American Journal of Emergency Medicine 38 (2020) 823–826

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American Journal of Emergency Medicine

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Brief Report

Emergency medicine clinical pharmacist's impact on ordering of

vancomycin loading doses☆
Francisco Ibarra Jr., PharmD
Community Regional Medical Center, P.O. Box 1232, Fresno, CA 93715, United States of America

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the impact of an emergency medicine clinical pharmacist's (EMCP) interven-
Received 21 August 2019 tion on physicians' prescribing of vancomycin loading doses at an institution with limited EMCP ser-
Received in revised form 4 December 2019 vices.
Accepted 6 December 2019 Methods: This was a retrospective, pre-post intervention study conducted at an academic Level 1 trauma
center. Adult patients who were ordered vancomycin and a broad spectrum antimicrobial at the same
Keywords:
time, within 12 h of arrival to the emergency department were included. During the three week inter-
Emergency medicine clinical pharmacists
Vancomycin
vention phase the EMCP lectured physicians and pharmacists on appropriate vancomycin loading
Clinical pharmacists doses, posted flyers in the ED physicians' work rooms, and uploaded a handout to the department of
Vancomycin loading doses pharmacy's website. Primary analysis compared the number of appropriate vancomycin loading doses
ordered before and after the EMCP intervention.
Results: Thirty and 31 orders from the pre- and post-intervention study periods were included in data
analysis, respectively. The number of appropriate vancomycin orders prescribed significantly increased
from 2 (6.7%) to 11 (35%) following the intervention (p b 0.05).
Conclusions: Following an EMCP intervention there was a statistically significant increase in the number
of appropriate vancomycin loading dose orders prescribed by emergency medicine physicians. The
EMCP's unique skill set and role within the emergency department permitted the EMCP to recognize
and resolve a discrepancy in vancomycin prescribing practices. This study further highlights the impor-
tance of having dedicated clinical pharmacists in the emergency department and encourages institutions
to develop, expand, and maintain EMCP positions.
© 2019 Elsevier Inc. All rights reserved.

1. Introduction
Clinical pharmacists are licensed pharmacists with advanced ed-
ucation and specialized training in providing comprehensive medi-
cation management in various healthcare settings, including the
Emergency Department (ED) [1]. Pharmacy services provided in
the ED were first described in the 1970s and primarily related to
medication distribution [2-4]. Since that time, pharmacists' presence
within the ED has increased, in addition to their involvement in di-
rect patient care activities.
Emergency Medicine Clinical Pharmacists (EMCP) optimize
medication use through order review, therapeutic drug monitoring,
☆ This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
E-mail address: fibarra@communitymedical.org.
direct patient care rounds, and medication procurement and prepa-
ration. Emergency Medicine Clinical Pharmacists decrease medica-
tion errors, minimize patient harm, and reduce costs [5-11]. The
American College of Emergency Physicians and American College
of Medical Toxicology recognize EMCP's critical role in ensuring
safe and effective medication use and advocate for their employ-
ment [12,13].
Despite the support of national Emergency Medicine societies
and documentation of EMCP's integral role in our healthcare system,
many institutions do not have EMCP or limit their hours [14]. Clini-
cal pharmacists are heavily involved in Antimicrobial Stewardship
activities and the ED offers EMCP many opportunities to optimize
antimicrobial selection and dosing. Vancomycin, a glycopeptide an-
tibiotic used to treat methicillin-resistant Staphylococcus aureus, is
often prescribed to ED patients. To minimize the incidence of treat-
ment failure, antibiotic resistance, and mortality, administration of
vancomycin loading doses are recommended in most patients to fa-
cilitate rapid attainment of target serum vancomycin concentrations

https://doi.org/10.1016/j.ajem.2019.12.015
0735-6757/© 2019 Elsevier Inc. All rights reserved.

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824 F. Ibarra Jr. / American Journal of Emergency Medicine 38 (2020) 823–826

[15-21]. This study determined the impact of an EMCP's intervention Table 1

on ED physicians' prescribing of vancomycin loading doses at an in- Patient characteristics.

stitution with limited EMCP services. Pre- Post-

(N = 30) (N = 31)
2. Methods Mean age, yr 58 58
Males, n (%) 20 (67) 15 (48)
This was a retrospective, pre-post intervention study conducted at Renal replacement therapy, n (%) 8 (27) 3 (10)
Indications, n (%)
an academic Level 1 trauma center in Central California with an annual
Blood stream infection 9 (30) 16 (52)
ED volume surpassing 100,000. Adult patients who were ordered van- Bone and joint infection 1 (3) 2 (6)
comycin and a broad spectrum antimicrobial (ampicillin/sulbactam, az- Central nervous system 8 (27) 5 (16)
treonam, cefepime, ceftriaxone, gentamicin, levofloxacin, meropenem, Respiratory tract infection 12 (40) 8 (26)
piperacillin/tazobactam) at the same time, within 12 h of arrival to the All comparisons were not statistically significantly different.
ED were included.
The study institution's two EMCP work opposite schedules to pro-
vide approximately 12 h a day, seven days a week coverage. The loading dose of 20 ± 2.5 mg/kg based on actual body weight was
EMCP participate in direct patient care rounds, medication order re- considered appropriate. A maximum initial loading dose of
view, therapeutic drug monitoring, resuscitation, precept pharmacy 2000 mg was considered appropriate irrespective of the calculated
students and residents, and educate physicians and nurses. In com- weight based dose; single doses exceeding 2000 mg are associated
parison to EMCP, non-EMCP (will be referred to as staff pharmacists with infusion related reactions and prolonged infusion times [15].
throughout the document) work remotely from the main pharmacy Appropriateness was not assessed for non-POEMS/bacteremia in-
and job accountabilities do not include direct patient care rounds, re- dications given loading doses are not recommended for these indi-
search, and scholarly activities. Medication orders for ED patients are cations. Orders placed through the institution's Sepsis Order Set
predominately verified by staff pharmacists, but EMCP do perform were not assessed for therapy appropriateness because the weight
this task as well. When ordering antimicrobials, physicians are re- based dose was preset.
quired to select the indication from a list embedded in the electronic Abstractors were not blinded to the study hypothesis, but ad-
order entry. hered to the study's protocol for collecting and reviewing data
The pre- and post-intervention study periods occurred during 12/ from the patients' electronic medical record. All data was readily ob-
1–12/31/18 and 05/06–06/05/19, respectively. The intervention tained from the medication administration record and laboratory
phase spanned three weeks and was completed by one of the results, did not require abstractor interpretation, and directly re-
institution's EMCP. During the intervention phase, the EMCP pro- corded into the data collection sheet unmodified. The abstractors re-
vided a lecture on appropriate vancomycin loading doses to the view patient charts in alignment with the study's protocol for data
School of Medicine faculty and residents during one of their monthly abstraction as part of their daily work activities and did not require
meetings and weekly conferences, respectively. The lecture included additional training for this study. Data abstracted was compared to
patient case presentations for the medical staff to apply and assess a system generated report which included all study variables for ac-
their knowledge of appropriate vancomycin loading doses. Approxi- curacy and completeness.
mately 20 faculty members and 30 medical residents attended these Non-normally distributed and normally distributed continuous var-
sessions. Following the lectures, flyers with information on appro- iables were compared using the Mann-Whitney U test and Student's t-
priate vancomycin loading doses were posted in all of the ED physi- test, respectively. Dichotomous variables were compared using the
cians' work rooms (Appendix). The EMCP created and reviewed with Chi-Square test. A priori p-value of b0.05 was used to determine statis-
the staff pharmacists an informational handout on appropriate van- tical significance. All study measures and procedures were approved by
comycin loading doses during the department's monthly meeting the local Institutional Review Board. There were no conflicts of interest
in which approximately half of the department was present. The to report.
handout included a table with various indications and corresponding
recommended loading doses, in addition to a time versus concentra-
tion graph comparing the area under the curve for regimens with 3. Results
and without a loading dose to demonstrate that regimens containing
a loading dose facilitate rapid attainment of target serum vancomy- Thirty and 31 orders from the pre- and post-intervention
cin concentrations. This handout was emailed to the entire depart- study periods were included in data analysis, respectively. Pa-
ment and uploaded to the department of pharmacy's website. tients from the two study periods were not statistically signifi-
Unlike the education provided to the physicians, education for the cantly different from one another (Table 1). The most common
pharmacists did not include patient case presentations for the phar- indication for vancomycin use was respiratory tract infection
macists to apply and assess their knowledge of appropriate vanco- (40.0%) and blood stream infection (52.0%) during the pre-and
mycin loading doses. post-intervention study periods, respectively. The number of ap-
Primary analysis compared the number of appropriate vanco- propriate vancomycin orders prescribed significantly increased
mycin loading doses ordered before and after the EMCP interven- from 2 (6.7%) to 11 (35%) following the intervention (p b 0.05)
tion. Criteria for assessing appropriate vancomycin loading doses (Table 2).
was based on the findings of several studies and the American Soci-
ety of Health-System Pharmacists (ASHP) and Infectious Diseases
Society of America 2009 guidelines [15,22-25]. Vancomycin load-
Table 2
ing doses ≥ 25 ± 2.5 mg/kg based on actual body weight were con-
Comparison of loading dose appropriateness pre- and post-intervention.
sidered appropriate for the following indications: pneumonia,
osteomyelitis, endocarditis, meningitis, sepsis (POEMS), or bacter- Pre- Post- p-Value
(N = 30) (N = 31)
emia. Antimicrobial indications were obtained from the order entry
selected indication. For patients being treated for POEMS/bacter- n, (%)
emia with renal insufficiency (creatinine clearance b 30 mL/min Appropriate 2 (6.7) 11 (35) b0.05
Inappropriate 28 (93.3) 20 (65) b0.05
per Cockcroft-Gault Formula, hemodialysis, peritoneal dialysis), a

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 F. Ibarra Jr. / American Journal of Emergency Medicine 38 (2020) 823–826 825

4. Discussion Potential resistance to employing an EMCP is cost. However,

the benefits of having EMCP far outweighs the costs of having
This study found that an EMCP intervention significantly increased them. Annual cost savings associated with having EMCP range
the number of appropriately prescribed vancomycin loading doses. from $500,000 to $3,000,000 [10,11,33]. This study further high-
The EMCP delivered education was effective and improved physicians' lights the unique role of EMCP in our healthcare system and en-
compliance with national guideline recommendations. This finding pos- courages institutions to develop, expand, and maintain EMCP
itively contributes to the literature supporting the role of clinical phar- positions.
macists in the ED. Documented patient care enhancements attributed This study has several limitations. This was a small, single center,
to EMCP include: increased percentage of patients receiving appropriate retrospective, pre-post intervention study. Author bias cannot be ex-
empiric antibiotics for sepsis, decreased time to initiation of post- cluded given the author of this study performed data collection and
intubation sedation, and reduced time to fibrinolytic administration analyses. Not assessing the interventions of several EMCP's limits
in stroke patients [26-28]. Clinical pharmacists practicing in other this study's generalizability. Lastly, the study's time periods may
healthcare settings have positively contributed to their respective fields have confounded the study's findings due to sample selection.
as well [29-31]. Changes in prescribing and verifying practices were not assessed at
In addition to engaging in clinical activities and providing educa- the individual level and it is possible that the study's findings are
tion, optimizing medication order entries is a recognized activity of not attributed to the EMCP intervention, but to differences in knowl-
EMCP [32]. Excluding a deficiency in physician knowledge of appro- edge between the physicians and pharmacists included in the two
priate vancomycin loading doses, the vancomycin order entry build time periods.
may have contributed to the high number of inappropriate orders
observed. The order entry was built with the following radio but- 5. Conclusions
tons: 10 mg/kg, 15 mg/kg, 1 g, 1.25 g, 1.5 g and required physicians
to manually enter any dose differing from these. Consequently, phy- This study found a statistically significant increase in the number
sicians may have been misdirected to only select from one of the of appropriate vancomycin orders prescribed by ED physicians fol-
five radio buttons. Following this study, two new vancomycin lowing an EMCP intervention. The EMCP's unique skill set and role
order entries, vancomycin loading and vancomycin maintenance, within the ED permitted the EMCP to recognize and resolve a dis-
were created. Physicians and pharmacists were notified via email crepancy in vancomycin prescribing practices. This study further
of the new vancomycin order entries and provided with condensed highlights the importance of having dedicated clinical pharmacists
versions of the study's educational handouts to refer to. These in the ED and encourages institutions to develop, expand, and main-
changes are expected to assist with preserving the study's positive tain EMCP positions.
findings.
This study further highlights the importance of having dedicated
clinical pharmacists in the ED. The American College of Clinical Phar-
macy (ACCP) and ASHP recognize clinical pharmacists as pharmacists Declarations of competing interest
with specialized advanced training who are engaged in direct patient
care rounds and integrated into the healthcare team [1,5]. Clinical phar- None.
macists frequently possess post-graduate residency training and ad-
vanced certification through the Board of Pharmacy Specialties Appendix A. Adult vancomycin loading dose recommendations for
accrediting body [32]. This training increases pharmacists' aptitude to the emergency department
critically think and assimilate into healthcare teams more effectively
than those only possessing a professional doctorate degree. The EMCP's
unique skill set and role within the ED permitted the EMCP to recognize
and resolve a discrepancy in vancomycin prescribing practices.
Although the EMCP intervention significantly increased the
number of appropriately prescribed vancomycin loading doses, the
overall percentage of appropriately prescribed orders was under
50%. A lack of full staff attendance at the lectures may explain this
finding. To compensate for this, an email with information on appro-
priate vancomycin loading doses was sent to the physicians and
pharmacists, flyers were posted in the ED physicians' work rooms,
and a handout was uploaded to the department of pharmacy's
website. Despite these additional efforts, the overall rates were sub-
optimal possibly due to the staff not reviewing their emails. To mit-
igate this finding, other contributing factors were reviewed. Upon
further investigation it was determined that the existing vancomy-
cin order entry was not conducive to ordering appropriate doses
and following this study the order entry was modified. These revi-
sions are expected to assist with raising the overall percentage of ap-
propriately prescribed vancomycin doses, but are unlikely to
completely resolve the issue given that current and new physicians
will require ongoing education about when to select the loading or
maintenance order entry, what infections require a loading dose,
and what an appropriate vancomycin dose is for patients with
renal dysfunction; all educational needs that can be fulfilled by
employing an EMCP. Identification of these shortcomings and inves-
tigation into the reasons for these failures are an added value of
EMCP to our hospital systems.

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