2019 Research Forum

Applicant: Robert Chiles PharmD R1 Principal Investigator & Faculty Sponsor: Jasmine Ho PharmD

RESULTS

The Impact of Education on Compliance of Kern Medical’s Heparin Protocol

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

*The percentage of time in therapeutic range was an average of 15.9% higher in 2017 vs 2019 (95% CI= 2.85% to 28.96%)

INTRODUCTION According to the Institute of Safe Medication Practice (ISMP), unfractionated heparin is considered a high-alert medication that requires cautious monitoring, prescribing, dispensing, and administration. At Kern Medical, there are two heparin protocols for specific indications: venous thromboembolism (VTE) and acute coronary syndrome (ACS). In 2016, a medication use review (MUE) of heparin showed suboptimal time within therapeutic range, which prompted changes in both heparin protocols to weight based infusion rate adjustments. In the new heparin protocol, healthcare providers are provided with targeted therapeutic ranges, initial dosing recommendations, dose adjustment recommendations based on patient’s weight, and monitoring parameters. Physicians would order the specific heparin protocol and nurses would follow the outlined steps for heparin management stated on the protocol sheet while clinical pharmacy provides monitoring and dosing recommendations for all patients on IV heparin. The updated protocol was implemented in 2017; however, the follow up evaluation revealed room for improvement with protocol compliance which prompted a pharmacist-led staff education campaign regarding the proper use of the new heparin protocols. PURPOSE To evaluate the effectiveness of the staff education on heparin protocol adherence and possible impact on time in therapeutic range. METHOD A pharmacist-led education campaign was conducted to physician residents and staff nurses from May to July 2018. Retrospective chart review was performed evaluating charts prior to the education campaign. They were compared to those who were treated with intravenous heparin post educational campaign from July 2018 to February 2019. Exclusion criteria include different target aPTTs from the protocol, indications other than VTE or ACS, lack of documentation using the required heparin flowsheet, and discontinuation of heparin infusion within 6 hours of initiation of therapy. The results of compliance to heparin protocol and efficacy of therapeutic outcomes from the pre- and post-education campaign were compared.

DISCUSSION The educational campaign was successful in improving compliance with heparin protocols in terms of utilization of correct heparin flowsheet, ordering heparinized PTT, and noting total body weight. However, the overall proportion of time in which patients were in therapeutic range decreased from 2017 to 2019. A subgroup analysis was conducted to assess the reason of decreased efficacy. There was a trend toward longer time to reach therapeutic range and overall less time in therapeutic range in patients where bolus doses were omitted. However, the subgroup analysis was not sufficiently powered to detect this difference. Further analysis is warranted and underway to further improve the outcomes associated with heparin protocols. CONCLUSIONS The heparin education campaign of 2018 was effective in improving heparin protocol compliance. However, the proportion of time in therapeutic range decreased during this time, which warrants further investigation and possible protocol revision.

10