Vanco: give or wait for vanco trough?

Esme12, ASN, BSN, RN · Jun 15, 2014

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...

We all make decisions that in hindsight should have been different.((HUGS)) Doing a peripheral stick is like an IV...ask if in the future you can get the lab yourself.

june2009 · Jun 15, 2014

I'm probable going to get neck for this response but we grae vanco troughs a half hour prior to third dose being due and then hang that third dose. There is about a 4-6 hour turnaround time for our labs to be resulted. When the trough comes back. We fax to pharmacy and do what they tell us to do with the dosing (LTC, no in-house lab or pharmacy). But OP, you said that you draw labs from PICCs and central lines. Shouldn't vanco always be administered via central line?

iluvivt, BSN, RN · Jun 16, 2014

Vancomycin is acidic with a ph of less than 5 so optimally is is best to give via a CVC to get adequate hemodilution. You can however, give it peripherally for a short time using the smallest shortest catheter that will meet your needs and look for a good large soft vein not in an area of flexion or in the wrist. Once it is determined that the patient needs long term therapy or does not have suuitable veins to safely administer peripherally than a CVC should be placed to administer the therapy as soon as feasable. Often providers want to wait and get a culture back so they know if they will need the drug long term. You would not want to withhold treatment while you wait for a CVC unless of course you are desperate and must wait after failed attempts at peripheral access.

IVRUS, BSN, RN · Jun 16, 2014

Yes, it is ideal that vancomycin, which has an average pH of 3, be administered in a central line, like a PICC, but it isn''t absolutely mandatory, as ILUVIVT stated. My other concerns regarding the vanco trough results is this: Did they get the trough result out of the same lumen that the Vanc was infusing in? AND surely the lab was drawn before it was given, not during or after.

The decision to wait and give the next dose depends on MD orders and facility policies. Someone else mentioned that in LTC, Vanco usually isn't held as the luxury of immediate results is not a reality... So true. So, know what your policy is, and if the MD doesn't adress it, follow the P&P of your institution.

SouthernPoint · Jun 16, 2014

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.

Yes, & No. I have seen many, many Vanc orders during my career written just like this.

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.)

Again, Yes & No. The lab being backed up is NOT EVER an acceptable excuse. But the P&P's are in place for us to use. I can almost guarantee calling the MD would have resulted in the MD telling her to just call the Pharmacist.

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.

Sorry, but having been on Vanc myself. Your statement is 100% incorrect. My MD ordered the Vanc, but it was ALWAYS the Pharmacist who Dosed. Pharmacist are Doctors of Pharmacy. Most know their Drugs.

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.

100% Correct. She should have NEVER hung the Vanc without clarification/guidance.

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.

I honestly don't think the "Physician" misspoke. Whom ever sent the Vanc to the floor should have never done so. The are reason why a Trough is being drawn. In my past experience of Vanc it has been the Pharmacist who wrote the on going orders for the medication and troughs.

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

100% Correct.

But with all of this said. Who really wrote the order? Was this the 1st order for Vanc? It doesn't seem so. Could it have been the Pharmacist whom wrote the order? Anyways. The Vanc should have not been given until the trough was drawn, not after. That trough is no good and now the patient has a lab charge that is basically bogus.

I personally believe that the OP really should read up on her medications before giving them if she has any questions.

glasgow3 · Jun 16, 2014

Quote from 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.

Yes, & No. I have seen many, many Vanc orders during my career written just like this.

1) That you have seen many poorly written orders is hardly the point; If you can produce an authoritative source that states a Vanco trough should be drawn at a time other than as I described, I would be interested. I don't believe you will find such a source.

More germaine to the current discussion, had you carefully read the OP's later clarification, you would have learned that the scenario was NOT as originally described: That is, as it turns out the order was NOT for a 1600 trough for the midnight dose.

An actual trough drawn eight hours before the scheduled daily dose would yield a misleading value because that is way too early. Due to the potential for underdosing the next dose, the order (had it actually existed as originally described) 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.)

Again, Yes & No. The lab being backed up is NOT EVER an acceptable excuse. But the P&P's are in place for us to use. I can almost guarantee calling the MD would have resulted in the MD telling her to just call the Pharmacist.

2) The facility Policy and Procedure manual no doubt required that an occurance report be made for a timed lab draw as late as described; such reports invariably require that the provider be notified and actually contain space to document that this had been done.

It is of no significance whether or not the provider took the news of the late draw well, or threw a fit, or told the notifying nurse to call pharmacy. The point here is that the provider has been notified of a significant deviation from the provider's order. That said, that would have been a perfect time, early in the evening, to "gently" clarify why the trough was ordered so early in relation to the scheduled dose in the first place. Catch?

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.

Sorry, but having been on Vanc myself. Your statement is 100% incorrect. My MD ordered the Vanc, but it was ALWAYS the Pharmacist who Dosed. Pharmacist are Doctors of Pharmacy. Most know their Drugs.

3) I have a great deal of respect for pharmacists and I am well aware of their extensive professional preparation and also which degree they have earned.

But the "iv Vanco, pharmacy to dose" order related by OP is proof positive that pharmacists may NOT dose a single mg of anything without a physician's order. Now the actual dosing methodology is invariably a product of the approval of one or more facility committees comprised of physicians and pharmacists etc. Make no mistake: the physicans know that the pharmacists have the bulk of the expertise BUT the pharmacists do not have free reign in a hospital setting. EVER.

When I run codes it may appear to an outside observer that I am ordering and dosing emergency drugs, however, I am actually following well defined, evidenced based protocols which have been approved by several committees. Any material deviation and I am toast.

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.

100% Correct. She should have NEVER hung the Vanc without clarification/guidance.

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.

I honestly don't think the "Physician" misspoke. Whom ever sent the Vanc to the floor should have never done so. The are reason why a Trough is being drawn. In my past experience of Vanc it has been the Pharmacist who wrote the on going orders for the medication and troughs.

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

100% Correct.

But with all of this said. Who really wrote the order? Was this the 1st order for Vanc? It doesn't seem so. Could it have been the Pharmacist whom wrote the order? Anyways. The Vanc should have not been given until the trough was drawn, not after. That trough is no good and now the patient has a lab charge that is basically bogus.

I personally believe that the OP really should read up on her medications before giving them if she has any questions.

(4 (5 (6 Sure glad I was given 100% on my last 3 points; with only 50% on the first 3, I might have failed and had to repeat the course or something.

ICURN3020 · Jun 19, 2014

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!

You're right..... :yes: it's a lesson learned and now you know. This is how we learn, by making mistakes and growing from them. It shows a lot that you took the time to review everything that had happened....or didn't happen.....and are trying to learn from the experience.

ICURN3020 · Jun 19, 2014

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....

It sounds like this nurse, instead of addressing the issue appropriately by contacting the lab and ensuring that the blood draw was done in a timely fashion, just pushed off the*problem*for you to deal with later.

These are my least favorite nurses to work with.... :no: I got report from one of them last night and could write a laundry list of things they "didn't have time to get to" or inconsistencies I found between what I was told in report and reality, but that would be getting off topic.

calivianya, BSN, RN · Jun 24, 2014

I love the way most of the physicians here write vanc orders. After the first couple of doses are given, they just have daily vanc levels and an order: give 1g vancomycin IV if vanc level

Sounds like you had a hectic day - any day you have something new/different to do in the world of electronic charting is a bad day. You now know for next time that it's very important to draw the trough first, and draw it yourself if you have to. Vanc is one of those drugs that it's really horrible for the level to get too high - we had a patient come in from a nursing home a couple of months back where they'd been giving her vanc but didn't monitor her level. We checked her and she was in the 80s. She ended up on dialysis. No preexisting renal issues, but you don't really need them when you have high levels of vanc on board.

One ray of semi-sunshine - if your non-trough level came back at 27, you probably didn't kill any kidneys this time. That's not an insanely high level.

~PedsRN~, BSN, RN · Jun 24, 2014

It sounds like this nurse, instead of addressing the issue appropriately by contacting the lab and ensuring that the blood draw was done in a timely fashion, just pushed off the*problem*for you to deal with later.
These are my least favorite nurses to work with.... I got report from one of them last night and could write a laundry list of things they "didn't have time to get to" or inconsistencies I found between what I was told in report and reality, but that would be getting off topic.

This, exactly. Previous Shift RN should have ridden someone's ASS to get that trough. Really, is a trough that is FIVE HOURS LATE or whatever - really even a trough at that point? Ugh. Hate it when that happens. Huge pet peeve. I will start harrassing lab two hours prior to the trough. LOL!

Loo17 · Jun 24, 2014

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!

Just wondering, if the Vanco is due at midnight, why is the trough being drawn at 4pm? That seems very early for a trough. Is your goal trough 15-20? I wonder if the dosing is accurate with the trough regularly being drawn 8 hours before the dose, vs the 1-2 hours I have seen. I would think the pharmacy might be inaccurately dosing the Vanco since they aren't getting a true trough.

As far as your question, the pharmacy/your facility should have a policy if dose is to be held for trough level results and if they don't then the MD writing the order needs to specify to hold or not to hold next dose.

~PedsRN~, BSN, RN · Jun 24, 2014

Just wondering, if the Vanco is due at midnight, why is the trough being drawn at 4pm? That seems very early for a trough. Is your goal trough 15-20? I wonder if the dosing is accurate with the trough regularly being drawn 8 hours before the dose, vs the 1-2 hours I have seen. I would think the pharmacy might be inaccurately dosing the Vanco since they aren't getting a true trough.
As far as your question, the pharmacy/your facility should have a policy if dose is to be held for trough level results and if they don't then the MD writing the order needs to specify to hold or not to hold next dose.

I believe I read that the previous nurse rescheduled the dose of Vancomycin? Am I making that up?