A pre- post-evaluation of implementing an inpatient warfarin monitoring and education program
Objective: The purpose of this study was to evaluate whether a new anticoagulation management program resulted in better monitoring of warfarin, increased warfarin patient education prior to discharge, and fewer bleeding complications associated with warfarin.
Methods: A retrospective chart review was conducted of patients who were inpatients and received warfarin from April 1, 2008 to July 31, 2008 (control group) and from April 1, 2009 to July 31, 2009 (after implementation of the new anticoagulation program). The frequency of warfarin-related laboratory orders that included international normalized ratios (INRs), complete blood counts (CBCs), and documented patient education by pharmacy, nursing, and dietary services were determined before and after program implementation. Also, data was collected to determine frequencies of bleeding complications associated with warfarin.
Results: There were 112 patients in the pre- and 115 patients in the post-program group. After implementation of the inpatient warfarin management program, obtaining baseline INRs increased from 74% to 90% (p=0.001). Orders for baseline CBCs increased from 85% to 94% (p=0.026). Obtaining CBCs every 3 days increased from 54% to 74%, (p<0.001). However, there was no significant change in orders for daily INRs (p=0.055). Education by nursing increased from 54% to 80%, (p<0.001), by pharmacy increased from 8% to 76%, (p<0.001), and by dietary increased from 11% to 79%, (p<0.001). Documentation by all three disciplines in each patient increased from 3.6% to 59%, (p<0.001). Significantly fewer patients received vitamin K and/ or fresh frozen plasma for supratherapeutic INRs with bleeding complications after the program was initiated compared to baseline (p=0.009).
Conclusion: The implementation of an inpatient warfarin management program led to better monitoring of patients receiving warfarin, and increased patient education. However, a larger and longer assessment is necessary to determine if these changes are maintained and how these changes affect long-term clinical outcomes.
Keywords: Warfarin. Inpatients. Pharmacy Service, Hospital. United States.
2. Dolan G, Smith LA, Collins S, Plumb JM. Effect of setting, monitoring, intensity and patient experience on anticoagulation control: a systematic review and meta-analysis o f the literature. Curr Med Res Opin. 2008;24:1459-1472.
3. Anonymous. NPSGs target anticoagulation therapy, patient deterioration. Healthcare Benchmarks Qual Improv. 2007;14:97-101.
4. Quinsey CA. The National Quality Forum: in search of patient safety. J Am Assoc Med Transcript. 2004;23:86-88.
5. The Joint Commission. National patient safety goals. 2010 national patient safety goals (NPSGs). Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ (Accessed 2010 Oct 20).
6. Matchar DB. Do anticoagulation management services improve care? Implications of managing anticoagulation services trial. Cardiac Electrophysiol Rev. 2003;7:379-381.
7. Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest. 2005;127:1515-1522.
8. Wilson SJ, Wells PS, Kovacs MJ, Lewis GM, Martin J, Burton E, Anderson DR. Comparing the quality of oral anticoagulation management by anticoagulation clinics and by family physicians: a randomized controlled trial. CMAJ. 2003;169:293-298.
9. Biscup-Horn PJ, Streiff MB, Ulbrich TR, Nesbit TW, Shermock KM. Impact of an inpatient anticoagulation management service on clinical outcomes. Ann Pharmacother. 2008;42:777-782.
10. Errichetti AM, Holden A, Ansell J. Management of oral anticoagulation therapy. Experience with an anticoagulation clinic. Arch Intern Med. 1984;144:1966-1968.
11. Cohen IA, Hutchison TA, Kirking DM, Shue ME. Evaluation of a pharmacist-managed anticoagulation clinic. J Clin Hosp Pharm. 1985;10:167-175.
12. Ford ND, Hale LS. Measuring the effectiveness of an in-patient, pharmacist-managed anticoagulation service. Available at: http://hdl.handle.net/10057/593 (accessed 2011 April 14).
13. Dager WE, Branch JM, King JH, White RH, Quan RS, Musallam NA, Albertson TE. Optimization of inpatient warfarin therapy: impact of daily consultation by a pharmacist-managed anticoagulation service. Ann Pharmacother. 2000;34:567-572.
14. Gulseth M. Daily INR Policy, St. Mary’s Medical Center, Duluth, MN, Pharmacy Policy and Procedure Manual. In: Gulseth M, ed. Managing Anticoagulation Patients in the Hospital: The Inpatient Anticoagulation Service. Bethesda, MD: American Society of Health-System Pharmacists; 2007:57.
15. Landefeld CS, Anderson PA. Guideline-based consultation to prevent anticoagulation-related bleeding. A randomized, controlled trial in a teaching hospital. Ann Intern Med. 1992;116:829-837.
16. Touchette DR, McGuinness ME, Stoner S, Shute D, Edwards JM, Ketchum K. Improving outpatient warfarin use for hospitalized patients with atrial fibrillation. Pharmacy Practice (Internet).2008;6(1):43-50.
The authors hereby transfer, assign, or otherwise convey to Pharmacy Practice: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print pr epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.