accepted, declined, or no response. Furthermore, comparisons of interventions between McClellan and Martinez were assessed. As the patient population utilizing HBPC continues to grow, the subsequent increase in demand for medication reviews by the clinical pharmacy staff will need to be met. Results and conclusions will be discussed.

B6 PediatricorGender SpecificCare

A COMPARISON OF TWO SURFACTANTS IN THE TREATMENT OF NEONATAL RESPIRATORY DISTRESS SYNDROME (B6). Iona Alabado, Fred Nishioka. Lucile Packard Childrens Hospital at Stanford, Palo Alto, CA (ialabado@lpch.org) IRB exempt. Background: Respiratory Distress Syndrome (RDS) is the leading cause of infant mortality in the United States. Over 80,000 babies are diagnosed with RDS every year and approximately 60 to 80% of infants born before 28 weeks gestational age will develop it. Currently, exogenous surfactants are the standard of care and have been shown to dramatically decrease infant mortality. Objective: The primary objective of this study is to compare the differences in efficacy and cost between two commercially available surfactant preparations, beractant and poractant alfa, when used to treat neonates with RDS. Methods: A drug inquiry report will be executed from the Pharmacy Departments electronic database to populate a list of all patients who have received one or more doses of either beractant or poractant alfa. From this list, only patients matching eligibility criteria will be selected for analysis. Eligibility criteria includes: neonates < 28 days old, with RDS or at high risk of developing RDS, without cardiac or other congenital anomalies. Data to be collected includes: age, gestational age, weight, drug administered, dose administered, number of doses administered, time between doses, and patient course (PIP, MAP, time to extubation, PaO2, FiO2). Once collected, data will be analyzed and differences between the two treatment groups will be identified. The results of this study will be presented.

SAFETY AND EFFICACY OF VARIOUS CONCENTRATIONS OF HEPARIN FLUSHES USED FOR LINE PATENCY OF CENTRAL AND PERIPHERAL CATHETERS IN PEDIATRIC PATIENTS (B6). Christine Bang. Allison Jun. CHOC Childrens, Orange, CA (kbang@choc.org) IRB approval pending. There is no consensus or recommendation on the type of flushing solution used in pediatric patients to maintain line patency. CHOC Childrens has traditionally used low-dose heparin (10 units/mL) to flush peripheral venous access catheters (PVAC) and high-dose heparin (100 units/mL) to flush central venous access catheters (CVAC). Starting March 1, 2011 CHOC Childrens will implement a hospital-wide policy to change current flushing solutions to normal saline for PVACs and heparin 10 units/mL for all short-term, non-tunneled CVACs. The hypothesis of this retrospective and prospective study is that there will be no significant difference in the rates of line occlusion once the new policy is in place. The study group will include all patients 18 years old with a PVAC or CVAC at CHOC Childrens after March 1. Every study patient will be matched with a historical control patient according to weight categories. The primary endpoint is duration of line use. Secondary endpoints include any intravenous complications due to normal saline or heparin flushes. A power analysis will be conducted retrospectively and a two-sided T-test will be used to compare the rates of line occlusion between the two groups. Statistical significance will be defined as a p-value of 0.05. Results and conclusions will be presented.

CONTINUOUS PENTOBARBITAL FOR REFRACTORY STATUS EPILEPTICUS (RSE) IN CHILDREN (B6), Michael Barberio, Pamela D Reiter. The Childrens Hospital, Aurora, CO. (Barberio.michael@tchden.org) IRB approved. Refractory status epilepticus, defined as seizure activity that persists despite multiple antiepileptic drugs, is associated with high morbidity and mortality. Continuous infusion pentobarbital has been used to manage refractory status epilepticus, despite a paucity of data. Therefore, the specific aims of this retrospective medical chart review will be to describe: (1) pentobarbital treatment regimens, (2) adverse events associated with therapy, and (3) clinical response/outcomes. We will review the records of all a patients treated with continuous pentobarbital for status epilepticus from January 2007 through January 2011. Patient data will be stratified and analyzed based on etiology of seizures (traumatic/ non traumatic). Descriptive statistics (mean s.d., or percent, as appropriate) will be used to characterize study subjects, treatment regimens, and treatment tolerance. Logistic regression analysis will be performed to assess the predictive ability of both patient and drug regimen factors on the achievement of positive outcomes (defined as no new neurologic deficit in patients with previous seizure history and seizure control in patients with traumatic and infective etiologies). A total of 38 children met initial criteria for chart review. Six patients were excluded because they received pentobarbital for reasons other than RSE, leaving a total of 32 patients for analysis. Results and conclusions will be presented.

RETROSPECTIVE EVALUATION OF APPROPRIATE DURATION OF INTRAVENOUS ANTIBIOTIC THERAPY FOR ACUTE EXACERBATION OF CYSTIC FIBROSIS (B6), Whitney Bennett, Jeffery Zobell. Primary Childrens Medical Center, Salt Lake City, UT (whitney.bennett@imail.org) IRB approved. The study objective was to evaluate the duration of intravenous antibiotic therapy for pulmonary exacerbation in hospitalized pediatric cystic fibrosis patients. This was a retrospective, observational study which utilized data obtained from medical records of an integrated health system, as well as the Cystic Fibrosis Foundation Patient Registry from January 1, 2006 to July 31, 2010. The study included patients from the Intermountain Cystic Fibrosis Pediatric Center admitted to Intermountain Primary Childrens Medical Center with a diagnosis of cystic fibrosis, age 6-18 years, for pulmonary exacerbation as determined by physician. Inclusion criteria was admission to the hospital for 14 days (plus/minus 4 days), treatment with combination therapy intravenous antibiotics (antipseudomonal beta-lactam and aminoglycoside), and a minimum of 3 PFTs for the admission. Exclusion criteria was no diagnosis of cystic fibrosis, age less than 6 years or greater than 18 years, or less than 3 PFTs for admission. Primary outcome was the percentage of patients who returned to baseline pulmonary function (FEV1,FVC) at 7 versus 14 days therapy. Secondary outcomes included median FEV1 percent predicted and median FVC percent predicted at both 7 and 14 days, time to next exacerbation, improvement in nutrition status from baseline (BMI), antibiotic susceptibility data (antibiogram), and appearance

of new microorganisms on culture. Results and conclusions will be presented.

EVALUATION OF VANCOMYCIN DOSING IN HOSPITALIZED PEDIATRIC PATIENTS (B6). Allyson Berg. The Childrens Hospital, Aurora, CO. (berg.allyson@tchden.org) IRB approved. The purpose of this study is to provide a correlation between age-specific vancomycin dosing for pediatric patients and serum vancomycin trough concentrations of 15 mcg/mL or greater. This retrospective chart review included all patients with normal renal function from age 31 days to 16 years old who were administered intravenous vancomycin and had a serum vancomycin trough concentration of 15 mcg/mL or greater documented between April 2006 and September 2010. Patients were identified in the electronic medical records database. Patients were excluded from the study if they had abnormal renal function based on their age-specific serum creatinine. The data was collected using the Research Electronic Data Capture database. Statistical analysis was performed using SAS V9.2 with the assistance of a biostatistician. Results and conclusions based on 500 patient encounters will be presented.

PROCEDURAL SEDATION IN THE NEONATAL INTENSIVE CARE UNIT USING PROPOFOL (B6), Christine Betz, Robert Kiley, David Nash. Memorial Health System, Colorado Springs, CO (Christine.betz@memorialhealthsystem.com) IRB approved. This study is a prospective, single-center, openlabel trial to determine if the use of propofol for procedural sedation in term neonates results in a decrease in number of ventilator days. Inclusion criteria include infants > 37 weeks of age undergoing laser eye surgery or inguinal hernia repairs. Patients undergoing these procedures from November 1, 2010 to April 30, 2011 will be identified and consented to undergo procedural sedation using propofol. The number of postoperative ventilator days, cumulative doses of anesthetic medications used, as well as vital signs recorded during anesthesia will be reviewed and compared to a similar control group undergoing the same procedures. The data from the control group will be compared to that of the propofol group and analyzed to determine the safety and efficacy of propofol for use in procedural sedation in the neonatal population. Results and discussion are currently pending and will be presented.

AN ANALYSIS OF IMPLEMENTING A STATUS EPILEPTICUS ALGORITHM IN A PEDIATRIC EMERGENCY DEPARTMENT (B6). Kathryn Bridger, Eric Harvey, Daniel Pak. Seattle Childrens Hospital, Seattle, WA (kathryn.bridger@seattlechildrens.org) IRB approved. Status epilepticus is a medical emergency that requires medications to be administered in an appropriate sequence and a timely fashion. The study objective was to determine if standardizing the treatment of convulsive status epilepticus in the emergency department would decrease the time to seizure termination. The intervention included implementation of a treatment algorithm and a matching CPOE orderset. The algorithm was designed with pharmacy, neurology, nursing, and emergency department input. Intranasal midazolam instead of rectal diazepam was used as first line therapy for patients without intravenous access. ICD-9 codes were used to identify patients who were treated for status epilepticus from June 2009 to June 2010 and for two months following algorithm implementation. Exclusion criteria included patients with nonconvulsive or mixed convulsive, nonconvulsive status epilepticus and patients whose status epilepticus management was initiated at an outside hospital. The following data was collected: medications administered prior to hospitalization, initial anticonvulsant medications and doses administered in ED or during hospitalization, need for patient care escalation (admission from ED to observation, medical unit, or intensive care unit), time to seizure termination, seizure recurrence within immediate

24 hours and time to recurrence, need for intubation, and mortality rates. Results will be presented and discussed.

COMPARISON OF SERUM VANCOMYCIN LEVELS DRAWN VIA PERIPHERAL VENIPUNCTURE OR CAPILLARY AND CENTRAL VENOUS CATHETERS (B6). Ashley Clark, Childrens Hospital Central California, Madera, CA (aclark2@childrenscentralcal.org) IRB approved. The objective of this study was to determine the congruency of serum vancomycin levels obtained from commonly used central venous catheters (CVCs) and direct venipuncture or capillary stick (peripheral). This was a prospective study to assess whether or not venipuncturederived blood samples are routinely necessary for therapeutic drug monitoring among pediatric patients with CVCs. Participating patients had central and peripheral blood samples obtained within 10 minutes of each other. Patients were asked to provide only one pair of blood samples during the study. Inclusion criteria was age 18 years and younger with a CVC (Mediport, Broviac, or PICC) receiving vancomycin per pharmacy protocol. Patients were excluded if they were hemodynamically unstable or the CVC device was known or suspected to be broken or dysfunctional. A CVC level 10 percent above or below the peripheral level was considered to be significantly different. The results and conclusions will be presented and discussed.

APHARMACISTRUNMONITORINGPROTOCOLFOR TOBRAMYCININPEDIATRICPATIENTSWITHCYSTICFIBROSIS (B6),SaraCook.SeattleChildrens,Seattle,WA (sara.cook@seattlechildrens.org)IRBapproved. Theobjectiveofthisstudywastoevaluatewhethera pharmacistrunmonitoringprotocolcouldimproveoutcomes forpediatricpatientswithcysticfibrosis(CF)whorequire antimicrobialtherapywithintravenoustobramycin.Patients withCFoftenexhibitunusualkineticresponsestomedications, andthusrequireatypicaldosingregimensandclosemonitoring, especiallyforthosemedicationswithnarrowtherapeutic indices.Appropriateintravenoustobramycindosingisassessed basedontheareaunderthecurve(AUC),whichrequirestwo serumlevelstobedrawnatspecifictimes.Giventhe uniquenessoftheseregimens,therapyisofteninitiatedatthe wrongdoseorinterval,andmonitoringlevelsarefrequently missedorinappropriatelytimed.Duringthestudyintervention period,ordersforCFpatientsfortobramycinwereevaluatedby theprincipalinvestigatorandrecommendationsforchangesin doseormonitoringweresubmittedtotheprescriberpriorto theadministrationofthefirstdose.Theinterventionalso includednursingreminderswhenlabdrawsweredue.Pre interventionperioddatawasassessedretrospectively,and outcomeparameterswerecomparedtothedatacollected duringtheinterventionperiod.Primaryoutcomesmeasured werenumberofappropriatestartingregimens,missedor mistimedlevels,andtimetotherapeuticAUC.Patientswere

includediftheyhadadiagnosisofCF,wereadmittedtothe hospital,andhadanorderforintravenoustobramycin.Results andconclusionswillbepresented.

CORTISOL LEVEL DETERMINIG INDOMETHACIN USE FOR NEONATAL INTRAVENTRICULAR HEMORRHAGE PROPHYLAXIS: RETROSPECTIVE STUDY (B6), Wendy Dinh, Helen Chen, Cynthia Schultz. Naval Medical Center, San Diego, CA (wendy.dinh@med.navy.mil) IRB Approval received. This study will be the first clinical trial to examine the use of cortisol level in determining which neonates are candidates for safe administration of indomethacin prophylaxis for intraventricular hemorrhage. It is a retrospective, observational, single center study that evaluates the effectiveness of the indomethacin prophylaxis protocol at Naval Medical Centers neonatal intensive care unit, in reducing spontaneous intestinal perforation rate associated with indomethacin administration. The study will evaluate neonates who were administered indomethacin for intraventricular hemorrhage prophylaxis before and after the indomethacin protocol implementation. The primary outcome measure is the perforation rate. Demographic data such as sex, gestational age, weight, ethnic group, maternal antenatal steroids, cause of admission, and comorbidities will be collected. Demographic data will be represented as rates with confidence intervals for categorical data and means with standard deviations for continuous data. The beforeversus-after rates will be tested for statistical difference using Fishers exact test of a contingency table. Results and conclusion will be presented.

PHARMACOKINETICS (PK) AND PHARMACODYNAMICS (PD) OF VALPROIC ACID IN CHILDREN WITH ABSENCE EPILEPSY (B6), Jonathan Faldasz, Edmund Capparelli, Tracy Glauser. Rady Childrens Hospital, San Diego, CA (jfaldasz@rchsd.org) IRB approved. The study objective was to determine valproic acid (VPA) monotherapy pharmacokinetics and determine correlations of platelet reduction and weight gain with VPA exposure and treatment duration in children with absence epilepsy. Children ages three to thirteen years diagnosed with absence epilepsy were initiated on VPA (Depakote) 10 mg/kg/day, with doses titrated up incrementally until freedom from seizures was attained (maximum 60 mg/kg/day) or until discontinuation of therapy. Weight, platelets and serum free and total VPA levels were measured every four weeks for duration of therapy up to two years. A total of 211 patients were included for analysis. The median age at initiation of therapy was 7 years 7 months; 7 children (3%) were less than 4 years old, 105 (50%) were 4 to less than 8 years old, 91 (43%) were 8 to less than 12 years old, and 8 (4%) were 12 to 13 years old at initiation of therapy. The average VPA dose needed to achieve seizure suppression was 27.8 mg/kg/day. A population PK analysis using NONMEM revealed a VPA V/F of 0.19 L/kg (38.7% between subject variability), and VPA CL/F of 0.025 L/h/kg (25.4% between subject variability). PK parameters and duration of VPA therapy will be correlated with weight gain and platelet changes. PD analyses and conclusions will be presented.

EXTEMPORANEOUS ORAL FORMULATIONS: STANDARDIZING THE OLD AND INTEGRATING THE NEW Ha-Mill Hwang, Lisa Musick, Julie Wilson-Ganz. UC San Francisco Medical Center, San Francisco, CA (HaMill.Hwang@ucsf.edu) IRB not needed-no human subject data. The pediatric population is three times more susceptible to medication errors than adults. Weight based dosing may require multiple concentrations of the same oral extemporaneous formulation (EF). These nonstandardized oral formulations increase the risk of pediatric adverse events. We reviewed our medical centers EF files and found outdated references, incomplete storage and stability data, and multiple concentrations for the same EF. We sought to standardize and update our oral EF files and to implement a process in which new formulations could be safely added. We reviewed each EF for the following criteria: drug name, concentration, ingredients, equipment, preparation instructions, and information regarding storage and stability. All criteria had to have supporting references. We performed a literature search to update EFs lacking the above listed criteria and to integrate oral formulations not previously identified. We tracked the changes made to existing preparations and the number of new EFs. The old EF files contained 276 formulations of which 188 were oral preparations. Upon completing our

analysis, we will determine the number of 1) oral drugs with different concentrations, 2) preparations without proper sourcing, 3) formulations without storage information, 4) formulations lacking expiration data, and 5) drugs with standardized concentrations. Results and conclusion will be presented.

REVIEW OF ADVERSE EVENTS RELATED TO PSYCHOTROPIC MEDICATION USE IN PEDIATRICS (B6). Zanette Kanani. The Childrens Hospital, Denver, CO (kanani.zanette@tchden.org) IRB approved. The objective of this study is to provide an analysis of psychotropic medication use within the pediatric population and establish correlation between current practice and adverse events. The aims of this study are to examine if there is a direct correlation between the prevalence and incidence of adverse events with each additional psychotropic medication added to a patients regimen, as well as to review if the incidence and severity of adverse events are predictable and dependent on dosing. This is a retrospective, systematic medical chart review from July 2009 through July 2010 of all patients less than or equal to 17 years old seen in the emergency room with at least one psychotropic medication (as needed medications will be excluded) reported on their medication reconciliation report. During the study period, 1,974 pediatric patients with one or more home psychotropic medications were seen in the emergency room. From the number of eligible patients, approximately 500 patients charts were reviewed for inclusion in this study. The data collected and reviewed included Global Assessment of Functioning (GAF) score; psychotropic medication information; and metabolic, cardiovascular, cerebrovascular, neurologic and miscellaneous adverse event data. The data will be analyzed using the Poisson regression model with the assistance of the Research Consulting Laboratory. Results and conclusions will be presented.

IMPLEMENTING STRATEGIES TO IMPROVE THE IMPACT OF EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO): A SINGLE CENTER RETROSPECTIVE REVIEW (B6), Nancy Kang, Anh Vuong Ly. Loma Linda University Med Ctr, Loma Linda, CA (nkang@llu.edu). IRB approval received. A circulatory modality, extracorporeal membrane oxygenation (ECMO) provides prolonged mechanical cardiopulmonary support in neonatal, pediatric and adult populations. Originally ECMO was used intraoperatively to facilitate cardiac surgery, but more recently it has shown utility in the ICU setting for more sustained support, particularly in severe acute respiratory and cardiac failure. The advent of technological advances, including heparincoated circuits and polymethylpentene (PMP) oxygenators, as well as pharmacological agents, such as antithrombin III, has improved the application of ECMO. In 2010, a novel antithrombin III protocol was implemented at Loma Linda University Medical Center (LLUMC). The objective of this study is to determine the clinical and economic impacts associated with the use of antithrombin III. Primary outcomes include (1) utilization of antithrombin III, (2) frequency of circuit replacements, and (3) ECMO survival rates. Secondary outcomes include the incidence of adverse effects and economic impacts. This retrospective chart review will include neonates to adolescents who have undergone ECMO at LLUMC from January 2005 to March 2011. Data analysis will include the clinical and economic impact before and after the implementation of the antithrombin III protocol. Results will be presented.

EFFICACY OF DORNASE ALFA VERSUS 7% HYPERTONIC SALINE TO TREAT ATELECTASIS IN MECHANICALLY VENTILATED PATIENTS (B6), Jessie Kim. Childrens Hospital Central California, Madera, CA (jkim2@childrenscentralcal.org) IRB approved. The study objective was to compare the efficacy of dornase alfa with hypertonic saline to treat atelectasis in mechanically ventilated patients in the pediatric intensive care unit. Data was collected through a retrospective chart review of patients on either dornase alfa or 7% hypertonic saline. Patients chest xrays were evaluated by the same physician and respiratory therapist to determine resolution of atelectasis. The primary outcome was the time to resolution of atelectasis compared to duration of treatment using either of the study medications. The secondary outcome included the time to resolution of atelectasis compared to different ranges of duration of treatment using dornase alfa (=/< 3 days, 4-7 days, and >7 days). Inclusion criteria included admission into the pediatric intensive care unit and mechanical ventilation for > 24 hours. Exclusion criteria included diagnosis of cystic fibrosis, preexisting nonpulmonary conditions that could prolong length of ventilation, and congenital anatomical lung/airway abnormalities. The results and conclusions will be presented.

EVALUATION OF RISK FACTORS ASSOCIATED WITH CLOSTRIDIUM DIFFICILE INFECTION (CDI) IN HOSPITALIZED PEDIATRIC PATIENTS (B6). Allison Lam, Susan McKamy. Long Beach Memorial Medical Center, Long Beach, CA. (alam@memorialcare.org) IRB approval received. Clostridium difficile outbreaks in the recent years have affected populations not previously recognized to be at risk for C. difficile infection (CDI), including children. Risk factors that may predispose patients to CDI include prolonged hospitalization, severe underlying diseases, antibiotic use, exposure to acid suppressing agents, and gastrointestinal procedures, but these factors have not been investigated in studies involving pediatric patients. The objectives of this study are to: (1) identify and describe potential risk factors for developing CDI in pediatric patients; and (2) review treatment options and patient outcomes to describe current practice in management of pediatric CDIs. A retrospective case control study was conducted in patients 1 to 17 years of age admitted to Miller Childrens Hospital between August 2008 and April 2011. Patients less than 1 year and greater than 18 years of age, asymptomatic carriers of C. difficile, cystic fibrosis patients, and patients with recurrent CDI were excluded from the study. Case subjects were identified as patients with positive C. difficile toxins during hospitalization. Control subjects were patients selected from the general hospital population in a 1:1 ratio with case subjects. Demographic data and potential risk factors for CDI were evaluated. Results and conclusions will be presented.

THE EFFECTS OF CYSTEINE ON METABOLIC ACIDOSIS IN NEONATES (B6). Helen Le. Rita Jew. Childrens Hospital of Orange County, Orange, CA (hle@choc.org) IRB approval received. Premature neonates are unable to endogenously synthesize amino acids, such as cysteine, due to immature liver enzymes, which brought forth the rationale for supplementing cysteine in their parenteral nutrition (PN). Another advantage of adding cysteine to PN is due to its acidic property that allows for the addition of more calcium in the PN, which indirectly promotes growth in neonates by enhancing bone mineralization. However, the major drawback of adding of cysteine to PN is the increased risk for metabolic acidosis in neonates, which may cause disturbances in cerebral blood flow, increased peripheral vascular resistance, periventricular hemorrhage, and decreased myocardial function. The hypothesis of this observational cohort study is that removal of cysteine from PN will reduce the risk of metabolic acidosis in neonates. Patients in the neonatal intensive care unit will be included in the study if they have received PN from day 1 of life during the study period of January 1, 2010 to June 30, 2011. The study will compare prospectively collected data of neonates without cysteine supplementation in their PN for 2 weeks and the historical, retrospective weightmatched control group of neonates supplemented with cysteine in their PN. Differences between the control and study groups will be analyzed using the two-sample independent t-tests. Statistical differences will be defined as a p-value of < 0.05. Results will be discussed.

STANDARDIZATION OF INTRAVENOUS CONCENTRATIONS IN THE NEONATAL INTENSIVE CARE UNIT (B6). Shirley Lee. Lisa Musick. Julie Wilson-Ganz. Sarah Scarpace Lucas. UCSF Medical Center, San Francisco, CA (shirley.lee@ucsf.edu). IRB approval is not needed. To reduce medication errors and enhance patient safety, this project is designed to assess the utilization of intravenous (IV) medications in neonatal patients at a pediatric hospital and to standardize concentrations of these medications. In a retrospective data analysis, 6 months of data (May 1 thru October 31, 2010) was collected from using the hospitals pharmacist order entry system. Consisting of intravenous continuous infusions, intermittent infusions, and intermittent bolus injections, our data included 16,365 IV medications that were dispensed. There were 1595 doses (9.7%), representing 29 different drugs, that were administered with an unmeasurable volume of less than 0.2 mL, resulting in the proposed addition of 25 new standard concentrations. We are also proposing to change 5 concentrations and delete 40 concentrations to minimize the number of concentrations available. Standardizing concentrations of the IV medications used in the ICN is expected to identify potential outsourcing opportunities and minimize calculations and double-checks previously required. Additionally, the list of standard concentrations will be built into the development of infusion libraries for SmartPump technology. Final results and conclusions will be discussed.

IMPLEMENTATION AND EVALUATION OF CRITERIA FOR USE OF PALIVIZUMAB FOR RESPIRATORY SYNCYTIAL VIRUS PROPHYLAXIS (B6). Linh Long, Michael Stander, Jessica Thompson. Renown Regional Medical Center, Reno, NV (llong@renown.org) IRB approved. The objective of this study is to determine the clinical and pharmacoeconomic benefit of screening pediatric patients for palivizumab eligibility using an order set created using the 2009 American Academy of Pediatrics RSV prophylaxis guidelines. This is a retrospective chart review, the study population will include any child admitted to Renown Regional Medical Center between November 2009 to April 2010 or November 2010 to April 2011 that was less than or equal to 24 months of age at discharge. Patients administered palivizumab will be identified. Palivizumab administration will be defined as documentation of administration on the medication administration record. RSV diagnosis will be defined by an ICD 9 code (79.6, 466.11, 480.1) or by positive RSV laboratory result. Data will be gathered using the electronic medical record of the health system. RSV season 2009/2010 will be compared with 2010/2011 to determine if there was an increase in administration of clinically appropriate doses of palivizumab according to the 2009 American Academy of Pediatrics RSV prophylaxis guidelines. A Z test will be utilized for this comparison.

Pharmacy cost will be compared from 2009/2010 to 2010/2011 with a T test after adjusting for census. RSV admission and readmission rates for 2009/2010 and 2010/2011 will be compared with a Z test for proportions. Results and conclusions will be presented.

USE OF DROPERIDOL IN THE MANAGEMENT OF HYPEREMESIS GRAVIDARUM AND ITS EFFECTS ON PREGNANY AND INFANT OUTCOMES (B6). Stella Min. Kimey Ung. Gerald Briggs. Robert Tindula. MemorialCare Center for Women, Millers Children Hospital, Long Beach, CA (smin@memorialcare.org) IRB approval is pending. The study objective was to identify and describe the effects of droperidol in the management of hyperemesis gravidarum and its effect on the mother and the infant. This study was a retrospective chart review. Patients admitted to MemorialCare Center for Women who were diagnosed with hyperemesis and who received droperidol during July 2008 - October 2010 were studied. Data were collected using a standard form and included maternal demographics, disease characteristics, droperidol therapy, and the pregnancy and neonatal outcomes. Pharmacy based records and the hospitals electronic medical record (EPIC) were used to obtain the data. Mainly descriptive analysis was used in this study. Statistical analysis was performed if applicable. Results and conclusions will be presented.

ACHIEVING VANCOMYCIN THERAPY TARGETS IN PEDIATRIC PATIENTS (B6). Stephanie Natale, Jennifer Le, Gale Romanowski, Bill Murray, Edmund Capparelli. Rady Childrens Hospital, San Diego, CA (snatale@rchsd.org) IRB approved. Vancomycin is the drug of choice for methicillinresistant staphylococcus aureus (MRSA) infections. No consensus has been reached in what should be the primary target for vancomycin therapy in pediatric patients. An AUC24/MIC >400 is associated with the most optimal outcomes in adults with invasive MRSA infections but full AUC measurements are not practical to measure clinically. While it has been suggested that vancomycin troughs of 1520 mg/L are required to ensure an AUC24/MIC >400 in adult patients, it is unclear if this correlates to children. The purpose of this study is to establish the ability of initial and subsequent pediatric dosing to achieve vancomycin trough and estimated AUC exposure targets. Medical records of 45 MRSA culture positive patients >3 months and <20 yrs and received >48 hrs of vancomycin were retrospectively reviewed. Vancomycin PK data were fit to a two compartment model and AUC determined from dose/(CL*tau). The mean age was 8 6 yrs, weight 28.3 19.9 kg, and height 112.7 38.0cm. Baseline infection characteristics included an average WBC 13.3 7.5, CRP 26.1 28.0, Tmax 38.1 1.3, and SCr 0.5 0.3. The average initial dose of vancomycin was 37.7 7.5 mg/kg/day with a mean first trough of 8.9 6.2 mg/L. 4% of patients had troughs between 15-20 mg/L with initial dosing. 15 patients developed nephrotoxicity (increase in SCr of >0.5

or 50% increase over baseline). AUC target achievement and a comparison with trough targets will be presented.

CONTINUOUS HYDROMORPHONE FOR PAIN AND SEDATION IN THE MECHANICALLY VENTILATED CHILD (B6). Jennifer Ng. The Childrens Hospital, Aurora, CO (ng.jennifer@tchden.org) IRB approved. Provision of adequate analgesia and sedation for critically ill children is a fundamental practice in the intensive care unit. Despite limited data, continuous intravenous (IV) hydromorphone has been used as a viable opioid alternative to facilitate patient-ventilator synchrony, improve oxygenation and provide patient comfort. Therefore, the specific aims of this retrospective medical chart review study are to (1) describe the current use of continuous IV hydromorphone in the mechanically ventilated infant and child, specifically: overall place in therapy, dosing requirements (initial dose, maximum dose, time from initial to maximum dose, duration of therapy), and concomitant pain and sedation therapy; and (2) to describe efficacy and tolerance of currently prescribed hydromorphone therapy by examining patient-specific pain and sedation scores and analyzing possible adverse drug events related to therapy. We will review the charts of all children (0 days to less than 18 years of age) who received continuous IV hydromorphone during a 5.5 year study period (June 2006- December 2010). Patients will be excluded from this study if they received hydromorphone via patient controlled analgesia or as an epidural. Descriptive statistics (mean s.d., or percent, as appropriate) will be

used to characterize study subjects, treatment regimens and treatment efficacy/tolerance. Based on the initial computer screening criteria, a total of 125 patients are eligible for primary chart review. Results and conclusions will be presented.

RETROSPECTIVE STUDY OF ANTIBIOTIC USE IN SUSPECTED VENTILATOR-ASSOCIATED PNEUMONIA IN CHILDREN (B6). Thomas Peterson, Jared Olson, Gitte Larsen, Emily Thorell, Andrew Pavia. Primary Childrens Medical Center, Salt Lake City, UT. (thomas.peterson@imail.org) IRB approved The purpose of this study was to define the current practice of antibiotic management of suspected ventilatorassociated pneumonia at a free standing childrens hospital. In this retrospective observational study, patients were identified for retrospective chart review from the Intermountain Electronic Data Warehouse. All PICU patients admitted to Primary Childrens Medical Center between January 2010 and August 2010 and receiving mechanical ventilation for at least 48 hours that had a protected brush or bronchoalveolar lavage culture were evaluated for study inclusion. Patients greater than 18 years of age were excluded. Data collection included the following: sex, weight, age, PICU days, antibiotic use, ventilator days, all culture results, chest x-rays, temperature, complete blood cell count with differential, viral respiratory panel, renal function tests, and hospital length of stay. Pathogens and susceptibilities from positive respiratory cultures were used to evaluate the adequacy of empiric antibiotic therapy for suspected VAP. Adequacy was defined as at least one empiric antibiotic with in vitro activity against the identified pathogen(s). We also evaluated adherence to the CDC 12 step campaign to prevent antimicrobial resistance, focusing on targeting the pathogen, not treating contamination or colonization, and

stopping treatment when infection is cured or unlikely. Results and conclusions will be presented.

EVALUATION OF ETHANOL LOCKS AS A PROPHYLACTIC THERAPY FOR CATHETER RELATED BLOODSTREAM INFECTIONS IN PEDIATRICS (B6), Carolyn Victoria, Susan McKamy. Long Beach Memorial Medical Center, Long Beach, CA (cvictoria@memorialcare.org) IRB approval received. The study objective was to determine the effect of ethanol lock as a prophylactic therapy on the rates of catheter related bloodstream infections (CRBIs) and the number of repeat hospitalizations due to CRBIs in pediatric patients aged 6 months to 18 years. Rates of CRBIs were expressed as the number of CRBIs per 1000 catheter days. Each patient was used as his or her own control where clinical outcomes that occurred prior to ethanol lock therapy were compared to outcomes that occurred post ethanol lock therapy. In addition, the study evaluated the optimal frequency of administration for ethanol locks (number of times per week) and the dwell time (number of hours per day) necessary to prevent a CRBI without compromising the integrity of the catheter. Lastly, the study examined potential adverse events caused by the prophylactic use of ethanol locks. Medical and laboratory records were reviewed retrospectively and relevant information was documented on a standardized data collection sheet. Patients who received ethanol lock as a prophylactic therapy at any point during the period of October 2009 through October 2010 were included in the study. All patients had a silicone central venous catheter with at least one CRBI prior to the initiation of ethanol lock therapy. Results and conclusions will be presented.

COMPARISON OF PORACTANT ALFA TO BERACTANT IN THE TREATMENT OF NEONATAL RESPIRATORY DISTRESS SYNDROME (B6). Yinan Wang, April Bowen, Randy Nederhoff. Presbyterian Healthcare Services, Albuquerque, NM (ywang@phs.org) IRB approved. The purpose of this prospective open label observational study is to compare the relative efficacy of commonly used surfactants beractant and poractant alfa in the treatment of Respiratory Distress Syndrome (RDS) in preterm neonates. The primary endpoints will include the number of doses used and respiratory support 1, 6, and 12 hours after the first dose. Respiratory support will be defined as the product of mean airway pressure (MAP) and fraction of inspired oxygen (FiO2). Secondary endpoints will include days intubated on mechanical ventilation and time on continuous positive airway pressure (CPAP) with nasal prongs. Participants include neonates admitted to the neonatal intensive care unit with gestational age less than 37 weeks with a diagnosis of RDS who require surfactant therapy as determined by a neonatologist. Patients will be excluded if they have any of the following: multiple congenital anomalies, respiratory failure not due to RDS, suspected lung hypoplasia, received surfactant at the transferring hospital prior to admit, or cyanotic heart disease. An estimate of 80 patients will be considered. Results and conclusions will be presented.

GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD) DEFICIENCY IN PATIENTS EXPOSED TO OXIDATIVE MEDICATIONS (B6), May Wu, Sharon Geaghan. Lucile Packard Children's Hospital, Palo Alto, CA (mawu@lpch.org) IRB approval not needed. The study objective was to assess the prevalence of G6PD deficiency in patients exposed to known oxidative medications and to determine if routine testing prior to receiving these medications is clinically warranted. Oxidative medications known to cause hemolytic anemia and considered unsafe for administration to G6PD-deficient patients were compiled from medical literature. A list of patients that received these medications (examples: sulfamethoxazole/trimethoprim, nitrofurantoin, phenazopyridine) was generated daily from the electronic medication administration records and outpatient prescription records. Samples of previously collected whole blood from these patients were retrieved and sent to a hematology laboratory for an enzymatic assay to evaluate G6PD activity. The study period was 3 months. Inclusion criteria: All patients that received oxidative medications or had active prescriptions in the outpatient setting during the study period. Results and conclusions will be presented.

B7 Pharmacokinetics

SIROLIMUS: CHANGE IN ASSAY, CHANGE IN OUTCOMES? (B7), Catherine Chiu, Janice Sudaria, Ashley Feist, James Lane. UC San Diego Medical Center, San Diego, CA (cychiu@ucsd.edu) IRB approval pending. The study objective is to determine the degree of equivalence for sirolimus concentrations measured by IMX microparticle enzyme immunoassay and Architect chemiluminescent assay. Monitoring sirolimus levels is important due to the narrow therapeutic window. High performance liquid chromatography tandem mass spectrophotometry is the gold standard for monitoring of sirolimus levels, but is unavailable at our institution. Therefore, immunoassays have been utilized at UCSD. The IMX microparticle enzyme immunoassay has been replaced by the Architect chemiluminescent assay. This retrospective chart review will include approximately 150 solid organ transplant patients who have had sirolimus whole blood concentrations measured by both assays between January 1 to December 31, 2010. Based on a preliminary analysis of 40 subjects, at least 80 subjects with paired samples would be needed for the study to be adequately powered to compare the two assays. An equivalence test will be used to evaluate the logtransformed paired samples with a significance level set at 0.05 and 90% confidence limits of 0.8-1.25. Dose changes and other patient outcomes (serum creatinine, CBC, lipid panel, and protenuria) associated with sirolimus toxicity will be evaluated. Full results will be presented and discussed.

EFAVIRENZ PLASMA LEVELS AND ASSOCIATION WITH CENTRAL NERVOUS SYSTEM SIDE EFFECTS IN CAUCASIAN AND VIETNAMESE PATIENTS (B7). Marisa Chun, Jessica Song. Santa Clara Valley Medical Center, San Jose, CA (Marisa.Chun@hhs.sccgov.org) IRB Approved. The objective of this study is to determine if there is an association of central nervous system (CNS) adverse effects on plasma efavirenz (EFV) levels in the Vietnamese population as compared to Caucasian patients. This will be shown by taking a trough (24 plus/minus 2 h) and midpoint (12 plus/minus 2 h) EFV levels in each study participant. To determine the severity of CNS side effects patients will be asked to complete the Pittsburgh Sleep Quality Index Questionnaire two times throughout the study. Inclusion criteria will be an active phone number for follow up, greater than 18 years of age, taking EFV for at least two weeks, 95 percent adherent to therapy, and a means of transportation. Patients will be excluded if they have a medical history involving the CNS, are currently taking cytochrome p450 2B6 inhibitors/inducers or agents causing insomnia or vivid dreams, alanine transaminase/aspartate aminotransferase levels greater than 5 times the upper limit of normal, Child Pugh Score B or C, pregnant, or using illegal substances. The trough, midpoint EFV levels of Vietnamese and Caucasian patients will be compared, using the Students t test. A p value of less than 0.05 will be classified as statistically significant. EFV plasma samples are currently being collected. All results and conclusions will be presented.

A RETROSPECTIVE REVIEW OF VANCOMYCIN PHARMACOKINETICS IN PEDIATRIC PATIENTS WITH NORMAL RENAL FUNCTION (B7). Kim Chuong, Jason Arimura, Betty Lee, Kathleen Gutierrez. Lucile Packard Childrens Hospital at Stanford, Palo Alto, CA (kchuong@lpch.org) IRB approval pending. Vancomycin continues to be a frequently prescribed antibiotic at Lucile Packard Childrens Hospital for suspected or confirmed Gram-positive infections. Our current guidelines recommend initiating vancomycin at 15mg/kg, given intravenously every 8 hours, for patients with normal renal function. However, we frequently observed that this regimen is inadequate to reach target trough levels of 10 to 20mcg/mL, as recommended by the 2009 practice guidelines of the Infectious Diseases Society of America (IDSA). This study aims to assess the frequency of achieving desired trough levels at the recommended starting dose and to perform pharmacokinetic evaluations to determine a more optimal initial dosing regimen for vancomycin. All patients that received vancomycin at a starting dose of 15mg/kg, given intravenously every 8 hours, within a defined period were identified through a search of our hospitals electronic medical record. The study included patients between the ages of 6 months to 18 years, who had received the recommended vancomycin starting dose and remained on therapy for at least 48 hours. These patients had to have normal renal function, adjusted body weight of 50kg, and at least one reported vancomycin serum level. Results and conclusions will be presented.

VANCOMYCIN DOSING IN CORONARY ARTERY BYPASS GRAFT AND/OR VALVE REPLACEMENT SURGERY (B7). Matt Hafermann. Clark Lyda. Ty Kiser. Doug Fish. Gerard Barber. Joseph Cleveland. University of CO Hospital, Aurora, CO (Mattthew.Hafermann@uch.edu) IRB approved. Vancomycin is commonly given to prevent infection stemming from cardiac surgery. Due to reduced susceptibility of methicillin-resistant Staphylococcus aureus (MRSA), higher vancomycin troughs of >15 mcg/ml are often recommended. Currently at the University of Colorado Hospital, patients undergoing a coronary artery bypass graft (CABG) and/or valve replacement surgery receive 1 gram of vancomycin for prophylaxis prior to surgery and a second 1 gram dose after surgery. Our study aimed to evaluate whether utilizing a weight-based dosing strategy could improve and sustain achievement of target vancomycin concentrations, eliminate the need for a second dose at the end of surgery, and provide more effective prophylaxis during surgery. The primary study outcome was the percentage of time patients maintained a vancomycin serum concentration above 15 mcg/ml. Secondary outcomes included vancomycin tissue concentration and number of patients who required a second dose of vancomycin. Twenty patients receiving a CABG and/or valve replacement surgery were randomized to either a 20 mg/kg dose (2 gram maximum) of vancomycin or a standard 1 gram dose prior to entering surgery. Endothoracic tissue was collected 45 minutes after the first dose of vancomycin to analyze tissue concentrations. Serum samples were measured before, during, and after cardiac bypass, and pharmacokinetic and pharmacodynamic analyses were performed. Results and conclusions will be presented.

SIROLIMUS PHARMACOKINETICS IN HISPANIC AND CAUCASIAN TRANSPLANT PATIENTS (B7), Grace Hsiao, Samuel Mendoza, Timothy Bassell, Linda Awdishu, Shirley Tsunoda. UC San Diego Medical Center, San Diego, CA (grhsiao@ucsd.edu) IRB approval received. The pharmacokinetics of the immunosuppressive agent sirolimus are highly variable. The narrow therapeutic range of this drug warrants therapeutic drug monitoring. Since sirolimus is a cytochrome P450 3A (CYP3A) and pglycoprotein (P-gp) substrate, there may be pharmacogenetic influences on its pharmacokinetics. The primary study objective is to determine if sirolimus dose to trough ratios are significantly different in Hispanic abdominal transplant patients compared to Caucasian abdominal transplant patients. For the secondary outcome measure, we will look at changes in HDL, LDL, total cholesterol, triglycerides, CBCs, liver function, and blood pressure in Hispanic versus Caucasian patients. Data from patients transplanted at our institution will be collected retrospectively and analyzed. Inclusion criteria are age greater than 18, Hispanic or Caucasian patients, kidney, liver, kidney pancreas, and kidney liver transplant patients, at least 3 months post transplant, on sirolimus, and documented sirolimus levels in our EMR from the last 10 years. Patients taking sirolimus concurrently with moderate or strong CYP3A4 inhibitors will be excluded. Electronic

and paper medical record systems will be used to obtain the data. Data will be collected and organized in Microsoft Excel. Logistic regression analysis will be conducted to using the statistical software STATA, SPSS, and R. Results and conclusions will be presented.

ACCURATE MEASUREMENT OF TENOFOVIR/EMTRICITABINE USING DRIED BLOOD SPOTS (B7), Jacob Langness, Peter Anderson. University of Colorado Hospital, Aurora, CO (jacob.langness@uch.edu) IRB Approved. Tenofovir (TFV) and emtricitabine (FTC) are used as the backbone of many combination antiretroviral therapies for HIV infection. The active form of TFV and FTC are the intracellular triphosphate-analogs. Venous blood draws are currently standard practice to measure plasma and intracellular drug concentrations. Dried blood spots are an encouraging alternative to evaluate plasma and intracellular pharmacokinetics, having shown to be effective in evaluating plasma concentrations of other drug molecules. The primary objective of this study is to examine the accuracy and feasibility of using dried blood spots for quantification of TFV/FTC concentrations. The secondary objective is to assess the accuracy and feasibility of quantifying intracellular TFV and FTC in the dried blood spots. The open label, observational study involves individuals currently receiving TFV/FTC therapy for the treatment of HIV infection. Concentrations of TFV from plasma, peripheral blood mononuclear cells, and red blood cells will be measured, as well as concentrations of both phosphorylated and parent forms of TFV and FTC from the dried blood spots. The concentrations will be compared to determine accuracy and precision. Plasma and intracellular TFV and FTC concentrations will be quantified through ultrasensitive liquid chromatography tandem mass spectrometry procedures developed and validated in the Colorado Antiviral Pharmacology Laboratory. The results and discussion will be presented.

EVALUATION OF DORIPENEM PHARMACOKINETICS IN PATIENTS UNDERGOING CONTINUOUS RENAL REPLACEMENT THERAPY. (B7), Angela Luetters, Norman Kwong, Will Lee, Ty Kiser. Exempla Saint Joseph Hospital, Denver, CO (luettersa@exempla.org) IRB approval received. The study objective is to characterize the pharmacokinetic parameters of doripenem dosed at 500mg IV every 12 hours in critically ill patients who are also receiving continuous venovenous hemodialysis (CVVHD). This is a prospective, open label, descriptive study including patients on CVVHD with no residual renal function and who have received at least 2 doses of doripenem 500mg IV every 12 hours. Patients will be excluded if they are expected to need CVVHD for fewer than 3 days or to receive less than 3 doses of doripenem. Serum and dialysate samples will be collected at 0, 1, 2, 4, 8, and 12 hours. Additional samples will be collected if the patient continues to meet inclusion criteria at least 2 days after the first samples are collected. Doripenem concentrations will be performed using high pressure liquid chromatography. Pharmacokinetic parameters will be calculated based on these values and evaluated to determine if doripenem dosed at 500mg IV every 12 hours provides doripenem concentrations that are adequate for treating common pathogens found in the intensive care unit. Results and conclusions will be presented.

ANALYSIS OF PHENYTOIN PROTEIN BINDING PHARMACOKINETICS IN A VETERAN POPULATION (B7). Shinobu Seragaki. Sunita Dergalust. Viet Huong Nguyen. VA Greater Los Angeles Healthcare System, Los Angeles, CA (Shinobu.Seragaki@va.gov) IRB approved. Despite the introduction of new antiepileptic drugs (AED) in recent years, phenytoin continues to be the most widely prescribed AED for both newly diagnosed and previously diagnosed patients with epilepsy in the veteran population. Phenytoin protein binding pharmacokinetics is highly variable and patient dependent. The objective of this study was to investigate phenytoin protein binding pharmacokinetics in our veteran patient population. We retrospectively reviewed phenytoin protein binding pharmacokinetics in patients with both documented free and total phenytoin levels at VAGLAHS from July 1, 1999 through October 1, 2010. Specifically, we assessed the degree of phenytoin protein binding in veteran patients with renal failure, veteran patients with hypoalbumenia, and critically ill or elderly veteran patients. We also examined whether widely utilized equations for estimation of phenytoin levels in patients with altered protein binding kinetics were clinically applicable in our veteran population. Results will be presented and discussed.

RELATIONSHIP BETWEEN INITIAL VANCOMYCIN DOSING INTERVAL AND TIME TO THERAPEUTIC TROUGH LEVELS (B7), Brett Stoecklein. Denver VA Medical Center, Denver CO (brett.stoecklein@va.gov) IRB approval pending. An initial study that analyzed the dosing practices of vancomycin at the Denver VA Medical Center was performed from June 1, 2009 through November 30, 2009 to determine the percent of patients with target vancomycin serum trough concentration of 15-20 mg/dL at steady state as a function of total daily dose. It was the intent of the previous study to lay the groundwork for this current study that will look at utilizing a loading dose in order to reach therapeutic trough levels more quickly. In August 2010 a 25mg/kg, maximum 2000mg, loading dose was initiated in all patients at the Denver VA Medical Center. The primary objective of this study was to determine the percent of patients with target vancomycin serum trough concentrations of 15-20 mg/dL at steady state as a function of loading dose compared to vancomycin serum trough concentrations at steady state of non-loaded patients from the initial study. Additional outcomes that were evaluated included the percent of patients who developed acute kidney injury, the percent of MRSA strains with MICs 2 mcg/mL to vancomycin, and supratherapeutic trough levels at any time during vancomycin therapy. The study period was 6 months. Data was collected retrospectively using the electronic health record. Descriptive statistics were utilized for the data analysis. Results and conclusions will be presented.

EVALUATION OF COCKROFT-GAULT CREATININE CLEARANCE VERSUS ACTUAL DRUG CLEARANCE IN CHRONIC SPINAL CORD INJURY PATIENTS (B7). Yi-Jiun Wang, Jennifer Lee. VA Long Beach Healthcare System, Long Beach, CA (yi-jiun.wang@va.gov) IRB approved. Chronic spinal cord injury (SCI) patients often suffer from complicated infections requiring high doses of renally eliminated antibiotics such as vancomycin and aminoglycosides. Decreased muscle mass due to long term immobility results in decreased creatinine production in SCI patients. Studies have shown that the Cockroft-Gault equation based on serum creatinine may overestimate creatinine clearance in SCI patients. The objectives of this study are to confirm an overestimation of renal function when using the Cockroft-Gault equation to estimate vancomycin and aminoglycoside clearance and to test the validity of the adjusted Cockroft-Gault equation for SCI patients found in the previous study. Differences in the accuracy of the Cockroft-Gault equation amongst different anatomical levels and degrees of injury will also be evaluated. Subjects from VA Long Beach with a diagnosis of SCI for at least one year, who received vancomycin or an aminoglycoside with at least one drug level at steady state from January 2009 to June 2010 were included in the study. Final results and conclusion will be presented.

EVALUATION OF VANCOMYCIN TROUGH LEVELS OBTAINED USING THE RVMC PROTOCOL (B7). Matthew White. Asante Health System, Medford, OR (mwhite@asante.org) IRB approved. The study objective was to evaluate the effectiveness of Rogue Valley Medical Centers current vancomycin protocol. The pharmacy department implemented the new protocol in November, 2009, and research was necessary to assess the accuracy of the protocol in achieving goal trough levels. A retrospective review of dosing and trough levels was done to determine: (1) the ability of the protocol to attain trough levels between 15-20 mcg/ml (at steady state, with and without loading doses); and (2) the ability of the protocol to attain trough levels after adjustments were made according to protocol. Cases were identified using a collection of retrospective vancomycin patient monitoring forms which were filed in the pharmacy. Primary outcomes were determined by the trough achieved prior to the 3rd or 4th vancomycin dose. If the trough is 15-20 mcg/ml the dosing will be considered successful. This data gave information for comparison between load dosed patients and non-load dosed patients as well as how often target vancomycin trough levels were achieved. The secondary outcome was determined by the trough achieved after adjustments were made per protocol. If the trough was in the new target range, the adjustment was considered successful. Rates of success were determined for each outcome. Results will be discussed. Nothing to disclose.

C1 Pharmacoeconomics, Admin.orFinancial Management

DEVELOPMENT OF A STRATEGIC PLAN FOR A COMMUNITY HOSPITAL PHARMACY DEPARTMENT UTILZING PERFORMANCE SURVEYS AND INITIATIVES (C1). Amy Armintrout. Yakima Valley Memorial Hospital, Yakima WA (AmyArmintrout@yvmh.org) IRB exempt. The objective of this study was to use McKessons High Performance Pharmacy (HPP) survey and framework to establish and begin implementation of a strategic plan for departmental improvement. All pharmacy managers and residents completed the HPP survey to identify and analyze existing departmental gaps in survey dimensions. These include medication preparation, delivery, safety and use; patient care services; financial performance; leadership and education. A retreat was held to group identified gaps into categories that were assigned to the Director of Pharmacy and appropriate assistant managers. Additionally, brainstorming occurred to identify plans for gap closure. A ranking system was created to quantitatively prioritize plans based on alignment with department mission/vision, return on investment, and resource needs for implementation. Assigned managers were charged with leading plan initiation for each area, and a calendar created with timelines for implementation or reassessment. Sharepoint technology was adopted for task identification and tracking, document management and an easily accessible department calendar. The study goal was to produce a pertinent and dynamic strategic plan to lead our pharmacy department toward its vision. Although the process is expected to extend beyond the residency year, results and conclusions for the study period will be presented.

IMPACT OF PHARMACIST DISCHARGE COUNSELING ON HEALTH CARE UTILIZATION COSTS: PROJECT PHARMD (C1). Tom Dilworth, Allison Burnett, Bernadette Johnson. University of New Mexico Hospital, Albuquerque, NM. (tdilworth@salud.unm.edu) IRB Approval received. The objective of this study is to determine the effects of pharmacist discharge counseling on healthcare utilization costs in the post-discharge period. English or Spanish speaking patients consenting to participation and discharged from the internal medicine service at UNM Hospital were included in the study.Patients in the intervention group received medication reconciliation before discharge, counseling on their medication(s) and disease state(s), and a follow-up phone call within 36 to 72 hours of discharge from a pharmacy resident in addition to standard hospital discharge information from nursing staff. Patients in the control group received the standard hospital discharge information from nursing staff. Hospital readmissions and ED visits were recorded from patient medical records 30 days post-discharge for both the intervention and control groups. Individual charges for readmissions and/or ED visits billed to patients by the hospital were also recorded from patient medical records. The total charge per patient was multiplied by the UNMH cost-to-charge ratio to obtain a cost per readmission and/or ED visit. Additionally, the total time spent by the pharmacy resident during the discharge process was recorded and multiplied by an entry-level pharmacist salary at UNMH. Health care utilization in the two groups will be compared using a cost-benefit analysis. Results and conclusions will be presented.

ASSOCIATION OF MEDICATION ADHERENCE IN CHRONIC CONDITIONS WITH MEDICAL HEALTHCARE EXPENDITURE. Patty M. Fong, Grant Knowles, Rachana Patel, Christine Lee, Grover Lee. American Health Care, Rocklin, CA. (p.fong@americanhealthcare.com). IRB N/A. Previous studies have indicated that higher levels of medication adherence correspond to positive health outcomes and may lower medical costs. The objective of this study is to evaluate varying levels of adherence as compared with medical costs for individuals with diabetes, hypertension, and dyslipidemia. Participants had medical and prescription claims during the analysis period with at least one of the following diagnoses of diabetes, hypertension, and dyslipidemia. A minimum of 2 ICD-9 codes associated with the diagnosis before the analysis period and 2 or more prescription claims for the same diagnosis was required within the analysis period. Excluded participants included members aged less than 18 years old and members without prescription drug claims for any of the 3 studied disease states. Adherence was recorded using the medication possession ratio (MPR). Total medical costs, prescription costs, and the composite endpoint of total healthcare cost were measured against five different levels of adherence rates (MPR of 0-19%, 20-39%, 4059%, 60-79%, and 80-100%). Results will be discussed.

DEVELOPMENT OF AN ONCOLOGY OUTREACH CLINIC INTO A RURAL AREA (C1), Kristen Halse. St Lukes Mountain States Tumor Institute, Boise, ID (halsek@slhs.org) IRB approval not needed-no human subject data. According to the American Cancer Society an estimated 1.5 million Americans were diagnosed with cancer in 2010. Many of these new patients live in rural areas without nearby oncology services and may have to drive hours to receive their treatments, manage their side effects and go to their follow-up appointments. The goal is to expand oncology services into a more rural community while still providing exceptional specialized patient care. Issues of physical building and equipment limitations, scheduling processes, staff training and budget estimations relating to pharmacy services will be addressed. Results such as implementation timeline, advances made and issues encountered will be discussed.

MEASURING PHARMACISTS VALUE (C1). Kathryn Hammer, Kathy Stoner, Kate Farthing. Legacy Health, Portland, OR (khammer@lhs.org) IRB approved. Historically, a product centered measure of pharmacists work effort has justified pharmacy staff levels without quantifying the value of clinical activities. The study objective was to measure clinical pharmacy productivity with the implementation of an electronic health record. Clinical pharmacy workload was collected from a single hospital and captured in the form of interventions and tasks. Interventions were subdivided into five categories (adverse drug events, drug optimization, dose optimization, medication reconciliation and drug interaction consults) and included a significance level, amount of time spent, response, outcome and supporting documentation. Tasks were initiated by providers and included per pharmacy protocol orders (antibiotics and anticoagulation) and pharmacy consults. Tasks were completed by pharmacy on a daily basis through an electronic work list. Solucient validated costs were applied to each intervention and task. Legacy Health specific costs were calculated when determined to be more appropriate. Primary endpoints of the study included cost savings and cost avoidance. These endpoints were summed and compared to pharmacist labor costs to show the net economic impact of clinical pharmacy activity for the hospital. Additional details about the data, results and conclusion will be presented.

PHARMACIST ROLE IN THE IMPLEMENTATION OF A SMOKE FREE CAMPUS (C1), Elaine Huang, Kim Donnelly. UW Medicine, Seattle, WA (huangy@u.washington.edu). IRB approval N/A The University of Washington Medical Center (UWMC) is a comprehensive academic medical center focused on improving the general health and well being of the public. The current policy at UWMC prohibits smoking in the hospital. Designated smoking areas exist outside the hospital for patients, visitors, and staff. A multidisciplinary group in partnership with the King County Health Department has been identified and charged with the implementation of a Smoke Free Initiative. The UWMC Pharmacy Department was asked to play an active role in supporting this initiative. Coordination of smoking cessation intervention for patients admitted to the hospital and subsequent electronic medical record documentation, along with repackaging of nicotine replacement therapy (NRT), and evaluation of the amount of pharmacist time required have been discussed with identified stakeholders. The multidisciplinary teams deliverables include implementing a Smoke Free Campus, defining the roles and responsibilities of clinicians in providing NRT support, smoking cessation interventions, and continuity of care upon discharge. The pharmacy specific deliverables of this project include cost for provision of NRT support for patients, visitors, and staff, identifying the role of clinical pharmacists in smoking cessation prescribing and counseling, and documentation of intervention. The implementation plan and financial assessment will be discussed.

ONLINE FDA RESOURCES VERSUS DATA ON FILE: MINIMIZING THE USE OF DATA ON FILE IN STANDARD MEDICAL RESPONSE DOCUMENTS (C1). Nancy Hwang, Angie Graham, Marbel Catolico. Genentech, Inc. South San Francisco, CA (Hwang.Nancy@gene.com) IRB approval not needed. In response to unsolicited requests for medical information from healthcare professionals, the medical communications department develops and provides standard medical response letters. These letters may cite, as data on file, unpublished materials like internal study reports or new drug applications that are generally inaccessible to the requester since they contain proprietary information. FDA (Food and Drug Administration) reviewers summaries and other documents are routinely posted on the FDA website for public access and have been cited in published studies and tertiary drug information resources. Since FDA materials can contain information otherwise undisclosed to the public, they could potentially replace certain date on file citations. The objective of this study was to evaluate whether information from the FDA website (http://www.fda.gov) could reduce the need to use data on file as a reference in standard medical response letters. Thirty-nine standard written response documents containing 145 data on file references were assessed to determine whether online FDA medical reviews or advisory committee briefing documents could replace the existing data on file citations. Twenty-six percent (37/145) of data on file references evaluated were found to be replaceable with publicly available information on the FDA

website. Updated results and conclusions will be presented.

IMPACT OF CPOE DECISION SUPPORT ON IV TO PO MEDICATION INTERCHANGE: ASSESSING QUALITY AND COST (C1), Michael Katzourakis, Kavish Choudhary, Craig Herzog, Linda Tyler, Univ. of Utah Hospital, Salt Lake City, UT (mjk8@utah.edu) IRB approval received. The University of Utah Hospitals & Clinics (UUHC) implemented CPOE in May 2009. As of fall 2010, clinical decision support system (CDSS) tools associated with CPOE had not been fully implemented. UUHC activated targeted CDSS tool the beginning of 2011. The purpose of this study is to evaluate the impact of Intravenous (IV) to oral (PO) medication clinical decision support on CPOE, by looking at quality and financial benefits. Alerts in CPOE will notify physicians and pharmacists when patients meet specific dietary criteria, or are tolerating other oral medications. The control group consisted of 100 randomly selected patients admitted to UUHC beginning January 1, 2010 to February 28, 2010, that are on IV medications listed in the UUHC IV to PO interchange therapeutic guidelines. The intervention group consisted of 100 randomly selected patients admitted to UUHC for 3 months following UUHC's implementation of the alerts. The outcomes included: change in the length of time to convert IV medications on the therapeutic interchange list to PO medications, change in cost due to change in hospital length of stay, and cost of medication therapy before and after CPOE decision support intervention. Results will be presented and discussed.

NOVEL METHODS TO COMBAT CLAIMS DENIALS AND UNDER REIMBURSEMENT IN A BRAVE NEW WORLD OF HIGH COST PHARMACEUTICALS (C1). Ryan Koca. Norman Hamada. Kristin Vaughan. Loma Linda University Medical Center (LLUMC), Loma Linda CA (rkoca@llu.edu) IRB pending. The cost of pharmaceuticals has increased significantly, while hospitals and health systems have seen their budget controls tighten and reimbursement rates shrink. This has forced administrators to look for unique ways to find additional income and prevent unnecessary financial losses. Numerous institutions have hired full time Clinical Financial Analysts (CFA) to develop protocols which promote networking of different departments involved in reimbursement to realize potential cost savings and revenue generation. LLUMC has recently implemented a pilot process. The objective of this retrospective analysis is centered on how the implementation of new cost saving protocols can impact the balance sheet of LLUMC. By targeting high cost drugs and implementing processes that screen elective outpatient treatments before therapy as well as monitoring reimbursement we hope to prevent claims denials and also capture increased revenue. We look to eventually cost-justify adding a full time equivalent Pharmacist in the role of a CFA who would be tasked with coordinating these efforts on a larger scale. Our goal is to evaluate how effective these protocols are in patients who received high cost medications via financial data for how much money the institution saved with the new process. Additionally we look to determine which 3rd party payers caused the most claims denials. Results pending.

IMPACT OF RITUXIMAB DOSE-ROUNDING IN HEMATOLOGY AND ONCOLOGY PATIENTS (C1), Ann Le, Samit Patel, Yi-an (Anne) Chen. Stanford Hospital and Clinics, Stanford, CA (anle@stanfordmed.org) IRB review not needed. Rituximab is a chimeric anti-CD20 monoclonal antibody currently being used for the treatment of various malignant and non-malignant disorders, such as nonhodgkins lymphoma and graft-versus-host disease. The range and number of doses can vary widely depending on the indication. As with other biologic therapy, rituximab is a costly agent available only as a single-dose vial. Currently, there is no consensus on dose-rounding of rituximab either up or down to the nearest vial size. This study is a retrospective chart review of all rituximab orders prescribed for hematologic or oncologic indications from April 2008 through September 2010. The impact of doserounding of rituximab will be evaluated by looking at the potential deviation from the prescribed dose to the dose of the nearest vial size. Pertinent data to be collected include patient demographics, drug utilization and administration, and financial data. From this analysis, the utility of developing a dosing protocol for monoclonal antibodies will be addressed. Full results and analysis will be discussed.

FINANCIAL IMPACT OF A HOSPITAL-BASED OUTPATIENT INFUSION CENTER UNDER THE 340B DRUG PRICING PROGRAM (C1). Yuk Ting Lydia Leung. Scott Evans. University of Southern California University Hospital, Los Angeles, CA (yukleung@usc.edu) IRB exempt. Infusion therapies were being provided at various sites at our institution. An outpatient infusion center eligible for 340B pricing provides opportunities for cost savings. The objective of this study was to determine the financial impact of an outpatient infusion center at our institution. Three data sets were compiled for this study. First, a profit-and-loss statement was analyzed, including reimbursements and drug costs, for all outpatient infusion visits from August 1, 2009 to July 31, 2010 at the health system. Next, using the above visit data, infusion center billing information, 340B drug prices, and the startup budget, a financial projection was made for the infusion center. Lastly, upon implementation of the infusion center in February 2011, the startup cost, drug cost, and actual reimbursement information will be collected for one year. These three data sets were compared against each other to determine the projected and actual financial impact, as well as the accuracy of the financial model used. Results and conclusions will be presented.

DEVELOPMENT AND IMPLEMENTATION OF A PHARMACY TECHNICNAN CHECK TECHNICIAN PROGRAM IN AN INPATIENT PHARMACY (C1). Tsung Chi Lien. Timothy Lopez. Keith Walsh. Kellie Allen. Community Regional Medical Center, Fresno, CA (tlien@communitymedical.org) IRB approved. The objective of this study is to develop, implement, and validate policies and procedures of a newly developed Pharmacy Technician Check Technician (PTCT) Program. This Program includes training, certification, and quality assurance measures. Phase I of this study determines the baseline accuracy rate of pharmacists checking unit dose cassettes (UDC) and develops policies and procedures of the PTCT Program. Phase II of this study involves identification and training of pharmacy technicians as specified in the PTCT policies and procedures. Upon completion of training, the accuracy rate of pharmacy technicians checking UDC is collected and assessed. The PTCT Program will be validated by comparing the accuracy rates of pharmacists and pharmacy technicians using the chi-square test. Quality assurance measures including annual recertification and random audits will be implemented to ensure the validity is maintained.Results and conclusions will be presented.

OUTCOMES AND HEALTH CARE UTILIZATION OF ADJUSTABLE GASTRIC BANDING (AGB) SURGERY (C1) Vincent Lin. University of Washington. Pharmaceutical Outcomes Research and Policy Program, Seattle, WA. (vwlin@u.washington.edu) IRB approved. The study objective is to understand the outcomes of AGB surgery in relation to characteristics of the surgical patients, as well as health care utilization after the surgery. Method: A multi-center, cross-sectional survey was used to collect primary data regarding pre- and postsurgical characteristics of patients, such as gender, BMI, insurance status, co-morbidities, additional surgical procedures, and health related quality of life (HR-QoL). Eligible participants were patients aged 18 years or older who had undergone AGB surgery at inpatient and outpatient surgical centers across Washington State. Multiple linear regression model was used to estimate the association between BMI change percentage and covariates. Interaction terms of obesity co-morbidities were tested for effect modification. Stepwise regression was used to identify candidate predictors for BMI change prediction. EQ-5D instrument and EQ-Visual Analog Scale were used to assess post-surgical HR-QoL. Results: A total of 742 surveys were returned and analyzed (response rate 47.6%). Mean BMI before AGB surgery was 44.96 Kg/m2. 70.05 % of surgical patients had insurance coverage. Mean time since surgery was 32.75 months. Average number of adjustment in the last year was 1.79. 84.69% of the patients had Lap-Band and 6.46% had Ethicon Realize Band. Comorbidities includes hypertension (35.15%), diabetes (10.81%), sleep apnea (37.41%), urinary incontinence

(14.61%), and immobility (3.78%). Further results and conclusions will be presented .

EVALUATION AND VALIDATION OF PHARMACIST WORKLOAD METRICS(C1), Chad Marsing, Tina Aramaki. Intermountain Healthcare, Salt Lake City, UT (Chad.Marsing@imail.org) IRB approval pending. Pharmacist provided clinical services in the inpatient setting have evolved significantly over the past 20 to 30 years. As the role of clinical pharmacists continues to evolve, it is necessary to design workload metrics that incorporate all types of clinical pharmacist functions. Historically, pharmacist workload, as defined by relative value units (RVU), has been assessed based upon doses dispensed, medication type, patient case mix, and self reported interventions. This system of measurement has a number of significant limitations. The purpose of this project is to establish a proof of concept for part of a clinical workload metric using complexity adjusted order processing (CAOP). Automated data capture methods will be used to ensure that pharmacist workflow is unimpeded. Data captured will provide a baseline for quality improvement and be a valuable resource for refining future workload metrics, assessing adequate staffing, and benchmarking appropriately. Three medications (docusate, warfarin, and heparin) will be evaluated to provide a proof of concept for the use of CAOP. A time and motion study will be performed to determine the average time required to clinically evaluate and process an order for each of the previously mentioned medications. Automated electronic data collection will be used to evaluate data based on the CAOP time.

IMPLEMENTATION OF PATIENT SPECIFIC INSULIN VIALS IN A COMMUNITY HOSPITAL (C1). Krista McCoy. Tom Van Hassel. Yuma Regional Medical Center, Yuma, AZ (kmccoy@yumaregional.org) IRB not needed- no human subject data. The study objective is to implement and evaluate a hospital wide conversion from floor stock insulin vials to patient specific insulin vials and to determine the safety and economic impact of these changes. This conversion also prepares the hospital for implementation of bedside barcode scanning. A plan for implementation was developed and education was provided throughout the hospital prior to implementation. Safety will be evaluated by comparing reported errors involving wrong insulin administration before and after implementation. Economic analysis will be done by comparing charge capture from the previous floor stock system to the new patient specific system. Results and conclusions will be presented.

IMPLEMENTATION OF AN ALCOHOL DEPENDENCE MANAGEMENT PROTOCOL IN A MULTIDISCIPLINARY HEALTH CARE MODEL (C1), Cassandra Metu, Pedro Solis Jr. Albuquerque Indian Health Center, Albuquerque, NM (Cassandra.Metu@ihs.gov) IRB approved. The objective is to explicate the incorporation of pharmacy management methods in the screening and treatment of alcohol dependent patients in an integrated health care model. Clinical Reporting Systems data was analyzed to see the effectiveness of current screening methodology. Current screening tools were compared to updated clinical guidelines on alcohol abuse and alcoholism. A protocol was developed using evidencebased research to alter the clinics present procedures in screening, treatment, and follow-up of this patient population. Staff members were surveyed to determine perceived feasibility of new methods and assess comfort level of pharmacy-integrated intervention in alcohol dependence management. An implementation plan was created to change current procedures in phases. The continuous quality improvement plan includes the following: collecting patient demographics, alcohol consumption, and current medications; documenting the rationale for possible therapeutic non-compliance; and demonstrating the efficacy of clinical interventions. Results and other data will be presented.

OCCURENCE OF NEW BOXED WARNINGS AND WITHDRAWALS FOR PRESCRIPTION DRUGS FROM 1996-2010 (C1).Mohamed Mohamoud. Christine Cheng. UCSF Medical Center, San Francisco, US (Mohamed.Mohamoud@ucsf.edu) IRB not needed-no human subjects. After marketing approval of prescription medications, the U.S. Food and Drug Administration (FDA) continue to monitor the safety of a drug through a post marketing surveillance system. The study objective is to determine the frequency and the timing of detection of new adverse drug reactions described in boxed warnings or that required withdrawal from the market. We obtained a list of all new molecular entities approved by the FDA between 1996 and 2010 by searching the drugs@FDA database. Next, we searched the FDAs MedWatch database to obtain all new boxed warnings issued between 1996 and 2010. We then searched the MedWatch database, FDA newsletters and published literature for market withdrawals during our study period. A Kaplan-Meier analysis was conducted to estimate the probability of acquiring a boxed warning or being withdrawn from the market over the last 15 years. Results and conclusion will be presented.

ECONOMIC ANALYSIS OF A HOME BLOOD PRESSURE MONITORING PROGRAM (C1) Lindsy Moore. Sarah Billups. Kaiser Permanente Colorado, Aurora, CO (Lindsy.R.Moore@kp.org) IRB approval received. The study objective was to evaluate the cost of a Home Blood Pressure Monitoring (HBPM) program compared to usual care in an integrated health care delivery model. A novel HBPM program was developed at Kaiser Permanente Colorado (KPCO) and studied in a randomized controlled trial conducted in 326 patients between August 2008 and June 2010. Patients in the HBPM study arm were provided a BP cuff with the capability to download results to a secure, online tool called HealthVault. Information was then transmitted to a KPCO disease-state management database, HealthTrac. Clinical pharmacists followed up with patients to adjust medications as needed and communicated recommendations through a secure e-mail or by phone. This innovative program resulted in significantly better blood pressure control in the HBPM group at six months (56% vs. 36%, p<0.001). A cost-effectiveness analysis, performed from the perspective of the health plan, was completed based on these results. Direct costs including clinic visits, hospitalizations, emergency room visits, telephone and e-mail encounters, labs, radiology, and medications as well as indirect costs were accounted for and compared between the intervention and usual care groups. The cost per controlled BP was calculated and the between group difference was evaluated. The preliminary results and conclusions of this study will be presented upon completion of data collection and analysis.

DEVELOPMENT AND UTILITY OF A HOSPITAL INPATIENT PHARMACY DASHBOARD (C1). Ashley Myers. Jane Hodding. Jennifer Le. Long Beach Memorial Medical Center, Long Beach, CA (amyers@memorialcare.org) IRB approval is not neededno human subject data. The study objective was to create and pilot a comprehensive pharmacy dashboard for use by staff and managers to help determine workload in both clinical and distribution functions, which ultimately govern staffing needs. Data was collected for a satellite pharmacy that provides care to non-critically-ill, hospitalized adult patients. Each prescription order or activity type was classified into one of three main categories: (1) clinical, (2) satellite distribution, or (3) central distribution. Orders or activities for satellite distribution included doses verified, number of auto-substitutions, missing doses requested from nursing, change in orders, simple interventions, adverse drug reactions, medication errors (type and stratified by severity), average time taken for an intervention, and cost from wasted drug. The clinical program category consisted of the number of pharmacy-regulated therapies (PRT), and average time for a pharmacist to complete a PRT. Central distribution categories were drug doses made and on-time deliveries from central pharmacy. All data was collected for a one-week period in three consecutive months and standardized to per patient days as deemed necessary for data normalization. Results and utility will be discussed.

IMPACT OF A FREE FIRST FILL PROGRAM ON PPI UTILIZATION IN A HEALTH PLAN (C1). Aaron Nelson. Sharon Burks. Galen Goertzen. Group Health Cooperative, Seattle, WA (nelson.aj@ghc.org) IRB approval not needed. Free first fill programs have gained popularity among health plans as a way to incentivize members on brand-name medications to switch to more affordable generic medications. The study objectives are to evaluate the utilization trends and financial impact of a free first fill program on Group Healths commercial members. Claims data was used to identify members with a dispensed prescription of a targeted brand name proton pump inhibitor (PPI) between October 1, 2010 and March 1, 2011. Members were sent a letter offering them a one time cost share waiver or reimbursement for switching to a generic PPI (i.e. omeprazole or lansoprazole). Data will be analyzed at baseline and six months post program implementation. Claims data will be used to determine the percentage of patients who switched to a generic PPI and the associated cost savings to the plan. Secondary outcomes such as the percentage of patients who revert back to using a brand name PPI will be presented.

IMPACT OF TELEPHONIC PHARMACIST CONSULTATION SERVICE ON IMPROVING QUALITY OF CARE FOR MEMBERS OF AN INDEPENDENT PRACTICE ASSOCIATION (C1), Hong Diep Nguyen.Hill Physicians Medical Group, San Ramon, CA (hongdiep.nguyen@hpmg.com) IRB approval is not needed-no human subject data. Pharmacist consultation, including medication reconciliation, has been shown throughout the literature to optimize therapeutic outcomes for individual patients. Telephonic pharmacist consultation in an Independent Practice Association setting is a unique service that has not been discussed in the published literature. The purpose of this prospective study is to determine 1) the effectiveness of a mailing to members as a communication method; and 2) the impact of telephonic pharmacist consultation on optimizing patient medication regimens. The study population included 660 Hill Physicians Medical Group members who had 3 or more chronic disease states, were on multiple medications (at least 7 prescription medications) and incurred more than 6,000 dollars in drug costs in 2010. The study period is from January 2011 to May 2011. The primary outcome measures are 1) the percentage of targeted patients who made an appointment with a pharmacist for a medication consultation; and 2) the average number of clinical interventions per patient made

during these consultations. Data collection is in progress. Results will be discussed.

MEDICATION DISTRIBUTION CHALLENGES: WHITE BAGGING AND ALTERNATE DISTRIBUTION CHANNELS (C1), Lam Nguyen, Mike Brownlee, Neil Edillo, Joe Fazio. Oregon Health & Science University, Portland, OR. (nguyenla@ohsu.edu) IRB Approval is received. White bagging is the practice of sending medications directly from a specialty pharmacy to a physicians office or hospital. This distribution challenge is increasing as private and state payers attempt to reduce costs by moving drugs from a medical benefit to a prescription benefit. This study includes the evaluation of a University Hospital outpatient clinic that was identified to have medication distribution challenges. Two prospective observational periods were planned with an educational intervention to providers and patients. Data is being collected by interviewing clinic personnel, reviewing electronic health records, Sentry 340B software. The primary objective is to measure the incidence of white bagging and alternate distribution channels occurring within the clinic. An interrupted time-series design was used to evaluate our observations. Secondary objectives include medication reconciliation of specialty medications being distributed, frequency of occurrence, incidence of medications being unused, storage conditions, medications recalled, 340B cost optimization opportunities, and payer mix. Results will provide an understanding of the impact white bagging and alternate distribution channels can have on a health institution. Observational outcomes remain under investigation with data collection and evaluation currently being conducted.

CHANGES IN ANTIBIOTIC IRRIGATION UTILIZATION FOLLOWING PHARMACY-LED EVIDENCE-BASED EDUCATION (C1), Tricia Rader, Janelle Duran, Laura Hanson. Scottsdale Healthcare, Scottsdale, AZ (TrRader@shc.org) IRB approved. A pharmacist-led initiative was put into place at Scottsdale Healthcare in April 2010 to educate surgeons on the lack of supporting evidence for the use of irrigation with antibiotic additives during operative procedures. In June, the surgery committee agreed to transition stock irrigation in the operating room from a double polymyxin/bacitracin antibiotic irrigant to a single cefazolin and a single bacitracin irrigant. The objective of this study was to evaluate changes in operative irrigation use following the transition of stock irrigation solution and to assess the need for additional pharmacist-led evidencebased education on this initiative. During the six month study period, irrigation utilization was assessed by analyzing a drug utilization report for the three months prior to (control phase) and the three months following (phase I) the stock irrigation transition date for each solution: polymyxin/bacitracin, cefazolin, bacitracin, and normal saline. All operative procedures in which irrigation solution was utilized were included in the analysis. Patient sensitive information was excluded. The Students t-test was used to assess whether the initiative made a statistically significant impact on irrigation utilization. Results and conclusions will be presented.

ROLE OF A CLINICAL PHARMACIST ACTIVELY INVOLVED IN KAISER PERMANENTES NEW MEMBER PROGRAM (C1). Kimberly Riego. Kaiser Permanente Roseville. Roseville, CA (Kimberly.K.Riego@kp.org) IRB not needed. The study objective was to determine the impact New Member Program (NMP) pharmacists can have in ensuring cost effective therapy for Kaiser Permanentes new members, as well as, physician satisfaction with this pharmacy service. New members enrolled to Kaiser Permanente are contacted by New Member Services, who then forward the medication list of a new member to the Ambulatory Care Pharmacist. Prior to a new members first Primary Care Physician (PCP) visit, the pharmacist reviews each patients medication list and forwards any formulary recommendations to the PCP. A retrospective cohort study was conducted using a list containing the names of all patients enrolled in KP Rosevilles NMP program. Inclusion criteria consisted of new, as well as returning members enrolled into the NMP program between January 1, 2010 and December 31, 2010. The same study group prior to any pharmacist interventions served as the control group. The drug cost avoidance was calculated using Kaisers Outpatient Pharmacy Information Management Systems (PIMS) point of sale data, annualized for the remaining calendar year. A Return on Investment (ROI) was calculated by subtracting the cost of the pharmacy service from the drug cost avoidance. A short anonymous internet-based survey of five questions was sent to KP Rosevilles Primary Care Physicians to

determine satisfaction with pharmacist involvement in the NMP program. Results and conclusions will be presented.

A RETROSPECTIVE ANALYSIS OF THE EFFECTIVENESS AND IMPACT OF A PHARMACY LOCK-IN PROGRAM IN A MEDICAID MANAGED CARE PLAN. (C1). Jacqueline Robichaud. CalOptima, Orange, CA (jrobichaud@caloptima.org) IRB approval pending. The study objective is to characterize and evaluate the effectiveness and financial and administrative impacts of a pharmacy lock-in program at CalOptima. CalOptima is a Medicaid managed care health plan in California which implemented a pharmacy lock-in program in March 2004 as a strategy to contain costs and reduce polypharmacy. Key components of all prescriptions processed by CalOptima between January 1, 2008 and December 31, 2010 will be abstracted, including dispense date, drug name, drug strength, drug therapeutic class, quantity dispensed, days-supply, member identifier, pharmacy identifier, prescriber identifier, member age, member gender, and total cost. The number of prescriptions, pharmacies, and prescribers utilized and the cost of prescriptions before and after a member is locked into a pharmacy will be compared to observe financial and utilization effects of the pharmacy home program. Clinical aspects, including drug-drug interactions, duplicate therapies, and contraindications will also be compared before and after lock-in. Trends in the number of members affected will be analyzed over time. Risk factors will be explored, including drug therapeutic class, member age, and member gender. ANOVA will be used to compare populations before and after lock-in. Results and conclusions will be presented.

COST-UTILITY OF COLLAGENASE CLOSTRIDIUM HISTOLYTICUM, LIMITED FASCIECTOMY, AND PERCUTANEOUS NEEDLE FASCIOTOMY IN DUPUYTREN'S CONTRACTURE (C1). Sau C, Bounthavong M, Tran JN, Wilson RL. VA San Diego, San Diego, CA (crystal.sau@va.gov) IRB exempt. A Markov model was developed to simulate Dupuytrens contracture progression and estimate clinical/economic implications of limited fasciectomy (LF), percutaneous needle fasciotomy (PNF), and collagenase clostridium histolyticum (CCH) treatments from a US healthcare payer perspective. Transition probabilities were estimated based on results from randomized, clinical trials. Health state utilities and direct costs of therapies were obtained from published sources. Half-cycle correction was used with a 1-year cycle length over a 10-year time horizon. One-way sensitivity analyses were performed on relevant variables to test the robustness of the model. Probabilistic sensitivity analysis was performed using 10,000 trial simulations for all variables and results were presented as acceptability curves. The model used a discount rate of 3% per annum and reported in 2010 $US dollars. Primary outcomes evaluated incremental costeffectiveness ratios. Of the 3 treatment decisions, LF was the dominant strategy. PNF and CCH were estimated to cost an additional $247 and $1844 compared to LF, respectively. An expected difference of -0.1 and -0.04

quality-adjusted life years were projected for PNF and CCH relative to LF, respectively. The acceptability curve showed that LF had a higher probability of being costeffective compared to other treatment modalities across a WTP threshold of $0 to $500,000. However, the cost of surgery was sensitive in our model which may vary from site to site.

COST-EFFECTIVENESS ANALYSIS FOR BISPHOSPHONATE TREATMENT DECISIONS IN A VETERAN POPULATION USING A MARKOV MODEL (C1). Jacob Smith. VA Medical Center, Salt Lake City, UT (jacob_b.smith@utah.edu) IRB approved. We compared cost per quality-adjusted-life-year (QALY) for 6 different screening and treatment strategies for osteoporosis in veterans 70 years. We developed a decision analytic model using a hypothetical cohort in a Markov simulation. The 6 strategies were: (1) no screening or treatment; (2) current standard of care in the Veterans Health Affairs (VHA) system; (3) wait for fracture then treat; (4) bone mineral density (BMD) screening and treatment in osteoporotic veterans; (5) absolute risk assessment followed by BMD screening for high-risk patients and treatment of osteoporotic veterans; and (6) absolute risk assessment followed by treatment for highrisk patients. Model was run from a United States healthcare perspective and a VHA healthcare system perspective. Cost inputs, risk estimates, treatment efficacy, and utilities were derived from the literature and from VHA data. Treatment was defined as 5 years of alendronate therapy. Outcomes were costs, life-years, QALYs, and incremental cost-effectiveness ratios. The incidence of fragility facture calculated via the Markov model will be validated against VHA data. Results and conclusions will be presented.

IS IT COST EFFECTIVE TO CONDUCT EMPIRIC GENETIC TESTING FOR CYP2D6 POLYMORPHISMS IN PATIENTS STARTING ON TAMOXIFEN? (C1), Jennifer Splawski. UCSF, San Francisco, CA (jennifer.splawski@ucsf.edu) IRB not needed-no human subject data. The objective of this study is to determine whether testing for CYP2D6 polymorphisms in postmenopausal women, starting on tamoxifen for adjuvant breast cancer treatment, leads to improvement of outcomes and is a cost effective use of healthcare resources. A cost-effectiveness analysis was carried out using published literature comparing genotyping of CYP2D6 gene before the start of endocrine treatment in breast cancer, compared to the standard of care. Drug costs were taken from wholesale acquisition costs and other unit costs were taken from standard sources. A sensitivity analysis was carried out to determine the effects of the changes. Results and conclusions will be presented.

PHARMACOECONOMICOUTCOMESOFAPHARMACISTLED MEDICATIONREVIEWPROGRAMFORMEDICAREPARTD BENEFICIARIESARETROSPECTIVEANALYSIS.(C1)SusanSteele. KernMedicalCenter,Bakersfield,CA. (steeles@kernmedctr.com)Retrospectivereviewofexisting program,IRBapprovalnotapplicable.Approvalgrantedfrom executiveteamofbeneficiaryplan. Theprogramobjectivewastoreducethecostof medicationsforplanmembersontargetedmedicationsfalling intotheMedicareGapaswellastoreducethetotaldrugcostto theplan.Thetop100medicationsbycosttotheMedicarePart Dhealthplanwereidentifiedandfromthatlist30medications weretargeted.Alltargetedmedicationshadevidencebased, clinicallyacceptablealternatives.Patientsreceivingthose medicationswereinvitedtomeetwithaPharmacistfora completeconsultationandmedicationreview. RecommendationswerewrittenbythePharmacistand forwardedtothepatientsphysicianforreviewand implementation.Pharmacyclaimswereusedtodetermineif changewasmadeandsustained.Medicalclaimswereusedto determineanychangeinhospitalizationsorurgentcarevisits6 monthsbeforeandafterconsultationtodeterminesafetyof program.Thestudyperiodwas1yearandpatientswere excludediftheydidnothave6monthsofclaimsfollowingtheir initialreview.Resultsandconclusionswillbepresented.

A PHARMACIST-LED DEVELOPMENT OF A RISK STRATIFICATION TOOL USING CLINICAL ANALYTICS (C1). Selina Tam, Allen Shek. Health Plan of San Joaquin, French Camp, CA (stam@hpsj.com) IRB exempt. Senior persons with disabilities (SPD) are a particularly difficult subset of patients to manage within the Medicaid population due to the type and severity of diseases inherent in these patients. The majority of SPDs were originally covered under the fee for service insurance model. However, with healthcare reform, the increasing deficit, and the belief that managed care can provide better outcomes, the State of California has required that SPDs be mandatorily enrolled into managed care Medicaid health plans. The influx of these potentially high utilizers can have a detrimental impact without adequate preparation by the health plan. Thus, it was imperative for Health Plan of San Joaquin (HPSJ) to develop a tool to stratify newly enrolled SPDs into high and low risk categories for patient outreach and management prioritization. To accomplish this task, we analyzed medical and prescription claims of SPDs that were already enrolled with HPSJ. From these analyses, we identified key diagnoses with a comorbidity threshold and medication classes that were associated with the high utilizers within this population. As a result, our final stratification tool was able to capture 66% of the top 15% of SPDs, which accounted for 83% of their total spent. This was achieved with a 63% specificity based on fiscal year 2010 data. The developmental process, design, and conclusion of this SPD stratification tool will be presented.

MEDICATION USE EVALUATION ON INSULIN IN A TERTIARY TEACHING HOSPITAL (C1). Joyce Ting, Nancy Lee. Ronald Reagan UCLA Medical Center, Los Angeles, CA (jhting@mednet.ucla.edu) IRB approval pending. The study objective is to explore the current insulin usage pattern at Ronald Reagan UCLA Medical Center and to search for cost-saving strategies to reduce the annual pharmacy expenditure on insulin while maintaining patient safety. Currently, a specific, multi-dose vial or device is dispensed to each patient during hospitalization as recommended in the best practices guidelines from CDC and ASHP. Any unused portion of the insulin is discarded once the patient is discharged or after the insulin vial has been opened for 28 days. Using the electronic patient database, the actual doses of insulin received by patients during their entire hospital stay were reviewed retrospectively. The primary outcome was to estimate the percentage of patients who received insulin less than 300 units during their entire stay. The secondary outcome was to review the pattern in prescribing and dispensing that might contribute to the excess cost. Adult internal medicine and surgical patients receiving subcutaneous insulin admitted within a 4-week period were evaluated. Patients exclusively on insulin pump were excluded. With the data collected, we could project the potential savings by converting from 10mL insulin vials to 3mL vials. Additional interventions would be proposed to contain the cost of insulin. Results and conclusions will be presented.

STABILITY AND STERILITY TESTING OF PHARMACY COMPOUNDED EPINEPHRINE AND PHENYLEPHRINE SYRINGES (C1). Long Tran, Amine Ale Ali. Stanford Hospital and Clinics, Stanford, CA (lotran@stanfordmed.org). IRB approval not needed. The objective of this study is to evaluate the stability and sterility of pharmacy compounded epinephrine and phenylephrine syringes in order to potentially reduce pharmacy costs due to medication waste and out-sourcing. All compounding will be performed using aseptic technique in a USP 797 approved IV preparation room. Epinephrine and phenylephrine dilutions will be prepared in 100 ml 0.9% sodium chloride for injection to a concentration of 10 mcg/ml and 100 mcg/ml, respectively. 3 milliliters of the resulting dilutions will be drawn into 5 ml syringes and sealed with a red syringe cap. Four syringes for each compound will be kept at room temperature and the other half will be refrigerated. Daily temperatures will be recorded in order to stay within a defined range, 3 to 6 C for refrigerated syringes and 22 to 25 C for room temperature syringes. All samples will be stored in a light-protected bag to minimize exposure. Aliquots will be analyzed at days 0, 14, and 28 for stability. Physical stability will be assessed by visual examination for color changes and presence of precipitation. Chemical stability will be determined with the use of highperformance liquid chromatography (HPLC) analysis. Aliquots from each syringe will be incubated at the beginning of the study for two weeks to gather sterility data. Results and conclusions will be presented.

SELF PERCEIVED READINESS FOR RESIDENCY: RESULTS OF A NATIONAL POSTGRADUATE YEAR 1 SURVEY (C1). J Truong, M Barnett, E Ip, T Tang, K Knapp, J Teeters. Touro University College of Pharmacy, Vallejo, CA (julie.truong@tu.edu) IRB exempt. A thorough literature search suggests that surveying of postgraduate year one (PGY1) residents of self perceived readiness for residency is a novel endeavor. The purpose of this study was to: 1) assess PGY1 resident self perceived readiness for a residency program; and 2) examine resident level factors impacting self perceived readiness. Residents in an American Society of Health System Pharmacists (ASHP) accredited PGY1 program were emailed an individualized invitation to take an online survey. The survey collected demographics (e.g., age, gender, race et al), other information (e.g., pharmacy school attended, year graduated, prepharmacy education et al) along with self ratings (5 point Likert scale) of readiness for residency training. Areas of training readiness were stratified by: 1) organization/time management skills; 2) foundational/clinical skills; 3) project research skills and; 4) communication skills. A total of 533 usable surveys were returned for a final response rate of 29.6%. Comparisons were made using T Tests and ANOVA for continuous data, Chi Square tests for categorical data and Wilcoxon Rank Sum Test for Likert scale responses. Results and conclusions (forth coming) will be presented.

UTILIZATION AND COSTS ASSOCIATED WITH PHOSPHODIESTERASE TYPE 5 INHIBITORS, ENDOTHELIAN ANTAGONISTS AND PROSTANOIDS FOR TREATMENT OF PULMONARY HYPERTENSION (C1), Curtis Wander. SelectHealth, Inc., Murray, UT. (Curtis.Wander@SelectHealth.org) IRB approved. The objective of this study is to evaluate utilization and costs associated with phosphodiesterase type 5 (PDE5) inhibitors, endothelian antagonists and prostanoids, as well as the resulting medical cost outcomes associated with treatment with these medications. The study will utilize a retrospective analysis of members enrolled with SelectHealth from January 2008 through December 2009. Data will be collected from pharmacy and medical electronic claims databases and electronic medical records for members with paid medical claims for ICDs related to pulmonary hypertension and paid pharmacy claims for PDE5 inhibitors, endothelian antagonists or prostanoid medications. Medication costs will be measured as the amount paid by SelectHealth. Medical outcomes will be compared using hospitalization rates and costs secondary to pulmonary hypertension. Analysis of the treatments will be conducted to identify dosing regimens being utilized for each treatment. Results and conclusions will be presented.

EVALUATION OF PATIENTS ON TUMOR NECROSIS FACTOR INHIBITORS AND ABATACEPT FOR APPROPRIATE THERAPY (C1). Sarah Wenger. Denver VA Medical Center, Denver, CO (Sarah.Wenger@va.gov) IRB approved. Tumor necrosis factor (TNF) inhibitors and the immune modulator abatacept are FDA approved for a variety of autoimmune diseases including: Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Plaque Psoriasis, Ulcerative Colitis and Crohns Disease. All of the TNF inhibitors have more than one indication from the list of autoimmune diseases described above. The dose and frequency of administration is dependent on the indication and varies between medications. Due to the multitude of dosing regimens for each drug, there is increased risk and potential for error. Inappropriate dosing is not only dangerous, but can also be very costly. The potential for prescribing errors and high cost make evaluation and appropriate utilization essential. This retrospective analysis of current prescribing practices of TNF inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab) and abatacept at the Denver VA Medical Center determined the proportion of patients receiving appropriate dose, duration and frequency according to indication. Data was collected for patients prescribed a TNF inhibitor or abatacept as an outpatient between October 1, 2008 and March 31, 2010. All patient specific data was collected using the VA computerized patient record system. Descriptive statistics were utilized for the data analysis. Results and conclusions will be presented.

C2 Technology Management

EFFECTS OF COMPUTER PRESCRIBER ORDER ENTRY IMPLEMENTATION ON CORE MEASURE COMPLIANCE RATES (C2). Jody Adams, Stacy Shadburne, Sarah Bemis, Jennifer Davis. Exempla Lutheran Medical Center, Wheat Ridge, CO (adamsj@exempla.org). IRB approved. The purpose of this study is to evaluate core measure compliance rates related to heart failure, acute myocardial infarction, pneumonia and surgical care prior to and after initiation of computer prescriber order entry (CPOE) at Exempla Lutheran Medical Center. Core measure compliance rates from January 2010 to October 2010 at Exempla Lutheran Medical Center were obtained from the Quality Decision Support department. Preliminary evaluation was conducted to describe the processes employed that encourage core measure compliance without the use of CPOE or computerized order sets. Computer prescriber order entry was implemented on December 4, 2010. Data summarizing core measure compliance rates from December 4, 2010 through March 2011 will be evaluated and compared to 2010 data. Appropriate statistical tests will be performed to identify significant differences in core measure compliance rates. Further investigation based on evaluation of statistical data will be conducted to identify areas of opportunity and determine the need for process improvement related to core measure compliance. Statistical data and conclusions will be summarized and presented.

THE ROLE OF A RESIDENT PHARMACIST IN TECHNOLOGY AND STANDARDIZATION OF SMART PUMPS IN REDUCING AND PREVENTING MEDICATION ADMINSTRATION ERRORS (C2). Matthew Ancheta. Desert Regional Medical Center, Palm Springs, CA (matthew.ancheta@tenethealth.com) IRB not needed. Intravenous (IV) administration of medication represents the greatest risk of possible medication errors. Smart pump technology utilizes dose error reduction (DER) software to provide a major step forward in the safeguard of drug administration at the bedside. DER software can be customized to meet the specific needs of various practices throughout the hospital. The implementation of smart pumps is a multidisciplinary approach to include physicians, nursing, biomedical, information services, and central supply. An essential component of continuous quality improvement (CQI) is the availability of clinical reports extracted from the pump database, which is vital for improving the safety of IV infusions. Current CQI data suggests that smart pump technology has contributed to a culture of complacency; where as long as the drug delivered falls within the dose error guidelines then the dose must be safe and appropriate. Smart pumps add another layer of safety to the prevention puzzle but cannot replace sound clinical judgment. We describe the implementation of DER technology experience at DRMC and the role of the pharmacy resident in technology implementation and medication safety enhancements.

OPTIMIZATION OF DRUG INTERACTION ALERTS (C2), Naz Askari. Palomar Pomerado Health, Escondido, CA (Naz.askari@pph.org) IRB approved. The objective of this study was to determine the number of drug drug interaction, drug duplication and drug allergy alerts that fire, and to implement database customizations to reduce computer alert fatigue for pharmacists. Following a Centers for Medicaid and Medicare Services survey in 2008, the pharmacy department implemented a quality improvement project to reduce the number of drug interaction alerts. Conducting a quality improvement project on drug duplication and drugallergy alerts will further reduce the number of alerts experienced daily. Drug interaction alerts were reviewed for potential improvements. A baseline audit of computer alerts was performed at Palomar Pomerado Health. Drug interactions, drug duplications, and drug allergy alerts that fired during pharmacist order entry for 5, 1, and 10 days, respectively, were downloaded from Cerner. Each drug drug interaction alert was assigned a significance level based on Hansten and Horns Drug Interactions Analysis Management. In collaboration with clinical pharmacists specific actions were assigned to each interaction. The drug duplication and drug allergy alerts were classified according to their drug categories, e.g. opioids, antibiotics, etc. Once classified the drug categories were assigned a specific action: 1) Suppress alert, 2) Customize alert 3) no change on current alert, 4) no change on current alert but create a procedure to address the alert. After the actions are implemented, a repeat audit will be conducted to determine the new alert rate. Results and conclusion will be presented.

EVALUATION OF A COMPUTERIZED DECISION SUPPORT SYSTEM FOR STRESS ULCER PROPHYLAXIS IN HOSPITALIZED PATIENTS (C2), Andrea Carder. VA Sierra Nevada Health Care System, Reno, NV (andrea.carder@va.gov) IRB approval pending. The objective of this study is to determine whether use of a computerized decision support system increases appropriate and cost effective prescribing of acid suppressive therapy for stress ulcer prophylaxis in hospitalized patients. Proton pump inhibitors and histamine 2 receptor antagonists are often initiated or continued for the prevention of stress ulcers without appropriate indications present. Additionally, studies suggest that these agents may be associated with increased rates of Clostridium difficile associated disease and pneumonia. In an effort to increase appropriate, cost effective prescribing and reduce adverse events, a computerized decision support tool was developed. This tool outlines indications for stress ulcer prophylaxis and guides prescribers to initiate medication therapy when appropriate. Following review by the Pharmacy and Therapeutics committee, the tool was implemented and medical staff was educated. A retrospective chart review of a three month period in 2010 and in 2011 will be conducted to evaluate prescribing patterns both prior to and following implementation. A total of 100 non ICU medical and surgical patients admitted to the VA Sierra Nevada Health Care System will be reviewed. The primary outcome is rate of appropriate prescribing of acid suppressive therapy. Secondary outcomes include appropriateness of continued therapy and

cost effective analysis of patients reviewed. Results and conclusions will be presented.

THE IMPACT OF MAIL ORDER PHARMACY ON MEDICATION ADHERENCE AND HEALTH OUTCOMES IN DIABETIC PATIENTS (C2). Sarah Chou, Annet Arakelian, Eunis Ngor, MaryHelen Black. Kaiser Permanente Medical Care Program, Panorama City, CA (sarah.x.chou@kp.org) IRB approved. Mail order pharmacy is a convenient service that can help patients overcome certain barriers to obtaining their medications. The purpose of this retrospective cohort study is to describe and compare medication adherence rates between mail order and local pharmacy users with type 2 diabetes within Kaiser Permanente, and to explore differences in clinical outcomes associated with each group. Patients were included if they were 18 years of age or older, had a pharmacy drug benefit, had type 2 diabetes, and were prescribed a new antihyperglycemic medication between January 1 to June 30, 2009. Adherence was measured using the Medication Possession Ratio (MPR) and was calculated from initial dispensing to a maximum of 12 months of follow up, medication discontinuation, or June 30, 2010. Change in glucose control was assessed by difference in Hemoglobin A1C (HbA1c) between index medication dispensing and end of follow up. Statistical tests will be used to describe the demographic and clinical characteristics associated with each group, analysis of adherence between groups, and association between mail order pharmacy use, adherence and HbA1C. Results and conclusions will be presented.

A RETROSPECTIVE DATABASE TIME ANALYSIS OF NOW MEDICATION ORDERING (C2). Anita Chu. Michelle Wilhardt. Todd Rowland. Phoenix VA Health Care System, Phoenix, AZ (anita.chu2@va.gov) IRB approved. The objective of this study is to describe variations in the time when medications are ordered by prescribers in the Computerized Patient Record System (CPRS) as now orders, and when the now orders are documented as being administered via Bar Code Medication Administration (BCMA). This is a retrospective, database study. Now orders for inpatients admitted to Internal Medicine, Surgery, and Intensive Care Units (ICUs) from September 15, 2009 to September 14, 2010 may be included in this study. Data will be extracted from the medical record utilizing a File Manager (FileMan) report, and quality assurance will be performed on a limited number of charts using CPRS. The primary objective will quantify the time between when a provider orders the now order in CPRS, when the pharmacist verifies the now order, and when the nurse documents the now order as being administered via BCMA. The secondary objectives will stratify the times by time of day medication is ordered, medication type, ward, month of the year, day of the week, and by staffing hours. Results and conclusion of this project will be presented.

INCREASING PATIENT SAFETY THROUGH IMPLEMENTATION OF A FORMAL PROCESS FOR MANAGING RISK EVLAUATION MITIGATION STRATEGIES (C2). Chris Cook. Carol Vanevenhoven. Anthony Haralson. Scott VanHorn, Angela Stewart. Yakima Valley Memorial Hospital, Yakima, WA (ChristopherCook@yvmh.org) IRB exempt. The Food and Drug Administration Amendments Act (FDAAA) of 2007 gives the FDA the authority to require manufacturers to develop Risk Evaluation and Mitigation Strategies (REMS) to increase medication safety. REMS are required for medications that have an increased potential to harm. The four components of REMS are; an additional medication guide, a communication plan, elements to assure safe use, and an implementation system, or combinations of these components. There are currently 160 medications with requirements for implementation of one or more aspects of the REMS program. An efficient process for fulfilling the REMS requirements is paramount to providing safe and quality patient care. A formal process for managing REMS requirements will be incorporated into pharmacist workflow for inpatients and outpatients. The improved workflow processes will be based on optimizing patient safety not just fulfilling the requirements of the REMS. Combinations of order entry hard stops, a REMS database, and the pharmacist intervention systems will be utilized to provide better patient education while maximizing workflow efficiency. Rates of adherence to requirements will be assessed before and after program implementation.

IMPROVING WORKFLOW IN THE IV ROOM: IMPLEMENTATION OF DOSEEDGE SOFTWARE (C2). Alan DeMartini, Steven Chinn. Lucile Packard Childrens Hospital at Stanford, Palo Alto, CA (ademartini@lpch.org) IRB approval not needed. The preparation and documentation of sterile medication doses is a manual and time intensive process. Increased drug recalls to the patient level as well as increased state and federal regulations are causing dose preparation time to increase due to additional steps in the pharmacy process, primarily, documentation. The objective of this study is to determine the amount of time required to prepare and document an intravenous dose before and after the implementation of Baxa DoseEdge Pharmacy Workflow Manager. In the current process, a label is generated by a pharmacist and given to the technician. The technician then picks the correct medication, prepares it, and manually documents its manufacturer, lot number, and expiration date. DoseEdge however, places the order in a queue from which the technician selects the medication to prepare and then prints the label. The technician then picks the correct medication and prepares it. DoseEdge provides digital image capture of the source container and thus eliminates the need for manual documentation of manufacturer, lot number and expiration date. The preGoLive and post-GoLive data were collected by observing the time required to prepare each dose from the time the technician receives the label to the time the dose is prepared, documented and ready for final check by the pharmacist. Results and conclusions will be presented.

DEVELOPMENT OF A TRANSDERMAL MEDICATION PATCH PROTOCOL IN A COMMUNITY HOSPITAL (C2). Kaylee Drenker. Deborah Burr. St. Lukes Magic Valley Medical Center, Twin Falls, ID. (drenkk@mvrmc.org) IRB not needed no human subject data. The objective of this project was to improve patient safety by standardizing management of transdermal medication patches throughout the hospital. Because of the recent FDA warnings regarding medication patches, a survey was conducted to assess our current practices and found a lack of consistency between departments within the hospital. A protocol was developed to standardize management of medication patches from admission to discharge. The protocol addresses assessment of patients, documentation, removal, and wastage of transdermal medication patches as well as management of medication patches during imaging studies. A chart audit assessing appropriate documentation of placement and removal of medication patches was conducted before and after implementation of the protocol. Results will be presented.

OPTIMIZING PHARMACIST INTERVENTIONS IN AN INTERDISCIPLINARY FALL RISK REDUCTION PROGRAM (C2). Jocelyn Frey, Michelle Murray. Legacy Health, Portland, OR (jefrey@lhs.org) IRB approved. The study objective is to assess the impact of implementing a Best Practice Advisory in the Epic electronic health record to identify patients at increased risk of falling, and subsequently trigger a comprehensive medication review by pharmacy. All pharmacists received education on the impact of medications on falls and how to complete a fall risk medication review. A knowledge evaluation was completed by all pharmacists before and after fall risk education. All facilities within Legacy Health initiated a best practice bundle of interdisciplinary interventions targeted at reducing inpatient falls. Only one hospital in our system has implemented the Epic electronic health record. Within Epic, a Best Practice Advisory was triggered to prompt initiation of a comprehensive medication review by a pharmacist in patients with a Morse fall risk score greater than or equal to 45, one or more targeted medications that may increase fall risk, and age greater than or equal to 55 years. Pharmacists then communicated any recommendations from their medication review to the patients physician. Outcomes to be measured are overall patient fall rates and pharmacist knowledge before and after targeted education. The hospital with the Epic Best Practice Advisory in place will be compared to other facilities without the Epic electronic health record. Results and conclusions will be presented.

MEDICATION ORDER ERROR RATE AFTER COMPUTERIZED PRESCRIBER ORDER ENTRY IN THE NICU (C2), Matt Gebarski, Craig Herzog, Sara Ridges, Franklin Huggins. University of Utah Hospital, Salt Lake City, UT (matt.gebarski@hsc.utah.edu) IRB Approval received. The objective of this study is to observe the change in the baseline medication order error rate and categories for neonatal ICU patients after the implementation of computerized prescriber order entry (CPOE.) After review of all available medical literature on the subject, a beforeafter study design was chosen to achieve our primary objective. Baseline order error rate and category were obtained from a previous study by our group of the same unit using hand written orders. Since that time, CPOE has taken over all orders for medications with the exception of TPNs. All NICU medication orders during the study period were included for review. Data collection was performed by NICU specialty pharmacists who review NICU patient medication profiles as part of their daily care. Medication order errors encountered were recorded using a data collection form similar to the one used in our previous study. For each order deemed in error, the date, medication involved, and patient identifiers were recorded. Data collection will take place over two months, after which medication order error rate will be calculated and compared to our baseline data. Medication order errors identified will be classified by the primary researchers in a blinded fashion according to a standardized system. Results of this review will be presented at Western States Conference and submitted for publication.

EVALUATION OF DRUG-DRUG INTERACTION ALERTS WITH A COMPUTERIZED PHYSICIAN ORDER ENTRY SYSTEM IN A COMMUNITY HOSPITAL (C2), Yevgenia Gorodinsky. Long Beach Memorial Medical Center, Long Beach, CA (ygorodinsky@memorialcare.org) IRB approval pending. The primary objective of this study is to analyze how implementation of a clinical decision support system through drug-drug interaction alerts, specifically those involving antimicrobial agents, affects clinicians prescribing behavior. Data was collected for patients hospitalized at Long Beach Memorial Medical Center who had drug-drug interaction alerts that fired upon order entry over a 6 month period. The primary data of interest collected was the different classes of drugs for which drugdrug interaction alerts fired and how many of these alerts seen by clinicians were overridden or accepted. Additional data collected included the antimicrobial drugs involved, indication for antimicrobial therapy, any pertinent cultures, and vital signs or lab results that could aid in determining the need for the specific medication. Descriptive analysis was performed to determine whether the acceptance of the alert was appropriate. Alerts that were acted upon by healthcare providers other than physicians and their representatives, such as nurses and pharmacists were excluded from this study. Results and conclusions will be presented.

THE EVOLUTION OF MEDICATION ERRORS AFTER COMPUTERIZED PRESCRIBER ORDER ENTRY (CPOE) IMPLEMENTATION (C2), Lara Haddad. NorthBay Medical Center, Fairfield, CA (lhaddad@northbay.org) IRB approved. The main objective of this research is to analyze the effects of Computerized Prescriber Order Entry (CPOE) on medication errors. CPOE has revolutionized the healthcare system but needless to say, this new process is a major adjustment for everyone involved in patient care. With any fundamental change, there are obstacles that must first be overcome before any benefits can be realized. Studies have shown that the time period directly following the launch of CPOE is when the majority of system problems surface and have the potential to cause serious medication errors. Therefore, it is essential that institutions adopting CPOE are well informed about the issues to expect in order to strategize a seamless plan for system conversion that minimizes errors and potential harm to patients. Changes in medication errors due to CPOE were analyzed retrospectively by comparing the quarterly Medication Error Reports one year before and one year after CPOE implementation at NorthBay Medical Center. In addition, a questionnaire was voluntarily completed one year after the launch of CPOE by NorthBay Medical Center prescribers in order to gather qualitative data which may help prioritize decision making regarding CPOE implementation. Results and conclusions will be presented.

IMPLEMENTATION OF AUTOMATED DISPENSING MACHINE PATIENT-SPECIFIC PROFILING IN THE EMERGENCY DEPARTMENT (C2). Karalea Jasiak, Dan Hays. University of Arizona, Tucson, AZ (jasiak@pharmacy.arizona.edu) IRB approved. The objectives of this study were to characterize medication overrides and evaluate nursing satisfaction with automated dispensing machines (ADMs) before and after the implementation of patient-specific profiling in the emergency department (ED). A retrospective analysis involving all medications removed from the ADMs in the ED during a 10-day time period approximately one month post-implementation of patient-specific profiling was completed. The description of the medication removed, the date and time of removal, and whether the medication was removed via the override function or not was recorded. Medications removed from ADMs via the override function were linked to the electronically written physician order to determine the time relationship and identify variances between the physician order and medication removed. A 5item survey instrument was also utilized to assess nursing satisfaction with ADMs pre- and post-implementation of patient specific profiling in the ED. Results and conclusions will be presented.

EFFECT OF COMPUTERIZED PHYSICIAN ORDER ENTRY IMPLEMENTATION ON RATE OF MEDICATION ERRORS IN A HOSPITAL SETTING (C2), Alexis Joy, Jennifer Davis, Jason Cardona. Exempla Lutheran Medical Center, Wheat Ridge, CO (joyal@exempla.org). IRB approved. The objective of this study was to determine the effect of computerized physician order entry (CPOE) on the rate of medication adverse events at Exempla Lutheran Medical Center. Exempla Lutheran Medical Center implemented CPOE in December 2010. Prior to CPOE the pharmacy department was responsible for the transcription of orders written by the ordering physicians. Following CPOE implementation, the pharmacy department continued to intercept these orders, however for verification rather than transcription. Using a standardized data collection form, the pharmacy department evaluated all received medication orders for medication errors. Three one week surveys were conducted, with one data collection period conducted prior to CPOE implementation and two data collection periods conducted post CPOE implementation. Information collected included the medication involved, severity of the error, and the error mode. This information was then analyzed for differences surrounding CPOE implementation. Additionally, differences in the rate of self-reported errors were assessed. A self-reporting medication error system was analyzed prior to CPOE implementation during the months of January, February and March for 2010, and post CPOE implementation for the months of January, February and March for 2011. Results and conclusions will be presented.

DRUG-DRUG INTERACTION AND DUPLICATE MEDICATIONS CLINICAL DECISION SUPPORT EFFECT ON PHARMACISTS INTERVENTIONS (C2), Vincent Le, Stephanie Ferrell, Vipul Patel. Cedars-Sinai Medical Center, Los Angeles, CA. (vincent.le@cshs.org) IRB not needed. Evidence based guidance for clinical decision support (CDS) is limited thus the importance of developing a strategy for decision support lies in the clinical implications which result when optimizing therapy for patients while avoiding alert fatigue. To date, there are limited numbers of studies assessing the use of CDS by pharmacists. Approximately one year after the initiation of a new pharmacy information system, Cedars Sinai implemented CDS for drug-drug interactions and duplicate medications. The objectives of this study are to: evaluate the impact of CDS on quantity and category of pharmacist interventions related to drug-drug interactions and duplicate medications prior to and after CDS; determine if any correlation exists with implementation of CDS alerts and actions taken by the pharmacist based on severity level; and identify which alerts should be maintained and deployed in computerized physician order entry (CPOE) based on clinical significance and low

frequency of override. Evaluation of the frequency of alerts, types of interventions, and alert overrides post implementation of CDS will provide additional data to guide on the development of strategies to ensure optimal benefit of the CDS alerts and as well as to minimize the chances of alert fatigue.

IMPROVING CLINICAL PHARMACIST INTERVENTION DOCUMENTATION BY IMPLEMENTING AN ELECTRONIC HEALTH RECORD BASED DOCUMENTATION SYSTEM (C2), Ming na Lee, Jerry Gonzales, Tom Jurewitz, NorthBay Healthcare, Fairfield, CA (tlee@northbay.org) IRB approved. Pharmacists conduct interventions, however poor documentation practices can undermine administrative efforts to accurately estimate the value of clinical pharmacy services. The main objective of this study is to improve the documentation rates of clinical pharmacist interventions by implementing a documentation form integrated in both the patient electronic health record and the pharmacy order entry system; the secondary objectives are to improve transitioning workflow between pharmacists and identify areas where infrastructure and methodology are needed to facilitate and improve quality of interventions. The study design is a prospective observational, crossover study comparing the number of interventions documented over one month prior to and after initiating documentation form; subanalyses include comparing documentation rates between pharmacists, between pharmacist shifts, and percentage of incomplete tasks. Surveys will be conducted to evaluate pharmacist satisfaction and generate ideas to improve the documentation system. The results will be discussed to assess the value of the electronic health record based documentation system.

PHARMACY OUTREACH USING THE RAND EPRESCRIBING TOOLSET (PORT) PILOT STUDY (C2). Elisa Ashton. Sokkim Lim. UC San Francisco, Department of Clinical Pharmacy, San Francisco, CA (sokkim.lim@dhcs.ca.gov) IRB approval pending. The study objective was to assess the usability and usefulness of the RAND Toolset and a pharmacy resident as resources in addressing barriers to ePrescribing in independent pharmacies. Pharmacy managers of Leader Pharmacies volunteered their pharmacies for the study during an information session. Pharmacy staff members of the participating Leader Pharmacies attended an orientation and training session on the use of the Toolset. The Toolset consisted of ePrescribing information related to workflow redesign, costs and benefits, and troubleshooting common problems. The pharmacies were also provided with technical and workflow support by corresponding with the eHealth Policy and Research Resident through phone, email, and on site visits. The pharmacies were given access to both resources in the course of their own ePrescribing implementation effort. At the end of the study, the participants completed surveys about the usability and usefulness of both resources. The data from the surveys were collected for analysis. The study period was 8 weeks. The inclusion criteria was employment at a Leader Pharmacy. Participants were excluded if they were not an employee of a Leader Pharmacy. Results and conclusions will be presented.

ELECTRONIC PHARMACY MANAGEMENT SOFTWARE FOR HIV CLINICS IN RESOURCELIMITED COUNTRIES (C2), Megan McCurdy, Elvin Geng, Peter Hunt, Jeff Martin, Jennifer Cocohaba. UC San Francisco, San Francisco, CA (megan.mccurdy@ucsf.edu) IRB approval not needed. Although pharmacists are in an optimal position to improve adherence and outcomes for patients receiving antiretroviral therapy, they remain an underutilized healthcare resource in developing countries. Four opensource electronic pharmacy management software programs used in HIV clinics in developing countries were evaluated for their ability to facilitate pharmacist impact in patient care. A tool was developed to qualitatively evaluate these pharmacy programs based on an assessment of the potential needs of pharmacists to practice higher-level medication management in a resource-limited setting. Six main functionalities were assessed: (1) patient medication history, (2) ARV dispensing, (3) adherence tracking, (4) clinical recordkeeping, (5) stock inventory control, and (6) pharmacy report generation. The four electronic pharmacy records evaluated were iDART, mSupply, OpenClinic, and the Joint Clinical Research Center Pharmacy Program. While all software programs performed patient medication history, ARV dispensing, and stock inventory-- none of the four met all of the criteria outlined in the qualitative assessment tool. Clinical recordkeeping and adherence tracking were limited in each of the programs. Improving pharmacy electronic management software in developing countries can improve the ability for pharmacists to play a more active role in HIV management.

THINKING SMART: A LOOK AT THE KEY FACTORS FOR A HIGHLY EFFECTIVE SMART INFUSION PUMP SYSTEM IN THE NICU (C2). Dat Ngo. Kaiser Permanente Medical Care Program, Downey, CA (dat.t.ngo@kp.org) IRB Exempt Recently, smart infusion pumps have received more attention in regards to preventing medication errors by serving as a 'double check' for nurses prior to medication administration. For the medical centers within Kaiser Permanente Southern California (KPSC), the Medfusion 3500 syringe pump have now been upgraded to include smart functions. These smart functions require the development of a drug library, which allow for dose limits to be applied to any IV medication given through the syringe pump. Even with an implemented drug library, each medical center should have a process to ensure utilization of these smart functions for patient safety. This study will look at how developing a comprehensive drug library correlates with an effective compliance rate. The study population focused only on syringe pumps in the NICU at different medical centers within KPSC. The important components for developing a complete drug library will be presented. For patient safety, a compliance rate in regards to smart function utilization was determined through a process that required physical audits and data mining from the syringe pump. By obtaining a high compliance rate through data, it would ensure that the smart infusion maximizes its ability to prevent medication errors. Also included in the study were the number of safety events documented by the syringe pump. Results and conclusions will be presented.

IMPLEMENTATION OF A REGIONAL PERFORMANCE MEASURE DASHBOARD TO MONITOR AND IMPROVE IMMUNIZATION STATUS (C2). Carrie Nolan, Jan Carmichael, Richard Pham. VA Sierra Pacific Network, Reno, NV (carrieann.nolan@va.gov) IRB approval pending. Public health data has shown that vaccinations prevent disease and result in cost savings, however infectious disease still accounts for a large percentage of physician visits and exacts a toll in treatment costs and lost productivity. The VA healthcare system has established performance measures for influenza and pneumococcal vaccines. The goal of this project was to develop a web based tool to assist administrators and clinicians to identify, track and improve adult immunizations recommended by the CDC for patients in the VISN 21 region, where care is provided for approximately 270,000 patients. Baseline documentation of current vaccination rates did not appropriately reflect guidelines, leading to the conclusion that either vaccination documentation is not accurate or patients are not being vaccinated. To help close this gap, an actionable real-time immunization dashboard was developed. Rates of vaccination for relevant adult immunizations (influenza, pneumococcal, Td/Tdap, HPV and zoster) were reported. Dashboard capabilities include drill down analysis to station, provider and patient level, and actionable reports integrated for future appointments and case managers. Results and analysis will be presented.

IMPLEMENTING A PROCESS FOR CATEGORIZING THE SEVERITY OF PRESCRIBING ERRORS INTERCEPTED BY PHARMACISTS (C2) Katherine Palmer, Rita Shane. Cedars-Sinai Medical Center, Los Angeles, CA (Katherine.palmer@cshs.org) IRB approval pending. The study objective is to evaluate the severity of prescribing errors intercepted by pharmacists utilizing a modified National Coordinating Council for Medication Error Reporting and Prevention error index and to validate the severity level using inter-rater reliability. Pharmacists categorize the severity of prescribing errors intercepted using the modified error index. Staff have been educated to ensure consistency in selection of the severity level. The data will be sorted by severity and validated by another pharmacist using inter-rater reliability. Physicians will also evaluate intercepted errors categorized as Life Threatening to validate the severity level. Intercepted errors will be evaluated based on the type of error, medications involved and patient populations to determine if there is any relationship between these subsets and the severity of intercepted errors. Analysis of errors that would be intercepted by computerized physician order entry will be conducted. Errors intercepted will be used as examples for education of pharmacists and physicians to improve prescribing practices and safe medication use. This information will be used to demonstrate the value of clinical pharmacy services in the prevention of medication errors. Ultimately, the results of this study will be incorporated into a clinical pharmacy dashboard to capture

the many clinical activities pharmacists complete each day. Results and conclusions will be presented.

IMPROVING MEDICATION SAFETY BY PROVIDING PHARMACISTS WITH PATIENT DIAGNOSIS ON ELECTRONIC PRESCRIPTION (e-RX) ORDERS (C2). Nisha Patel, Sandra Leal, Michael Rupp, Terri Warholak. El Rio Health Center, Tucson, AZ (nishap@elrio.org) IRB approved. The objectives of the project are to: 1) measure the incidence and nature of drug therapy problems that are identified by pharmacists when a diagnosis is transmitted with the prescription order 2) evaluate the likelihood, severity and cost of patient harm that was avoided by providing pharmacists with patient diagnosis on the eprescription order. Pharmacists in the in-house pharmacy will be asked to record all medication therapy interventions they make on e-Rxs during the study period. Medication therapy interventions will be recorded on a data collection form. Medication therapy problems of interest will include inappropriate drug, excessive dose, excessive quantity/duration, insufficient dose, insufficient quantity/duration, inappropriate dosage form, duplication of therapy, drug-drug interaction, drug allergy/sensitivity and drug disease interaction. Following a four week collection of baseline data, providers will begin to enter the diagnosis in the comment field for each new prescription for another four week period. We anticipate that this project will improve the continuity and quality of care provided to our patients by enhancing interdisciplinary community. Additionally, we anticipate utilizing data derived from this project to increase organization-wide sensitivity to the importance of continuous quality improvement in mission-

critical activities. Results and conclusions will be presented.

QUANTIFYING PHARMACIST CLINICAL INTERVENTIONS (C2) Gustavo Perez. Tucson Medical Center, Tucson, AZ (gustavo.perez@tmcaz.com) IRB approval received. The objective of this project is to standardize the documentation and stratify clinical interventions performed by pharmacists. As technology advances and with the drive to decrease healthcare costs, the justification of clinical pharmacy services is necessary. The addition of more specific categories will streamline documentation and better evaluate the pharmacist activities. Pharmacist interventions in all areas will be included. Baseline intervention data will be collected for February 2010. Inservices will be provided to the pharmacists reviewing the new intervention categories and procedure in January 2011. Post implementation data will be gathered for February 2011. Data from the same month, one year apart, will prevent census and patient type variability. The data will be compared between the 2010 and 2011 time periods to assess the impact of the new intervention category types. The number of interventions will be shown weekly on the pharmacy homepage as an indicator of activity. Additionally, time spent on vancomycin, IV to PO, and chemotherapy interventions will be collected and used later to develop cost avoidance values for those pharmacist activities. The results and conclusion will be discussed.

DEVELOPMENT OF A QUALITY ASSURANCE PROGRAM FOR INPATIENT PHARMACY AUTOMATION SYSTEMS (C2), Bryan Sandlund, Andrew Cheung, Scarlett Eckert. UCSF Medical Center, San Francisco, CA (bryan.sandlund@ucsf.edu) IRB not needed-no human subject data. UCSF medical center recently implemented a robotic automation system for patient cassette fill, in an attempt to reduce potential human error and streamline production. The automation system is located at an offsite facility; scheduled patients medications are delivered twice daily to the hospital. Initial validation of the system was performed by 100% checks of all unit dosed products and scheduled fills. Results from these 100% checks revealed regular checking was unnecessary if the system was functioning properly. In order to ensure continued operation of the automated systems, we developed a Quality Assurance (QA) program to track system performance. The QA system tracks accuracy of the system at critical steps including: medication inventory procurement, medication loading and unloading, unit dosing, medication storage, and order entry communication. Results from the QA program and conclusions will be presented.

TRACKING COMPETENCY ACHIEVEMENT IN A NEWLY IMPLEMENTED LONGITUDINAL PHARMACY PRACTICE COURSE FOR SECOND YEAR PHARMACY STUDENTS (C2). Nathan Shipman. Pacific University, Hillsboro, OR (ship8034@pacificu.edu) IRB not needed no human subject data. The objective of this project is to develop a portfolio system that will allow students and faculty to document and track competency progress in a year-long pharmacy practice course. Our current experiential education management system has the capability to include a user-specific electronic portfolio that is customizable. Major project phases included working with the software vendor to receive training and determine customization options, meeting with current faculty to map out functionality of the system, and building portfolio templates. The system is expected to be tested and fully functional before fall 2011 classes begin. The results will be a work in progress as this project will continue the following year and is the first step in a multipart expansion of documenting student performance and achievement across the curriculum. Results and conclusions will be presented and discussed.

IMPLEMENTATION OF A PHARMACY INFORMATICS APPLICATION TO MAINTAIN REGULATORY COMPLIANCE (C2). Nathan Singer, Brett Brodowy. UC San Francisco Medical Center, San Francisco, CA (nathan.singer@ucsf.edu) IRB approval not needed - no human subject data. The purpose of this project is the implementation of a pharmacy informatics solution at the University of California, San Francisco (UCSF) in order to maintain compliance with California State Board of Pharmacy (BOP) regulations regarding record keeping for compounded medications. This includes tracking the lot and expiration of all products involved in medication compounding. The UCSF Medical Center and Benioff Childrens Hospital is a 722 bed academic medical center. In 2010, the BOP passed regulations which included extensive record keeping requirements for pharmacies that compound medication. Interim solutions were utilized at UCSF, but a final solution was required. Selection criteria for a system to meet these requirements included cost, efficiency, and adequacy of meeting BOP regulations. The project was initiated with a definition of the project goals, as well as identification of a project manager and key decision makers. Planning for the project required development of a project scope, timeline, milestones, and metrics. It also included consideration of resources, issues resolution, and quality assurance (QA) testing. Once the final details of implementation have been agreed upon, project execution will begin, including installation, go-live, and testing of the system. The conclusion of the project will require clear reports to management on the success and

or/challenges of the project, the outcomes achieved and the results of the QA testing. Results will be presented.

EVALUATING THE IMPLEMENTATION OF A COMPREHENSIVE MEDICATION ENTERING TOOL ON MEDICATION RECONCILIATION ACCURACY FROM ADMISSION TO DISCHARGE (C2). Lisa Vogel. Tucson Medical Center, Tucson, AZ (lisa.vogel@tmcaz.com) IRB approved. The study objective is to determine if implementation of an electronic medication reconciliation tool entitled discrete sigs into the electronic medical record (Epic) of a community teaching hospital will increase the overall accuracy of medication reconciliation from admit to discharge. Furthermore, the results will be examined in multiple categories of discrepancies and will be quantified to analyze trends. Data will be collected retrospectively from the charts of 50 patients prior to implementation of the medication entering tool and again for 50 patients after implementation. Inclusion criteria are age greater than 18, and admit to the hospital to either the adult medicine or adult surgical units. The medication entering tool was implemented in December of 2010. Data collection for the pre implementation phase occurred in August of 2010 and for the post implementation phase during January and February of 2011. Medication regimens for each subject will be reviewed at admission and discharge and evaluated for discrepancies. The results will be evaluated using ANOVA or two tailed t tests as appropriate. Results and conclusions will be presented.

WORKLOAD BALANCING IN OUTPATIENT PHARMACIES (C2), Johnny Wong. Kaiser Permanente Medical Care Program, Downey, CA (Johnny.X.Wong@kp.org) IRB approval exempt. The cost of healthcare has been increasing 2.4% faster than GDP since 1970 and per CMS projections, healthcare spending will be over $4.3 trillion by 2018. With the rising cost of healthcare and the increasing use of pharmaceuticals, there is a need to keep pharmaceutical cost affordable. In a typical outpatient pharmacy, workload fluctuates throughout the day due to the unpredictable nature of patient needs. Advances in technology and automation have provided new opportunities for remote distribution of workload and processing of prescriptions across multiple outpatient pharmacies. The Downey Service Area aims to explore these new opportunities in order to advance the pharmacy business model. The purpose of this study is to determine how workload balancing fits into our current business practice. Remote workload balancing will play a role in increasing efficiency and productivity and help support the growing cost in the outpatient pharmacies. First, the existing pharmacy workflow will be evaluated and baseline workload data will be collected. Then rapid improvement model (RIM) testing will be conducted to determine workload balancing potential. Finally, the results from the RIM testing will be analyzed. A summary report of the process and results will be reported and discussed.

EVALUATION OF PHARMACIST INTERVENTIONS IN THE VA CARE COORDINATION HOME TELEHEALTH PROGRAM (C2) Daniel Worland. Jason Parrish. Scott Mambourg. VA Sierra Nevada Health Care System, Reno, NV (daniel.worland@va.gov) IRB approval pending. The project objective is to expand the care coordination home telehealth program to rural veterans where access to health care is often limited and to utilize the VA pharmacist scope of practice in the management of enrolled patients. The telehealth program specifically monitors diabetes, hypertension, chronic obstructive pulmonary disorder, and heart failure. For this project, telehealth candidates are identified by the pharmacy resident. Enrolled patients are issued a small electronic device called a health buddy. The patient answers questions from the health buddy, enters vital signs, and receives on screen education daily. Data is transmitted through a standard phone line to a care coordinator who reviews the information and alerts the pharmacy resident when health care goals are not met. The pharmacy resident collaborates with the patient to formulate, adjust, and reach treatment goals. The patients' primary care provider is consulted for issues outside the pharmacy resident's scope of practice. The project goal is to enroll 40 new rural health patients. Clinical outcomes will include patient targeted health goals compared to baseline including hemoglobin A1C, blood pressure, and low density lipoprotein. Hospital admissions, emergency room visits, and clinic visits will be compared to baseline. Average daily census will be evaluated. Results and conclusions will be presented.

IMPLEMENTATION OF A REGIONAL MEDICATION SAFETY DIGITAL DASHBOARD (C2), Samantha Wright, Jan Carmichael, Bob Coleman, Richard Pham, Joy Meier. VA Sierra Pacific Network (VISN 21), Reno, NV (samantha.wright2@va.gov) IRB approval pending. As patient advocates, pharmacists are tasked with utilizing processes and programs to ensure safe medication use. This projects objective is to enhance pharmaceutical care by developing intuitive clinical decision support systems to improve that optimize safe outpatient medication therapy. Evidence-based medication safety metrics will be designed, implemented, and monitored within a regional network of six medical centers with an interactive online digital dashboard. Sources for these metrics include the National Quality Forum, Veterans Health Administration initiatives, clinical practice guidelines, and package inserts. Metrics for initial inclusion were selected based upon feedback provided by healthcare professionals at each medical center using a modified Delphi process. The metrics will be displayed in an online clinical dashboard accessible by providers and pharmacists. Data for each metric will be obtained from clinical data warehouses and updated daily. Lists of specific patients not meeting each measure will be obtainable through the digital dashboard for intervention. The results of this implementation will be presented. Statistical analysis of performance on each metric will compare baseline results and results one to two months after implementation using general linear models. Conclusions will be discussed at the conference.

DEVELOPMENT AND IMPLEMENTATION OF COMPUTER DECISION SUPPORT FOR BASAL BOLUS INSULIN AND HYPOGLYCEMIA PREVENTION IN A VETERANS HEALTH CARE SYSTEM (C2). David Zhang. VA Sierra Nevada Health Care System, Reno, NV (david.zhang@va.gov) IRB pending. This is a descriptive study utilizing computerized decision support for inpatient insulin and hypoglycemia management in an effort to improve glycemic control and minimize hypoglycemia events. An insulin order menu was developed to assist physician prescribing of insulin therapies that were approved by our local endocrinology service and pharmacy & therapeutics committee. The order menu provides information on indications for use, target blood glucose, and supplemental orders required for basal bolus insulin and requests pharmacist involvement in initiating orders. Pharmacists, utilizing a newly developed progress note, calculate initial basal bolus insulin doses and document the initial insulin care plan. In addition, updates were made to the facilitys current hypoglycemia protocol and were built into computer decision support menus as well. Education was provided to medical staff on use of the order menu. The tools developed, including computerized decision support and progress notes, will be discussed. Clinical outcomes include glycemic control, hypoglycemic events, and appropriateness of prescribing based on the order menus. Results and conclusions will be presented.