Delivery of Optimized Inpatient Anticoagulation Therapy

Consensus Statement From the Anticoagulation Forum

Edith A Nutescu PharmD FCCP; Ann K Wittkowsky PharmD CACP FASHP FCCP; Allison Burnett PharmD PhC; Geno J Merli MD FACP; Jack E Ansell; David A Garcia MD

Disclosures

The Annals of Pharmacotherapy. 2013;47(5):714-724.

3. Integration

The inpatient anticoagulation management system should be reliable, sustainable, and seamlessly integrated with all patient-care resources of the health care organization.

Whenever possible, processes and tools utilized by the inpatient system of anticoagulation management should be hard-wired (electronically built and connected) into the health care organization and should not be person-dependent. The anticoagulation management system must incorporate a reliable means of identifying and tracking patients receiving anticoagulant therapy. If an outpatient anticoagulation management system is associated with the hospital and uses computer software for tracking patients, it may be beneficial to adopt the same or a similar software program tailored for inpatient use. Use of evidence-based, standardized, approved anticoagulation order sets is encouraged for initiation and maintenance of anticoagulation to promote consistent, sustainable practices. Hospital administration should provide adequate resources (eg, staffing, technology, and support for clinical initiatives) to ensure sustainability of the anticoagulation management system. Additionally, the inpatient anticoagulation management system must be seamlessly integrated with all patient-care resources in the health care system to facilitate accurate, efficient communication of pertinent patient information and delivery of optimized care. Table 2 provides recommendations for integration of the inpatient anticoagulation system.

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Table 1. Systematic Approaches for Safe and Effective Inpatient Anticoagulation Management
System	Possible Action
Storage	Separation of anticoagulants in the pharmacy and in medication dispensing cabinets Distinct labeling to identify anticoagulants as high-risk medications
Ordering	Electronic alerts in pharmacy order entry system for required laboratory tests (eg, weight, SCr, INR) pertinent to anticoagulation therapyUse of approved, standardized preprinted or electronic order sets for all anticoagulants to promote uniformity and decrease errors related to illegible handwritingUse of computerized physician order entry
Preparation	Minimize number of stock concentrations of anticoagulants
Distribution	Dispense anticoagulants in oral unit dose, prefilled syringes, or premixed infusions when possible
Administration	Independent double check by nursing prior to administrationUse of programmable infusion pumpsBedside barcode scanning
Therapeutic management	Utilization of dedicated anticoagulation programs and services that facilitate coordinated care managementInvolvement of pharmacists as drug experts in the care of patients on high-risk medications such as anticoagulants

INR = international normalized ratio; SCr = serum creatinine.

Table 2. Integration of the Inpatient Anticoagulation System with the Health Care Organization
Integration of pharmacy order entry system with laboratory reporting system to promote review of key laboratory values prior to processing of orders or dispensing of anticoagulants
Process for quickly communicating and responding to critical anticoagulant laboratory values or adverse events
Dietary department or another responsible entity should have a method to identify patients with potential for significant drug-food interactions, authority to address these, and a method to document recommendations or changes
Provision of anticoagulation recommendations in a manner that is time sensitive and accessible to all practitioners
Method of providing clear documentation of recommendations for dose adjustments of anticoagulants
Anticoagulation education initiatives for both staff and patients aligned with initiatives, resources, and workflow of the health care system
Case management consultations to triage insurance coverage of outpatient medications and arrangement of follow-up appointments
Method to ensure continuity of anticoagulation management as care providers change (eg, change of shift) and as patients transition to different levels of care within the hospital
Method of providing clear documentation of the inpatient anticoagulation dosing history, along with any patient education or other pertinent anticoagulation information to outpatient providers in a concise, user-friendly format

Table 3. Drug-Specific Standards of Practice
Anticoagulant dosing
Novel oral anticoagulant (DTIs, factor-Xa inhibitors) dosing guidelines
Warfarin initiation dosing guidelines/nomograms
Warfarin maintenance dosing guidelines
Heparin dosing protocol(s)
Intravenous DTI dosing protocols
LMWH and fondaparinux dosing guidelines for various indications
Use of LMWHs, factor-Xa inhibitors, and DTIs in obesity
Use of LMWHs, factor-Xa inhibitors, and DTIs in renal failure and hemodialysis
Use of warfarin, UFH, LMWHs, factor-Xa inhibitors, and DTIs in pregnancy
Use of warfarin, UFH, LMWHs, factor-Xa inhibitors, and DTIs in pediatric patients
Drug interaction recognition and management
Use of anticoagulants around neuraxial procedures
Thrombolytic dosing and monitoring guidelines
Selection and dosing of reversal therapies (eg, Vitamin K, protamine, prothrombin complex concentrate, recombinant factor VII)
Anticoagulant dosing and monitoring in the critically ill patient
Anticoagulant administration
Infusion pump policies and procedures
Acceptable subcutaneous injection sites for anticoagulants
Timing of initiation of VTE prophylaxis for surgical and high-risk medical patients
Timing of resumption of full-intensity anticoagulation in postoperative patients
Time of administration of anticoagulants
Accurate patient weight in kilograms
Anticoagulant monitoring
Target INR and INR goal range for various indications
Frequency of INR monitoring
Target aPTT and aPTT goal range for various indications
Frequency of aPTT monitoring
Alternative monitoring parameters for special circumstances
Required baseline and ongoing laboratory values for various anticoagulants (eg, CBC with differential, basic metabolic panel,^a ACT, ECT, TT, anti-Factor Xa assay)
Patient monitoring for signs and symptoms of bleeding and thrombosis

ACT = activated clotting time; aPTT = activated partial thromboplastin time; CBC = complete blood count; DTI = direct thrombin inhibitor; ECT = ecarin clotting time; LMWH = low-molecular-weight heparin; TT = thrombin time; UFH = unfractionated heparin; VTE = venous thromboembolism.
^aBasic metabolic panel = glucose, calcium, sodium, potassium, CO₂, chloride, blood urea nitrogen, serum creatinine.

Table 4. Disease-Specific Standards of Practice
Disease management
DVT treatment
PE treatment
Stroke prevention in AF
VTE prophylaxis for medical and surgical patients, including risk stratification
Extended VTE prophylaxis
Risk stratification for periprocedural anticoagulation bridging
Bridging therapy guidelines
Guidelines for anticoagulation management in cardioversion
Treatment of cancer-associated thrombosis
Guidelines for transitioning between various anticoagulants
Guidelines for anticoagulation management in special circumstances such as patients with mechanical devices, bypass circuits, presence of a coagulopathy
Adverse effects management
Management of bleeding
Treatment of heparin-induced thrombocytopenia
Reversal of anticoagulation
Correction of over-anticoagulation
Methods to prevent and treat dental bleeding
Bleeding risk assessment

AF = atrial fibrillation; DVT = deep venous thrombosis; PE = pulmonary embolism; VTE = venous thromboembolism.

Table 5. Anticoagulation Therapy Certification and Training Programs for Multidisciplinary ^a Care Providers Involved in the Management of Patients Receiving Anticoagulants
Certified Anticoagulation Care Provider (CACP)
Bestowed by the National Certification Board for Anticoagulation Providers to formally recognize anticoagulation providers meeting educational and patient-care experiential requirements
American Society of Health-System Pharmacists Foundation Antithrombotic Pharmacotherapy Traineeship
Curriculum consists of a self-study program and a 5-day experiential program
University of Southern Indiana College of Nursing and Allied Health Professions Anticoagulant Therapy Management Certificate Program
Interactive 6-week, 40-hour internet certificate program for nurses, pharmacists, and physicians
University of Florida College of Pharmacy Anticoagulation Therapy Management Certificate Program
A 12-week program containing 3 independent learning modules of independent study and assignments

^aMedicine, nursing, pharmacy.

Table 6. Competency Domains for Anticoagulation Providers ^a
Applied Physiology and Pathophysiology of Thromboembolic Disorders
Working knowledge regarding the normal physiologic processes of hemostasis and thrombosis, and the etiology, risk factors, and clinical manifestations of pathologic thrombus formation
Patient Assessment and Management
Knowledge, skills, and competencies to manage and monitor patients receiving anticoagulant therapy including the ability to assess the efficacy and toxicity of the prescribed anticoagulant treatment, determine whether the therapeutic goals have been achieved, and identify patient-related variables that affect therapy
Patient and Family Education
Ability to provide patient education that is tailored to patients' specific needs to promote safety, enhance adherence, and positively affect clinical outcomes; perform an educational assessment; develop an educational plan; and document the educational activities in the patient's medical record
Applied Pharmacology of Antithrombotic Agents
In-depth knowledge regarding the pharmacologic properties of all antithrombotic drugs
Operational (Administrative) Procedures
Evaluate need for services, assess personnel and compensation requirements, develop effective communication strategies with patients and health care team, perform quality assurance and risk management activities, compliance with standards

^a Adapted from www.ncbap.org.

Table 8. Care Transitions Checklist
Element/s of Care
Patient family education on disease state(s) and medication(s) and verbal expression of understanding
Demonstration of ability and comfort to self-administer parenteral anticoagulant
Assurance of affordability, insurance coverage, and retail availability of anticoagulant therapies
Appropriate and accurate prescriptions given to patient prior to discharge
"Safety net" phone number provided to patient prior to discharge
Referral to outpatient anticoagulation clinic (if applicable) prior to discharge
Follow-up appointment within prespecified timeframe scheduled with primary care physician or subspecialist prior to discharge
Inpatient dosing history, discharge instructions, and discharge summary sent to receiving provider in time to allow for receiving provider to effectively care for the patient
Verbal communication between inpatient and receiving providers regarding patient's anticoagulation therapy in time to allow for receiving provider to effectively care for the patient
Follow-up phone call to patient/family within 48–72 hours after discharge

Table 9. Anticoagulation Quality Indicators
Process measures
Inpatient	Rate of use of anticoagulation protocols Percentage of patients receiving anticoagulation education prior to discharge Percentage of patients with appropriate VTE prophylaxis Percentage of patients with appropriate duration of overlap anticoagulation therapy Percentage of patients with appropriate laboratory monitoring of anticoagulation parameters Percentage of patients with supratherapeutic INRs Number of days to therapeutic INR Percentage of patients with follow-up appointment scheduled prior to discharge
Transition	Percentage of patients with appropriate referral to outpatient anticoagulation clinic Percentage of patients receiving follow-up phone call within the specified time period Rate of documented communication between inpatient and outpatient providers Percentage of patients with discharge instructions and discharge summary sent to receiving provider Percentage of patients with documented follow-up within prespecified timeframe of discharge Percentage of patients with therapeutic INR at the first follow-up visit posthospitalization
Outcome measures	Incidence of thrombotic events Incidence of bleeding events Incidence of incidental adverse effects (eg, heparin-induced thrombocytopenia)

INR = international normalized ratio; VTE = venous thromboembolism.

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Delivery of Optimized Inpatient Anticoagulation Therapy

Consensus Statement From the Anticoagulation Forum

3. Integration

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Authors and Disclosures

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