2026 Eastern States Conference

Title: Evaluation of heparin dosing in obesity for treatment of deep vein thrombosis and pulmonary embolism. 

Authors: Elise Paskowski, PharmD; Brandon Snyder, PharmD, BCPS 
Acknowledgments: Aundrea Rosenberger, PharmD, BCIDP; Theodore Bell, MS 

Objective: This study aims to look at the safety of using actual body weight in our deep vein thrombosis (DVT) and pulmonary embolism (PE) heparin protocol by comparing supratherapeutic aPTT values in obese and non-obese populations. 

Background: Obesity rates in the United States are rising, yet venous thromboembolism (VTE) guidelines lack dosing strategies for obese patients. Research has shown mixed results, supporting the use of actual bodyweight or adjusted bodyweight in obese patients. 

Methods: A retrospective chart review was conducted from May 1, 2024, to September 1, 2025, on patients who were ordered the heparin DVT/PE order set. Inclusion criteria were age ≥18, one aPTT drawn 5–7 hours after heparin initiation, and dosing based on actual body weight with no prespecified cap. Exclusion criteria included pregnancy, prior heparin use, no bolus given, protocol ordered but not administered, non-protocol aPTT goals, incorrect timing, or use of non-actual body weight. Currently at WellSpan Ephrata Community Hospital, patients receive an 80 unit/kg bolus dose followed by 18 unit/kg/hr based on actual body weight. Average aPTT values were compared between obese (BMI ≥ 30kg/m2) and non-obese patients. The primary outcome is a comparison of the average first aPTT values in the obese vs non-obese populations. The secondary outcome is the incidence of major bleeding events. 

Results: Mean aPTT values were compared between obese and non-obese populations. For the primary outcome, the mean aPTT in the non-obese group was 79.4 seconds. The mean aPTT in the obese group was 105.19 seconds. The institutional therapeutic range for aPTT values is 45-70 seconds. Major bleeding events occurred in eight patients from the non-obese group and one patient from the obese group. Major bleeding events were defined as bleeding that led to a drop in hemoglobin of greater than or equal to 2, a drop in hemoglobin requiring a transfusion or a bleed in a critical site like the cerebrum or abdominal area. A demographic comparison was completed between groups. 

Conclusions: Supratherapeutic aPTT values are a nursing-driven protocol. Using adjusted body weight in obese patients reduces mean aPTT and nursing workload. Elevated aPTT values put both populations at risk for major bleeds. These findings support using adjusted body weight in obese patients. Limitations to this study include being a single-center retrospective chart review with a small sample size, evaluating one indication at a single time point. 

Self-assessment question: 
What are some benefits to using adjusted bodyweight in obese patients shown by this study? (Choose all that apply) 
A. Decreased bleeding events
B. Decreased nurse workload
C. Decreased mean aPTT value
D. Increased bleeding events   

References:  

1. Pennsylvania department of health. Obesity. Commonwealth of Pennsylvania. https://www.pa.gov/agencies/health/diseases-conditions/chronic-disease/obesity. 2025. Accessed on August 3, 2025.  
2. Gerlach AT, Folino J, Morris BN, Murphy CV, Stawicki SP, Cook CH. Comparison of heparin dosing based on actual body weight in non-obese, obese and morbidly obese critically ill patients. Int J Crit Illn Inj Sci. 2013;3(3):195-199. doi:10.4103/2229-5151.119200 
3. J. Hirsh, S. S. Anand, J. L. Halperin, & V. Fuster. Circulation. Guide to Anticoagulant Therapy: Heparin: A Statement for Healthcare Professionals From the American Heart Association. AHA/ASA Journals. https://www.ahajournals.org/doi/10.1161/01.cir.103.24.2994. June 19, 2001. Accessed August 3, 2025.  
4. Fan J, John B, Tesdal E. Evaluation of heparin dosing based on adjusted body weight in obese patients. Am J Health Syst Pharm. 2016;73(19):1512-1522. doi:10.2146/ajhp150388
5. M. Safani, S. E. Hill, R. Winters, S. Kawanishi, S. W. Eppstein, S. Min, & M. Drachenberg. CHEST journal. The Use of Average Body Weight in Dosing Unfractionated Heparin. https://journal.chestnet.org/article/S0012-3692(13)60435-3/fulltext#:~:text=recommend%20the%20use%20of%20weight,)%20of%200.07%20L/kg. June 2013. Accessed August 3, 2025.  
6. Nguyen K, Murray B, Campbell-Bright S, et al. Adjusted Versus Total Body Weight Dosing for Intravenous Heparin Infusions and Target Attainment in Obese Patients. Hosp Pharm. Published online June 29, 2025. doi:10.1177/00185787251348377 

• Title: Standardization of Tablet Splitting Workflows at JHHS
• Authors: Eric Mackin, PharmD; Ian Watt, PharmD; Emily Pherson, PharmD, BCPS; Rosemary Duncan, PharmD, BCPS; Lisa Hutchins, PharmD, BCPPS; Dave Stimler, PharmD, MBA
• Objective: Audience members will be able to outline the steps used to develop a standardized split tablets workflow across a health system.
• Self Assessment Question: Which of the following is a benefit of standardizing split tablet practices across a health system?
  1. A. Clear accountability across departments
  2. B. Automatic selection of dispense code in EHR when dispensing split tablets
  3. C. Reduced variability for employees who work at multiple sites
  4. D. Decreased manual manipulation of orders on verification and reverification
  5. E. All of the above
• Background: The purpose of this project is to gain consensus among Johns Hopkins Health System hospital sites on the preferred practice for splitting tablets, i.e., when tablets should be split in the pharmacy prior to dispensing or split by a nurse on the unit.
• Methods: The objective of this project is to develop a workflow for splitting tablets that aligns Johns Hopkins Health System (JHHS) and allows for the implementation of enhancements to the EHR (Epic). To accomplish this, the project team confirmed current workflows for all JHHS hospitals, surveyed other hospitals and health systems to determine common practices, and gathered data on all enteral dispenses across JHHS in October 2025 using Epic SlicerDicer. This data was then analyzed in Microsoft Excel to quantify total enteral dispenses, dispenses that require splitting a tablet, repackaged doses dispensed, number of split dispenses for which a commercially available tablet exists for the intended dose, and most frequently split medications. A summary of the data was presented to a health system-level Automation and Operations Committee, and stakeholders from each hospital collaborated to gain consensus on the newly aligned workflow.
• Results: JHHS hospitals initially reported varied split tablet workflows, ranging from pharmacy staff splitting all tablets to nurses splitting all tablets. JHHS hospitals also reported differences in prepackaging practices (unit dose packaging a pre-split tablet). Surveys of other health systems revealed no standard tablet-splitting practice. In October 2025, 2.2% of all enteral dispenses required splitting a tablet, with 28.7% being dispensed from pharmacy and 71.3% dispensed from ADC. Data analysis showed that this number could be further decreased by purchasing the lowest commercially available strength of more medications and increasing prepackaging practices. After discussion, the workgroup came to consensus on option 3: pharmacy staff split all tablets dispensed from the pharmacy; nursing staff split all tablets dispensed from the ADC. Pharmacy staff will also minimize the number of dispenses that require splitting by optimizing prepackaging and purchasing practices.
• Conclusion: No national standard exists for tablet splitting workflows, creating variance in practice and complicating EHR optimization. JHHS pharmacies were able to come to consensus on a new workflow that works for all hospitals by assessing the objective impact of each potential new workflow and developing solutions that emphasize safety, accuracy, and efficiency.