• 10
    Nov
  • Implementation and Evaluation of a Warfarin Dosing Service for Rehabilitation Medicine: Report from a Pilot Project: DISCUSSION part 2

Less Favourable Results for the Control Groups

The 2 control groups (baseline and concurrent) showed less favourable patient outcomes. Physicians performing warfarin dosing for the 2 control groups did not have the benefits of warfarin nomograms, protocols, or specific training. Increased morbidity and mortality were reported (Tables 4 and 8).

The higher morbidity and mortality in the control groups are consistent with the literature. Warfarin is one of the most complex drugs prescribed worldwide, because of the need for individualized dosing and monitoring and its narrow therapeutic range. Optimal DVT prophylaxis and anticoagulation management continues to be a challenge for most health care facilities in North America.

Advantages of the Rehabilitation Warfarin Dosing Service

The goals and objectives for the warfarin dosing service were met during the 5-month pilot project. This evaluation clearly showed several advantages of the new service:

  • effective and safe anticoagulation therapy (indicated by achievement and maintenance of therapeutic INR results)
  • fewer negative patient outcomes (e.g., hemorrhage, thromboembolism)
  • prevention of DVT and pulmonary embolism

Other advantages were case management (continuity of care) by qualified personnel, routine risk assessment, and regular scheduling of INR tests, all consistent with the consensus guidelines of the Anticoagulation Guidelines Task Force. These activities were associated with fewer warfarin orders per patient, more clinical pharmacy time (i.e., total of 16 to 139 minutes for 1 to 10 patients per day) and only 1 minor bleeding event (hematoma).
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Table 4. Outcomes for Patients in Baseline Control Group (n = 42)




Characteristic




No.


(%)

of
Patients


New diagnosis (during admission)


Deep vein thrombosis


0


Pulmonary embolism


1 (2)


Cerebrovascular accident


0


Death (warfarin-related or not)


0


Hemorrhagic events


Minor


0


Major*


1 (2)


Life-threatening


0


*Hematuria (INR
= 7.7).

It has been subjectively reported that the delegation of warfarin management to pharmacy is beneficial because it reduces nursing and physician time. Other sites (such as Burnaby Hospital in Burnaby, British Columbia) have seen other benefits:

  • less time and fewer telephone calls between nurses and physicians for ordering INR tests and for transmitting daily warfarin orders
  • less time spent contacting the laboratory for INR results and orders (and faster response time by pharmacists)
  • more efficient management of warfarin drug interac­tions (i.e., changing to noninteracting substitutes)
  • greater credibility for pharmacists among other hospital staff and hospital administration through requirement for training and certification in warfarin management
  • routine quality control to support safe and effective anticoagulation management
  • greater patient mobility (through earlier discontinuation of unfractionated heparin and LMWH)
  • earlier hospital discharge (i.e., faster time to therapeutic INR)

Feasibility and Sustainability of Warfarin Dosing Service

This evaluation clearly showed that a warfarin dosing service at Providence Healthcare would be safe, effective, efficient, and feasible. The use of standardized warfarin nomograms and protocols and the availability of qualified personnel led to favourable results. The higher rate of morbidity and mortality in the 2 control groups strongly supports implementation of a hospital- wide warfarin dosing service.
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Sustainability of the hospital-wide warfarin dosing service will depend upon the volume of patients, clinical pharmacy resources, physician referrals, and other factors. There was strong demand to expand the service throughout the hospital. If this expansion takes place, the anticoagulation pharmacists could set the following 12-month goals:

  • maximum of 40 min for work-up for a new patient (by using a simplified patient monitoring form)
  • maximum of 20 min for initial interview for a new patient
  • maximum of 20 min daily for each patient requiring follow-up (obtaining INR results, writing warfarin orders, risk assessment, etc.)

Through its 2004/2005 business plan, Pharmacy Services at Providence Healthcare was successful in obtaining an additional 0.6 full-time equivalent dispensary pharmacist to allow clinical pharmacists more time for the warfarin dosing service. More resources may be required in the future as the service grows, such as funding for new certified anticoagulation pharmacists, continuing education, and semiannual audits. However, reallocation of resources to the warfarin dosing service may decrease morbidity, mortality, nursing time, and physician time.

Table 8. Outcomes for Concurrent Control and Pilot Project Groups


Characteristic


No.
(%)
of Patients Concurrent
Control Warfarin Dosing Service (Physician Dosing) (n

= 33) (n
= 33)


New diagnosis (during admission)


Deep vein thrombosis


0


0


Pulmonary embolism


1*


(2)


0


Cerebrovascular accident


0


0


Death


Related to warfarin therapy


1*


(2)


0


Not related to warfarin therapy


0


0


Hemorrhagic events


Minor


2t


(6)



(3)


Major



(6)


0


Life-threatening


0


0

CONCLUSIONS

This evaluation of the pilot project clearly showed that the pilot warfarin dosing service at Providence Healthcare was safe, effective, efficient, and feasible. The availability of qualified personnel is necessary to ensure optimal anticoagulation and safe, continuous patient care and to minimize risk and liability.
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The following benefits of delegating warfarin management to qualified personnel (such as anticoag- ulation pharmacists) may be realized:

  • a decrease in nursing and physician time
  • less time and fewer telephone calls between nurses and physicians for tracking and ordering INR tests and for adjusting daily warfarin orders
  • less time spent contacting the laboratory for INR results and INR orders
  • more efficient management of warfarin drug interac­tions (i.e., assessment of major warfarin interactions that may or may not require drug substitutions)
  • greater credibility for pharmacists among other hospital staff and hospital administration through the requirement that all pharmacists be trained and certified in warfarin management
  • routine quality control to support safe and effective anticoagulation management
  • greater patient mobility through earlier discontinuation of unfractionated heparin and LMWH
  • earlier hospital discharge (i.e., faster time to therapeutic INR)
  • more comprehensive patient counselling

The results reported here support the implementation of a hospital-wide warfarin dosing service. Allocation of resources to this service will decrease morbidity, mortality, nursing time, and physician time at Providence Healthcare.

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