Inpatient Pharmacist-Based Hemostasis/Thrombosis Service

Inpatient management of patients with complex hemorrhagic and thrombotic disorders requires close supervision, and anticoagulant therapy continues to contribute to adverse drug events. Management strategies include an expanding array of therapeutic options which must be managed in patients with multiple other medical conditions. Examples include: peri-operative and peri-procedural management of antithrombotic therapies, use of direct thrombin inhibitors in patients with heparin-induced thrombocytopenia, and use of hemostatic agents in patients with bleeding complications (inherited as well as acquired).

 

 

To address this need, we have developed an inpatient service staffed by pharmacists which provides a consultative service for the management of hemostatic and antithrombotic therapies. The inpatient service works closely with the inpatient hematology consult service, the Clinical Coagulation Laboratory, and the outpatient Anticoagulation management Service (AMS), facilitating transition of patients followed by the AMS from inpatient to outpatient management.

 

Patients receiving direct thrombin inhibitors (DTI’s), factor products, heparin agents, and warfarin are identified by referral from the inpatient hematology consult service, the AMS, by direct consultation from other medical and surgical services, or by pharmacy computer report. Indication for theses agents is reviewed to ensure appropriateness of therapy. Dosing and monitoring recommendations are made and patients are managed by the pharmacist based service while receiving these antithrombotic or hemostatic agents. Follow-up is arranged with the outpatient AMS upon discharge of the patient from the hospital if indicated

 

Patients with new deep vein thrombosis who qualify for outpatient management or peri-procedural bridge therapies are identified through the ED, pre-op screening, or the AMS. These patients then are educated regarding their disease state, medications, and medication schedules. Transition to the outpatient AMS is facilitated, decreasing the length of hospitalizations for these patients.

 

Patients who are new to anticoagulation therapy are identified and counseled regarding anticoagulant indication, dose, diet, medication interactions, alcohol interactions, disease state interactions, and symptoms of unusual bruising or bleeding.

 

This service started seeing inpatients beginning in September, 2004. Our initial experience has confirmed that the inpatient pharmacist-based, hemostasis and thrombosis service has been successful at enhanced continuity of care, standardization of care, decreased length of hospitalizations, improved patient education, and confirming appropriate outpatient follow-up.