Infection Control & Hospital Epidemiology SCAN: A novel approach for vancomycin time-out
Kayihura Manigaba PharmD1, Samuel J. Borgert PharmD1, Kenneth P. Klinker PharmD2, Kartikeya Cherabuddi MD3 and Veena Venugopalan PharmD2 1University of Florida Health Shands Hospital, Gainesville, Florida and, 2College of Pharmacy, University of Florida, Gainesville, Florida and 3University of
Florida, College of Medicine, Gainesville, Florida
To the Editor—Approximately 30%–50% of antimicrobials pre- scribed in hospitals are either inappropriate or unnecessary.1 The Joint Commission (TJC), Centers for Disease Control (CDC), and Infectious Diseases Society of America (IDSA) in partnership with the Society of Healthcare Epidemiology (SHEA) have all issued performance elements for antimicrobial stewardship programs (ASP).2–4 One core element in these standards is use of a systematic process for evaluating the need for treatment after a set period of time, most often referred to as “antibiotic time-out.” Although there is unanimous agreement that use of prospective strategies to evaluate antibiotic treatment is essential, little guidance on how to best integrate an antibiotic time-out process into clinical practice exists. We present an innovative approach to perform vancomycin time-out in a hospital setting.
Methods
The Stop and ReConsider Advancing CoNsult (SCAN) policy was implemented at our institution in November 2017 after approval from thehospitalanti-infectivesubcommitteeand thePharmacy and Therapeutics Committee. In this policy, one of the first steps taken by the pharmacist is review of microbiological data to ensure that appropriate cultures are obtained (Fig. 1). Next, 72 hours from initiation of vancomycin, the SCAN protocol is triggered which requires the pharmacist to assess criteria for continuation of therapy. These criteria include positive cultures for methicillin-resistant Sta- phylococcus aureus (MRSA), history of MRSA, culture results ≤24– 48 h, severe β-lactam allergy with no alternative antibiotics, and purulent cellulitis. If criteria are met, vancomycin therapy is con- tinued. If criteria are not met, the pharmacist communicates with the primary team and either recommends discontinuing vancomy- cinorconsultationwiththe infectious diseases service if continua- tion of therapy is needed. The SCAN protocol permits deviation from predefined criteria in cases of clinical instability or critical illness. A training video was developed by the ASP, discussing how SCAN would be integrated into pharmacist workflow. Prior to performing SCAN, pharmacists arerequiredtotakethistraining and to pass a competency assessment. Pharmacists are required to document SCAN using a standardized template in the electronic medical record (EMR). We conducted a 3-month retrospective review following the implementation of SCAN to assess pharmacist adherence to this new process and impact on vancomycin utilization. Patients with
Author for correspondence: Veena Venugopalan, PharmD, BCPS, Department of
Pharmacotherapy and Translational Research, University of Florida, College of Phar- macy, P.O Box 100484, Gainesville, FL 32610. Email:
vvenugopalan@cop.ufl.edu Cite this article: Manigaba K, et al. (2018). SCAN: A novel approach for vancomycin
time-out. Infection Control & Hospital Epidemiology 2018, 39, 1501–1502. doi: 10.1017/ ice.2018.249
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
a pharmacokinetic (PK) consult, who received ≥48 hours of vancomycin were included in the analysis. Patients who were followed by the infectious diseases consult service during the first 48 hours of vancomycin therapy were excluded. The University of Florida Institution Review Board approved this study as a quality improvement project.
Results
In total, 269 patients met inclusion criteria for analysis. Pharmacists performed SCAN at 72 hours in 157 of 269 (58%) of patients, meaning they assessed presence of indications for vancomycin use. The most common reasons for continuation of vancomycin beyond 72 hours was pending culture (26 of 157 patients, 17%), positive cultures or history of MRSA (26 of 157 patients, 17%), and purulent cellulitis (7 of 157 patients, 4%). Vancomycin was discontinued in 89 of 157 patients of the SCAN group (57%) compared to 32 of 112 patients in the non- SCAN group (29%; P<.05). The median length of vancomycin therapy was 3.3 days (range, 2.6–4.7 days) in the SCAN group compared to 4.1 days (range, 2.9–5.9 days) in the non-SCAN group (P<.05). Prior to the implementation of SCAN, the average length of vancomycin therapy was 8 days based on an internal audit.
Discussion
Vancomycin monitoring through a PK consultation service is a pharmacist-lead initiative at most institutions. Historically, the focus of this consultative service has been on vancomycin dosing accuracy with less emphasis on treatment appropriateness. The SCAN protocol is unique because it incorporates an evaluation of vancomycin use at 72 hours into the PK consult. With any new process, we noticed a ramp-up phase for adoption of this protocol. In the first month, the compliance rate was approxi- mately 50%, and it increased to 65% in the third month post- implementation. There was a significant decline in vancomycin days of therapy in the SCAN group versus the non-SCAN group (3.3 vs 4.1 days; P<.05). The implementation of the SCAN protocol was motivated by the need to improve the vancomycin PK consult workflow, decrease antibiotic utilization, and inte- grate antibiotic stewardship strategies into existing institutional policies. The impact of SCAN potentially extends beyond van- comycin. Following implementation, front-line pharmacists are reporting enhanced stewardship discussions on all prescribed antibiotics, not just vancomycin. This is an intriguing finding and supports the role of active communication when integrating stewardship into practice.5,6 Based on feedback from pharma- cists, one barrier to performing SCAN was fear of missing
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