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Vancomycin and Preserving Kidney Function:

Electronic Medical Record Clinical Decision Support

Abdulelah A. Albukhari

Health Care Informatics, University of San Diego

HCIN-552-01-FA20: Electronic Medical Record Systems

Professor Cynthia Reed

December 17, 2020

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Executive Summary

The project looks at various ideas on clinical decision support for vancomycin. Vancomycin is

an effective antibiotic treatment for some severe infections from methicillin-resistant

staphylococcus; hence, people value it. The research addresses how the accurate consumption of

vancomycin and its concentration level in the body can help avoid nephrotoxicity due to

vancomycin. This cause justifies the need for studying the topic in question. The project paper's

proposed method provides the best solution to avoid mistakes with vancomycin doses. It

suggests using a clinical decision support system as the best way to handle prevailing issues. The

implementation, evaluation, and monitoring sections of this paper address the final parts of using

the clinical decision support system to ensure the patient has an accurate vancomycin dose. This

paper is divided into five parts: (a) the introduction, (b) justification, (c) proposed method, (d)

implementation plan, and (e) evaluation and monitoring.

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Vancomycin and Preserving Kidney Function: Electronic Medical Record Clinical Decision

Support

People value vancomycin because of its effectiveness in treating severe infections from

methicillin-resistant staphylococcus aureus. Vancomycin-associated nephrotoxicity can be

avoided to prevent kidney failure with attention focused on risk factors to ensure careful

monitoring of patients receiving antibiotics (Vora, 2016),. In order to diagnose patients with

chronic kidney disease (CKD), physicians need lab results for creatinine clearance (CrCl)or

creatinine level to detect if there are kidney abnormality functions to review. lab results step

ensures assigning the right patient doses that do not cause acute kidney disease. Vancomycin is

cost effective compared to other drugs that serve the same purpose. Vancomycin helps patients

heal faster and with a low budget, as it is both effective and inexpensive. Nevertheless,

vancomycin may cause many issues to the kidney, which may raise the cost of treatment.

Ideally, the creatinine clearance test will always show essential information that

concerns the kidneys. Body muscle metabolism produces creatinine as chemical waste.

Sometimes, when kidneys do not function properly, there is a tendency for abnormal creatinine

clearance levels to accumulate in the blood.

Patient safety essential in any treatment. Exposing a patient to a higher level of

vancomycin has several risk factors. One exposure-related factor includes more extensive

exposure to vancomycin (i.e., greater than 15 mg/L) and its prolonged treatment (Vora, 2016). In

addition, when patients develop nephrotoxicity due to Vancomycin, they must stay in the

hospital longer for treatment, thus increasing their medical costs (Jeffres, 2017). Some metrics

have been used to control and incorporate patients through vancomycin dosage levels. According

to research, an excess of 4 g/day of vancomycin directly related to an increase in toxicity, which

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impacts the kidneys (Rybak et al., 2020). Recent clinical data suggests reevaluating the current

dosing of vancomycin pharmacokinetics while monitoring the recommendation. An increased

creatinine level in a person indicates impaired kidney functioning (Rybak et al., 2020). In some

cases, physicians have mistakenly prescribed vancomycin without checking the patient’s level of

creatinine concentration. Clinical Decision Support Systems (CDSS) have helped providers

attain patient health in the organization. CDSS in pharmacy and pathology is beneficial because

it improves patient safety by determining whether drug choice and dose are unusual in the

context of specific diagnoses. CDSS is currently used to prevent errors in pharmaceutical dosing,

drug-drug interactions, and other medication-related parameters (Castaneda, 2015).

This paper introduces a method to mitigate patients with abnormal kidney function from

acute kidney injuries due to vancomycin dose. Those patients can be identified by abnormal

creatinine clearance levels. CDSS can help physicians ensure proper doses of vancomycin, and

modify the dose, if necessary, to correspond to the patient’s level of creatinine clearance. This

method ensures the patient’s health, safety, and prevention of future kidney complications.

Justification

In many cases, the correct consumption of antibiotics is useful for the body. However,

when there is a high level of antibiotic concentration, side effects may emerge. An abnormal

level of vancomycin will cause kidney problems, determined by the increased creatinine

clearance. Acute injury of the kidney is a severe complication that hospitalized patients endure,

as it increases mortality rate. Acute kidney injury has many causes, including the use of

antibiotics. One commonly used antibiotic is vancomycin, which directly relates to acute kidney

injury. Monitoring the creatinine concentration level regularly in a patient using vancomycin is
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essential in controlling the antibiotic consumption level. The use of CDSS for decisions is

essential in maintaining patient safety by modifying doses accordingly.

Proposed Method

Using CDSS has been one of the best ways to solve clinical problems. There have been

cases of administering a patient with vancomycin without checking the creatinine clearance

level. Technology has improved to simplify clinical procedures. To avoid medical errors to

ensure the physician has considered the creatinine clearance level when the order sits, and the

pharmacist is notified if the physician has concerns about creatine levels before vancomycin

disposal, there has to be an alert system matching the patient’s creatinine clearance level. When

levels depart from the standard, the doctor is alerted to modify the patient’s vancomycin dose. In

many instances, physicians forget to check the creatinine level in a patient, putting that patient at

risk of nephrotoxicity.

The CDSS can integrate into the Electronic Health Record (EHR) to allow an extension

of the alert system coded with states of creatinine clearance levels in a patient. When the level is

abnormal, the pop-up alert notifies the physician of the patient’s creatine clearance level and

modifies the dose of vancomycin or changes the medication. This CDS project uses the pop-up

alert because itis used only for high-risk and high-priority conditions (Office of the National

Coordinator for Health Information Technology, 2016). In this case, it is high priority to notify

the physician of the patient’s creatine clearance level. Doing so will ensure the patient’s safety

every time, thus reducing kidney problems.

The CDS will appear in the EMR as an extension order alert system that detects the level

of creatinine clearance in patients. When the physician orders vancomycin, the CDS appears as a

pop-up alert window with the latest creatinine clearance level and three options: (a) to confirm
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the dose without changes, (b)modify the dose, (c) to change the drug, or cancel the order (see

Figures 1 and 2). When the order arrives to the pharmacist, the system documents on the same

order page that the physician has already been notified about the patient’s creatinine clearance

level. In the case of verbally transcribed orders over the telephone by a nurse, it will go through

the same process because the pharmacist will set the order through the computerized physician

order entry (CPOE) in the patient’s EHR.

The patient’s creatinine level should range from 60 to 110 micromoles per liter, 0.7 to 1.2

milligrams per deciliter (Vora, 2016), and the normal range of CrCl is 110 to 150mL/min in men

and 100 to 130mL/min in women (Shahbaz & Gupta, 2020). The appearance of CDS in the EMR

will benefit patients, physicians, and pharmacists.

Implementation Plan

Once the committee approves the CDS request (i.e., the clinician, management, and IT

departments), it is time for the design/intake validation with the EHR vendor and the committee.

To ensure proper CDS workflow, system functions, and abilities, clinicians and others should be

presented with confirmation from the growing medical literature demonstrating the successful

use of CDS to achieve meaningful clinical benefits for both patients and physicians. This step

will take 1 month, and the budget will depend on vendor consultation and committee team

working hours. The committee’s estimated work hours are 25 in total—15 hr for 1 month and 10

hr allocated to be spent with the vendor. The budget will be $5,400 for the clinician (average for

15 hr for four doctors), $3,000 for IT (average of 15 hr work for two people), 10 hr for the

management team, which costs $2,500, and $5,000 for 10 hr with the vendor consultant. The

total cost for this step will be $15,900.

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After approving the step for designing the CDS, the committee’s build strategy, and the

vendor role for division work between the IT team, clinician, and vendor, the next step will

involve developing the project’s schedule. The build step will take 1 month with a total budget of

$12,600. Ten working hours will be needed from the clinician, costing $3,600. Twenty hours

from IT will cost $4,000, and 10 hours for vendors will cost $5,000.

The next steps are testing and validation of the CDS. The CDS system should be tested

before training for 2 weeks to validate data are accurate. For the CDS to works properly, it must

be free of mistakes and perform the necessary testing (i.e., system testing, user acceptance testing

[UAT], and volume testing)

Training the staff who will work with the CDS systems (60 medical doctors, 40

pharmacists) is a small implementation. They will watch an online module in PowerPoint.

Hospital training by the preparation team will take 3 weeks. Moreover, staff will have 3 weeks to

complete the training during work hours. There is no need for a capital budget that will take 10

hr from training team time with the cost of $2,000 for two people from the training team.

The implementation plan timeline will be 2 months to design and build, 2 weeks of

testing and validation, and 6 weeks for training before the GO-Live implementation.

The GO-Live implementation step will not affect the hospital's work because it will be

for a specific drug and specific group of patients. The implementation will be a Big-Bang all

over at once., with a total budget of $30,500 (see Figure 3).

Evaluation and Monitoring

Evaluation and monitoring the success of this project will be achieved by many metrics.

First, CDS will monitor the percentage of modified dosage and drug changes after the prescriber
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is notified the patient is at high risk of nephrotoxicity. The project’s target is to achieve 60% of

dose modifications or drug changes in the first 6 months.

Second, the physician will check the prescribed dosage before and after the project and

review how the CDS affected dosage changes. The evaluation also monitors the patient treatment

cost, patients who develop acute kidney diseases, and hospitalization length.

To ensure the CDS is working accurately, it must be monitored frequently and randomly

if the alert is working according to the condition applied by examining creatinine level with log

file for pop-up alerts by checking if it matches or not. The CDS evaluation and monitoring (post

live) will be repeated and evaluated every 6 months.

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References

Casteneda, C., Nalley, K., Mannion, C., Bhattacharyaa, P., Blake, P., Pecora, A., Goy, A., &

Suh, K. S. (2015). Clinical decision support systems for improving diagnostic accuracy

and achieving precision medicine. Journal of Bioinformatics, 5(4).

https://doi.org/10.1186/s13336-015-0019-3

Jeffres, M. N. (2017). The whole price of Vancomycin: Toxicities, troughs, and time. Drugs,

77(11), 1143-1154. https://doi.org/10.1007/s40265-017-0764-7

Office of the National Coordinator for Health Information Technology. (2016). General

instructions for the SAFER self–assessment guides. Safety Assurance Factors for EHR

Resilience. https://www.healthit.gov/sites/default/files/safer/guides/safer_cpoe.pdf

Rybak, M. J., Le, J., Lodise, T. P., Levine, D. P., Bradley, J. S., Liu, C., … Lomaestro, B. M.

(2020). Therapeutic monitoring of Vancomycin for serious methicillin-resistant

staphylococcus aureus infections: A revised consensus guideline and review by the

American society of health-

System pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious

Diseases Society, and the Society of Infectious Diseases Pharmacists. American Journal

of Health–System Pharmacy, 77(11), 835–864. https://doi.org/10.1093/ajhp/zxaa036

Shahbaz, H., & Gupta, M. (2020). Creatine clearance. In StatPearls [Internet]. StatPearls

Publishing.

Vora, S. (2016). Acute renal failure due to vancomycin toxicity in the setting of unmonitored

vancomycin infusion. Baylor University Medical Center Proceedings, 29(4), 412–413.

https://doi.org/10.1080/08998280.2016.11929491
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Figure 1

Workflow the CDS

Lab enter the CrCl <110 mL/min in CDS appears as

patient creatinine males and 100 YES pub-up window
Physician set mL/min in females
clearance in the EHR
vancomycin order with CrCL level and Cancel
through CPOE 3 options the order

Creatinine
clearance in
the patient
Confirm
the Modify
NO
change
chart in EHR dose with NO the NO the
rational dose medicine
note

YES YES YES

Contact
physician NO
Pharmacist
review and The order
check if the New dose
send to the
physician
or new drug
Disposal the YES
notice about pharmacy
the CrCl
vancomycin
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Figure 2

Pop-Up Vancomycin Alert

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Figure 3

Implementation Plan Steps and Budget

GO-Live

build (one month) total budget

committee approves $12600 $30,500

design/intake Training (6 weeks) Evaluation and

validation 2000$ monitoring (post
one month live) every 6 month
$15900