Clinical Pharmacy Specialist Research Articles

P122 The role of the clinical pharmacy specialist in monitoring adherence to inhaled therapies in patients with cystic fibrosis in the Republic of North Macedonia

P122 The role of the clinical pharmacy specialist in monitoring adherence to inhaled therapies in patients with cystic fibrosis in the Republic of North Macedonia

Impact of Academic Detailing on Opioid Prescribing at the Veterans Health Administration

In 2014, the United States Veterans Health Administration (VHA) Pharmacy Benefits Management Academic Detailing Service (ADS) began national implementation of academic detailing (AD), a one-on-one educational outreach program delivered by specially trained clinical pharmacy specialists to address mental health disorders and pain management. Consequently, ADS adopted the mission of the VHA Opioid Safety Initiative (OSI) to align providers' opioid prescribing with evidence-based practice.

Does an encounter with the ambulatory clinical pharmacist in the transitional setting play a role in clinic attendance and patient engagement?

BackgroundPatient engagement is an important aspect in improving patient outcomes. However, there is a paucity of literature regarding patient engagement in a nonresearch health care setting and the impacts of ambulatory clinical pharmacist interventions. Patient engagement has several definitions making it challenging to assess, but attendance to initial primary care provider (PCP) visits is an important aspect of patient engagement. ObjectiveThe study objective was to assess if improved patient engagement, defined as attendance to an initial PCP visit, was associated with differences in services provided or pharmacist participation during postdischarge clinic appointments. Practice descriptionThe site of this study was the Johns Hopkins After Care Clinic (JHACC), an interdisciplinary postdischarge, safety net clinic in Baltimore, MD. Practice innovationThrough an interdisciplinary health care team including pharmacists, patients received comprehensive care to assist with postacute disease-state management and transitions of care. Evaluation methodsInitial PCP visit attendance after a postacute visit in a high-risk population was evaluated for differing service delivery factors between groups who attended and did not attend their initial PCP visit. Descriptive statistics and chi-square tests were used for analysis. ResultsPatients were statistically significantly more likely to engage in primary care when clinical pharmacy specialists participated in their JHACC appointment (P = 0.02). Medication education and disease-state counseling improved initial PCP visit attendance, both of which are key pharmacist activities. ConclusionThis study suggests ambulatory clinical pharmacy specialists’ roles in an interdisciplinary clinic model correlates with increased attendance to initial PCP visits, a surrogate for patient engagement. Disease-state education and medication education are both important activities in improving this measure; however, additional research is necessary to determine specific pharmacist interventions associated with patient engagement. As research in patient engagement continues, the positive effects of pharmacist involvement in this area could support their value in ambulatory care services.

Implementation of a pharmacist care manager model to expand availability of medications for opioid use disorder.

The rise in opioid prescribing, often for chronic pain management, resulted in an increased prevalence of opioid use disorder (OUD) throughout the United States, including within the Veterans Affairs (VA) healthcare system. The veteran population has been especially vulnerable to opioid-related harms, but rates of prescribing medications for OUD have been low. Use of care manager models for OUD have increased access to treatment. In this article we provide an overview of a clinical pharmacist care manager (CPCM) model for medications for OUD treatment implemented within the Minneapolis Veterans Affairs Health Care System. A CPCM model for medications for OUD was identified as a care model that would address patient and facility barriers to effective OUD treatment. Pharmacists were integral in program development and implementation and served as the main care providers. An interim evaluation of the program established that the proportion of patients with OUD receiving medications for opioid use disorder (MOUD) had increased, with use of the program resulting in treatment of 109 unique patients during 625 visits. Key program implementation facilitators included the facility leadership establishing increased use of MOUD as a priority area, identification of a physician champion, and a history of successful expansion of clinical pharmacy specialist practice within the VA system. Implementation barriers included factors related to provider engagement, patient identification, and program support. The CPCM model of provision of MOUD expanded the pharmacist role in buprenorphine management. The need to increase the number of patients receiving MOUD led to the implementation of a CPCM model. The program was effectively implemented into practice and expanded the availability of MOUD, which allowed patients to access treatment in multiple care settings.

331: Impact of a Clinical Pharmacy Specialist in the Medical/Cardiovascular/Neuro Intensive Care Unit

331: Impact of a Clinical Pharmacy Specialist in the Medical/Cardiovascular/Neuro Intensive Care Unit

Increasing access to care for rural veterans through intensive hands‐on‐training of advanced practice pharmacists

AbstractIntroductionThe “Increasing Access to Care for Rural Veterans by leveraging Clinical Pharmacy Specialist (CPS) Providers,” known as the CPS Rural Veteran Access Initiative (CRVA), focused on providing access to comprehensive medication management (CMM) for rural Veterans in the areas of primary care, mental health, and pain management. Clinical pharmacy boot camps trained CPS to accomplish this goal.ObjectivesThe objectives of the boot camps were to address training needs ensuring consistency and quality for the provision of CMM for the CRVA CPS to increase access to care.MethodsA needs assessment survey was administered to determine curriculum content. Participants completed pre‐ and post‐boot camp knowledge assessments for the topics taught in the curriculum. An analysis was performed comparing the results before and after the training program for participants completing one pre‐ and one post‐boot camp survey.ResultsThere were 87 primary care boot camp attendees and 52 mental health and pain attendees included in the analysis. For primary care, 13 courses (59%) saw ≥50% growth in the number of participants deeming themselves to have a working knowledge or better from pre to post boot camp. For mental health/pain, seven courses (29%) saw ≥50% growth in the number of participants deeming themselves to have a working knowledge or better from pre to post. Direct patient care encounter tracking 6 months pre‐ and post‐training showed an average monthly mean encounter total increase for the primary care group from 134.4 pre‐training to 146.1 post‐training (P = .08) and for the mental health/pain group from 124.5 pre‐training to 136.1 post‐training (P = .32).ConclusionBased on the results, this program was successful in accomplishing its goals of improving the participants' knowledge, especially in areas lacking practice experience. These results were found across participants in both programs. Successes seen in these programs are now serving as models for CPS training in the VA for the future.

Ensartinib as Treatment for ALK-Rearranged NSCLC

Ensartinib as Treatment for ALK-Rearranged NSCLC

In celebration of American Pharmacists Month, a look at lives dedicated to pharmacy

In celebration of American Pharmacists Month, a look at lives dedicated to pharmacy

Integrated Nurse Practitioner and Pharmacist Post-discharge Heart Failure Clinic: Impact on Patient Outcomes

IntroductionThe American Heart Association recommends implementation of integrated transition of care programs to manage patients following hospitalization for acute decompensated heart failure (ADHF). At our site, a Nurse Practitioner (NP) has been historically responsible for seeing patients post discharge in the Heart Failure Access Clinic (HFAC). Whether the addition of a clinical pharmacy specialist (CPS) to co-manage patients at the HFAC clinic leads to improved outcomes is not known. Therefore, we conducted a pilot study to assess the feasibility and potential benefits of this integrated approach.ObjectiveWe evaluated 30-day heart failure readmission, emergency department (ED) visits, and all-cause mortality in post-discharge patients who were seen in our integrated CPS and NP pilot HFAC clinic. The clinic process and CPS interventions were also assessed.MethodsPatients who were discharged from the hospital for ADHF were eligible for the pilot study if they had at least mild LV systolic dysfunction (LVEF ≤50%). In the integrated HFAC clinic, the NP determined patients’ volume and perfusion status, implemented a flexible diuretic plan, and set parameters for patients contacting the HF team. Responsibility for medication reconciliation, neurohormonal medication education, and dose optimization was shifted to the CPS. Descriptive statistics were used as appropriate.ResultsBetween 11/18/2019 and 3/10/2020, 24 visits were conducted in the integrated clinic. Our patients were predominantly Caucasian (88%), male (96%), and elderly (mean age: 70 ± 12 years). Most patients (75%) had LVEF ≤40%. The 30-day post-discharge readmission rate was 2/24 (8%), while both ED visits and all-cause mortality rates were 0%. Historically, veterans at our NP led HFAC clinic have had a 30-day readmission rate of 15.8% (data from 2019). The average time to appointment was 12 ± 8 days post-discharge with 25% patients seen within 7 days. The mean duration of the CPS visit was 36 minutes; the NP visit was 41 minutes (n=12). The CPS noted medication discrepancies in 14/24 (58%), alerted other providers for medication issue follow-up in 10/24 (42%), and identified HF inappropriate medications in 3/24 (13%). HF medications were titrated by the CPS in 13/24 (54%), and 16/24 (67%) patients were scheduled with CPS for ongoing medication dose titration. One patient (4%) was referred for tobacco treatment.ConclusionsEarly analysis indicates that the integrated HFAC leads to high-quality patient care as evidenced by a very low 30-day hospital readmission rate without ED visits or fatality. These outcomes compare favorably to our institution's 30-day readmission rate observed prior to implementation of this pilot project. Potential benefits of adding a CPS as a provider to our HFAC include medication reconciliation and education, identification of harmful drugs, and timely medication titration. Further analysis is warranted to compare the impact of the integrated HFAC versus standard of care over a longer time frame.

Identification of the optimal primary care clinical pharmacy comprehensive medication management practice in the veterans health administration

AbstractClinical pharmacists are well‐positioned as the medication experts on the health care team to work collaboratively with providers and patients to achieve optimal medication use in order to maximize patient benefit and outcome. Comprehensive medication management (CMM) is defined as a patient‐centered approach to optimizing medication use and improving patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health care providers. Lack of fidelity in practice model design and implementation make generalization of results of clinical pharmacy CMM practice difficult. There is currently no organization that evaluates standardized implementation of clinical pharmacists providing CMM in a Patient‐Centered Medical Home (PCMH) leading to wide variability of CMM implementation within the PCMH model. The Veterans Health Administration (VA) is the largest integrated health care system in the United States. Clinical pharmacy specialists (CPS) in the VA work autonomously but collaboratively under a practice area‐based scope of practice with prescriptive authority. The goal of the Clinical Pharmacy Practice Office Platinum Practice Designation was to develop a standardized review process to recognize sites that have achieved core elements of desired primary care pharmacy practice. In this paper, we describe the creation and implementation of this process. The submission process consisted of three rounds ranging from survey, data submission, data review and validation, and a facility interview. A total of 19 submissions were completed with two sites identified as achieving greater than 90% fidelity to the CMM model and were considered best practices. The creation of a rigorous set of implementation tools and measurement metrics creates the necessary fidelity to evaluate programs across different geographic areas. Identified sites provide examples for other facilities to emulate and creates momentum for pharmacy practice advancement throughout the nation.

Implementation of a Protocol to Manage Patients at Risk for Hospitalization Due to an Ambulatory Care Sensitive Condition.

Ambulatory care sensitive conditions (ACSCs), such as type 2 diabetes mellitus, chronic obstructive pulmonary disease, hypertension, congestive heart failure, urinary tract infections, asthma, dehydration, bacterial pneumonia, angina without an in-hospital procedure, and perforated appendix put patients at risk for hospitalization. Currently at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, no standardized process or protocol exists that can identify and optimize primary care for patients with ACSCs who have been hospitalized but are predicted to be at low risk for rehospitalization. This project aimed to evaluate the implementation of offering further referrals and care for these patients. A pharmacy resident conducted a baseline chart review using a standardized template in the US Department of Veterans Affairs (VA) Computerized Patient Record System to identify additional referrals or interventions a patient may benefit from based on any identified ACSC. Potential referral options included a clinical pharmacy specialist or nurse care manager disease management, whole health/wellness, educational classes, home monitoring equipment, specialty clinics, nutrition, cardiac or pulmonary rehabilitation, social work, and mental health. Comparing the 3 months prior to and the 3 months after offering referrals, there was a cumulative quantitative decrease in the number of emergency department visits (5 to 1) and hospitalizations (11 to 5). Identifying patients at risk for hospitalization from an ACSC via a review and referral process by using the VA patient aligned care team structure was feasible and led to increased patient access to primary care and additional services.

Multidisciplinary practice advancement: Role of a clinical pharmacy specialist in a pediatric specialty clinic.

To describe clinical pharmacy specialists' role in improving the use of specialty medications within a pediatric outpatient setting. The outpatient pediatric specialty clinic (PSC) at the University of Iowa added a clinical pharmacy specialist to multidisciplinary teams within the PSC to focus on patient education, providing clinical recommendations, coordinating insurance approval, addressing barriers to adherence, and performing follow-up monitoring. Supplemental activities include coordinating between the electronic health record-integrated on-site specialty pharmacy and the PSC, assisting with quality improvement projects, developing policy revisions, negotiating access to specialty products, and answering medication information questions. Benefits in workflow efficiency, documentation, and revenue generation resulting from implementation of the pharmacist within the PSC have been identified by the clinic and the specialty pharmacy. The specialty pharmacy identified an increase in the rate of specialty prescription capture from 14% to 50%, leading to an increase in revenue for the health system. Within 12 months of the addition of the pharmacist to the team, an improvement in the rate of 13-valent pneumococcal conjugate vaccine administration to pediatric patients of 25.7 percentage points, medication adherence of >90%, and a 75% relative increase in appropriate hydroxychloroquine dosing were recognized. Due to the pharmacist's impact on the PSC, a full-time pharmacist was added to the pediatric team to cover additional clinics, and 2 benefits investigation technicians were hired and funded by the PSC. An interdisciplinary team with an integrated pharmacist has facilitated sustainable improvements in medication access and adherence and clinical and quality measures, benefiting patients, the pediatric clinic, the specialty pharmacy, and the hospital organization.

Analysis of patient-specific factors contributing to effectiveness of glucagon-like peptide-1 receptor agonists

BackgroundGlucagon-like peptide-1 receptor (GLP-1) agonists are antidiabetic medications used to improve hemoglobin A1c (HbA1c) and promote weight loss. Per the Veterans Affairs/Department of Defense guidelines for the management of type 2 diabetes, GLP-1 agonists are expected to lower HbA1c by 1%-1.5%. The clinical pharmacy specialist in the women’s health primary care clinic at the Louis A. Johnson Veterans Affairs Medical Center noted cases of women started on GLP-1 agonists achieving greater than expected HbA1c reduction. ObjectivesThe primary objective of this study was to determine if there are any patient-specific factors that may increase the effectiveness of GLP-1 agonists. Secondary objectives included an analysis of average weight and HbA1c, use of the Pearson rank correlation test to determine if there is a correlation between weight change and HbA1c reduction, and an analysis of HbA1c reduction associated with each GLP-1 agonist prescribed. MethodsA retrospective chart review was conducted. Data collected from the charts included age, sex, height, GLP-1 agonist prescribed, and HbA1c and weight before and after GLP-1 agonist initiation. For primary outcomes, statistical analyses were run between 2 groups: patients who had an HbA1c reduction of greater than 1.5% and patients who had an HbA1c reduction less than or equal to 1.5%. ResultsWomen were more likely to have an HbA1c reduction of greater than 1.5% (P = 0.001). Patients with a lower baseline weight were more likely to attain an HbA1c reduction greater than 1.5% (P = 0.045). Higher baseline HbA1c was correlated with an increased likelihood of HbA1c reduction greater than 1.5% (P = 0.001). ConclusionGLP-1 agonists may be more effective at reducing HbA1c in female patients, those with a lower baseline weight, and those with a higher baseline HbA1c.

Pandemic exerts emotional toll.

In areas that have been hit hard by COVID-19, pharmacists acknowledge feeling strained and worried about what lies ahead. “We have seen a lot of cases,” said Karan Raja, infectious disease clinical pharmacy specialist at Clara Maass Medical Center in Belleville, NJ. He described the intensity of the pandemic as “a very trying time.” Megan Rech, emergency medicine clinical pharmacist at Loyola University Medical Center in Maywood, IL, likewise said her hospital has “seen a lot of COVID-19 patients,” and the workplace is “more stressful than normal.” New Jersey and Illinois were the second and third states, after New York, to report 100,000 COVID-19 cases. Cook County, which includes Maywood, had the nation’s highest cumulative COVID-19 case count in late May and ranked fourth nationally in deaths, according to county-level data from Johns Hopkins University. Essex County, NJ, home to Bellville, ranked 10th nationally in COVID-19 deaths and was in the top 20 in case counts.

Virtual academic detailing (e-Detailing): A vital tool during the COVID-19 pandemic

As the coronavirus disease (COVID-19) pandemic continues its course in 2020, telehealth technology provides opportunities to connect patients and providers. Health policies have been amended to allow easy access to virtual health care, highlighting the field’s dynamic ability to adapt to a public health crisis. Academic detailing, a peer-to-peer collaborative outreach designed to improve clinical decision-making, has traditionally relied on in-person encounters for effectiveness. A growth in the adoption of telehealth technology translates to increases in academic detailing reach for providers unable to meet with academic detailers in person. The U.S. Department of Veterans Affairs (VA) has used academic detailing to promote and reinforce evidence-based practices and has encouraged more virtual academic detailing (e-Detailing). Moreover, VA academic detailers are primarily clinical pharmacy specialists who provide clinical services and education and have made meaningful contributions to improving health care at VA. Amid the COVID-19 pandemic and physical isolation orders, VA academic detailers have continued to meet with providers to disseminate critical health care information in a timely fashion by using video-based telehealth. When working through the adoption of virtual technology for the delivery of medical care, providers may need time and nontraditional delivery of “evidence” before eliciting signals for change. Academic detailers are well suited for this role and can develop plans to help address provider discomfort surrounding the use of telehealth technology. By using e-Detailing as a method for both familiarizing and normalizing health professionals with video-based telehealth technology, pharmacists are uniquely poised to deliver consultation and direct-care services. Moreover, academic detailing pharmacists are ambassadors of change, serving an important role navigating the evolution of health care in response to emergent public health crises and helping define the norms of care delivery to follow.

Virtually there: An innovative approach for training oncology pharmacy residents in gynecologic oncology

ObjectiveTo develop an alternative approach to provide oncology pharmacy practice residents’ education and training in the management of gynecologic malignancies in the absence of a specialist in this area at their institution. SettingGynecologic oncology is a unique specialty in oncology. There is a need for more oncology clinical pharmacy specialists to participate in the care of patients with gynecologic malignancies as many do not have specific education in this area. Practice descriptionA virtual learning experience was developed that included all aspects of a typical experience with the exception of direct patient care. Postgraduate year 2 oncology pharmacy residents from 3 different programs were included. Practice innovationAlthough the number of oncology clinical pharmacy specialists who are subspecialized in gynecologic oncology has grown, it is difficult to find experienced preceptors in gynecology oncology. We set to offer a virtual learning environment for programs that did not have a dedicated or highly specialized pharmacist in this area. EvaluationA pre- and postlearning assessment of the resident’s knowledge of gynecologic malignancies was administered. Each trainee independently completed a validated 20-question gynecologic oncology knowledge assessment tool before and again after completion of all sessions. Midpoint and end-of-experience evaluations were completed via the phone with each resident. All evaluations were documented in PharmAcademic (McCreadie Group, Ann Arbor, MI), a required software program for postgraduate residency training programs. ResultsTo date, 7 oncology pharmacy practice residents completed the virtual experience. A 42% improvement in scores pertaining to gynecologic oncology knowledge was identified. Residents were also satisfied with the overall virtual experience. Based on the assessment tool, all the residents gave positive evaluations with “always true” for 6 of the 7 questions. ConclusionsThis pilot of a virtual experience was a successful platform to provide clinical knowledge and skills for oncology pharmacy residents in gynecologic oncology.

Analysis of Pharmacist Interventions Used to Resolve Safety Target of Polypharmacy (STOP) Drug Interactions

Statin drug interactions commonly increase the risk of muscle-related toxicities. The medical literature supports consultative pharmacist interventions to resolve drug interactions, but studies demonstrating autonomous pharmacist interventions are lacking. To evaluate the complementary impact of using pharmacist-led protocols and pharmacists with prescriptive authority to resolve statin drug interactions. Pharmacist-led protocols were developed to address gemfibrozil-statin and niacin-statin interactions. Pharmacists discontinued gemfibrozil and niacin by protocol or referred patients to the Patient Aligned Care Team (PACT) Pharmacy Clinic for individualized management. After all drug interactions were addressed, a retrospective quality improvement analysis was conducted. The primary outcome was to evaluate the impact of gemfibrozil and niacin discontinuation by protocol on patients' triglyceride (TG) laboratory results. The coprimary endpoints were the change in TGs and the percentage of patients with TGs ≥ 500 mg/dL, following pharmacist discontinuation by protocol. Secondary outcomes included the time required to resolve the interactions and a description of the PACT Clinical Pharmacy Specialists' (CPS) pharmacologic interventions. The gemfibrozil and niacin protocols addressed 397 drug interactions. Seventy-six patients underwent gemfibrozil discontinuation by protocol and had TG laboratory results available. TG levels decreased or increased by < 100 mg/dL for 62 patients (82%), and 1 patient (1.3%) experienced TG elevation above the threshold of 500 mg/dL. Thirty-six patients had niacin discontinued by protocol and available laboratory results. The TG levels decreased or increased by < 100 mg/dL for 33 patients (91.7%), and no patients had TG levels increase above the threshold of 500 mg/dL. The mean time required to resolve both gemfibrozil and niacin drug interactions was 15.5 minutes per patient. A total of 129 patients were referred to the PACT Pharmacy Clinic to manage gemfibrozil and niacin drug interactions. TG laboratory results were available for 80 gemfibrozil patients (74.8%) and 16 niacin patients (72.7%). The PACT CPS made 171 pharmacologic interventions to address drug interactions and the median of 2 encounters per patient. This single-site quality improvement analysis supports the complementary use of protocols and pharmacists with prescriptive authority to resolve statin drug interactions. These data support expanded roles for pharmacists, across settings, to mitigate select drug interactions.

Implementation of a pharmacist-led transitional care clinic.

To describe a pharmacist-led transitional care clinic (TCC) for high-risk patients who were recently hospitalized or seen in the emergency department (ED). The Memphis Veterans Affairs Medical Center (VAMC) established a pharmacist-led face-to-face and telephone follow-up TCC to improve posthospitalization follow-up care through medication optimization and disease state management, particularly for veterans with high-risk disease states such as chronic obstructive pulmonary disease (COPD) and heart failure (HF). The clinic's clinical pharmacy specialists (CPSs) ordered diagnostic and laboratory tests, performed physical assessments, and consulted other providers and specialty services in addition to performing medication reconciliation, compliance assessment, and evaluation of adverse drug events. TCC patients were typically seen within 2 weeks of discharge and subsequently referred back to their primary care provider or a specialty care provider for continued management. A retrospective review of 2016 TCC data found that 7.8% of patients seen in the TCC were readmitted within 30 days of discharge; readmission rates for COPD and HF were reduced to 13% and 10%, respectively, compared to hospital-wide readmission rates of 17% and 24%. A separate observational analysis found that 30-day readmissions for COPD and HF were reduced in TCC patients, with pharmacists documenting an average of 6.2 interventions and 3.3 medication-related problems per patient. To reduce clinic appointment no-shows, the CPSs worked with inpatient providers and schedulers to emphasize to patients the importance of clinic attendance; also, TCC services were expanded to include telehealth appointments to increase access for rural and/or homebound patients. A pharmacist-led TCC effectively reduced readmissions and prevented medication-related problems for high-risk patients who were hospitalized or seen in the ED.

Impact of an Oncology Clinical Pharmacist Specialist in an Outpatient Multiple Myeloma Clinic

IntroductionImprovements in cancer treatment and supportive care, as well as the approval of oral chemotherapy medications over the past decade, have resulted in an increasing number of cancer patients being treated in outpatient settings. Transitioning cancer treatments to the outpatient setting places greater emphasis on proper medication counseling and optimal management of adverse effects. We therefore evaluated the clinical and financial impact of an oncology clinical pharmacist specialist in an interdisciplinary multiple myeloma clinic by using a validated scoring tool. MethodsThe oncology clinical pharmacist specialist was available for consult by the multiple myeloma clinic staff. The pharmacist may be consulted for any medication-related inquiry. On the basis of the consult, the pharmacist categorized interventions into 12 predefined intervention categories. ResultsImplementation of a clinical pharmacy specialist into a multiple myeloma clinic over 39 clinic days resulted in 241 patient consults and 474 interventions made by the pharmacist. The most frequent interventions made by the pharmacist were medication teaching (n = 97), dose adjustments (n = 82), and medication reconciliation (n = 63). The value of interventions made by the pharmacist during the study period was $189,441, with a predicted annual value of $757,764. ConclusionThe addition of an oncology pharmacist to an outpatient multiple myeloma clinic can improve clinical and financial outcomes.

Increased Intravenous N-Acetylcysteine Dosing Following Massive Acetaminophen Ingestion: A Case Report

Kristen M. Audley, Postgraduate Year-2, Critical Care Pharmacy Resident, Christiana Care Health Services I Pharmacy Services Administration, Newark, DE. Jamie M. Rosini, Clinical Pharmacy Specialist, Emergency Medicine, Postgraduate Year-2 Critical Care Residency Program Director, Christiana Care Health Services I Pharmacy Services Administration, Newark, DE