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The Successful Application of a Heparin Nomogram in a Community Hospital

The Successful Application of a Heparin Nomogram in a Community Hospital Abstract Background: Heparin administration by physicians can vary greatly, and this variance can result in ineffective anticoagulation and reduced effectiveness of treatment. Objective: To examine the use of a heparin nomogram in two community hospitals to validate its effect on anticoagulation parameters and to determine its influence on length of hospital stay. Methods: Prenomogram and postnomogram intervention in two community hospitals in Sudbury, Ontario. All patients who presented and were admitted to the hospitals between 1991 and 1994 with a confirmed primary diagnosis of deep vein thrombosis and/or pulmonary embolism were eligible for the study. A heparin nomogram was instituted in April 1993 for treatment of deep vein thrombophlebitis and pulmonary embolism in hospitalized patients. The study patients were designated as prenomogram or postnomogram. Anticoagulation parameters (time to therapeutic activated partial thromboplastin time), number of diagnostic tests, percentage of times within the therapeutic range, and length of hospital stay were recorded for both groups. Results: A total of 326 patients were identified from the database; 163 (50%) met the inclusion criteria. Patients in both groups appeared to be similar. Adequate anticoagulation was achieved faster (17.9 hours postnomogram vs 48.8 hours prenomogram; P<.001) and remained sub-therapeutic less frequently in the postnomogram group (number of activated partial thromboplastin time tests below the therapeutic window; 56% prenomogram vs 28% postnomogram; P<.001). There were no differences between the groups with respect to length of stay (11.3 days prenomogram vs 10.9 days postnomogram; P=.60). More activated partial thromboplastin time tests were ordered in the postnomogram group (15.6 postnomogram vs 12.7 prenomogram; P=.001); however, fewer prothrombin time tests were ordered in the postnomogram group. Conclusions: A heparin nomogram was successfully used in a community hospital without a structured hematology-thrombosis service. Therapeutic anticoagulation was achieved faster and maintained more frequently, with less logistical problems, with this protocol. However, additional measures may be required to reduce the length of hospital stay.(Arch Intern Med. 1995;155:2095-2100) References 1. Hirsh J. Heparin. N Engl J Med . 1991;324:1565-1574.Crossref 2. Hirsh J, van Aken WG, Gallus AS. et al. Heparin kinetics in venous thrombosis and pulmonary embolism. Circulation . 1976;53:691-695.Crossref 3. Saya FG, Colemen LT, Martinoff JT. Pharmacist-directed heparin therapy using a standard dosing and monitoring protocol. Am J Hosp Pharm . 1985;42:1965-1969. 4. Wheeler A, Jaquiss R, Newman J. Physician practices in the treatment of pulmonary embolism and deep vein thrombosis. Arch Intern Med . 1988;148:1321-1325.Crossref 5. Flaker GC, Bartolozzi J, Davis V, McCabe C, Cannon CP. Use of a standardized heparin nomogram to achieve therapeutic anticoagulation after thrombolytic therapy in myocardial infarction. Arch Intern Med . 1994;154:1492-1496.Crossref 6. Hirsh J, Dalen JE, Deykin D, Poller L. Oral anticoagulants. Chest . 1992;102:312S-326S.Crossref 7. Hull RD, Raskob G, Hirsh J, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximalvein thrombosis. N Engl J Med . 1986:315:1109-1114.Crossref 8. Hull RD, Raskob GE, Rosenbloom D, et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med . 1992;152:1589-1595.Crossref 9. Cruickshank MK, Levine MN, Hirsh J, Roberts R, Siquenza M. A standard heparin nomogram for the management of heparin therapy. Arch Intern Med . 1991;155:333-337.Crossref 10. Kramer MS, Feinstein AR. Clinical biostatistics LIV: the biostatistics of concordance. Clin Pharmacol Ther . 1981;29:111-123.Crossref 11. Kaplin E, Meier D. Non-parametric estimation from incomplete observations. JAm Stat Assoc . 1959;53:457-481.Crossref 12. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep . 1966;50:163-170. 13. Hull RD, Raskob GE, Hirsh J, et al. Heparin for 5 days as compared with 10 days in the initial management of proximal vein thrombosis. N Engl J Med . 1990;322:1260-1264.Crossref 14. Haynes RB. Loose connections between peer-reviewed clinical journals and clinical practice. Ann Intern Med . 1990;113:724-728.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Successful Application of a Heparin Nomogram in a Community Hospital

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430190089012
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: Heparin administration by physicians can vary greatly, and this variance can result in ineffective anticoagulation and reduced effectiveness of treatment. Objective: To examine the use of a heparin nomogram in two community hospitals to validate its effect on anticoagulation parameters and to determine its influence on length of hospital stay. Methods: Prenomogram and postnomogram intervention in two community hospitals in Sudbury, Ontario. All patients who presented and were admitted to the hospitals between 1991 and 1994 with a confirmed primary diagnosis of deep vein thrombosis and/or pulmonary embolism were eligible for the study. A heparin nomogram was instituted in April 1993 for treatment of deep vein thrombophlebitis and pulmonary embolism in hospitalized patients. The study patients were designated as prenomogram or postnomogram. Anticoagulation parameters (time to therapeutic activated partial thromboplastin time), number of diagnostic tests, percentage of times within the therapeutic range, and length of hospital stay were recorded for both groups. Results: A total of 326 patients were identified from the database; 163 (50%) met the inclusion criteria. Patients in both groups appeared to be similar. Adequate anticoagulation was achieved faster (17.9 hours postnomogram vs 48.8 hours prenomogram; P<.001) and remained sub-therapeutic less frequently in the postnomogram group (number of activated partial thromboplastin time tests below the therapeutic window; 56% prenomogram vs 28% postnomogram; P<.001). There were no differences between the groups with respect to length of stay (11.3 days prenomogram vs 10.9 days postnomogram; P=.60). More activated partial thromboplastin time tests were ordered in the postnomogram group (15.6 postnomogram vs 12.7 prenomogram; P=.001); however, fewer prothrombin time tests were ordered in the postnomogram group. Conclusions: A heparin nomogram was successfully used in a community hospital without a structured hematology-thrombosis service. Therapeutic anticoagulation was achieved faster and maintained more frequently, with less logistical problems, with this protocol. However, additional measures may be required to reduce the length of hospital stay.(Arch Intern Med. 1995;155:2095-2100) References 1. Hirsh J. Heparin. N Engl J Med . 1991;324:1565-1574.Crossref 2. Hirsh J, van Aken WG, Gallus AS. et al. Heparin kinetics in venous thrombosis and pulmonary embolism. Circulation . 1976;53:691-695.Crossref 3. Saya FG, Colemen LT, Martinoff JT. Pharmacist-directed heparin therapy using a standard dosing and monitoring protocol. Am J Hosp Pharm . 1985;42:1965-1969. 4. Wheeler A, Jaquiss R, Newman J. Physician practices in the treatment of pulmonary embolism and deep vein thrombosis. Arch Intern Med . 1988;148:1321-1325.Crossref 5. Flaker GC, Bartolozzi J, Davis V, McCabe C, Cannon CP. Use of a standardized heparin nomogram to achieve therapeutic anticoagulation after thrombolytic therapy in myocardial infarction. Arch Intern Med . 1994;154:1492-1496.Crossref 6. Hirsh J, Dalen JE, Deykin D, Poller L. Oral anticoagulants. Chest . 1992;102:312S-326S.Crossref 7. Hull RD, Raskob G, Hirsh J, et al. Continuous intravenous heparin compared with intermittent subcutaneous heparin in the initial treatment of proximalvein thrombosis. N Engl J Med . 1986:315:1109-1114.Crossref 8. Hull RD, Raskob GE, Rosenbloom D, et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med . 1992;152:1589-1595.Crossref 9. Cruickshank MK, Levine MN, Hirsh J, Roberts R, Siquenza M. A standard heparin nomogram for the management of heparin therapy. Arch Intern Med . 1991;155:333-337.Crossref 10. Kramer MS, Feinstein AR. Clinical biostatistics LIV: the biostatistics of concordance. Clin Pharmacol Ther . 1981;29:111-123.Crossref 11. Kaplin E, Meier D. Non-parametric estimation from incomplete observations. JAm Stat Assoc . 1959;53:457-481.Crossref 12. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep . 1966;50:163-170. 13. Hull RD, Raskob GE, Hirsh J, et al. Heparin for 5 days as compared with 10 days in the initial management of proximal vein thrombosis. N Engl J Med . 1990;322:1260-1264.Crossref 14. Haynes RB. Loose connections between peer-reviewed clinical journals and clinical practice. Ann Intern Med . 1990;113:724-728.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 23, 1995

References