Abstract
BackgroundModel-informed precision dosing (MIPD) can serve as a powerful tool during therapeutic drug monitoring (TDM) to help individualize dosing in populations with large pharmacokinetic variation. Yet, adoption of MIPD in the clinical setting has been limited. Overcoming technologic hurdles that allow access to MIPD at the point-of-care and placing it in the hands of clinical specialists focused on medication dosing may encourage adoption.ObjectiveTo describe the hospital implementation and usage of a MIPD clinical decision support (CDS) tool for vancomycin in a pediatric population.MethodsWithin an academic children’s hospital, MIPD for vancomycin was implemented via a commercial cloud-based CDS tool that utilized Bayesian forecasting. Clinical pharmacists were recognized as local champions to facilitate adoption of the tool and operated as end-users. Integration within the electronic health record (EHR) and automatic transmission of patient data to the tool were identified as important requirements. A web-link icon was developed within the EHR which when clicked sends users and needed patient-level clinical data to the CDS platform. Individualized pharmacokinetic predictions and exposure metrics for vancomycin are then presented in the form of a web-based dashboard. Use of the CDS tool as part of TDM was tracked and users were surveyed on their experience.ResultsAfter a successful pilot phase in the neonatal intensive care unit, implementation of MIPD was expanded to the pediatric intensive care unit, followed by availability to the entire hospital. During the first 2+ years since implementation, a total of 853 patient-courses (n = 96 neonates, n = 757 children) and 2,148 TDM levels were evaluated using the CDS tool. For the most recent 6 months, the CDS tool was utilized to support 79% (181/230) of patient-courses in which TDM was performed. Of 26 users surveyed, > 96% agreed or strongly agreed that automatic transmission of patient data to the tool was a feature that helped them complete tasks more efficiently; 81% agreed or strongly agreed that they were satisfied with the CDS tool.ConclusionsIntegration of a vancomycin CDS tool within the EHR, along with leveraging the expertise of clinical pharmacists, allowed for successful adoption of MIPD in clinical care.
Highlights
Vancomycin is a commonly used antibiotic in hospitalized neonates and children, yet it remains challenging to dose in the clinical setting (Hsieh et al, 2014; Brogan et al, 2018)
During the first 2+ years of clinical implementation (May 2017 to June 2019), a total of 853 patient-courses (n = 96 neonates, n = 757 children) comprising 7,800 doses and 2,148 vancomycin therapeutic drug monitoring (TDM) levels were evaluated by clinical pharmacists within the Model-informed precision dosing (MIPD) Clinical decision support (CDS) tool
Among all vancomycin patient-courses at our hospital the percentage in which the MIPD CDS tool was utilized is shown by Neonatal Platforma Child Platformb (n = 96)
Summary
Vancomycin is a commonly used antibiotic in hospitalized neonates and children, yet it remains challenging to dose in the clinical setting (Hsieh et al, 2014; Brogan et al, 2018). Starting doses commonly recommended for neonates and children frequently fail to achieve desired target exposures (Frymoyer et al, 2013; Ringenberg et al, 2015; Frymoyer et al, 2019; Miloslavsky et al, 2017; Dao et al, 2019). This is due in part to the influence of growth and development on the disposition of drugs which results in large variation in vancomycin pharmacokinetics (PK) between patients (Kearns et al, 2003). Overcoming technologic hurdles that allow access to MIPD at the point-of-care and placing it in the hands of clinical specialists focused on medication dosing may encourage adoption
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