Five years of therapeutic drug monitoring in the intensive care did not change vancomycin prescription behaviour: perceived needs for decision support

Background. This study aims to assess clinicians' behaviour in prescribing vancomycin in the Intensive Care Unit (ICU) and their adherence to local guidelines for therapeutic drug monitoring (TDM). Methods. In this observational cohort study we included all consecutive patients admitted to a 28-bed multidisciplinary mixed adult ICU of a large university hospital in Amsterdam between January 2002 and September 2007 who were prescribed vancomycin for >= 3 days. We measured guideline adherence by checking for each given advice the corresponding action and monitored adherence over time using Statistical Process Control. Results. In 475 patients prescribed vancomycin, 1336 serum concentrations were measured, of which 598 in time and 738 with a median delay of 31 hours. Dose or dose frequency adjustments were often not done (54% in advice 2 [half dose frequency] and 86% in advice 4 [increase dose with 50%]) or not done concordantly (32% in advice 2 [half dose frequency] and 60% in advice 7 [half dose frequency if trough serum concentration]). Although adherence was stable over time, the average level was low (58.7%). Conclusions. Five years of TDM did not achieve the desired prescription behaviour in the ICU and clinicians feel there is a need for computerized decision support. Local projects should measure adherence and implement appropriate solutions. (Minerva Anestesiol 2012;78:684-92)