Unfractionated IV Heparin
Hi fellow Clinical Informaticists,
To get the ball rolling, I thought I'd share my own personal success with leading a team to redesign the workflow for titrating Unfractionated IV Heparin.
THE WIN :
Rethinking and redesigning an Unfractionated IV Heparin titration protocol for improved ease-of-use, efficiency, and safety.
THE BACKGROUND :
If there is anything to file under the category of 'bread-and-butter-medicine', it's Unfractionated IV Heparin. It's an IV drip that's commonly used to treat acute blood clots, whether they are in your legs (Deep Vein Thrombosis), your lungs (Pulmonary Embolism), or your heart (Acute Coronary Syndrome). It's used in hospitals all around the world, every day, to immediately help treat these common conditions until further interventions are available.
This particular workflow is quite complex. It requires frequent monitoring, to help ensure that it's at the right dose. To do this, it requires kind of a complex, well-coordinated effort between:
And because most organizations already have a protocol in place to do this, it usually happens pretty seamlessly, allowing clinical staff to treat patients with blood clots.
THE CHALLENGE :
I was working for a former employer around 2014 when a new titration lab parameter became available, known as anti-Factor Xa activity. This new lab test offers a more accurate prediction of the effectiveness of heparin, so our laboratory leadership asked me if we should be using it in our IV Heparin Titration protocol, instead of the traditional Partial Thromboplastin Time (aPTT) measuring tool.
The new test offered more accurate results with fewer blood draws. While at first this seemed like an easy decision, there were a number of challenges to redesigning this workflow:
And finally - Because the activity of the drug depends somewhat on the calibration of your laboratory assays, the manufacturer of the drug does not really offer clear dosing guidelines. During our literature search, we found journal articles dating back to the early 1990s discussing 'heparin dosing nomograms', but they didn't offer us exact instructions because the actual titration parameters typically depend on the calibration of devices in your laboratory.
A lot of design challenges, for sure, but whatever the solution, we wanted it to be smooth, easy, and safe.
THE SOLUTION :
At the time, I was very fortunate to have an excellent Nurse Informaticist on my team, Andrea Hoffman, RN. Before building our workgroup, Andrea and I first started working on the design parameters, workflows, and list of stakeholders. We created a project folder, and spent a few days at a whiteboard, continuously drawing and re-drawing out the ideal workflows :
THE OUTCOME :
After additional analysts, informaticists, and trainers were able to obtain our blueprints, they built the electronic versions of the tools, tested them, educated them, and around 2017 went live with the new protocol. On go-live, people who were aware of this project texted me to thank me for making it as easy-to-use and foolproof as possible.
And, I'm glad to report that it's easy to sell great workflows - The entire protocol was reviewed by a best-practice committee which adopted it as a best-practice workflow across the entire hospital network. This easier, safer, and more efficient common clinical workflow is now available for use across multiple hospitals in the system, anytime, 24/7.
IV Heparin may not be the most glamorous drug or talked-about workflow in medicine, but it's an genuine honor knowing that our little community-hospital workflow design team, led by our small-but-dedicated Clinical Informatics team (Andrea Hoffman and myself), was able to rebuild this common bread-and-butter medicine workflow, from scratch, making it easier, more efficient, and safer.
Have any Clinical Informatics success stories you'd like to share, big or small? Use the contact box in the side bar to send your email, and I'll contact you!
To get the ball rolling, I thought I'd share my own personal success with leading a team to redesign the workflow for titrating Unfractionated IV Heparin.
THE WIN :
Rethinking and redesigning an Unfractionated IV Heparin titration protocol for improved ease-of-use, efficiency, and safety.
THE BACKGROUND :
If there is anything to file under the category of 'bread-and-butter-medicine', it's Unfractionated IV Heparin. It's an IV drip that's commonly used to treat acute blood clots, whether they are in your legs (Deep Vein Thrombosis), your lungs (Pulmonary Embolism), or your heart (Acute Coronary Syndrome). It's used in hospitals all around the world, every day, to immediately help treat these common conditions until further interventions are available.
This particular workflow is quite complex. It requires frequent monitoring, to help ensure that it's at the right dose. To do this, it requires kind of a complex, well-coordinated effort between:
- Providers - who diagnose these conditions and order this treatment
- Pharmacists - who dispense this IV medication with the right concentration
- Registered Nurses - who administer this IV medication to a patient, and then titrate the medication according to a set of rules developed by pharmacy, laboratory, nursing, and physician leaders.
- Laboratory Technicians - Who have to perform the blood tests (ordered by physicians) that let nurses and physicians know when the medication is at the right dose, when it needs to be adjusted up, and when it needs to be adjusted down
And because most organizations already have a protocol in place to do this, it usually happens pretty seamlessly, allowing clinical staff to treat patients with blood clots.
THE CHALLENGE :
I was working for a former employer around 2014 when a new titration lab parameter became available, known as anti-Factor Xa activity. This new lab test offers a more accurate prediction of the effectiveness of heparin, so our laboratory leadership asked me if we should be using it in our IV Heparin Titration protocol, instead of the traditional Partial Thromboplastin Time (aPTT) measuring tool.
The new test offered more accurate results with fewer blood draws. While at first this seemed like an easy decision, there were a number of challenges to redesigning this workflow:
- While the anti-Factor Xa assay offered a more accurate predication of heparin functioning, and potentially fewer blood draws for a patient - it also had certain cases where it couldn't be easily interpreted in the lab (especially in patients with hyperlipidemia or pronounced anemia)
- The existing protocol was a bit cumbersome, both to the providers and the nurses who were referencing a written piece of paper to know when to draw labs and how to adjust the drip.
- The entire process required the careful training and coordination of providers, nursing, pharmacy, and laboratory.
And finally - Because the activity of the drug depends somewhat on the calibration of your laboratory assays, the manufacturer of the drug does not really offer clear dosing guidelines. During our literature search, we found journal articles dating back to the early 1990s discussing 'heparin dosing nomograms', but they didn't offer us exact instructions because the actual titration parameters typically depend on the calibration of devices in your laboratory.
A lot of design challenges, for sure, but whatever the solution, we wanted it to be smooth, easy, and safe.
THE SOLUTION :
At the time, I was very fortunate to have an excellent Nurse Informaticist on my team, Andrea Hoffman, RN. Before building our workgroup, Andrea and I first started working on the design parameters, workflows, and list of stakeholders. We created a project folder, and spent a few days at a whiteboard, continuously drawing and re-drawing out the ideal workflows :
- Initiating Unfractionated IV Heparin using anti-Factor Xa monitoring parameters
- Changing Unfractionated IV Heparin using anti-Factor Xa into aPTT monitoring
- Discontinuing Unfractionated IV Heparin, using either anti-Factor Xa or aPTT monitoring.
- Deep Vein Thrombosis / Pulmonary Embolism
- Acute Coronary Syndrome
- Other (custom-dosing) indication
- Starting Unfractionated IV Heparin Infusion/Titration using anti-Factor Xa - For ACS
- Starting Unfractionated IV Heparin Infusion/Titration using anti-Factor Xa - For DVT/PE
- Starting Unfractionated IV Heparin Infusion/Titration using anti-Factor Xa - For custom dosing
- Starting Unfractionated IV Heparin Infusion/Titration using aPTT - For ACS
- Starting Unfractionated IV Heparin Infusion/Titration using aPTT - For DVT/PE
- Starting Unfractionated IV Heparin Infusion/Titration using aPTT - For custom dosing
- Converting Heparin Titration using anti-Factor Xa into aPTT
- Discontinuing Unfractionated IV Heparin Infusion/Titration
After developing this list of workflows, were then able to meet with the additional stakeholders from laboratory and pharmacy, to complete our design team and really begin developing these workflows.
Along the way, we discovered that the nursing flowsheet was really the key to easy titration. In the past - nurses were going from the flowsheet back to a different piece of paper (the protocol with the titration parameters), to determine next steps and how to titrate the drip. By combining the titration parameters with the flowsheet, it made a much smoother, more intuitive, easier-to-understand workflow.
And after several meetings with these nursing, laboratory, and pharmacy stakeholders, we were able to calibrate our titration parameters for anti-Factor Xa and aPTT, without needing to resort to copying the parameters from another hospital. Essentially, the entire protocol was rebuilt from scratch in an evidence-based manner, without borrowing any materials from other hospitals.
We also learned, just through discussion of these mock scenarios, of the importance of fail-safes. To help make sure patients were safe, we made sure that it was easy to identify, communicate, and intervene by converting the entire protocol from anti-Factor Xa monitoring over to aPTT monitoring.
Our designs worked. At the end of these design sessions, our team left a well-developed set of blueprints, mockups, policy, and training, for our analyst team to build and tackle.
THE OUTCOME :
After additional analysts, informaticists, and trainers were able to obtain our blueprints, they built the electronic versions of the tools, tested them, educated them, and around 2017 went live with the new protocol. On go-live, people who were aware of this project texted me to thank me for making it as easy-to-use and foolproof as possible.
And, I'm glad to report that it's easy to sell great workflows - The entire protocol was reviewed by a best-practice committee which adopted it as a best-practice workflow across the entire hospital network. This easier, safer, and more efficient common clinical workflow is now available for use across multiple hospitals in the system, anytime, 24/7.
IV Heparin may not be the most glamorous drug or talked-about workflow in medicine, but it's an genuine honor knowing that our little community-hospital workflow design team, led by our small-but-dedicated Clinical Informatics team (Andrea Hoffman and myself), was able to rebuild this common bread-and-butter medicine workflow, from scratch, making it easier, more efficient, and safer.
Have any Clinical Informatics success stories you'd like to share, big or small? Use the contact box in the side bar to send your email, and I'll contact you!
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