Background Intravenous unfractionated heparin (IV UFH) has a narrow therapeutic index and poses a high risk of bleeding. Objective To determine the impact of pharmacy monitoring and intervention on adherence to and appropriate implementation of IV UFH protocol. Setting A 438 bed hospital specializing in cardiac services. Methods This is a retrospective chart review study. Pre-pharmacy intervention data were collected from November 2013 to January 2014 and compared to post-pharmacy intervention data obtained between August 2014 and October 2014. Patients were included if they received IV UFH for at least 24 hours. The first three daytime laboratory draws were collected for each patient and analyzed using generalized estimating equations to quantify the association between pharmacy monitoring and adherence to the institution’s protocol. Main outcome measures Designation of appropriate protocol, accurate selection of initial infusion rate, timing of anti-Xa levels within 60 min of anticipated due time, change of infusion rate within 120 min of laboratory result, and appropriate adjustment of infusion rates. Results A total of 195 data points were included. The initial selection of infusion rate and subsequent adjustments were more appropriate in the post-intervention period with an odds ratio of 8.36 (95% CI 2.41–29.01, p value = 0.0008), and 4.66 (95% CI 1.41–15.43, p value = 0.0118), respectively. Conclusion The results of this study indicate that pharmacy monitoring of IV UFH therapy has improved adherence to an institution’s protocol and is associated with more accurate selection of initial infusion rates and adjustment of infusions based upon laboratory results.
Anticoagulants Anti-Xa levels Pharmacist intervention Unfractionated heparin United States
This is a preview of subscription content, log in to check access.
No funding was requested or received in conjunction with this project.
Conflicts of interest
Michaela Lysogorski and Richard Geisler were employed by the Mercy Hospital of Buffalo where data collection took place. Other authors have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Niccolai CS, Hicks RW, Oertel L, Francis JL. Unfractionated heparin: focus on a high-alert drug. Pharmacotherapy. 2004;24(8):146S–55S.CrossRefPubMedGoogle Scholar
Biscup-Horn PJ, Streiff MD, Ulbrich TR, Nesbit TW, Shermock KM. Impact of aninpatient anticoagulation management service on clinical outcomes. Ann Pharmacother. 2008;42:777–82.CrossRefPubMedGoogle Scholar
Melloni C, Alexander KP, Chen AY, Newby LK, Roe MT, Allen LaPointe NM, et al. Unfractionated heparin dosing and risk of major bleeding in non-ST-segment elevation acute coronary syndromes. Am Heart J. 2008;56(2):209–15.CrossRefGoogle Scholar
Khoo AL, Teng M, Lim BP, Tai HY, Lau TC. A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapore experience. Jt Comm J Qual Patient Saf. 2013;39(5):205–12.CrossRefPubMedGoogle Scholar
Edgar TA, Lee DS, Cousins DD. Experience with a national medication error reporting program. Am J Hosp Pharm. 1994;51(10):1335–8.PubMedGoogle Scholar
Thanimalai S, Shafie AA, Hassali MA, Sinnadurai J. Comparing effectiveness of two anticoagulation management models in a Malaysian tertiary hospital. Int J Clin Pharm. 2013;35:736–43.CrossRefPubMedGoogle Scholar
Dager WE, Branch JM, King JH, White RH, Quan RS, Mussallam NA, et al. Optimization of inpatient warfarin therapy: impact of daily consultation by a pharmacist managed anticoagulation service. Ann Pharmacother. 2000;34:567–72.CrossRefPubMedGoogle Scholar
Dawson NL, Porter IE 2nd, Klipa D, Bamlet WR, Hedges MA, Maniaci MJ, et al. Inpatient warfarin management: pharmacist management using a detailed dosing protocol. J Thromb Thrombolysis. 2012;33(2):178–84.CrossRefPubMedGoogle Scholar
Fowler S, Gulseth MP, Renier C, Tomsche J. Inpatient warfarin: experience with a pharmacist-led anticoagulation management service in a tertiary care medical center. Am J Health-Syst Pharm. 2012;69(1):44–8.CrossRefPubMedGoogle Scholar
Johnson SG. Improving cost-effectiveness of and outcomes from drug therapy in patients with atrial fibrillation in managed care: role of the pharmacist. J Manag Care Pharm. 2009;15(6 Suppl B):S19–25.PubMedGoogle Scholar
Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166:955–64.CrossRefPubMedGoogle Scholar
Wellman JC, Kraus PS, Burton BL, Ensor CR, Nesbit TW, Ross PA, et al. Development and implementation of a pharmacist-managed inpatient anticoagulation monitoring program. Am J Health Syst Pharm. 2011;68(10):934–9.CrossRefPubMedGoogle Scholar
Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest. 2005;127(5):1515–22.CrossRefPubMedGoogle Scholar
Wong YM, Quek YN, Tay JC, Chadachan V, Lee HK. Efficacy and safety of a pharmacist-managed inpatient anticoagulation service for warfarin initiation and titration. J Clin Pharm Ther. 2011;36(5):585–91.CrossRefPubMedGoogle Scholar
Van Roessel S, Middeldorp S, Cheung YW, Swinderman AH, de Pont AC. Accuracy of aPTT monitoring in critically ill patients treated with unfractionated heparin. Neth J Med. 2014;72(6):305–10.PubMedGoogle Scholar
Fruge S, Lee YR. Comparison of unfractionated heparin protocols using antifactor Xa monitoring or activated partial thrombin time monitoring. Am J Health-Syst Pharm. 2015;72(17 Suppl 2):S90–7.CrossRefPubMedGoogle Scholar
Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM, Weitz JI. Parenteral anticoagulants: American College of chest physicians evidence-based clinical practice guidelines. Chest. 2008;133:141S–590S.CrossRefPubMedGoogle Scholar
Smith ML, Wheeler KE. Weight-based heparin protocol using antifactor Xa monitoring. Am J Health-Syst Pharm. 2010;67(5):371–4.CrossRefPubMedGoogle Scholar
Mittal M, Harrison DL, Thompson DM, Miller MJ, Farmer KC, Ng YT. An evaluation of three statistical estimation methods for assessing health policy effects on prescription drug claims. Res Social Adm Pharm. 2016;12(1):29–40.CrossRefPubMedGoogle Scholar