Gap Analysis for the Conversion to Area Under the Curve Vancomycin Monitoring in a Small Rural Hospital
Objective: Consensus guidelines for vancomycin monitoring now recommend area under the curve (AUC) calculations for optimal vancomycin efficacy and safety. This will be a major practice change for many facilities. Implementation guidance is available but has not been reported in smaller, primary care hospitals. The objective of this study was to measure the uptake of AUC monitoring implementation in a rural facility.
Methods: This is a gap analysis evaluating the appropriateness of vancomycin levels tests after the April 1, 2019 transition. All vancomycin levels between April 2019 and June 2019 after the go-live date were included with no exclusions in a retrospective chart review. The primary outcome was the proportion of levels in the appropriate time frame: peaks 1 to 2 hours after infusion with troughs at least 1 half-life after initial dose and prior to the next dose. Secondary outcomes included reasons identified for inappropriate levels and the proportion of AUC 24 calculations within therapeutic range (400-600 mg.h/L). Descriptive statistics were used to measure the scope and outcomes of this transition.
Results: The transition was effective with 97% of cases utilizing AUC-based methods. There were 65 vancomycin levels in the 3-month study period with 86% deemed appropriate. Of the 9 inappropriate levels, 4 had to be repeated for accurate monitoring. There were 28 two-level couplets used for AUC 24 calculations, 17 (61%) fell within therapeutic range.
Conclusion: Implementation strategies for the AUC transition described in tertiary medical centers can be successfully utilized in primary facilities.
Limitations
There are several limitations to consider with this study. Operating procedures and implementation processes may vary between facilities, which could limit the generalizability of these results. Given the small facility size, the overall number of laboratory tests drawn was much smaller than those seen in larger facilities. The time needed for AUC calculations is notably longer than older methods of monitoring; however, this was not objectively assessed. It is important to note that clinical outcomes were beyond the scope of this gap analysis and this is an area of future research at the study facility. Vancomycin laboratory tests that were missed due to procedures and subsequently rescheduled were occasionally observed but not accounted for in this analysis. Additionally, vancomycin courses without monitoring (appropriate or otherwise) when indicated were not assessed. However, anecdotally speaking, this would be a very unlikely occurrence.
Conclusion
Conversion to AUC-based vancomycin monitoring is feasible in primary, rural medical centers. Implementation strategies from tertiary facilities can be successfully utilized in smaller hospitals. Quality assessment strategies such as a gap analysis can be utilized with minimal resources for facility uptake of new clinical practices.
