Presentation Details
| Evaluation of nurse-managed heparin nomogram adherence after implementation of an electronic medical record-embedded heparin calculator Taylor Robichaux1, John Lindsley1, Vi Gilmore1, Rosemary Duncan1, Catherine Kiruthi1, Erica Willits2, Michael Streiff3, Rakhi Naik3, Jennifer Yui3, Kathryn Dane1. 1Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA.2Department of Nursing, The Johns Hopkins Hospital, Baltimore, MD, USA.3Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA |
Abstract
Background Unfractionated heparin (UFH) is the most widely used anticoagulant. 1 Due to interindividual variability in dose response, therapeutic intensity UFH infusions require titration to target a therapeutic activated partial thromboplastin time (aPTT).2 After development of the first UFH nomogram in 1991, UFH nomograms have become a common method to guide therapeutic UFH infusion dose adjustments.3 Historically UFH nomograms were provider-driven, but in recent years nurse-driven protocols have become increasingly popular.4 Nurse-driven heparin nomograms have been shown to significantly reduce the time to therapeutic aPTT achievement compared to physician titration.4 At The Johns Hopkins Hospital (JHH) and Johns Hopkins Bayview Medical Center (JHBMC), a computerized nurse-managed heparin calculator was built into the EMR to reduce the risk of nurse-managed UFH medication errors and increase adherence to institutional nomograms. To our knowledge, there are no prior publications comparing the impact of EMR-embedded nurse-managed heparin calculators to traditional written UFH nomograms. Objective The purpose of this study is to evaluate the implementation of an EMR-embedded heparin calculator on nurse-managed heparin nomogram adherence. Methods A retrospective, observational cohort study was conducted at two institutions within a single health-system. Patients admitted to adult services who received nurse-managed UFH for 4 consecutive hours were included. Patients admitted between March 2019 and March 2021 constituted the pre-implementation cohort and patients admitted August 2021 through August 2023 were included in the post-implementation cohort. Nurse-managed nomogram adherence will be compared between the pre- and post-implementation cohorts. Assessment of therapeutic aPTT achievement at 6, 12, and 24 hours after initiation and adherence to recommended management of critical aPTT results will be compared between cohorts. Results A total of 3,065 patients were included in the pre-implementation cohort and 2,162 in the post-implementation cohort. The median (IQR) age was 63 (20) for both the pre- and post-implementation cohorts. A total of 3,323 patients received an infusion only, 115 received an initial bolus and infusion, 48 received an infusion and rebolus, and 1,741 received an initial bolus, infusion, and rebolus. The total number of patients with an aPTT critical action value was 601 and 644 in the pre- and post-implementation cohorts, respectively. A comparison of nomogram adherence, therapeutic aPTT achievement at 6, 12, and 24 hours, and adherence to recommended critical aPTT management will be conducted between the pre- and post-calculator implementation cohorts. Conclusion This project will provide valuable insight into the impact of an EMR-embedded nurse-managed heparin calculator on nomogram adherence and efficacy. These results will aid health systems in justifying the significant workload required to build and implement an EMR-based calculator. References 1. Qiu M, et al. Biomed Pharmacother. 2021 2. Jia Z, et al. J Transl Med. 2015 3. Cruickshank MK, et al. Arch Intern Med. 1991 4. Schurr JW, et al. Clin Appl Thromb Hemost. 2018
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