The Duke Heparin Protocol Implementation of Nurse Driven Heparin Protocol at Duke University Hospital Jordan Hildenbrand, MS2; Kimberly Hodulik PharmD, CACP, CPP; Adam Root PharmD; Jason Funaro PharmD; Dorothy Filippi MSN, RN, CCRN; Faryl Podolle RN; Susan Ashland RN; Megan Greenland PharmD; Noppon Setji MD; Nilesh Patel MD Departments of Medicine, Pharmacy, and Nursing, Duke University Hospital Technology • Lack of current EMR based decision support tools • Multiple processes and options for heparin ordering Nursing Phlebotomy • No timed labs at DUH • Delay from time of order to draw, exacerbated based on phlebotomist scheduling • Process potentially more complex than other nurse driven infusions • Variable experience based on nursing unit Physicians • Perceived low compliance with institutional policy • Delay to follow up and intervention on monitoring labs • Communication among team delayed • Variable experience with heparin Leadership • No structured education focused on heparin infusions • Policies difficult to find with current tools Pharmacy • High patient and team volume per PharmD • Variable local ordering cultures of heparin HEPARIN MANAGEMENT ERRORS FISHBONE DIAGRAM AIMS • The new Duke Heparin protocol will improve adherence with the dosing, timing, and communication required with the institutional nomogram • The new Duke Heparin protocol will decrease the time to therapeutic range for patients on heparin BACKGROUND • Patients are anticoagulated in the inpatient setting using heparin for reasons including deep vein thrombosis, acute coronary syndromes, and atrial fibrillation • Advantages of heparin are titratability, reversibility, and use in renal failure • Disadvantages include a narrow therapeutic window • Under-dosing, inconsistent adherence to nomogram, and delayed communication are barriers to ideal heparin dosing INTERVENTIONS • Formation of an inter-professional team, including leadership, nurses, physicians, and pharmacists • Assessment of current heparin management process, including ordering process (through Epic®), indications, frequency of use, and amount of oversight • Assessment of current factors leading to heparin management errors (see fishbone) and development of new heparin process map • Development of education program for 110 nurses regarding heparin indications, management, and complications • Development of new educational, policy and calculator tools through DukeCore.org/heparin • One-on-one training of all bedside nurses on heparin management process • Development of feedback process on all errors regarding heparin with nursing, pharmacy, and physician leads • Evaluate nomogram to potentially deliver faster times to therapeutic to patients • Expand the protocol to more units within Duke University Hospital • EPIC/EMR integration of decision support tools • Engage phlebotomy leadership in decreasing delays to aPTT draws • Re-evaluate nursing comfort as experience continues NEXT STEPS • General medicine nurses are engaged in delivering a safe heparin protocol to patients • Nursing protocols improve compliance with an institutional nomogram • Nurses and physicians deliver similar results in heparin titration • Nurses are comfortable in managing heparin infusions • Improved safety endpoints compared to before initiation • RNs respond quickly to aPTT values and make corresponding dose titrations CONCLUSIONS & LESSONS LEARNED OUTCOMES DEMOGRAPHICS Pre-Protocol (n=33) On-Protocol October -January (n=33) On-Protocol January-May (n=42) Indication DVT/PE 18 (55%) 19 (40%) 29 (69%) Atrial fibrillation /mechanical valve 11 (33%) 7 (21%) 9 (21%) ACS/MI 3 (9%) 5 (15%) 2 (5%) Stroke 0 (0%) 0 0 Other 1 (3%) 2 (6%) 2 (5%) PROCESS MEASURES Pre-Protocol Value On-Protocol Value (October-January) On-Protocol Value (January-May) # aPTTs per patient 4 4 4.6 Inappropriate Bolus Adjustments 53/177 (30%) 7/125 (6%) 33/192 (17%) Inappropriate Infusion Adjustments 70/177 (40%) 10/125 (8%) 36/192 (19%) Adjustments within 60 minutes of aPTT result 38/71 (54%) 54/70 (77%) 61/78 (78%) Mean time to RN adjustment 1.3 hours 0.7 hours 0.84 hours OUTCOMES Pre-Protocol Value On-Protocol Value (October-January) On-Protocol Value (January-May) Number of patients having therapeutic aPTTs 23/33 (70%) 21/33 (66%) 38/42 (90%) Time to Therapeutic (mean) 15.9 hrs 14.4 hrs 16.2 hrs SAFETY MEASURES Pre-Protocol Value On-Protocol Value (October-January) On-Protocol Value (January-May) Minor Bleeding 2 (6%) 4 (12%) 3 (7%) Major Bleeding 4 (12%) 5 (15%) 1 (2%) Recurrent Thrombus 0 0 0