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Characterization of Institution-Specific Risk Factors for Post-Operative Atrial Fibrillation in Patients Undergoing Cardiac Surgery
Ruth Murar, PharmD; Sarah Bailou, PharmD, MPH, BCCCP; Emily H. Hsu; and Gideon Berdahl, PharmD, BCCCP
Abstract: Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery and is associated with increased morbidity, prolonged hospitalization, and higher healthcare costs. Risk assessment tools have attempted to predict POAF using factors such as comorbidities, cardiac function, and perioperative characteristics, but these variables have not been consistently validated or standardized across diverse patient populations. This retrospective, single-center study aimed to characterize the proposed clinical and perioperative POAF risk factors in patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), mitral valve replacement (MVR), or a combination of these procedures at Providence St. Vincent Medical Center between July 30, 2022, and September 2, 2024. Following IRB approval in December 2024, 1,287 patients were screened using the Adult Cardiac Surgery Database; of these, 951 met inclusion criteria and were stratified into two groups: those who developed POAF after 48 hours post-procedure and those who did not. Comparative analyses were conducted using Wilcoxon rank-sum, chi-square, and T-tests. Patient characteristics studied include age, gender, comorbidities (e.g., hypertension, COPD, diabetes), procedure characteristics, and relevant periprocedural medications. Perioperative electrolyte levels (potassium and magnesium) were also collected via Epic’s SlicerDicer tool and manual chart review. Analysis of potassium and magnesium trends are ongoing to evaluate their potential predictive value. Results indicated that POAF was more common among patients undergoing complex procedures, particularly combination surgeries including AVR + CABG (9.21% POAF vs. 7.42% non-POAF, p < 0.000001), MVR + CABG (2.3% POAF vs. 0.31% non-POAF, p < 0.000001), as well as isolated MVR (3.95% POAF vs. 2.47% non-POAF). In contrast, isolated CABG (39.1% POAF vs. 51.3% non-POAF, p < 0.000001) and AVR (12.17% POAF vs. 15.3% non-POAF, p 0.000001) were associated with lower POAF incidence, suggest-ing that procedure type and additive effects of combination surgery significantly impacts arrhythmia risk. While many baseline characteristics were similar be-tween groups, POAF was more frequent in patients with COPD (22% POAF vs 17% non-POAF, p < 0.05), prior cerebrovascular accidents (10.86% POAF vs. 6.34% non-POAF, p < 0.02), and history of myocardial infarction occurring 21 days or later prior to surgery (13.82% POAF vs 10.97% non-POAF, p < 0.05). Additionally, postoperative serum creatinine 48 hours post-surgery was statistically significantly higher in the POAF group (p < 0.004), indicating an association with renal dysfunction. These findings are consistent with prior research linking procedural complexity and cardiopulmonary comorbidities to POAF, though the stronger associations seen with combination valve procedures and renal dysfunction are less well described in the literature.
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The impact of an emergency department code sepsis alert on empiric antibiotic effectiveness
Elizabeth Nguyen, PharmD; Samantha Wagner, PharmD, BCEMP; and Sarah Ballou, PharmD, MPH, BCCCP
Abstract: Sepsis bundles, known as SEP-1, provide hourly recommendations to ensure timely identification and administration of antibiotics to patients with sepsis or septic shock. To ensure compliance with SEP-1, the Centers for Medicare and Medicaid Services (CMS) tied hospital reimbursements to SEP-1 protocol adherence in early 2024. Since these reimbursements have been put in place, there have been limited studies to evaluate antibiotic prescribing practices. This study aims to evaluate the impact of a Code Sepsis alert on empiric antibiotic prescribing practices for patients with sepsis or septic shock in the Emergency Department at Providence St. Vincent Medical Center (PSVMC). This is a single-center, retrospective chart review study including adult patients > 18 years old who met CMS sepsis criteria and received antibiotics in the Emergency Department (ED) from February 2023 to May 2024. This study utilizes the Providence Acute Care Sepsis Matrix Explorer, an existing data set for patients who qualify for sepsis diagnoses based off CMS sepsis criteria in the ED at PSVMC. The primary outcome is an assessment of the effectiveness of the empiric antibiotic(s) prescribed for patients meeting sepsis criteria in the ED before and after a Code Sepsis alert implementation. Effectiveness will be assessed by using culture data to evaluate antibiotic coverage and discharge diagnoses to determine if patients had true infections. Secondary outcomes include SEP-1 compliance (time to antibiotic administration < 60 minutes), inpatient mortality, and changes in prescribing patterns using the antibiotic spectrum index (ASI) score. Baseline characteristics will be evaluated using descriptive statistics. Chi-squares tests will be used to evaluate the primary and secondary outcomes. The effects of multifactorial variables (lactate value, vasopressor use, duration of septic shock, and number of hypotensive episodes) on survivorship at 24 and 72 hours will be evaluated using linear binomial regression. A two-tailed significance of p < 0.05 will be considered statistically significant. Preliminary results will be presented, and conclusions will be presented when the project is completed (IRB approved). Learning Objectives: Evaluate the impact of a code sepsis alert on empiric antibiotic effectiveness for patients with sepsis or septic shock. Presentation Category: Emergency Department
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IVIG Stewardship to Evaluate Outpatient Infusion Use
Judy Nguyen, PharmD and Ian Ingram
Abstract: IVIG is an IV medicine that is made from human donor plasma and is approved to treat low Immunoglobulin G (IgG) serum levels to reduce the risk of infections. IgG is the most common antibody and is a part of the immune system to help protect against bacterial and viral infections. IVIG works by modulating cells in the immune system to help replenish low IgG levels. Current CDC and NCCN guidelines recommend IVIG replacement for IgG levels < 500 mg/dL for hypogammaglobulinemia caused by different disease states such as CLL, multiple myeloma, B-cell malignancies. Based on current observations and practices at Providence Franz Cancer Center, IVIG is administered at regular intervals without regard to IgG levels. With anticipation of increased use of IVIG with recent approval of multiple bispecific antibodies that recommend using IVIG prophylaxis, a more formal use criteria protocol for IVIG is necessary to assure appropriate use and avoid unnecessary treatment and cost for patients. Eligible patients ≥18 years old who received IVIG between January 2023 to January 2025 at Providence Franz Cancer Center and Providence Outpatient Infusion Center. Patients with hypogammaglobulinemia, CLL, multiple myeloma, immunodeficiency, follicular lymphoma, diffuse large B-cell lymphoma. Data collection through SlicerDicer with IVIG administration from January 2023 to January 2025 and manual chart review to obtain dose and frequency of IVIG and IgG levels as available. Project evaluates use of IVIG and compliance with IgG level-based dosing to identify if administration is appropriate based on current recommendations. The aim of the project is to evaluate overall IVIG use, and patients’ cost savings and treatment burden associated with IgG level-based dosing. Preliminary results will be presented. Results and conclusions will be shared when the project is completed. (IRB exempt).
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Evaluating the role of social determinants of health on disparities in breast and prostate cancer screening and treatment: a retrospective analysis
Zach Nunemaker, PharmD and Jenifer Smith
Recent advances in cancer screening and treatment have led to improved outcomes, including earlier detection, increased overall survival rates, and enhanced quality of life across several cancer types. Despite these advancements, significant disparities in cancer care persist across the United States, particularly among racial and ethnic minority groups and medically underserved populations. These disparities are largely driven by the complex interplay of social determinants of health (SDOH). Although extensive research has been conducted, substantial knowledge gaps remain in understanding how SDOH contribute to disparities in cancer screening and treatment, specifically for breast and prostate cancer. The purpose of this study is to evaluate whether an association exists between key SDOH (such as socioeconomic status, race/ethnicity, language, geographic location) and outcomes for patients diagnosed with breast or prostate cancer. Additionally, we assessed whether these factors contribute to delayed diagnoses and higher rates of late-stage cancer at presentation. Findings from this study will help inform targeted interventions and policies aimed at reducing disparities and improving outcomes for all individuals across the cancer care continuum. This is a single center retrospective cohort analysis of Providence Health Plan (PHP) patients diagnosed with breast or prostate cancer between January 1, 2022 and December 31, 2024. Patients for all lines of business (Commercial, Medicare, and Medicaid) with continuous enrollment in health plan (six years prior to breast cancer diagnosis and 10 years prior to prostate cancer diagnosis) and within screening recommendation age group (≤70 years for prostate cancer and females ≤75 years for breast cancer) were included. The primary outcome is to determine whether SDOH are associated with lower rates of receiving guideline-recommended screening and/or first-line treatment. The secondary outcome is to determine whether SDOH are associated with worse clinical outcome, defined as late-stage disease at time of diagnosis. Results and conclusions will be shared upon completion of the project. This study is IRB exempt. Learning objectives: 1. Identify the social determinants of health that contribute to disparities in breast and prostate cancer screening and treatment 2. Discuss the implications of screening and treatment disparities related to social determinants of health on cancer stage at diagnosis in patients with breast and prostate cancer Presentation Category: Managed Care/Population Health
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Efficacy of Procainamide vs Amiodarone for Atrial Fibrillation in Emergency Department Patients
Tommy Pham, PharmD; Emily H. Hsu; Marian Dobles; and Samantha Wagner, PharmD, BCEMP
Abstract: Procainamide has been shown to be safe and effective for atrial fibrillation, and it has a rapid onset to cardioversion. However, its efficacy compared to amiodarone is not well-characterized. Current literature suggests that procainamide may have a faster time to conversion than amiodarone. The purpose of this study is to compare rate and time to conversion of atrial fibrillation to normal sinus rhythm (NSR) between procainamide and amiodarone in emergency department (ED) patients. The potential to discharge patients more quickly and lessen ED burden is especially important in the era of ED overcrowding. This is a retrospective, propensity-matched, multi-center, observational study. Adult patients who received procainamide or amiodarone for atrial fibrillation/flutter in the ED at a Providence Hospital in the Oregon region from 2014 to 2024 were included. Patients were identified and screened through the use of EPIC Hyperspace and Slicer Dicer. Descriptive statistics were utilized to compare baseline characteristics. Rate of conversion to NSR and other categorical variables were compared with the chi-square test. Time to conversion to NSR and other continuous variables were compared with Student’s t-test. Linear or logistic regression analysis will be conducted to determine factors significantly associated with rate and/or time to conversion to NSR. Preliminary results were gathered with 22 patients receiving procainamide and 19 patients receiving amiodarone. There was no significant difference between incidence of atrial fibrillation (91.0% vs 78.9%) vs atrial flutter (9.0% vs 2.1%) between procainamide and amiodarone groups, respectively (p = 0.28). There was no significant difference between paroxysmal (50.0% vs 73.7%) vs new-onset (50.0% vs 26.3%) atrial fibrillation/flutter between procainamide and amiodarone groups, respectively (p = 0.062). Fifty percent of patients converted on procainamide, and 57.9% of patients converted on amiodarone (p = 0.613). For patients that did not convert to NSR, subsequent electrical cardioversion was successful in 100% of patients on procainamide and 26.3% of patients on amiodarone (p = 0.154). Time to conversion appeared to be shorter with procainamide (7.14 hours) vs amiodarone (16.4 hours), though this result did not achieve statistical significance likely due to lack of power (p = 0.069). Length of stay was significantly shorter in the procainamide group compared to the amiodarone group (10.1 vs 27.5 hours, p = 0.0059). Significantly more patients in the procainamide group were discharged from the ED compared to the amiodarone group (86.0% vs 31.6%, p < 0.001). Final conclusions will be shared when the formal analysis is completed. (IRB approved) Learning objectives: 1) Describe the impact of procainamide vs amiodarone on time to discharge for patients who present to ED with atrial fibrillation/flutter, 2) Compare the safety and effectiveness of procainamide versus amiodarone for atrial fibrillation/flutter Presentation Category: Cardiology/Emergency Medicine
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Methicillin-Resistant Staphylococcus Aureus Nasal Testing Negative Predictive Value for Skin and Soft Tissue Infections
Sabra Woodruff, PharmD
Learning Objectives: 1. Assess the importance of MRSA nasal screening versus culture data when it comes to guiding therapy for SSTI management. 2. Identify if there are any infection characteristics that significantly impact outcome of predictive values of MRSA NAAT PCR testing. Abstract: Introduction Methicillin-Resistant Staphylococcus aureus (MRSA) NAAT PCR has been a valuable tool for de-escalating vancomycin, including for management of skin and soft tissue infections (SSTIs). However, providers have reported instances where a negative MRSA NAAT has led to narrowing antibiotics, but the wound culture revealed MRSA growth. Due to the short time for MRSA nasal swab result compared to wound culture result, this could be a common occurrence in the hospital setting. Previous research shows MRSA NAAT negative predictive value for all SSTI to be anywhere between 80% to 98.4%. In this study, we assessed the negative predictive value of MRSA NAAT PCR with SSTIs. Methods Retrospective, single center study evaluating 162 patients with diagnosis of SSTI between November 2022 to January 2025. Analyzed impact of data using sensitivity, specificity, positive predicative value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. Results: This population included a majority of purulent infections (n=134, 82.7%) and patients with a diagnosis of cellulitis (n=65, 40.1%). Of the pa-tients included in this study, 92 (56.8%) had a negative MRSA NAAT PCR with no MRSA growth, 37 (22.8%) had a positive MRSA NAAT PCR with MRSA growth, 15 (9.3%) had a negative MRSA NAAT PCR with MRSA growth, and 18 (11.1%) had a positive MRSA NAAT PCR with no MRSA growth. This data calculated a negative predictive value (NPV) of 86% (95% CI, 77.6-91.7%) and a positive predicative value (PPV) of 67.3% (95% CI, 53.2-79%). Conclusion: MRSA NAAT PCR testing is a valuable tool for de-escalation; however, other factors need to be taken into consideration prior to use for de-escalation of vancomycin in the setting of SSTIs specifically
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