Novel approach to vancomycin level monitoring: Impact of a multidisciplinary monitoring system on timing of vancomycin levels

Peyko, Vincent; Friedman-Jakubovics, Michelle

doi:10.2146/ajhp160760

Cited by 16 publications

(14 citation statements)

References 21 publications

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“…A total of 1043 plasma vancomycin concentrations were collected; 939 (90%) during intermittent infusions and 104 (10%) during continuous infusions. A median (range) of 5 1–36 vancomycin concentrations were obtained in each course of therapy, collections occurring every 1.6 days (0.6–8 days).…”

Section: Resultsmentioning

confidence: 99%

“…Poorly timed sample collection is welldocumented in the clinical environment; only 20-59% of all TDM samples collected are trough concentrations. 8,12,16,32,33 Alternative approaches, such as Bayesian forecasting, that enable estimation of drug exposure from opportunistically collected samples are advocated, where available, to avoid misinterpretation of inappropriately timed collections, in addition to enabling optimal dosing. 34 Consistent with audits of other antimicrobials, 35 and perhaps most concerning, 44% of trough concentrations identified in the audit warranted dose adjustment according to guidelines, but were not acted upon.…”

Section: Discussionmentioning

confidence: 99%

“…However, only 14% of these were trough concentrations. Poorly timed sample collection is well‐documented in the clinical environment; only 20–59% of all TDM samples collected are trough concentrations 8,12,16,32,33 . Alternative approaches, such as Bayesian forecasting, that enable estimation of drug exposure from opportunistically collected samples are advocated, where available, to avoid misinterpretation of inappropriately timed collections, in addition to enabling optimal dosing 34 …”

Section: Discussionmentioning

confidence: 99%

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Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices

Carland

Stocker

Baysari

et al. 2021

Brit J Clinical Pharma

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Despite the availability of international consensus guidelines, vancomycin dosing and therapeutic drug monitoring (TDM) remain suboptimal. This study aimed to assess concordance of vancomycin dosing and TDM with institutional guidelines and to identify factors taken into consideration by clinicians when prescribing vancomycin. Methods: A retrospective audit of 163 patients receiving vancomycin therapy (≥48 hours) was undertaken. Data collected included patient characteristics, dosing history and plasma vancomycin and creatinine concentrations. Concordance of dosing and TDM with institutional guidelines was evaluated. Semi-structured interviews, including simulated prescribing scenarios, were undertaken with prescribers (n = 17) and transcripts analysed. Results: Plasma vancomycin concentrations (n = 1043) were collected during 179 courses of therapy. Only 24% of courses commenced with a loading dose with 72% lower than recommended. The initial maintenance dose was concordant in 42% of courses with 34% lower than recommended. Only 14% of TDM samples were trough vancomycin concentrations. Dose was not adjusted for 60% (21/35) of subtherapeutic and 43% (18/42) of supratherapeutic trough vancomycin concentrations, respectively. Interview participants reported that patient characteristics

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices

Carland

Stocker

Baysari

et al. 2021

Brit J Clinical Pharma

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“…Another study found that developing simple auto‐text tools improved the productivity of pharmacists when working with EMR systems. This is reflective of an increase in pharmacist involvement in TDM in our study 7,10 …”

Section: Discussionmentioning

confidence: 67%

Assessing the impact of an electronic therapeutic drug monitoring record in the management of vancomycin through pharmacist intervention: a single‐centre study

Ong

Oates

Banakh

2023

Pharmacy Practice and Res

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Background A gap in vancomycin therapeutic drug monitoring (TDM) electronic documentation, management, and related clinical pharmacist activities was identified by our clinical pharmacy team. In response, an electronic TDM (eTDM) template was planned, designed, and implemented by the pharmacy department team in collaboration with the electronic medical records team (EMR) and documentation committee. Aim To assess the impact of an electronic therapeutic drug monitoring (eTDM) template to measure the impact of adherence to vancomycin guidelines. Guideline adherence indicators include the number of vancomycin levels within the therapeutic range and the number of appropriate concentrations taken. Method An interventional, single‐centre study of vancomycin therapy in adult patients was performed from 2019–2021. Data were extracted from the electronic medical records and TDM paper‐based forms completed by clinical pharmacists. The number of concentrations within the therapeutic range and the number of appropriately taken levels were analysed by the chi‐square test. This study received an exemption from the Peninsula Health Human Research Ethics Commitee (QA/60523/PH‐2019/197291). Results There was a total of 198 concentrations collected in the ‘before’ period and 125 concentrations collected in the ‘after’ period. The number of concentrations in therapeutic range increased from 34.8% to 43.2% (p = 0.132), not statistically significant. The number of concentrations taken appropriately increased from 33.8% to 55.2% (p < 0.001). The proportion of patients with pharmacist involvement increased from 43.0% to 57.0% (p = 0.868). Conclusion The study shows that implementation of an electronic vancomycin monitoring template improved the proportion of appropriate levels taken and is the preferred method of documentation by clinical pharmacists. Future projects may benefit from analysing the cost associated with unnecessary vancomycin serum levels ordered or inclusion of pharmacists in the TDM of other narrow therapeutic medications.

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“…9 Erroneously timed trough blood draw was significantly affecting the quality of the TDM process and solutions have been proposed to improve it. 7,10,11 However, little was known about the timing issue associated with other steps involved in IV vancomycin administration, despite that IV infusion administration is an error prone process.…”

Section: Background and Significancementioning

confidence: 99%

Uncovering Discrepancies in IV Vancomycin Infusion Records between Pump Logs and EHR Documentation

2022

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Background Infusion start time, completion time, and interruptions are the key data points needed in both area under the concentration–time curve (AUC)- and trough-based vancomycin therapeutic drug monitoring (TDM). However, little is known about the accuracy of documented times of drug infusions compared with automated recorded events in the infusion pump system. A traditional approach of direct observations of infusion practice is resource intensive and impractical to scale. We need a new methodology to leverage the infusion pump event logs to understand the prevalence of timestamp discrepancies as documented in the electronic health records (EHRs). Objectives We aimed to analyze timestamp discrepancies between EHR documentation (the information used for clinical decision making) and pump event logs (actual administration process) for vancomycin treatment as it may lead to suboptimal data used for therapeutic decisions. Methods We used process mining to study the conformance between pump event logs and EHR data for a single hospital in the United States from July to December 2016. An algorithm was developed to link records belonging to the same infusions. We analyzed discrepancies in infusion start time, completion time, and interruptions. Results Of the 1,858 infusions, 19.1% had infusion start time discrepancy more than ± 10 minutes. Of the 487 infusion interruptions, 2.5% lasted for more than 20 minutes before the infusion resumed. 24.2% (312 of 1,287) of 1-hour infusions and 32% (114 of 359) of 2-hour infusions had over 10-minute completion time discrepancy. We believe those discrepancies are inherent part of the current EHR documentation process commonly found in hospitals, not unique to the care facility under study. Conclusion We demonstrated pump event logs and EHR data can be utilized to study time discrepancies in infusion administration at scale. Such discrepancy should be further investigated at different hospitals to address the prevalence of the problem and improvement effort.

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Novel approach to vancomycin level monitoring: Impact of a multidisciplinary monitoring system on timing of vancomycin levels

Cited by 16 publications

References 21 publications

Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices

Are vancomycin dosing guidelines followed? A mixed methods study of vancomycin prescribing practices

Assessing the impact of an electronic therapeutic drug monitoring record in the management of vancomycin through pharmacist intervention: a single‐centre study

Uncovering Discrepancies in IV Vancomycin Infusion Records between Pump Logs and EHR Documentation

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