BACKGROUND:Warfarin is implicated in approximately 30% of reported anticoagulant‐related errors. In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist‐Directed Anticoagulation Service (PDAS).OBJECTIVE:To evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.DESIGN:Cluster randomized trial.SETTING:Large, urban teaching hospital and level 1 trauma center.PATIENTS:All patients receiving warfarin on two medical and two cardiology units.INTERVENTION:A PDAS provided dosing, monitoring, and coordination of transition from the inpatient‐to‐outpatient setting.MEASUREMENTS:Endpoints were assessed during hospitalization and 30 days after discharge. Transition of care was considered effective if compliance with all of the transition of care metrics occurred. The transition of care metrics included: appropriate enrollment in the anticoagulation clinic, documented inpatient‐to‐outpatient provider contact, documented inpatient provider‐to‐anticoagulation clinic communication and patient follow‐up with the anticoagulation clinic within five days of discharge. Safety was measured by the composite endpoint of thromboembolism, major bleeding, or international normalized ratio (INR) ≥5.RESULTS:This study included 500 patients. Transition of care metric compliance occurred in 73% more patients in the PDAS group (P < 0.001). There was also a 32% reduction in the composite safety endpoint in the PDAS group (P = 0.103). This finding was driven by a reduction in rate of INR ≥5 (P = 0.076).CONCLUSIONS:Implementation of a PDAS provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting. Journal of Hospital Medicine 2011;6:322–328. © 2011 Society of Hospital Medicine

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Implementation of a focused inpatient PDAS was associated with improved efficiency of dosing, improved monitoring, and low bleeding risk.

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Advanced heart failure continues to be a significant cause of morbidity and mortality in the US. Patients with advanced heart failure have a poor prognosis without cardiac transplantation. The use of left ventricular assist devices (LVADs) as destination therapy for these patients is therefore expected to increase in the coming years as technology advances. The HeartMate II, a continuous flow implantable device, is currently the only LVAD that has been approved by the Food and Drug Administration for destination therapy in patients with advanced heart failure. The pharmacotherapy associated with this device is very complex and, therefore, the need for expertly trained clinical pharmacists to care for this expanding patient population will also likely increase. Unfortunately, most pharmacists are unfamiliar with the effect of LVADs on the physiology and pharmacotherapy of a patient's heart failure. The purpose of this article is to give clinical pharmacists an introduction to the most common pharmacotherapeutic issues for patients with LVADs and present practical solutions for managing common drug therapy problems.