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Standardizing periprocedural anticoagulation management: a stewardship initiative

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Abstract

Background

Study data indicates anticoagulant interruption peri-procedurally can increase the risk of anticoagulation-related bleeding and thrombosis. Management of anticoagulated patients during the peri-procedural period poses clinical challenges given the potential for thrombosis and bleeding in this complex, high risk population. As such, there is a need for enhanced emphasis on anticoagulated patient care throughout the peri-procedural period with the goal of optimizing patient safety and efficacy.

Purpose

To operationalize an effective, efficient, comprehensive, and standardized anticoagulation management peri-procedural process housed within the electronic health record (EHR).

Design

The IPRO-MAPPP clinical decision support logic was adapted into a nurse-managed protocol to guide anticoagulation therapy use during the elective peri-procedural period at Bassett Medical Center, an Anticoagulation Forum Center of Excellence. A second phase of this initiative endorsed peri-procedural warfarin and bridging management by the Anticoagulation Management Service.

Results

Outcomes revealed 30-day hospital or emergency department admissions remained at or below 1% of the surgical patient population, and below the published national standards for both phases of implementation. Further, no emergent anticoagulation reversal agent use was attributed to peri-procedural care during the assessment period.

Conclusions

The phased implementation of this Anticoagulation Stewardship initiative in elective peri-procedural anticoagulation management successfully describes the operationalization and demonstration of high-quality care and low provider practice variation from policy. The integration of clinical decision support systems, in consort with effective communication, via the EHR, provides stability, sustainability, and drives high quality care to optimize patient outcomes.

Key Points

The risk of anticoagulant adverse drug events in the peri-procedural period remains high, at approximately 0.3–3.5% rate of thrombosis and 0.3–6.1% risk of bleeding.

Anticoagulation Stewardship calls for coordinated, efficient and sustainable efforts which focus on creating optimal anticoagulant-related health outcomes and minimizing adverse drug events.

The IPRO Management of Anticoagulation in the Elective Peri-procedural Period (MAPPP) is a tool which can guide clinicians in achieving high quality, cost-effective evidence-based clinical decision making for anticoagulants peri-procedurally.

The integration of clinical decision support systems, in consort with effective communication, via the EHR, provides stability, sustainability, and drives high quality care to optimize patient outcomes.

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Acknowledgements

Anne Myrka, BSPharm, MAT, CPHQ.

Holly Rubino, MS.

Melissa Scribani, MPH.

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Authors and Affiliations

  1. Oklahoma State University Center for Health Sciences Tulsa, Oklahoma, USA

    Kelly Rudd

  2. Clinical Pharmacy Services, Bassett Healthcare Network, Cooperstown, NY, USA

    Amanda Winans

  3. Anticoagulation Forum, Newton, MA, USA

    Darren Triller

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  1. Kelly Rudd
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Correspondence to Kelly Rudd.

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Rudd, K., Winans, A. & Triller, D. Standardizing periprocedural anticoagulation management: a stewardship initiative. J Thromb Thrombolysis 56, 361–367 (2023). https://doi.org/10.1007/s11239-023-02854-2

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