PSHP 2026 Residency Conference

Purpose
 Evaluate the characteristics of patients started on intravenous heparin for a thrombotic indication that experienced PTT prolongation at Jefferson Einstein Philadelphia Hospital.
 
Methods
This study included patients at least 18 years old that received heparin for a thrombotic indication and had at least 48 hours of PTTs available in their chart. Prolonged PTT was defined by two or more PTT values greater than 112 seconds within 48 hours of heparin. If patients experienced a prolonged PTT, they were evaluated to determine if a bleeding event had occurred within 48 hours of heparin. Patients were excluded if they were pregnant at data collection. The primary endpoint was a multivariable analysis of characteristics that predisposed patients to prolonged PTTs, including hypertension, abnormal renal and/or liver function, previous stroke, history of bleed, baseline PTT 1.5 times the upper limit of normal, age, alcohol use disorder, body mass index, male sex, bolus on initiation, black race, and thrombolytic or anticoagulant use within 48 hours of heparin initiation. The secondary endpoint was the incidence of bleeding with prolonged PTT.
 
Results
Data was analyzed using GraphPad Prism 10.6.1. Out of 344 patients, 58 (16.9%) did not experience PTT prolongation. Baseline characteristics between both groups were similar. PTT 1.5 times the upper limit of normal (5.8, 95% CI [1.1-107], p=0.04) was the only variable associated with PTT prolongation. All other variables were considered statistically nonsignificant. Among the 286 patients (83.1%) that experienced PTT prolongation, 65 patients (22.7%) experienced a bleeding event within 48 hours of heparin initiation.
 
Conclusion/Summary
This study with 344 patients found that a baseline PTT 1.5 times the upper limit of normal is associated with PTT prolongation. Limitations include single-center, retrospective nature, and small sample size. Future steps include conducting a study using a nomogram with conservative heparin dosing in this cohort of patients with PTT prolongation at baseline and more frequent monitoring to prevent adverse outcomes.

Purpose: To compare the safety and efficacy of enoxaparin versus unfractionated heparin for venous thromboembolism prophylaxis in hospitalized patients with chronic liver disease by evaluating in-hospital bleeding and thromboembolic events.
Methods: This retrospective, single-center cohort study included adult patients (> 18 years) with a documented diagnosis of cirrhosis or chronic liver disease as identified by relevant ICD-10 codes from January 2020 to June 2025 that have received VTE prophylaxis with UFH or enoxaparin during hospitalization. The data collected includes baseline patient characteristics, admission diagnosis, prior to admission medications, important baseline laboratory values, MELD score, Child-Pugh score, VTE and bleed risk assessment tools, and VTE prophylaxis administered. The primary endpoint is the incidence of in-hospital bleeding events. Secondary endpoints include incidences of in-hospital International Society on Thrombosis and Haemostasis (ISTH) major and minor bleeding, in-hospital VTE events, drug discontinuations due to thrombocytopenia or anemia, and mortality. Data analysis was completed using descriptive statistics.
Results: A total of 82 patients were included (enoxaparin n=46; UFH n=36). Baseline demographics, laboratory values, and liver disease severity were similar, with median age 60 years and most patients classified as Child-Pugh C. All patients were high VTE risk by PADUA and IMPROVE scores. New bleeding events occurred in 8.6% with enoxaparin and 5.6% with UFH. Major bleeding occurred only with UFH (5.6%), while minor bleeding occurred only with enoxaparin (8.6%). VTE events were rare and comparable (2.2% vs 2.7%). Therapy discontinuation for non-bleeding events was more frequent with enoxaparin (32.6% vs 22.2%). In-hospital mortality was numerically lower with enoxaparin (6.5% vs 13.8%).
Conclusion: In hospitalized patients with cirrhosis requiring VTE prophylaxis, enoxaparin demonstrated similar efficacy to UFH in preventing thromboembolic events. Although bleeding occurred more often with enoxaparin, events were minor and did not require discontinuation of therapy, whereas fewer but more severe bleeding events were seen with UFH. These findings suggest that enoxaparin may be a safe alternative, though larger prospective studies are needed.

Purpose: Evaluate the impact of inpatient pharmacist interventions on SGLT2 inhibitor initiation in hospitalized heart failure patients and compare pre- and post-intervention rates, pharmacist involvement, barriers, and 30-day readmissions. 
 
Methods: This retrospective, pre- and post-quality improvement study included adult patients hospitalized with heart failure over two six-week periods. Data collected included demographics, heart failure classification, laboratory values, guideline-directed medical therapy (GDMT), pharmacist interventions, and 30-day readmissions. The intervention consisted of increased inpatient pharmacist involvement through chart review, documentation, medication recommendations, discharge counseling, and assistance with medication access. Statistical analyses included chi-square tests for categorical variables and t-tests for continuous variables.
 
Results: A total of 164 pre- and 170 post-intervention patients were included. Baseline demographics and clinical characteristics were similar between groups. Pharmacist interventions significantly increased from 7.3% pre-intervention to 21.3% post-intervention (p<0.001).
 
SGLT2 inhibitor use at discharge remained similar between groups (28.0% vs 27.2%, p=0.866), and initiation rates during hospitalization did not significantly change (12.2% vs 12.4%, p=0.949). Other GDMT utilization also showed no statistically significant differences.
However, 30-day readmission rates increased from 34.8% pre-intervention to 48.5% post-intervention (p=0.011). Barriers to SGLT2 inhibitor initiation were similar between groups (32.9% vs 30.8%).
 
Conclusion: Inpatient pharmacist involvement significantly improved documentation and intervention rates but did not result in increased SGLT2 inhibitor initiation. Despite enhanced pharmacist engagement, no reduction in 30-day readmissions was observed. These findings show persistent barriers to therapy initiation suggesting additional strategies beyond pharmacist intervention may be necessary to improve clinical outcomes in heart failure patients.
 
Authorship: 
Katherine Ghattas, PharmD; James Helms, PharmD, BCPS; Bonny Brownstein, PharmD, BCPS, BCPPS

Purpose
The purpose of this study was to characterize and assess the safety and efficacy of alpha-2 agonist utilization in the setting of fentanyl and presumed medetomidine withdrawal at a tertiary academic medical center in Philadelphia, PA.
 
Methods
This retrospective, single-center chart review evaluated patients admitted to an academic medical center between 1/1/2025 and 10/31/2025 with fentanyl and suspected medetomidine withdrawal and received an alpha-2 agonist(s) for withdrawal management. Patients were excluded if they received mechanical ventilation or vasopressors, experienced severe alcohol withdrawal, or underwent surgery during their withdrawal management. The primary objective was to characterize alpha-2 agonist use, including agent, dose, frequency, and route. Secondary objectives assessed safety and efficacy. Safety endpoints included incidence of hemodynamic instability and ICU disposition. Efficacy endpoints included incidence of ICU escalation and patient-directed discharge and the change in maximum Clinical Opiate Withdrawal Scale (COWS) scores within 72 hours of admission. 


Results
There were 100 included patients: 53 in the ICU and 47 on general medicine floors. All patients received clonidine, largely as oral tablets; 18% received tizanidine and 52% dexmedetomidine. The median maximum total daily dose of clonidine was 1.2 mg [IQR 1-1.6] for a median duration of 108.9 hours [IQR 72.7-159.7]. Dexmedetomidine had a median maximum infusion rate of 1.2 mcg/kg/hr [IQR 1-1.5] and a median of 27.3 hours [IQR 18.6-42]. Clonidine was held in 65% of patients (bradycardia). A heart rate <60 bpm occurred in 51% and a systolic blood pressure <90 mmHg in 5% of patients. The median COWS by day 2 had decreased from 22 [IQR 16.5-26] to 6 [IQR 4-8]. Many patients (58%) were discharged on clonidine, and 27% had self-directed discharge.


Conclusions
Alpha-2 agonists improved COWS scores over 72 hours and were well tolerated, with bradycardia being the most common adverse effect. Clonidine was the most frequently used alpha agonist, with dexmedetomidine reserved for ICU-level patients. Overall, these findings support the use of alpha-2 agonists for fentanyl with presumed medetomidine withdrawal management with careful hemodynamic monitoring and individualized dosing and tapering strategies.


This study was approved by the University of Pennsylvania Institutional Review Board (Protocol #859692).

Purpose:  The purpose of this project is to evaluate the current treatment practices in the critical care units for complex withdrawal and organize formal education surrounding a high priority clinical topic.

Methods: The study will use a newly implemented protocol in the medical intensive care unit and pharmacy resident education to screen current treatment practices and assess gaps in knowledge. An anonymous survey was developed and consisted of questions regarding experience treating complex withdrawal and self-reported confidence in the management in clinical practice. Data will be collected including the attendees professional practice setting. The education and the survey will be presented to the appropriate departments and afterwards survey results will be used to assess changes in knowledge and confidence with future adherence to the implemented protocol. The primary endpoint is the improvement in healthcare professional knowledge regarding the management of complex withdrawal, measured by completed survey results. Secondary endpoint includes change in confidence pre and post-educational sessions.  
 
Results: Approximately ~75 healthcare professionals were given formal education, and a total of 40 were able to complete the survey due to access at time of presentation. Self-reported confidence in the treatment of opioid with suspected adulterant withdrawal increased from 42% to 78% after education was given. Two clinical questions regarding the presentation of medetomidine withdrawal were asked and 30% and 63% of responders were “not confident” in their answer choices. When asked to report confidence in using the presented material 78% and 96% of responders were confident in applying the material to clinical practice. Even though not every participant was able to take the pre- and post-surveys the reminders for close monitoring and proactive care has reinforced different specialties their importance in managing complex withdrawal. 
 
Conclusion: Implementation of a standardized complex withdrawal management protocol, along with educational sessions was found to improve self-reported confidence and knowledge in managing complex withdrawal. Ongoing monitoring of protocol use and interdisciplinary support to promote long-term adherence to the newly implanted protocol. Future evaluation may include clinical outcomes, such as length of hospital stay, length of intensive care unit stay and incidence of withdrawal-related complications 

Purpose: 
North Philadelphia is disproportionately affected by opioid use disorder and related deaths. The objective of this study is to evaluate the effectiveness of a community-centered opioid harm reduction education program for pharmacy students.


Methods:
This is a prospective, quasi-experimental, pilot study evaluating outcomes of the Naloxone Access and Medication Education (NAME) Initiative. The study was conducted at a single ACPE-accredited school of pharmacy in Philadelphia, Pennsylvania. The program consisted of a two-hour training course followed by a two-hour community outreach Introductory Pharmacy Practice Experience (IPPE). Students completed pre- and post-surveys to assess their knowledge of opioid overdose recognition and response using the validated Opioid Overdose Knowledge Scale (OOKS) and confidence to engage meaningfully in community service using the validated Community Service Self-Efficacy Scale (CSSES). The primary endpoint was the change in OOKS scores pre- and post- didactic training. The secondary endpoint was the change in CSSES scores from pre- to post-IPPE. Pre- and post-survey data were analyzed using paired t-tests.


Results:
A statistically significant improvement of 0.91 points (SD ± 3.0) was seen in OOKS scores after students received didactic training (p=0.049). Significant improvement was primarily seen in the “Action” domain of the OOKS score (p=0.01). Seventy percent (31/44 students) completed the post-CSSES. Of those completed the survey, an improvement of 3.5 points (SD± 8.4) was observed; however, this was not statistically significant (p=0.053).


Conclusions:
Utilization of a didactic training program followed by a community outreach IPPE led to improvement in pharmacy student knowledge of opioid harm reduction and management and may increase perceived self-efficacy with educating community members.

Purpose: This study was designed to evaluate whether a standardized inpatient pharmacist-driven naloxone protocol increased the number of naloxone prescriptions dispensed to patients at risk for opioid induced respiratory depression (OIRD). 
Methods: This was a retrospective, single-center, cohort study where a pharmacist-driven naloxone protocol was implemented directing pharmacists to identify patients prescribed an opioid and at high risk for OIRD. A report was developed to standardize identification of at-risk patients from April 2025 to June 2025. Pharmacist then counseled on the importance and use of naloxone, communicated with providers, and pended naloxone prescriptions. Patients included were those at risk for OIRD and expected to take opioids at discharge or have a diagnosis of opioid use disorder. Patients excluded were those less than 18 years old and those discharged to a rehabilitation or skilled nursing facility. Patients were characterized into either a pre- or post-protocol group based off the discharge date. Dispensing of the naloxone prescription was then confirmed with the affiliated outpatient pharmacy. This study was approved by the institutional review board. 
Results: Those included in the pre- and post-protocol groups were 54 and 42, respectively. The median age was 44 (range, 39 to 55), median BMI was 24 (range, 20 to 30) and median outpatient MME per day per patient was 180 (range, 45 to 564) in the pre-protocol group. The median age was 42 (range, 36 to 51), median BMI was 25 (range, 22 to 34) and median outpatient MME per day per patient was 94 (range, 46 to 360) in the post-protocol group. The total number of orders pended in the post-protocol group was 9 out of 42 (21%) and common reasons for not pending were either not documented (43%) or already had naloxone (28%). The number of naloxone prescriptions dispensed outpatient in the pre- and post-protocol groups are pending.  
Conclusion: The most common risk factors identified for OIRD were active smoking, diagnosis of opioid use disorder, and concomitant sedative/hypnotic use. The most common outpatient opioids prescribed were methadone, oxycodone, and buprenorphine/naloxone. Results on the impact on naloxone dispensing are pending.