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


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

In This Article

4. Standards of Practice

4.1 The inpatient anticoagulation management system should use evidence-based standards of practice to ensure appropriate use of all related drug therapies in typical and special circumstances.

The clinical use of anticoagulants in the inpatient setting should be organized on a drug-specific basis using protocols, guidelines, policies, and procedures and/or other means to address the use of individual agents. All medical staff, house staff, pharmacists, mid-level providers, and nurses should be educated on the use of these protocols, guidelines, policies, and procedures. Examples of drug-specific standards of practice are noted in Table 3. It may be helpful to categorize these standards of practice as related to anticoagulant dosing, administration, and monitoring. They should be derived from evidence-based guidelines, with additional detail according to the formulary status of specific agents, as well as further evidence from clinical trials, published experience in various clinical settings, and institutional experience with individual agents.

Anticoagulant use also may be organized from a disease management perspective, addressing the treatment and prevention of venous and arterial thromboembolism as well as the prevention and treatment of adverse effects associated with anticoagulant therapy. Examples of disease-specific standards of practice are noted in Table 4. These standards should be derived from evidence-based guidelines, with additional institution-specific detail as necessary. A multidisciplinary approach to the development and implementation of institutional standards of practice is recommended. The input of various disciplines and specialists in the diverse aspects of anticoagulant dosing, administration, and monitoring, as well as prevention, diagnosis, and treatment of relevant disease states, is critical to successful patient care. Leadership from hospital administration may be helpful to direct the overall process of development and implementation of clinical standards, and the guidance of a specialist "champion" is recommended.

4.2 These clinical standards should be reviewed and updated on a periodic basis to ensure that they reflect current evidence and are synchronized with other institutional processes, policies, and procedures.

A formalized method for review of institutional standards of practice is recommended. As new evidence becomes available or as new evidence-based guidelines are published, they should be incorporated into practice in a timely manner to ensure the effectiveness and safety of anticoagulant therapy. In addition, as hospital processes change (eg, the transition from pharmacist order entry to computerized physician order entry), clinical standards should be aligned accordingly.