This project would also monitor supratherapeutic events as defined by aPTT over 117 seconds (Smythe et al., 2016). Knowing the impacts extended TTR has on outcomes and transitioning to oral anticoagulation, the P & T Committee recommended this project be prioritized to improve care of patients with VTE and PE events.
#Heparin drip manual
Based on the manual chart review of 48 male patients with a mean age of 70.5 years and a variety of protocols applied, GBMC found 22% of patients were placed on inappropriate heparin drip protocols, of which deep vein thrombosis (DVT) and pulmonary embolism (PE) combined accounted for 50% of the failure to reach TTR. Included in the study to determine efficacy were protocol usage, time to anticoagulation, literature review for best practice guidelines, and a comparison of aPTT and anti-Xa correlations between GBMC and other laboratories.
Define the Clinical Problem and Pre-Implementation PerformanceĪs part of the ongoing work by GBMC’s Pharmacy and Therapeutics (P & T) Committee, a study of outcomes was completed and presented in February 2019 related to heparin drip protocols. As part of the evolving COVID-19 best practices, we noted highs and lows in reaching our 24-hour TTR, which speaks to the peaks and valleys of prevalence in COVID-19 diagnoses from March 2020 through the present. Since July 2019, we’ve seen an increase in our 24 hours-or-less TTR of 162%, despite the complexities surrounding COVID-19 coagulopathy.
#Heparin drip verification
Through this process, the need for extensive re-education related to the pharmacy verification process and nursing IV pump use was noted and completed prior to the October 2019 roll out of the improved order set. Using Failure Modes and Effects Analysis (FMEA) methodology, the Project Team combined Epic analysts with key clinical stakeholders from ordering providers, pharmacists, and nursing over several months to rebuild the EHR Pharmacy to Dose Heparin order set through the mitigation of over 100 potential failure points, incorporating end-to-end testing from point of order entry through delivery and titration of the heparin drip via IV pump at the bedside. Time to therapeutic range (TTR) was selected as the outcome metric to best replicate INR outcome measurement used to measure discharge criteria.
Noting the 22% inappropriate protocol selection and the variations in reaching therapeutic activated partial thromboplastin time (aPTT) ranges as measured in hours, further investigation was recommended by the Clinical Pharmacy team to identify opportunities to improve patient care and outcomes as it related to heparin drips. In February of 2019, the Pharmacy team performed an in-depth analysis of current the Greater Baltimore Medical Center (GBMC) order set related to heparin drip for efficacy and outcomes.
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