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An Audit of Prescribing LMWHs in Acute Coronary Syndrome
- 1. An Audit of Prescribing LMWHs in Acute Coronary Syndrome Katrina Lines Medical Student, Cardiff University Dr Rob Perry Clinical Supervisor, Consultant in Emergency Medicine
- 3. Current Guidelines Weight 1mg/kg BD5 Renal function If GFR <30ml/min, reduce dose to 1mg/kg OD6
- 5. Methodology
- 6. Results 19 patients identified Weight 40% - Emergency Department 47% - medical wards 26% had no recorded weight Renal Function No patients had a documented eGFR Inconsistent prescribing Overall 26% received the wrong dose
- 7. Interventions Letter to Nurses in Charge Change nursing documents Poster campaign Emergency Department Biochemistry Acute Medical Wards Poster campaign Prescribing guidelines poster eGFR routine Talk to ward pharmacist Prescribing sticker
- 8. So did we improve things? No.74% 74%50% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Proportion of patients weighed Proportion of patients prescribed correct dose Pre-Intervention Post-Intervention
- 9. Recommendations More weighing facilities Local policy on weighing patients Local policy on prescribing in renal impairment Multidisciplinary teaching Lack of equipment Confusion Confusion & lack of awareness Weight Renal Function Dosing chart/sticker
- 10. References 1. Peters RJ, Mehta S, Yusuf S; Acute coronary syndromes without ST segment elevation. BMJ. 2007 Jun 16;334(7606):1265-9 2. LaPointe NM, Chen AY, Alexander KP, et al. Enoxaparin dosing and associated risk of in-hospital bleeding and death in patients with non-ST-segment elevation acute coronary syndromes. Archives of Internal Medicine. 2007; 167:1539-44 3. Hoffmann P. Keller F. 2012. Increased major bleeding risk in patients with kidney dysfunction receiving enoxaparin: a meta-analysis. Eur J Clin Pharmacol. 2012. 68(5):757-65 4. National Patient Safety Agency. Reducing treatment dose errors with low molecular weight heparins. July 2010. Available at: www. nrls.npsa.nhs.uk/resources (accessed 25th September 2012) 5. British National Formulary 63rd edition. London. British Medical Association and Royal Pharmaceutical Society of Great Britain; 2012. 6. Clexane pre-filled syringes. Summary of Product Characteristics last updated on the eMC: 03/01/2012. Available at: http://www.medicines.org.uk/emc/ (accessed 26th September 2012) 7. McArtney R et al. An audit of therapeutic doses of low molecular weight heparins. Clinical Pharmacist. 2011; 3:158 8. Hilmer SN et al. Failure to weigh patients in hospital: a medication safety risk. Int Med J. 2007; 37:647-50
Editor's Notes
- Good afternoon ladies and gentleman. My name is Katrina, I am a final year medical student at Cardiff University. Thank you for the opportunity to tell you about an audit I performed as part of my Senior Clinical Project. My project was based in the Emergency Department in ysbyty gwynedd, Bangor.
- Acute Coronary Syndrome is an umbrella term for a range of conditions which lead to obstruction of the coronary arteries. Major causes include myocardial infarction and unstable angina. ACS is common, affecting over 100,000 people each year in the UK. Heparin is one of the drugs used in the treatment of ACS. It is an indirect inhibitor of thombin and prevents the thrombus from enlarging and worsening the myocardial ischaemia. Enoxaparin (clexane) is the LMWH of choice in Ysbyty Gwynedd. Studies have shown that an excess dose of LMWH is associated with a risk of major bleeding and death. And worryingly, between 2005-2009 the NPSA received 2716 reports of dosing errors relating to LMWH.
- by subcutaneous injection for 2-8 days Exception is if over 75 years and STEMI, 0.75mg/kg Weight should be accurately recorded in kg on the drug chart and patient notes Clexane is excreted renally, and studies have shown that patients with renal impairment are at an increased risk of major bleeding. Refer to product literature which states: Grey area in mild and moderate renal impairment. The product literature does not advise dose adjustment but some leading bodies recommend reducing the dose or switching to unfractioned heparin which is not as reliant on renal excretion.
- Weight is used to calculate the dose. accurately recorded in kg on the drug chart and in patients notes. Renal function is considered when prescribing LMWH
- http://www.ons.gov.uk/ons/dcp171778_239518.pdf the National Patient Safety Agency received reports of 2716 dosing errors relating to LMWH. The NPSA then released a Rapid Response Report concerning the prescribing of LMHWs. They made 6 recommendations. We used 2 of the recommendations as the basis for the audit. Recommendation 1: “A patient’s weight is used as the basis for calculating the required treatment dose of LMWH. The weight must be accurately recorded in kilograms (kg) in the inpatient medication chart (when in use) and clinical record. Patients should be weighed at the start of therapy and, where applicable, during treatment” Recommendation 2: “Renal function is considered when prescribing treatment doses of LMWHs. The renal function test should not delay initiation of the first dose but every effort must be made to base subsequent dosing on these results.”
- Collecting data involved me going to the acute medical wards, looking through all inpatient notes to see if anyone was treated with enoxaparin for ACS. If they were, I would look through the medical and nursing notes to see if a weight had been taken, and record the dose of enoxaparin they were prescribed. If no weight was recorded I would ask the patient if they had been weighed and then weigh them myself. Where renal function was not known, an estimated GFR was calculated using the Cockcroft-Gault formula. Data was collected over a 3 week period
- 40% patients had a weight recorded in the ED One patient had severe renal impairment and their dose was halved and given twice daily, rather than giving the same dose once daily. Four patients had moderate renal impairment, and two of these had their dose adjusted to once daily One patient with normal renal impairment was given a once daily dose Our results are similar to other studies conducted in Wales, and throughout the world which show a high proportion of patients not weighed and receiving the wrong dose.
- An all-Wales audit conducted in 2008 and involving 599 patients found that 19% had no recorded weight. (ours 26%) An Australian study conducted in 2007 found that 73% of patients prescribed therapeutic doses of LMWH were not weighed. It also showed that those patients who were not weighed experienced more haemorrhagic complications than those who were weighed A large study conducted in USA involving >10,000 patients . 2007
- From our results, we believed improvements could be made in both the Emergency Department and on the medical wards. In the ED I noticed that there wasn’t anywhere to record weight in the nursing documents. I therefore altered the nursing notes to include weight under initial observations. I then wrote to the nurses in charge to inform them of this change, and ask that they encourage nursing staff to weigh patients I also put posters up in ED to remind nursing staff and doctors to weigh patients I didn’t think asking doctors to perform a Cockcroft-Gault formula for every patient was realistic, so I liased with biochemistry to introduce eGFR as a routine investigation on all sets of U+Es I then looked at the medical wards, and again put up posters encouraging staff to weigh patients Our initial results indicated that there may be some confusion over when and how to adjust the dose in renally impaired patients. I produced a poster with prescribing guidelines and put them next to the drug cupboard. A prescribing sticker was produced and put on the front of all drug charts, to serve as a visual reminder. Attend doctors handover I spoke to the ward pharmacist to ask that they pay special attention to enoxaparin prescriptions Data was collected for a further 2 weeks
- Only 10 patients were identified. This graph shows that the proportion of patients weighed actually decreased from 74% to 50%. This was true of both the ED and the medical wards. We did find that all patients received the correct dose of enoxaparin after our intervention. However, our patient numbers were so small we couldn’t draw statistical significance from it. In terms of renal function, no patients in our post-intervention group had severe renal impairment, and therefore we do not know if our intervention would helped more accurate prescribing in this group. Two patients had moderate renal impairment and in neither case had this been documented. Our sticker was used in 3/10 patients, and in these renal function was noted.. Which appears to be an improvement. However, two patients had moderate renal impairment and this hadn’t been documented. So we cannot conclude that our interventions have improved practice, but we can conclude that not all patients receiving medication based on their weight are being weighed. And that renal function is not routinely taken into account when prescribing. Clearly the number of patients involved in our study is very small and we are unable to draw statistical conclusions from the results. However, our findings do show that a suboptimal number of patients are weighed. Our results also raise concern over the prescribing of clexane in renally-impaired patients.
- What our results did show was that a suboptimal number of patients were weighed. Reasons for this include a lack of weighing facilities and confusion over whose job it is to weigh patients and at what stage during their stay. To rectify this, we recommend investing in more weighing facilities, including trolleys with weighing capabilities for rhesus. We also recommend local policies on weighing patients to clarify who should be weighing and when. To make prescribing in renal impairment consistent, we recommend a local policy is produced on prescribing in renal impairment. To reduce the number of dosing errors, we recommend multidisiplinary teaching and the introduction of a dosing chart or sticker.