Effect of education on the appropriateness of serum drug concentration determination

Educational intervention to improve appropriate digoxin therapeutic drug monitoring: a quasi-experimental study

OBJECTIVES

Our previous retrospecive study evaluating the appropriateness of serum digoxin concentration (SDC) measurements revealed errors in the timing of blood specimen collection in 98% of the tests. The aim of this study is to evaluate the appropriateness of the SDC measurements and the factors involved in inappropriate test-ordering, after training health personnel in digoxin therapeutic drug monitoring.

METHODS

This is a training-based quasi-experimental study. The residents and nurses of the Cardiology Clinic were trained first in December 2017, and refresher training courses were carried out every month throughout the study. The medical data of the inpatients receiving digoxin therapy were recorded prospectively, between January and December 2018. The appropriateness of the physicians' orders for SDC measurement was evaluated according to the criteria of the right indication and right timing of blood collection. The results are presented by descriptive statistics, Student's t-test and χ² analysis.

RESULTS

A total of 232 SDC tests were ordered for 121 patients (age: 71.0±12.6 years, 56.2% women). Of these orders,129 (55.6%) were considered appropriate: 205 (88.4%) for indication and 129 (62.9%) for blood collection timing. There was a significant correlation between inappropriate order for SDC test and the age of the patient, female gender, impairment of renal function tests, high levels of serum BNP and the number of medications used (P<0.005).

CONCLUSIONS

Approximately a one-half decrease in inappropriate tests compared with our previous study results imply that education has a positive effect on physician behaviour. However, physicians' concerns due to increased risk factors for the patient still play a role in inappropriate test-ordering.

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Purpose

Vancomycin prescribing requires individualized dosing and monitoring to ensure efficacy, limit toxicity, and minimize resistance. Although there are nationally endorsed guidelines from several countries addressing the complexities of vancomycin dosing and monitoring, there is limited consideration of how to implement these recommendations effectively.

Methods

We conducted a systematic search of multiple databases to identify relevant comparative studies describing the impact of interventions of educational meetings, implementation of guidelines, and dissemination of educational material on vancomycin dosing, monitoring, and nephrotoxicity. Effect size was assessed using ORs and pooled data analyzed using forest plots to provide overall effect measures.

Results

Six studies were included. All studies included educational meetings. Two studies used implementation of guidance, educational meetings, and dissemination of educational materials, one used guidance and educational meetings, one educational meetings and dissemination of educational materials, and two used educational meetings solely. Effect sizes for individual studies were more likely to be significant for multifaceted interventions. In meta-analysis, the overall effect of interventions on outcome measures of vancomycin dosing was OR 2.50 (95% CI 1.29–4.84); P< 0.01. A higher proportion of sampling at steady-state concentration was seen following intervention (OR 1.95, 95% CI 1.26–3.02; P<0.01). Interventions had no effect on appropriate timing of trough sample (OR 2.02, 95% CI 0.72–5.72; P=0.18), attaining target concentration in patients (OR 1.50, 95% CI 0.49–4.63; P=0.48, or nephrotoxicity (OR 0.75, 95% CI 0.42–1.34; P=0.33).

Conclusion

Multifaceted interventions are effective overall in improving the complex task of dosing vancomycin, as well as some vancomycin-monitoring outcome measures. However, the resulting impact of these interventions on efficacy and toxicity requires further investigation. These findings may be helpful to those charged with designing implementation strategies for vancomycin guidelines or complex prescribing processes in hospitals.

Appropriateness of vancomycin therapeutic drug monitoring and its outcomes among non-dialysis patients in a tertiary hospital in Singapore

Background Vancomycin therapeutic drug monitoring (TDM) is commonly performed to ensure safe and effective use of the antibiotic. Aim of Study To evaluate appropriateness of vancomycin TDM and its outcomes in Singapore General Hospital. Method A retrospective, cross-sectional study was conducted between 1 January 2014 and 28 February 2014 involving patients who received ≥ 1 dose of intravenous vancomycin with TDM. Patient demographics and relevant vancomycin TDM data were collected from medical records. Results Of 746 vancomycin troughs measured among 234 patients, 459 troughs (61.5%) were taken inappropriately, with a median time of 2.6 h (interquartile range 1.1-4.3) before the next scheduled dose. Inappropriate interpretation of vancomycin troughs resulted in 41 unnecessary dose suspensions, 24 dose changes, and 102 unchanged vancomycin doses. The cost incurred due to inappropriate interpretation and measurement after discontinuation of treatment was US$7286. No differences in rates of vancomycin related nephrotoxicity, ototoxicity, recurrent infection, development of infection secondary to vancomycin resistant microorganism and mortality were observed (p > 0.05). Conclusion This study highlighted a high incidence of inappropriate vancomycin TDM which has led to increased healthcare cost.

Safety and Outcome of Pharmacy-Led Vancomycin Dosing and Monitoring

Background: Therapeutic vancomycin trough levels correlate with therapeutic success and the development of renal failure. In this study, we aimed to describe the safety and outcome of pharmacy-led vancomycin dosing and monitoring. Methods: We included adults requiring vancomycin for >48 h and who had a vancomycin trough level drawn near steady state. The primary outcome of the comparison was the achievement of therapeutic trough levels, defined as 10-20 µg/ml. Secondary outcome included acute renal failure. We compared these outcomes before and after the implementation of pharmacy-led vancomycin dosing and monitoring. Result: During the study period, a total of 278 patients were in the preimplementation phase and 286 were in the postintervention phase. There was a clear increase in the percentage of patients achieving the therapeutic range (50.5 vs. 79.7%, p = 0.0001) and an increase in the percentage of levels within the therapeutic range (31.6 vs. 59.1%; p = 0.0001). The number of cases receiving vancomycin increased by 5% and the duration of therapy decreased by 19.5%. More patients attained a therapeutic range of 10-20 µg/ml (i.e. the level was 31.6% in the preintervention and 59.1% in the postintervention phase). Conclusions: A higher percentage of patients achieved a therapeutic range and less nephrotoxicity when using a pharmacy-led protocol for vancomycin dosing.

Implementation of the systems approach to improve a pharmacist-managed vancomycin dosing service

PURPOSE

Quality improvements achieved by applying the systems approach to assess the clinical effectiveness, operational efficiency, and financial feasibility of a pharmacist-managed vancomycin dosing service are described.

SUMMARY

Faced with increased patient volumes and resource demands, the pharmacy department at Tufts Medical Center conducted an evaluation of its adult inpatient vancomycin dosing service using the systems approach, which emphasizes multidisciplinary assessment of system inputs, processes, and outcomes and consensus-building methods to identify needed changes and recommended action steps. A multidisciplinary committee composed of representatives of the medical center's pharmacy, internal medicine, infectious diseases, nursing, phlebotomy, and clinical laboratory services was assembled; in a series of three moderated monthly sessions, committee members deliberated and ultimately reached consensus on a list of action items. Relative to a concurrent intradepartmental assessment of the vancomycin dosing service based solely on pharmacist feedback, the systems approach identified a greater number and wider array of needed improvements in key program areas. Quality improvements implemented as a direct result of the systems-based analysis included a policy change authorizing pharmacists to order serum vancomycin determinations without physician cosignature and inclusion of a vancomycin dosing algorithm in the institutional antibiotic dosing guide. Future changes based on deliverable action items will result in a structured process to help direct program resources toward the patients most in need of pharmacist-managed vancomycin dosing services.

CONCLUSION

The systems approach allowed for a comprehensive multidisciplinary evaluation of the service, as indicated by the identification of process improvements not identified by the department of pharmacy alone.

Short term impact of guidelines on vancomycin dosing and therapeutic drug monitoring

BACKGROUND

After medical center implementation of 2009 ASHP/IDSA guidelines, we evaluated the appropriateness of vancomycin dosing and TDM.

OBJECTIVE

Our primary objectives were to assess short term effects on (1) appropriateness of initial vancomycin dosing, (2) appropriateness of sampling of plasma levels, before and after implementation of guidelines.

METHOD

The study was conducted in two phases, pre-guideline and post-guideline implementation. The interventions included (1) Nurses and phlebotomist education regarding the appropriate timing of vancomycin sampling, (2) A nomogram for appropriate initial dosing that was distributed to medical staff. Patient demographics, dosing and timing of sampling were collected in eligible patients and assessed for appropriateness.

RESULTS

The appropriateness of the prescribed dose increased from 51% (128/253) of patients during the pre period to 78% (155/200) (p < 0.0001) during the post period. Similarly, overall appropriateness of sampling of vancomycin troughs at steady state improved from 36% (63/173) pre to 55% (106/191) (p < 0.03) post. Specifically, the appropriate timing of troughs (within 30 min of the next dose) increased from 37% (64/173) during the pre period to 78% (149/191) during the post period (p < 0.0001). Conclusion Adoption of the guidelines with associated training resulted in significant short term improvement in vancomycin dosing and TDM.

Best practice in therapeutic drug monitoring

It is the goal of Therapeutic Drug Monitoring (TDM) to use drug concentrations to manage a patient's medication regimen and optimise outcome. Limited resources require that drug assays should only be performed when they do contribute to patient management. For this to be the case a therapeutic drug monitoring service has a far greater role than just therapeutic drug measuring. This article describes the roles and functions of a Best Practice TDM service. The features which can and should be strived for in each step of the TDM process-the decision to request a drug level, the biological sample, the request, laboratory measurement, communication of results by the laboratory, clinical interpretation and therapeutic management-are discussed.