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Bjornson S, Grindeland CJ, Werremeyer AB. Impact of Implementing Screening and Interventions to Target Prevention of Opioid Misuse and Accidental Overdose in the Inpatient Setting. J Pharm Pract 2024; 37:442-447. [PMID: 36472932 DOI: 10.1177/08971900221144183] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Introduction: There are limited publications supporting the use of screening tools to implement upstream prevention of opioid-related problems. Opioid and Naloxone Education (ONE) is utilized in outpatient pharmacies to screen and identify patients at risk of opioid-related problems and make interventions. Objectives: To implement ONE in the inpatient setting to promote prevention of opioid-related problems and overdose risk mitigation. Methods: For this pilot, ONE screening tool was completed via chart review and patient interview for inpatients prescribed an opioid. Risk scores were calculated and recommendations were provided. Outcomes evaluated included morphine milligram equivalents (MME) prior to hospitalization, inpatient screening pre-, post-, and at discharge; naloxone orders at discharge; and comparison of overdose risk from different sources. Results: The control group (n = 44) had a mean MME decrease of 1.5, and following implementation of pharmacist interventions, the experimental group (n = 45) observed a mean MME decrease of 28.6 (P = .0001). For the threshold of 50 MME, 8.6% of patients in the control group had a change from >50 MME to <50 MME at 24 hour follow up. This change occurred in 29% of patients in the experimental group (P = .03). For non-opioid analgesics, 6.8% of patients in the control group had non-opioid analgesic orders added or increased compared to 26.6% in the experimental group (P = .01). Conclusion: Screening for opioid misuse and accidental overdose risk appears impactful in the inpatient setting. Screening and appropriate risk-based intervention was associated with decreases in total daily MME and increased non-opioid analgesics.
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Affiliation(s)
- Siri Bjornson
- Department of Pharmacy, Sanford Medical Center, Fargo, ND, USA
| | | | - Amy B Werremeyer
- Department of Pharmacy, Sanford Medical Center, Fargo, ND, USA
- School of Pharmacy, North Dakota State University, Fargo, ND, USA
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Thorvilson DA, Skiba CC, Muzzy JD, Grindeland CJ, Mohamed MW. Successful therapy for congenital sodium diarrhea by enteral management: A case report. Nutrition 2023; 114:112096. [PMID: 37399692 DOI: 10.1016/j.nut.2023.112096] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/14/2023] [Accepted: 05/22/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Congenital sodium diarrhea (CSD) is a rare disorder causing electrolyte imbalances due to excessive diarrhea. In pediatric literature, common practice for treating CSD includes parenteral nutrition (PN) for fluid, nutrient, and electrolyte support through the first year of the patient's life. The aim of this study was to report a neonate who showed common symptoms of CSD, including a distended abdomen, large amounts of clear, yellow fluid draining from the rectum, dehydration, and electrolyte abnormalities. CASE SUMMARY A diagnostic gene panel was completed and confirmed heterozygous variant GUCY2C gene associated with autosomal dominant CSD. The infant was initially treated with PN to maintain fluid, nutrient, and electrolyte status, but was subsequently transitioned to full enteral feeds, showing improvement in symptoms. Frequent therapy adjustments were required to maintain appropriate electrolyte levels during the duration of the hospital stay. At discharge, the infant followed an enteral fluid maintenance plan that provided symptomatic control through the first year of life. CONCLUSION This case demonstrated the ability to maintain electrolyte levels in a patient through enteral means while avoiding long-term use of intravenous access.
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Affiliation(s)
- Dana A Thorvilson
- North Dakota State University College of Pharmacy Nursing and Allied Sciences, Fargo, North Dakota, United States.
| | - Caleb C Skiba
- North Dakota State University College of Pharmacy Nursing and Allied Sciences, Fargo, North Dakota, United States
| | - Julia D Muzzy
- Sanford Children's Hospital, Fargo, North Dakota, United States; Department of Pharmacy Practice, North Dakota State University, Fargo, North Dakota, United States
| | | | - Mohamed W Mohamed
- Department of Pediatrics, Sanford Children's Hospital, Fargo, North Dakota, United States
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Nguyen SH, Grindeland CJ, Leedahl DD. Pharmacist-managed multistep order transmittal for electronic specialty prescriptions reduces represcribing burden in ambulatory clinics: A retrospective cohort pilot study. J Manag Care Spec Pharm 2022; 28:778-785. [PMID: 35737857 PMCID: PMC10373038 DOI: 10.18553/jmcp.2022.28.7.778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Specialty medications pose unique prescribing challenges, including complexities with drug dosing and safety monitoring, need for prior authorization and patient financial assistance, use of payer-mandated specialty pharmacies, and special requirements for storage and handling. These challenges can lead to higher rates of represcribing for specialty clinic providers, who may be operating with inadequate information or limited resources. Multistep order transmittal (MSOT) is an electronic medical record (EMR) prescription work queue functionality used by a specialty pharmacy service to support select ambulatory clinics. OBJECTIVE: To explore the relationship between an MSOT specialty pharmacy support service and represcribing burden of specialty medications for providers in an ambulatory care setting. METHODS: A retrospective cohort pilot study was performed before and after MSOT implementation. Prescription data were queried from Sanford Health's EMR for patients who were electronically issued at least 1 prescription for an injectable biologic medication at a dermatology and rheumatology clinic. The pre-intervention group included index prescriptions prescribed between October 1, 2017, and June 20, 2018. The post-intervention group included index prescriptions prescribed between October 1, 2018, and June 20, 2019. Retrospective EMR review was completed to identify any prescriptions that were represcribed and the reason for represcribing. The primary outcome was the rate of represcribing. Secondary endpoints explored reason for represcribing, when it occurred. Nominal data were compared using Pearson's chi-square tests. Regressions were performed to account for potential confounders. RESULTS: The pre-intervention group included 880 index biologic prescriptions, and the post-intervention group included 941 index biologic prescriptions. The aggregate represcribing rate decreased from 12.73% in the pre-intervention group to 9.56% in the postintervention group (P = 0.03). Represcribing directly by providers as a result of needing to modify the destination pharmacy decreased significantly from 6.25% of the pre-intervention group to 0.64% of the post-intervention group (P < 0.01). However, represcribing due to patient preferences and prescribing errors increased significantly between the pre- and post-intervention groups, with patient preferences increasing from 0.91% to 2.55% (P = 0.01) and prescribing errors from 0.68% to 1.70% (P = 0.05), respectively. Represcribing due to provider preferences and payer restrictions remained similar between groups. CONCLUSIONS: Within 2 ambulatory care clinics in an integrated health care system, the use of pharmacist-managed MSOT reduced overall represcribing burden. The need to represcribe owing to wrong destination pharmacy was nearly eliminated, while appropriate represcribing to accommodate patient preferences and correct prescribing errors increased. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to disclose.
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Byerley EM, Dykhuizen SN, Haak JR, Grindeland CJ, Muzzy Williamson JD. Medication Management In LaCtation- A Pharmacist Education Pilot Project (MILK-PHED): Part One Survey. J Am Pharm Assoc (2003) 2022; 62:1389-1393.e2. [DOI: 10.1016/j.japh.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 11/17/2022]
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Byerley EM, Perryman DC, Dykhuizen SN, Haak JR, Grindeland CJ, Muzzy Williamson JD. Breastfeeding and the Pharmacist's Role in Maternal Medication Management: Identifying Barriers and the Need for Continuing Education. J Pediatr Pharmacol Ther 2022; 27:102-108. [PMID: 35241980 PMCID: PMC8837210 DOI: 10.5863/1551-6776-27.2.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/30/2021] [Accepted: 07/23/2021] [Indexed: 10/04/2023]
Abstract
Breastfeeding offers a multitude of benefits for infants, mothers, and society. Exclusive breastfeeding of infants is recommended for at least the first 6 months of life. Although transfer of drug into breastmilk can occur, most medications are safe to use during breastfeeding. Pharmacists, regarded as the most accessible health care professionals, recognize their role as medication specialists for breastfeeding women. Unfortunately, a lack of formal and continuing education on medication use during lactation often results in pharmacists providing the unnecessary recommendation to disrupt breastfeeding during medication use. In addition to lack of education, other barriers pharmacists experience in providing optimal patient care during lactation include difficulty identifying breastfeeding status and inconsistency in recommendations between scientific resources. Pharmacists must voice their need for additional continuing education and take action to close the knowledge gap and address barriers to providing care.
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Affiliation(s)
- Eva M. Byerley
- Department of Pharmacy Practice (EMB, DCP, SND, JDMW), North Dakota State University, Fargo, ND
| | - Dillon C. Perryman
- Department of Pharmacy Practice (EMB, DCP, SND, JDMW), North Dakota State University, Fargo, ND
| | - Sydney N. Dykhuizen
- Department of Pharmacy Practice (EMB, DCP, SND, JDMW), North Dakota State University, Fargo, ND
| | | | | | - Julia D. Muzzy Williamson
- Department of Pharmacy Practice (EMB, DCP, SND, JDMW), North Dakota State University, Fargo, ND
- Department of Pharmacy (CJG, JDMW), Sanford Children's Hospital, Fargo, ND
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Byerley EM, Mohamed MW, Grindeland CJ, Muzzy Williamson JD. Neonatal Abstinence Syndrome Practices in the United States. J Pediatr Pharmacol Ther 2021; 26:577-583. [PMID: 34421406 DOI: 10.5863/1551-6776-26.6.577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To survey current practices for the treatment of neonatal abstinence syndrome (NAS) among institutions in the United States to identify changes in national practice over time. METHODS Previous NAS management reports were referenced in the development of our 26-question electronic survey, which was distributed in the fall of 2019 to pediatric practitioners of 2 national clinical pharmacy organizations via email list servers. Not all questions required a response and responses from incomplete surveys were included. Institution demographics and NAS management strategies, including location of care, observation period, and inpatient and outpatient pharmacotherapy, were queried. RESULTS Seventy respondents representing institutions from all US geographic regions participated in the survey The most commonly reported inpatient observation durations were 3 (18 of 61, 29%) and 5 (22 of 61, 36%) days. Respondents indicated that neonates were typically transferred to the NICU if pharmacologic management was required (38 of 56, 68%). According to participants, first-line agents used for NAS management were morphine (45 of 56, 80%), methadone (5 of 56, 9%), clonidine (2 of 56, 4%), and buprenorphine (2 of 56, 4%). Among respondents, only 20% (11 of 56) reported that infants may be discharged home on pharmacotherapy, including morphine (n = 6), phenobarbital (n = 3), clonidine (n = 1), and methadone (n = 1). CONCLUSIONS Opioids are the most commonly used first-line agents for NAS management in the United States. The primary site of NAS management is the inpatient setting, as only 20% of institutions report discharging patients on pharmacotherapy.
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Vettleson KL, Larson HJ, Mohamed MW, Grindeland CJ, Muzzy Williamson JD. Micronutrient Monitoring and Management in Parenteral Nutrition-Dependent Premature Neonates: A Case Series. J Pediatr Pharmacol Ther 2021; 26:200-204. [PMID: 33603585 DOI: 10.5863/1551-6776-26.2.200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/22/2020] [Indexed: 11/11/2022]
Abstract
We present a prospective case series of 3 premature neonates with abnormal vitamin A, vitamin E, and selenium levels after being managed on prolonged parenteral nutrition (PN). All 3 patients experienced gastrointestinal complications including spontaneous intestinal perforation, necrotizing enterocolitis, and/or short bowel syndrome. Additionally, all 3 patients developed PN-associated liver disease, which required the use of a mixed lipid emulsion and a fish oil-based lipid emulsion for a short period of time. We evaluated the micronutrient levels of these patients after they had been receiving PN for 1 to 2 months. After the early identification of these abnormalities, we promptly attempted to correct the levels through supplementation and restriction, as appropriate. One barrier we experienced in the treatment of these patients was the conflicting guidance of daily micronutrient dosing in PN and when to evaluate levels in premature infants from the European and American pediatric nutrition organizations, the European Society for Paediatric Gastroenterology Hepatology and Nutrition and the American Society for Parenteral and Enteral Nutrition. Additionally, after we assessed micronutrient levels, we experienced a lack of guidance on how to adjust dosing and when to monitor subsequent levels.
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Greenmyer JR, Grindeland CJ, Kobrinsky NL. Eradication of factor IX neutralizing and anaphylactic inhibitors in a patient with severe haemophilia B using cyclophosphamide immune suppression and factor IX desensitization. Haemophilia 2020; 26:e51-e54. [PMID: 31961035 DOI: 10.1111/hae.13926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Jacob R Greenmyer
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
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Grindeland JW, Grindeland CJ, Moen C, Leedahl ND, Leedahl DD. Outcomes Associated With Standardized Ideal Body Weight Dosing of Intravenous Immune Globulin in Hospitalized Patients: A Multicenter Study. Ann Pharmacother 2019; 54:205-212. [DOI: 10.1177/1060028019880300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: There are limited outcomes data for ideal body weight (IBW)-based dosing of intravenous immune globulin (human, IVIG) in hospitalized patients. Objective: To investigate clinical outcomes associated with a standardized change from total body weight to IBW-based dosing of IVIG. Methods: This was a retrospective, multicenter, pre-post sequential period analysis. Data from pre-implementation and post-implementation of an IBW-based dosing strategy for IVIG were collected in 2-year periods (October 1, 2012, to August 31, 2014, and October 2, 2014, to October 1, 2016, respectively). The primary outcome was incidence of 30-day hospital readmission. Length of stay (LOS) was analyzed as a secondary outcome. Results: For the 2 study periods, 297 patients were included for analysis. Both groups had similar demographics, IVIG indications, and body weight measurements, but the post-implementation period had a lower median grams per dose as compared with the pre-implementation period (40 vs 30 g, P ≤ 0.01). 30-Day hospital readmission rates were not significantly different (4% vs 9%, P = 0.07). In-hospital all-cause mortality was also not statistically significant (7.7% vs 3.4%, P = 0.11). The 2 study groups had a similar median hospital LOS (8 vs 7.6 days, P = 0.27). Conclusion and Relevance: The implementation of a standardized IBW IVIG dosing strategy was not associated with a statistically significant increase in 30-day hospital readmission or LOS but was associated with significantly fewer grams per dose given. Application of these data may aid in decreasing institutional drug spend without affecting patient outcomes. However, the study was underpowered, and further investigation is necessary to validate these findings.
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Affiliation(s)
| | | | - Cassandra Moen
- North Dakota State University School of Pharmacy, Fargo, ND, USA
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Johnk SR, Grindeland CJ, Leedahl DD, Carson PJ, Leedahl ND. Impact of a multicenter stewardship-targeted carbapenem justification requirement on the use of carbapenems in 23 hospitals. J Am Coll Clin Pharm 2018. [DOI: 10.1002/jac5.1021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sydney R. Johnk
- Department of Pharmacy Services; Sanford Medical Center; Fargo North Dakota
| | | | - David D. Leedahl
- Department of Pharmacy Services; Sanford Medical Center; Fargo North Dakota
| | - Paul J. Carson
- Department of Infectious Diseases; Sanford Medical Center; Fargo North Dakota
| | - Nathan D. Leedahl
- Department of Enterprise Pharmacy; Sanford Medical Center; Fargo North Dakota
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