Conference Report Published by CareFusion Center for Safety and Clinical Excellence
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- Figure 3. Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis Table 1. UCSD VTE Heparin Goals
- Figure 4. DVT Prophylaxis: Results
- Recognition of HIT
- Improving Heparin Safety
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Improving physician compliance Physicians are trained to be self-reliant experts and leaders and to value their autono- my. They also tend to resist change. Soliciting their advice and involving them early when protocols are developed helps to increase phy- sician compliance. If physicians are involved, they can use their experience to improve the protocol, are more motivated to make the protocol work, and feel less like they are being forced to do something. Late adopters may continue to resist using an order set from a VTE protocol because they do not believe their patients experience ADEs or they trust their own instincts over proven therapies. This reluctance may be addressed by publish- ing outcome data, presented the findings at educational sessions, such as grand rounds, seeing early adopters using the protocol and getting good results and ensuring the proto- col makes their work simpler—and failure to use the protocol more difficult. Figure 3. Percent of Randomly Sampled Inpatients with Adequate VTE Prophylaxis Table 1. UCSD VTE Heparin Goals • Get proper baseline labs • Give heparin 5+ days with INR > 2 for 2 days • Give, document appropriate education • Ensure timely lab / clinic follow up • UFH, not LMWH, when CrCI > 30 • UFH infusions by protocol • Offer chronic LMWH to CA patients Baseline Q 1
'05 Q 1
'06 Q 1
'07 Q 2
'05 Q 2
'06 Q 2
'07 Q 3
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'07 100%
90% 80%
70% 60%
50% 40%
30% 20%
2894 audits over 12 quarters, mean of 242 audits per quarter Consensus building Real time ID and intervention Order Set Implementation and Adjustment
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Executive Summary Conference Report 9th Invited Conference: Improving Heparin Safety Summary The use of an evidence-based protocol can help standardize and guide heparin dosage and adjustments and reduce opportunities for error. Like airplane pilots, physicians need alerts and checklists to help ensure safety. Such a protocol should prompt a physician to consider both the use of standard care, and special situations in which deviation from standard care are appropriate for individual patients. For example, UCSD’s heparin-based VTE prevention protocol encourages wide use of heparin unless contraindications are present, improving both VTE utilization and the rate of VTE. Tracking ADEs is important to identify possible adverse events from proto- cols, but requires active investigation to yield reliable results; real time investigation also offers opportunities to intervene in patients who either need therapy or have suffered an adverse event. Soliciting physician advice and involvement when the protocol is developed can help increase physician compliance—as well as identify clinical insights that improve the protocol.
1. Wein L, Wein S, Haas SJ, Shaw J, Krum H. Pharmacological venous thromboembolism prophylaxis in hospitalized medical patients: a meta-analysis of randomized con- trolled trials. Arch Intern Med. 2007;167(14):1476-86. 2. Data from LDS hospital, Salt Lake, presented by Brent James, MD, at the Intermountain Healthcare Advanced Training Program in Quality. Figure 4. DVT Prophylaxis: Results • "Preventative" VTE: 3.3 v 0.56* – RRR 83%; NNT 365 • VTE: 13.4 v 7.7* – RRR 43%; NNT 175 • PE: 3.95 v 1.22* • DVT: 15 v 8.76* PVT
VTE PE DVT 16 14 12 10 8 6 4 2 0 All values per 1000 patients; p< .05; "hospital acquired only Pre
Post Executive Summary Conference Report
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PROCEEDINGS There are two forms of thrombocytopenia caused by exposure to heparin. The more common, non-immune-mediated form occurs within the first few days after expo- sure to heparin when a slight decrease in the platelet count occurs. In this situation it is unclear whether heparin therapy needs to be stopped, because it has not been associ- ated with thrombosis. In contrast, the less fre- quent, immune-mediated heparin-induced thrombocytopenia (HIT) is associated with a greater reduction in platelet counts (50% reduction). Lower platelet counts during the acute phase of HIT have been correlated with an increased incidence of thrombosis 1 .
bosis can occur up to 30 days out but may be most common during the first few days after onset of thrombocytopenia. Since HIT can occur in any setting where heparin therapy is used, it is important to monitor platelet counts and educate professionals about rec- ognizing HIT.
No laboratory test alone can reliably diag- nose HIT. Currently diagnosis depends on assessment of associated heparin-exposure history, timing of the onset of thrombocy- topenia, the magnitude of the drop in plate- let count, presence of other causes of throm- bocytopenia or a positive HIT-antibody test. Three onset patterns have been observed after heparin exposure. The onset of HIT can be immediate if there has been a recent exposure to heparin. Onset more commonly occurs approximately four to ten days after heparin exposure. Delayed onset may even occur up to 40 days after discontinuing heparin. Monitoring To recognize and prevent HIT-related complications, the platelet count should be closely monitored to recognize decreasing values and the potential onset of the syn- drome. Pre-test probability tools, such as the 4T’s proposed by Warkentin, can assist clinicians in determining presence of HIT 2-3 .
One way to do this is to incorporate platelet count monitoring into heparin order sets. The frequency of platelet count monitoring may depend on the situation, as suggested in the College of American Pathologists-proposed guidelines 4 .
The description and corresponding defini- tion of HIT can depend on the clinical situa- tion of the patient. Acute HIT may be defined as the period of time when the platelet count is low and thrombosis risk highest. During this period, it is important to consider treat- ment with another parenteral anticoagulant such as a direct thrombin inhibitor (DTI). This treatment may be followed by a period when the platelet count is recovering and alternative anticoagulation therapy is being administered. Management considerations include tran- sitioning to prolonged anticoagulant therapy for one month for isolated HIT (no associ- ated thrombosis) or for at least three months for HIT thrombosis syndrome (HITTS). For patients with a history of HIT after platelet count has recovered and prolonged antico-
• Compared with the more common, non-immune-mediated heparin-induced thrombocytopenia (HIT), immune-mediated HIT is associated with a greater reduction in platelet counts (50%) and increased incidence of thrombosis. • Since HIT can occur in any setting where heparin therapy is used, it is important that platelet counts be monitored and professionals be educated about recognizing HIT. • After HIT is suspected, it is important to consider treatment with another parenteral anticoagulant such as a direct thrombin inhibitor (DTI). • Target aPTT ranges should be established based on the ratio to baseline aPTT. • Since aPTT assays may respond differently to a DTI, sharing of dosing protocols may result in different infusion rates. Heparin-induced Thrombocytopenia William Dager, PharmD, FCHSP, Pharmacist Specialist, University of California Davis Medical Center, Sacramento, CA
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Executive Summary Conference Report 9th Invited Conference: Improving Heparin Safety agulation has been discontinued, starting anticoagulant therapy for a separate indica- tion may require an alternative approach. After HIT is suspected, it is important to initiate an alternative management plan. This includes use of an alternative anticoagulant and an understanding of how its use should be initiated and monitored. It is important to have rapid access to an alternative agent and information available on its use, because bedside clinicians may have very limited clinical experience. In the case of the DTIs, the INR may also rise because of a crossover reaction with the assay resulting in values that do not reflect corresponding antico- agulation in the patient. Clinicians should be educated to recognize the potential for false assay results before automatically stopping the infusion if there is a high INR in warfarin- naïve patients. DTI dosing approaches should also con- sider altered drug elimination in liver, renal of cardiac dysfunction, or ongoing procedures with increased risks for bleeding 5 . Target aPTT ranges should be established based on the ratio to baseline aPTT. The aPTT range established for heparin should not be used because the pharmacology of each agent and how it influences the aPTT differs. As with the aPTT and heparin, different aPTT assays may respond differently to a DTI 6 . Therefore it is important to keep in mind that any sharing of dosing protocols may result in different infu- sion rates.
Immune-mediated HIT is associated with an increased incidence of thrombosis and can occur in any patient for whom heparin is used. A means should be developed to monitor platelet counts, educate profession- als about recognition and management of HIT, and provide rapid access to an alterna- tive agent such as a DTI. Target aPTT ranges should be established based on the ratio to baseline aPTT to ensure accurate infusion rates.
References 1. Warkentin TE. Clinical presentation of heparin-induced thrombocytopenia. Semin Hematol 1998;35 (4 suppl 5):9-16; discussion 35-6. 2. Warkentin TE. Heparin-induced thrombocytopenia: pathogenesis and management. Br J Haematol 2003; 121:535-5. 3. Janatpour KA, Gosselin RC, Dager WE, et al. Usefulness of optical density values from heparin- platelet factor 4 antibody testing and probability scoring models to diagnose heparin induced thrombocytopenia. Am J Clin Path 2007;127:429-33. 4. Warkentin TE. Platelet count monitoring and laboratory testing for heparin-induced thrombocytopenia. Arch Pathol Lab Med 2002;126:1415-23. 5. Dager WE, Dougherty JA, Nguyen PH, et al. Heparin- Induced Thrombocytopenia: A Review of Treatment Options and Special Considerations. Pharmacother 2007; 27:564-87. 6. Gosselin RC, King JH, Janatpour KA, et al. Comparing direct thrombin inhibitors using aPTT, ecarin clotting time and thrombin inhibitor management testing. Ann Pharmacother 2004;38(9):1383-8.
Attendees Peter Angood, MD Vice President and Chief Patient Safety Officer The Joint Commission Oakbrook Terrace, IL Bona E. Benjamin, BS Pharm Director, Medication-Use Quality Improvement American Society of Health-System Pharmacists Bethesda, MD Michael R. Cohen, RPh, MS, ScD President Institute for Safe Medication Practices Huntingdon Valley, PA William E. Dager, PharmD, FCSHP Pharmacist Specialist UC Davis Medical Center Sacramento, CA Cynthia L. Dakin, PhD, RN Associate Professor Program Coordinator Graduate Nursing Studies Elms College Chicopee, MA Joseph F. Dasta, MSc, FCCM Professor Emeritus, The Ohio State University Adjunct Professor, University of Texas Hutto, TX Darlene Elias, MD Scripps Health San Diego, CA John Fanikos, RPh, MBA Assistant Director of Pharmacy Brigham and Women’s Hospital Boston, MA James Fuller, PharmD Director of Pharmacy Vice President, Clinical Support Services Wishard Health Services Indianapolis, IN Samuel Goldhaber, MD (via tape) Director, Anticoagulation Service, Director, Venous Thromboembolism Research Group Brigham and Women’s Hospital Boston, MA Vicki Good, MSN, RN, CCRN, CCNS Critical Care Clinical Nurse Specialist Cox HealthCare System Springfield, MO Robert Gosselin, CLS Coagulation Specialist UC Davis Medical Center Sacramento, CA Michael P. Gulseth, PharmD, BCPS University of Minnesota College of Pharmacy Duluth/ Saint Mary's Medical Center Duluth, MN CareFusion Center for Safety and Clinical Excellence Invited Conference
March 13-14, 2008 Vikas Gupta, PharmD, BCPS CareFusion MedMined Services Birmingham, AL Kathleen A. Harder, PhD Director
Center for Human Factors Systems University of Minnesota Minneapolis, MN Amy Herrington, RN, MSN, CEN Staff Development Specialist, Emergency Department/Stroke University of Kentucky Lexington, KY Charles Homer, MD, MPH (via phone) President National Institute for Children’s Healthcare Quality Cambridge, MA Doug Humber, PharmD Clinical Coordinator, Pharmacy Department UC San Diego Medical Center San Diego, CA Marla Husch, RPh Director, Quality and Patient Safety Central DuPage Hospital Winfield, IL Ian Jenkins, MD Hospitalist UC San Diego Medical Center San Diego, CA Patricia Kienle, RPh, MPA, FASHP Director, Accreditation and Medication Safety CareFusion Center for Safety and Clinical Excellence San Diego, CA Julie Lear, RN, BSN, CCRN Nurse Manager ICCU Mary Immaculate Hospital Newport News, VA Ray Maddox, PharmD Director of Clinical Pharmacy, Research and Respiratory Care St. Joseph Candler Savannah, GA Steven Meisel, PharmD Director, Medication Safety Fairview Health System Minneapolis, MN Karla M. Miller, PharmD, BCPP Director of Medication Usage and Safety HCA Nashville, TN Robert Raschke, MD, MS Director, Critical Care Services Banner Good Samaritan Medical Center Phoenix, AZ Darryl S. Rich, PharmD, MBA, FASHP Surveyor, Division of Accreditation and Certification Operations The Joint Commission Oakbrook Terrace, IL John Santell, MS, FASHP Director, Practitioner Programs and Services, Pharmacopeial Education USP Rockville, MD Phil Schneider, MS, FASHP Director of Latiolais Leadership Program Clinical Professor The Ohio State University Columbus, OH Sylvia Martin-Stone, PharmD Cedars Sinai Medical Center Los Angeles, CA Oxana Tcherniantchouk, MD Cedars Sinai Medical Center Los Angeles, CA Tim Vanderveen, PharmD, MS Vice President CareFusion Center for Safety and Clinical Excellence San Diego, CA Misty Vo, PharmD IDS/Regulatory Safety Coordinator Banner Desert Hospital Pharmacy Mesa, AZ
LeAnn Warfel, RN, BSN Director, 4 Acute Doylestown Hospital Doylestown, PA Gay Wayland, RN Project Manager, Performance Improvement Scripps Health San Diego, CA Jonathan Weisul, MD VP Medical Affairs Christus St. Francis Cabrini Hospital Alexandria, LA CareFusion 1. Sherri-Lynne Almeida, DrPH, RN, MSN, MEd, CEN, FAEN 2. Sally Graver, Medical Writer 3. Charlie Ham, PharmD 4. Richard Johannes, MD 5. Steve Lewis, MD 6. Natasha Nicol, PharmD 7. Carl Peterson, PharmD 8. Ray Stermer, RPh, MBA 9. Michael Yang, MD 3ED2305 0509/1000 Yüklə 1 Mb. Dostları ilə paylaş:
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