Wessel, Rebecca J

Abstract Purpose No consistent recommendations exist on how best to educate pharmacists to facilitate implementation of new evidence-based practices. This study aimed to determine whether spaced learning was more effective than traditional education when learning a new evidence-based practice (β-lactam therapeutic drug monitoring, or TDM). Summary β-lactam TDM was implemented in a phased fashion at Mayo Clinic in Rochester. Two go-lives took place, separated by 6 months, which allowed for a natural experiment to test education delivery methods (traditional education in the first go-live group of pharmacists vs spaced learning in the second go-live group of pharmacists). Each group received the same base educational package, with pharmacists in the spaced learning group also offered monthly in-person sessions for 6 months before go-live to discuss key considerations and cases with experts. There was no difference between the spaced learning group and the traditional education group when assessing appropriate use of TDM as defined by (1) appropriate patient selection; (2) correct ordering of laboratory testing; (3) appropriate clinical action; and (4) completed documentation. Assessments of secondary knowledge transfer also showed no difference between the groups. Pharmacists in the different education groups had similar satisfaction scores related to the effect and utility of the education. Both spaced learning and traditional education were part of a comprehensive implementation plan for β-lactam TDM, which might have influenced the outcomes. Spaced learning for future pharmacist education efforts needs further study. Conclusion As part of a greater β-lactam TDM implementation effort, altering the education delivery method did not impact the degree of knowledge transfer.

Abstract Beta-lactam antibiotics are widely used in the intensive care unit due to their favorable effectiveness and safety profiles. Beta-lactams given to patients with sepsis must be delivered as soon as possible after infection recognition (early), treat the suspected organism (appropriate), and be administered at a dose that eradicates the infection (adequate). Early and appropriate antibiotic delivery occurs in >90% of patients, but less than half of patients with sepsis achieve adequate antibiotic exposure. This project aimed to address this quality gap and improve beta-lactam adequacy using the Define, Measure, Analyze, Improve, and Control Lean Six Sigma quality improvement framework. A multidisciplinary steering committee was formed, which completed a stakeholder analysis to define the gap in practice. An Ishikawa cause and effect (Fishbone) diagram was used to identify the root causes and an impact/effort grid facilitated prioritization of interventions. An intervention that included bundled education with the use of therapeutic drug monitoring (TDM; i.e. drug-level testing) was projected to have the highest impact relative to the amount of effort and selected to address beta-lactam inadequacy in the critically ill. The education and TDM intervention were deployed through a Plan, Do, Study, Act cycle. In the 3 months after “go-live,” 54 episodes of beta-lactam TDM occurred in 41 unique intensive care unit patients. The primary quality metric of beta-lactam adequacy was achieved in 94% of individuals after the intervention. Ninety-four percent of clinicians gauged the education provided as sufficient. The primary counterbalance of antimicrobial days of therapy, a core antimicrobial stewardship metric, was unchanged over time (favorable result; P = .73). Application of the Define, Measure, Analyze, Improve, and Control Lean Six Sigma quality improvement framework effectively improved beta-lactam adequacy in critically ill patients. The approach taken in this quality improvement project is widely generalizable to other drugs, drug classes, or settings to increase the adequacy of drug exposure.

AbstractBeta‐lactam therapeutic drug monitoring (TDM) can improve precision dosing and clinical outcomes in critically ill patients, but has not been implemented widely in the United States. Mayo Clinic recently implemented a beta‐lactam TDM program. This single‐center experience forms the basis of the manuscript which outlines practical considerations involved with beta‐lactam TDM implementation, including the pharmacist's role as a leader. Our implementation effort focused on three primary domains. First, we aimed to ensure a supportive organizational infrastructure. Early leadership engagement by the pharmacist‐led core team facilitated advocacy for the clinical need, allocation of resources, and assay development. Second, core clinical workflows were developed that addressed the preferred patient population for use, desirable pharmacokinetic and pharmacodynamic targets, and the preferred sampling strategy. Clinical tools to guide pharmacists in interpreting the results (e.g., pharmacokinetics calculator) and documenting decisions were developed. Third, stakeholders were offered repeated exposure to evidence and expertise to facilitate understanding and application of the new practice. This act of ‘individual internalization’ seems to be uniquely important to beta‐lactam TDM implementation compared with the implementation of other antimicrobial TDM programs. Educational strategies and supportive materials that were developed were focused on providing substantive and varied information tailored to the stakeholders' role in the process. For pharmacists, this included both clinical and operational considerations. A continuous improvement plan to support management of the process was instituted to address necessary updates and changes that inevitably emerged. In summary, the described approach to implementation of a pharmacist‐led beta‐lactam TDM program could be used as a roadmap to aid other institutions that aim to develop such a program.