Importance of Decision Support Implementation in Emergency Department Vancomycin Dosing

Brett Faine,Nicholas Mohr,Kathryn Rolfes,Brian Fuller,Kari Harland,Blake Porter

doi:10.5811/westjem.2015.4.25760

Abstract

IntroductionThe emergency department (ED) plays a critical role in the management of life-threatening infection. Prior data suggest that ED vancomycin dosing is frequently inappropriate. The objective is to assess the impact of an electronic medical record (EMR) intervention designed to improve vancomycin dosing accuracy, on vancomycin dosing and clinical outcomes in critically ill ED patients.MethodsRetrospective before-after cohort study of all patients (n=278) treated with vancomycin in a 60,000-visit Midwestern academic ED (March 2008 and April 2011) and admitted to an intensive care unit. The primary outcome was the proportion of vancomycin doses defined as “appropriate” based on recorded actual body weight. We also evaluated secondary outcomes of mortality and length of stay.ResultsThe EMR dose calculation tool was associated with an increase in mean vancomycin dose ([14.1±5.0] vs. [16.5±5.7] mg/kg, p<0.001) and a 10.3% absolute improvement in first-dose appropriateness (34.3% vs. 24.0%, p=0.07). After controlling for age, gender, methicillin-resistant staphylococcus aureus infection, and Acute Physiology and Chronic Health Evaluation II score, 28-day in-hospital mortality (odds ratio OR 1.72; 95% CI [0.76–3.88], p=0.12) was not affected.ConclusionA computerized decision-support tool is associated with an increase in mean vancomycin dose in critically ill ED patients, but not with a statistically significant increase in therapeutic vancomycin doses. The impact of decision-support tools should be further explored to optimize compliance with accepted antibiotic guidelines and to potentially affect clinical outcome.

Highlights

The emergency department (ED) plays a critical role in the management of lifethreatening infection
The electronic medical record (EMR) dose calculation tool was associated with an increase in mean vancomycin dose ([14.1±5.0] vs. [16.5±5.7] mg/kg, p
A computerized decision-support tool is associated with an increase in mean vancomycin dose in critically ill ED patients, but not with a statistically significant increase in therapeutic vancomycin doses

Summary

Introduction

Vancomycin is a glycopeptide antibiotic that exhibits time-dependent killing. It has been used for more than five decades to treat resistant organisms, such as methicillinresistant Staphylococcus aureus (MRSA), and in the empiric treatment for severe sepsis and septic shock. An AUC/MIC ratio of ≥400 with trough serum concentrations of 15-20mg/L are recommended to achieve clinical effectiveness and limit the development of resistant microorganisms.[1] MRSA. Vancomycin Dosing vancomycin treatment failures are occurring with increasing frequency, and vancomycin-intermediate Staphylococcus aureus (VISA) has emerged as a leading cause of vancomycin failures and poor clinical outcomes.[2,3]. Due to the association of conventional dosing and subtherapeutic vancomycin trough levels, current guidelines advocate for weight-based dosing algorithms.[1,8]

Methods

Results

Discussion

Conclusion