| Principal Investigator: | Eric C. Dougherty, PharmD, BCPS |
| Co-Principal Investigator/Collaborator: | Rebecca A. Rottman-Sagebiel |
| Organization: | South Texas Veterans Health Care System |
Abstract
Problem
The Joint Commission National Patient Safety Goal (NPSG) 2008 03.05.01 seeks to reduce the likelihood of patient harm associated with the use of anticoagulant therapy. In 2008, South Texas Veterans Health Care System had a heparin infusion order set that allowed providers to select a standard titration protocol or develop patient specific, weight-adjusted protocol. In February 2009, Veterans Affairs Directive required weight-adjusted heparin bolus and infusions.
Evidence
Available evidence supports reduced recurrent thromboembolism with weight-adjusted heparin regimens. Heparin nomograms following aPTT levels vary depending upon response to reagents and coagulometers used. Anti-factor Xa heparin levels (anti-Xa) provide predictable monitoring and adjustments with infusions. Target levels remain constant, not varying with reagent utilized.
Strategy
An Anticoagulation Subcommittee of the Pharmacy and Therapeutics Committee formed in spring 2008 including internal medicine (esp. hematology, cardiology, and intensivists), nursing, patient safety, laboratory, and pharmacy to develop a weight-adjusted heparin protocol utilizing anti-Xa for monitoring. The goal was reduced time to therapeutic range.
Practice Change
A pilot of the new protocol was conducted in the Cardiac Care Unit for effectiveness and safety for three months. Extensive education was provided to all disciplines. The protocol was subsequently rolled out hospital wide with continued monitoring ongoing.
Evaluation
Baseline data was collected to evaluate the existing protocol for effectiveness. Pilot data was reviewed monthly by the Subcommittee.
Results
Time to therapeutic range decreased from an average of four days to less than 24 hours. Monitoring anti-Xa afforded less variability in lab results versus a PTT.
Recommendations
Effective use of interdisciplinary committees allowed for safe, effective, and timely implementation of hospital protocols that promotes better patient outcomes. Future goals include developing protocols for utilizing, titrating, and monitoring low molecular weight heparins.
Lessons Learned
Developing and implementing new protocols to meet NPSG can be challenging. Acquiring interdisciplinary committee members that can provide leadership across services greatly facilitates this process.
Recognition
- 1st place poster winner, 2010 Summer Institute on Evidenced-Based Practice
Bibliography
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