Background Growing evidence suggests that continuous infusion of vancomycin (CIV) is superior to intermittent infusion of vancomycin (IIV) in neonates. Prescribing CIV in neonates in the UK remains relatively untested and is an unlicensed use. This quality improvement (QI) project aimed to transition from IIV to CIV with earlier and improved attainment of therapeutic vancomycin levels.
Objectives This project aimed to clarify the utility, benefit and safety of CIV over current IIV usage in our department, aiming to inform future vancomycin regimens both locally and more widely. Following baseline measurements of IIV, a QI project was undertaken for implementation of CIV using sequential Plan Do Study Act (PDSA) cycles over 10 months (July 2019 to May 2020) with Specific, Measurable, Achievable, Realistic and Timely (SMART) aims to:
Reduce the time taken to achieve vancomycin target level by 50%.
To increase first TDM levels within target range from 36% to 60%.
To increase total TDM therapeutic levels from 44% to 70% in neonates.
If successful, this would add to current evidence that CIV is superior to IIV in neonates and should be regarded as best practice.
Methods The Model for Improvement framework with Plan Do Study Act cycles was used. Prospective data were collected during three phases: IIV, CIV-1 and CIV-2.
Results Using IIV, 36% (9/25) of first vancomycin levels were within target range. CIV achieved therapeutic levels twice as quickly as IIV (p < 0.05) with improved first vancomycin target levels (IIV 36%, 9/25; CIV-1 55%, 16/29; CIV-2 61%, 14/23) and total therapeutic levels (IIV 44%, 37/84; CIV-1 56%, 55/98; CIV-2 69%, 79/114).
Conclusions It was established that IIV outcomes were not meeting expected standards, particularly in terms of delayed time to therapeutic levels and high percentage of out of range levels. This project was successful in establishing a change to CIV which produced a modest benefit over IIV, particularly in regard to time taken to achieve vancomycin target levels and proportion of therapeutic levels. The findings of this project and information regarding our implementation process provide guidance to other NICUs to transition from IIV to CIV.