Date of this Version
7-30-2025
Document Type
DNP Project
Abstract
This project highlighted both the opportunities and challenges involved in implementing a nurse-led quality improvement initiative in a high-acuity intensive care unit (ICU). The primary aim was to enhance therapeutic drug monitoring (TDM) of vancomycin by implementing a nurse-driven structured protocol supported by electronic health record (EHR) decision support tools. Early assessments revealed significant non-adherence to proper timing of trough-level collection and inconsistency in patient care practices. These gaps were addressed through the development and implementation of a standardized protocol that improved documentation, streamlined workflow, and strengthened communication across disciplines.
One of the key process improvements observed was a marked increase in timing compliance, rising from a baseline average of 30.9% to 74.9% post-intervention. This enhancement not only ensured more reliable monitoring of vancomycin levels but also supported safer and more effective dosing strategies. Importantly, although the project did not formally measure nephrotoxicity using clinical markers such as serum creatinine changes, the risk of toxicity was tracked using trough levels exceeding 20 mcg/mL, classified as critical. This served as a proxy indicator for nephrotoxic risk. During the baseline period, the average toxicity risk was 13.4%, which improved modestly to 11.9% in the post-intervention phase, suggesting a potential benefit in reducing the incidence of toxic vancomycin levels.
Despite these encouraging results, the project’s limitation in directly capturing nephrotoxicity rates remains a constraint in fully assessing patient safety outcomes. Routine creatinine monitoring was present, but a structured method to track vancomycin-associated acute kidney injury (AKI) was not integrated into the protocol. As vancomycin is a high-risk medication with well-documented nephrotoxic potential, future quality improvement efforts should include formal outcome monitoring to better understand the impact on renal function.
A major lesson from this initiative was the importance of frontline staff engagement, ensuring that the intervention remained clinically relevant and feasible within the dynamic ICU environment. Adaptability and interprofessional collaboration were key enablers of success, with contributions from nursing, pharmacy, medical, and IT teams ensuring the protocol aligned with institutional workflows and national goals for antimicrobial stewardship.
Looking ahead, this project provides a strong foundation for broader application and future advancement. Opportunities exist to expand outcome measures, integrate additional decision-support features, and scale the protocol to other care areas. More importantly, it fosters a culture grounded in accountability, evidence-based practice, and collaboration. Given the critical nature of vancomycin therapy in intensive care, the insights gained from this initiative can inform efforts to reduce variability, minimize adverse drug events, and promote safe, effective treatment across complex clinical settings.
Recommended Citation
harris townsend, tajae and delgado, victor, "Optimizing Blood Draw Practices and Nurse-Driven Vancomycin Trough-Level Monitoring to Enhance Patient Outcomes in the Intensive Care Unit: A Quality Improvement Initiative" (2025). Nicole Wertheim College of Nursing Student Projects. 356.
https://digitalcommons.fiu.edu/cnhs-studentprojects/356