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An Audit of Prescribing LMWHs in Acute Coronary Syndrome
Katrina LinesMedical Student, Cardiff University
Dr Rob PerryClinical Supervisor, Consultant in Emergency Medicine
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Background
Enoxaparin (Clexane®)
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Current Guidelines
Weight1mg/kg BD5
Renal functionIf GFR <30ml/min, reducedose to 1mg/kg OD6
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Weight Renal Function
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Methodology
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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
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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
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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
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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
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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