Change in anticoagulation management to Anti-Xa monitoring during COVID-19 Pandemic to avoid ICH in VV ECMO patients

Introduction: At the outset of the COVID-19 pandemic we observed an unacceptably high incidence of intracranial hemorrhage during VV ECMO support for COVID-19 related respiratory failure. The relationship between PTT and Anti-Xa values was explored by pharmacy and facility ECMO leadership, and found COVID patients to have elevated Anti-Xa levels at prescribed PTT levels. Method(s): We retrospectively analyzed data of 38 adult COVID-19 VV ECMO patients at Massachusetts General Hospital from March 18, 2020 to February 1, 2022 for incidence of ICH before and after anticoagulation protocol was changed on May 12th 2020. Result(s): Prior to change in practice, ICH was present in 33% (n = 4) of all COVID+ VV ECMO runs (n = 12). ICH was present in 57% of all deaths (n = 7) during this period. On May 12th 2020, after a pharmacy review, along with regional/international meetings among many ECMO centers MGH initiated a new protocol for COVID-19 positive ECMO patients targeting an Anti-Xa range of 0.15-0.29 with heparin titration. After this change, there were a subsequent 26 VV ECMO runs meeting the criteria for this study. ICH was present in only 3.8 % of patients (n = 1). And was present 6.3% (n = 1) of all deaths (n = 16). Conclusion(s): Anti Xa guided anticoagulation strategy resulted in a 88% decrease in the incidence of ICH in COVID-19 positive VV ECMO patients during the time of this retrospective analysis and proved a safe alternative to PTT guided heparin therapy.

Leadership During a Crisis

Background: Leadership during a crisis requires looking out for the needs of others. Leaders need to act decisively while considering input from followers, stakeholders and clients/patients. A disaster or pandemic plan can help guide the preparation, initial response and recovery phases however leaders also need flexibility to adjust to rapidly changing conditions and to be open to opportunities when others will see barriers. Objective(s): To describe strategies and tactics used to manage a regional multi-site pharmacy service in the early months of the COVID-19 pandemic. Methods: Various approaches were used during the pandemic of which several will be described as successes and lessons learned in leading teams with communication, visioning, setting expectations for staff, attending to relationships and maintaining positive staff morale. Results: Examples to be shared of leveraging communications to build trust and inspire staff, pivoting staff to ensure redundancy in priority roles, managing inventory of essential medications and COVID vaccines, and building new bridges with other internal departments and external partners. Conclusions: Effective leadership in a crisis demands the leader communicate clearly, concisely and with purpose. Varied methods are often needed to keep staff informed and inspired, to maintain trust and focus on delivering essential services even when conditions may be changing and beyond one's control.