inCongress
ASHP: Poor Physician
Compliance with Heparin Guidelines Results in
Haemorrhage |
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By Paula Moyer
SAN DIEGO, CA -- June 9, 2003 -- Poor physician
compliance with the heparin guidelines issued by the
American Heart Association and American College of
Cardiology (AHA/ACC) is associated with high haemorrhage
rates and other adverse drug events.
These results were presented here on June 2nd at the
2003 annual summer meeting of the American Society of
Health-System Pharmacists.
"We need to remember that haemorrhage after heparin
administration often [occurs] 3 days after dosing," said
Binh Dang, PharmD, lead author and a pharmacy practice
resident at University of Pennsylvania Hospital, in
Philadelphia. "Education of medical staff may not be
adequate to insure compliance. At our institution, we
are building enforcement in the form of intervention by
the pharmacy department at the point of care."
Dr. Dang's institution began using the AHA/ACC
heparin-dosing nomogram, based on the individual
patient's weight, in 1997. In 2001, however, the
pharmacy department began documenting a marked increase
in spontaneous adverse drug event reports among
heparin-treated patients in the cardiac care unit (CCU)
and cardiac intensive care unit (CICU), despite an
initial decrease in the number of bleeds.
Dr. Dang and his co-investigators conducted a
prospective drug usage evaluation to identify deviations
in heparin administration, compliance with the
institution's established guidelines, and adverse drug
events.
The institution's own guidelines called for a bolus of
heparin consisting of 70 units/kg in patients with
pulmonary embolism, deep-vein thrombosis, dilated
cardiomyopathy, and atrial fibrillation, as well as
after placement of an intra-aortic balloon pump. After
the bolus, patients were to receive a heparin infusion
of 18 units/kg per hour.
Their findings show that physicians followed the AHA/ACC
guidelines for heparin use in patients with acute
coronary syndrome.
The investigators used the pharmacy computer to identify
all patients in the CCU and CICU with new orders for
heparin over a 10-week period. The database under review
consisted of 32 patients.
Overall compliance regarding justification for use was
reasonably high, with appropriate justifications in 91%
of patients. The investigators found low compliance,
however, regarding an appropriate initial heparin bolus
and infusion rate. In these cases, 16% received the
appropriate bolus dose, and 22% received the appropriate
infusion dose.
Among these, 31% of patients achieved a therapeutic
activated partial thromboplastin time (aPTT) within 24
hours. Proper monitoring of aPTT prior to heparin
administration occurred in 56% of patients, and in 45%
of patients 6 to 8 hours after the initial bolus and
infusion.
Major haemorrhagic complications occurred in 19% of
patients, and 47% experienced minor bleeding. Dr. Dang
and his colleagues also documented the use of
concomitant medications that could be problematic for
patients receiving heparin. The most common of these
were acetylsalicylic acid, which was taken by 78% of
patients, and warfarin, which was taken by 38% of
patients.
Dr. Dang said that he and his co-investigators plan to
use the results of this evaluation to improve the
practice of heparin usage among house staff at their
institution, and also to determine factors that increase
haemorrhage risk when heparin is not used according to
accepted guidelines.
[Study title: Evaluation of Heparin Usage at a
University Medical Center. Abstract P-15E]
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