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Marino K, Crowley KE, Ware L, Lupi K, Alblooshi ASEM, Alradini FA, Eyre A. Development and Implementation of an In-Hospital Pharmacist Emergency Response Simulation Training Curriculum. J Am Pharm Assoc (2003) 2024:102053. [PMID: 38401840 DOI: 10.1016/j.japh.2024.102053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Medical simulation is an effective educational tool used to increase confidence, improve knowledge, and refine skills when responding to high acuity situations. Despite established roles of the pharmacist on the hospital code team, most institutions lack formalized pharmacist training for code team responses. OBJECTIVE This pre-post analysis aimed to evaluate the impact of a didactic and simulation-based code response training for pharmacists on self-perceived improvement and preparedness when responding to in-hospital medical emergencies. METHODS An emergency response curriculum (ERC) was developed for pharmacists and pharmacy residents at our institution. The curriculum, led by four lead clinical pharmacy specialists, included a sixty-minute didactic code competency lecture followed by two medical emergency simulations and a debrief after each scenario. Following completion of the simulation portion of the ERC, participants were given a survey to complete which assessed their confidence utilizing a 5-point Likert scale (1=very unconfident to 5=very confident) in completing the course objectives prior to and post the ERC. RESULTS Seventy-two pharmacists completed the ERC and 60 completed the post course survey. Of those who completed the post course survey, 70% were pharmacy residents. Using a 5-point Likert scale (1=very unconfident to 5=very confident), median participant confidence rose from 3 [IQR 2-4] before the session to 4 [IQR 3-5] after the session (p <0.001). Of the participants, 95% believed the ERC training should be required annually or multiple times a year and 100% of respondents felt the ERC training was beneficial. CONCLUSION Development of a pharmacist ERC including didactic and simulation-based learning improved the confidence and preparedness of pharmacists when participating as members of the hospital code team. Future studies should continue to evaluate pharmacist training and curriculum development in code team responses.
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Affiliation(s)
- Kaylee Marino
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Kaitlin E Crowley
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Lydia Ware
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Kenneth Lupi
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Afaf Sulaiman Ebrahim Mohammed Alblooshi
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital and Department of Medical Education, United Arab Emirates University-College of Medicine and Health.
| | - Faten Abdullah Alradini
- STRATUS Center for Medical Simulation, Brigham and Women's Hospital and Department of Medical Education, Princess Nourah Bint Abdulrahman University.
| | - Andrew Eyre
- STRATUS Center for Medical Simulation, Department of Emergency Medicine, Harvard Medical School.
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Bhatt AS, Varshney AS, Moscone A, Claggett BL, Miao ZM, Chatur S, Lopes MS, Ostrominski JW, Pabon MA, Unlu O, Wang X, Bernier TD, Buckley LF, Cook B, Eaton R, Fiene J, Kanaan D, Kelly J, Knowles DM, Lupi K, Matta LS, Pimentel LY, Rhoten MN, Malloy R, Ting C, Chhor R, Guerin JR, Schissel SL, Hoa B, Lio CH, Milewski K, Espinosa ME, Liu Z, McHatton R, Cunningham JW, Jering KS, Bertot JH, Kaur G, Ahmad A, Akash M, Davoudi F, Hinrichsen MZ, Rabin DL, Gordan PL, Roberts DJ, Urma D, McElrath EE, Hinchey ED, Choudhry NK, Nekoui M, Solomon SD, Adler DS, Vaduganathan M. Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization. J Am Coll Cardiol 2023; 81:1680-1693. [PMID: 36889612 PMCID: PMC10947307 DOI: 10.1016/j.jacc.2023.02.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed. OBJECTIVES The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF). METHODS In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee. RESULTS Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups. CONCLUSIONS Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA; Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California, USA
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Alea Moscone
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Zi Michael Miao
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Safia Chatur
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Mathew S Lopes
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria A Pabon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Ozan Unlu
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaowen Wang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bryan Cook
- Mass General Brigham Center for Drug Policy, Boston, Massachusetts, USA
| | - Rachael Eaton
- Department of Pharmacy, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jillian Fiene
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dareen Kanaan
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie Kelly
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Danielle M Knowles
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenneth Lupi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lina S Matta
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Liriany Y Pimentel
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan N Rhoten
- Department of Pharmacy Services, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | - Rhynn Malloy
- Department of Pharmacy, Children's Hospital Colorado, Denver, Colorado, USA
| | - Clara Ting
- University of Chicago Medical Center, Chicago, Illinois, USA
| | - Rosette Chhor
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Joshua R Guerin
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Scott L Schissel
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Brenda Hoa
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Connie H Lio
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Kristina Milewski
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Michelle E Espinosa
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Zhenzhen Liu
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Ralph McHatton
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Jonathan W Cunningham
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Karola S Jering
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Bertot
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adeel Ahmad
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Muhammad Akash
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Farideh Davoudi
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | | | - David L Rabin
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | | | - David J Roberts
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Daniela Urma
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Erin E McElrath
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily D Hinchey
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Niteesh K Choudhry
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mahan Nekoui
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Dale S Adler
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA.
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Bhatt AS, Varshney AS, Nekoui M, Moscone A, Cunningham JW, Jering KS, Patel PN, Sinnenberg LE, Bernier TD, Buckley LF, Cook BM, Dempsey J, Kelly J, Knowles DM, Lupi K, Malloy R, Matta LS, Rhoten MN, Sharma K, Snyder CA, Ting C, McElrath EE, Amato MG, Alobaidly M, Ulbricht CE, Choudhry NK, Adler DS, Vaduganathan M. Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study. Eur J Heart Fail 2021; 23:1191-1201. [PMID: 33768599 DOI: 10.1002/ejhf.2163] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. METHODS AND RESULTS Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, β-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events. CONCLUSIONS Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Anubodh S Varshney
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Alea Moscone
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Karola S Jering
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Parth N Patel
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Thomas D Bernier
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Leo F Buckley
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Bryan M Cook
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jillian Dempsey
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Kelly
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kenneth Lupi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rhynn Malloy
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Lina S Matta
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Megan N Rhoten
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Krishan Sharma
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Clara Ting
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Erin E McElrath
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary G Amato
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Maryam Alobaidly
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Catherine E Ulbricht
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA.,Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dale S Adler
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Bhatt AS, Varshney A, Moscone A, Cunningham J, Jering K, Sinnenberg L, Nekoui M, Buckley L, Cook B, Dempsey J, Kelly J, Knowles D, Lupi K, Malloy R, Matta L, Rhoten M, Hinchey E, McElrath E, Alobaidly M, Amato M, Ulbricht C, Ting C, Bernier T, Choudhry N, Adler DS, Vaduganathan M. Feasibility of Virtual Optimization of Guideline Directed Medical Therapy in Hospitalized Patients with HFrEF During the Covid-19 Pandemic: The IMPLEMENT-HF Pilot Study. J Card Fail 2020. [PMCID: PMC7527179 DOI: 10.1016/j.cardfail.2020.09.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Implementation of GDMT for HFrEF remains low. We assessed the feasibility of a virtual GDMT Team for optimization of GDMT during hospitalization for non-CV conditions. Hypothesis A GDMT Team will improve GDMT optimization compared with usual care. Methods Consecutive hospitalized patients with HFrEF≤40% were prospectively identified. Patients with critical illness, cardiology consult, de-novo HF, COVID-19 & SBP ≤90mmHg were excluded. February 3 to March 1, 2020 served as a pre-intervention period during which patients were screened, but did not receive GDMT Team interventions. From March 2 to June 21, 2020, a pharmacist-physician team provided up to 1 suggestion daily for GDMT optimization (evidence-based ß-blockers, ACEi/ARB/ARNI, & MRA) to treating teams based on an evidence-based algorithm. The primary outcome of a composite GDMT optimization score, the net of positive therapeutic changes (+1 for new initiations/uptitrations) & negative therapeutic changes (-1 for discontinuations/downtitrations) during hospitalization, was compared between the pre- vs. post-intervention periods. Multivariable linear regression models were built adjusting associations for clinical factors. Safety outcomes requiring intervention or GDMT downtitration were identified. Results Of 187 encounters, 84 (45%) met eligibility criteria: 28 pre-intervention, 56 post-intervention. Mean age was 68±11 yrs, 70% men, and 61% White. Of 88 GDMT Team suggestions, 49 (56%) were followed by discharge. During the intervention, cumulative COVID-19 hospitalizations rose from 0 to 11085 in MA. Mean GDMT optimization score was -0.14 (95% CI: -0.58 to +0.30) pre-intervention & +0.64 (95% CI: +0.35 to +0.93) post-intervention (P=0.004). In a model inclusive of demographics, comorbidities, vital signs, potassium levels, eGFR, & LVEF, the intervention was the only factor associated with higher GDMT optimization score (β coeff 0.89; P=0.008). Safety events included 1 instance each of AKI, hyperkalemia, bradycardia, & hypotension. Conclusion Admission for non-CV conditions is a feasible setting for GDMT optimization. A virtual GDMT Team was associated with improved GDMT; this implementation strategy warrants testing in a prospective RCT.
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