Implementation and Evaluation of a Warfarin Dosing Service for Rehabilitation Medicine: Report from a Pilot Project
Patients are routinely referred from acute care sites to rehabilitation hospitals for subacute care and transition into the community. Providence Healthcare is a Toronto health care facility specializing in rehabilitation for patients who have experienced strokes, orthopedic surgery, and lower limb amputation. Services include complex continuing care, long-term care, and community outreach, with a particular emphasis on the clinical treatment and care of elderly patients. One of the Providence Healthcare sites, Providence Hospital (where the study reported here took place) is the third-largest rehabilitation and complex continuing care hospital in Ontario, with 338 beds.
The care required by rehabilitation patients is often complex; for example, elderly patients who have undergone orthopedic surgery may also require the expertise of an interdisciplinary team, including geriatricians and specialists in anticoagulation management, to prevent venous thromboembolism and/or arterial thrombosis (i.e., stroke). The major problems encountered in preventive antithrombotic care are lack of warfarin expertise among physicians, nurses, and pharmacists; subtherapeutic dosing; inconsistent laboratory monitoring; and fragmented care. For over 20 years, anticoagulation clinics and services in Ontario, Quebec, and the United States have provided safer and more effective preventive antithrombotic care than traditional warfarin management under the supervision of family physicians.
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As is the case for many health care facilities in North America, Providence Healthcare had no warfarin dosing or anticoagulation management service. In early 2002, the institution’s Medical Advisory Committee identified the need to improve warfarin management. There was strong support from the medical, nursing, and administrative staff for a pharmacy-directed warfarin dosing service, and a proposal from the pharmacy department for a warfarin dosing service was approved in June 2002 by the Pharmacy and Therapeutics Committee for implementation as a pilot project.
The goals and objectives for the warfarin dosing service were to provide effective and safe anticoagulation therapy by achieving and maintaining therapeutic international normalized ratio (INR) quickly and safely; to improve the consistency of warfarin dosing, especially during weekends and statutory holidays; to improve patient outcomes and increase patient safety; to decrease errors in warfarin dosing; to ensure that patients’ current and past medical history, medication history, and drug-food interactions were evaluated before a dose recommendation; and to decrease the frequency of INR testing.
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This article reports an evaluation of a pilot project conducted preparatory to establishing a pharmacy- directed warfarin service at Providence Healthcare.