An Audit of Prescribing LMWHs in Acute Coronary Syndrome

Katrina LinesMedical Student, Cardiff University

Dr Rob PerryClinical Supervisor, Consultant in Emergency Medicine

Background

Enoxaparin (Clexane®)

Current Guidelines

Weight1mg/kg BD5

Renal functionIf GFR <30ml/min, reducedose to 1mg/kg OD6

Weight Renal Function

Methodology

Results19 patients identified

Weight40% - Emergency Department47% - medical wards26% had no recorded weight

Renal FunctionNo patients had a documented eGFRInconsistent prescribing

Overall26% received the wrong dose

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

So did we improve things?

No.

Proportion of patients weighed Proportion of patients prescribed correct dose

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

74% 74%50%100% Pre-Intervention

Post-Intervention

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 FunctionDosing chart/sticker

References1. 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