Pharmacy and Pharmaceutical Sciences Commons^™

Issue 17: Pulmonary & Critical Care Insider, Bharat Bajantri Md, Sarah Ellsworth Mls, Stephanie Subart Pharmd

Critical Care & Pulmonary

Pulmonary & Critical Care Insider Issue 17

Compiled by Bharat Bajantri, MD, and librarian Sarah Ellsworth, MLS for the clinicians of the Pulmonary and Critical Care team of Parkview.

The Pulmonary & Critical Care Insider newsletter was created by Dr. Bharat Bajantri, MD and Sarah Ellsworth, MLS in 2023 as a form of current awareness for current practice at our hospital, Parkview Health.

Topics: 

• Management of Uncomplicated Gram-Negative Bacteremia
• Complicated Urinary Tract Infection Guidelines Update
• Ketamine vs Etomidate for RSI
• STORM-PE 
• Lung Ultrasound–Guided Weaning
•  D-Dimer for Pulmonary Embolism
• Extubation Failure
•  A Multimodal, physiology-Driven approach to pleural effusions
• Dexmedetomidine for Hyperactive …

Evaluation And Optimization Of Outpatient Parenteral Antimicrobial Therapy Laboratory Monitoring For Beta-Lactam Antibiotics., Stephanie Subart Pharmd, Trent Towne Pharmd, Bcps, Sarah Pehlke Pharmd, Bcps, Robert D. Beckett Pharmd, Bcps

Pharmacy Residency

Presented at the ASHP Midyear Clinical Meeting. New Orleans, LA

This evaluation found that among patients who experienced eosinophilia, only one exhibited signs of hypersensitivity, while seven required a change in therapy. This indicates that while eosinophilia is a concern, its direct clinical impact may be limited for the majority of patients. In the cohort experiencing elevated LFTs including AST, ALT, or alkaline phosphatase levels, fewer than 2% necessitated a change in therapy. This low rate suggests that routine LFT monitoring may not always correlate with significant clinical decisions, raising questions about the necessity of frequent lab draws.

Improving Prescription Capture Rates Through A Standardized Meds To Beds Program At Parkview Heart Institute, Haley Michaud Pharmd, Tara Jellison, Katelyn Wees Pharmd, Sarah Ferrell Pharmd, Shery Grosjean Pharmd, Inderjit Ajimal

Pharmacy Residency

Background

Objectives

Pro: The Use Of Sugammadex Does Not Preclude The Need For Objective Neuromuscular Monitoring., J Ross Renew, Dustin D. Linn

Parkview Pharmacy Department

Based on strong evidence, optimal management of neuromuscular block should incorporate objective (or quantitative) neuromuscular monitoring with appropriately dosed antagonists such as sugammadex. Sugammadex has the unique ability to antagonize aminosteroidal-induced neuromuscular block at any level; however, neostigmine is a reasonable alternative at minimal levels. Blind or excessive administration of sugammadex does not eliminate the risk of patients having postoperative residual neuromuscular block. Significant variability exists in how patients respond both to neuromuscular blocking agents and their antagonists.

Incorporating Pediatrics In Clinical Education: A Call To Action In Inpatient Pharmacy Practice., Caroline M Sierra, Amanda C Capino, Cober M Petrea, Lea S Eiland, Norm Fenn Bcps, Bcpps, Nicholas M Fusco, Lucas E Orth

Parkview Pharmacy Department

Background

The recently revised 2025 Accreditation Council for Pharmacy Education (ACPE) Standards state the expectations of Advanced Pharmacy Practice Experiences (APPEs) are to “emphasize continuity of care and incorporate acute, chronic, and wellness-promoting patient-care services…[and] expose students to diverse patient populations as related to age, sex race/ethnicity, socioeconomic factors…and disease states.”1 These expectations describe the conditions under which student pharmacists are expected to develop and demonstrate competence in the entrustable professional activities (EPAs), which were revised in 2022 to more accurately reflect current pharmacy practice.2 However, the definition of required APPE (Standard 3.2.d.) states that the inpatient patient …

Forecasting The Impact Of Artificial Intelligence On Clinical Pharmacy Practice, Adrian Wong Pharmd, Mph, Fccp, Trenton Flanagan Pharmd, Elizabeth W. Covington Pharmd, Elaine Nguyen Pharmd, Mph, Mba, Dustin D Linn Pharmd, Mba, Gretchen Brummel Pharmd, Brian Hoffmaster Pharmd, Mba, Diana Issacs Pharmd, Fccp, Sandra L. Kane-Gill {Harmd, Msc, Fccp

Parkview Pharmacy Department

There is a need to understand contemporary scientific advances as clinical pharmacy evolves. One rapidly expanding area is artificial intelligence (AI), which has grown significantly over the past year because of the public availability of large language models. This commentary reviews published literature describing and evaluating applications of AI to each aspect of the medication use process and forecasts potential future roles for AI in pharmacy practice. Potential challenges in implementation are also described.

Evaluation Of Corticosteroid Use In Pediatric Patients With Bronchiolitis, Kaitlyn Margraf Pharmd

Pharmacy Residency

Presented at Midyear Clinical Meeting.

Nearly 67% of pediatric patients treated for bronchiolitis received steroids with no underlying indication, which deviates from clinical guidelines. Patients who received steroids without an indication had an apparent trend toward more oxygen support and had an increase in maximum flow rate compared to patients with an indication for steroid use.

Use Of Finerenone For Chronic Kidney Disease In Type 2 Diabetes: A Cross-Sectional Study At A Large Health System, Robert D. Beckett

Parkview Pharmacy Department

Presented at the Midyear Clinical Meeting.

While most patients met individual KDIGO finerenone initiation criteria, fewer than one-third met all guideline recommended parameters. Guideline directed K+ monitoring following initiation was underperformed, highlighting a need for improved follow up Procedures.

Evaluation And Reduction Of Pediatric Precaution Alert Volume Across A Large Community Health System, Sarah Ferrell Pharmd

Parkview Pharmacy Department

Presented at the Midyear Clinical Meeting.

This evaluation found the potential to remove 15,174 alerts per year. Based off a physician spending a median of 8 seconds processing an alert, a reduction of 15,174 alerts per year saves about 34 hours of physician work-time per year.

Stool Rules: Evaluation Of Fidaxomicin Use Before And After Formulary Addition And Implementation Of Use Criteria, Anna Koeva Pharmd

Pharmacy Residency

Presented at the Midyear Clinical Meeting.

This evaluation found that appropriate use of fidaxomicin improved after addition to formulary with use restrictions, along with a decrease in 30-day CDI recurrence.

Naloxone Addition To The Nursing Admission Order Set: A Retrospective Review, Sydney Pelnick Pharmd

Pharmacy Residency

Presented at the Midyear Clinical Meeting

Nurse access to naloxone improved after implementation of standing order. Post-implementation outcomes demonstrated more appropriate use of naloxone. An increase in opioid utilization within 12 hours of naloxone supports a greater use for intended purpose.

Catch Flights, Not Rsv: Real-World Evaluation Of Respiratory Syncytial Virus (Rsv) Vaccine Use In Maternal And Older Adult Populations, Afamefuna Nzekwe

Pharmacy Residency

Present at the Midyear Clinical Meeting.

This evaluation found that most vaccinated patients met criteria. About 1/3 of newborns received RSV protection, but post-birth nirsevimab use could not be confirmed for non-Parkview patients.

Evaluating A Clinical Pharmacist's Role In An Internal Medicine Graduate Medical Education Primary Care Residency Clinic, Le Thien Truc Pham Pharmd

Pharmacy Residency

Presented at the Midyear Clinical Meeting

Approximately 98% of all survey participants were satisfied with the clinical pharmacy services. Diabetes management was found to be the most valuable pharmacy service.

Comparison Of Hypertension Outcomes In Pharmacist Managed Patients Versus Cardiology Provider-Only Care Models, Alexis Clarke Pharmd

Pharmacy Residency

Presented at Midyear Clinical Meeting.

In this study, pharmacist-managed patients achieved BP goal 80 days faster than provider-only patients. Integrating pharmacists into care teams helps patients achieve their BP goal faster through increased visits and closer follow-up. Pharmacist managed groups had less therapeutic inertia regarding drug class changes.

No Cap! Evaluation Of Empiric Antibiotic Duration For Community Acquired Pneumonia, Bailey Castato Pharmd

Pharmacy Residency

Presented at the Midyear Clinical Meeting.

This evaluation found that patients hospitalized for CAP (including severe) without culture data or with negative respiratory cultures met clinical stability criteria early in admission. The maximum time to clinical stability was approximately 5 days. However, total median antibiotic duration was 7 days (IQR 6.0- 8.7), resulting in 2 days (IQR 1.5-3.9) of excess antibiotics.

Evaluation Of A Pharmacist-Driven Electrolyte Replacement Protocol In A Community Health System, Corey Uetrecht Pharmd Candidate

Pharmacy Residency

This evaluation found a higher rate of pharmacist consults for electrolyte management, though these were not always indicated. Repletion via oral route was not optimized and there were opportunities for improvement in protocol alignment.

Presented at Great Lakes PRC

Implementation Of An Evidence Based Skin And Soft Tissue Infection Algorithm At A Large Community Health System, Jennifer Mccarthy Pharmd, Ms

Pharmacy Residency

This study found a continued need for an updated skin and soft tissue infection algorithm. Ongoing reliance on IV antibiotics suggests underutilization of oral options. Promoting oral antibiotic use may reduce inpatient admissions and length of stay.

Presented at OHIO PRC

Evaluating The Impact Of A Pharmacist-Led Wellness And Weight Management (Wwm) Service In The Primary Care Setting, Nicholas Buttermore Pharmd

Pharmacy Residency

This evaluation found superior weight loss from baseline with pharmacist management, along with comparable GLP-1 and non-GLP-1 use and considerable financial benefits.

Hypertensive Hijinks: Implementation Of An Emergency Department Hypertensive Emergency Order Panel, Caleb Hoppe Pharmd Candidate

Pharmacy Residency

This evaluation found that the order panel was effective in promoting rapid blood pressure attainment and appropriate antihypertensive dosing.

This was presented at the OHIO PRC.

Daratumumab Monotherapy: Reconsidering Relapsed And Refractory Multiple Myeloma Maintenance Therapy, Gabrielle O. Carreon Pharmd, Ms

Pharmacy Residency

Results from this study support the continued use of daratumumab monotherapy in carefully selected patients who may not be candidates for more intensive combination therapies due to age, comorbidities, or prior toxicities. However, further research is needed to confirm these early observations.

Presented at Great Lakes PRC

Silent Pressure: Outcomes Of As-Needed Antihypertensives In Hospitalized Adults*, Corey Uetrecht Pharmd Candidate

Pharmacy Residency

Presented at ACCP

This study found that PRN antihypertensives are frequently used for AEBP in hospitalized patients, despite limited benefit and potential risk of hypotension-related adverse events.

Development And Implementation Of An Analgesia, Sedation, And Paralysis Order Panel For Mechanically Ventilated Pediatric Patients At A Large Community Health System, Kristin Lytal Pharmd, Mspgx

Pharmacy Residency

This project describes best practices and steps taken in development of a protocol for analgesia, sedation, and paralysis in pediatric patients.

This was presented at OHIO PRC.

Levetiracetam-Induced Acute Kidney Injury In A Pediatric Patient, Makaila A. Geese Pharmd Candidate, Norm Fenn Bcps, Bcpps

Parkview Pharmacy Department

Presented at PPA Meeting.

Objective: To describe a case of acute kidney injury following levetiracetam administration in an adolescent patient.

Key takeaways:

Acute kidney injury (AKI) following levetiracetam is rare, especially in pediatric patients

Kidney injury was not correlated with supratherapeutic levetiracetam concentrations

Morganella Morganii Meningitis In A Neonate: A Case Report, Madelin Vessels Pharmd Candiadate, Cassie Rough Pharmd Candidate, Robyn Schmucker Md, Mph, Norm Fenn Bcps, Bcpps

Parkview Pharmacy Department

Presented at Midyear Clinical Meeting

Objective: To summarize the interventions that took place to add to the limited data that exists in the world surrounding the treatment and outcomes of M. morganii infections.

Key takeaways: 

• M. morganii meningitis is highly rare in neonates
• There are no defined treatment guidelines or outcomes available to date
• Cefepime sufficiently treated M. morganii meningitis, bacteremia, and concurrent E. coli urinary tract infection

Comparison Of Isoflurane To Sevoflurane In A Pediatric Patient With Refractory Status Asthmaticus: A Case Report, Janella Rianna N. Benitez Mba, Pharmd, Norm Fenn Bcps, Bcpps, Fashp

Parkview Pharmacy Department

Presented at Midyear Clinical Meeting.

Objective: To describe the use of inhaled anesthetics in a pediatric patient with severe, refractory status asthmaticus unresponsive to conventional therapies.

Implementation Of An Updated Intravenous Iron Order Panel In The Acute Care Setting: A Pre/Post Study, Robert D. Beckett

Parkview Pharmacy Department

Presented at Midyear Clinical Meeting

Implementation of the revised order panel led to reduced utilization including a reduction in the proportion of patients receiving IV iron, number of total doses, proportion of patients receiving more than one dose, and proportion of patients receiving more than 200 mg.

One Bolus, Many Benefits: Implementing Tenecteplase For Acute Ischemic Stroke, Robert D. Beckett Pharmd

Parkview Pharmacy Department

Presented at the Midyear Clinical Meeting.

Overall, no statistically significant differences in door-to-needle time or secondary outcomes between alteplase and tenecteplase groups was identified. This could relate to time in imaging and patient evaluation. Patients treated with tenecteplase showed greater bleeding risk versus alteplase, though these results were not statistically significant when accounting for baseline age in an exploratory regression. Patients who received tenecteplase were slightly older, on average.

Evaluation Of Terlipressin Use At A Community Health System, Robert D. Beckett Pharmd

Parkview Pharmacy Department

Presented at the Midyear Clinical Meeting.

Findings of this evaluation suggest opportunities to improve terlipressin utilization by sharing results back to Nephrology and GI and

reviewing P&T-approved criteria for use, implementing EMR alerts to reinforce dosing

protocols every 24-48 hours for dose adjustments

or discontinuation based on Scr trends (day 4 and

beyond), and supporting daily monitoring of fluid

and respiratory status.

Findings of this evaluation suggest opportunities to improve terlipressin utilization by sharing results back to Nephrology and GI and

reviewing P&T-approved criteria for use, implementing EMR alerts to reinforce dosing

protocols every 24-48 hours for dose adjustments

or …

Anticoagulation Strategies After Left Ventricular Thrombus., Corey Uetrecht Pharmd, Jennifer Sposito Pharmd, Bcps, Bcccp, Kassandra Foellinger Pharmd, Bcps, Jamie Gaul Pharmd, Bcps, Sarah Ferrell Pharmd, Bcps

Pharmacy Residency

Presented at the ASHP Midyear Clinical Meeting,

This medication use evaluation found that prescribing practices of DOAC and warfarin did not change after AHA guidance publication. Patients with HFrEF were more often discharged on warfarin, while those with Afib were more often discharged on DOACs. Those discharged on a DOAC had the highest incidence of LV thrombus resolution up to 6 months post-discharge. Physicians within Parkview Health do not routinely utilize a loading dose when discharging a patient on a DOAC.

Stepping Back: Evaluating Antipseudomonal Antibiotic Use In Diabetic Foot Infection., Hannah Davis Pharmd, Michele Walters Pharmd, Bcps, Aq-Id, Sarah Ferrell Pharmd, Bcpps, Jui Patel Pharmd, Bcps, Tiffany O'Keefe Pharmd, Bcgp

Pharmacy Residency

Presented at the ASHP Midyear Clinical Meeting. New Orleans, LA

This study found that anti-pseudomonal (PsA) coverage is overutilized in diabetic foot infection (DFI), even when broad qualifying criteria are applied. The proposed criteria were poor predictors of PsA growth, which was present in a small number of cases. Patients who did grow PsA were somewhat more likely to have severe DFI, history of DFI, and 90-day history of admission or anti-PsA antibiotic use, but many patients without PsA growth also met these criteria.