Title: Impact of a Pharmacist-Led Practice Change in Anti-Xa Monitoring on Bleeding Rates in Burn Injury Patients Receiving Enoxaparin for Venous Thromboembolism Prophylaxis
Authors: Jacob King, Nirali Naik
Background: Burn patients are at an increased risk of venous thromboembolism (VTE) and often receive enoxaparin for VTE prophylaxis. Official guidelines do not exist that outline enoxaparin dosing strategies in burn patients, possibly leading to an increased risk of VTE or bleeding events. A recent increase in bleeding events has raised concerns regarding whether current dosing and monitoring is appropriate. The goal of this study was to determine if pharmacist-led monitoring of weight-based enoxaparin compared to current standard practice is associated with less major bleeding events while reducing risk of VTE.
Methods: This study is a single-center retrospective chart review designed to evaluate weight-based enoxaparin dosing and monitoring in burn injury patients in a pharmacist-led protocol (PLP) group compared to current standard practice (SP). Adult patients admitted with a burn injury during two different time periods, who received weight-based enoxaparin for VTE prophylaxis were evaluated. The SP group was reviewed from January 1, 2025, through February 15, 2025 and the PLP group from July 1, 2025 through August 15, 2025. Patients were considered eligible if they received at least 3 consecutive weight-based enoxaparin doses. Patients with renal dysfunction (CrCl < 30 mL/min on admission), coagulation disorders, heparin induced thrombocytopenia, receiving therapeutic anticoagulation or a factor Xa inhibitor within 72 hours of enoxaparin administration, or decompensated cirrhosis were excluded. The primary outcome was to evaluate if a difference exists in major bleeding events when comparing the SP group to the PLP group in regard to anti-Xa monitoring in burn injury patients receiving weight-based enoxaparin for VTE prophylaxis. Secondary outcomes included incidence of patients achieving an anti-Xa within goal range within the first 48 hours, rate of patients who did not achieve goal anti-Xa levels overall, incidence of VTE or minor bleeding events, number of dose adjustments required to achieve goal anti-Xa levels, number of pharmacist interventions and total doses of enoxaparin received during admission. Statistical analysis included descriptive statistics, t-tests for continuous variables, and chi-square or Fisher’s exact tests for categorical variables.
Results: Twenty-five patients were included in the SP group and thirteen patients were in the PLP group. The primary outcome of major bleed events was the same between both groups (p = 1.000). More patients in the PLP group achieved an anti-Xa level within goal range within the first 48 hours (23% vs 0%, p = 0.034). In the PLP group after 48 hours, 2 patients achieved goal anti-Xa levels at the second level and 1 patient at the third level. No patients in the SP group achieved an anti-Xa level within goal range throughout their admission compared to 7 patients in the PLP group (100% vs 54%, p=0.001).
Additional secondary outcomes included the number of pharmacist interventions (n=27), total doses of enoxaparin received during admission (SP group = 332 vs. PLP group n=210), and minor bleed events (p=0.11). There were no reported incidences of VTE events in either group.
Conclusion: There was no statistically significant difference found when evaluating the primary outcome of major bleeding events between groups. Statistical significance was observed in some secondary outcomes: more patients in the PLP group were able to achieve goal anti-Xa levels within 48 hours, with additional patients being able to achieve goal anti-Xa levels prior to discharge. The difference in the findings of the secondary outcomes in the PLP may be correlated with the pharmacist-led interventions. Due to a limited sample size and potential confounding variables, all outcomes should be interpreted with caution and within context. Future research should prioritize prospective studies with larger cohorts and rigorous controls for confounding variables to ensure the definitive validation of all outcomes.
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