Published in the January 2012 issue of Today’s Hospitalist
SAFELY MANAGING ANTICOAGULATION in the hospital is a challenge, even when patients are stable. But when you factor in patients arriving from various settings, often with a spotty anticoagulation history, and the number of medications that can interact with warfarin, managing anticoagulants becomes that much harder. Throw unexpected surgical procedures into the mix and barriers to follow-up, and you end up with tough political and safety problems.
The 802-bed Henry Ford Hospital in Detroit found a way to mitigate many of those issues: Put pharmacists on the front lines and have them manage anticoagulation. That pharmacist role lasts from a patient’s first warfarin order until the patient is officially “received” by an outpatient physician or clinic.
Now four years old, the pharmacist-directed anticoagulation service has not only reduced bleeds and other complications on inpatient units, but it’s helped prevent patients from falling through the cracks after discharge. According to a study of the program reported in the August 2011 Journal of Hospital Medicine, patients covered by the pharmacist-led service had one-third fewer bleeds, thrombotic events or incidents of INR values greater than five. The service also scored an impressive 73% success rate with post-discharge transitions.
A dedicated service
Staffing the program is a core group of five dedicated pharmacists, says James Kalus, PharmD, study co-author and the hospital’s senior clinical pharmacy manager. The key to the program’s success, he notes, is robust communication.
“We set up direct lines of communication between the pharmacy and the anticoagulation service, and between the staff managing the inpatient side and the outpatient physician or clinic,” Dr. Kalus explains. “Even if the anticoagulation has been a small part of the hospitalization, it’s managing that transition that’s the key advantage.”
The pharmacist-led service was first launched on two medicine and two cardiology units where the majority of anticoagulation patients are housed, then rolled out on surgical units. During any given month, Henry Ford has between 600 and 800 patients on anticoagulation.
When the pharmacy receives an order for warfarin or another anticoagulant, a pharmacist from the service visits the patient within 24 hours of admission. That pharmacist, who works solely on the service, handles dosing changes and INR monitoring.
As part of the service, those pharmacists visit assigned patients daily and report any changes or concerns to the attending hospitalist or other physician. (The service covers patients on nontraditional or new agents such as dabigatran, although those patients aren’t monitored as frequently as those on warfarin.) The pharmacists also prepare an anticoagulation discharge summary that is sent to a designated clinician. And they make sure that patients have a post-discharge appointment arranged.
“The fact that we have a small group of people who are accountable makes it work,” says Dr. Kalus. “You don’t have an ‘everybody is responsible so nobody does it’ situation. That’s what we were trying to avoid.”
Another factor in the program’s success: “The pharmacists on the service aren’t looking at the whole patient or figuring out which antibiotic he or she should be on,” he says. “And pharmacists are very focused on the transition.”
Having one standard of care is particularly important when it comes to discharge, both for patients in the Henry Ford system and for uninsured and unassigned patients. For uninsured or unassigned patients, the service faxes the discharge summary to a clinician “which might be a regional clinic for the underserved “rather than sending it through the system’s electronic medical record.
Patients at discharge also receive a laboratory card allowing them to have an INR drawn within the Henry Ford system; once that INR is drawn, the outpatient anticoagulation clinic affiliated with the hospital knows which patients are already in the system and alerted to those who aren’t. Pharmacists on the service always communicate with an outpatient physician or clinic.
“For years, we’ve had a good inpatient system and good outpatient management,” Dr. Kalus points out. “But in the transition, if you can’t get patients there for the INR check, it doesn’t matter how good your system is.”
The service has also standardized the verbal and written education that patients receive. That helps prevent confusion that can lead to duplicate prescriptions or over-dosing. Service pharmacists also discuss dietary issues that can complicate or compromise anticoagulation.
“We start that education with the first pharmacist inpatient visit and continue it through the first outpatient visit, using the same materials,” Dr. Kalus says. Before the service was launched, patients might receive one message from nursing, another from a physician and yet another from outpatient clinic staff.
Physicians on board
Putting the program in place wasn’t easy. But Henry Ford was able to repurpose existing pharmacists through intensive education.
Most of the pharmacists on the service, Dr. Kalus notes, already had a good working knowledge of anticoagulation medications, dosing and therapy pitfalls. They received additional training on national guidelines and evidence-based literature, and on how to manage those medications in complex patients.
Henry Ford also designed in-house software to create a “new anticoagulation patient alert” so pharmacists don’t have to rely on a physician to notify them about a new patient. The hospital now uses a commercial software system that tracks patients on anticoagulation.
Understandably, Dr. Kalus notes, most physicians embraced the program. The doctors appreciate the back-up and the pharmacists’ input on patient education.
They also like that patients have post-discharge appointments made and that the pharmacist service works with surgeons to make sure it’s safe to start anticoagulation in patients within 48 hours of surgery. Hospitalists also appreciate the fact that they can focus on other areas of patients’ discharge, knowing that the service is covering education related to anticoagulation.
Issues with transfer patients
Although they’re infrequent, Dr. Kalus points out that bleeds and complications still occur, even with the service in place. But Henry Ford has intensified its post-event analysis so the pharmacists can quickly address any issues that crop up. One big lesson learned is that patients transferred from other facilities can have heparin concentrations all over the map. “If you don’t anticipate that,” says Dr. Kalus, “there could be errors.”
Could smaller facilities replicate Henry Ford’s success? According to Dr. Kalus, even if smaller hospitals couldn’t launch an extensive service, hospitals would benefit from involving clinical pharmacists in anticoagulation to standardize communication and improve discharge planning. He also recommends designating point persons, possibly hospitalists, to lead such an initiative.
And if hospitals have to pick just one point in anticoagulation to concentrate on, Dr. Kalus says that it should be the transition of care.
“That transition is the biggest issue, one hospitals should focus on from a pharmacy standpoint, whether they develop a dedicated service or not,” he says.
Bonnie Darves is a freelance health care writer based in Seattle.