Purpose: Intravenous unfractionated heparin (UFH) remains an important anticoagulation (AC) agent, particularly in the inpatient setting. Historically, the activated partial thromboplastin time (aPTT) has been the primary laboratory test used to monitor and adjust UFH. Given that several biologic factors can influence the aPTT, independent of the effects of UFH, institutions have transitioned to monitoring heparin with anti-Xa levels. Clinical data show that conversion from aPTT to anti-Xa monitoring may offer a smoother dose-response curve, such that levels remain more stable, requiring fewer blood samples and dosage adjustments.
Background/Problem: The Cleveland VA Medical Center (CVAMC) provides annual care to over 105,000 veterans. It was recently designated as a center for implantation of left ventricular assist devices (LVADs.) As part of the AC monitoring for these patients, a hematologist introduced the use of anti-Xa assay as the test of choice to monitor heparin. Favorable results in this patient cohort prompted consideration for a hospital-wide change in heparin monitoring and a new heparin dosing protocol.
Methods: A multidisciplinary group assembled in November 2015 and developed a low-intensity and high-intensity heparin protocol with anti-Xa as the test to monitor heparin. Laboratory staffing was increased to accommodate phlebotomy rounds. Alaris IV pumps were re-programmed. Physicians developed a specific order set. Nurses designed an AC nurse’s note, and pharmacists devised safe-guard strategies when dose changes are made. Clinical Nurse Specialists developed an educational program for all 228 inpatient registered nurses which will be completed on July 3rd. All stakeholders are expected to meet and confirm their readiness to fully implement the new protocol.
Data Analysis: Anti-Xa equipment was purchased and validation tests were completed. In LVAD patients, therapeutic levels within 24 hours were noted in 86% of the cases.
Results: Hospital-wide implementation of the new heparin protocol is projected for August 1, 2016.
Implications: Presently, there are only 9 VAMCs using the anti-Xa assay to manage heparin anticoagulation. The CVAMC has developed a comprehensive implementation process that consists of new order sets, templates, training programs, and tools for common references. A poster at the AVAHO meeting will illustrate the process and provide postimplementation updates.