Clinical Pharmacy Forum
Sunday, November 12, 2023
12:45 PM–02:15 PM
Abstract
Service or Program: Guidelines recommend serum factor anti-Xa (anti-Xa) concentration monitoring with enoxaparin chemoprophylaxis dose-adjustment in trauma patients. Pharmacy consultation was established in 2019 for enoxaparin chemoprophylaxis management in ICU and floor patients at a level 1 trauma center. Programmatic elements included a collaborative practice agreement, anti-Xa ordering, enoxaparin dosage adjustment, daily monitoring, and progress note documentation. A baseline evaluation demonstrated 56.5% of anti-Xa trough concentrations were appropriately drawn. A pharmacist-led process improvement (PI) initiative using the Institute for Healthcare Improvement Model for Improvement was undertaken to improve anti-Xa serum monitoring reliability.
Justification/Documentation: An interprofessional stakeholder analysis identified and assembled a team of physicians, nurses, phlebotomists, information technologists, and pharmacists. “Go Sees”, high level process mapping, Failure Modes Effects Analysis, Pareto chart, and root cause analysis (RCA) were performed. Over 80% of process failures occurred due to anti-Xa assays not being collected as ordered. RCA identified discordant awareness between assay collection and the medication administration record (MAR) with variation between floor (phlebotomy draw) and ICU (nurse draw) systems. Iterative Plan-Do-Study-Act cycles were performed for assay timing, assay order communication, and MAR comments in both environments. MAR comments entered by clinical pharmacist visually signifying lab due time paired with the respective enoxaparin dose was the most reliable intervention. Over the 3-month period of the project, appropriate anti-Xa collection increased from 45% to 77% for floor patients and 50% to 83% for ICU patients.
Adaptability: Pharmacist-driven, lab-medication linked signifier on the MAR enhanced reliability of appropriately drawn anti-Xa assays for trauma patients. This initiative demonstrated positive feedback from stakeholders, including pharmacists’ desire to implement similar workflow improvements necessitating timed serum laboratory monitoring for pharmacotherapy.
Significance: Pharmacists fulfill ACCP clinical practice standards by facilitating the care delivery process through collaborative practice agreements for enoxaparin chemoprophylaxis. Pharmacist-led, interprofessional PI can improve key drivers across pharmacy and non-pharmacy workstreams.
Presenting Author
Molly Droege PharmD, BCPSUniversity of Cincinnati Medical Center
Authors
Paige Bradshaw PharmD, BCCCP
UC Health - University of Cincinnati Medical Center
Eric Mueller PharmD, FCCM, FCCP
University of Cincinnati Medical Center
Carri Philpott PharmD, BCCCP
University of Cincinnati Medical Center
Lauren Dehne PharmD, BCCCP
UC Health - University of Cincinnati Medical Center
Chris Droege PharmD, BCCCP, FCCM, FASHP, FACCP
University of Cincinnati Medical Center
Jessica Winter PharmD, BCPS
University of Cincinnati Medical Center
Timothy Rice PharmD
University of Cincinnati - James L. Winkle College of Pharmacy