2019 Research Forum

THE IMPACT OF EDUCATION ON COMPLIANCE OF KERN MEDICAL’S HEPARIN PROTOCOL

Robert Chiles PharmD R1, Jasmine Ho PharmD, Jeff Jolliff PharmD

Kern Medical Department of Clinical Pharmacy

Results

Introduction

Discussion

Table 1: Demographics

At Kern Medical, there are two heparin protocols for specific indications: venous thromboembolism (VTE) and acute coronary syndrome (ACS). In 2016, a medication use evaluation (MUE) of heparin showed suboptimal time within therapeutic range, which prompted changes in both heparin protocols from fixed dose to weight based infusion rate adjustments. The updated protocol was implemented in 2017; however, the follow up MUE revealed room for improvement with protocol compliance which prompted implementation of a new heparin flowsheet and “Heparinized PTT” orders (which prompts lab to process aPTT as “STAT” and notify RN with results to minimize delays to infusion adjustments). A pharmacist-led staff education campaign regarding the proper use of heparin protocols was provided to nursing personnel and physician residents in July 2018.

Figure 1: Indications

References • Post-education analysis showed a statistically significant increase in multiple compliance metrics including correct initial infusion rate, correct form use, notation of total body weight, and utilization of heparinized PTT • There was a significant decrease in percentage of time within therapeutic range and a trend toward longer time to reach the first therapeutic aPTT • Our subgroup analysis showed a trend of decreased percentage of time in therapeutic range and trend toward longer time to reach aPTT in those patients that did not receive a initial bolus, though the subgroup analysis was not sufficiently powered to detect this difference • Follow-up analysis is needed and underway to determine if the omission of bolus dosing was warranted in each case and if these omissions were responsible for the overall decrease in time within therapeutic range Conclusion • Overall, the educational campaign regarding the proper use of heparin protocols was effective in significantly improving protocol compliance • There will be continued education to nurses and physicians about the proper use of heparin protocols 1. Lexi-Comp Online, Lexi-Drugs Online, Hudson, Ohio: Lexi-Comp, Inc.; 2019. Updated Periodically 2. Taylor, Breann N., et al. “Evaluation of Weight-Based Dosing of Unfractionated Heparin in Obese Children.” J Pediatr , vol. 163, no. 1, 2013, pp. 150–153., doi:10.1016/j.jpeds.2012.12.095. 3. Khan, Samar U., et al. “Optimal Dosing Of Unfractionated Heparin In Obese Patients With Venous Thromboembolism.” Chest , vol. 128, no. 4, 2005, doi:10.1378/chest.128.4_meetingabstracts.406s-c. 4. Gerlach, Anthony, et al. “Comparison of Heparin Dosing Based on Actual Body Weight in Non-Obese, Obese and Morbidly Obese Critically Ill Patients.” Int J Crit Illn Inj Sci , vol. 3, no. 3, 2013, p. 195., doi:10.4103/2229-5151.119200. 5. Raschke RA., et al. The Weight-based Heparin Dosing Nomogram Compared with a Standard Care Nomogram: A Randomized Controlled Trial. Ann Intern Med . ;119:874–881. doi: 10.7326/0003-4819-119-9-199311010-00002

Pre-Edu n=23

Post-Edu n=39

P value

Pre-Edu

Post-Edu

0.965

57.3 ± 17.57 57.15 ± 15.39

Age [Avg. years ± SD]

ACS 35%

VTE 46%

ACS 54%

VTE 65%

Male: 27 Female: 12

Male: 12 Female: 11

0.2763

Sex [n]

0.261

80.63 ± 20 85.82 ± 15.38

Weight [Avg. kg ± SD]

Table 2: Heparin Protocol Compliance

Pre-Edu (n=23)

Post-Edu (n=39)

P value

8 (32)

20 (51)

0.292

Correct initial bolus dose [n(%)]

Objective

5 (20)

26 (66)

0.001

Correct initial infusion dose [n(%)]

To determine the effectiveness of staff education on the compliance and efficacy of heparin protocols.

11 (48)

39 (100)

< 0.001

Correct heparin flowsheet [n(%)]

Methods

3(13)

33 (84)

0.019

Total body weight noted [n(%)]

Retrospective chart review from 7/2018 to 2/2019 Inclusion Criteria: • Age ≥ 18 years old • Indication for VTE or ACS • Targeted aPTT listed in protocol Exclusion Criteria: • Discontinuation of heparin infusion within 6 hours of initiation therapy Primary outcome: protocol compliance

19 (87)

36 (92)

0.408

Baseline aPTT/CBC Noted [n(%)]

24/36 (67)

117/185 (63)

0.849

Infusion adjustments [correct/total adjustments (%)]

9 (39)

38 (97)

< 0.001

Heparinized PTT [n(%)]

Time to titrate heparin infusion (after lab results received) [mean hours ± SD]

0.43 ± 0.4

0.18 ± 0.4

0.0299

• Correct initial bolus dose • Correct initial infusion dose • Correct use of heparin flowsheet • Total body weight noted on flowsheet • Baseline aPTT/CBC noted • Utilization of “Heparinized PTT” • Correct infusion adjustments • Time to first therapeutic aPTT • Percentage of total hours therapeutic on drip

Table 3: Heparin Protocol Efficacy

Table 4: Post-Education Subgroup Analysis

Initial Bolus (n=25)

No Initial Bolus (n=14)

P value

Pre-Edu (n=23)

Post-Edu (n=39)

P value

Acknowledgements

Time to first therapeutic aPTT [mean hours ± SD] Percentage of time in therapeutic range [mean % ± SD]

Time to first therapeutic aPTT [mean hours ± SD] Percentage of time in therapeutic range [mean % ± SD]

16.59 ± 10.64 24.00 ± 23.96 0.189

13.3 ± 8.1 19.7 ± 17.6 0.104

Special thanks to: • Alice Peng, PharmD, BCPS • Janet Yoon, PharmD, BCPS • Brittany Andruszko, PharmD, BCIDP • Everett Yano, PharmD, CDE • Jay Joson, PharmD, APh, BCGP, BCPS, BC-ADM

Secondary outcome: efficacy

48.8 ± 24.43 37.48 ± 21.27 0.155

58.6 ± 25.6 42.7 ± 24.3 0.0178

• Jessica Beck, PharmD, BCPS • Shalom Sakowski, BSN, RN

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