Evaluation of Nurse-Managed Heparin Nomogram Adherence After Implementation of an Electronic Health Record–Embedded Heparin Calculator: An Antithrombotic Stewardship Initiative

Abstract

Background:

Therapeutic intensity unfractionated heparin (UFH) infusions require titration to target a therapeutic activated partial thromboplastin time (aPTT) or UFH anti-Xa. At The Johns Hopkins Hospital (JHH) and Johns Hopkins Bayview Medical Center (JHBMC), a computerized nurse-managed UFH calculator was built into the electronic health record (EHR) to improve adherence to institutional nomograms.

Objective:

This study evaluated the impact of implementation of an EHR-embedded UFH calculator on nurse-managed UFH nomogram adherence.

Methods:

A retrospective, observational cohort study was conducted at 2 institutions within one health system. Patients admitted to adult services who received nurse-managed UFH for at least 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. The primary outcomes were nurse-managed UFH nomogram adherence, management of critical aPTT results, and therapeutic aPTT achievement.

Results:

A total of 2128 patients were included in the pre-implementation cohort and 2517 in the post-implementation cohort. The mean age was 61 for both the pre- and post-implementation cohorts. The post-implementation cohort experienced an increase in adherence to initial bolus dose recommendations when compared with the pre-implementation cohort (85.9% vs 92%, P < 0.001) as well as increased adherence to correct initial infusion doses (80.8% vs 95.9%, P < 0.001). Infusion dose adjustment error rates were reduced in the post-implementation cohort (4.9% vs 1.5%, P < 0.001). Fewer patients experienced nomogram nonadherence errors in the post-implementation cohort (20.2% vs 5.3%, P < 0.001). Critical aPTT nomogram adherence improved after calculator implementation for resumption at the recommended dose (72.4% vs 94.0%, P < 0.001). However, the time to therapeutic aPTT achievement was similar between pre-implementation and post-implementation cohorts.

Conclusion and Relevance:

A stewardship initiative to implement an EHR-embedded nurse-managed UFH calculator significantly increased adherence to nomogram-recommended initial doses and dose adjustments.

Keywords

anticoagulation unfractionated heparin adherence drug monitoring medication errors medication safety therapeutic monitoring

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