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Vancomycin Dosing and Monitoring – Adult – Inpatient [129]

Vancomycin Dosing and Monitoring – Adult – Inpatient [129] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 129

Delegation Protocol Title:
Vancomycin Dosing and Monitoring - Adult - Inpatient

Delegation Protocol Applies To:
All adult admitted patients and those in the Emergency Department

Target Patient Populations:
Admitted adults and adults in the Emergency Department with orders for intravenous vancomycin

Delegation Protocol Champions:
Alex Lepak, MD – Department of Medicine – Infectious Disease
Barry Fox, MD – Department of Medicine – Infectious Disease

Delegation Protocol Reviewers:
Joshua Vanderloo, PharmD – Department of Pharmacy
Lucas Schulz, PharmD – Department of Pharmacy

Responsible Department:
Department of Pharmacy

Purpose Statement:
To delegate from the ordering provider of vancomycin to the Inpatient and Emergency Department
pharmacists the authority for the initial vancomcyin dosing, vancomycin dosing adjustment based on
renal function, vancomycin dosing adjustment based on vancomycin therapeutic drug monitoring, and
ordering of labs necessary to monitor therapy of based on the Intravenous Vancomycin Use – Adult –
Inpatient Clinical Practice Guideline.

Who May Carry Out This Delegation Protocol:
Pharmacists that have been trained in the use of this delegation protocol. All new pharmacists complete
four-hour pharmacokinetic/pharmacodynamic training and competency as part of new-hire orientation.
Prior to protocol implementation pharmacists will complete a CBT module with a case-based
competency assessment.

Guidelines for Implementation:
1. This protocol is initiated for any active order of intravenous vancomycin. This protocol does not
authorize pharmacists to initiate medication therapy.
2. Inclusion criteria:
2.1. Eighteen years of age or older AND
2.2. Inpatient order for intravenous vancomycin
3. Exclusion criteria. If the patient meets any of the exclusion criteria the protocol does not apply and a
provider will be consulted prior to placing any orders.
3.1. Patients younger than 18 years of age
3.2. Patients with daily vancomycin doses of six grams (6000 mg) or greater
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

3.3. Administration instructions with wording “Do not adjust per protocol” or other language
conveying this intent
4. Pharmacist will modify orders, if necessary, for vancomycin according to the UW Health Intravenous
Vancomycin Use – Adult – Inpatient Clinical Practice Guideline. Pharmacist will also review the
medical record for previously entered orders to avoid unnecessary duplicates.
5. Pharmacists will also place ordes for laboratory tests including vancomycin concentration,
creatinine, and BUN according to the Intravenous Vancomycin Use – Adult – Inpatient Clinical
Practice Guideline.
6. A pharmacist will enter progress notes detailing subjective information, objective information, an
assessment, and a plan. The pharmacist’s subjective and objective evaluation and plan formulation
will be documented using the Clinical Pharmacist Vancomycin Pharmacokinetic/Pharmacodynamic
Note template.

Order Mode:
Medications – Protocol/Policy Without Cosign
Laboratory Orders – Cosign Required – Protocol/Policy

References: NA

Collateral Documents/Tools:
UW Health Intravenous Vancomycin Use – Adult – Inpatient Clinical Practice Guideline

Approved By:
Antimicrobial Use Subcommittee: August 2015
UWHealth Lab Practice Committee: November 2015
Pharmacy and Therapeutics Committee: September 2015
UWHC Medical Board: December 2015

Effective Date: December 2015

Scheduled for Review: December 2017
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org