Clinical Decision Support in the Electronic Medical Record to Increase Rates of Influenza Vaccination in a Pediatric Emergency Department.

OBJECTIVES: Vaccination against influenza has been shown to decrease the morbidity and mortality from the virus; however, rates remain below the Healthy People 2020 target of 70%. The emergency department (ED) provides a unique opportunity to administer influenza vaccines; however, interventions must be efficient to be successful. During the 2014 to 2015 season, an electronic medical record (EMR) intervention was implemented in an effort to increase influenza vaccination rates. METHODS: Using Lean methodology, a multidisciplinary team designed a series of triggers, alerts, and orders in the EMR to address the barriers to adoption and their root causes. The EMR functionality was implemented for the 2014 to 2015 influenza season. Reports on compliance with each EMR step were completed for the 2014 to 2015 and 2015 to 2016 influenza seasons. RESULTS: In the 2013 to 2014 influenza season, the ED administered 42 doses of the vaccine, representing 0.3% of eligible visits. After implementation of the EMR tool, the ED administered 1320 doses of influenza vaccine. This represents approximately 8.8% of qualified patients based on age group and eventual discharge from the ED. The results were sustained during the 2015 to 2016 influenza season with 1031 doses administered, representing 6% of eligible visits. CONCLUSIONS: The ED influenza vaccination program vaccinated approximately 20 times the number of eligible patients after automated EMR screening and ordering. Using knowledge of a multidisciplinary team, integration into the existing workflow, and visual cues in the EMR, we were able to increase the number of influenza vaccines administered substantially.

Population Pharmacokinetics and Pharmacodynamics of Extended-Infusion Piperacillin and Tazobactam in Critically Ill Children.

The study objective was to evaluate the population pharmacokinetics and pharmacodynamics of extended-infusion piperacillin-tazobactam in children hospitalized in an intensive care unit. Seventy-two serum samples were collected at steady state from 12 patients who received piperacillin-tazobactam at 100/12.5 mg/kg of body weight every 8 h infused over 4 h. Population pharmacokinetic analyses were performed using NONMEM, and Monte Carlo simulations were performed to estimate the piperacillin pharmacokinetic profiles for dosing regimens of 80 to 100 mg/kg of the piperacillin component given every 6 to 8 h and infused over 0.5, 3, or 4 h. The probability of target attainment (PTA) for a cumulative percentage of the dosing interval that the drug concentration exceeds the MIC under steady-state pharmacokinetic conditions (TMIC) of ≥50% was calculated at MICs ranging from 0.25 to 64 mg/liter. The mean ± standard deviation (SD) age, weight, and estimated glomerular filtration rate were 5 ± 3 years, 17 ± 6.2 kg, and 118 ± 41 ml/min/1.73 m(2), respectively. A one-compartment model with zero-order input and first-order elimination best fit the pharmacokinetic data for both drugs. Weight was significantly associated with piperacillin clearance, and weight and sex were significantly associated with tazobactam clearance. Pharmacokinetic parameters (mean ± SD) for piperacillin and tazobactam were as follows: clearance, 0.22 ± 0.07 and 0.19 ± 0.07 liter/h/kg, respectively; volume of distribution, 0.43 ± 0.16 and 0.37 ± 0.14 liter/kg, respectively. All extended-infusion regimens achieved PTAs of >90% at MICs of ≤16 mg/liter. Only the 3-h infusion regimens given every 6 h achieved PTAs of >90% at an MIC of 32 mg/liter. For susceptible bacterial pathogens, piperacillin-tazobactam doses of ≥80/10 mg/kg given every 8 h and infused over 4 h achieve adequate pharmacodynamic exposures in critically ill children.