Reducing Vancomycin Use in a Level IV NICU.

BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

Simulation Prepares an Interprofessional Team to Evacuate a 60-Bed Level 4 Neonatal Intensive Care Unit.

In August 2011, a 5.8 magnitude earthquake struck the Baltimore/Washington, District of Columbia, corridor. The event identified a critical requirement to prepare our interprofessional team to evacuate approximately 60 neonatal patients. A needs assessment indicated that 60% of staff members had little or no knowledge of the unit's evacuation plan and 55% of respondents were not aware of their specific role in an emergency evacuation. The neonatal intensive care unit educators in collaboration with the unit's medical team, the leadership team, the hospital emergency management team, and the unit practice and professional council coordinated the design, implementation, and assessment of the simulated evacuation activity. To encourage realism within the simulated activity, prepared manikins were placed in patient rooms and assigned varying levels of acuity. The training session began with a prebrief session that included a description of the evacuation plan, delineation of roles, responsibilities based on scope of practice, use of the evacuation equipment, and unit emergency bags. Participants engaged in a debrief session following each session during which the staff notably expressed an increased confidence with the evacuation plan, roles, and operation of the evacuation equipment. In addition, the debriefing allowed for identification of latent threats, which the planning group used to streamline the evacuation process.