Elena Galagan, Joy Peterson, Karen Barlow
Wellstar Kennestone Regional Medical Center, Marietta, GA
BackgroundVancomycin has a narrow therapeutic index, requiring individualized pharmacokinetic dosing to maintain trough levels between 10–20 mcg/mL while minimizing the risk of acute kidney injury (AKI). Despite its common use, many institutions lack formal metrics to assess vancomycin dosing appropriateness. This quality assurance project at Wellstar Kennestone Regional Medical Center (WKRMC) aimed to create a sustainable, ongoing quality metric and real-time monitoring system for vancomycin dosing practices.
Objectives/MethodsThe project was conducted in two parts. The primary objective was to develop an ongoing quality metric that evaluates vancomycin dosing quality by monitoring therapeutic trough levels and AKI in adult patients. The secondary objective was to use this metric and Microsoft® Power BI dashboard to enhance decision-making and increase the proportion of patients achieving therapeutic targets.
Part 1 (establishing a baseline) was a retrospective quality assurance project including data from three fiscal years (July 1, 2021, through June 30, 2024). Adult patients who received intravenous vancomycin during an inpatient admission at WKRMC, had vancomycin dosed by a clinical pharmacist, and had at least one vancomycin trough level were included; pediatric patients under 18 years were excluded. The baseline percentage of patients with therapeutic vancomycin levels (10–20 mcg/mL) was calculated to establish the goal for the metric.
Baseline AKI incidence was determined by collecting up to three serum creatinine values around the time of trough collection and measuring the frequency of AKI as defined by Kidney Disease: Improving Global Outcome (KDIGO) criteria. A random sample of 123 patients was selected by choosing every 100th patient from each fiscal year for detailed review to validate the dashboard, estimate data capture performance, identify opportunities for improvement, and refine variables.
Part 2 (implementation) focused on developing a sustainable, ongoing quality metric and monitoring dashboard. Core metric components included the percentage of patients achieving therapeutic trough levels and the incidence of AKI, with stratification by key risk factors. Data elements were mapped to automated reports from Epic®, aggregated in a secure environment, and visualized in Microsoft® Power BI to create an interactive dashboard for clinical pharmacists. The dashboard was designed to support ongoing monitoring, early detection of trends, and continuous optimization of vancomycin dosing practices.
ResultsThe 123-patient review validated data accuracy, assessed variable performance, and guided refinement of the quality metric. This process led to adjustments in data capture, including the addition, modification, and removal of specific variables to enhance clinical relevance and reliability. Variables related to trough timing, serum creatinine trends, and AKI risk factors were refined to improve clarity and support clinical decision-making.
Findings from the review were used to validate automated Epic® data feeds, ensuring accurate representation of therapeutic trough attainment and AKI indicators. Based on these insights, targeted education was provided to clinical pharmacists on interpreting dashboard metrics and using the tool for ongoing dosing evaluation. The finalized dashboard enables monitoring of vancomycin dosing, supports trend and outlier identification, and provides a foundation for continuous quality improvement.
ConclusionThis project developed and validated a sustainable, ongoing quality metric for vancomycin dosing, supported by an interactive Power BI dashboard. Although this project was conducted around vancomycin troughs, the concept is also applicable to Area Under the Curve (AUC) targets. The goal of this initiative is to provide actionable information to clinical pharmacists to assess and improve vancomycin dosing accuracy, with the intent of increasing the proportion of trough levels within the therapeutic range while supporting ongoing renal safety surveillance.
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