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Abstract

Background:

Safe and effective transition of patients receiving injectable anticoagulation, from an inpatient to an outpatient setting, requires patient education, prescription coordination, and appropriate follow-up.

Objective:

To evaluate a long-standing, hospital-wide, pharmacist-managed injectable anticoagulation discharge program at an urban academic medical center.

Methods:

This observational study included adults discharged on an injectable anticoagulant between December 1, 2008, and February 28, 2009. The primary endpoint was program adherence, defined as percent of discharged patients whose anticoagulation therapy was coordinated by a pharmacist. Secondary endpoints included duration of patient counseling and medication procurement (including confirmation of current home supply or need for complete procurement of a full/new prescription); length of hospital stay for patients with a primary diagnosis of venous thromboembolism (VTE); and VTE recurrence and bleeding rates at 3 months. Descriptive statistics were used and are presented as proportions and mean (SD).

Results:

A total of 207 patients discharged on an injectable anticoagulant (3.2 discharges/day) were included. Pharmacist coordination was documented for 180 (87%) patients. Overall, pharmacists spent 37.6 (25.5) minutes per patient, including 19.4 (9.6) minutes for counseling and 19.7 (19.7) minutes for medication procurement; 150 (83%) patients required complete medication procurement lasting 21.4 (19.6) minutes. The length of hospital stay for patients with a primary diagnosis of VTE was 3.2 (2.4) days. At 3 months, 5.3% and 1.4% of assessable patients had recurrent VTE or major bleeding events, respectively. Patients with major bleeding experienced intracranial hemorrhage (n = 2) and gastrointestinal bleeding (n = 1), all beyond the first 2 weeks after discharge.

Conclusions:

The pharmacist-managed injectable anticoagulation discharge program was completed in a large proportion of patients. Patient education and medication procurement require the majority of time-related resources. Continual process improvement is crucial for hospitals to ensure that all patients discharged with injectable anticoagulation are assessed and receive anticoagulation education.

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Outcomes of a Comprehensive,Pharmacist-Managed Injectable Anticoagulation Discharge Program for the Prophylaxis and Treatment of Venous Thromboembolism