Vanco: give or wait for vanco trough?

[rn.5245]

Hi! I am trying to figure out if I took the right action with an order for vanco and trough levels. My patient was on vanco q 24 hours. The doctor wrote the following order:

"vanco iv pharmacy to dose."

"draw vanco trough at 1600."

When i arrived for my 7pm shift, the trough for 1600 had still not been drawn, as the lab was backed up. The daily vanco was scheduled for midnight. The renal labs were wnl. I checked the trough from 2 days prior, and it was low, 4.6, so i called pharmacy about the order and they sent me the scheduled dose, which i gave at midnight. Then at 1:30 am lab calls with a vanco level of 27. Apparently they drew it late, on my shift.

This patient had past orders for vanco troughs and specific hold/wait parameters for the dose, and as i understood it, since this order didnt instruct to wait for the trough and didnt give parameters to hold vanco if the trough is a certain level, I was supposed to give it based on pharmacy and the schedule for the dose, and the trough was not to determine my midnight dose.

My question is, did make an error bc i didnt wait for the trough, or did i follow the order correctly as written?

Any feedback would be so helpful. Thanks!

[Guttercat, ASN, RN]

Does your facility have standing Vanco protocol? I would assume so, since the MD ordered "per pharmacy dose."

Pharmacy is then responsible to dose according to lab draw results. Lab draw was late, and someone in pharmacy decided to send the med. (This puts you in a bit of a bind as the person ultimately responsible for administering the drug.)

Unfortunately for you, that doesn't mean "give it." In your efforts to use deductive reasoning (prior trough levels, renal status) and get the job done, you bit yourself in the butt.

If a vanco is ordered and a trough is due that day, don't give it until the trough is back. Document that you called lab, and are awaiting results.

[Esme12, ASN, BSN, RN]

IF you gave the vanco.... then that result of 27 isn't a trough is it...as the dose was given.

Pharmacy should not have sent a dose of vanco based on a trough of 2 days ago.

Lab should have drawn the timed vanco dose. Being "busy" is not an excuse for poor patient care. You, actually the nurse before you, should have drawn the the vanco level yourselves.

Every one was wrong. Yes it is an error.

What is your routine policy for vanco dosing by pharmacy?

[rn.5245]

Thanks for the feedback. I definitely see what you are saying.

At my facility I have often seen hold parameters written for vanco and the lab draw, but other times not.

When I see orders such as "draw vanco trough at...hold next dose if >20 (or what level they specify), this very clearly means wait and use the result to determine whether to give.

When they said "draw trough at...pharmacy to dose" instead of "draw trough at...hold dose if..." I saw this as one has parameters, one doesnt, and in the second case the trough is to see how things are at the current vanco dose/frequency.

But then again, if a BP med had no parameters and the BP is low, this is not implying give the med no matter what their BP is. You would clarify before giving.

You are definitely right that just because pharm sends something, this is not a green light that it is ok to give, but I just thought that in the case of "pharmacy to dose", they were deciding how much and when to give...

So I guess I was just wondering if ordering a vanco trough was usually meant to determine the next dose, or if it is sometimes meant to change future doses, but not necessarily change the admin time.

Thanks for replying to my post.

[RNNPICU, BSN, RN]

Usually you do need to wait for a vanc trough. Typically it is to be drawn half an hour before the third dose of vanc. There are times when a random trough may be needed especially in renal patients or in patients that are on vanc for a long time. Next time if the order is not clear as to give nor not to give just ask for a clarification. I understand why you gave the dose. If the lab drew the trough too soon after you gave the dose it could artificially elevate the level.

[Esme12, ASN, BSN, RN]

Thanks for the feedback. I definitely see what you are saying.

At my facility I have often seen hold parameters written for vanco and the lab draw, but other times not.

When I see orders such as "draw vanco trough at...hold next dose if >20 (or what level they specify), this very clearly means wait and use the result to determine whether to give.

When they said "draw trough at...pharmacy to dose" instead of "draw trough at...hold dose if..." I saw this as one has parameters, one doesnt, and in the second case the trough is to see how things are at the current vanco dose/frequency.

But then again, if a BP med had no parameters and the BP is low, this is not implying give the med no matter what their BP is. You would clarify before giving.

You are definitely right that just because pharm sends something, this is not a green light that it is ok to give, but I just thought that in the case of "pharmacy to dose", they were deciding how much and when to give...

So I guess I was just wondering if ordering a vanco trough was usually meant to determine the next dose, or if it is sometimes meant to change future doses, but not necessarily change the admin time.

Thanks for replying to my post.

It really depends on the MD and the facility. But you still gave the does before the trough was drawn. Pharmacy dosed on a 2 day old trough. I agree it is poorly written order I would have clarified it with the MD.

Lab is still wrong for not drawing the the lab. I would have drawn the lab myself if lab was running that late or I would have bugged them until they came.

[melosa08, BSN]

What I would of done is waited til lab drew the trough, especially since it was to be drawn at 1600. That way if they need to hold or adjust the dose, the ordering physician can be notified of the results as well unless there was a order written to hold within these parameters.

In your case, I would of called the lab to see how soon someone could come as it was already 3 hours late. I hope the person that gave you report keep checking in with lab because it was to be drawn on their shift. I'm not sure what area you work, but I use to work in the ICU and lab always called to see if the pt a stick or line draw so I know when they are there. In my experience with vanco, I'm use to seeing orders to hold if greater than 20. I agree with those above, pharmacy shouldn't of sent that med especially since trough results were not in.

[glasgow3]

1) The order was poorly written; as mentioned earlier a Vanco trough should be drawn immediately before (normally understood to mean less than 30 minutes before) the scheduled dose. Since the daily scheduled dose was timed for midnight, a true trough draw should have been scheduled for 2330. Since it was actually ordered as a trough (as opposed to just a scheduled lab) the physician's order should have been clarified.

2) The lab was "backed up" for a timed draw is NOT an acceptable excuse for it not being done until several hours late; an occurrence report should have been prepared and all notifications made per your facility's policy and procedures. (At that time you could have clarified the physician's intentions and what he/she wanted you to do now.)

3) Pharmacists never "decide how much and when to give" Vanco, but rather with a physician's order they may follow certain preapproved protocols. In some facilities only specified pharmacists may make these adjustments. In any event the "pharmacy dose" must be determined by the protocol/calculation. If the late draw conflicted with the dosing protocol they should clarify with the provider.

4) The nurse is always the "last line of defense" in med administration; If you weren't satisfied with pharmacy's explanation, seek guidance/clarification from the provider before hanging the med.

5) All that said, I'm fairly certain that the physician merely "misspoke" when he/she wrote for a Vanco "trough" and that he/she fully expected that a dose would be given at midnight per protocol. It's the pharmacist's responsibility to determine whether or not that late draw will interfere with his dosage calculation.

6) In any event, when you know you have an issue early in the evening, it's best to resolve it then.

[rn.5245]

Thank you all for sharing your knowledge and experience with me. I am in my first year of nursing, about 9 months in...

I definitely see where I fell short in this scenario, being the last line of defense I know I should have followed up.

I'm not sure if this changes anything, but upon review all my papers and the mar, I realized that the vanco was actually scheduled for 1700, with the trough at 1600.

When lab never came, the day nurse passed it to me by calling pharm and changing the time to midnight. But this was not really clear, as I did not realize the full situation....

So I am frustrated with myself in that I mishandled the situation, and just bummed that I did not realize/clarify with each team member that was involved, because I was on the receiving end of each of their actions, while they got to pass it down the line...

I hope this doesn't turn into a write up, although I would understand if it does happen...i will think of it every time i have a trough in the future, as i add it to my collection of mishaps i will hopefully never repeat this mistake!

[MunoRN, RN]

I'm still trying to wrap my head on how lab could have been 8 hours behind in their lab draws, if that's the case then that's the biggest problem here. Lab draws are an inconsistent workflow, so I realized not everything is going to get drawn on time, but after an hour, definitely two, I'd let them know that this has to be the next draw they do.

It's very important to determine when the draw actually was done in comparison to when you hung the vanco, if it was drawn any time after the vanco starting infusing then it means the vanco level has a very different meaning, and you wouldn't want pharmacy re-dosing the vanco on a lab result that wasn't actually a trough.

[Cook26]

Just a question, but why didn't you draw the lab yourself instead of waiting for phlebo to come? Also, in what area of the hospital do you work?

In my ICU (and all others at my hospital), we don't have anyone to draw labs and are responsible for all patient sticks. In the progressive and floor areas there is someone from lab who comes and gets them.

[rn.5245]

I am on a DOU step-down unit at a small community hospital. We only do our own draws if the patient has a PICC, central line, or port, all peripheral draws are done by phlebotomy.

Basically I should have followed up, and although this is no excuse, it was very chaotic on our floor that day because we were in the middle of day 1 of transitioning to a new electronic charting system, a very atypical day, and so lab and pharmacy were chaotic as well up on the floors...meds being entered wrong, orders incorrect, and not fully knowing how to correct things yet...During the whole transition process, and every other day I have had as a nurse, that first transition day was uniquely the most confusing and stressful day...

I definitely dropped the ball with this detail, and so did other departments...I always ask someone or get help when I am unsure...and under normal circumstances I would have had a calm second to think it through...