Improving safety of unfractionated heparin: a retrospective, quasi-experimental, observational study of the impact of a pocket card and a computerised prescription aid tool in the University Hospitals of Geneva

BACKGROUND: Despite the rapid rise of direct oral anticoagulants, unfractionated heparin (UFH) remains the mainstay anticoagulant in specific situations such as severe renal failure, perioperative setting or in critical care units. However, its titration is often challenging. OBJECTIVES: To investigate the effect of a pocket card and a computerised prescription aid tool (CPAT) on the quality of UFH anticoagulation. DESIGN: Monocentric retrospective, quasi-experimental, observational study. SETTING: Inpatient primary care centre between 1 January 2016 and 31 December 2019. PARTICIPANTS: >18 years-old treated with therapeutic UFH for more than 24 hours. There were 819 and 1169 anticoagulation episodes before and after intervention, respectively. INTERVENTION: In October 2017, we implemented a pocket card with evidence-based recommendation for therapeutic UFH initiation, monitoring and dosing adaptation. In October 2019, we implemented a CPAT in a group subset. PRIMARY AND SECONDARY OUTCOMES: The primary outcome was the time needed to reach a therapeutic anti-Xa before and after the implementation of the pocket card. The secondary outcomes included a subgroup analysis assessing the effect of the CPAT. Other secondary outcomes were the anti-Xa status (infratherapeutic, therapeutic or supratherapeutic) at 7 and 24 hours of UFH treatment. RESULTS: We found a significant increase in the time to reach therapeutic dosing with pocket card-guided recommendations implementation (10.1 vs 14 hours, HR of 0.8, 95% CI: 0.70 to 0.93). However, the CPAT was associated with a significant decrease in the time needed to reach the therapeutic range (13.9 vs 7.1 hours, HR of 1.74, 95% CI: 1.17 to 2.60). CONCLUSION: Although we observed an increase in time to reach therapeutic anti-Xa with the pocket card, possibly due to a selection bias (use of activated partial thromboplastin time for monitoring before the pocket card), the implementation of CPAT significantly decreased the delay for effective therapy. Further studies are needed to confirm these findings, and to determine the optimal initial dose of UFH anticoagulation.