Pharmacists' perceptions of implementing a pharmacist‐managed area under the concentration time curve‐guided vancomycin dosing program at a large academic medical center

Abstract

Introduction A pharmacist‐managed area‐under the concentration time curve/minimum inhibitory concentration (AUC/MIC)‐based vancomycin dosing and monitoring strategy was implemented at the University of Maryland Medical Center (UMMC) in January 2017. Because this was a large change in practice and methodology, we sought to understand pharmacists' perceptions of the practice before and after implementation. Methods A mixed methods preimplementation survey was sent to all pharmacists, including residents, completing vancomycin dosing training at UMMC 1 month prior to transition to an AUC‐guided pharmacist‐to‐dose practice. The postimplementation survey was subsequently sent 8 months after program rollout to the same study participants. Results A total of 127 responses completed the survey: 78 in the preimplementation and 49 in the postimplementation arm. Clinical specialist pharmacists represented 53.8% vs 49.0%, clinical pharmacists represented 32.1% vs 36.7%, and residents represented 14.3% vs 14.1%, respectively. Prior to implementation, 42.3% responded that AUC/MIC was the ideal pharmacokinetic/pharmacodynamic parameter, compared with 93.9% postimplementation (P < 0.0001). Weight‐based dosing was primarily used preimplementation as opposed to postimplementation (46.2% vs 6.1%; P < 0.0001). The average time spent evaluating a vancomycin dose increased from 8 (interquartile range [IQR] 5‐15) minutes to 15 (IQR 10‐17.5) minutes (P < 0.0001). Respondents strongly agreed that pharmacist‐to‐dose AUC/MIC vancomycin for working at the top of their degree (53.1% preimplementation vs 61.5% postimplementation; P = 0.261). Main concerns regarding changes in vancomycin dosing practices included lack of pharmacist competency, which decreased after rollout (48.7% preimplementation vs 24.5% postimplementation; P = 0.081). Before implementation, respondents felt that practice problems and training sessions (69.2%) and computer decision support (57.7%) would be key to a successful rollout. Satisfaction with the rollout increased postimplementation (26.9% vs 49.0%, respectively P = 0.011). Conclusion Pharmacists were in support of pharmacist‐to‐dose AUC vancomycin dosing practices, but there were concerns regarding competency. Training sessions with practice problems and integrated clinical decision support improved the rollout process.

Would they accept it? An interview study to identify barriers and facilitators to user acceptance of a prescribing advice service

“…Limited work has been undertaken to understand user integration of TDM interventions into routine workflow [ 8 , 15 , 16 ]. This study applied the TDF to synthesise barriers and facilitators to user uptake of a pilot TDM Service.…”

“…Studies that have explored factors influencing uptake of TDM interventions have identified barriers including poor coordination of TDM processes, time constraints, perceived lack of user competency and the prescribing hierarchy [ 8 , 15 , 16 ]. While these findings are useful, systematically identifying barriers and facilitators to uptake using a theory-based framework provides an evidence-based approach to enhance intervention design and achieve successful integration into routine workflow [ 17 , 18 ].…”

Pharmacist and physician insight of vancomycin therapeutic drug-monitoring changes

“…8 Another pharmacist-only vancomycin AUC transition survey also found an overall increased perception of patient safety. 9 Based on the idea that efficacy is unlikely to be impacted regardless of TDM method due to achieving AUC ≥ 400 mg*h/L in most cases with trough concentrations >15 mg/L, it is not surprising that the respondents in our postintervention survey believed that the change would not lead to increased efficacy. 10 In fact, likely due in part to our education efforts, most of the postintervention survey respondents chose "no difference" in efficacy, whereas in the preintervention survey, 57.3% thought an increase in efficacy would be achieved.…”