Evaluation of appropriate heparin titration dose adjustments after - - PowerPoint PPT Presentation
Evaluation of appropriate heparin titration dose adjustments after implementation of a dose adjustment calculator Jeremy Andis, Pharm.D. PGY-1 Pharmacy Resident HSHS St. Elizabeths Hospital OFallon, IL Conflicts of Interest 2 The
PGY-1 Pharmacy Resident HSHS St. Elizabeth’s Hospital O’Fallon, IL
2
3
4
– Saint Louis University Family Medicine – Nursing Residency Program – PGY-1 Pharmacy Residency – PGY-2 Pharmacy Informatics Residency
– 20 ICU beds – 22 ER beds
5
– More than 17,000 heparin-related errors reported between 2003 and 2007 by USP
6
Santell, J. Improving Heparin Safety. 2008 Mar. San Diego, Ca.
– Cardiac: 0.3-0.5 units/mL – Medical: 0.3-0.7 units/mL
7
Smith ML, Wheeler KE. Am J Health Syst Pharm. 2010;67(5):371‐374.
8
9
10
11
Calculator during initial start of heparin drip
12
Calculator during adjustment of heparin rate after result of subtherapeutic anti-xa
If Anti-Xa result is less than 0.06: Bolus with 60 units/kg and increase heparin drip rate by 300 units/hour.
13
Calculator after result of therapeutic anti-Xa
If Anti-Xa result 0.3 - 0.5: NO CHANGE, AT GOAL and REPEAT level in AM unless this is the first level within range, then REPEAT level in 6 hours.
14
Calculator during adjustment of heparin rate after result of supratherapeutic anti-Xa level
If Anti-Xa result 0.71 - 1.1: HOLD heparin drip for one hour, REPEAT STAT LEVEL after 1
0.7, continue to HOLD infusion and REPEAT STAT level every 1 hour. Once level is less than 0.7, RESTART infusion but DECREASE by 200 units/hour.
– IRIS: Incident Risk Information System – Utilizes software provided by RLDatixTM
15
16
17
Design: Pre and post implementation, randomized, retrospective chart review Time period:
Inclusion Criteria
– Utilization of a heparin dosing protocol
Exclusion Criteria
– Age < 18 years – Modification of standard heparin dosing protocol – Three or less heparin anti-Xa levels available
Data extracted from EMR data repository:
Xa level that resulted within the designated time period
(post implementation)
18
Primary Endpoint
– Rate of heparin infusion rate adjustment errors that occurred
Secondary Endpoints
– Inappropriate use of protocol – Number of dose adjustment errors that were formally reported in an IRIS – Inappropriate use of calculator
19
20
Pre-Implementation Post-Implementation Number of Rate Adjustments 205 364 Calculator Use
Anti-Xa Levels per Patient (mean) 6.9 7.4 Total anti-Xa levels per month reviewed 64 402.5 June 236
34
18
59
37
January
Patients Anti-Xa Levels Pre-Implementation (n) 56 386 Post-Implementation (n) 110 805
Sample size:
Primary Outcome:
21
Pre-Implementation (n=205) Post-Implementation (n=364) P-value
Rate Adjustment Errors, No. (%) 23 (11.2) 32 (8.8) 0.376
Post-Implementation Evaluation Calculator (n=258)* No Calculator (n=106)* P-value
Rate Adjustment Errors, No. (%) 15 (5.8) 17 (16) 0.005
n: total number of rate adjustments n: total number of rate adjustments
Secondary Outcomes:
22
Pre-Implementation Post-Implementation P-value Inappropriate use of protocol, No. (%) 67 (17.4) 110 (14.9) 0.099
Inappropriate bolus dose, No. (%)
4 (5.1) 32 (17) 0.010
Inappropriate monitoring, No. (%)
37 (9.6) 83 (10.3) 0.758 Total Pre- Implementation Post- Implementation Number of errors formally reported,
36 (20*) 21 15 *Compared to the total number of errors involving heparin found during chart review
Secondary Outcomes:
23
Calculator Assessment Inappropriate use of calculator, No. (%) 10 (2.1)
Baseline anti-Xa entered into calculator with start of heparin 3 (0.6) Initiation of heparin infusion with rate adjustment based on baseline anti-Xa 0 (0) Incorrect anti-Xa entered into calculator 1 (0.2) Input of most recent anti-Xa level after holding period of heparin due to supratherapeutic level 2 (0.4) Failure to decrease heparin rate after holding period 2 (0.4)
– Difference found when looking at calculator vs no calculator use in the post-implementation group – Less than optimal use of calculator
– Worse in post implementation group
24
– Not statistically significant for primary outcome – Factors that may have affected outcome
– Low rate of errors with calculator use seen – May be falsely low due to data collection bias and difficulty identifying errors in EMR
25
– Data collected soon after implementation of calculator
– Majority of pre-implementation data collected during June – Multiple data collectors – Reliance on EMR documentation – Retrospective study design
26
– Computer-based learning programs – Active promotion of calculator utilization by nurse managers
– Additional field asking if the previous dose was held
– Comparisons of different facilities in health system – Assessment of clinical outcomes (time in therapeutic range, mortality, rate of adverse event occurrence)
27
PGY-1 Pharmacy Resident HSHS St. Elizabeth’s Hospital O’Fallon, IL