As I started my pharmacist foundation training year (formerly known as the preregistration year) at Bradford Royal Infirmary, Yorkshire, I was involved in managing the care for a large number of patients on antimicrobial treatment. I actively took part in antibiotic audits as part of my role, where I reviewed the appropriateness of treatment in accordance with local guidelines. Vancomycin was a commonly prescribed drug on many of the wards I worked on and was nearly always given inappropriately, with doses rarely given promptly. On a number of cases, trough levels were taken several hours after their due time and many clinical staff were not entirely aware of how they would manage patients on the medicine.
Having had a good feel of this clinical area, I decided to make it my responsibility to investigate further. I liaised with Alison Haigh, the antimicrobial pharmacist at Bradford Teaching Hospitals NHS Foundation Trust, on how we could explore this. We ran a report on the trust’s electronic prescribing system to identify all the patients who were prescribed vancomycin over a three-year period — the period of time since the system went live.
I wanted to keep the study simple to establish a baseline, so I focused on a set list of parameters to help with this. Inclusion criteria for the study comprised adult patients (aged 18 years and above) prescribed IV vancomycin who were not receiving dialysis. Exclusion criteria comprised paediatric patients and patients who were treated with dialysis, as separate guidelines were available for these groups of people. I then selected 25 patients at random. Information regarding drug indication, weight, serum creatinine, doses administered, date of doses, infusion start and end times, serum trough levels and time of serum levels were documented.
After further analysis of the 25 patients, only 10 of them met the criteria we were looking for. Across the 10 patients, 26 trough levels were obtained — only 5 of which reflected accurate trough level readings according to the current guidelines. Out of these 5 results, only 2 of them illustrated infusions that delivered accurate doses over the correct time period. No patient was treated in complete accordance with the trust guidelines.
I noticed there were many reasons for inaccurate dose administrations and trough level readings. In four instances, a lack of nursing staff was responsible for late trough level readings. In 5 cases, ‘Nursing Judgement’ was documented as the reason for late dose infusions with no explanation as to what decision was made to delay treatment. Most dose adjustments made after the loading dose were generally done incorrectly. In 2 cases, doses subsequent to the loading dose needed to be reduced but this did not happen. In one instance, the initial loading dose was one band too high as the patient’s renal function was not considered.
According to the electronic prescribing system, doses were not administered correctly, mostly owing to them being ‘early/late dose’. Early/late doses were a result of nursing judgements (n=5), standardisation of administration times (n=5), the drug not being available (n=1) and no IV access (n=1). The documentation of one patient included many entries from doctors and medical staff asking for timely trough levels. Only one out of the 4 levels obtained was correctly taken. Two patients had no trough level monitoring results on the system. One patient was repatriated from a different trust and so only had one infusion of vancomycin at Bradford Royal Infirmary. Their trough level reading was therefore classed as negligible.
Using a pharmaceutical care plan for every patient prescribed IV vancomycin looks like a sensible idea. This will help to illustrate which parameters need particular attention and will allow healthcare professionals to tick these off as they manage their patients care. A powerplan can also be used on the electronic prescribing system. This will flag vancomycin if it is prescribed for a patient, which can prompt healthcare staff to put the necessary interventions in place to avoid errors (i.e. to take timely trough-level readings).
I learned a lot in this experience. I did not realise how many errors happen when administering medicines to patients until you look back and analyse how things have been done. The NHS is definitely stretched at the moment — that’s something that everyone can agree on. Bradford Royal Infirmary is unfortunately no exception to this, and most (if not all) other NHS trusts are likely to be in the same boat.
Several different reasons have contributed to non-compliance to trust guidelines in this study and you can argue that general staff shortages, lack of understanding and poor documentation have been the main offenders. It is very likely that the situation will be the same elsewhere, so other hospitals should carry out their own audit to see how well they are following their policies.
Since the study, the pharmacy team has been better informed on what to look out for when dosing and monitoring vancomycin. Posters have been put up around the department and staff have been encouraged to educate other members of the interdisciplinary team on how to accurately manage patients on treatment. I have since left the trust; although I discussed plans with Alison about re-auditing after six months to see if improvements have been made. I admit it will probably take a lot of time for staff to adopt their practice owing to the reasons mentioned above; however, it’s one giant step towards optimising patient’s medicines and improving health outcomes.
Uwaise Rehman, now a clinical pharmacist at Bradford District Care NHS Foundation Trust