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Poor Physician Compliance with Heparin Guidelines Results in Haemorrhage: Presented at ASHP

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 2^nd 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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