2025 Southeastern Residency Conference

Implementation and Analysis of a Pharmacist-Managed Heparin Infusion Service at an Academic Medical Center 
Abigail Mason, Brittany White, Emily Goodwin, Ashley Williams, Jesse Briscoe, Kyle Knapp

Background
Unfractionated heparin is widely used as a first-line anticoagulant for hospitalized patients due to its rapid onset of effect and short duration. Given the inherent risk of bleeding with heparin administration, frequent lab monitoring is required to maintain target lab levels and to minimize risk of adverse effects. An internal analysis of a historic nurse-led heparin infusion protocol revealed frequent protocol non-compliance and deviations resulting in a facility change to a pharmacist-led protocol in December 2023. This project compares historic lab outcomes and safety events between nurse-driven and pharmacy-driven heparin protocols.

Methods
This IRB-approved, retrospective cohort analysis compared laboratory and safety outcomes between historic nurse-led protocol and pharmacist-led protocol. Patients meeting the following criteria were identified for inclusion in the pharmacist-led cohort: age greater than 18 years, admission to Erlanger Baroness Hospital, and receipt of the standard, reduced-dose, or low-dose Heparin Infusion Protocols between March 1, 2024 and March 30, 2025. Patients were excluded if they received heparin therapy for less than 24 hours or if the baseline activated partial thromboplastin time (aPTT) exceeded 40 seconds. The primary outcome of this study was difference between cohorts in mean time, in hours, to first aPTT result at or above the protocol-specified target range. Results were stratified by heparin infusion protocol. Secondary outcomes included pharmacist-led heparin protocol adherence, mean number of aPTT checks in therapeutic range, and documented bleeding events during the hospitalization. Adherence to heparin protocols in the pharmacist-led group was assessed in three domains. This included selection of correct initial heparin bolus dose, correct initial infusion rate, and correct subsequent rate adjustments as specified by the ordered heparin protocol. Additionally, the mean time from aPTT result to pharmacist order change and time from pharmacist order change to nurse medication administration was analyzed.

Results: The implementation of a pharmacist-managed heparin service at Erlanger resulted in a statistically significant reduction in the median time to achieve the primary outcome of first therapeutic aPTT or higher, decreasing from 10.1 hours in the nurse-managed group to 6.3 hours (p<0.0001). This significant improvement was observed across standard-dose (10.4 to 6.3 hours, p<0.0001), reduced-dose (10.0 to 6.4 hours, p=0.0207), and low-dose protocols (9.0 to 6.2 hours, p=0.0099). Regarding secondary outcomes, the pharmacist-managed group demonstrated a statistically significant decrease in the percentage of sub-therapeutic aPTT checks per patient (40% to 31%, p=0.0003) and a significant increase in therapeutic checks (p=0.0180) compared to the nurse-managed group. Notably, there were no significant differences between groups in the rates of supratherapeutic aPTT checks or aPTTs exceeding 150 seconds. Pharmacist adherence to the protocol was high at 95.4%, with a median time of 4.5 minutes from lab result to order entry and 18 minutes to rate change documentation.

Conclusions: In conclusion, the pharmacist-managed heparin service at Erlanger effectively improved the time to therapeutic anticoagulation and improved the proportion of therapeutic aPTTs without increasing the risk of excessive anticoagulation.