266. Implementation and Evaluation of a Pharmacist-Managed Pediatric Vancomycin Protocol

Abstract

BackgroundPediatric studies have shown that pharmacist-guided vancomycin dosing leads to reduction in time to initial target vancomycin trough, duration of vancomycin therapy, time to clinical stability, and shorter hospital stay. At Boston Medical Center, 65% of pediatric patients receiving vancomycin did not achieve initial therapeutic troughs between 10 and 20 μg/mL from October 1, 2016 to September 30, 2017. Through implementation of a pharmacist-managed pediatric vancomycin protocol, the project aim was to increase the percentage of patients achieving initial therapeutic troughs from 35% to 60% and percentage of patients achieving therapeutic troughs within 3 days from 67% to 90% by May 1, 2018. Secondary aims included reducing the incidence of supratherapeutic troughs from 10% to 5% and maintaining the incidence of vancomycin-associated nephrotoxicity (VAN) at 0%.MethodsA quality improvement (QI) initiative based on the Institute for Healthcare Improvement Model was utilized, testing change through Plan-Do-Study-Act (PDSA) cycles. In PDSA cycle 1, pharmacists designed and implemented a standardized vancomycin dosing protocol for pediatric patients. In PDSA cycle 2, the addition of area under the curve (AUC)-guided dosing was implemented in select patients. Process and balancing measures included percentage of appropriately drawn vancomycin troughs, provider adherence to the new dosing protocol, and incidence of supratherapeutic troughs.ResultsA total of 32 pediatric patients were assessed. Compared with baseline data, percentage of patients achieving initial therapeutic troughs increased from 35% to 44% and percentage of patients achieving therapeutic troughs within 3 days increased from 67% to 92%. The incidence of supratherapeutic troughs decreased from 10% to 0% and the incidence of vancomycin-associated nephrotoxicity was maintained at 0%.ConclusionStandardized initial vancomycin dosing with increased pharmacy involvement led to more patients achieving initial therapeutic troughs, shorter times to therapeutic troughs, and a reduction in supratherapeutic troughs. Next steps include hospital-wide implementation of a pediatric vancomycin per pharmacy protocol.Disclosures All authors: No reported disclosures.