Implementation and Evaluation of a Warfarin Dosing Service for Rehabilitation Medicine: Report from a Pilot Project: METHODS
An evaluation of the pilot project was conducted as an open case series. The aim was to enroll 30 patients in the pilot warfarin dosing service over a 5-month study period (October 16, 2003, to March 18, 2004).
All patients admitted to a single rehabilitation unit handling orthopedic, amputation, and stroke rehabilitation (unit B2R [known in 2002 as 5AR and 3BR]) were eligible for referral to the warfarin dosing service during the study period. Patients were excluded if their admission lasted for less than 24 h and/or they received less than 24 h of warfarin therapy. A single certified anticoagulation pharmacist (T.C.) was primarily responsible for providing the service during the study period, as recommended by consensus guidelines. During any absences, a second clinical pharmacist (M.M.L.) provided coverage. Patients’ warfarin therapy was categorized as follows: initiation (first dose of warfarin provided on the rehabilitation unit; no warfarin before admission to the rehabilitation unit), maintenance (stable warfarin dosages and INR results before and during admission to the rehabilitation unit), and transition (fluctuating warfarin dosages and INR results before and during the admission). suhagra 100
The warfarin protocol, dosing nomograms, policies, and procedures for the pilot project were adapted from those of the Lakeridge Health Corporation, Oshawa, Ontario, and were approved by the Pharmacy and Therapeutics Committee and the Medical Advisory Committee of Providence Healthcare in 2002. During the study period, INR samples were obtained by venipuncture and were processed (and the results reported) by off-site laboratory services.
All bleeding events were classified by severity. Minor bleeding was defined as bleeding that did not require specific medical intervention to stop the bleeding, such as nose bleeds and small hematomas. Major bleeding was defined as bleeding for which specific medical interventions, hospital observation for more than 24 h, or significant diagnostic testing were required and/or bleeding that might have been fatal or life-threatening without medical attention. Life-threatening bleeding events were defined as fatal events, those occurring intracra- nially or in other sites where they were potentially lethal, those associated with cardiopulmonary arrest or hypotension, and those requiring major interventions such as surgery or angiography. Cialis Jelly
Chart reviews were conducted for 2 retrospective control groups: baseline warfarin dosing by rehabilitation physicians in 2002 (the baseline control group) and warfarin dosing by rehabilitation physicians in 2003-2004 (during the period of the pilot project; the concurrent control group). For the baseline control group, the Medical Records Department randomly selected charts for review from patients admitted to the rehabilitation unit between March 11, 2002, and July 11, 2002. For the concurrent control group, the first 33 patients receiving warfarin who were admitted to units other than unit B2R during the study period (mid- October 2003 to mid-March 2004) and who met the inclusion criteria (i.e., admission to the rehabilitation unit and warfarin therapy for more than 24 h) were automatically enrolled. Figure 1 shows an overview of the timeline for the 3 study groups.
The control groups yielded information on traditional warfarin management (without protocols or nomograms), details of warfarin dosing by physicians, and other similar data.
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A 6-month postintervention observation period (March 19, 2004, to September 18, 2004) was planned to evaluate patient outcomes after discharge. An anticoagulation and research consultant (W.A.L.) was hired to assist with implementation, evaluation, and reporting of the pilot project. Data were collected by 2 investigators (including T.C.) and reviewed by 2 other investigators (W.A.L., M.R.). Data entry and analysis were conductedwith Excel version 5.0 (Microsoft, Seattle, Washington). No statistical tests were performed.