Clinical audit of Heparins use in rift valley general hospital, Nakuru county, Kenya
Gichobi, Alice Njeri
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Introduction: Heparin remains the most widely used parenteral anti- thrombotic drug. It is a high risk medicine that may cause significant harm including death if not used properly. Heparin has low therapeutic index and is ranked among the top 5 “high alert” medications by the Institute of Safe Medication Practices. Heparin-related medication errors can occur at any stage from prescribing, dispensing, administration to monitoring of therapy. Its use should therefore be monitored to prevent possible errors and maximize benefits of use. There are no local studies assessing the heparin use process or highlighting the prevalence of outcomes related to heparin use. This is an important gap which this study seeks to address through the implementation of a clinical audit. Aim: To examine the processes and outcomes of heparin use in adult in- patients at the Rift Valley General Hospital, Nakuru through the conduct of a clinical audit. Methodology: An evidence-based, structured clinical audit tool was developed through a consolidation of information from various sources. The tool was then used to examine and audit the structures, processes and outcomes which characterize the current use of heparin. The structures supporting heparin use were examined by physically assessing availability of policies, guidelines or protocols for heparin use. Availability of antidote protamine and laboratory reagents for monitoring heparin use were also physically assessed in the pharmacy, wards and laboratory respectively. The processes and outcomes of heparin use were audited through the prospective observation of heparin administration and monitoring among eligible adult in-patients being managed with heparin regardless of diagnosis. Each patient was followed up for at least three days and data on the administration and monitoring of heparin use recorded. To supplement the clinical audit, a cross-sectional study of in-patient reports of patients managed with heparin was also carried out to establish the indications, laboratory monitoring, dose adjustment, and adverse effects that characterize in-patient heparin use. Descriptive statistics were then used to summarize and present this data. Results: The clinical audit revealed that there were no policies, protocols or guidelines to guide in the use of heparin at Rift Valley General Hospital. The reagents for tests used to monitor heparin use i.e. Full Blood Count, activated Partial Thromboplastin Time and International Normalised Ratio were available, though incidents of delayed or lack of heparin monitoring were observed. Heparin termination was done well by introduction of warfarin at least three days before stopping heparin in majority of the patients. Approximately half of patients and/or caregivers indicated that they were satisfied with the quality of care. The overall clinical audit score at Rift Valley General Hospital was 60.6% which showed minimal compliance to the performance threshold/standard of heparin use. Analysis of the data from the records of 238 in-patients on heparin showed deep vein thrombosis as the most prevalent diagnosis at 74.8%; 18.9% had fractures while 6.3% had other diagnoses. A majority of the patients (57%) did not have any tests done to monitor heparin use. Information on any adverse drug reaction was poorly reported, with no such information in 236 (99.2%) of all the files. Conclusions: An evidence based tool was developed for the audit of heparin use and it was subsequently used to conduct a clinical audit for structures, processes and outcomes that characterize heparin use. This clinical audit for heparin use in Rift Valley General Hospital, concluded minimal compliance to the set standards. Heparin monitoring and reporting of adverse drug reactions is not adequate at Rift Valley General Hospital, though termination of heparin therapy was relatively well done. There is need to put strategies in place to ensure use of heparin is improved and maximum benefit is realized. A Quality Improvement Plan was developed for use by the Rift Valley General Hospital management for this purpose.