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John A. Hollingsworth, MD, FRCPC, MRCPI; Brian H. Rowe, MD, MSc, CCFP(EM); Frances J. Brisebois, BPharm, MRPharmS(GB); Patricia R. Thompson, BScPharm; Lucio M. Fabris, BScPharm

Arch Intern Med. 1995;155(19):2095-2100.

Abstract
Background
Heparin administration by physicians can vary greatly, and this variance can result in ineffective anticoagulation and reduced effectiveness of treatment.

Objective
To examine the use of a heparin nomogram in two community hospitals to validate its effect on anticoagulation parameters and to determine its influence on length of hospital stay.

Methods
Prenomogram and postnomogram intervention in two community hospitals in Sudbury, Ontario. All patients who presented and were admitted to the hospitals between 1991 and 1994 with a confirmed primary diagnosis of deep vein thrombosis and/or pulmonary embolism were eligible for the study. A heparin nomogram was instituted in April 1993 for treatment of deep vein thrombophlebitis and pulmonary embolism in hospitalized patients. The study patients were designated as prenomogram or postnomogram. Anticoagulation parameters (time to therapeutic activated partial thromboplastin time), number of diagnostic tests, percentage of times within the therapeutic range, and length of hospital stay were recorded for both groups.

Results
A total of 326 patients were identified from the database; 163 (50%) met the inclusion criteria. Patients in both groups appeared to be similar. Adequate anticoagulation was achieved faster (17.9 hours postnomogram vs 48.8 hours prenomogram; P<.001) and remained sub-therapeutic less frequently in the postnomogram group (number of activated partial thromboplastin time tests below the therapeutic window; 56% prenomogram vs 28% postnomogram; P<.001). There were no differences between the groups with respect to length of stay (11.3 days prenomogram vs 10.9 days postnomogram; P=.60). More activated partial thromboplastin time tests were ordered in the postnomogram group (15.6 postnomogram vs 12.7 prenomogram; P=.001); however, fewer prothrombin time tests were ordered in the postnomogram group.

Conclusions
A heparin nomogram was successfully used in a community hospital without a structured hematology-thrombosis service. Therapeutic anticoagulation was achieved faster and maintained more frequently, with less logistical problems, with this protocol. However, additional measures may be required to reduce the length of hospital stay.

(Arch Intern Med. 1995;155:2095-2100)

Author Affiliations
From the Departments of Internal Medicine (Dr Hollingsworth) and Emergency Medicine (Dr Rowe), Sudbury (Ontario) General Hospital; Northeastern Ontario Family Medicine Program, University of Ottawa School of Medicine (Dr Rowe); and Shared Pharmacy Services, Sudbury General, Memorial, and Algoma Hospitals, Sudbury, Ontario, and Espanola (Ontario) General Hospital (Mss Brisebois and Thompson and Mr Fabris).

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