Here's how hospital handled enoxaparin and heparin protocols

Argatroban use greatly decreased

Winter Haven Hospital in Winter Haven, FL, developed several protocols involving the pharmacy's involvement with anticoagulation therapy, including protocols specific to enoxaparin and heparin.

Here is how those protocols worked:

• Enoxaparin: "For this protocol we screen every patient who starts on enoxaparin for renal function," says Jovino Hernandez, PharmD, clinical coordinator of pharmacy services at Winter Haven Hospital.

Pharmacists can adjust enoxaparin dosing on all physician orders when appropriate, based on the protocol.

"We reduce their dose based on their renal function," he says. "We screen for patients even if their creatinine clearance was less than 50."

Anecdotal evidence has shown less retroperitoneal bleeding associated with enoxaparin use since the protocol was implemented, Hernandez says.

"The physicians were very responsive, and many of these initiatives are discovered in conjunction with quality outcomes here," he adds.

• Heparin: Pharmacists manage all patients' heparin therapy based on the heparin protocol, Hernandez says.

"We also have screening for patients who have heparin- induced thrombocytopenia (HIT), and we work in conjunction with the lab," he adds. "Whenever someone orders a HIT study, the pharmacy follows up on the results and proper management."

Prior to implementing the HIT portion of the heparin protocol, there was no specific process for handling these issues.

"Before, when a patient's platelets dropped while on heparin, we didn't tend to notice like we do now," Hernandez says. "When there was a HIT screening order there was no one designated to follow-up on these."

Now, pharmacists will follow-up with the lab and try to obtain the results as quickly as possible.

Also, pharmacists and hematologists have educated physicians that a decrease in platelets on heparin is not necessarily an indication for treating for HIT.

"What we now do is a grading system that assesses previous heparin use and time from a patient's last heparin exposure to the decrease in platelets," Hernandez explains. "We check with physicians to see if there are any signs or symptoms of thrombosis."

For example, if there's an active clot, they'll start on argatroban, the treatment for HIT.

The outcome has been a cost savings from a decrease in the inappropriate use of argatroban, Hernandez says.

"That saves an enormous amount in costs," he adds. "Argatroban costs over $1,000 a day, and patients can take 4-5 days of the drug."

In the past year, the hospital has used only 12 vials of the drug, a five-fold decrease that has saved thousands of dollars, he says.