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Multicenter Study
. 2023 Aug 1;45(4):508-518.
doi: 10.1097/FTD.0000000000001059. Epub 2023 Mar 21.

Why is the Implementation of Beta-Lactam Therapeutic Drug Monitoring for the Critically Ill Falling Short? A Multicenter Mixed-Methods Study

Erin F Barreto  1 , Pooja N Chitre  2 , Kathleen H Pine  3 , Kathryn K Shepel  4 , Andrew D Rule  5   6 , Mohammad H Alshaer  7   8 , Mohd Hafiz Abdul Aziz  9 , Jason A Roberts  9 , Marc H Scheetz  10   11 , Sara E Ausman  12 , Lindsay N Moreland-Head  1 , Christina G Rivera  1 , Paul J Jannetto  13 , Kristin C Mara  14 , Kasey R Boehmer  4   15
Affiliations
Multicenter Study

Why is the Implementation of Beta-Lactam Therapeutic Drug Monitoring for the Critically Ill Falling Short? A Multicenter Mixed-Methods Study

Erin F Barreto et al. Ther Drug Monit. .

Abstract

Background: Beta-lactam therapeutic drug monitoring (BL TDM; drug level testing) can facilitate improved outcomes in critically ill patients. However, only 10%-20% of hospitals have implemented BL TDM. This study aimed to characterize provider perceptions and key considerations for successfully implementing BL TDM.

Methods: This was a sequential mixed-methods study from 2020 to 2021 of diverse stakeholders at 3 academic medical centers with varying degrees of BL TDM implementation (not implemented, partially implemented, and fully implemented). Stakeholders were surveyed, and a proportion of participants completed semistructured interviews. Themes were identified, and findings were contextualized with implementation science frameworks.

Results: Most of the 138 survey respondents perceived that BL TDM was relevant to their practice and improved medication effectiveness and safety. Integrated with interview data from 30 individuals, 2 implementation themes were identified: individual internalization and organizational features. Individuals needed to internalize, make sense of, and agree to BL TDM implementation, which was positively influenced by repeated exposure to evidence and expertise. The process of internalization appeared more complex with BL TDM than with other antibiotics (ie, vancomycin). Organizational considerations relevant to BL TDM implementation (eg, infrastructure, personnel) were similar to those identified in other TDM settings.

Conclusions: Broad enthusiasm for BL TDM among participants was found. Prior literature suggested that assay availability was the primary barrier to implementation; however, the data revealed many more individual and organizational attributes, which impacted the BL TDM implementation. Internalization should particularly be focused on to improve the adoption of this evidence-based practice.

Trial registration: ClinicalTrials.gov NCT04755777.

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Conflict of interest statement

M. H. Scheetz reports a previous research contract with Allecra. E. F. Barreto reports an ongoing consultancy agreement with Wolters-Kluwer. For the remaining authors, no conflicts of interest were declared.

Figures

Figure 1.
Figure 1.. The conceptual framework for beta-lactam therapeutic drug monitoring implementation.
Successful implementation is determined by a supportive setting that serves as the foundation for internalization at the individual level and workflow development at the organizational level. Elements of an ideal setting to implement beta-lactam TDM include adequate, well-trained staff, access to validated tests with rapid turnaround time, information infrastructure such as an electronic health record and access to reference materials, robust communication networks, and deep leadership engagement. Individuals need the time to experience enough repeated exposure to credible evidence and expert insights to internalize, make sense of, and agree to embrace a beta-lactam TDM program. Finally, numerous decisions must be made to operationalize beta-lactam TDM, including the choice of patient candidates and pharmacokinetic/pharmacodynamic targets. Process mapping based on legacy TDM programs can facilitate the identification of gaps, inefficiencies, and responsible parties. Abbreviations: TDM: Therapeutic drug monitoring; PK/PD: Pharmacokinetic/pharmacodynamic
Figure 2.
Figure 2.. Clinician perceptions about beta-lactam TDM (upper panel) and potential barriers to implementation of beta-lactam TDM (lower panel).
Abbreviations: Center 1-NI: Not implemented; Center 2-PI: Partially implemented; Center 3-FI: Fully implemented
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Comment in

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