Impact of proactive pharmacist‐assisted warfarin management using an electronic medication management system in Australian hospitalised patients

Abstract

Aim: To evaluate whether pharmacist-assisted electronic warfarin charting and monitoring reduces warfarin-related errors and improves post-discharge continuum of care. Method: Cardiology and medical patients admitted for at least 24 h and prescribed at least one warfarin dose were included in a pre/post-intervention study. The intervention involved pharmacists proactively charting warfarin and ordering international normalised ratios (INRs) using electronic prescribing software, following discussion with medical doctors. Endpoints included: percentage of patients with one or more warfarin errors, INR > 5.0 during admission, readmission within 30 days for anticoagulant-related issues and warfarin discharge plan (WDP) completeness (including documentation of next dose/s, and when and where the next INR was to be checked). Results: Pre-and post-intervention groups comprised 130 and 108 patients, respectively. Post-intervention, more patients received warfarin following heart valve replacement and fewer for venous thromboembolism. Post-intervention, pharmacists ordered 130 doses (72 patients) and 98 INRs (59 patients). Percentage of patients with one or more warfarin errors declined from 27.7 to 7.4% (p < 0.01), with INR> 5.0 decreased from 7.7 to 2.8% (p = 0.17) and readmission within 30 days for anticoagulation problems occurred in 4 and 0 cases pre-and post-intervention, respectively. While there was a non-significant decline in the proportion of patients with a WDP post-intervention, when patients had a WDP it was more comprehensively completed (p < 0.01). Conclusion: Pharmacists proactively charting and monitoring warfarin reduced warfarin-related errors during hospitalisation and improved elements of post-discharge communication. Closer multi-disciplinary communication and 7-day pharmacy services may result in further continuum of care improvements.

Systematic review of clinical outcomes of clinical pharmacist roles in hospitalised general medicine patients

“…Tyedin et al conducted a pre-and post-intervention study with pharmacist management of warfarin in cardiology and general medicine patients. 12 The post-intervention involved the pharmacist proactively reviewing and monitoring warfarin doses and making dosing recommendations to medical teams. The primary endpoint was the proportion of patients with one or more warfarin-related error during their admission, with secondary endpoints of the proportion of patients with: INR > 5, readmission within 30 days for an anticoagulation problem, and a pharmacist completed a warfarin discharge plan at time of discharge.…”