Clinical research study
Adherence to Pharmacological Thromboprophylaxis Orders in Hospitalized Patients

https://doi.org/10.1016/j.amjmed.2009.11.017Get rights and content

Abstract

Objective

We compared adherence to unfractionated heparin (UFH) 2 or 3 times daily prophylaxis orders versus low-molecular-weight heparin (LMWH) once daily orders. Our goals were to determine which strategy demonstrated the best adherence in terms of timing and frequency of dose administration, and to determine reasons for ordered heparin not being administered.

Methods

We queried our electronic medication administration record where nurses document reasons for delayed administration or omitted doses. We identified 250 consecutive patients who were prescribed prophylaxis with UFH 2 or 3 times daily or LMWH once daily. We followed patients for their hospitalization to determine adherence to physicians' prophylaxis orders.

Results

Adherence, defined as the ratio of prophylaxis doses given to doses ordered, was greater with LMWH (94.9%) than UFH 3 times daily (87.8%) or UFH twice daily (86.8%) regimens (P <.001). Patients receiving LMWH more often received all of their scheduled prophylaxis doses (77%) versus UFH 3 times daily (54%) or UFH twice daily (45%) (P <.001). There were no differences between regimens regarding reasons for omitted doses. The most common reason for late or omitted doses was patient refusal, which explained 44% of the UFH and 39% of the LMWH orders that were not administered.

Conclusions

LMWH once a day had better adherence than UFH 2 or 3 times daily. For both LMWH and UFH, patient refusal was the most common reason for not administering prophylaxis as prescribed. These findings require consideration when evaluating pharmacological prophylaxis strategies. Educational programs, explaining the rationale, may motivate patients to improve adherence during hospitalization.

Section snippets

Methods

Brigham and Women's Hospital has a computer system that integrates medical, laboratory, nursing, and pharmacy information. Physicians enter all medication orders into the computer order entry system. A pharmacist reviews the medications, and, once approved, the medications become part of the electronic medication administration record. Nurses are prompted to administer medications as part of a work shift to-do list (Figure 1). The nurse scans the medication's bar code, the patient

Results

Of the 125 patients receiving LMWH prophylaxis, 103 (82.4%) were admitted to the Medical Service. Patients were most often admitted to the Oncology, General Medicine, and Neurology Services (Table 1). Of the 125 patients receiving UFH prophylaxis, UFH was prescribed 3 times daily for 97 (77.6%) and twice daily for 28 (22.4%) patients. UFH 3 times daily was most commonly prescribed in Thoracic Surgery, Gastroenterology, General Medicine, and Surgical Oncology patients. UFH twice daily was most

Discussion

Our drug utilization review of 250 consecutive patients demonstrates that twice daily or 3 times daily regimens of UFH have adherence rates of 87%. Adherence improves to 95% with once daily LMWH. Only 47% of patients ordered for UFH regimens received every scheduled dose, whereas adherence to every scheduled dose of LMWH was 78%.

Patient refusal was the most frequent reason for omitted doses, regardless of whether UFH or LMWH was ordered. Patients might refuse injection-based prophylaxis because

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Funding: Sanofi-aventis.

Conflict of Interest: John Fanikos, RPh, MBA serves on the Speakers Bureau for sanofi-aventis and GlaxoSmithKline and has served as a consultant/advisory board participant. Samuel Z. Goldhaber, MD, receives research funds and is a consultant for sanofi-aventis, Eisai, Bristol-Myers Squibb, and Boehringer-Ingelheim. The remaining authors have no conflicts to disclose.

Authorship: All authors had access to the data and participated in the manuscript preparation.

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