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Safety and Efficacy Analysis of an Inpatient Collaborative Drug Therapy Management Service for Direct Thrombin Inhibitors

Heather Kokko, Pharm.D., Carol White, Pharm.D., David Taber, Pharm.D., Tanna Cooper, Pharm.D., Walt Uber, Pharm.D., Joseph Mazur, Pharm.D.

Medical University of South Carolina Medical Center, Charleston, North Carolina

Direct thrombin inhibitors (DTI) are considered the first line option for anticoagulation in patients with heparin-induced thrombocytopenia (HIT).  Currently, no uniform guidelines exist for the management of DTIs with dosage adjustments based on Activated Partial Prothrombin Times (aPTTs).  When the Joint Commission® updated the National Patient Safety Goals in 2008 to include reducing the likelihood of patient harm associated with the use of anticoagulation, pharmacy practitioners at our institution recognized an opportunity to play a major role in guiding appropriate management of DTI therapy to improve patient safety and outcomes. 

A pharmacist-driven DTI protocol was developed to establish guidelines for the use and monitoring of DTIs. It also included development of a collaborative drug therapy management (CDTM) service.  The DTI protocol consisted of five main sections: practice pearls for diagnosing HIT, initial dosing and choice of DTIs, nurse- and pharmacist-driven instructions for the monitoring of DTI therapy, information for safely transitioning from a DTI to warfarin, and a scoring system for determining the probability of HIT. The CDTM service for the inpatient setting was developed to improve patient outcomes and reduce medication errors related to the monitoring and adjusting of DTI dosages. Prior to implementing the CDTM service, three major areas were addressed: pharmacist competencies and credentialing, the drug ordering process, and required clinical documentation.   Patient data was collected prior to and following implementation of the DTI protocol and CDTM service in order to determine the effects this program had on clinical outcomes and patient safety.

A total of 50 patients were included in the analysis, 25 patients in each group.  Patients in the post-implementation group achieved therapeutic aPTTs more rapidly (7.7 hrs vs. 3.4 hrs, p=0.009) and maintained a therapeutic aPTT more consistently (81% vs. 93%, p=0.001)than those in the pre-implementation group. Despite the higher acuity of illness seen in the post-implementation group, bleeding rates (12% in the pre-implementation group, 20% in the post-implementation group, p=NS) and overall mortality rates (20% in the pre-implementation group, 24% in the post-implementation group p=NS) were similar between groups.  Before initiation of the program, medication errors stemming from both prescribing and administration mistakes occurred in 40% of patients receiving DTI therapy, while only 12% of patients treated per the DTI protocol encountered medication errors (p=0.05). The most notable difference in the incidence of medication errors was in the prevalence of prescribing errors. Prior to the DTI program, prescribing errors occurred in 24% of the patients receiving DTI therapy. Following the advent of the protocol and ‘pharmacy to dose’ program, prescribing errors were completely eliminated (p=0.02).

Implementation of a comprehensive DTI protocol with an innovative inpatient pharmacist-driven CDTM program resulted in improved clinical outcomes and patient safety.

View a pdf of the poster from the Midyear Meeting (416 KB).