Anticoagulation Management Service (AMS) Under Pharmacy Oversight

BWH Anticoagulation Management Service members.

With the Department of Pharmacy Services now overseeing the Anticoagulation Management Service (AMS), several new initiatives and service improvements have been put in place to help facilitate the management of about 2,500 patients on warfarin (Coumadin©, Jantoven© ) and other anticoagulants.

“Pharmacists are well-positioned to provide leadership to this service because of our training in pharmacotherapy, pharmacodynamics and pharmacokinetics,” said Bill Churchill, MS, RPh, executive director of Pharmacy Services. “We work in collaboration with our medical director, Jean Connors, MD, and content expert Samuel Z. Goldhaber, MD, as well as physician assistants, attending physicians, nurse practitioners and patients to help manage these high risk medications. Our goal is to be one of the best—if not the best—anticoagulation management service in the country.”

Since the service transitioned to pharmacy leadership in November 2008, several process improvement efforts were implemented to improve procedures, protocols and practices within the anticoagulation service. In addition, AMS staff are working closely with the National Patient Safety Anticoagulation Safety Task Force to standardize compliance initiatives across all BWH affiliated anticoagulation clinics.

“One of our longer term goals is to bring all of these services under the same umbrella and standardize practices to make the process of anticoagulation management easier for care providers and patients throughout the hospital,” said Karen Fiumara, PharmD, medication safety officer, who oversees the day-to-day operations of the anticoagulation management service. “We are actively working with several primary care practices as well as with BIMA, DFCI and Brookside Community Health Center anticoagulation clinics to begin this effort.”

The main campus AMS is staffed by pharmacists, physician assistants, nurse practitioners and clerical and support staff to manage all aspects of anticoagulation for patients referred from primary care practitioners, cardiologists and surgeons. One of the main benefits of moving the AMS under pharmacy is that the inpatient Pharmacy staff can now provide backup staffing and support to the clinic whenever it is needed.

In addition to standardizing practices, the service already has completed the following process improvement initiatives:

Developed a warfarin maintenance dosing protocol

Developed a post-surgical orthopedic warfarin protocol

Improved communication to patients with routine letters

Participated in the development and distribution of a warfarin education guide for patients

Began to provide services to new groups of patients, such as thoracic patients who stay in town post-surgery

Worked more closely with individual practitioners to provide anticoagulation management services to patients

One major initiative underway is helping patients obtain home testing machines that enable them to get their International Normalized Ratio (INR) results right at home and have results reported to the clinic, rather than traveling to the lab each month.

“Our hope is to expand that to provide greater convenience and the same degree of reliability,” Fiumara said.

The Pharmacy team also is working to give physicians and other care providers easy access to patient information. Coming this fall, an anticoagulation management service icon will be available in LMR and Inpatient Pod Monitor for all patients managed by the service. By toggling that icon, physicians can see the patient’s last three INR values and the dosing recommendations made by the service.

Also underway are:

A new referral process from the physicians’ offices so AMS staff receive more complete information about patients.

A web site that provides information for patients and links to policies, procedures, and referrals.

Software to improve and streamline information, such as dosing and lab results, to make it available for patients and improve access for caregivers in and outside the hospital.

These processes help BWH comply with the National Patient Safety Goals in anticoagulation management.

“AMS staff have participated in the Partners HealthCare initiative to improve anticoagulation safety across the network,” said John Fanikos, MBA, RPh, assistant director of Pharmacy Services. “It’s a way to improve care delivered to these patients.”