Revisiting the Heparin Nomogram: Leveraging Technology to Improve Quality

• Published in: Blood 2012-11, Vol.120 (21), p.1168-1168
• Main Authors: Hamilton, Aaron C, Bartholomew, John R., Militello, Michael, Patrick, Robert, Kandpal, Saurabh, Bulgar, Alina, Bixler, Sarah, Klein, Deborah, Skowronsky, Catherine, Li, Ina, Rosenbaum, Keith, Gomez, Erron, Goodman, Jennifer, Sakenes, Sandra, Marchant, Kandice, Phillips, Shannon
• Format: Article
• Language: English
• ISSN: 0006-4971; 1528-0020
• DOI: 10.1182/blood.V120.21.1168.1168

Abstract 1168 Continuous infusions of unfractionated heparin (UFH) are still commonly used in the initial treatment of venous thromboembolism (VTE). As a result of UFH's high risk profile and common usage, weight-based UFH nomograms were developed more than two decades ago to standardize its dosing. Since that time, there has been scant literature on improving UFH administration. Specifically, upgrading current UFH nomograms, improving therapeutic monitoring, and exploring and expanding the role of Computerized Physician Order Entry (CPOE) and the Electronic Health Record (EHR) to achieve optimal delivery methods have little published research or quality improvement work. Several factors previously identified contributing to sub-optimal UFH therapy at our institution include timing of aPTT lab ordering and reporting, errors in dose adjustments, lack of boluses when clinically indicated, pharmacy and nursing administration errors, and suboptimal design and use of CPOE order sets. A multidisciplinary team at this academic medical center designed an intervention to improve the quality and safety of continuous UFH infusions in hospitalized patients. The aims were two-fold: reduce the time to initial therapeutic aPTT values and increase the overall time patients spent in therapeutic range without increasing time supra-therapeutic. To determine the percent time spent in different therapeutic ranges, linear averaging was used between aPTT values over time. As UFH is given continuously and monitoring aPTT values has inherent variability, we proposed that looking at time spent in therapeutic ranges gives a more realistic and meaningful clinical picture than current accepted metrics that look at single point-in-time aPTT values. We feel that these historic metrics, which focus on the percentage of patients with a therapeutic aPTT at 24 hours and time to therapeutic aPTT, do not provide sufficient information to impact optimal therapeutic dosing. The intervention involved four core changes to our existing UFH nomogram: 1.Dedicated UFH order set for treatment of VTE incorporating weight-based initial and subsequent boluses, and further dosage adjustments.2.Built-in online weight-based dosing calculator.3.Development of a new lab order aPTTAC (activated partial thromboplastin time anticoagulant) which prompted a priority lab draw and lab processing.4.Nursing dual sign-off on all dosage adjustments. We extracted data from the EHR of 8629 patients that were on continuous