PSHP 2026 Residency Conference

This study evaluated provider adherence to the emergency department diuretic order set for patients admitted with a heart failure exacerbation, specifically assessing IV diuretic doses and timing of administration to optimize care.


This single-center, retrospective chart review at Thomas Jefferson University Hospital included patients identified via the electronic medical record between 4/1/2025 and 9/30/2025 who presented to the emergency department with heart failure, dyspnea, or fluid overload and received an IV loop diuretic. Those with a mean arterial pressure < 65, on dialysis, or missing data were excluded. Patients were classified as adherent or non-adherent based on the standardized ED admission order set. Non-adherent patients were further classified as either under- or overdosed in relation to the dosing recommended in the order set. The primary endpoint analyzed provider adherence incidence using descriptive statistics. Secondary endpoints—door-to-diuretic time, administration relative to timing of labs, and method of arrival—were analyzed using descriptive statistics and compared between groups using Fisher’s exact and Kruskal-Wallis tests.


A total of 210 patients were included; 54% (114/210) were male and 60% (125/210) were African American. Providers were non-adherent to the order set in 66% (139/210) of patients; 69% (96/139) of those were underdosed vs order set recommendations. 15% (31/210) of patients had a door-to-diuretic time of ≤100 minutes, and 90% (190/210) had their first IV diuretic after labs resulted. Fisher’s exact test (p ≤ .001) showed a significant association between door-to-diuretic time and diuretics being given before labs resulted. Kruskal-Wallis test found no significant difference in door-to-diuretic time across the three methods of arrival to the ED (ambulatory, fire rescue/emergency medical services, unknown), χ2 ([2], N = 210) = 5.411, p = .067.


Provider adherence to the emergency department diuretic order set was low, with frequent underdosing and delays in treatment. Early diuretic administration was uncommon, and many providers waited to treat until after labs resulted, prolonging door-to-diuretic time. These findings highlight opportunities to improve adherence and reduce delays in dosing to optimize outcomes in heart failure patients experiencing an exacerbation.


IRB Approval: Exempt


Authors: Kaylee Morosky, PharmD & Margo Graybill, PharmD; Thomas Jefferson University Hospital (TJUH), Philadelphia, PA - Department of Pharmacy

Title: Pharmacist Intervention To Optimize Guideline-Directed Medication Therapy (GDMT) In Patients With Heart Failure With Reduced Ejection Fraction (HFrEF)
Purpose: The objective of this study is to showcase the benefits of pharmacist involvement in reference to HFrEF patients and support the addition of a heart failure pharmacist practicing under a collaborative practice agreement (CPA).
Methods: The study was a retrospective chart review with the primary endpoints assessing patient GDMT and readmission. Secondary endpoints will include an assessment of how quickly an 80% cut-off of GDMT score can be reached and time used for providers. These will be assessed over a 6-month period and may be compared depending on the endpoint. Inclusion and exclusion criteria will mirror previous reviews done at our institution. The GDMT scoring system was determined to assess GDMT utilization and was agreed upon by authors prior to implementation. Appropriate statistical assessments were conducted to the data.
Results: Demographics were comparable between both arms of the review. The transition of care (TOC) group included 41 patients versus the general population (control) group’s 49 patients. Baseline scores were comparable (3.85±2.23 vs 3.96±2.12; p=0.819). At 6 months, the TOC arm had higher GDMT scores (4.93±2.34 vs 3.94±2.25; p=0.031) and a greater change in scores (1.07±2.34 vs -0.02±1.70; p=0.015). During the observational period, readmission favored the TOC group (24.4% vs 40.8%; p=0.100) and provider office time used was comparable (126.95±66.19 vs 137.14±60.94 minutes; p=0.449). Achievement of ≥80% GDMT score occurred in 2 patients in the TOC group and 1 patient in the control group.
Conclusions: Pharmacist intervention via TOC had a positive impact on HFrEF patients. Future studies should increase the number of charts reviewed and use a more validated scoring system. Repeating this study would improve case numbers and comparing cohorts may show progression in care practices. Additionally, a comparison between TOC encounters and patients managed by a pharmacist under a CPA may help distinguish pharmacist led care to another degree.

The purpose of this research project is to evaluate current dosing practices and identify opportunities to improve safety in underweight and overweight patients through development and implementation of a dosing guideline.


A retrospective chart review was conducted to evaluate adult patients from January to June 2025 who received venous thromboembolism (VTE) prophylaxis with enoxaparin and unfractionated heparin (UFH) and qualified for dosing adjustments instead of standard prophylaxis dosing. Inclusion criteria were adult patients weighing ≤ 45 kg (or with a body mass index (BMI) ≤ 18.5 kg/m2) or weighing ≥100 kg (or with a BMI ≥30 kg/m2) who received VTE prophylaxis for at least 48 hours. The primary outcome was incidence of VTE. Secondary outcomes include major bleeding events, duration of therapy, change in VTE prophylaxis regimen during the same admission period, and length of stay. A dosing guideline was developed and approved by the appropriate committees followed by staff education.  Post guideline implementation data was collected from January to March 2026 to assess guideline compliance. This quality improvement project received IRB exemption.


Pre-guideline data (n=299 total) resulted in underweight patients with standard dose UFH having a 9.1% post-discharge bleeding rate and 4.5% VTE rate, while reduced-dose recipients had none for both. Standard-dose enoxaparin had an 11.8% VTE rate versus none with reduced dosing. Among overweight patients, standard-dose UFH had a 2% inpatient bleeding rate and 2% VTE rate. Post-guideline data (n=123 total) showed 88% and 86% guideline compliance in underweight and overweight patients, respectively. Underweight patients with reduced-dose UFH had one VTE event and reduced-dose enoxaparin had one inpatient bleeding event. Overweight patients receiving dose-adjustments had 9.1% and 7.9% bleeding rates with UFH and enoxaparin, respectively.


Preliminary data suggests greater awareness of dose adjusting enoxaparin compared to heparin. In overweight patients, dosing remained more conservative than dosing in underweight patients. After the implementation of a weight-based VTE prophylaxis guideline, VTE events were reduced. Bleeding events persisted in some dose-adjusted groups, which highlights the importance of continued monitoring and further study with a larger sample size.

Purpose: To assess the feasibility and benefits of low dose buprenorphine induction (LDBI) for opioid use disorder (OUD) management in patients using illicit fentanyl compared with standard buprenorphine induction.
Methods: A single-center, retrospective cohort study was conducted at St. Mary Medical Center between August 1, 2024-December 1, 2025. Included patients reported fentanyl use and were inducted on buprenorphine for OUD treatment during hospitalization. The primary outcome was successful completion of buprenorphine induction defined as receiving at least 8 mg/day of buprenorphine and Clinical Opiate Withdrawal Score maintained at less than or equal to 12 from protocol start to completion or reported, subjective low levels of withdrawal. Secondary outcomes included length of stay (LOS), induction duration, clinical pharmacy specialist (CPS) consult, buprenorphine prescription on discharge and within 30 days, and switch to alternative therapy. The safety outcomes were naloxone administration, precipitated withdrawal occurrence, and rapid response events. 
Results: Sixteen patients in the standard induction arm and 18 patients in the LDBI arm were enrolled.  More patients in the LDBI arm successfully completed induction compared with standard (9 [50%] vs. 3 [19%], p =0.08). CPS was consulted in 100% of successful low dose inductions. The odds of precipitated withdrawal were significantly higher among patients receiving standard induction compared to LDBI (OR 5.7, 95% CI 1.31-25.05) and 19% of standard induction patients had a rapid response event attributed to precipitated withdrawal. The LDBI group had a longer LOS of 6.8 days compared with 2.6 days in the standard group, but had less patient directed discharges and more buprenorphine prescriptions on discharge and within 30 days. 
Conclusion: LDBI was found to be associated with a higher rate of successful inpatient buprenorphine inductions compared with standard induction. LDBI had significantly lower odds of precipitated withdrawal and patients were more likely to follow up based on a higher incidence of discharge scripts. LDBI provides a feasible and well-tolerated alternative to standard induction for inpatient illicit fentanyl withdrawal management. 
IRB Approval: Approved

PURPOSE: Medetomidine-adulterated fentanyl is associated with complex withdrawal, increasing the need for hospital resources. This research characterizes the use of adjunctive medications to de-escalate the level of care in this population.


METHODS: This retrospective chart review conducted from 1/1/25-9/15/25 included patients admitted for opioid withdrawal receiving intravenous opioids with another adjunctive agent (alpha-2 agonists, benzodiazepines, gabapentin, or antiemetics). Patients were excluded for mechanical ventilation >48 hours; concurrent alcohol or benzodiazepine withdrawal; admission to surgical, trauma, or burn services; or patient-directed discharge prior to ICU discharge. 
Variables were collected throughout ICU course, 72 hours following ICU discharge, and at time of hospital discharge. 
The primary endpoint was the impact of clonidine initiated on day 1 (early initiation) versus after (late initiation) on hospital length of stay (LOS). The impact of high dose (>0.6 mg) clonidine on day 1 compared to low dose (≤0.6 mg) clonidine on hospital LOS was analyzed. The relationship between receipt of additional adjunctive agents and hospital LOS was also analyzed.


RESULTS: One hundred patients were included: median age 42 years, 61% male, and median fentanyl use 10 bags/day. Ninety-three received clonidine, 58 gabapentin, 29 tizanidine, 91 benzodiazepines, and 98 dexmedetomidine. Median ICU LOS was 58 hours and hospital LOS 120 hours. 
Early clonidine was not associated with shorter hospital LOS (p=0.091). In the early clonidine group, patients remained in the ICU for an additional 2 days in the high dose versus 3 days in the low dose group (p=0.14). Dexmedetomidine duration did not differ with clonidine dose or timing. 
For each adjunctive medication added to therapy, there was a 19% decrease in hospital LOS (p=0.018). This relationship was not seen with ICU LOS. Additional analysis is ongoing.


CONCLUSION: Though not statistically significant, early clonidine reduced hospital LOS, while early, high dose clonidine appeared to reduce ICU LOS. Additional adjunctive medications on ICU day 1 significantly reduced hospital LOS. The findings suggest multimodal and early withdrawal management may decrease hospital and ICU LOS. Further research into clonidine dosing strategies is needed to demonstrate impact.

The purpose of this study is to evaluate the effects of implementation of a new dexmedetomidine clinical practice guideline (CPG) in intermediate and intensive care units to manage α2 withdrawal at Thomas Jefferson University Hospital.
An update was made to the local clinical practice guidelines for the use of dexmedetomidine for α2 withdrawal management including an increase in the maximum allowed infusion rate and changing the titration parameters from RASS to vital signs (heart rate and blood pressure). A SlicerDicer report generated by Epic electronic health record (EHR) identified patients who had a dexmedetomidine continuous infusion order and a consult with the Jefferson Addiction Multidisciplinary Service (JAMS) from 01/01/2026-02/01/2026 for the pre-intervention group and from 3/17/2026-4/17/2026 for the post-intervention group. The primary endpoint was the average length of stay (LOS). Secondary endpoints included, disposition, ICU admission rate, ICU LOS, intubation rate, vital sign abnormalities, adverse side event occurrence, and dexmedetomidine infusion data. Descriptive statistics were used. The study was approved as exempt by the Jefferson IRB.
The baseline characteristics between the pre and post intervention groups were similar.  The primary endpoint of average length of stay was shorter in the post intervention group compared to the pre intervention group (5.2 vs 7.3 days). Results of the secondary endpoints were similar between both groups. The rate of ICU admission was greater in the post intervention group (45.4 vs 41.4%). The average maximum and minimum heart rates were marginally decreased in the post intervention group compared to the pre intervention group (128 vs 124; 63 vs 60 bpm). The duration of dexmedetomidine therapy was shorter in the post intervention group (64 vs 65.9 hours). None of the differences seen in the secondary outcomes were clinically significant.
The updated clinical guideline for dexmedetomidine resulted in a shorter length of stay in the post intervention group versus the pre intervention group.  All other endpoints remained similar between the two groups. Limitations included a small sample size, challenges in implementation, nursing workflow constraints, and an abbreviated data collection period. Further research is warranted to refine this approach to α2 withdrawal management. 

Open to all residents and preceptors. Choose the networking session most of interest.

Purpose: To evaluate the real-world patterns and outcomes of amiodarone therapy in lung transplant recipients who develop new-onset post-operative atrial arrhythmias (POAA) after surgery. 
Methods: This is a retrospective, single-center chart review of 46 lung transplant recipients at Temple University Hospital from September 1, 2021 to August 31, 2025, who were discharged on amiodarone due to new-onset atrial arrhythmia. The cumulative amiodarone dose received and the total number of days of amiodarone use were calculated using information from the electronic medical record. Secondary endpoints included incidence of amiodarone induced pulmonary toxicity; discontinuation of amiodarone due to pulmonary toxicity, thyroid dysfunction, or hepatotoxicity; incidence of readmissions due to arrhythmias; and risk factors associated with atrial arrhythmias after lung transplant. Data collection included baseline characteristics, rate control therapy, anticoagulation, and information regarding electrophysiology (EP) follow-up. Descriptive statistics were utilized to analyze the data. 
Results: Amiodarone therapy was used for longer than six months in 10/46 patients. The average cumulative amiodarone dose was 29,228 mg, 95% CI [26,069, 32,387] and average duration of amiodarone was 100 days, 95% CI [86, 115]. There were no reports of amiodarone-induced pulmonary toxicity. Amiodarone was discontinued for one patient that was found to have elevated liver enzymes attributed to amiodarone. Two patients had elevated TSH levels attributed to amiodarone, but the medication was not discontinued. Twenty-five patients followed up with EP at an average of 88 days after discharge. Risk factors for the patient population evaluated included 88% over the age of 60 years, 78% male, and 56% with a history of coronary artery disease (CAD). 
Conclusion: Lung transplant recipients face increased risk of POAA. Amiodarone was generally well tolerated in this cohort, with short treatment durations and no cases of pulmonary toxicity. Limited adverse effects occurred, including one discontinuation for hepatotoxicity and two cases of thyroid dysfunction. Consideration should be given to defining optimal treatment duration, adverse effect monitoring, EP follow-up, and assessment of risk factors. 

Purpose: Evaluate the impact of low-dose fluconazole (LDF) versus clotrimazole (CTZ) on tacrolimus (TAC) trough levels, dose adjustments needed to maintain serum levels, and prophylaxis (ppx) of oropharyngeal candidiasis (OC).
Methods: This was a single-center, IRB-exempt, retrospective chart review at Jefferson Einstein Philadelphia Hospital including adult kidney transplant recipients (KTRs) transplanted between 4/1/23 - 4/30/25, who received TAC and OC ppx. They were excluded if they had a multiorgan transplant, history of gastric bypass, concomitant CYP inhibitors/inducers, or positive yeast donor cultures. KTRs received rabbit antithymocyte globulin, mycophenolate, and steroids per protocol. KTRs were stratified based on antifungal received. TAC trough levels were monitored throughout with a difference of >1.5 ng/mL determined to be clinically significant. The primary endpoint was the change in the TAC trough level 7 days after discontinuation of OC ppx. Secondary endpoints included the change in the TAC trough level 14 days after discontinuation, incidence of OC at 30 and 60 days, and the impact of sex, race, and early steroid withdrawal on TAC levels.
Results: Of 139 KTRs, 112 were included in the final analysis, with 71 in the CTZ group and 41 in the LDF group. The mean difference in TAC level change between CTZ and LDF was 1.83 ng/mL 7 days after discontinuation of OC ppx [95% CI (0.4, 3.3); p = 0.0123]. The mean TAC level change on day 7 in the CTZ group was -2.52 ng/mL [95% CI (-3.5, -1.6); p<0.001] and -0.69 ng/mL in the LDF group [95% CI (-1.5, -0.2); p = 0.166]. The mean dose of TAC increased from 6.6 mg to 9.4 mg in CTZ KTRs 14 days after discontinuation while LDF KTRs remained stable. There was a larger TAC level decrease seen in the steroid-free KTRs only in the CTZ group. There were no differences between sex and race. No patients developed OC.
Conclusion: Among KTRs that received OC ppx, there was a larger reduction in tacrolimus trough levels following discontinuation of clotrimazole than with low-dose fluconazole. Both antifungals were effective in preventing OC. This data suggests that low-dose fluconazole is preferred to clotrimazole to minimize drug-drug interactions among KTRs started on tacrolimus for immunosuppression with no difference in OC ppx efficacy.

Purpose: This study aimed to determine the incidence of solid organ transplant recipients receiving insulin therapy following taper to maintenance corticosteroid dose, which is around the 6-month mark at our institution


Methods: This single-center retrospective study included adult heart or lung transplant recipients transplanted between September 1, 2023, and September 1, 2024, with at least 6 months of follow-up. Patients with a history of prior or multi-organ solid organ transplantation, or those who did not survive 6 months post-transplant, were excluded. The primary outcome was the proportion of patients remaining on insulin therapy at 6 months post-transplant. Secondary outcomes included use of non-insulin antihyperglycemic agents, median corticosteroid dose at 6 months, incidence of treated acute rejection episodes, occurrence of hyperglycemia-related infections, and HbA1c trends during the follow-up period. Descriptive statistics were used to analyze the baseline characteristics, primary, and secondary outcomes. Time-to-event analysis was performed to evaluate the association between patient subgroups and time to insulin discontinuation.


Results: During the study period, 102 patients were screened and 91 met inclusion criteria (36 heart, 55 lung). Overall, 21% had prior diabetes and 47% had endocrinology follow-up. At 2 weeks post-transplant, 80% of patients required insulin with a median prednisone dose of 30 mg. By 6 months, this declined to 41.8% with a median dose of 10 mg. Time-to-event analysis demonstrated that prior diabetes (log-rank p=0.009) and endocrinology follow-up (p<0.001) were associated with delayed insulin discontinuation. Steroid discontinuation, rejection treatment, and transplant type were not significantly associated with time to insulin discontinuation.


Conclusion: A substantial proportion of patients remained on insulin therapy at the time of steroid weaning, although the incidence declined across successive follow-up periods over the first post-transplant year. This trend likely reflects the progressive reduction in corticosteroid dosing over time following transplantation.


IRB Approval: IRB #859535

Purpose
To evaluate the compliance rate of administering the first dose of antibiotic within 60 minutes to neonates diagnosed with late-onset sepsis following the implementation of interdisciplinary education and electronic order set modifications. 
 
Methods
This was a retrospective, single center, observational study utilizing a pre- and post-intervention cohort of patients 72 hours old to 180 days old. Study timeframes for the pre- and post-interventional cohort were June 1, 2023 to December 31, 2023 and June 1, 2025 to December 31, 2025. The primary outcome of time to administration is a composite of the time from ordering to verification, verification to final preparation check, and final preparation check to administration. Antibiotics were not assessed for time to administration if they were not the very first antibiotic given for a new infection or an agent used to broaden antibiotic coverage. Antibiotic orders that did not broaden coverage were excluded if an antibiotic was given within the last 72 hours and all orders for treatment of early-onset sepsis were excluded. Secondary outcomes reviewed all-cause 14-day and 30-day mortality and presence of high-risk comorbidities.  
 
Results 
The primary outcome of time to antibiotic administration from order placement was statistically significant for being shorter in the post-cohort with a median difference of 12.5 minutes (p < 0.001) and 47.7% of patients in the post-cohort had antimicrobials within 60 minutes as compared to 23.9% of patients in the pre-cohort (p = 0.007). Furthermore, every component of the composite primary outcome was statistically significant for being shorter in the post-cohort (p < 0.001). The secondary outcomes of the number of patients with late-onset sepsis risk factors (p = 0.804), 14-day mortality (p = 0.244), and 30-day mortality (p = 0.818) were not statistically different between cohorts.  
 
Conclusion
A greater percentage of patients received antibiotics within 60 minutes, which suggests that the interventions made by Pennsylvania Hospital made a clinical difference. The secondary outcome data suggests that neonates in both the pre- and post-cohort had comparable risk factors for developing late-onset neonatal sepsis. There was no statistical difference in mortality between the cohorts. 

Purpose: Respiratory Syncytial Virus (RSV) is a leading cause of infant morbidity and mortality. The purpose of this study was to identify barriers to timely and equitable uptake of RSV prevention and evaluate their clinical impact. 


Methods: This was an IRB-exempted, single-center, retrospective chart review of infants born at Penn State Health Golisano Children’s Hospital from September 1, 2024 – March 31, 2025, with a first newborn follow up-visit post-hospital discharge within our system. The primary outcome was the percentage of mother-infant pairs who received RSV prophylaxis of any kind. Secondary outcomes included timing of infant RSV prophylaxis (age at administration of nirsevimab), time from discharge to first outpatient follow-up, and incidence of RSV infection and resulting hospitalization.


Results: 1364 infants were screened, and 946 met inclusion criteria. Of these, 76.7% of infants received RSV prophylaxis; 41.6% received nirsevimab, 35.1% with maternal vaccination, and 23.2% received no prophylaxis. Among prophylaxis recipients, 56.6% were White, 82.9% were not Hispanic, Latino, or Spanish origin, and 88.6% noted English as the preferred maternal language. Overall, 99.6% of infants who received RSV prophylaxis also received hepatitis B vaccine at a median age of 1 day of life, compared to 77.7% without RSV prophylaxis. Median time to outpatient follow-up post-hospital discharge was 2 days, with the median age of nirsevimab administration at 12 days (range 2-262). Commercial insurance was most common across groups.  


Conclusion: RSV prophylaxis uptake was lower than hepatitis B vaccine administration (76.7% vs 94.5%) in our study cohort. Hepatitis B vaccine is given inpatient at our health system, while nirsevimab is deferred to the outpatient setting. Given high hepatitis B vaccine uptake, lower nirsevimab use likely reflects access barriers rather than hesitancy. These findings highlight gaps in equitable access and the need to improve timely provision of RSV prevention.  

This study aimed to assess the rate of neonatal intensive care unit (NICU) admissions prior to addition of oral dextrose gel (ODG) to an internal treatment protocol for neonatal hypoglycemia. This was a single center retrospective review assessing the protocol without ODG. Inclusion criteria were gestational age ≥ 35 weeks, birth weight > 2 kg, and no other indication for NICU admission, pertinent exclusion criteria included receiving ODG. The primary outcome assessed was rate of NICU admission for neonatal hypoglycemia treatment and was descriptively compared to previously reviewed data for an internal treatment protocol with ODG. Secondary outcomes were resolution of hypoglycemia ≤ 60 minutes, length of stay (LOS) (hospital and NICU if applicable), and IV dextrose boluses administered. Additionally, data on maternal and fetal risk factors for severe hypoglycemia were collected. Data were extracted from the institutional electronic medical record (EMR) and REDCap was used for data storage. Statistical analysis utilized descriptive statistics. In the group without ODG, 285 charts were reviewed, 274 were excluded and 11 were included. Primary exclusion reason was an institutional EMR change limiting access to data needed to review eligibility criteria (n=157). In the protocol without ODG, 100% of patients were admitted to the NICU for hypoglycemia management with IV dextrose. In comparison, review of the protocol with ODG had a NICU admission rate of 27% (n=166). Total LOS in the without ODG protocol was a median (IQR) of 7 (6-13) days and NICU LOS was a median (IQR) of 7 (5-13) days. Three (27%) of 11 received dextrose boluses, none had resolution of hypoglycemia ≤ 60 minutes, and all received IV dextrose infusions. Results of this review demonstrated NICU admissions were frequent with the prior protocol and numerically higher compared to review done of the protocol with ODG. When not using ODG, feeds and dextrose boluses were unable to prevent IV dextrose infusions. Interpretation of results were limited by small sample size and access to data due to EMR change but will be useful for improving institutional management practices of neonatal hypoglycemia.

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.