ECU Health Pharmacy Services Annual Report FY22

PHARMACY SERVICES

ANNUAL REPORT - FISCAL YEAR 2022

Table of Contents

I. Table of Contents .......................................................................................................... 2
II. Message from the Chief Pharmacy Officer .................................................................. 3
III. Mission, Vision, and Values …………………………………………………………………………………….. 4
IV. Organizational Chart ................................................................................................……4
V. Pharmacy Leadership……………………………………………………………………………………………....5
VI. ECU Health Community Hospitals

ECU Health – Beaufort (A campus of ECU Health Medical Center) …………………….... 6
ECU Health – Bertie Hospital & ECU Health Chowan Hospital ……………………………… 7-8
ECU Health – Duplin Hospital ………………………………………………………………………………. 9-10
ECU Health – Edgecombe Hospital ………………………….…………………………………………... 11
ECU Health – North Hospital …………………………………….….……………………………………… 12-13
ECU Health – Roanoke - Chowan Hospital .……………….………………………………………….. 14
The Outer Banks Hospital …………………………………………………………………………………….. 15-16
VII. ECU Health Medical Center (Department Overview & Scope) ……………………………… 17
Antimicrobial Stewardship ......................................................................................... 18
Clinical and Patient Care Services – Adult Medicine and Behavioral Health …………. 19
Clinical and Patient Care Services – Critical Care and Emergency Medicine …………. 20
Clinical and Patient Care Services – Diabetes Program.............................................. 21
Inpatient Operations .................................................................................................. 22-23
Investigational Drug Service ....................................................................................... 24
Maynard Children’s Hospital ………………..................................................................... 25
Medication Safety ...................................................................................................... 26
Medication Reconciliation …………….…………………………………………………………………….. 27
Nutrition Support ………………………………...................................................................... 28
Oncology Pharmacy Services ..................................................................................... 29
Retail Pharmacy Services & Ambulatory Care ........................................................... 30-35
Cost Savings Initiatives ………………………………………………………………..…………………….…. 36
Residency Programs ................................................................................................... 37-40
VIII. System Pharmacy Services ……………………………………………………………..……....……………. 41-46
IX. Awards & Recognition .................................................................................................. 47-48
X. Scholarship & Research …………..................................................................................... 49
XI. Educational Programs ................................................................................................... 50
XII. Summary/Looking to the Future …………………………………………………………………………….. 51

Message from the Chief Pharmacy Officer Once again, we met our medication safety
goals for the year, restricting our Level 5 events to
I am excited to present the 2022 Annual below threshold, yet exceeding our Level 2 near
Report for the ECU Health Department of Pharmacy misses. In addition, we exceeded our Alaris®
Services. This report is especially noteworthy in that Guardrail compliance goals. Finally, many of our ECU
it represents the combined efforts of all ECU Health Health regional facilities implemented improved
Pharmacy Services. It is impressive both in its breadth medication refrigerator monitoring systems, as well
and significance of accomplishments, especially in as Glucommander® insulin infusion monitoring
light of the challenges facing healthcare over the past software.
year. Our team has once again shown that it can rise
above adversity to provide exemplary pharmaceutical Our Ambulatory pharmacy footprint
care to the patients of eastern North Carolina. continues to expand. This year we began a pilot with
Clinical Pharmacist Practitioners at the Tarboro
Our team’s accomplishments are detailed in Multispecialty Clinic evaluating the impact of a
the following pages, but I will highlight a few to pharmacist in a clinic environment. Our Outpatient
symbolize the level of accomplishments our Division Antibiotic Therapy (OPAT) team has been extremely
has produced over the past 12 months. busy with new patients and has served as a key player
in planning for a new Home Infusion service. Finally,
Several important Pharmacy Operations our Kinston Medical Services pharmacy team has
projects were completed this year. Following our worked hard to fine-tune medication processing,
commitment to stay with Pyxis® as our Automated pushing forward renovation goals.
Dispensing Cabinet (ADC) of choice, Pharmacy
implemented several pieces of BD® functionality to Our three outpatient pharmacies have had a
augment our dispensing processes. These include busy and productive year. The Cancer Care Specialty
Logistics, Health-Site Inventory Optimization, Pharmacy continues to expand limited drug
Diversion Manager and a new medication carousel. In distribution coverage and increase prescription
addition, we added chemotherapy preparation in our coverage at Marion Shepard Cancer Center, while our
Medical Center pediatric pharmacy satellite. Our ECU Outpatient Pharmacy has met its Meds to Beds roll-
Health Community Hospitals also went live on out goals for this year. Our Employee Pharmacy
Cardinal consignment to reduce replacement costs for continues to increase filling of expensive specialty
high dollar, but rarely used medications. medication for our employees, saving the Health Plan
significant expense.
Work-force management has been a
significant focus of our system Pharmacy work in Our 340b program continues to demonstrate
2022. Much time and effort has been devoted to the improvements as evidenced by declining wholesale
successful development and implementation of acquisition cost (WAC) percentage, remediation of
pharmacist and technician career ladder programs. stalled claims/third-party administrator (TPA)
Improved recruitment and retention are the intended challenges and successful completion of Assent™ and
goals of this work. HRSA audits. Finally, in the midst of all these other
accomplishments, Pharmacy was still able to
We are pleased to have realized the addition document over $1.5M in medication cost savings.
of two new residency programs including PGY-2
Infectious Disease and Emergency Medicine In summary, I am exceedingly proud of the
residencies. In addition, it was great to see last year’s many accomplishments our team and leadership
residents move into either practice or PGY-2 group has accomplished and look forward to many
positions. exciting opportunities in 2023.

-- Jim

Our Mission Our Values

To improve the health and well-being of eastern Integrity
North Carolina.
Doing the right thing. Our patients trust us. We owe it
Our Vision to them—and one another—to bring our best.

To become the national model for rural health and Compassion
wellness by creating a premier, trusted health care
delivery and education system. Connecting, caring and comforting unconditionally.
We’re here because we care about people.
ECU Health Pharmacy Organizational Structure
Education

Learning, adapting, improving and transforming.

Accountability

We are all responsible.

Safety

Achieving zero harm to patients, visitors, families and
team members.

Teamwork

Excellence requires all of us, working in partnership.

ECU Health Pharmacy Leadership

Administrator Pyxis System Manager
Jim Worden, PharmD Tammy Worden, BS Pharm

Community Hospital 340B Manager
Directors/Managers Natascha Aldrich, ACE, CHC, CHPC
Amy Bennett, PharmD
Vance Collins, PharmD Pharmacist Supervisors
Leigh Gurley, PharmD Karen Brown, PharmD, MS
Angela Hardy, PharmD Rand Chandler, BS. Pharm
Kelly Sexton, PharmD Joe Davis, PharmD, BCPS
Shelli Simmons, PharmD Paul Gibbs, BS Pharm, BCOP, CPP
Andy Tingen, BS Pharm Christy Turner, BS Pharm, MBA, BCSCP
April Quidley, PharmD, BCCCP, BCPS
Assistant Directors
Andy Grimone, PharmD, BCPS Pharmacy Supervisors – Retail & Specialty
(Operations) Chris Howard, PharmD
Angela Mayo, PharmD, MBA (Clinical) Badr Ibrahim, RPh, PhD
Grace Kriner, PharmD
Medication Safety Officer
Carol Labadie, PharmD, MS Technician Supervisors
Jessica Richardson, CPhT
Lisa Murphy, BA, CPhT

5|Page

ECU Health Beaufort Hospital

A Campus of ECU Health Medical Center
FY 2022 Pharmacy Update

Summary of Services:

The pharmacy department at ECU Health Beaufort Hospital is open 7
days a week from 0730 – 1730 on weekdays and 0730 - 1530 on
weekends & holidays. Pharmacy services are provided to the Marion
L. Shepard Cancer Center on Mon. - Fri. Remote order verification is
provided by ECU Health Medical Center pharmacists when the
Beaufort pharmacy is closed. A Beaufort pharmacist is also on-call
when the pharmacy is closed. We provide pharmaceutical care to
inpatients, outpatients, and emergency room patients. Our pharmacy
team has 10.7 FTEs (6 pharmacists and 6 pharmacy techs).

Pharmacy Operations: By the Numbers (FY2022): Pictured (L to R): Carol Preston (Pharmacist),
Jo Jo Gettys (Technician), Angie Russell
 111,734 medication orders verified on-site (Technician), Woody Furlough (Pharmacist).
 386,328 doses dispensed
 2,416 chemotherapy medications prepared
 15,018 clinical interventions documented

Summary & Accomplishments:

 Became a Campus of ECU Health Medical Center

(Project Pamlico)

 Adopted ECUH Medical Center antibiotic restrictions/criteria

 Completed successful Joint Commission Survey (11/2021)

 Implemented MacroHelix 340B split billing software

 Participated with multidisciplinary team to develop

standard of work for crash cart restocking process

 Worked with system Pharmacy IS team on EPIC clinical Pictured (L to R): Mary Jones (Technician), Andy Tingen
changes in TPN/PPN ordering (Pharmacy Manager), Susan Edwards (Pharmacist), My-
Hoa Pandya (Pharmacist), Ruby Hopkins (Technician),
 Completed annual pharmacy inventory by pharmacy staff Mandy Harris (Technician), Lisa Hardison (Technician).
 Worked with Anesthesia for new Anesthesia coverage of Not shown: Michael Dilullo (Pharmacist)

endoscopy procedures

 Members of our pharmacy team volunteered to serve at NC MedAssist’s visit to Beaufort County

Community College for the distribution of free over-the-counter medications to the public

 Continue to supply COVID vaccines to 7 clinics/practices in 2 counties
2023 Goals:

 Obtain approval of Pharmacy Buyer position

 Implement BD Logistics (virtual inventory control system) - April 2023

 Expand Pyxis Medstations on 2 East (surgical unit)

 Develop and retain pharmacy team members

 Utilize Daily Management System (DMS) board with pharmacy team

 Promote and increase utilization of biosimilar medications 6
 Participate and support system Medication Replacement program

ECU Health Bertie & Chowan Hospitals

FY2022 Pharmacy Update

Summary of Services: Pharmacists: Shelli Simmons, Nelson Spear, Terry Lovell,
Nastacia McArthur, Not Pictured- Wallace Nelson
 Provides services between 0730 and 1700 on weekdays and
0730 and 1230 on weekends and holidays. ECU Health Pharmacy Technicians: Kim Hufton, Jennifer Aycock, Norma
Medical Center provides coverage via Remote Order Phillips, Courtney Long, Not Pictured- Marie White and Amanda
Verification for all other hours. Gauthier

 Both hospitals heavily rely on Pyxis® Automated Dispensing Pharmacy Operations: By the numbers
Cabinets and Pyxis® anesthesia stations to assure timely (FY2022)
access to medications (97% of medications are dispensed  150,000 medication doses dispensed by
through Pyxis @ ECU Health Chowan while 99% are
dispensed through Pyxis @ ECU Health Bertie) the Chowan pharmacy
 48,000 medication doses dispensed by
 Both Critical Access Hospitals participate in the 340B
the Bertie pharmacy
 Clinical services provided by pharmacists include:  5 full time pharmacists, 5 full time
o therapeutic drug monitoring
o daily care team rounding and chart review pharmacy technicians and 1 PRN
o renal dose adjustments pharmacy technician (shared between
o pharmacy to dose per protocol for a variety of both sites)
medications
o order verification and general medication management 7
o drug information
o emergency response

 Staff pharmacists serve on system committees such as
AUSS, Alaris Validation Group, and the newly formed
Project Approval Team (pharmacist clinical ladder)

 Services provided by pharmacy technicians include:
o Unit dose medication distribution
o Management of Automated dispensing cabinets
(Pyxis)
o Maintain and process code cart and emergency drug
box medications
o Preparation of topical and oral non-sterile non-
hazardous compounded medications
o Management of controlled substances using C2 Safe
Pyxis technology
o Prepackage bulk oral solid medications
o Sterile Compounding (non-hazardous and hazardous)

Accomplishments:

 Provided COVID-19 Vaccines to 8 system owned physician practices and 2 Occupational Health offices
 Implemented pharmacy technician hazardous drug compounding (Feb 2022)
 Continued to promote team member engagement and recognition as evidenced by an increase in departmental

use of the Appreciation Portal
o Exceeded growth target of 20% by achieving a 67% increase from 15 to 25
o 40% of pharmacy staff used the Appreciation Portal to send recognition to team members

 Continued to exceed goal of ED STAT order verification time <5 minutes (and achieved all ED order verification
in less than 8 minutes)

 Continued to grow and support Pharmacy safety culture through Safety Intelligence Reporting
o Pharmacy team members increased reporting of near-miss events compared to FY21 by 220% (56 to
123 reports)
o Pharmacy team members reported 77% of all Med Events that were entered into SI

 AUSS Recommendation Acceptance Rates remained > 95% for ECUH Bertie and > 90% for ECUH Chowan
 Maintained a strong chemotherapy volume amongst the other regional hospitals
 Alaris Library use continued to increase throughout the year at both hospitals, with an all-time best at ECU

Health Bertie of 90.98% utilization and 82.37% at ECU Health Chowan
 MUEs completed on vancomycin, ciprofloxacin and pipercillin-tazobactam prescribing
 One new pharmacist on-boarded this past year (Nelson Spear)
 Two new pharmacy technicians on-boarded this past year (Courtney Long and Jennifer Aycock)

Zero Severity Level 5 Pharmacy team All SI Event Reporting FY22
med events reported 86% of
Near Miss med Non-
Pharmacy,
Pharmacy events
57, 23%

Safety Pharmacy,
188, 77%
Culture

All pharmacy team Pharmacy team Pharmacy Non-Pharmacy
members reported at reported 77% of all
medication events
least one SI event

2023 Goals:

 Implement USP797 environmental sampling
 Improve Alaris Guardrail usage by implementing pharmacy technician driven process for timely

updating of Alaris pumps post library update
 Maintain focus on Medication Event Reporting and correlation of safety habits to processes
 Mentor and empower team members to participate on career ladders
 Maintain focus on team engagement and communication
 Implement Logistics to streamline Pyxis Replenishment process (Dec 2022 & January 2023)
 Establish pharmacist leads for inventory (HSIO and Logistics) and Medication Safety (Diversion

Management and SI Report analysis)
 Design and implement a pharmacy driven technician monthly backorder management process
 Complete hazardous compounding training with remaining 2 pharmacy technicians by February 2023
 Establish a “just in time” chemotherapy inventory process to reduce waste
 Transition additional pharmacy purchasing and inventory management roles to pharmacy technicians

8

ECU Health Duplin Hospital L to R: Leigh Gurley, Sophie Thomas, Brittany Drew, Julie Borg, Anna Mobley,
Mollie Rouse, Jenessa White, Brittany Byrd, and Sharon Haney; not pictured:
FY2022 Pharmacy Update Kelli Westerbeek

Summary of Services:

The pharmacy team at ECU Health Duplin Hospital
consists of 3 full-time clinical/staff pharmacists, 4 full-
time certified pharmacy technicians and a number of
other part-time or PRN staff. Inpatient operational and
clinical pharmacy services are provided 7 days per week
with onsite presence 0700 -1700 on weekdays and 0700
– 1300 on weekends. On weekdays, this team also
supports the hospital-owned outpatient infusion center
for antibiotics, chemotherapy and other supportive
medications. Pharmacists participate in daily
multidisciplinary rounds for the intensive care
medical/surgical unit while supporting order verification
and pharmacy operations for the remainder of the
hospital.

Pharmacy Operations: By the Numbers (FY2022):
 72, 404 medication orders verified on-site
 237,573 doses dispensed
 1,279 chemotherapy and outpatient

medications prepared

Accomplishments: Sophie Thomas, pharmacy
technician immunizer, at Family
 Formed new relationships to expand student learning: Leonardo Duque, pharmacy student Flu Clinic
o Wayne Community College – Pharmacy from Campbell University College of
Pharmacy and Health Sciences Tara Kompare, PharmD,
BCACP, Network Clinical
Technology Program Pharmacist with Access East,
Inc. who is now working at
o Wingate University School of Pharmacy Duplin 1 day per week to
focus on Ambulatory Care
 Welcomed two pharmacy technician students for 8 week hospital rotations opportunities and partner
on diabetes projects.
 Precepted 7 student months (IPPE, APPE and Internal Medicine) for pharmacy
9
students from Campbell University College of Pharmacy and Health Sciences and

Wingate University School of Pharmacy

 Two pharmacy technicians and 1 pharmacist earned Immunization Certificates

 Modernized patient care unit storage with addition of Pyxis ES refrigerators

 Surpassed historic monthly volume for total hazardous and non-hazardous sterile

compounding

 Supported local clinics with management, distribution, and documentation of COVID

vaccines

 Increased documentation of safety catches from pharmacy and championed

reporting efforts within hospital

 Mobilized pharmacy technicians to ensure best possible medication history is

completed on all inpatient admissions; Trained all pharmacy technicians and

pharmacists and assigned role daily

Accomplishments (continued):

 Aligned reporting of opioid prescribing with NPSG recommendations to include quarterly evaluation of long
acting opioid administration, analysis of indication and product selection, naloxone administration and average
Morphine Milligram Equivalents (MME) per patient

 Launched Inpatient Diabetes project which focuses on optimizing medication management, updating
immunizations, providing Survival Kit basics and patient counseling; baseline data collection to affirm ~40%
admissions carry diagnosis of diabetes

 Awarded $148,000 grant from Cape Fear Memorial Foundation to collaborate with Duplin County Health
Department on the creation of an accredited DSME program; Pharmacists conducted gap analysis of services
available, access to care, compliance barriers and co-authored grant application

 Streamlined purchasing process to minimize WAC and non-contract spend; Observed lowest annual WAC % in
2022

 Pharmacist selected to for the Enriching Leadership Program, Cohort 2022: Mollie Rouse, PharmD, BCPS
 Collaborated with Duplin County Health Department to increase access to vaccinations and testing within

historically marginalized populations in Duplin County; Forged community partnerships with faith-based
organizations as well as local protein processing plants to provide vaccinations
 Student projects:

o Evaluation of compliance with dose optimization protocol for pre-op surgical prophylaxis in patients
weighing >120kg; cefazolin 2gm vs. 3gm

o Development of a standardized process to evaluate PYXIS override list; subsequent evaluation and
modification for two lists (standard and ICU)

o Assessment of ertapenem usage for FY22Q2 at ECU Health Duplin Hospital
o Review of all asymptomatic bacteriuria cases at ECU Health Duplin Hospital for FY22Q2
o Data collection as part of Medication Use Evaluation (MUE) for insulin prescribed for

Hypertriglyceridemia-induced pancreatitis
o Creation of a checklist for Diabetes Survival Kit and script for counseling of diabetic patients at Vidant

Duplin Hospital
 Modified ECUH Medical Center order set (Insulin for Hypertriglyceridemia Induced Pancreatitis) in order to

expand to corporate order set so that community hospitals can utilize safely
 Educated new nurses on common critical care/emergency infusions and provided case-based learning

opportunities; created and shared badge buddy cards for all ICU/ED staff
 Characterized all declined AUSS recommendations for trends or opportunities to enhance acceptance rate

2023 GOALS:

 Improve percentage of inpatients with complete and accurate medication history within 24 hours of
admission; Goal >95%

 Maximize grant funds to design a DSME program and obtain accreditation status
 Boost Alaris pump guardrail utilization to 95%
 Engage system leaders in creation of Opioid Stewardship Program for ECU Health
 Collaborate with Readmissions Reduction Committee to establish metrics and identify inpatient focus
 Improve safety and quality metrics related to diabetes care; Glucommander-specific metrics to include

improvement in hyperglycemic rate, time to goal range and percent of blood glucose values in range
 Encourage and support team members to participate in Pharmacy Technician Career Ladder and Pharmacist

Career Ladder
 Expand Diversion Manager pilot to standardized process for all pharmacies in ECU Health

10

ECU Health Edgecombe Hospital Pharmacy Operations: By the Numbers
(FY2022):
FY2022 Pharmacy Update  240,625 medication orders verified
 316,233 doses dispensed
Summary of Services:  24,114 Pharmacy interventions
 $3,221,192 in cost avoidance
The Pharmacy at ECU Health Edgecombe is open 7 days a  $2,145,494 in 340B Savings
week, providing services 0700 - 1730 on weekdays and 0700
- 1500 on weekends & holidays. We have a total of 13.6 FTEs Our Pharmacy team receiving the Safety Catch Award, Dec 2021.
(5 FT pharmacists, 7.6 FT technicians, 1 FT pharmacy
inventory control specialist). We also have 3 PRN 2023 Goals:
pharmacists. We offer clinical pharmacy services including  Continue to work on intervention
rounding with the patient care team in the ICU and
progression of care rounds with hospitalists and the documentation standardization.
interdisciplinary team. We also offer on-site pharmacist  Decrease use of broad spectrum antibiotics.
supported Antimicrobial Stewardship program. Our  Maintain current conservable days of
outpatient services include chemotherapy compounding
for the Cancer Center, distribution of outpatient antimicrobial therapy per quarter.
medications to employees and their dependents, and
pharmacist consulting for the ECU Health Endoscopy 11
Center.

Accomplishments:

 The Pharmacy is actively involved on several
teams and committees. Two of those teams had
successful re-certifications this year. The
Oncology Center received reaccreditation by the
Commission on Cancer and the hospital had a
successful Stroke Recertification Survey.

 The Pharmacy Team reported 49 Safety Catches
FY 22 and were the recipients of the Safety
Catch Award Winner December 2022.

 We continue to have approximately 500 days of
conservable days of antimicrobial therapy per
quarter.

 While working with other members of the
Clinical Quality Committee, the pharmacists
helped the hospital to maintain zero hospital
acquired MRSA infections for more than 400
days.

 This same team also decreased C. diff infections
by 72%.

 The pharmacists have been working with the
AUSS team to standardize intervention
documentation.

ECU Health North Hospital Pharmacy Operations: By the Numbers
(FY2022):
FY2022 Pharmacy Update  140,613 Medication orders verified on-site
 509,212 Medication doses dispensed
Summary of Services:  7,339 Sterile compound preparations
ECU Health North Hospital is open 7 days a week and  1,256 Chemotherapy medications prepared
provides on-site pharmacy services from 0700 – 1730 on  9,780 Clinical interventions documented
weekdays and from 0700 - 1530 on weekends. A pharmacist
is on-call after regular pharmacy hours. The pharmacy (including 2,380 Antimicrobial Stewardship
provides inpatient dispensing and clinical pharmacy services, interventions)
including an on-site pharmacist supported Antimicrobial  20,455 Medication histories completed
Stewardship program. Chemotherapy services are currently
offered Monday through Friday. The pharmacy also supports
a Pharmacy led Medication Reconciliation Program,
primarily serving Emergency Room patients, 24 hours a day,
7 days a week. The pharmacy has 24.03 FTEs which includes
8 full-time pharmacists including Director and 1 part-time
pharmacist; 9 pharmacy technicians; 1 Inventory Control
Technician; 1 340B specialist; 5 full-time and 2 part-time
medication reconciliation technicians.

Accomplishments:

 Implemented DicksonOne® continuous temperature

monitoring system on all medication refrigerators

freezers as well as a temperature and humidity sensor in

the USP 797 IV Cleanroom suite.

 Installed Pyxis® Medstations in each ED Trauma room,

allowing for faster medication access and the reduction of

medication kits stored outside of Pyxis®

 Implemented Pyxis® Healthsight Inventory to optimize

medication inventory in Pyxis® across the facility, ensuring

access to medications by nursing while decreasing the

number of visits to the Medstations by pharmacy team

members and decreasing waste of expiring medications. ED Trauma Room Pyxis® Medstation
 Implemented Pyxis® Healthsight Diversion Manager to

track and trend potential cases of controlled substance  Celebrated the retirement of our 40 year
diversion.
department veteran, Paula Burton.
 Participated in the implementation of Neonatal and  Hired one new pharmacist, Miranda Haislip, and two
Pediatric Emergency Carts.
new pharmacy technicians, Matthew Imparato and
 Coordinated the overhaul of the Adult Emergency Cart,
Michael Hawkins.
optimizing medication and supply access during adult  Retained our Pharmacy Led Medication
codes.
Reconciliation Program in the Emergency
 Implemented Cardinal Medication Consignment to
Department, completing med recs on about 80% of
decrease carrying expense of high cost, low use
Emergency Department patients.
medications.
 Implemented an employee prescription delivery
 Implemented Pharmacy Technician Career Ladder to
service for team members to increase usage of this
encourage professional growth in our pharmacy
employee benefit.
technician team.
12

New and Improved Adult Emergency Cart

Pharmacy team celebrating Paula Burton’s retirement
after 40 years

Pictured from left to right: Top row: Betty Brown, Tiara Dukes,
Ashely Nickels, Teresa Bennett. Middle Row: Tammy Arwood,
Brittaney Carroll, Anita Fleming, Page Watson, Paula Burton,
April Taylor, Brittany Keel, and Amanda Wrenn. Bottom row:
Stephanie Iles, Danielle McGee, Judy Fulkerson, Michelle Liles,
Amy Kelly, Debbie Frances, and Samantha Hearp

Medication Tray for Pediatric/Neonatal
Emergency Cart

2023 Goals:
 Improve documentation of pharmacist clinical interventions
 Implement Pyxis® Logistics for optimization of centralized medication inventory
 Implement controlled substance waste container system
 Implement Pharmacist career ladder
 Continued improvement in team member communication and engagement

13

ECU Health Roanoke-Chowan Hospital

FY2022 Pharmacy Update

Summary of Services: (Left to Right): April Shannon (Technician), Earl Phillips (Admin, Operations), Melissa Barnes
The pharmacy at ECU Health Roanoke-Chowan is (Technician), Danielle Ellis (Technician), Philip Broome (Pharmacist), Louise Harris (Technician), Kelly
open from 0700 – 1700 on weekdays and 0730 - Sexton (Manager, Pharmacist), Cheyenne Revelle (Technician), Michelle Hoggard (Technician),
1230 on weekends & holidays. A pharmacist is on- Bridget Willoughby (Technician), Evan Winn (Pharmacist), Danielle Woodard (Pharmacist) Not
call after regular pharmacy hours. The pharmacy shown: David Broome (Pharmacist), Monte Thompson (Pharmacist)
provides inpatient and clinical pharmacy services
daily. The pharmacy also provides outpatient
infusion services including oncology Monday through
Friday. We have a total of 12.7 FTE, including 6 full-
time pharmacists, one part-time pharmacist and 3
PRN pharmacists. We have a 5.6 FTE pharmacy
technicians and a pharmacy Pyxis coordinator.

Pharmacy Operations: By the numbers
(FY2022)
 411,783 Medication doses dispensed
 1,814 Chemotherapy medications prepared
 2,683 Clinical interventions documented

Accomplishments: Chemo Prep Room

 Digitalization of 340B Chemotherapy inventory into Pyxis Logistics IV Room Organization with Wall-
 Pyxis and CII Safe Upgraded Mounted Bins
 Improvement in Pyxis Tower numbering system
 Initiated labeling of bulk products instead of packaging 14
 Electronic report created for after-hours bulk package removal from ANNEX
 Addition of ENDO Unit A-Station
 Consolidated Pyxis stations due to floor consolidation – now 2 stations on

Medical Unit
 IM Methotrexate kit for ectopic pregnancy (after-hours)
 Priming chemo lines prior to release of orders (improved delivery time)
 Patient-specific bins in ICU
 Cardinal Consignment medication program implemented

2023 Goals:
 Optimize chemotherapy inventory control
 Add additional hazardous hood to decrease turnaround time and improve

efficiency
 Decrease pharmacy related safety events
 Promote interest in hosting pharmacy students
 Plan continuing education events and identify places where we begin projects

to increase more pharmacy ownership
 Create new revenue streams through contract pharmacy
 Foster relationships with outpatient prescribers to increase use of biosimilars

The Outer Banks Hospital Pictured (L to R): Mary Terrell (Pharmacist), Hampton Hall
(Pharmacist), Melanie Bright (Technician), Vance Collins (Director),
FY2022 Pharmacy Update Shannon Wright (Technician), MJ Moseley (Pharmacist), Jennifer Pearce

Summary of Services: (Technician), Cara Wingate (Technician) Not shown: Amy Feltz
(Pharmacist), Mike Mazza (Technician)
The Outer Banks Hospital (TOBH) is open 7 days a week
and provides on-site services from 0700 – 1700 on
weekdays and 0730 – 1230 on weekends & holidays. A
Pharmacist is on-call 24/7. The Pharmacy provides
inpatient dispensing and clinical pharmacy services. The
Pharmacy also provides safe medication practice
consulting services for The Outer Banks Medical Group
(14 practices). Chemotherapy services are currently
offered Monday thru Friday. The Pharmacy has 7.8 FTEs
(5 pharmacists including Director and 5 technicians
including chemotherapy technician).

Pharmacy Operations: By the Numbers (FY2022)

 66,348 medication orders verified on-site
 143,934 doses dispensed
 3,500 sterile compounds dispensed

(not including chemotherapy)
 2,225 chemotherapy medications prepared
 5,123 clinical interventions documented

Summary & Accomplishments:

 Installed Dickson One® temperature monitoring

solution on all medication refrigerators and

freezers.

 Conducted staff education on the safe

administration of chemotherapy outside of

Medical Oncology

 Improved documentation of administration of

contrast agents Oncology BD Pyxis® Helmer® Radiology Pyxis® for contrast
 Designed pharmacy and IV room space for new refrigerator storage

Oncology Center opening 2023 15

 Conducted team building and engagement exercises

 Redesigned department safety huddle processes

 Installed Pyxis® for contrast dispensing in Radiology

 Resumed OBMG clinic medication inspections

 Installed Helmer® Pyxis® refrigerator in Medical Oncology unit

 Assisted with purchase and programming of new CADD® epidural pumps

 Participated in design and set-up of virtual provider and specialist program

 Converted PRN pharmacy technician to 0.5 FTE

 3 new employees

Oncology Services & Chemotherapy at TOBH Pharmacy Chemotherapy Team
 The National Accreditation Program for Breast Centers (NAPBC) Pictured (L to R): Melanie Bright
of The American College of Surgeons has awarded accredited (Technician), Amy Feltz (Pharmacist)
status to The Outer Banks Hospital (TOBH) Breast Care Program
(the only critical access hospital in the United States to achieve
this status).
 Pharmacy Department actively involved in this program by:
o 2 members on Cancer Committee
o 1 member on Breast Cancer Team
o Participate in daily oncology rounds
o Collaborate with Oncology providers for chemotherapy
optimal regimens and dosing
o Collaborate with Oncology Navigator for optimal
reimbursement

2023 Goals:
 Improve documentation of pharmacist clinical interventions
 Quality project to ensure capture of medication
administrations
 Continued optimization in purchasing of drugs and supplies
and inventory processes
 Continued improvement in team communications and team
engagement
 Staffing and operational planning for new Oncology Center
 Restart Pharmacist in Primary Care project

16

ECU Health – Medical Center

Department Overview & Scope:

The ECU Health Pharmacy Division provides inpatient and outpatient services to assure safe,
appropriate, and timely medication access to all patients served. The pharmacy is comprised of over 300
pharmacist and technical team members across nine inpatient and four outpatient settings. The Medical
Center inpatient pharmacy provides 24/7 operations and supports the eight community hospitals
through remote order verification. More than 95% of medications are dispensed using Pyxis® Automated
Dispensing Cabinets and Pyxis® anesthesia stations to assure timely access to medications. ECU Health
pharmacies utilize USP 797 compliant sterile product preparation areas for hazardous and non-
hazardous sterile compounding. ECU Health pharmacists provide drug information, consultations, and
pharmacy to dose per protocol for a variety of medications. At the Medical Center, pharmacists round
on 15 different patient care teams. Medication Reconciliation Technicians obtain medication histories,
either in-person or virtually for all patients admitted to ECU Health facilities. Our strong commitment to
education and training is evident through the more than 160 pharmacy student rotation months
provided annually. In addition, the Medical Center supports PGY-1 and PGY-2 pharmacy residencies in
pharmacy practice, critical care, emergency medication and infectious diseases.

The ECU Health Employee Pharmacy dispenses more than 140,000 medications to employees
and dependents across ECU Health. The ECU Health Specialty Pharmacy is ACHC/URAC accredited and
assures access to specialized medications for patients across Eastern North Carolina. The ECU Medical
Center Outpatient pharmacy provides Meds-to-Beds discharge prescriptions to facilitate medication
access at discharge. Finally, ECU Medical Center provides medication infusions at our Medical Center
Infusion Center, as well as our ECU Health Kinston - Oncology location. The breadth of pharmacy services
support illustrates how we collectively live the Mission & Vision of ECU Health.

17

ECUH Medical Center Pharmacy

Clinical and Patient Care Services - Antimicrobial Stewardship Program (ASP)

Summary & Statistics: Pictured (L to R): David Laurent, PharmD, BCPS, BCIDP; Nicole
Nicolsen, PharmD, BCPS. BCIDP; Paul Cook, MD, FACP, FIDSA;
The goal of the ASP team is to support antimicrobial Melissa George, PharmD, BCIDP; and Mackenzie Dolan, PharmD
stewardship efforts, manage the Antimicrobial
Utilization and Stewardship Subcommittee (AUSS) of the *Does not include Q4 FY2022 data
ECUH P&T, and perform day-to-day antimicrobial
patient care for patients at ECUH MC. In addition to 2023 Goals:
routine program activities, the team has accomplished
several notable initiatives, including:  Optimize anti-Pseudomonal drug usage (with a
focus on piperacillin/tazobactam) and decrease
 Updated and published a new version of the ECUH SAAR closer 1 (to show similar use to national
Guide to Antimicrobial Therapy resource benchmark data)

 Maintained the ASP quarterly newsletter which  Incorporate the PGY-2 Infectious Diseases
provides ASP updates and a therapeutic review pharmacy resident into the ECUH ASP and
expand patient coverage
 Started PGY-2 Infectious Diseases Pharmacy
Residency to support program growth  Increase antimicrobial stewardship in the ED
 Evaluate ECUH MC rapid blood culture
 Precepted learners including infectious diseases
fellows and pharmacy residents identification clinical guidance
 Quantify compliance with institutional
 Presented antimicrobial review lectures for APPs (via
the Best Practice Updates section in the antimicrobial therapy guidelines to meet
LearnCenter), ECU infectious diseases fellows, and updated Joint Commission Standards
UNC pharmacy students  Revive inpatient penicillin skin testing

 Presented a clinical practice update at ID Case 18
Conference titled “Are Two Beta’s Than One?
Combination Therapy for MRSA Bacteremia”

 Began participating in rounds with the ID consult
service

 Three team members earned infectious disease
pharmacist board certification (BCIDP) – Melissa
George, David Laurent, and Nicole Nicolsen

 Assumed responsibility of reviewing rapid molecular
blood culture results

 Implemented MRSA nasal screen ordering by
pharmacists as part of pharmacy to dose vancomycin
protocol to further decrease inappropriate
vancomycin usage

 Collaborated with nursing on improving urine culture
collection technique and penicillin allergy
assessments

ECUH Medical Center Pharmacy

Clinical and Patient Care Services – Adult Medicine and Behavioral Health

Summary of Services:

 The Adult Medicine and Behavioral Health Pharmacy

team consists of 19 clinical decentralized pharmacists

and one pharmacist supervisor

 The pharmacists on the team have diverse training

backgrounds and as of 2022, 60% have obtained board

certification in specialties such as pharmacotherapy,

cardiology, and psychiatry

 The team has expanded coverage to a total of 11

inpatient adult acute care units spanning internal

medicine, family medicine, oncology, cardiology, Accomplishments:

surgery, neurology, rehab, and behavioral health  Created and implemented the new system-wide
 Services provided by unit-based clinical pharmacists pharmacist career ladder

include: therapeutic drug monitoring, chart review,  Placed a pharmacist in the ambulatory care
renal dose adjustments, order verification, medication setting at Tarboro Family Medicine
management, drug information, emergency response,
and operational assistance  Expanded the Meds2Beds program to an
additional five inpatient units (COU, 1-South, 3N-

 Decentralized pharmacy services are provided Monday NSU, 4N-SIU, 2N-MIU)

through Friday from 0700 – 1530 and unit pharmacists  Participated in the completion of publications,

are easily accessible for providers, nursing, and reviews, clinical quality projects, cost savings
support staff initiatives, MUEs, and research
 2nd shift clinical pharmacy services are provided for  Re-imagined a medicine FTE as a hybrid
medical/surgical units from 1200-2230 M-F medicine/critical care position to support clinical
 The team participates in experiential education for two coverage in our ICUs and on-boarded a PGY-2
contracted schools of pharmacy (UNC & Campbell critical care trained pharmacist
University) and ECUH Medical Center PGY-1 pharmacy  Re-defined and stabilized 2nd shift medicine
practice residents clinical pharmacy services
 Pharmacists also serve the community through public  Completed a pharmacy discharge stewardship
education and volunteering at the local shelter clinic pilot program in rehab medicine
 Developed discharge medication reconciliation

review process in rehab services and piloted use

on 2 inpatient units (2S and 3E)

2023 Goals:

 Standardize system-wide pharmacy student
rotations

 Refine pharmacist career ladder and stabilize
system project approval team

 Continue to expand the role of the pharmacist
in the inpatient and outpatient settings

19

ECUH Medical Center Pharmacy

Clinical and Patient Care Services - Critical Care and Emergency Medicine Pharmacy Services

Summary & Accomplishments

 Clinical pharmacy services including patient care rounding, therapeutic drug monitoring, emergency
response, medication order verification and drug information provided Monday-Friday during first shift
for all adult ICUs.

 Critical Care trained pharmacists provide clinical pharmacy services to all adult ICUs for extended
evening shifts (1400 – 0130).

 Unit leads and clinical pharmacists provided clinical support for standardization of:
o Heparin infusion for embolic stroke
o Phenobarbital for alcohol withdrawal
o Conversion to system wide use of tenecteplase for acute ischemic stroke
o Formulary addition of Anavip®

 Clinical pharmacy services in the Emergency Department 12 hours/day, 7 days/week provide order
verification, drug information and clinical support in medical emergencies, trauma, stroke, and
procedures.

Emergency Medicine Pharmacist Chelsie Sanders Critical Care Pharmacist Tyler Chanas rounds with the multidisciplinary
prepares medications for a patient in the Trauma Bay team in the Cardiac ICU

Critical Care/ED Services by the numbers:
~14,000 documented pharmacist interventions
112 Critical Care Beds with direct patient care services
8 Critical Care Board Certified pharmacists (70%)
3 National presentations or publications

2023 Goals

 Work with antimicrobial stewardship to promote appropriate use of broad-spectrum antimicrobials
 Ongoing standardization of kits and medication use across ECU Health System

20

ECUH Medical Center Pharmacy

Clinical and Patient Care Services - Diabetes Program

Summary & Accomplishments:

The Diabetes Program is comprised of the Diabetes Program Manager, Devon Johnson, Devon Johnson, PharmD, BCPS
PharmD, BCPS and Medical Director, Dr. B. Francesca Ramirez, MD. The team works
collaboratively with key stakeholders across the region to improve care for patients with Diabetes Program Manager
diabetes.

During FY22, the Diabetes Program facilitated the successful rollout of new Glucommander®
software from Glytec® throughout the ECU Health system for all IV insulin infusions.
Glucommander® will provide the Diabetes Program essential, real-time data, to drive
system-wide quality and safety improvements in the care of diabetic patients.

Additional Program Projects In-Process Include:

1. Categorizing, organizing, and trending monthly KPI data received from Glytec® in order to identify Francesca Ramirez, MD
opportunities for improvement in Glucommander® usage.
Diabetes Fellowship Director
2. Reconvening system-wide interdisciplinary Diabetes Steering Committee, with subsequent scheduled Clinical Assistant Professor,
reports to the Excellence in Clinical Practice (ECP) Committee on diabetes-focused initiatives. Division of Endocrinology

3. System-wide workflow improvement in the safety of IV insulin bolus dose ordering/administration for Diabetes Steering Committee:
the treatment of hyperkalemia. Reporting Structure

4. Creation of an EHR link between Glucommander® orders and meal tray ticket printing, to facilitate Clinical Excellence
timely and accurate carbohydrate/diet intake for diabetic patients. Committee (CEC)
Dr. Niti Armistead
5. Mapping of future #34 Glucoview™ stations as a safety enhancement for Glucommander® software. Dr. Daphne Brewington
6. ED-specific enhancements to create an EHR flag for Type 1 patients denoting admission priority/ high

acuity care requirement, and serial every four hour BMP monitoring on all insulin infusions begun in
the ED.

Data collected 9/8/22 via Glucometrics platform

Excellence in Clinical
Practice (ECP)

Dr. Teresa Anderson

Dr. Anthony Smith

Diabetes Steering
Committee

Dr. Devon Johnson

Dr. Francesca Ramirez

Represents YTD Hypoglycemia rates (BG <70mg/dL) in Glucommander®-treated
patients vs those not treated on Glucommander® protocol for all adult, inpatient units

2023 Goals:

 Develop a structured program to report hospital glycemic management metrics.
 Begin tracking, trending, and reporting CMS electronic clinical quality measures (severe

hypoglycemic and severe hyperglycemic events).
 Rollout of Glucoview™ monitoring as an enhancement to Glucommander™ software.
 Expand available diabetes inpatient services.

21

ECUH Medical Center Pharmacy IV Additives

Pharmacy Operations  Non-hazardous and hazardous sterile
medications prepared in a USP 797 compliant
Summary of Services: cleanroom suite.

Pharmacy operations is responsible for assuring timely,  Prepare 25 - 30 Total Parenteral Nutrition
accurate, and safe medication access for patients at ECU (TPNs) daily using an automated compounding
Health Medical Center. The Main and IV Additives device (Baxa® machine) – includes adult,
Pharmacy provides services 24 hours a day, 7 days per pediatric, and neonatal TPNs
week to all inpatients at ECUH Medical Center.
Pharmacy Operations also includes the Operating Room  Sterile products prepared as IV admixtures,
(OR) Satellite and the East Carolina Heart Institute (ECHI) add-a- vial, and premixed products.
Satellite, which provide pharmacy services from 0600-
2230, 7 days per week. ECHI Satellite

Pharmacy Operations: By The Numbers (FY2022)  Provides pharmacy services for cardiothoracic
and vascular surgeries within 7 Cardiovascular
 2.37 million medication orders verified OR (CVOR) suites.
 5.7 million doses dispensed
 245,000 sterile compounds dispensed  Provides pharmacy services for the ECHI
 Over 750,000 oral doses repackaged inpatient tower and CVOR.

Main Pharmacy  Services include order verification and
medication therapy management, sterile
 Verify medication orders and dispense to inpatients compounding, as well as distributive services
at ECUH Medical Center and Pyxis refill management.

 Unit dose medication distribution, including oral
repackaging of bulk products

 Refill and manage automated dispensing cabinets
(Pyxis)

 Maintain and process code cart and emergency drug
box medications using RFID technology

 Prepare topical and oral non-sterile hazardous and
non-hazardous compounded medications

 Manage controlled substances using C2 Safe Pyxis
technology

OR Satellite

 Provides pharmacy services to 26 OR rooms
 Pharmacists provide medication review of peri-

operative medications and collaborate with surgery
and anesthesia staff regarding medication therapy
 Technicians prepare medications as needed during
surgery, refill Pyxis machines and anesthesia
workstations for all OR suites and offsite areas.

22

Accomplishments:

 Managed over 100 drug shortages to assure appropriate medication access
 Installed new BD medication carousel with integration of Epic orders and Logistics inventory in main

pharmacy
 Implemented Epic Compounding and Repackaging (CNR) for sterile batched products
 Renovated pharmacy repackaging and unit dose area
 Implemented new oral unit dose repackager
 17% reduction in pharmacy inventory ($1.4M decrease)
 Implemented BD Health Sight Inventory Optimization (HSIO) with over $50K in documented savings

through optimized par levels
 Implemented cycle counts for main and storeroom carousels

Doses Dispensed - ECU Health Medical Center by Quarter (FY19 - FY 22)

1,750,000 Total doses
1,500,000 dispensed at pre-
COVID numbers

# of Doses dispensed 1,250,000

1,000,000

750,000

500,000

Pharmacy Orders Verified (ECU Health Medical Center) FY21 vs. FY22

# of medication orders verified 220000
210000
200000

190000
180000
170000
160000

Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

FY2021 FY2022

2023 Goals:

 Implement hospital provided scrub program for sterile compounding areas
 Implement monthly environmental sampling in all sterile compounding areas
 Implement pharmacy kits in Stat Stock (RFID technology for refilling)
 Standardize training for technicians across all areas
 Expand the use of Logistics inventory into other areas of pharmacy operations (IV room)
 Increase Dispense Prep compliance for sterile compounding

23

ECUH Medical Center Pharmacy

Investigational Drug Service

Summary of Service:

 Meet with Investigational Drug Study Sponsors to Rachel Hupfeld, PharmD, MBA
assist with site selection for research Tammy Worden, RPh

 Provide pharmacy services for investigational drug
studies including receipt, storage, dispensing, and final
disposition of investigational product

 Assist providers in obtaining emergency use of an
unapproved investigational drug or biologic for life
threatening situations

 Voting members of the University and Medical Center
Institutional Review Board

 Provide quarterly updates of new studies to Pharmacy
and Therapeutics Committee

 Partner with Center for Research and Grants to
facilitate excellence throughout the research cycle

 Precept pharmacy students

Investigational Drug Services Activities for FY2022: COVID related activities:

 Currently support 73 clinical trials (20% increase from  Continued to participate in COVID research
FY 2021)  Continued to support the North Carolina

 Dispensed 496 study doses (32% increase from FY Department of Health and Human Services
2021) distribution of COVID medications authorized
under Emergency Use Authorization (EUA)
 Participated in 39 study monitor visits (11% increase  Worked with a multidisciplinary team on the
from FY 2021) evolution of oral COVID therapies and updated
COVID monoclonal antibody treatment for the
 Assisted with opening 18 new studies at VMC (1% health system
increase from FY 2021)  Presented COVID-19 Therapeutics Evolving EUAs
for Internal Medical Grand Rounds
 Prepared 12 Oncology Study Protocol Treatment plans
for Beacon (20% increase from FY 2021)

Monkeypox related activities:

 Participated in setting up the FDA Form 1572 for ECU Health Medical Center to receive and dispense tecovirimat
(TPOXX)

 Manage the distribution and process required for maintaining stock of oral and iv tecovirimat (TPOXX)

2023 Goals:

 Continue to develop pharmacy staff to assist with investigational drug studies in the specialty areas
such as oncology, pediatrics, etc.

 Partner with Campbell University and The University of North Carolina at Chapel Hill to encourage
pharmacy students to participate in an Investigational Drug Services rotation at ECUH Medical Center

24

ECUH Medical Center Pharmacy

Maynard Children’s Hospital

Summary & Accomplishments:

• Provides distributive services to Children and
Women’s service line 24 hrs per day, 7 days a week.

• Distributive services include oral, intravenous,
topical and compounded medications. An important
distinction in pediatric pharmacy is the individual
weight based doses processed by our staff.

• IV admixtures prepared in USP 797 sterile clean
room suite by specially trained pharmacy
technicians.

• Significant time invested in planning and training
both technicians and pharmacists in the production
of chemotherapy products.

• Certifications acquired for the Hazardous Sterile
Cleanroom in order to transition pediatric
chemotherapy production to the Children and
Women’s Pharmacy.

• Exemplary effort from pediatric pharmacists in
building pediatric entries into the Alaris pump
library increasing safety.

Pediatric Pharmacy - By the Numbers (FY2022) 14000 Doses dispensed from Children and
 73,863 oral doses prepared 12000 Women's pharmacy for FY22
 52,837 IV dose dispensed 10000
Oral syringes Total IV preps
Clinical Services 8000
6000
• Clinical pharmacists included and round on patient 4000
care teams in PICU, NICU and Oncology 2000

• Support learners by providing consistent 0
opportunities for pharmacy students and pharmacy
residents.

• Pharmacists provide routine education to medical
staff.

2023 Goals:

 Standardization of oral batch times to decrease waste
 Initiate Dispense Prep and Compounding/Repacking for all IV admixtures to increase safety in sterile

compounding

25

ECUH Medical Center Pharmacy Pharmacy team with Safety Catch Trophy
Alaris Pump Trends
Medication Safety Adults

Summary: Pediatrics

 The Medication Safety Program is managed by the NICU
Medication Safety Officer with the goal of creating a
culture of reporting and identifying near misses to trend 26
events before reaching the patient.

 The team works with hospital Quality on hospital-wide
medication events and evaluates system medication
trends to identify opportunities for improvement.

 ECUH focus this year was to increase safety catch
reporting by 12%. ECUH Medical Center substantially
surpassed this goal with a pharmacy increase of 20%.
Pharmacy won the Safety Catch trophy once this year.

 Self-reported events are reviewed and evaluated by
PGY-1 pharmacy residents with guidance from the
medication safety officer, reviewed daily at the
pharmacy huddle, and summarized monthly for all
pharmacy staff.

 Pharmacy Safety Coaches established to support team
members in safe practices by encouraging open
communication about safety.

Safety Data:

 Harm Score 2 events: Goal > 266, actual 271
 Harm Score 5 events: Goal < 4; actual 2
 Average monthly safety catches: 42

Accomplishments:
 Updated Alaris pump libraries: adult, pediatrics, NICU

resulting in increased use of guardrails.
 Increase in Harm Score Near Miss reporting with

subsequent decrease in Reached the Patient events
 Reduction in pharmacy-to-dose errors
 Winner of the Safety Catch Trophy

2023 Goals:

 Expand role of Safety Coaches
 Continue improving compliance with smart pump

Guardrails use

ECUH Medical Center Pharmacy

Medication Reconciliation

Summary:

 The Medication Reconciliation Technicians are the first line
for patient home medication information. Their goal is to
obtain the best possible medication history on each patient.

 Technicians review the prior to medication admission list and
compare to the prescription information from Dr.First, a
vendor who provides retail pharmacy information.

 The technician then interviews the patient, validates the
information, and completes the home medication list.

 The technician will communicate with the unit pharmacist
when discrepancies in medications are identified after the
provider has ordered the home medication to ensure
patients receive appropriate doses during the hospitalization.

 Medication reconciliation technicians provide services in the
Emergency Department for patients being admitted; units in
the hospital to capture direct admissions; and patients
scheduled for elective surgeries.

 Services are available 22 hours/day in the Emergency
Department; 8 hours/day on the units, and 8 hours/day
Monday-Friday for scheduled elective surgeries.

 The technicians also provide training and mentoring to
pharmacy school students from Campbell University and
University of North Carolina Schools of Pharmacy. Twenty six
students were trained and provided more than 600 hours of
medication reconciliation support.

 The medication reconciliation technicians developed a daily
morning and evening huddle to provide areas of focus,
staffing, and activities of interest.

Accomplishments & Workload data:

Average monthly patient admissions: 3356
Average monthly patients completed: 2420 (71%)
Average monthly patients completed < 24 hours: 73%

2023 Goals:

 Increase technician certification with CPhT
 Improve communication between team

members

27

ECUH Medical Center Pharmacy CONSULTSPictured (L to R): Amy Li PharmD, BCPS,
Oct-21Monica McPherson RPh, Robin Latham RPh,
Nutrition Support Program Nov-21Stephanie Cutrell MS, RD, LDN, CNSC and
Dec-21Taylor Jones PharmD
Summary & Statistics: Jan-22Not pictured: Matt Cahoon PharmD
Feb-22
The Nutrition Support Program is a multidisciplinary Mar-22NST CONSULTS
service comprised of a clinical dietitian and pharmacists who Apr-22
specialize in parenteral nutrition (PN). This team works May-22800
collaboratively with physicians, advanced practice providers and Jun-22600
nursing to ensure evidence-based practices are utilized to Jul-22400
optimize the effectiveness and safety of PN therapy in Aug-22200
hospitalized patients of all ages. In addition to ordering and Sep-22
managing all adult PN, the nutrition support program assists 0
providers with correcting electrolytes, adjusting maintenance
fluids and insulin doses in their assigned patient population. This MONTH
team is also involved in transitions of care when patients are
discharged home on PN by providing a safe and stable PN formula TPN Preps/Month
to the patient’s home infusion company.
1000
Given the complexity of parenteral nutrition therapy and 800
the risks associated with administration, education of the 600
program members and other individuals is of high importance. 400
Members of the nutrition support program stay abreast of all 200
current guidelines and recommendations through participation in 0
the American Society of Parenteral and Enteral Nutrition (ASPEN).
Stephanie Cutrell also represents ECU Health Medical Center on MONTH
the ASPEN national committees for PN Safety and Malnutrition. VOLUME
Participation on these committees promotes information-sharing Oct-21
and best practices among similar colleagues nation-wide. This Nov-21
knowledge is then brought back to ECU Health Medical Center Dec-21
and shared with other pharmacists, pharmacy residents and Jan-22
students, and dietetic students during nutrition support Feb-22
rotations. Stephanie Cutrell continues to help coordinate Mar-22
Malnutrition Awareness Week, which is presented annually by Apr-22
ASPEN and other national organizations to provide educational May-22
webinars on various topics addressing malnutrition. Jun-22
Jul-22
We’re very proud of the tremendous work of our Aug-22
Nutrition Support team and how they support safety and quality Sep-22
outcomes for patients requiring parenteral nutrition!

2023 Goals:

 Expand educational opportunities about nutrition support therapies for pharmacy team members
through continuing education programming

 Continue to educate pharmacy/dietetic students and our residents
 Plan to start a NST journal club in 2023

28

ECUH Medical Center Pharmacy

Oncology Services

Summary:
 Dedicated oncology trained pharmacy team of

over 20 pharmacists and technicians including 3
Board Certified Oncology Pharmacists, 2 Board
Certified Sterile Compounding Pharmacists, and a
Board Certified Sterile Compounding Technician
 Oversees verification, compounding, and
dispensing of intravenous medications for adult
and pediatric inpatient and outpatient oncology
patients.
 Dedicated hazardous and non-hazardous
cleanroom suites for sterile compounding per
USP guidelines
 Direct interaction between pharmacy staff and
patients, establishing trust and being a
readily available resource at chair-side for the
patient and clinic staff
 Average over 3450 medications dispensed each
month.
 Average over 1450 intravenous chemotherapy
preparations each month.

2023 Goals

 Implement Volumetric/Gravimetric/Camera
Technology to assist with product
preparation/verification.

 Expand EPIC BEACON functionality to include
ordering ability for Pediatric Oncology.

 Assist in the expansion of pharmacy services
through the addition of a home infusion
pharmacy.
29

Retail Pharmacy Services

ECU Health Employee Pharmacy

Summary & Accomplishments:  Specialty drug business has held steady
over the past year.
 The Employee Pharmacy services employees and
dependents at ECU Health Medical Center, ECU Health  Filling 54% of the plan’s specialty drug
Community Hospitals and ECU Health Medical Group. claims.

 The purpose is to reduce the overall spend for  Worked with Medimpact, our PBM, to
prescription medications for the health system and generate savings of $2.1 million for the
employees. health plan by maximizing payment values
of manufacturer copay cards.
 For 2021 fiscal year, the pharmacy filled approximately
140,000 prescriptions at a cost of $25.8 million. Michele Lamm, retail pharmacy TPAT committee representative.

 Copay savings of $1.98 million were provided through
billing of copay cards

 Currently fill 56% of team members prescriptions;
other 40% is filled at an outside retail pharmacy.

 Became a dispensing site for oral COVID-19 drugs for
employees in accordance with EUA guidelines

 OTC department continues to be a source for
employees to purchase needed items for themselves
and their families

 Provided medications at $0 copay to employees
participating in ECU Health Wellness program

2023 Goals:

 Continue to explore mail order pharmacy business to service team members that do not have easy
access to our pharmacy

 Expand specialty drug business for increased cost savings to the health plan
 Seek licensure in other states for mail order services
 Research 340b options for Employee Pharmacy for further cost savings
 Pharmacy “Brown Bag” Event, Medication Therapy Management, for employees planned for FY23 as

part of Pharmacy Technician Career Ladder

30

Retail Pharmacy Services

ECU Health Medical Center Outpatient Pharmacy

Summary & Accomplishments: Tiffany Prescott getting ready for a M2B
Delivery
 The Outpatient Pharmacy opened in 2019 and dispenses discharge
medication(s) to patients prior to going home. The program helps to
assure patients have access to medications they need before discharge
from inpatient units at ECU Health Medical Center.

 For 2022 fiscal year, the pharmacy dispensed approximately 54,000
prescriptions, a 20% increase from previous year.

 A total of 13,174 patients were provided discharge medications; a 12%
increase in number of discharges from previous year.

 Average monthly Rx capture rate of 36% (without ED discharges).
 Safety Catch Award winner for the month of October, 2021.
 Completed Meds-to-Beds (M2B) service rollout to the entire

Cardiovascular Tower (5 units), North Tower (3 units) and Oncology
Tower (3 units).
 Continued success of $4/$6 program. Dispensed 30-day medications to
3,780 patients at $4/$6 for a total of 8800 prescriptions.
 Dispensed 30-day free meds to 953 patients, a total of 4800
prescriptions managed by various benevolent funds.

2023 Goals

 Expanding Meds-to-Beds rollout to Pediatric units by end of FY2023.
 Growing average monthly prescription capture rate to 40%.

31

Retail Pharmacy Services

ECU Health Specialty Pharmacy

Major Accomplishments:

 Accreditation through ACHC and URAC in 2020
 Increased prescription volume by 3% from previous year
 Grew services to reach patients at ECU Health Beaufort Hospital
 Gained access to numerous limited distribution drugs, including: Xpovio,

Iclusig and Lumakras
 Received a 100% satisfaction result from medical oncology providers on

our last survey
 Completed the rebranding process to become ECU Health Specialty

Pharmacy
 Surpassed our goal of 5% or less of call abandonment
 Completed a quality improvement project for accreditation
 Filled two new positions: liaison and pharmacy technician
 Gained the ability to bill Medicare Part B

Clinical Interventions by quarter

40

30

20

10

0 Quarter 2 Quarter 3 Quarter 4
Quarter 1 Physician Patient

2023 Goals:

 Begin servicing patients from ECU Health North Hospital
 Begin servicing patients from ECU Health Roanoke-

Chowan Hospital
 Growing our business to reach patients in the

surrounding state of Virginia
 Pharmacist licensing in Virginia

32

Ambulatory Care Pictured (L to R): Ashley Basden, Jansen Bonds,
PharmD, MS, BCOP; and Wesley Pontbriand, CPhT
Kinston Medical Services Oncology Pharmacy

Summary & Statistics:
 New pharmacy addition with on-site pharmacist for
verification, compounding oversight, and dispensing
of intravenous medications
 Improved safety of compounding and dispensing of
chemotherapy; protecting both patients and clinic
staff
 Sterile compounding of hazardous and non-
hazardous products per USP guidelines
 On-site pharmacy resource to clinic medical staff
promoting improvements in continuity of care and
procedural efficiency
 Direct interaction between pharmacy staff and
patients, establishing trust and serving as a
readily available resource at chair-side for the patient
and clinic staff

Medications Dispensed 2021-2022

1800
1600
1400
1200
1000

800
600
400
200

0

Summary & Accomplishments:

 Implementation of Cardinal Health Medication Ordering
 Implementation of SmartSense Temperature Monitoring System
 Implementation of Simplifi 797 Environmental Monitoring Application
 Installation of mini-split HVAC systems for segregated compounding areas (SCAs) to optimize

environmental control parameters per USP 797 Guidelines
 Implemented Control Substance Ordering System (CSOS)

2023 Goals: 33

 Obtain independent pharmacy license with NC Board of Pharmacy
 Continued interventions to improve appropriateness, efficacy and safety in prescribing,

compounding and dispensing of hazardous/non-hazardous medications
 Continued improvement in interdepartmental communication and process efficiency initiatives

Ambulatory Care

Tarboro Multispecialty Clinic

Summary & Accomplishments:

 This year, Lani True and Lindsey Stever entered into collaborative
practice agreements with the family medicine providers and are
developing a pilot primary care pharmacist service

 A pharmacist is currently at the Tarboro Multispecialty Clinic four days
per week

 Lani and Lindsey are primarily focusing on patients with multiple
chronic disease states with at least one not at goal (particularly
hypertension and diabetes) as well as benzodiazepine and opioid
down-tapering, BEERs drug de-prescribing and optimizing medication
regimens around out-of-pocket cost constraints

 Pharmacists are also being leveraged to optimize provider’s schedules
by seeing walk-in patients and blood pressure checks under a co-visit
model

 Currently, billing has focused on co-visits and level 1 visits however patients are being enrolled in chronic
care management

 In just the first 15 days of pharmacist’s presence at the clinic:
o There have been 34 captured unique patient interactions, including 15 co-visits, 7 one-on-one
patient visits and 55 total clinical interactions with patients
o Positive physician feedback has been provided regarding the immediate availability of
pharmacists for medication therapy questions

2022-2023 Goals:

 Develop a process for, and begin billing under CCM
 Obtain CPP credentials for pharmacists working at the Tarboro clinic
 Enrollment in RX Outcomes for MTM billing
 Develop a standardized workflow to scale outpatient primary care pharmacist services

34

Ambulatory Care:

Advanced Heart Failure Program/LVAD Clinic

Summary & Accomplishments: Ann Fugit, PharmD, BCACP, CPP
Erika Schoenborn, PharmD, BCCP, CPP
 Ann Fugit and Erika Schoenborn are licensed and practicing as Clinical
Pharmacist Practitioners (CPP), along with maintaining credentialing at
ECUHMC and ECUHMG. They have implemented new pharmacist services
to better support care of patients with complex heart failure (HF) in
eastern NC.
o The Heart Failure Pharmacotherapy Optimization Telemedicine
Clinic Pilot started in June 2022

 As CPPs, Ann and Erika manage anticoagulation for patients who have
received left ventricular assist devices (LVADs). Since program inception,
55 patients have received this advanced therapy.
o Time in therapeutic range (TTR) for anticoagulation is a Joint
Commission Quality Indicator and predictor for decreased
bleeding and thrombotic complications. Our LVAD Program
consistently meets or exceeds goal TTR rates when compared to
published data.
o Patient impact:
 Compared with national registry data, ECUHMC patients
have experienced lower rates of total & gastrointestinal
bleeding, pump thrombosis, and early & late stroke.
 Patients’ Quality of Life survey results meet or exceed
national comparators.

 In addition to patient care, Ann and Erika are actively involved in industry-
sponsored and investigator-initiated research projects and also precept
resident and student learners.

2023 Goals:
 Planning is underway expand enrollment in the Heart Failure Pharmacotherapy Optimization
Telemedicine Clinic and also develop a Cardiovascular Pharmacotherapy Optimization Clinic.
 Planning is underway to develop a PGY2 Residency Program in Cardiology

35

Cost Savings Initiatives

 Part of living the ECU Health Mission and promoting the Strategic Framework of fiscal responsibility is
reducing medication expense and assuring appropriate medication use.

 The pharmacy documented over $1.5M in cost savings through 11 different initiatives between 2021 to
2022.

 Many of these projects have exceeded their target savings.
 Many projects required multidisciplinary efforts, illustrating the teamwork and resilience required to

complete despite the challenges of the pandemic, competing priorities, and medication shortages.
 The Pharmacy has identified over $3.5M in cost savings opportunities for FY2023

ECU HEALTH MEDICAL CENTER - PHARMACY COST SAVINGS DASHBOARD FY2021/2022

FY22 Target Implementation FY22 Savings Target
Savings Completion
Cost Savings Project Project Owner $52,500 Date to date
Definity to Lumason conversion April Quidley/Angela Mayo $133,000 Date
Increase use of biosimilars - Rituximab Paul Gibbs $200,000 12/1/20 $53,195 11/30/21
Convert Velcade to generic bortezomib Paul Gibbs $337,500 5/31/22
Vasopressin (premade bottles) Andy Grimone $350,000 6/1/21 $126,655 7/31/23
Daptomycin generic Karen Brown $12,816 1/31/23
Calcitonin pharmacy prepared April Quidley $100,000 8/1/22 $123,624 9/30/22
Retacrit biosimilar Joe Davis $29,000 2/28/22
TNKase vs. alteplase for stroke April Quidley/Angela Mayo $177,500 2/1/21 $313,050 2/28/22
Pemetrexed biosimilar Paul Gibbs $26,880 1/31/22
Cefazolin 2 gm conversion to MPB Andy Grimone $12,500 10/1/21 $591,817 6/30/2023
Ephedrine syringes Andy Grimone 7/31/23
3/1/21 $14,850 9/30/23

3/1/21 $101,186

2/1/21 $29,801

7/1/22 $174,395

8/1/22 $31,423.00

9/1/22 $6,907.40

TOTAL $1,500,000 $1,566,903

36

Pharmacy Residency Programs

 ECU Health Medical Center expanded its residency program offerings to 4 residency programs

during 2022

o Two existing programs are accredited by the American Society of Health System

Pharmacists (ASHP) in Pharmacy Practice (PGY1) and Critical Care (PGY2)

o Additional PGY2 programs in Emergency Medicine and Infectious Diseases began in

June 2022

 The 2021-2022 residency class marked the 30th year of Pharmacy Residency Training at ECU

April Quidley Health Medical Center
PGY1 Pharmacy o Over 50 pharmacy residents have completed the PGY1 program and serve in a variety
Residency Director of clinical roles nationwide

PGY1 Poster Presentations of Medication Use Evaluations (MUEs)

 Magnesium use during targeted temperature management
o Resident: Samantha Benvie, PharmD
o Preceptor: Tyler Chanas, PharmD

 Comparison of thiazide diuretics in management of fluid overload
o Resident: Katie Blowe, PharmD
o Preceptor: Tyler Chanas, PharmD

 Recombinant Factor VIIa use in the neonatal ICU
o Resident: Erin Nifong, PharmD
o Preceptor: Meredith Chanas, PharmD

 Anticoagulation use in continuous renal replacement therapy
o Resident: Kayla Rose, PharmD
o Preceptor: Chad Alligood, PharmD

Platform Presentations of Research at the Southeastern Residency Conference

 Andexanet alfa verus 4-Factor prothrombin complex concentrate for intracranial hemorrhage
o Resident: Samantha Benvie, PharmD
o Preceptor: Spencer Livengood, PharmD

 Sedation following long-acting neuromuscular blockade in rapid sequence intubation
o Resident: Katie Blowe, PharmD
o Preceptor: Ginger Gamble, PharmD

 Enoxaparin dosing for venous thromboembolism prophylaxis in trauma
o Resident: Erin Nifong, PharmD
o Preceptor: Emily Whitehead, PharmD

 Titration of goal directed medical therapy in acute decompensated heart failure
o Resident: Kayla Rose, PharmD
o Preceptor: Erika Schoenborn, PharmD

37

In January, residents and pharmacists delivered 6 hours ACPE- Accredited Continuing
Education on Infectious Diseases

The PGY-1 residents completed their training in June 2022 and were successful in obtaining PGY2 Residencies
or clinical positions in their areas of interest:

 Samantha Benvie – PGY2 Cardiology Resident, Tristar Centennial, Nashville, TN
 Katherine Blowe – Clinical Pharmacist, ECU Health Medical Center, Greenville, NC
 Erin Nifong – PGY2 Oncology Resident, Wake Forest Baptist Univ Medical Center, Winston Salem, NC
 Kayla Rose – Clinical Pharmacist – Medical Oncology, West Virginia Univ Medical Center, Charleston, WV

End of Year Residency Celebration and Certificate Ceremony

Pictured Left to Right: Lauren Chambers (PGY2 Critical Care Director), Kate Jimison (PGY2 Critical Care), Kayla
Rose (PGY1), Katie Blowe (PGY1), Sam Benvie (PGY1), Erin Nifong (PGY1), April Quidley (PGY1 Director)

38

PGY2 Residency Programs

 ECU Health Medical Center now has three American Society of Health System Pharmacists (ASHP) residency
programs in Critical Care (accredited), Emergency Medicine (candidate status), and Infectious Disease (candidate
status)

 The programs are developing future leaders in these specialized fields through direct patient care experiences,
focused research involvement, and preceptor mentorship

Lauren Chambers Ginger Gamble Nicole Nicolsen
PGY2 Critical Care PGY2 Emergency Medicine PGY2 Infectious Disease
Program Director
Program Director Program Director

PGY2 Critical Care  Sarah Lamon (2022-2023
PGY2 Critical Care
 Katelyn Jimison (2021-2022 Resident) completed her
PGY2 Critical Care Resident) PGY1 Pharmacy Practice
contributed to quality Residency at NCH
improvement initiatives Healthcare System in
through her MUE of Naples FL and is excited
management of to start her training here
hypertriglyceridemia at ECU Health Medical
induced pancreatitis which Center
resulted in order set
changes to enhance safety  Sarah’s current MUE will evaluate the use of
valproic acid for the management of agitation
 Katelyn presented her PGY1 research “Evaluation in TBI patients with project mentor Emily
of cultures and antibiotic use following cardiac Whitehead
arrest” virtually at SCCM’s 51st Critical Care
Congress  Sarah’s research project will be evaluating
diuretic efficacy in patients with
 Katelyn presented her MUE virtually at ASHP’s hypoalbuminemia with project mentor Tyler
Annual Midyear Meeting and presented virtually Chanas
at the 53rd Annual Southeaster Residency
Conference (SERC)  Throughout her residency year, Sarah will be
working with the Safety Officer in identifying
 Katelyn successfully completed her term as the trends and optimizing safety culture within the
PGY2 Critical Care Resident Representative for the critical care environments
SERC Planning Committee at the conclusion of her
residency year 39

 Following residency, Katelyn accepted a Critical
Care position at Atrium Health Wake Forest
Baptist

PGY2 Emergency Medicine

 Carrie Lutheran (2022-2023 PGY2 Emergency Medicine Resident) graduated from
High Point University Fred Wilson School of Pharmacy in 2021 and completed her
PGY1 Pharmacy Practice Residency at Moses H. Cone Memorial Hospital. Carrie is
thrilled to be completing her Emergency Medicine training at ECU Health Medical
Center.

 Carrie will complete a variety of rotations that will provide comprehensive training
experience in emergency medicine, including Emergency Medicine, Toxicology, and
Pre-Hospital Care with EMS.

 Carrie’s research project will be evaluating safety of tenecteplase versus alteplase for
acute ischemic stroke at ECU Health Medical Center. Her project mentor is Ginger
Gamble.

 In addition, Carrie’s MUE is focusing on the safety of Glucommander use in the
Emergency Department with project advisor Chelsie Sanders.

 Carrie has already given a lecture to the Emergency Medicine Residents during
Grand Rounds on Antimicrobial Practices in the ED and is scheduled to give 3 more
lectures to the residents this year.

PGY2 Infectious Disease

 Emily Chang (2022-2023 PGY2 Infectious Diseases Resident) graduated from the
University of North Carolina Eshelman School of Pharmacy in 2021 and completed
her PGY1 Pharmacy Practice Residency at UF Health Jacksonville. Emily is very
excited to train in infectious disease at ECU Health Medical Center

 Emily will complete a variety of rotations that will provide a comprehensive training
experience in infectious disease. This fall, Emily’s rotation schedule includes
Antimicrobial Stewardship Program, Infectious Diseases Consults, Microbiology
Laboratory, and HIV clinic

 Emily’s project for the 2022-2023 year will be an evaluation of remdesivir and
baricitinib use and compliance with criteria restriction in the ECU Health system.
Emily’s project mentor is Nicole Nicolsen

 In addition, Emily will present a journal club to the infectious diseases department
in September 2022

 Emily was also selected to deliver a journal club presentation at a statewide
infectious diseases pharmacy conference in October 2022

 Other presentations that Emily will complete this fall include a didactic lecture to
Physician Assistant students and ID Case Conference

40

ECU Health System Pharmacy Services Pictured (L to R): David Laurent, PharmD, BCPS, BCIDP; Melissa
George, PharmD, BCIDP; Mackenzie Dolan, PharmD; and Nicole
Antimicrobial Stewardship Program
Nicolsen, PharmD, BCPS, BCIDP
Program Summary:
ASP Pharmacist Acceptance Rates for ECU Health
The ECU Health (ECUH) Antimicrobial Stewardship FY 2022
Program (ASP) had another incredibly busy and
productive year. The team continued to support 100
antimicrobial stewardship efforts throughout the region,
manage the Antimicrobial Utilization and Stewardship 95
Subcommittee (AUSS) of the ECUH P&T, and perform day-
to-day antimicrobial patient care for ECUH MC and six of 90
the community hospitals. The team also continued to
support clinical staff with antimicrobial stewardship 85
efforts, manage the antimicrobial formulary, update
facility-specific infectious diseases treatment guidelines 80
and policies, provide educational programs related to
antimicrobials, track and analyze antimicrobial use data, 75
and identify areas of antimicrobial improvement for
ECUH. 70

Accomplishments: Oct-Dec 2021 Jan-Mar 2022 Apr-Jun 2022 Jul-Sep 2022

 Implemented MRSA nasal screen ordering by Intervention success rates across all hospitals are
pharmacists as part of pharmacy to dose vancomycin ECUHMC ECUH ROA ECUH BER ECUH CHO
protocol to further decrease inappropriate consistently >80%
vancomycin usage TOBH ECUH BFT ECUH DUP

 Collaborated with pharmacy to improve compliance 2023 Goals:
with antimicrobial policies (dosing and IV to PO)
 Standardize antimicrobial stewardship services
 Continued the ASP quarterly newsletter which across the health system
provides AUSS updates and a therapeutic review
 Implement rapid molecular blood culture systems
 Merged ECUH BFT with ECUH MC for antimicrobial use in the community hospitals, which will improve
data and full antimicrobial restrictions time to targeted antimicrobial therapy by 24-48
hours for patients with positive blood cultures.

 Evaluate vancomycin AUC-guided dosing
practices

 Characterize usage of remdesivir and baricitinib in
COVID-19 patients

 Assess safety and clinical efficacy of single-dose
aminoglycosides for cystitis caused by ESBL
Enterobacterales

41

ECUH System Pharmacy Services

340B Program

Program Summary:

The 340B program enables ECU Health to stretch scarce Federal
resources as far as possible, reaching more eligible patients and
providing more comprehensive services to the communities we
serve. The function of the 340B team is to ensure regulatory
compliance and optimization of the program.

ECU Health Medical Center Program Highlights FY22 340B Team

 Hospital Savings Total: $29M
 WAC Spend goal of less than 15% total purchase for the year met
 Contract Pharmacy Expansion to include the use of Optum Pharmacy
 ECU Health Medical Center Contract Pharmacy Net Revenue: $245K

ECU Health System Highlight FY22

 ECU Health Beaufort Hospital became part of the ECU Health Medical Center 340B
Campus in FY22

 Combined System Savings over $33M
 Contract Pharmacy combined Net Revenue $1.7M

Program
Savings Dollars
are increased
by lowering
WAC Spend

2023 Goals:

 Optimizing Contract Pharmacy through evaluating current and prospective retail pharmacies
 Reduce or maintain WAC% for all hospitals
 Initiate additional agreements within the system for Contract Pharmacy agreements
 Optimization of system savings and explore new opportunities

42

ECUH Health System Pharmacy Services

Medication Access Program

Summary & Accomplishments:

 Our Medication Access Program provides replacement
medications used to treat eligible uninsured and indigent
patients and is administered by two Medication Access
Coordinators, Crystal Jackson, CPhT and Holley Buda, CPhT.

 These technicians receive daily data feeds from Epic indicating
which admitted patients are uninsured, indigent and receiving
medications to which there is a pharmaceutical manufacturer
(PM)-sponsored replacement program. They complete required
paperwork then submit the paperwork to the appropriate
manufacturer. Once approved by the manufacturer,
replacement medication is sent to one of our many ECU Health
facilities and the patient’s bill is credited by Finance.

 Holley and Crystal have visited each ECUH Hospital and some
ECUH Practices to introduce the Medication Access program,
answer questions and set up processes to be able to utilize a
common medication access program throughout the healthcare
system. They continue to develop new relationships with both
ECU Health providers and outside providers in an effort to
continue to help patients to gain access to medications that
would otherwise be unavailable to them.

 Crystal and Holley have overseen medication savings of over
$3.7 million for ECUH including $2.3 million at ECUHMC.

ECU Health Medication Access Savings FY22

$500,000
$400,000
$300,000
$200,000
$100,000

$0

October-21 November-21 December-21 January-22
February-22 March-22 April-22 May-22
June-22 July-22 August-22 September-22

2023 Goals: 43

 Revisit each site to educate newest team members
 Support the ongoing integration of ECU and Vidant Pharmacy services through Patient

Assistance Programs

ECUH System Pharmacy Services

Virtual Medication Reconciliation Program

Summary:

 The virtual medication reconciliation program provides
medication history support to eight of the community hospitals
within the ECU Health system (9AM to 9PM daily).

 This is a centralized program with pharmacy technicians
working from ECUH Medical Center and interviewing patients
via a video link through Jabber, the corporate messaging
system.

 The virtual technicians perform the same duties as the ECUH
Medical Center medication reconciliation technicians utilizing a
video link in lieu of direct patient contact.

 The technicians monitor the hospital Emergency Department
patients, identifying patients for admission.

 Once identified, the technicians review the prior to admission
list and compare the list to Dr.First.

 They notify the patient’s nurse that that are ready to interview
the patient. The nurse rolls an iPad into the patient’s room and
calls the technician who conducts the interview through this
secure link.

 Staffing challenges this year deterred from meeting contract
clinical indicators.

Accomplishments & Workload data:

Average monthly patient admissions: 741

Average percent patients completed: 95%

Contract Clinical Indicators:

Percent of patients completed before provider orders home
medications (target > 75%): average for FY21 = 68%

Available staff (target > 90%): average for FY21 = 81%

2023 Goals:

 Increase number of patients completed before
provider orders home medications

 Expand program to include patients on units in
medication reconciliation process

44

ECUH System Pharmacy Services ECUH FY 22 Metrics

Outpatient Antibiotic Therapy (OPAT) Program Pre-OPAT data Avg LOS 11 days; Outliers (LOS >29d) excluded

Summary & Statistics:

 OPAT was consulted on 919 inpatients FY22.
o 230% increase from FY21.
o All ECU Health Hospitals are now able to consult
OPAT.

 OPAT received 195 outpatient referrals FY22.
o 400% increase from FY21.

 Goals of OPAT:
o Decrease length of stay by shifting the
administration of IV antibiotics to the outpatient
setting while not compromising patient care
o Early identification of adverse drug reactions in
able to manage in the outpatient setting to
prevent ED visits/readmissions
o Decrease placement of PICC lines by optimizing
evidenced based IV to PO transition of antibiotics
and use of long acting therapies.

The OPAT team consists of: LOS avoided LOS cost avoidance
2658 days ~$2.3 million
o T. Ryan Gallaher, MD, FACP, FIDSA (Medical director)
o Nichole Allen, PharmD, BCPS, CPP (Program OPAT benefits

Coordinator) PICC avoided PICC avoidance
o Michelle DeHart, PharmD, CPP (Program 464 lines $650,000

Coordinator)
o Rebekah Baro, MSW, LCWS (Case manager)
o Renee Jones, CPhT (Program technician)
o Michelle Smith, RN (Program technician)

2023 Goals:

 Decrease time from admission to consult by implementing a system wide protocol for OPAT
consultation
o Focus on hospitals with LOS > 8 days

 Integration into ECU Health Home Infusion process
 Quantify ED visits secondary to antibiotic therapy and identify solutions to decrease ED visits

45

ECUH System Pharmacy Services

Remote Order Verification (ROV) Services

Summary & Accomplishments: ROV Pharmacist Team (left to right): Barry Parker, Brenna Bristol,
 ECUH Medical Center Pharmacy provides Jennifer Styron, Rand Chandler (Not Pictured: Casey Eure, Niko
Nuguid, Monique Banisa)
after hours remote order verification for
all ECUH Community Hospitals seven Average verification time in minutes (FY 2022)
days a week with hours varying by
location. 6
 The goal of the ROV program is to 5
provide seamless pharmacy care across 4
all shifts and locations. 3
 ECUH Medical Center pharmacists verify 2
35,000 to 45,000 orders per month, in 1
addition to providing drug information 0
and “pharmacy-to-dose” consultations.
 Added a full time pharmacist to the ROV BERT CHO TOBH DUP EDG RCH BEAUF NORTH
team and shifted a second shift
pharmacist to the ROV shift to provide 1ST QTR 2ND QTR 3RD QTR 4TH QTR
more complete coverage during the
hours with the highest volume of orders.
# of orders
Minutes
Total ROV order verified month per facility (FY2022)

12000
10000

8000
6000
4000
2000

0

BERTIE CHOWAN OBH DUPLIN EDGECOMBE RCH BEAUFORT NORTH

Oct Nov Dec Jan Feb Mar April May June July Aug Sept

2023 Goals:

 Improve turn-around time for order verification, with a goal of 99% of orders verified in less than
30 minutes.

 Engage our ROV pharmacists in monitoring antibiotic regimens.

46

Awards and Recognition

Board of Pharmacy Specialties (BPS) Certifications PTCB (CPhT) Certifications

Pharmacotherapy Specialists (BCPS): Caroline Asby Karen Beaman
Natasha Bowser Latasha Bradley-Darden
Jennifer Adema Nichole Allen Sam Boyd Leigh Byrum
Brenna Bristol Christina Brizendine Daniel Cale Angel Carden
Joe Davis Christopher Dennis April Cook Elizabeth Craft
Kyle Graham Andy Grimone Ally Curria Mary Beth Darrah-Smith
Michelle Herrmann Devon Johnson Jennifer Durham Phillip Durrence
Christie Jones David Laurent Becky Evans Latoya Forbes
Amy Li Sierra Mullen Rene Freeman Jeff Gardner
Nicole Nicolsen April Quidley Linda Gibson Rebecca Hall
Andriana Sacchini Jennifer Styron Karen Harrison Ashley Harrison
Kelsey Tuttle Kacy Whyte Karen Hedgepeth Cheryl Henderson
Sherry Johnson Janet Leggett
Ambulatory Care (BCACP): DeWanda Little Marla Mackey
Nicki Manning Brandyn McClary
Ann Fugit Lani True Pam McKinley Misty Mills
Laural Morgan Amber Murphy
Cardiology Pharmacy (BCCP): Lisa Murphy Wesley Pontbriand
Sharese Pugh Miroslava Raschkova
Erika Schoenborn Kacy Whyte Meagan Rowland Tonya Sampson
Jonaisha Sessoms Cathy Silverthorne
Compounded Sterile Preparations (BCSCP): Logan Skelson Pam Slade
Sabrina Smith Jay Swigart
Matt Wilson Stephanie Marquart Sherry Tayler Logan Thumm
Patricia Todd Elaine Toler
Christy Turner Tim Twiddy Paula Tyson
Kristi Young Deneen White
Critical Care Pharmacy (BCCCP): Dana Woodard

Lauren Chambers Tyler Chanas

Ginger Gamble Alexandra Guido

Chelsie Sanders April Quidley

Emily Whitehead Brittany Wills

Jennifer Wilson

Infectious Diseases (BCIDP)

Melissa George David Laurent

Nicole Nicolsen PTCB (CSPT) Certification
April Cook
Oncology (BCOP):
Jansen Bonds Paul Gibbs
Cathi Wallace

Pediatrics (BCPPS): Emily Ludwig
Meredith Chanas
Niko Nuguid

Psychiatric Pharmacy (BCPP):
Shannon DuBois

47

 Michelle DeHart, PharmD, CPP, David Laurent, PharmD, BCPS and Nicole Nicolsen, PharmD, BCPS were
recognized for their educational contributions with appointments as Affiliate Teaching Assistant
Professors in the Department of Internal Medicine, Brody School of Medicine at ECU.

Licensed Clinical Pharmacist Practitioners

 Nichole Allen, PharmD, BCPS, CPP
 Michelle DeHart, PharmD, CPP
 Ann Fugit, PharmD, BCACP, CPP
 Paul Gibbs, RPh, BCOP, CPP
 Emily Merritt, PharmD, CPP
 Erika Schoenborn, PharmD, CCP, CPP

Pharmacy Technician Career Ladder Promotions

Congratulations to the following Pharmacy Technicians who successfully promoted on the new
Pharmacy Technician Career Ladder in FY2022:

 Paul Tyson (ECU Health Medical Center) promoted to Operations Pharmacy Technician III
 Tim Twiddy (ECU Health Medical Center) promoted to Specialist Pharmacy Technician II
 Pam McKinley (ECU Health Medical Center) promoted to Operations Pharmacy Technician III
 Natasha Bowser (ECU Health Medical Center) promoted to Clinical Pharmacy Technician II
 Samantha Hearp (ECU Health North Hospital) promoted to Specialist Pharmacy Technician III

Aspiring Allied Health Leader Program

New to ECU Health this year is a year-long program for allied health team members who are interested
in professional development and preparing for potential advancement opportunities in the health
system. Applications were accepted from all allied health teams and interested candidates participated
in interviews with multi-disciplinary leaders across the organization. Out of 50+ initial applicants, a
class of 25 Aspiring Allied Health Leaders were selected.

We are proud to share that six pharmacy team members (1 technician and 5 pharmacists) were
selected for the program’s first cohort!

 Lauren Chambers
 Meredith Chanas
 Tyler Chanas
 Megan Check
 Amber Gardner
 Devon Johnson

48

Scholarship and Research

Adema JL, et al. Understanding and Application of Daptomycin-Susceptible Dose-Dependent Category for
Enterococcus: A Mixed-Methods Study, Open Forum Infectious Diseases, Volume 9, Issue 1, January 2022,
https://doi.org/10.1093/ofid/ofab611

Clark I, Rogers A, Allman R, Goda T, Smith K, Chanas T, et al. Multimodal pain management protocol to
decrease opioid use and to improve pain control after thoracic surgery. Ann Thorac Surg. 2022. doi:
10.1016/j.athoracsur.2022.03.059

Cardone KE, Maxson R, Cho KH, Davis JM, et al. Pharmacy Practice Standards for Outpatient Nephrology
Settings. Kidney Med. 2022. doi: 10.1016/j.xkme.2022.100509

Bolina J, Soriano-Pereira N, Bland C, Reed BN, Quidley A, Bookstaver B, Break time: Examining pharmacy
residency application deadlines and the potential impact of a proposed timeline shift, Currents in Pharmacy
Teaching and Learning, Volume 14, Issue 9, September 2022, 1177-1184,
https://doi.org/10.1016/j.cptl.2022.07.030

Quidley, A. Surgical Interventions in Obesity. American Society of Health-System Pharmacists, Weight
Management Certificate Program. March 2022

Stever LM, Chambers LB, Demitraszek CJ, Tuttle K, et al. Side effects of beta adrenergic antagonists and
antianginal drugs, Side Effects of Drugs Annual, https://doi.org/10.1016/bs.seda.2022.08.008

Grimone, A. (Peer Reviewer). Advanced Pharmacology for Prescribers. Luu B, Kayingo G, and Hass V (Editors).
Springer Publishing. 2022.

ASHP Midyear 2021 posters (virtual):

Nifong E, Chanas M. Characterization of recombinant activated factor VII use in the neonatal intensive care
unit
Rose, K, Alligood C. Assessment of the impact of pre-filter heparin on filter duration during continuous renal
replacement therapy
Benvie S, Chanas T. Magnesium dosing during targeted temperature management (TTM) following cardiac
arrest
Blowe K, Chanas T. Evaluation of the use of thiazide diuretics for sequential nephron blockade

Southeastern Residency Conference

Nifong E, Whitehead E. Assessment of enoxaparin dosing regimens in trauma patients
Rose K, Schoenborn E. Impact of goal directed medical therapy titration on in-patients with acute
decompensated heart failure
Benvie S, Livengood S, Quidley A. Comparison of Andexanet alfa to 4-factor prothrombin complex concentrate
for intracranial hemorrhage
Blowe K, Gamble G. Use of sedation following the neuromuscular blocking agents for rapid sequence
intubation

49

Pharmacy Education Programs

Overview

 Pharmacy was actively engaged in delivery of intra-
and interdepartmental educational programs
across ECU Health

 Interdepartmental education
o Nursing in-services
o Grand Rounds

Technician Noon Conferences

 Treatment of Spider Bites, Ron Sugg, PharmD
 Guillain-Barre and Treatment, Niko Nuguid, PharmD, BCPPS
 CHF and Treatment, Devon Johnson, PharmD, BCPS
 Pneumonia and Treatment, Matthew Jordon, PharmD
 COVID and Treatment, Matt Cahoon, PharmD
 Designer Drugs, Jennifer Styron, PharmD, BCPS
 Insomnia and Treatment, James Nobles, PharmD
 Sickle Cell Disease and Treatment, Matthew Jordon, PharmD
 Pharmacy Law, Megan Check, PharmD
 Arthritis and Treatment, Kevin Pandya, PharmD
 Neuropathic Pain and Treatment, Casey Eure, PharmD

Pharmacist Grand Rounds

 Pharmacogenomics, Brenna Bristol, PharmD, BCPS
 Updates in Management of Continuous IV Infusion Insulin, Michelle Herrmann, PharmD BCPS
 Post Cardiac Arrest Care, Tyler Chanas, PharmD, BCCCP
 Immunotherapy to Infinity and Beyond, Paul Gibbs, PharmD, BCOP, CPP
 Successful Patient Counseling in the Hospital, Spencer Livengood, PharmD, BCPS
 Are two Beta than one? Combination Therapy for MRSA Bacteremia, Mackenzie Dolan, PharmD
 Remote Pharmacy Services, Brenna Bristol, PharmD, BCPS, Jennifer Sytron, PharmD, BSN

For FY23!

Continued partnership with UNC Eshelman School of
Pharmacy for system-wide delivery of Accreditation
Council for Pharmacy Education (ACPE) accredited

Continuing Education credits

50