• Effect of Blood Glucose in the Emergency Department on Hospital Length of Stay

      Patanwala, Asad; DiLeo, Jessica; Johnson-Clague, Michaela; Prze, Jennifer; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2013)
      Specific Aims: The objective of this study is to evaluate the effect of early blood glucose correction in the Emergency Department (ED) on hospital length of stay. Methods: This study has received institutional review board approval. This is a retrospective cohort study conducted in an academic medical institution. Diabetic patients with hyperglycemia in the ED between June 1st, 2011 and June 30th, 2012 were included. Patients were excluded if they were less than 18 or greater than 89 years of age, not admitted, had diabetic ketoacidosis or hyperglycemic hyperosmolar state, treated with insulin for hyperkalemia, trauma patients, or had an initial blood glucose value of 200 mg/dL or less. Patients were categorized into two groups based on blood glucose control achieved within the first 24 hours from triage. The primary outcome of this study was to compare hospital length of stay between the groups. Main Results: A total of 161 patients were included in this study. Baseline demographics between groups were statistically similar with the exception of gender (p=0.635), ethnicity (p = 0.149), and co-morbidities calculated by the Charlson Co-Morbidity Score (p = 0.112). Blood glucose values in the ED did not statistically correlate to hospital length of stay (p = 0.299), however, co-morbidities were predictive of hospital length of stay (p = 0.025). Conclusion: Early correction of blood glucose values in the ED are not associated with hospital length of stay.
    • Effect of emergent magnetic resonance imaging on alteplase utilization for acute ischemic stroke

      Patanwala, Asad; Munoz, Jonis; Reyes, Dana; College of Pharmacy, The University of Arizona (The University of Arizona., 2018)
      Objectives: The purpose of this project was to assess appropriateness of alteplase (tPA) administration in patients undergoing magnetic resonance imaging (MRI) at Banner-University Medical Center Tucson (BUMC-T) and identify interruptions in therapy that could have been prevented. Methods: This descriptive quality improvement project evaluated retrospective data from the electronic health records at BUMC-T. Data was collected from patient charts using Epic. The data collection form included items based on demographics, tPA, symptoms and severity, utilization of computerized tomography, MRI, interventional radiology (IR), and complications. Wilcoxon Rank-sum test was used to compare the door-to-needle times if patients did or did not receive an MRI. Fisher’s exact test was used to compare the proportion of patients with interruption of infusion with or without emergent MRI (P<0.050). Main Results: Ninety-six patients received tPA for acute ischemic stroke with 13 having an interruption in infusion. Reasons documented were placed into 4 categories: MRI related, blood pressure related, adverse reactions related to tPA, or other. Four of 13 interruptions were related to an emergent MRI. This was not statistically significant (p>0.050). The remainder were not preventable as tPA was discontinued because of an adverse event. Patients that received an MRI received tPA faster than those patients who did not receive an MRI (48 minutes versus 63 minutes, respectively) (P=0.006). Conclusions: Alteplase interruptions did not occur more frequently in patients who received MRI. However, all preventable interruptions were due to MRI. Alteplase administration logistics should be optimized to minimize any preventable interruptions in therapy.
    • Efficacy of Low Dose Levetiracetam for Seizure Prophylaxis in Traumatic Brain Injury

      Patanwala, Asad; Truong, Elaine; Kurita, Alina; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2015)
      Objectives: Guidelines from the Brain Trauma Foundation recommend that after traumatic brain injury (TBI) patients should be given seizure prophylaxis for up to seven days. Currently, phenytoin is the first line therapy for this indication. However, levetiracetam is increasingly being used as an alternative because it does not require serum concentration monitoring and has a desirable safety profile. Studies evaluating levetiracetam have used a loading dose, followed by a maintenance dose of 1000 mg every 12 hours. The primary objective of this study was to evaluate the efficacy of low-dose (500 mg every 12 hours) levetiracetam for seizure prophylaxis after TBI. Methods: This was a retrospective cohort study conducted in a tertiary care, academic institution that is designated as a level 1 trauma center. Institutional review board approval was obtained prior to data collection. Consecutive patients with TBI between 2010 and 2012, who received levetiracetam for seizure prophylaxis, were included. Patients who met at least one of the following criteria were included: cortical contusion on computerized tomography scan, subdural hematoma, epidural hematoma, intracerebral hematoma, depressed skull fracture, penetrating head injury, or Glasgow Coma Scale (GCS) of 10 or less. Patients were excluded if they were less than 16 years of age, had a previous head injury, previous neurosurgery, history of seizure, or anti-seizure medication, or were given a loading dose of levetiracetam, or given a maintenance dose greater than 500 mg every 12 hours. The primary outcome was the occurrence of a seizure within seven days of TBI. A one-sample test of proportions was used to compare the rate of seizures while being treated with levetiracetam to a hypothesized value of 3.6 percent (from previous trials), using an a priori alpha for 0.05. Results: There were a total of 146 patients included in the study, who were treated with levetiracetam 500 mg every 12 hours. The median age was 51 years (interquartile range 31 to 65 years), 110 (75 percent) were male, and the median GCS on admission was 11 (interquartile range 5 to 14). The mechanisms of injury were fall (n equals 49), motor vehicle or motorcycle collisions (n equals 42), pedestrian or bicyclist (n equals19), assault (n equals16), suicide attempt (n equals 2), and other (n equals18). The median time to first dose of levetiracetam was 4 hours after injury (interquartile range 1 to 13 hours). After initiation of levetiracetam, there were 5 (3.4 percent) patients who had a seizure within seven days. This was not significantly different than the hypothesized population value (p equals 0.910). The median length of stay was 13 days (interquartile range 9 to 21) and 7 (4.8 percent) patients died during hospitalization. Conclusions: A low-dose of levetiracetam 500 mg every 12 hours after TBI was effective for early seizure prevention. This regimen may be an appropriate alternative to phenytoin or traditional dose levetiracetam for this indication. Future, prospective studies are needed to confirm these findings.
    • Evaluation of Anticoagulation Parameters After Discontinuation of Argatroban in Critically Ill Patients.

      Erstad, Brian; Patanwala, Asad; Gerfen, Ashlee; Jiang, Manfei; Erstad, Brian; Patanwala, Asad; Gerfen, Ashlee; College of Pharmacy, The University of Arizona (The University of Arizona., 2015)
      Objectives: Argatroban is the current drug of choice for type II heparin induced thrombocytopenia. Primarily metabolized by the liver, this direct thrombin inhibitor has a volume of distribution of approximately 174 mLs per kg. While few studies suggested no differences in coagulation parameters or clinical outcomes between obese and non-obese populations receiving argatroban, a recent case report revealed elevated anticoagulation parameters for 20 days post argatroban discontinuation in a morbidly obese female. The purpose of this study is to assess anticoagulation parameters in obese and non-obese patients in an intensive care unit (ICU) setting who received argatroban treatment during their stay. Methods: This is a retrospective, observational, single-centered study. Participants of the study must be adults, at least 18 years of age. Patient must be an inpatient and have received argatroban for either suspected or confirmed heparin-induced thrombocytopenia (HIT). All patients in the study were screened for the above criteria between November 2008 and September 2013. Patients admitted to the cardiac ICU were excluded from the study. Main anticoagulation parameters post discontinuation evaluated were daily international normalized ratio (INR) and activated partial thromboplastin time (aPTT), while safety outcomes included major, minor and non-bleed events. All data were analyzed with STATA 13 with P less than 0.05 being considered as statistically significant. Results: The study included a total of 51 patients, 37 were non-obese with body mass index (BMI) less than 30 kg per m2 (73 percent), and 14 were obese with BMI greater or equal to 30 kg per m2 (27 percent). Among basic demographic data, no differences were found between age, sex, race, height and SOFA scores at baseline between the two groups, BMI less than 30 kg per m2 and BMI greater or equal to 30 kg per m2. (P equals 0.7, 0.21, 1.0, 0.41, 0.51 respectively). However, as expected, weight was the only characteristic that was different at baseline (P less than 0.01). Primary outcome of time of INR to normalization post argatroban administration (2.73 seconds plus or minus 0.27 seconds) as well as safety outcomes including major, minor, and non-bleed adverse events (P equals 0.61) were statistically non-significant between the two groups. Conclusions: In this retrospective, observational, single centered study, no differences were identified between non-obese and obese groups in terms of argatroban administration, primary anticoagulation parameters, and safety outcomes. The length of time required for coagulation parameters to normalize after discontinuation of argatroban therapy for HIT does not appear to be influenced by BMI. Large, multicenter, and random controlled trials are needed to evaluate obesity on pharmacokinetic parameters and clinical outcomes of argatroban.
    • Evaluation of Medication Use and Outcomes in Patients Suffering an In-Hospital Cardiac Arrest

      Patanwala, Asad; McCusker, Erin; Sloan, Cole; Vanessa Jordan; Patanwala, Asad; McCusker, Erin; Sloan, Cole; College of Pharmacy, The University of Arizona (The University of Arizona., 2015)
      Objectives: There is limited information regarding medication use during in-hospital cardiac arrest (IHCA). The purpose of this study was to characterize medication use during IHCA, and determine the association between medications used and survival to hospital discharge. Methods: This was a retrospective cohort study conducted in an academic medical center looking at IHCA between October 2009 and December 2013. Data regarding medication use during IHCA and other pertinent predictors of survival were collected. The primary objective was to characterize medications used during IHCA and to assess the relationship between medications used and survival to hospital discharge. Results: There were 171 patients who were included in the study and 44 (26%) survived to hospital discharge. The medications most commonly used were epinephrine, sodium bicarbonate, calcium chloride or gluconate, atropine, amiodarone, vasopressin, magnesium sulfate, and lidocaine. Patients who died were more likely to receive total epinephrine ≥3 mg (53% versus 27%, p=0.005), sodium bicarbonate (73% versus 55%, p=0.025), and calcium (59% versus 27%, p<0.001), compared to survivors, respectively. After adjusting for duration of resuscitation, total epinephrine ≥3 mg (OR 0.38, 95% CI 0.18 to 0.83, p=0.015) and calcium (OR 0.30, 95% CI 0.14 to 0.64, p=0.002) was associated with decreased survival. Conclusions: This study found that 3 mg or more of epinephrine, calcium salts and sodium bicarbonate are linked to decreased survival to hospital discharge. Further research should be done to define the cause of this link.
    • Evaluation of Prescribed Empiric Cellulitis Therapy at an Academic Medical Center Emergency Department

      Matthias, Kathryn R.; Patanwala, Asad; Bissing, Joe; Ito, Satoru; Erwin, Lam; Matthias, Kathryn R.; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi-square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost-effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.
    • Evaluation of Prescribed Empiric Cellulitis Therapy at an Academic Medical Center Emergency Department

      Matthias, Kathryn R.; Patanwala, Asad; Bissing, Joe; Satoru, Ito; Lam, Erwin; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi- square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost- effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.
    • Evaluation of Therapy Prescribed for Uncomplicated Urinary Tract Infection in Patients in an Emergency Department

      Nix, David E.; Matthias, Kathryn; Patanwala, Asad; Zeleke, Belay; Nix, David E.; Matthias, Kathryn; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: 1• Determine the results of urine culture and susceptibility testing for patients with uncomplicated UTI at an emergency department 2• Determine empiric antibacterial agents prescribed for treatment of uncomplicated UTI in the emergency department 3• Compare pathogen susceptibility pattern specific for patients with uncomplicated UTI compared to the overall institution antibiogram Examine the use of cephalexin for uncomplicated UTI in emergency department patients Methods: A retrospective electronic medical records of adult female patients admitted to University Medical Center in Tucson, Arizona, emergency department with a diagnosis of uncomplicated urinary tract infection (UTI) between June 1, 2010 and May 31, 2011 were collected. Different aspects of uncomplicated urinary tract infection (UTI) were characterized, and prescriptions for empiric antibiotic treatment were recorded. Culture results and susceptibility reports as well as antibacterial treatment decisions were studied to evaluate types of pathogens and resistance patterns along with therapy prescribed. The data was managed and analyzed by using SAS. All data was tabulated and described using summary statistics. Main Results: The dominant isolate of the study population was E.coli (88%). Cephalexin was prescribed 76% of the time, nitrofurantoin 8.4%, ciprofloxacin 7.6%, and TMP/SMX 5% of the time. The susceptibility rate of ampicillin was 50%, cefazolin 91%, ciprofloxacin 98%, nitrofurantoin 92%, and TMP/SMX 76%. Conclusions: Our study revealed that the resistant rate of TMP/SMX exceeded 20%; however, ciprofloxacin and nitrofurntoin susceptibility remains high. Cephalexin was the most commonly prescribed treatment, but not included in the antimicrobial susceptibility test (AST) panel.
    • Long-Acting Neuromuscular Blocker use During Pre-Hospital Transport of Critically Ill Trauma Patients

      Patanwala, Asad; Elofson, Kathryn; Girardot, Sarah; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2012)
      Specific Aims: During pre-hospital transport, trauma patients may be given a long-acting neuromuscular blocker (NMB) to facilitate endotracheal intubation or to prevent movement. The purpose of this study was to determine the rate of long-acting NMB use and evaluate the concurrent use of sedatives. Methods: This was a retrospective cohort study conducted in a tertiary care, academic emergency department of trauma patients aged 18-89 years who were intubated in the pre-hospital setting. The primary outcome was to determine the rate of long-acting NMB use. The use of post-intubation sedatives was compared between the groups using Wilcoxon rank-sum test or Fisher’s exact test, using an a priori alpha level of 0.05 for all analyses. Main Result: A total of 51 patients were included in final analyses. All patients received etomidate or midazolam for intubation. 86% (n=44) received succinylcholine, 10% (n=5) were given rocuronium and 4% (n=2) did not receive a NMB. After intubation, 75% (n=38) received an additional long-acting NMB to prevent movement (vecuronium (n=22) or rocuronium (n=16)) . Overall, 82% (n=42) of patients received a long-acting NMB during transport. There was no difference in the rate of post-intubation sedative use between groups (79% versus 67%, respectively, p=0.42). The long-acting NMB group received midazolam less promptly after intubation (16 versus 7 minutes, respectively, p=0.04). Conclusions: The use of long-acting NMB is common during the pre-hospital transport of trauma patients. Some of these patients may not be given sedatives or have delays in receiving sedatives following intubation and be at risk of being paralyzed without sedation.
    • Vancomycin Loading Doses in Septic Patients

      Patanwala, Asad; He, Junyan; Mee, George; Bingaman, Marc; Patanwala, Asad; College of Pharmacy, The University of Arizona (The University of Arizona., 2015)
      Objectives: To (1) characterize loading doses of vancomycin administered to patients with sepsis and (2) evaluate the relative impact of loading dose on clinical outcomes between patients who received a 1 gram loading dose or any other amount. Methods: Retrospective, observational chart review of adult patients who received vancomycin for treatment of sepsis through emergency department triage. Data from November 2013 through March 2014 were obtained for timing and administration of vancomycin as well as clinical outcomes: survival; length of hospitalization and intensive care unit (ICU) stay; need for mechanical ventilation. Results: Sepsis-related hospital encounters were identified for 123 patients, of which 114 charts were fully able to be evaluated. The majority of patients (84.21%) received a 1 gram loading dose as opposed to any other amount (p=0.001); few patients (1.75%) received a dose within 25-30 mg/kg. No significant differences in trends for timing of administration, inpatient survival, duration of hospital stay, or need for mechanical ventilation were identified between patients who received 1 gram doses or any other amount. Greater effective vancomycin loading doses were associated, albeit not significantly, with shorter durations of hospitalization, ICU admissions, and mechanical ventilation. Conclusions: Despite weight-based loading dose recommendations, vancomycin was frequently administered as a fixed 1 gram loading dose to patients with sepsis. However, there was little distinguishable impact on clinical outcomes in this preliminary study.