therapeutic drug monitoring (tdm) sticker project a new method for documenting times of medication...

Therapeutic Drug Monitoring (TDM) Sticker Project

A New Method for Documenting Times of Medication Doses and Drug Levels

Goals and Objectives

Primary objective

To implement a system to encourage complete and accurate documentation of

dose / level information at the bedside to allow for an accurate assessment of

antibiotic levels for optimization of antibiotic treatment

Secondary objective

To reduce the need for repeating antibiotic levels, to minimize…

Delayed attainment of therapeutic levels of drug

Delayed attainment of safe levels of drug

Discomfort to patient

Increased cost associated with levels

TDM Stickers

Therapeutic Drug Monitoring (TDM) Record

Med: Vancomycin Gentamicin Tobramycin Amikacin Other: ____

Dose: ____ Frequency: q6h q8h q12h q24h Other: ____

Date / precise time of preceding dose; Date: ____ Time: ____

Date / precise time of serum concentration; Date: ____ Time: ____

Why are we doing this???

• Real life case #1

– A 13 year old boy with CF is being treated with tobramycin. A tobramycin peak and trough are

ordered with the 4th dose due at 1600. The antibiotic is timed at 0000, 0800, 1600. The 1600

dose is not charted. The tobramycin trough = 2.8 mcg/ml (goal < 2 mcg/ml) and peak = 14.2

mcg/ml (goal 10-14). The timing documented in the computer for the trough and peak are both

reported as 1600. Of note, it is now 1100, and today’s 0800 dose has not yet been given.

– Assessment: Cannot accurately assess the levels…

• Was the 2nd dose given??? If yes, at what time???

• Were the trough and peak drawn at the right times, at the end of the interval and 1 hour

post-dose, respectively???

– Plan: Recommend repeating tobramycin peak and trough levels

– Implications

• Potential delayed optimization of treatment… safety and effectiveness

• Potential increase discomfort to patient… peripheral venipuncture

• Increase cost… repeat levels

The Health-Care Team and The TDM Sticker Project

Physicians

NursesPharmacists

The success of this program is dependent upon the active involvement of all professionals involved in the process of monitoring drug levels

TDM Sticker Project – Procedures

Physician orders antibiotic requiring monitoring of drug levels

Physician orders drug levels Nurse processes order for drug level and clips sticker(s) to nurses notes

Nurse administers dose preceding TROUGH level and documents precise time of dose on sticker, then adheres sticker in nurses notes section of patient bedside chart

Nurse draws trough level and documents precise time level drawn on sticker

Nurse draws peak level and documents precise time level drawn on sticker

Nurse administers dose preceding PEAK level and documents precise time of dose on sticker, then adheres sticker in nurses notes section of patient bedside chart

Pharmacist assesses level(s) and makes recommendation regarding dose modification

TDM Sticker: Commonly Asked Questions

What antibiotics do I need to use the sticker for???

The sticker should be used whenever levels are ordered for vancomycin, gentamicin, tobramycin, and amikacin

Where do I place the sticker in the patient’s chart???


To keep things easy, the sticker should be placed where

you normally document your notes, in the nursing notes

section of the patient bedside.

What if there is no room in the nurse’s notes section???


In that case, you can add a new progress notes sheet to

your nurses notes and place it there.

How do I fill out the sticker???


It’s easy. Just circle the medication, fill in the dose, circle the frequency,

and write in the precise time you gave the dose before the level was drawn, and then the precise time you drew the level. We’ll do an example in just a few minutes.

What does “precise time” mean for dose and serum concentration???


Good question. This is important. The precise times

should be exactly when the dose was started or the level was

taken. If the dose was given on a previous shift, this information may need to be obtained during

sign-out.

Do I need to fill out two stickers if I am checking a peak and a

trough???


Yes. When only a trough is ordered, such as for vancomycin, only one

sticker is needed. But, when both a peak and trough are ordered, such as for the aminoglycosides; gentamicin, tobramycin, & amikacin, two

stickers must be used.

TDM Sticker Examples




Date / precise time of preceding dose; Date: ______ Time: ____

Date / precise time of serum concentration; Date: ______ Time: ____

10010-1-07 0755

133010-1-07

So my patient is being treated with vancomycin 100mg IV q6h and has a trough ordered with the 4th dose. The 3rd dose was

scheduled to be given at 0800, but I gave it at 0755. I drew the level at 1330. This is how I

am going to fill out the sticker…


Med (Circle): Vancomycin Gentamicin Tobramycin Amikacin

Dose: _25__ mg Frequency (Circle): q6h q8h q12h q24h

Date / precise time of preceding dose; Date: 10-1-07 Time: 0810

Date / precise time of serum concentration; Date: 10-1-07 Time: 1605






2510-1-07 0810

160510-1-07


Med (Circle): Vancomycin Gentamicin Tobramycin Amikacin

Dose: _25__ mg Frequency (Circle): q6h q8h q12h q24h

Date / precise time of preceding dose; Date: 10-1-07 Time: 0810

Date / precise time of serum concentration; Date: 10-1-07 Time: 1605






2510-1-07 1610

174010-1-07

So my patient is being treated with gentamicin 25mg IV q8h and has a peak and trough

ordered with the 3rd dose. The 2rd dose was scheduled to be given at 0800, but I gave it at 0810. I drew the trough level at 1605. The 3rd dose was scheduled to be given at 1600, but I

gave it at 1610. The peak level was due at 1710, but I actually drew it at 1740. This is how I

am going to fill out the sticker…

Efficacy of a TDM Sticker Protocol on V7

• Pilot study

– Site: Variety 7

– Design: Open, case-control study

– Inclusion: All patients requiring vancomycin, gentamicin, tobramycin, or

amikacin levels, who were admitted to V7 during 1/1/2006 – 12/31/2006

• Patients were identified by a clinical pharmacist rounding on V7

– Patient demographics

• Aminoglycoside: n = 11 patients (18 sets of levels)

• Vancomycin: n = 5 patients (6 sets of levels)

Results

Use of the sticker appeared to increase the % of drug levels that could be accurately assessed

Improvement = 67% for the monitoring of aminoglycoside levels

0

2

4

6

8

10

12

14

16

18

Overall AG

Gentamicin

Tobramycin

Amikacin

Vancomycin

Sticker protocol Standard

Ass

essa

ble

Leve

ls (

n)

100%

33%

100%

36%

100%50% 0%

100%

100%

Note: Time of dose and level

documented via sticker indicated the trough level

was drawn a mean 0.26 hours (range 0.04-0.62 hours) later than

standard documentation

indicated

Results

Use of the sticker allowed for better assessment of the drug level

The calculated mean peak appeared to be lower in the sticker protocol group, while the calculated mean trough appeared to be similar between the two groups

0

2

4

6

8

10

12

14

16

18

Sticker protocol Standard

Cal

cula

ted

dru

g le

vel (

mg

/L)

Implementation of the therapeutic drug monitoring sticker project on a

general pediatric floor appeared to result in…

Improved data collection verses traditional methods

A more accurate assessment of antibiotic levels for optimization

of antibiotic treatment

A hypothesized decreased need for repeating levels

Conclusions

therapeutic drug monitoring (tdm) sticker project a new method for documenting times of medication...

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