Common use of Learning Objectives Clause in Contracts

Learning Objectives. Recognize the 4 factors that make up the 4T score and understand how to assess each factor. Identify proper diagnosis and treatment for HIT based on calculated 4T score. Which of the following factors does not impact on the 4T score? A timing of platelet decrease B: degree of thrombocytopenia C: type of heparin exposure D: presence of other causes of thrombocytopenia Select the best course of therapy for a patient with a 4T score of 6? A Wait for laboratory testing to prove HIT prior to transitioning to non B Assume HIT, transition to a non-heparin anticoagulant, and do not C Continue heparin as prescribed and do not order laboratory testing D Transition to a non-heparin anticoagulant while awaiting laboratory Q1 Answer: C Q2 Answer: D D: Hypertension and dyslipidemia are not risk factors for atherosclero ACPE Universal Activity Number 0121-9999-18-362-L01-P What referral should be made in diabetic patients for initial care management? A Cardiologist for cardiovascular disease management B Eye care professional for annual dilated eye exam C Dentist for comprehensive dental and periodontal examination D Both B and C Q1 Answer: C Q2 Answer: D Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) ACPE Universal Activity Number 0121-9999-18-360-L01-P Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Jordan L. Clark*, PharmD, Brenda B. Clark, PharmD, BCPS, Sandra K. Lemon, PharmD, BCPS, BCCCP Community Health Network,7150 Clearvista Dr,Indianapolis,IN,46256 jachenbach@ecommunity.com Purpose: Warfarin has significant interpatient variability, numerous drug and food interactions, and a narrow therapeutic index requiring close monitoring via an international normalized ratio (INR). Thrombotic and hemorrhagic adverse events due to poorly managed warfarin can have serious and even fatal implications for patients. Joint Commission Hospital National Patient Safety Goal 03.05.01 describes reducing the risk of patient harm associated with anticoagulant therapy through the use of an approved protocol for the initiation and maintenance of anticoagulant therapy. An automatic pharmacist-managed inpatient warfarin protocol was implemented in June 2013 at Community Health Network (CHNw). A follow-up study had not been completed to evaluate the protocol since shortly after its initiation. The primary objective of this study was to evaluate the safety and efficacy of an inpatient pharmacist managed warfarin protocol compared to physician-managed warfarin. Methods: A retrospective chart review was completed to evaluate outcomes of patients newly initiated on warfarin at four hospitals within CHNw between August 22, 2012 to June 23, 2013 before protocol implementation and July 1, 2016 to June 30, 2017 after protocol implementation. Patients were excluded if they were a protected population, had an international normalized ratio (INR) goal other than 2 2.5, 2-3, or 2.5-3.5, on warfarin prior to admission, on warfarin for an orthopedic indication, managed by a pharmacist prior to the automatic protocol, did not follow-up with a network-affiliated anticoagulation clinic within one week, or received less than four doses of warfarin during admission. The primary endpoint compared the average time to therapeutic INR of pharmacist and physician-managed inpatient warfarin. Secondary endpoints compared out of range INR values, INR values at the first outpatient follow-up appointment, and incidence of bleeding and thrombotic events throughout the admission and 30 days post-discharge. Results and conclusions will be presented at the Great Lakes Pharmacy Residency Conference.

Learning Objectives. Recognize Explain the 4 factors that make up impact menopause has on a woman’s quality of life when symptoms are not managed properly. Describe the 4T score and understand how to assess each factorbenefit of utilizing a designated clinical pharmacist in a GYN clinic for menopause management. Identify proper diagnosis and treatment for HIT based on calculated 4T score. The average age of menopause onset is: A 43 B: 52 C: 39 D: 65 Which of the following factors does not impact on is the 4T scoregold standard treatment of menopause? A timing of platelet decrease B: degree of thrombocytopenia C: type of heparin exposure D: presence of other causes of thrombocytopenia Select the best course of Spironolactone B Herbal supplements C Surgery D Hormonal therapy for a patient with a 4T score of 6? A Wait for laboratory testing to prove HIT prior to transitioning to non B Assume HIT, transition to a non-heparin anticoagulant, and do not C Continue heparin as prescribed and do not order laboratory testing D Transition to a non-heparin anticoagulant while awaiting laboratory Q1 Answer: C B Q2 Answer: D D: Hypertension and dyslipidemia are not risk factors for atherosclero B Dispose of unused pills by mixing them in undesirable products be ACPE Universal Activity Number 0121-9999-18-362377-L01-P What referral should be made C Use all prescribed pills until gone D Do not use non-opioid pills in diabetic patients for initial care management? A Cardiologist for cardiovascular disease management B Eye care professional for annual dilated eye exam C Dentist for comprehensive dental and periodontal examination D Both B and C combination with this medication Q1 Answer: C A Q2 Answer: D B Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) ACPE Universal Activity Number 0121-9999-18-360717-L01L04-P Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Jordan L. ClarkCassandra M. Diamond, PharmD.*, PharmDPhilip DiMondo, Brenda B. ClarkPharmD. BCPS, Hope Broxterman, PharmD, BCPS, Sandra K. LemonCynthia Nichols, PharmD, BCPS, BCCCP Community Health Network,7150 Clearvista DrPhD Munson Medical Center,2751 ARBORVIEW DR,IndianapolisApt 3,TRAVERSE CITY,IN,46256 jachenbach@ecommunity.com MI,496857303 cdiamond@mhc.net Statement of Purpose: Warfarin has significant interpatient variability, numerous drug and food interactions, and Heparin induced thrombocytopenia (HIT) is an immune mediated disorder that is defined as the decrease of platelets in relation to a narrow therapeutic index requiring close monitoring via an international normalized ratio (INR)heparin infusion. Thrombotic and hemorrhagic adverse events HIT often goes unrecognized due to poorly managed warfarin can have serious various factors playing a role in decreasing a patient’s platelet count. When HIT develops, it has a greater than 30% mortality rate making early recognition, cessation of heparin and even fatal implications for patients. Joint Commission Hospital National Patient Safety Goal 03.05.01 describes reducing the risk treatment of patient harm associated HIT with a non- heparin based anticoagulant therapy through the use of an approved protocol for the initiation and maintenance of anticoagulant therapy. An automatic pharmacist-managed inpatient warfarin protocol was implemented in June 2013 at Community Health Network (CHNw). A follow-up study had not been completed to evaluate the protocol since shortly after its initiationessential. The primary objective of this study was is to retrospectively evaluate the current argatroban infusion nomogram to ensure patient safety, evaluate adequate anticoagulation and implemen changes to the current nomogram if necessary.Statement of Methods used: This study will be a retrospective, chart review evaluatin patients who are initiated on an argatroban infusion for more than 24 hours. The protocol for this study will be submitted to the Institutional Review Board for approval. The primary outcome of this study is to evaluate activated partial thromboplastin time (aPTT) data to ensure patients obtained a therapeutic aPTT within 24 hours of therapy. Specific patient factors to be included in the data collection are age, gender, weight, diagnosis for implementation of argatroban, current argatroban dosing nomogram (ICU v. non-ICU), aPTT, total bilirubin, serum creatinine, liver function tests and time to achieve therapeutic aPTT. Patient safety and efficacy will be the secondary endpoint of an inpatient pharmacist managed warfarin protocol compared to physician-managed warfarinthis study, specifically assessing patient bleeding, clotting and duration of argatroban therapy. Methods: A retrospective chart review was completed to evaluate outcomes of patients newly initiated on warfarin at four hospitals within CHNw between August 22, 2012 to June 23, 2013 before protocol implementation and July 1, 2016 to June 30, 2017 after protocol implementation. Patients were excluded if they were a protected population, had an international normalized ratio (INR) goal other than 2 2.5, 2-3, or 2.5-3.5, on warfarin prior to admission, on warfarin for an orthopedic indication, managed by a pharmacist prior Data collected will help guide future improvements to the automatic current argatroban infusion protocol, did not follow-up with a network-affiliated anticoagulation clinic within one week, or received less than four doses .Summary of warfarin during admission. The primary endpoint compared the average time Preliminary results to therapeutic INR of pharmacist and physician-managed inpatient warfarin. Secondary endpoints compared out of range INR values, INR values at the first outpatient follow-up appointment, and incidence of bleeding and thrombotic events throughout the admission and 30 days post-discharge. Results and conclusions will be presented at the Great Lakes Pharmacy Residency Conferencesupport conclusion: Preliminary results are pending.Conclusions: Pending.

Learning Objectives. Recognize List three additional risk factors for the 4 factors development of acute kidney injury while a patient is on vancomycin and piperacillin-tazobactam Discuss two signs that make up indicate the 4T score and understand how to assess each factor. Identify proper diagnosis and treatment for HIT based on calculated 4T score. development of acute kidney impairment Which of the following factors does not impact on is a risk factor for the 4T scoredevelopment of acute kidney injury? A timing Combination of platelet decrease piperacillin-tazobactam and scopolamine B: degree History of thrombocytopenia migraine headaches C: type Combination of heparin exposure piperacillin-tazobactam and vancomycin D: presence History of other causes creatinine clearance greater than 100 mL/min Which combination therapy has the highest risk for the development of thrombocytopenia Select the best course of therapy for a patient with a 4T score of 6acute kidney injury? A Wait for laboratory testing to prove HIT prior to transitioning to non metronidazole + linezolid B Assume HIT, transition to a nonIV contrast dye + gentamicin C clindamycin + piperacillin-heparin anticoagulant, and do not C Continue heparin as prescribed and do not order laboratory testing D Transition to a non-heparin anticoagulant while awaiting laboratory Q1 Answer: C Q2 Answer: D D: Hypertension and dyslipidemia are not risk factors for atherosclero ACPE Universal Activity Number 0121-9999-18-362-L01-P What referral should be made in diabetic patients for initial care management? A Cardiologist for cardiovascular disease management B Eye care professional for annual dilated eye exam C Dentist for comprehensive dental and periodontal examination D Both B and C Q1 Answer: C Q2 Answer: D tazobactam Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) D vancomycin + micafungin Q1 Answer: C Q2 Answer: B ACPE Universal Activity Number 0121-9999-18-360867-L01-P Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Jordan L. ClarkSandy A Ezzet, PharmD*, PharmD, Brenda B. ClarkMeghan McComb, PharmD, BCPS, Sandra K. LemonCPAP, Nancy Shapiro PharmD, FCCP, BCPS, BCCCP Community Health Network,7150 Clearvista DrBCACP, CPAP, Ellen Uppuluri PharmD, BCACP University of Illinois at Chicago,833 South Wood st,IndianapolisChicago,IN,46256 jachenbach@ecommunity.com IL,60612 sezzet2@uic.edu Purpose: Warfarin has significant interpatient variabilityDue to limited efficacy and safety data of Direct Oral Anticoagulants (DOACs) in patients with obesity, numerous drug this study aims to describe the prescribing pattern of oral anticoagulants in patients with a BMI greater than 40 kg/m2 and/or weight greater than 120 kg at our institution and food interactionsdetermine the efficacy and safety of oral anticoagulants i this patient population.Method: This is a retrospective, observational study that includes patients 18 years or older with a history of venous thromboembolism (VTE) and/or atrial fibrillation with an outpatient prescription for either warfarin or a DOAC. Patients will be included if they have a BMI > 40 kg/m2 and/or weight >120 kg. Pregnant women and patients on anticoagulation for orthopedic VTE prophylaxis or any- off label indication will be excluded from this study. Patients with an electronic prescription order in Cerner for a narrow therapeutic index requiring close monitoring via DOAC or warfarin and an international normalized ratio (INR). Thrombotic and hemorrhagic adverse events due to poorly managed warfarin can have serious and even fatal implications ICD 9 or ICD 10 code for patients. Joint Commission Hospital National Patient Safety Goal 03.05.01 describes reducing the risk of patient harm associated with anticoagulant therapy through the use of an approved protocol obesity will be screened for the initiation and maintenance of anticoagulant therapy. An automatic pharmacist-managed inpatient warfarin protocol was implemented in June 2013 at Community Health Network (CHNw). A follow-up study had not been completed to evaluate the protocol since shortly after its initiationeligibility by performing a chart review. The primary objective outcome is the number of this study was warfarin or DOAC prescriptions in patients with obesity. Secondary outcomes include any recurrent VTEs or strokes to evaluate the safety assess efficacy and efficacy any major or minor bleeding events to assess safety. Preliminary results and conclusion: Between August 2014 and August 2017, 332 patients with a BMI> 40 kg/m2 and/or weigh >120 kg were prescribed a oral anticoagulant. Of these patients, 59% (196) were prescribed warfarin and 41% (136) were prescribed a DOAC. Further data collectio and analysis on outcome data of an inpatient pharmacist managed warfarin protocol DOACs compared to physician-managed warfarin. Methods: A retrospective chart review was completed to evaluate outcomes of patients newly initiated on warfarin at four hospitals within CHNw between August 22, 2012 to June 23, 2013 before protocol implementation are ongoing and July 1, 2016 to June 30, 2017 after protocol implementation. Patients were excluded if they were a protected population, had an international normalized ratio (INR) goal other than 2 2.5, 2-3, or 2.5-3.5, on warfarin prior to admission, on warfarin for an orthopedic indication, managed by a pharmacist prior to the automatic protocol, did not follow-up with a network-affiliated anticoagulation clinic within one week, or received less than four doses of warfarin during admission. The primary endpoint compared the average time to therapeutic INR of pharmacist and physician-managed inpatient warfarin. Secondary endpoints compared out of range INR values, INR values at the first outpatient follow-up appointment, and incidence of bleeding and thrombotic events throughout the admission and 30 days post-discharge. Results and conclusions results will be presented at the 2018 Great Lakes Pharmacy Residency Conference.

Learning Objectives. Recognize the 4 patient-specific factors that make up the 4T score for which dose adjustments of apixaban and understand how to assess each factor. rivaroxaban are recommended based on FDA-approved product labeling Identify proper diagnosis appropriate direct oral anticoagulant treatment regimens for nonvalvular atrial fibrillation and treatment for HIT based on calculated 4T score. of venous thromboembolism Which of the following two patient-specific factors does not impact would indicate a reduced dose of apixaban for nonvalvular atrial fibrillation based on the 4T scoreFDA approved product labeling? A timing Concomitant use of platelet decrease aspirin and weight ≤ 60 kg B: degree Concomitant use of thrombocytopenia aspirin and CrCl ≤ 30 mL/min C: type of heparin exposure Age ≥ 80 years old and weight ≤ 60 kg D: presence Age ≥ 80 years old and CrCl ≤ 30 mL/min Which of other causes the following is the most appropriate dosage of thrombocytopenia Select the best course of therapy for rivaroxaban to initiate in a patient with a 4T score normal renal function for treatment of 6venous thromboembolism? A Wait for laboratory testing to prove HIT prior to transitioning to non 15 mg PO BID x 21 days, then 20 mg PO daily B Assume HIT20 mg PO BID x 7 days, transition to a non-heparin anticoagulant, and do not then 10 mg PO daily C Continue heparin as prescribed and do not order laboratory testing 20 mg PO daily D Transition to a non-heparin anticoagulant while awaiting laboratory 10 mg PO daily Q1 Answer: C Q2 Answer: D D: Hypertension and dyslipidemia are not risk factors for atherosclero A ACPE Universal Activity Number 0121-9999-18-362349-L01-P What referral should be made in diabetic patients for initial care management? A Cardiologist for cardiovascular disease management B Eye care professional for annual dilated eye exam C Dentist for comprehensive dental and periodontal examination D Both B and C Oppositional defiant disorder Q1 Answer: C D Q2 Answer: D Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) C ACPE Universal Activity Number 0121-9999-18-360348-L01-P Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Jordan L. ClarkActivity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Dana M. Chavez, PharmD*, Steve C. Ebert, PharmD, Brenda B. ClarkFCCP, PharmD, BCPS, Sandra K. Lemon, PharmD, BCPS, BCCCP Community Health Network,7150 Clearvista DrFIDSA Meriter Hospital,202 S. Park Street,IndianapolisMadison,IN,46256 jachenbach@ecommunity.com WI,537151304 dana.chavez@unitypoint.org Purpose: Warfarin has significant interpatient variabilitySubtherapeutic serum vancomycin concentrations in the first one to two days of therapy may result in suboptimal treatment outcomes such as higher failure rates, numerous drug and food interactionsslower eradication of bacteremia, and a narrow therapeutic index requiring close promotion of growth of vancomycin-intermediate bacteria. Conversely, supratherapeutic serum vancomycin concentrations could result in nephrotoxicity. Though vancomycin clearance correlates with estimated creatinine clearance, wide interpatient variability exists and serum concentration monitoring via an international normalized ratio (INR). Thrombotic and hemorrhagic adverse events due to poorly managed warfarin can have serious and even fatal implications for patients. Joint Commission Hospital National Patient Safety Goal 03.05.01 describes reducing the risk of patient harm associated with anticoagulant therapy through the use of an approved protocol for the initiation and maintenance of anticoagulant therapy. An automatic pharmacistis typically performed at steady-managed inpatient warfarin protocol was implemented in June 2013 at Community Health Network (CHNw). A follow-up study had not been completed to evaluate the protocol since shortly after its initiationstate. The primary objective purpose of this study was is to evaluate determine the safety accuracy of using a post-first dose vancomycin serum level for dosing regimen design and efficacy prediction of vancomycin clearance and steady-state serum concentration. This wi allow for an inpatient pharmacist managed warfarin protocol compared to physician-managed warfarinearlier adjustment in the dosing regimen and quicker therapy optimization. Methods: A retrospective chart This study is a prospective cohort review was completed of adult patients on intravenous vancomycin maintenance therapy from December 2017 to evaluate outcomes of patients newly initiated on warfarin at four hospitals within CHNw between August 22, 2012 to June 23, 2013 before protocol implementation and July 1, 2016 to June 30, 2017 after protocol implementationpresent. Patients were are included if they are started on vancomycin for an active infection, have stable renal function and have received no more than one vancomycin dose prior to inclusion into the study. Patients are excluded if they were a protected populationhave changing renal function (serum creatinine change >25%), had an international normalized ratio (INR) goal other than 2 2.5, 2-3are on dialysis, or 2.5-3.5are on vancomycin for surgical prophylaxis only. After the initial vancomycin dose (per pharmacy protocol), on warfarin prior to admission, on warfarin for an orthopedic indication, managed by a pharmacist vancomycin serum level will be drawn roughly 2 hours prior to the automatic protocol, did not follow-up with second dose. Using a network-affiliated anticoagulation clinic within one week, or received less than four doses of warfarin during admission. The primary endpoint compared the average time to therapeutic INR of pharmacist and physician-managed inpatient warfarin. Secondary endpoints compared out of range INR values, INR values at Bayesian kinetic model incorporating both the first outpatient followdose serum concentration and local population pharmacokinetics, an estimation of the patient’s vancomycin clearance is calculated. This estimated clearance is used to predict eac patient’s steady-up appointment, and incidence of bleeding and thrombotic events throughout state vancomycin level which will then be compared to the admission and 30 days post-dischargeactual steady state serum level (single data point level or midpoint level). Results Results: The results and conclusions of this study are pending and will be presented at the 2018 Great Lakes Pharmacy Residency Conference.

Learning Objectives. Recognize Review the 4 factors that make up the 4T score and understand how to assess each factorcurrent literature regarding use of DOACs in obese patients. Identify proper diagnosis and treatment for HIT based on calculated 4T scorerisk factors associated with developing a VTE. Which of the following factors does not impact is true regarding the 2016 International Society of Thrombosis and Haemostasis guidance statement? A Large randomized trials that focus on the 4T scoreuse of DOACs in obese B: Doses for DOACs should be increased in patients weighing greate C: There are no concerns with using DOACs in morbidly obese patie D: Standard dosing of DOACs is recommended in patients weighing l Which of the following is not a potential major risk factor for VTE? A timing Major trauma within 3 months of platelet decrease B: degree VTE diagnosis B Body mass index less than 30 kg/m2 C Orthopedic surgery within 3 months of thrombocytopenia C: type of heparin exposure D: presence of other causes of thrombocytopenia Select the best course of therapy for a patient with a 4T score of 6? A Wait for laboratory testing to prove HIT prior to transitioning to non B Assume HIT, transition to a non-heparin anticoagulant, and do not C Continue heparin as prescribed and do not order laboratory testing VTE diagnosis D Transition to a non-heparin anticoagulant while awaiting laboratory Factor V Leiden mutation Q1 Answer: C D Q2 Answer: D D: Hypertension and dyslipidemia are not risk factors for atherosclero B ACPE Universal Activity Number 0121-9999-18-362343-L01-P What referral should be made in diabetic patients for initial care management? A Cardiologist for cardiovascular disease management B Eye care professional for annual dilated eye exam C Dentist for comprehensive dental and periodontal examination D Both B and C Q1 Answer: C Q2 Answer: D Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) ACPE Universal Activity Number 0121-9999-18-360344-L01-P Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Jordan Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Irene L. ClarkCapistrano, PharmD*, Jaimini Patel, PharmD, Brenda B. ClarkDaniel C. Hidalgo, MD, Erin Mancl, PharmD, BCPS, Sandra K. LemonBCCCP, Megan Rech, PharmD, MS, BCPS, BCCCP Community Health Network,7150 Clearvista DrLoyola University Medical Center,2160 S 1st Ave,IndianapolisMaywood,IN,46256 jachenbach@ecommunity.com IL,60153 irene.capistrano@lumc.edu Purpose: Warfarin has significant interpatient variabilityThere is conflicting evidence regarding outcomes of obese critically ill patients given that obesity is typically associated with the development of chronic illnesses. Despite this association, numerous drug and food interactions, and some studie also suggest that elevated body mass index may confer a narrow therapeutic index requiring close monitoring via an international normalized ratio mortality benefit compared with patients of normal weight (INRobesity paradox). Thrombotic However, increased adiposity alters metabolic response and hemorrhagic adverse events due secretion o various inflammatory cytokines may lead to poorly managed warfarin can have serious and even fatal implications for patientsworse outcomes. Joint Commission Hospital National Patient Safety Goal 03.05.01 describes reducing In addition, alterations in pharmacokinetic parameters in obese critically ill patients complicate optimal medication dosing. One previous study demonstrated that obese patients tended to receive lower doses of vasopressors which could ultimately affect time to hemodynamic stabilit during various shock states. At this time, the risk practice of patient harm associated with anticoagulant therapy through the use of an approved protocol for the initiation and maintenance of anticoagulant therapy. An automatic pharmacistusing weight based or non-managed inpatient warfarin protocol was implemented in June 2013 at Community Health Network (CHNw). A follow-up study had weight based dosing to titrate vasopressors is not been completed to evaluate the protocol since shortly after its initiationstandardized. The primary objective of this study was to evaluate determine the safety and efficacy cumulative vasopressor dose required by obese patients versus non- obese patients who experienced distributive, cardiogenic, hypovolemic, or obstructive shock during the first 72 hours of an inpatient pharmacist managed warfarin protocol compared to physician-managed warfarintherapy. Methods: A retrospective chart review was completed to evaluate outcomes of patients newly initiated on warfarin This retrospective, single centered, cohort study included adults with shock who received vasopressors in the emergency department, medical, trauma/surgical, cardiology or neurosciences intensive care unit (ICU) services at four hospitals within CHNw between August 22, 2012 to June 23, 2013 before protocol implementation and Loyola University Medical Center from January - July 1, 2016 to June 30, 2017 after protocol implementation. Patients were excluded if they were a protected population, had an international normalized ratio (INR) goal other than 2 2.5, 2-3, or 2.5-3.5, on warfarin prior to admission, on warfarin for an orthopedic indication, managed by a pharmacist prior to the automatic protocol, did not follow-up with a network-affiliated anticoagulation clinic within one week, or received less than four doses of warfarin during admission2017. The primary endpoint compared the average time to therapeutic INR of pharmacist outcome was cumulative vasopressor doses in obese and physiciannon-managed inpatient warfarinobese adult patients at 72 hours. Secondary endpoints compared out included in-hospital and 28-day mortality, duration of range INR valuesshock, INR values at the first outpatient followaddition of a second agent, time to hemodynamic stability, hospital length of stay, ICU-up appointment, free days and incidence of bleeding and thrombotic events throughout vasopressor related side effects. Baseline characteristics were analyzed using descriptive statistics. Categorical data were analyzed by the admission and 30 days postChi-dischargesquare or Fischer's Exact test. Continuous data were analyzed by t-test or by the Mann-Whitney U test as appropriate. The study was approved by the Institutional Review Board. Results and conclusions will be presented at the Great Lakes Pharmacy Residency Conference.

Learning Objectives. Recognize Describe the 4 factors that make up pathway of rivaroxaban metabolism and excretion. Discuss the 4T score drug-drug interaction between rivaroxaban and understand how to assess each factordiltiazem. Identify proper diagnosis and treatment for HIT based on calculated 4T score. Which of the following factors does not impact on the 4T scoreRivaroxaban is primarily metabolized by which CYP enzyme? A timing of platelet decrease Cyp2c9 B: degree of thrombocytopenia Cyp3a4 C: type of heparin exposure Cyp1a2 D: presence Cyp2d6 The drug-drug interaction between rivaroxaban and diltiazem is a result of other causes of thrombocytopenia Select the best course of therapy for a patient with a 4T score of 6? diltiazem’s activity as a: A Wait for laboratory testing to prove HIT prior to transitioning to non Moderate CYP3A4 and P-gp inhibitor B Assume HIT, transition to a nonModerate CYP2J2 and P-heparin anticoagulant, gp inhibitor C Strong CYP3A4 and do not C Continue heparin as prescribed and do not order laboratory testing P-gp inhibitor D Transition to a non-heparin anticoagulant while awaiting laboratory Strong CYP3A4 inducer Q1 Answer: C B Q2 Answer: D D: Hypertension and dyslipidemia are not risk factors for atherosclero A C Increased intensive/critical care length of stay ACPE Universal Activity Number 0121-9999-18-362313-L01-P What referral should be made in diabetic patients for initial care management? A Cardiologist for cardiovascular disease management B Eye care professional for annual dilated eye exam C Dentist for comprehensive dental and periodontal examination D Both B and C All of the above Q1 Answer: C D Q2 Answer: D Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) ACPE Universal Activity Number 0121-9999-18-360312-L01-P Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) Jordan L. Clark*Activity Type: Knowledge-based Contact Hours: 0.5 (if ACPE number listed above) ▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, PharmD, Brenda B. Clark*; ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇, PharmD, BCPS, Sandra K. Lemon, ; ▇▇▇▇▇▇▇ Accurs PharmD, BCPSBCACP Veteran Affairs - Chalmers ▇. ▇▇▇▇▇,420 ▇. ▇▇▇▇▇ ▇▇,▇▇▇▇▇▇▇▇,▇▇,▇▇▇▇▇ ▇▇▇▇▇▇▇.▇▇▇▇▇▇▇@▇▇.▇▇▇ Hospital readmissions are extremely costly to the healthcare system. Effective medication management is an imperative part of transitional care for patients after hospital discharge. To date, BCCCP Community Health Network,7150 Clearvista Dr,Indianapolis,IN,46256 jachenbach@ecommunity.com Purpose: Warfarin literature has significant interpatient variabilitydemonstrated the role of the pharmacist at discharge but literature is scarce to support models that operate from the primary care setting. To improve the care of high-risk Veterans transitioning from the hospital back to primary care, numerous drug the Columbus VA has initiated a pilot, pharmacist- managed transitions of care (ToC) clinic. The ToC pharmacist screened utilization review documents to identify patients who had recently been discharged from the hospital. Patients with a Care Assessment Needs (CAN) score greater than 90 were called and food interactionsoffere a ToC visit within 14 days of discharge. Hospital records were assessed along with patient interviews to identify medication related problems. All recommendations were summarized in an encounter note and alerted to the primary care physician (PCP) for ▇▇▇▇▇▇.▇▇ date, and a narrow therapeutic index requiring close monitoring via an international normalized ratio (INR). Thrombotic and hemorrhagic adverse events due to poorly managed warfarin can have serious and even fatal implications for the ToC pilot clinic has enrolled 21 patients. Joint Commission Hospital National Patient Safety Goal 03.05.01 describes reducing The clinic will continue to see patients through June 2018. Outcomes of clinic interventions will be assessed next year using the risk inverted research model. Clinic implementation presents unique challenges at each individual facility. Independent of patient harm associated facility variation, it is critical to the success of a clinic to gain support from pharmacy leadership and collaborating providers. One way to build acceptance is with anticoagulant therapy through a thorough needs assessment of the use of an approved protocol facility by soliciting input from all key stakeholders. A standard operating procedure for the initiation clinic may then be designed to optimize workflow and maintenance of anticoagulant therapy. An automatic pharmacist-managed inpatient warfarin protocol was implemented address the gaps in June 2013 at Community Health Network (CHNw)patient care. A follow-up study had not been completed timeline has served as a useful tool when creating the building blocks of the clinic factoring in patient recruitment, physical space in the clinic and pharmacist availability. Adapting the clinic after implementation has meant consistent reevaluation of workflow and time utilization. Outline one approach to evaluate a transitions of care clinic in the protocol since shortly after its initiation. The VA healthcare system Describe challenges and lessons learned from implementation of a transitions of care clinic Which of the following is an advantage to incorporating a transitions of care pharmacist into the primary objective of this study was to evaluate the safety and efficacy of an inpatient pharmacist managed warfarin protocol compared to physician-managed warfarin. Methods: care team? A retrospective chart review was completed to evaluate outcomes of patients newly initiated on warfarin at four hospitals within CHNw between August 22, 2012 to June 23, 2013 before protocol implementation and July 1, 2016 to June 30, 2017 after protocol implementation. Patients were excluded if they were a protected population, had an international normalized ratio (INR) goal other than 2 2.5, 2-3, or 2.5-3.5, on warfarin prior to admission, on warfarin for an orthopedic indication, managed by a pharmacist prior to the automatic protocol, did not follow-up Coordinating care with a network-affiliated anticoagulation clinic within one week, or received less than four doses of warfarin during admission. The primary endpoint compared the average time to therapeutic INR of pharmacist and physician-managed inpatient warfarin. Secondary endpoints compared out of range INR values, INR values at the first outpatient follow-up appointment, and incidence of bleeding and thrombotic events throughout the admission and 30 days post-discharge. Results and conclusions will be presented at the Great Lakes Pharmacy Residency Conference.specialists