Importance of Decision Support Implementation in Emergency Department Vancomycin Dosing.
BACKGROUND
The 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.


METHODS
Retrospective 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.


RESULTS
The 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.


CONCLUSIONS
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. The impact of decision-support tools should be further explored to optimize compliance with accepted antibiotic guidelines and to potentially affect clinical outcome.
University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa.
Brett
B
Faine
University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa.
Nicholas
N
Mohr
University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa.
Kari K
KK
Harland
University of Iowa College of Pharmacy, Iowa City, Iowa.
Kathryn
K
Rolfes
University of Iowa College of Pharmacy, Iowa City, Iowa.
Blake
B
Porter
Washington University, Department of Anesthesiology, St. Louis, Missouri.
Brian M
BM
Fuller
D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D016638:Critical Illness / Q000628:therapy; D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008508:Medication Errors; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000188:drug therapy*; D014640:Vancomycin / Q000008:administration & dosage*
D000900:Anti-Bacterial Agents; D014640:Vancomycin