Errors in prescribing, monitoring or an omission with antithrombotics have been associated with serious adverse events in hospitalized patients. Because of the risks, Henry Ford Hospital implemented a pharmacist-directed anticoagulant service (PDAS) in order to improve the safety of patients receiving anticoagulants throughout the hospital health system.
The following were identified as areas for improvement in the medication-use process for antithrombotics: 1) dosing; 2) monitoring; 3) patient education; 4) patient transition from the inpatient to outpatient setting. The pharmacy department garnered support for a PDAS and led the multidisciplinary team that planned, initiated and implemented the service over a 10-month timeframe.
Patient values of International Normalized Ratio (INR) greater than 5 declined by 80 percent over an 18-month timeframe. Trends suggest that patients managed by pharmacists from the anticoagulant service were more likely to achieve an INR greater than 2 during the inpatient stay and more likely to achieve a therapeutic INR prior to discharge than patients managed with the standard of care. The rate of early follow-up with an anticoagulation clinic within 5
and 7 days of discharge was 21 percent (p=0.002) and 17 percent (p=0.001) higher, respectively, among PDAS managed patients. Patients discharged from the PDAS also required 80 percent fewer dose adjustments upon presentation to the first outpatient anticoagulation clinic visit. As compared to patients managed with the standard of care, there was a 26-percent reduction with PDAS in anticoagulation-related readmissions within 30 days of discharge. Improved management of other anticoagulants was also noted.
Implementation of a PDAS produces significant improvement in patient safety with regard to the use of anticoagulants and improves hospital efficiency.
Multidisciplinary Team
James S. Kalus, Pharm.D., BCPS
William Conway, M.D.
Veronica Hall, R.N., M.B.A.
Michael Hudson, M.D.
Scott Kaatz, D.O.
Gregory Krol, M.D.
Philip Kuriakose, M.D.
Nancy MacDonald, Pharm.D., BCPS
Jessica M. Schillig, Pharm.D,. BCPS
Brian De Smet, Pharm.D., M.S.
Edward G. Szandzik, B.S. Pharm., M.B.A.
Moses Wu, B.S. Pharm.
The International Normalized Ratio is a value used to measure or determine the clotting tendency of blood. INR values greater than 5 are associated with an increased risk of bleeding. Values between 2 to 3 are used to prevent thrombosis and clot formation.