The Duke Heparin ProtocolImplementation of Nurse Driven Heparin Protocol at Duke University Hospital

Jordan Hildenbrand, MS2; Kimberly Hodulik PharmD, CACP, CPP; Adam Root PharmD; Jason Funaro PharmD; Dorothy Filippi MSN, RN, CCRN; Faryl Podolle RN; Susan Ashland RN; Megan Greenland PharmD; Noppon Setji MD; Nilesh

Patel MDDepartments of Medicine, Pharmacy, and Nursing, Duke University Hospital

Technology• Lack of current

EMR based decision support tools

• Multiple processes and options for heparin ordering

Nursing Phlebotomy• No timed labs at

DUH• Delay from time of

order to draw, exacerbated based on phlebotomist scheduling

• Process potentially more complex than other nurse driven infusions

• Variable experience based on nursing unit

Physicians• Perceived low compliance

with institutional policy• Delay to follow up and

intervention on monitoring labs

• Communication among team delayed

• Variable experience with heparin

Leadership• No structured

education focused on heparin infusions

• Policies difficult to find with current tools

Pharmacy• High patient and

team volume per PharmD

• Variable local ordering cultures of heparin

HEPARIN MANAGEM

ENT ERRORS

FISHBONE DIAGRAM

AIMS• The new Duke Heparin protocol will improve adherence

with the dosing, timing, and communication required with the institutional nomogram

• The new Duke Heparin protocol will decrease the time to therapeutic range for patients on heparin

BACKGROUND• Patients are anticoagulated in the inpatient setting using

heparin for reasons including deep vein thrombosis, acute coronary syndromes, and atrial fibrillation

• Advantages of heparin are titratability, reversibility, and use in renal failure

• Disadvantages include a narrow therapeutic window• Under-dosing, inconsistent adherence to nomogram, and

delayed communication are barriers to ideal heparin dosing

INTERVENTIONS• Formation of an inter-professional team, including leadership,

nurses, physicians, and pharmacists• Assessment of current heparin management process,

including ordering process (through Epic®), indications, frequency of use, and amount of oversight

• Assessment of current factors leading to heparin management errors (see fishbone) and development of new heparin process map

• Development of education program for 110 nurses regarding heparin indications, management, and complications

• Development of new educational, policy and calculator tools through DukeCore.org/heparin

• One-on-one training of all bedside nurses on heparin management process

• Development of feedback process on all errors regarding heparin with nursing, pharmacy, and physician leads

• Evaluate nomogram to potentially deliver faster times to therapeutic to patients

• Expand the protocol to more units within Duke University Hospital• EPIC/EMR integration of decision support tools• Engage phlebotomy leadership in decreasing delays to aPTT draws• Re-evaluate nursing comfort as experience continues

NEXT STEPS

• General medicine nurses are engaged in delivering a safe heparin protocol to patients

• Nursing protocols improve compliance with an institutional nomogram

• Nurses and physicians deliver similar results in heparin titration• Nurses are comfortable in managing heparin infusions• Improved safety endpoints compared to before initiation• RNs respond quickly to aPTT values and make corresponding dose

titrations

CONCLUSIONS & LESSONS LEARNED

OUTCOMES

DEMOGRAPHICS Pre-Protocol (n=33)On-Protocol

October-January (n=33)

On-Protocol

January-May (n=42)

Indication

DVT/PE 18 (55%) 19 (40%) 29 (69%)

Atrial fibrillation

/mechanical valve11 (33%) 7 (21%) 9 (21%)

ACS/MI 3 (9%) 5 (15%) 2 (5%)

Stroke 0 (0%) 0 0

Other 1 (3%) 2 (6%) 2 (5%)

PROCESS MEASURES Pre-Protocol ValueOn-Protocol Value

(October-January)

On-Protocol Value

(January-May)

# aPTTs per patient 4 4 4.6

Inappropriate Bolus

Adjustments53/177 (30%) 7/125 (6%) 33/192 (17%)

Inappropriate Infusion

Adjustments70/177 (40%) 10/125 (8%) 36/192 (19%)

Adjustments within 60

minutes of aPTT result38/71 (54%) 54/70 (77%) 61/78 (78%)

Mean time to RN

adjustment1.3 hours 0.7 hours 0.84 hours

OUTCOMES Pre-Protocol ValueOn-Protocol Value

(October-January)

On-Protocol Value

(January-May)

Number of patients having

therapeutic aPTTs23/33 (70%) 21/33 (66%) 38/42 (90%)

Time to Therapeutic (mean) 15.9 hrs 14.4 hrs 16.2 hrs

SAFETY MEASURES Pre-Protocol ValueOn-Protocol Value

(October-January)

On-Protocol Value

(January-May)

Minor Bleeding 2 (6%) 4 (12%) 3 (7%)

Major Bleeding 4 (12%) 5 (15%) 1 (2%)

Recurrent Thrombus 0 0 0