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Lysogorski MC, Hassan AK, Lampkin SJ, Geisler R. The impact of pharmacy monitoring and intervention in patients receiving intravenous heparin. Int J Clin Pharm 2017; 39:844-850. [PMID: 28508323 DOI: 10.1007/s11096-017-0482-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 05/08/2017] [Indexed: 11/26/2022]
Abstract
Background Intravenous unfractionated heparin (IV UFH) has a narrow therapeutic index and poses a high risk of bleeding. Objective To determine the impact of pharmacy monitoring and intervention on adherence to and appropriate implementation of IV UFH protocol. Setting A 438 bed hospital specializing in cardiac services. Methods This is a retrospective chart review study. Pre-pharmacy intervention data were collected from November 2013 to January 2014 and compared to post-pharmacy intervention data obtained between August 2014 and October 2014. Patients were included if they received IV UFH for at least 24 hours. The first three daytime laboratory draws were collected for each patient and analyzed using generalized estimating equations to quantify the association between pharmacy monitoring and adherence to the institution's protocol. Main outcome measures Designation of appropriate protocol, accurate selection of initial infusion rate, timing of anti-Xa levels within 60 min of anticipated due time, change of infusion rate within 120 min of laboratory result, and appropriate adjustment of infusion rates. Results A total of 195 data points were included. The initial selection of infusion rate and subsequent adjustments were more appropriate in the post-intervention period with an odds ratio of 8.36 (95% CI 2.41-29.01, p value = 0.0008), and 4.66 (95% CI 1.41-15.43, p value = 0.0118), respectively. Conclusion The results of this study indicate that pharmacy monitoring of IV UFH therapy has improved adherence to an institution's protocol and is associated with more accurate selection of initial infusion rates and adjustment of infusions based upon laboratory results.
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Affiliation(s)
| | - Amany K Hassan
- School of Pharmacy, D'Youville College, Buffalo, NY, USA.
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Downing A, Mortimer M, Hiers J. Impact of a pharmacist-driven warfarin management protocol on achieving therapeutic International Normalized Ratios. Am J Health Syst Pharm 2016; 73:S69-73. [PMID: 26896529 DOI: 10.2146/sp150039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Warfarin is a high alert medication and a challenge to dose and monitor. Pharmacist-driven warfarin management has been shown to decrease the time international normalized ratio (INR) is out of range, which may reduce undesired outcomes. The purpose of this study is to assess the effect of the implementation of a pharmacist-driven warfarin management protocol on the achievement of therapeutic INRs. METHODS A warfarin management protocol was developed using evidence based literature and similar protocols from other institutions. Pharmacists utilized the protocol to provide patient specific warfarin dosing upon provider referral. To evaluate the protocol's impact, a retrospective chart review pre- and post-implementation was completed for admitted patients receiving warfarin. RESULTS Three hundred twenty-seven charts were reviewed for pre- and post-implementation data. INRs within therapeutic range increased from 27.8% before protocol implementation to 38.5% after implementation. There was also a reduction in subtherapeutic INRs (55.3% pre to 39% post) and supratherapeutic INRs 5 or above (3.7% pre to 2.6% post). Supratherapeutic INRs between 3 and 5 did increase from 13.2% before protocol implementation to 19.9% in the pharmacist managed group. In addition to reducing the time to achievement of therapeutic INRs by 0.5 days, implementation of the protocol resulted in an increased the number of patients with at least one therapeutic INR during admission (35% pre to 40% post). CONCLUSION The implementation of a pharmacist-driven warfarin dosing protocol increased therapeutic INRs, and decreased the time to therapeutic range, as well as the proportion of subtherapeutic INRs and supratherapeutic INRs 5 or greater. Additional benefits of the protocol include documentation of Joint Commission National Patient Safety Goal compliance, promotion of interdisciplinary collaboration and increased continuity of care.
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Affiliation(s)
- Amanda Downing
- PGY-1 Pharmacy Practice Resident, Elliot Health System, Manchester, NH
| | - Molly Mortimer
- Clinical Coordinator, Elliot Health System, Manchester, NH
| | - Jill Hiers
- Clinical Pharmacist, Elliot Health System, Manchester, NH
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Brancaccio A, Giuliano C, McNorton K, Delgado G. Impact of a phenytoin loading dose program in the emergency department. Am J Health Syst Pharm 2015; 71:1862-9. [PMID: 25320136 DOI: 10.2146/ajhp140039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use of a combined physician-and pharmacist-directed phenytoin loading dose program in an emergency department (ED) was evaluated. METHODS This single-center, observational, preimplementation-postimplementation study evaluated adult patients who received a phenytoin loading dose in the ED. The primary outcome compared the proportion of optimal phenytoin loading doses in the preimplementation and postimplementation groups. The postimplementation group was further stratified into pharmacist- and prescriber-dosing groups. Other outcomes evaluated included the numbers of appropriate serum phenytoin concentrations measured, adverse drug reactions (ADRs), and recurrence of seizures within 24 hours of loading dose administration in the preimplementation and postimplementation groups. RESULTS There was no difference in the proportion of optimal phenytoin loading doses between the preimplementation and postimplementation groups (50% versus 62%, respectively; p=0.19). When stratified by individual groups, the rate of optimal phenytoin loading doses increased by 64% in the postimplementation pharmacist group (50% versus 82%, p=0.007), while the rate in the prescriber-dosing group remained relatively unchanged (50% versus 49%, p=0.91). The number of appropriate serum phenytoin concentrations significantly improved in the postimplementation versus preimplementation group (65% versus 40%, p=0.025). Rates of ADRs and recurrence of seizures did not differ across the study groups. CONCLUSION No change in the percentage of optimal phenytoin loading doses in the ED was observed after implementation of a combined pharmacist- and physician- dosing program. When stratified into pharmacist or prescriber dosing, the pharmacist-led dosing program significantly improved the proportion of patients who received optimal phenytoin loading doses.
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Affiliation(s)
- Adam Brancaccio
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| | - Christopher Giuliano
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC.
| | - Kelly McNorton
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
| | - George Delgado
- Adam Brancaccio, Pharm..D., BCPS, is Clinical Pharmacist Generalist-Internal Medicine, University of Michigan Health System, Ann Arbor, and Adjunct Clinical Faculty, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, St. John Hospital and Medical Center (SJHMC), Detroit, MI. Christopher Giuliano, Pharm.D., is Assistant Professor, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, and Clinical Specialist, Internal Medicine, Department of Pharmacy, SJHMC. Kelly McNorton, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care; and George Delgado Jr., Pharm.D., is Clinical Pharmacy Specialist, Emergency Medicine/Infectious Diseases, Department of Pharmacy, SJHMC
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Shaha M, Wüthrich E, Stauffer Y, Herczeg F, Fattinger K, Hirter K, Papalini M, Herrmann L. Implementing evidence-based patient and family education on oral anticoagulation therapy: a community-based participatory project. J Clin Nurs 2015; 24:1534-45. [PMID: 25763658 DOI: 10.1111/jocn.12743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2014] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES This study aimed at developing and implementing evidence-based patient and family education on oral anticoagulation therapy. BACKGROUND The number of persons with chronic diseases who live at home is increasing. They have to manage multiple diseases and complex treatments. One such treatment is oral anticoagulation therapy, a high risk variable dose medication. Adherence to oral anticoagulation therapy is jeopardised by limited information about the medications, their risk and complications, the impact of individual daily routine and the limited inclusion of family members in education. Hence, improved and tailored education is essential for patients and families to manage oral anticoagulation therapy at home. DESIGN AND METHODS A community-based participatory research design combined with the Precede-Proceed model was used including a systematic literature review, posteducation analysis, an online nurse survey, a documentation analysis and patient/family interviews. The study was conducted between April 2010-December 2012 at a department of general internal medicine in a teaching hospital in Switzerland. Participants were the department's nursing and medical professionals including the patients and their families. RESULTS The evidence-based patient and family education on oral anticoagulation therapy emerged comprising a learning assessment, teaching units, clarification of responsibilities of nurse professionals and documentation guidelines. CONCLUSION AND CLINICAL RELEVANCE The inclusion of the whole department has contributed to the development and implementation of this evidence-based patient family education on oral anticoagulation therapy, which encompasses local characteristics and patient preferences. This education is now being used throughout the department.
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Affiliation(s)
- Maya Shaha
- Institute of Nursing Education and Research, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutic Areas, Inselspital Bern University Hospital, Bern, Switzerland
| | - Erika Wüthrich
- Department of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutic Areas, Inselspital Bern University Hospital, Bern, Switzerland.,University Clinic of General Internal Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Yvonne Stauffer
- Department of Nursing, Quality and Development, University Clinic of General Internal Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Franziska Herczeg
- University Clinic of General Internal Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Karin Fattinger
- Department of Medicine and Rehabilitation, Hospital of Schaffhausen, Schaffhausen, Switzerland
| | - Kathrin Hirter
- Department of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutic Areas, Inselspital Bern University Hospital, Bern, Switzerland
| | - Marianne Papalini
- University Clinic of General Internal Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Luzia Herrmann
- Department of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutic Areas, Inselspital Bern University Hospital, Bern, Switzerland
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Padron M, Miyares MA. Development of an Anticoagulation Stewardship Program at a Large Tertiary Care Academic Institution. J Pharm Pract 2013; 28:93-8. [DOI: 10.1177/0897190013514091] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pharmacist-directed anticoagulation management services (AMSs) have been shown to significantly lower anticoagulation-related mortality, length of hospital stay, bleeding complications, blood transfusion requirements, and cost of therapy. AMSs are only 1 component of an anticoagulation stewardship program. Frequently, stewardship programs are limited to inpatient populations. Incorporating components that facilitate transition to outpatient status will ideally encompass complete care. The purpose of this program was to expand anticoagulation services and standardize care by implementing a full-service stewardship program including a transition of care service. The first component of the study involved medication surveillance for inpatients on anticoagulation therapy. The second component involved transitioning patients on anticoagulation, primarily with venous thromboembolism (VTE) to outpatient management. Finally, the pharmacist identified areas for optimization. Optimization involved developing or updating protocols to reflect updates in the literature as well as updating institution-specific information resources. Interventions made through medication surveillance and utilization of the VTE transition of care services translated into a total cost savings of approximately US$270 320. A postgraduate, first-year pharmacy resident contributed to improving patient outcomes while reducing utilization of hospital services and obtaining substantial cost savings through participation in anticoagulation stewardship services.
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Affiliation(s)
- Maria Padron
- Department of Pharmacy, Jackson Memorial Hospital, Miami, FL, USA
| | - Marta A. Miyares
- Department of Pharmacy, Jackson Memorial Hospital, Miami, FL, USA
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