Background

To determine the impact pharmacist monitoring and intervention has had on safety and efficacy outcomes of IV UFH at an urban teaching hospital.

Effect of Clinical Pharmacist Monitoring and Intervention in PatientsReceiving Intravenous Heparin

Michaela Raes, PharmD Candidate1,2; Amany Hassan, B Pharm, PhD2; Stacie Lampkin, PharmD2,3;

Richard Geisler, PharmD1

Mercy Hospital of Buffalo1, D’Youville College School of Pharmacy2, Women’s and Children’s Hospital of Buffalo3

Study Design•A retrospective, observational study compared adherence to the hospital heparin protocol before and after clinical pharmacist involvement in IV UFH monitoring.•Patients started on IV UFH using the hospital’s low or high protocol were identified using hospital data software. Each patient included in the study was analyzed for the following:

• Timing of anti-Xa levels• Acknowledgment of anti-Xa levels• Appropriateness of infusion rate adjustments• Appropriate protocol followed

Subject Selection •Inclusion Criteria

• Lab draws obtained from a patient with inpatient status• Between Dec. 2013 - Jan. 2014 (pre-intervention)• Between Aug. 2014 – Sept. 2014 (post-intervention)

• Lab draws obtained from a patient who received heparin infusion for at least 24 hours

•Exclusion Criteria• Subcutaneous heparin administration• Data from patients who received IV UFH for less than 24 hours • Patients with two or less documented data points • Data points with duplicate documentation• Patients who have undergone a thrombectomy

Statistical Analyses• Means and frequencies were used to summarize continuous and

categorical data.• Chi square tests were used to test the difference in proportions for

categorical variables.• Student t-tests were used to test difference in continuous data

• Generalized linear models will be used to quantify the association between pharmacist involvement in IV UFH and study endpoints while adjusting for baseline differences between patients

• Power analysis • A total sample of 98 data points was required to achieve 80% power

to detect a 20% increase in adherence to accurate timing of labs and timely acknowledgment of results

• Analyses were conducted at an significant alpha level = 0.05 and using SAS V. 9.3

Conclusions

results

objective

methods

references1Niccolai CS, Hicks RW, Oertel L, et al. Unfractionated heparin: focus on a high-alert drug. Pharmacotherapy, 2004;24(8):146S-55S2Biscup-Horn PJ, Streiff MD, Ulbrich TR, et al. Impact of inpatient anticoagulation management service on clinical outcomes. Annals of Pharmacotherapy, 2008; 42:777-823Dager WE, Branch JM, King JH, et al. Optimization of inpatient warfarin therapy: impact of daily consultation by a pharmacist managed anticoagulation service. Annals of Pharmacotherapy, 2000; 34:567-72. 4Fowler S, Gulseth MP, Renier C, et al. Inpatient warfarin: experience with a pharmacist-led anticoagulation management service in a tertiary care medical center. Am J Health-Syst Pharm, 2012; 69:44-48.5Kaboli PJ, Hoth AB, McClimon BJ, et al. Clinical pharmacists and inpatient medical care. Arch Intern Med, 2006; 166:955-64.6Witt DM, Sadler MA, Shanahan RL, et al. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest, 2005; 127(5):1515-22.7Wong YM, Quek YN, Tay JC, et al. Efficacy and safety of a pharmacist-managed inpatient anticoagulation service for warfarin initiation and titration, 2011; 36:585-91.

Previous studies have shown that intravenous heparin (IV UFH) accounts for 4.5-5.5% of reported medication errors that result in patient harm1. Other studies relating to anticoagulants have shown that pharmacist management increases the amount of time patients spend in therapeutic ranges, minimizes time spent above therapeutic range, eliminates interacting drugs, and reduces clinically significant bleeding. Pharmacist involvement in management of patients receiving IV UFH could improve adherence to hospital heparin protocols2-7.

250 data points from 30 patients were included in this retrospective analysis (147 labs pre-intervention, 103 labs post-intervention). Following the implementation of pharmacist monitoring of IV UFH, the number of lab draws in which the indication for heparinization matched the protocol selected significantly improved. Additionally, infusion adjustments per protocol significantly improved. Lab draw within 60 min of anticipated time and change of infusion within 120 min from lab draw were not significantly different.

Demographics and Baseline characteristics

Variable No Pharmacist Monitoring

(N= 18)

Pharmacist Monitoring

(N= 13)

P-value

Age, mean (SD) 64 (13) 70 (11) 0.1861 1

Gender , n (%)Male Female

12 (67)6 (33)

7 (54)6 (46)

0.4696 2

Race, n (%) CaucasianOther

17 (94)1 (6)

11 (85)2 (15)

0.3610 3

Heparin Protocol, n (%)Low doseHigh dose

11 (61)7 (39)

11 (85)2 (15)

0.2374 3

Appropriate initial infusion per weight, n (%)

Yes No

7 (41)10 (59)

10 (77)3 (23)

0.0711 3

Location, n (%)EmergencyCritical careSurgeryTelemetryPost-operativePost-PCIStroke

7 (39)4 (22)0 (0)0 (0)5 (28)1 (6)1 (5)

2 (15)4 (31)0 (0)0 (0)6 (46)0 (0)1 (8)

0.8783 3

1Independent two-sample t-test2Chi-square test3Fisher exact test Discussion

This preliminary results of this study indicate that pharmacist monitoring of IV UFH led to improved adherence to the institution’s heparin protocol in terms of appropriate infusion rate adjustments and protocol selection. Limitations of this study include that there is minimal data at this point and the analysis was focused on laboratory draws rather than a per-patient basis. Further data collection will be used to assess differences in adherence to protocol at the patient level.

Pharmacist monitoring of IV UFH appears to improve adherence to IV UFH protocol and infusion adjustments. Future analyses are needed to determine the impact of pharmacist monitoring on patient-specific outcome measures including hospital length of stay.

* p-value <0.05

The authors have nothing to disclose