Overview of Important CPOE Changes for the Implementation of the IV Vancomycin
Pharmacist-Physician Collaborative Practice Protocol at UConn Health
Prepared by: Jeffrey R. Aeschlimann, Pharm.D. (Co-Chair, Antimicrobial Stewardship Program)
Background:

The IV Vancomycin Pharmacist-Physician Collaborative Practice (“VCP”) Protocol will officially begin in
March 2014

The VCP protocol is a highly-detailed, evidence-based, and rigorously-structured Collaborative Practice
Protocol that conforms to Connecticut state law (Section 20-631 of the General Statutes).

The VCP Protocol was developed with valuable input from various UConn Health departments and was
approved by the Pharmacy, Therapeutics, and Medication Safety Committee.

The VCP protocol permits Pharmacist-led dosing and therapeutic monitoring of intravenous vancomycin
therapy for adult inpatients at UConn Health.

The goal of the VCP protocol is to optimize the safety and efficacy of IV Vancomycin therapy for adult
inpatients at UConn Health.
Summary of CPOE Changes Associated with the VCP Protocol:

All current individual listings for IV Vancomycin products will be removed from the CPOE system

IV Vancomycin products will only be found within various existing and new CPOE Ordersets
New Method for the Initiation of IV Vancomycin Therapy:
Step #1:

The prescribing clinician can either:
1.) Pick a Vancomycin Order Set from the list in the “Order Sets” tab, or
2.) Search for a Vancomycin product:
***Note:
 When searching for Vancomycin, there now are only 6 possible options (see screenshot on
next page)
 The 3 options for IV Vancomycin are listed at the top of the “Search Results” box
Important Definitions/Explanations:
VANCOMYCIN IV-PHARMACIST DOSED:

This option should be selected if the Prescriber wants to initiate IV Vancomycin therapy to treat a
suspected/documented infection using the VCP protocol
VANCOMYCIN IV-PHYSICIAN DOSED:

This option should be chosen if the Prescriber wants to initiate and manage IV Vancomycin therapy
on his/her own
VANCOMYCIN IV-SURGICAL PROPH:

This option should be chosen if the Prescriber wants to initiate IV Vancomycin only for Surgical
Prophylaxis
Initiation of IV Vancomycin Therapy via “opting-in” to the VCP Protocol:
Once you select the VANCOMYCIN IV-PHARMACIST DOSED option, the next screen will look like this:
Important Definitions, Explanations, and Instructions:
a.) Therapeutic Range Selection:

Under the VCP Protocol, the default target therapeutic trough concentration range will be 10-20 mg/L:
o
o
This is a revision from the previously-recommended target therapeutic trough concentration
range of 15-20 mg/L for serious methicillin-resistant Staphylococcal infections such as
pneumonia, bacteremia, osteomyelitis, etc. that was published in the 2009 Consensus Review
Statement on the therapeutic monitoring of vancomycin in adult patients (jointly published by
ASHP, IDSA, and SIDP)
Rationale:
 The 15-20 mg/L target trough recommendation was categorized as “B-III” (“Moderate
evidence to support a recommendation for use” with the type of evidence as “Evidence
from opinions of respected authorities, based on clinical experience, descriptive studies,
or reports of expert committees”)
 A critical review of clinical data published since this 2009 Consensus Review Statement
indicates that there are likely to be (i) no additional therapeutic benefits in patients
with troughs > 15 mg/L, but (ii) significantly greater risks for nephrotoxicity in patients
with troughs > 15 mg/L.

However, the prescribing clinician also can use his/her clinical judgement and can select a lower
therapeutic trough range (5-15 mg/L) for non-staphylococcal infections and/or for less-serious infections
such as localized urinary tract infections

Similarly, the prescribing clinician can use his/her clinical judgement and select a higher/narrower
therapeutic trough range (15-20 mg/L)
b.) Selection of the Initial IV Vancomycin Dose:

To ensure prompt initiation of antibiotic therapy, the prescribing clinician should select the first dose of
IV Vancomycin based on the patient’s actual body weight
c.) Final Steps in the Process for IV Vancomycin Therapy for VCP Protocol Patients:


Upon receipt of a new order for IV Vancomycin via the VCP protocol, the Pharmacist will independently
manage the patient’s IV Vancomycin therapy with formalized feedback and communication to
caregivers at all points in the process
The Pharmacist will:

Collect, assess, and document pertinent baseline patient data needed to develop the initial IV
Vancomycin regimen

Enter the initial IV Vancomycin regimen into the Siemens Pharmacy system

Schedule and order blood draws for serum vancomycin concentration assessments

Perform daily followup on relevant clinical and laboratory data related to IV Vancomycin
therapy

Modify IV vancomycin regimens based on assessments of serum vancomycin concentration
results

Document all relevant activities in the patient’s permanent medical records via the use of two
standardized progress notes (Pharmacy Note: Initial IV Vancomycin Dosing per Collaborative
Practice Protocol, and Pharmacy Follow-Up Progress Note: IV Vancomycin Therapy per
Collaborative Practice Protocol)
Initiation of IV Vancomycin Therapy via “opting-out” to the VCP Protocol:
Once you select the VANCOMYCIN IV- PHYSICIAN DOSED option, the next screen will look like this:
Definitions/Explanations:

With this option, the prescribing clinician will select an initial IV Vancomycin regimen based on the
patient’s actual body weight and creatinine clearance.

The prescribing clinician will also need to:

Schedule and order blood draws for serum vancomycin concentration assessments

Perform daily followup on relevant clinical and laboratory data related to IV Vancomycin
therapy

Modify IV vancomycin regimens based on assessments of serum vancomycin concentration
results
If a change in the initial IV Vancomycin dose and/or interval is needed, the prescriber should:





Discontinue the currently-active IV Vancomycin order
Go back into the VANCOMYCIN IV-PHYSICIAN DOSED orderset
Scroll all the way to the bottom of this orderset (see screenshot below)
Select the desired new IV Vancomycin dose
Change the default “q12h” interval to the new desired interval (if needed)