Ranked by U.S. News & World Report as one of the nation’s best children’s hospitals, the 629-bed Cincinnati Children’s Hospital Medical Center is a leading medical research institution and teaching hospital caring for children from across the globe. Established in 1883, the healthcare system’s 15,260 employees engage in 1.25 million patient encounters each year, including approximately 34,000 admissions and 103,000 emergency department visits.
Cincinnati Children’s comprises the Department of Pediatrics of the University of Cincinnati College of Medicine, offering comprehensive clinical services ranging from treatments for rare and complex conditions to well-child care. It is the third-highest recipient of research grants from the National Institutes of Health among pediatric institutions and is among just 7% of hospitals in the U.S. to have earned Magnet-designation (2013-2017) by the American Nurses Credentialing Center.
With a growing body of evidence associating acute kidney injury (AKI) with an increased risk for development of chronic kidney disease, end-stage renal disease and mortality, Cincinnati Children’s was determined to reduce rates of AKI among its pediatric inpatient population. Baseline data indicated that, on average, six inpatients each week developed AKI during or within a week of discontinuing a vancomycin course. Additional evidence also suggested that extended courses of vancomycin—which when used beyond four days for empiric courses creates potentially unnecessary exposure to a nephrotoxic medication—may have been unintended.
Thus, vancomycin utilization was a natural target as the healthcare system embarked upon its mission to reduce the risk of AKI in pediatric patients. Specifically, Cincinnati Children’s sought to:
- Decrease episodes of acute kidney injury associated with vancomycin use.
- Decrease vancomycin exposure.
- Decrease prolonged courses of vancomycin.
- Increase oversight and approval for prolonged vancomycin exposure.
Success would require a close partnership between pharmacists and physicians that would enable implementation of an innovative, multistep quality improvement program focused on reducing the risk of vancomycin-induced kidney injury in pediatric patients. It also necessitated implementation of surveillance, clinical decision support and reporting technology capable of triggering interventions and educating clinicians on best practices.
Integrated within an existing antimicrobial stewardship program (ASP) and AKI reduction efforts, a core team of pharmacists, physicians, the chief medical resident and a quality improvement expert identified key drivers and implemented interventions including standardized orders, improved medical record documentation and integration of new processes into normal workflow. This enabled a stepwise approach using “plan-do-study-act” cycles.
Cincinnati Children’s also deployed the VigiLanz ASP solution to automate key processes, including screening and monitoring patients. The cloud-based platform leverages data collected from Cincinnati Children’s electronic medical record, physician order entry, laboratory and pathology systems to monitor patients in real-time for drug interactions and ineffective or inappropriate antibiotics. When potential issues are identified, alerts are triggered to enable clinical pharmacists and other members of the care team to take appropriate action.
Leveraging VigiLanz helped Cincinnati Children’s to create a sustainable and scalable framework that guides appropriate and safe use of antimicrobials while also promoting the safe and effective use of other medications. By enabling the provision of enterprise-wide guidance on the use of vancomycin in a matter of minutes each day, the technology helped drive significant improvements. These included:
- Decreasing AKI associated with vancomycin exposure to an average of 4 per week from a baseline average of 6 per week, with sustained efforts likely to prevent an estimated 100 cases of vancomycin-associated acute kidney injury per year.
- Decreasing vancomycin exposure (days of therapy/1000 patient days) by 43%, putting Cincinnati Children’s below the 25th percentile from a baseline near the 50th percentile.
- Decreasing instances of prolonged courses of vancomycin by 44% hospital-wide.
- Increasing ASP/ID approval in courses of vancomycin greater than four days to an average of 95% from a baseline average of 53%.
Cincinnati Children’s efforts to reduce AKI were recognized by the Association of Health-System Pharmacists, which gave the health system its 2016 Award for Excellence in Medication Safety.
“…We believe we can decrease the potential downside by choosing antibiotics that are likely to be just as effective but have less risk of increasing antibiotic resistance,” said David Haslam, M.D., an infectious disease specialist who joined Cincinnati Children’s specifically to launch its ASP initiative. “…Some hospitals just say ‘you can’t use that drug.’ Our approach will be ‘you might want to consider [another drug].’ We hope physicians will view this as bringing a lot of potential benefit.”– Silva, Mary. “Finding the Balance.” Research Horizons. Winter 2014.