Anticoagulation Clinic Guidelines (Draft) Dean Medical Center



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Anticoagulation Clinic Guidelines (Draft)

Dean Medical Center


The Anticoagulation Clinic(AC Clinic) is a service staffed by pharmacists and nurses with specific knowledge in anticoagulation therapy. Anticoagulation care is managed under the supervision of the AC Clinic Medical Director and the patient’s physician.
I. Goals and Objectives
A. To provide services to physicians initiating anticoagulation therapy and assist physicians

in the management of oral and parenteral anticoagulants.

B. To provide consistent management and follow-up care for patients receiving

anticoagulation therapy by evaluating patient-specific data and pertinent laboratory tests

dependent upon the anticoagulant regimen.

C. To provide consistent education to the patient and/or family members about warfarin

and other anticoagulant therapy. To make them aware of potential problems during therapy

and the signs and symptoms of bleeding, embolic events and other adverse effects.


D. To consistently identify patients who are non-adherent with the anticoagulation care plan

and provide education to improve adherence and reduce the potential for adverse events

and maximize the benefits of treatment.

.

E. To maintain an anticoagulation flowsheet for each patient and provide complete



documentation of the care provided in the patient’s electronic medical record.
F. To consult with other providers involved with the patient’s care when needed.
II. Scope of Care
A. Patient Referral
1. Patients may be referred to the AC Clinic if they have demonstrated the capability to

self-administer medication, or have a responsible caregiver who can supervise the

medication administration, or other acceptable process in place to ensure adherence to

the treatment plan. A reliable method of communication must exist for the

patient to be enrolled in the AC Clinic. The AC Clinic is unable to manage the

patients with the following issues:

a. uncontrolled alcohol abuse

b. underlying psychiatric problems hindering adherence to program expectations

c. inability to adhere to care plan

d. patients with no reliable means of communication




  1. Patients may be referred to the AC Clinic at any point during anticoagulation therapy

provided that a collaborative care agreement exists between the AC Clinic and

the supervising physician (See below: Collaborative Care Agreement). The patient

must be assessed by the supervising physician periodically to determine need for

further anticoagulation therapy.



Dean Anticoagulation Clinics

COLLABORATIVE CARE AGREEMENT
I, __________________________________ MD / DO, acknowledge that I have read and approve the Guidelines of the Dean Anticoagulation Clinics (AC Clinic). My signature on this document authorizes the AC Clinic clinician to monitor my patients’ anticoagulation therapy. This collaborative agreement may be terminated at any time for an individual patient either by me or the AC Clinic clinician for any reason including: anticoagulation therapy is discontinued, patient desires to be followed by the primary physician alone, or the patient misses 3 consecutive appointments, blood draws or other laboratory test used to maintain control of the anticoagulation therapy without contacting the AC Clinic staff.
Check all of the following that apply:
___ It is not necessary for the AC Clinic clinician to call me for routine changes in

therapy.
___ The AC Clinic clinician may authorize prescriptions for warfarin to the

patient’s pharmacy on my behalf.

Physician’s Signature___________________________________ Date_______________

Please print name____________________________________________________________

4. Referrals to the AC Clinic can be made by the primary physician verbally, by

electronic referral, or by written orders. The referral should indicate the reason for use,

desired intensity of treatment, and planned length of treatment. If the physician has

already prescribed a dosage of the anticoagulant, the strength of medication and dosage

per day needs to be indicated.


5. The AC Clinic will establish a computerized patient file for each new referral.

After reviewing the patient’s medical record, the AC Clinic clinician will complete a

initiation form in Epic. The patient’s medical record will be evaluated to obtain

the information listed below. If not specified by the primary physician, the desired INR

range will be based on the current American College of Chest Physicians Consensus

Conference guidelines for the specific indication along with individual patient

characteristics. The AC Clinic clinician will contact the physician, when needed, to

determine the target range and duration of treatment for the intended therapy. The AC

clinician will provide the physician the literature recommendations for usual target

range and duration of therapy for the specified indication, if needed. The computerized

medical record should have the following information available to the AC Clinic

clinician for review:

a. patient name, address and telephone number (home/work)

b. emergency notification contact (telephone number home/work)

c. date of birth, weight, height, gender

d. current medications, including prescription and nonprescription

e. medical history: known diseases and surgeries, drug allergies and reactions,

conditions relating current medication regimen, surgical history, and hospitalizations.

f. indication for anticoagulation therapy

g. target INR range and planned duration of therapy

h. if already receiving anticoagulation therapy include: start date, current dose

i. history of bleeding including major and minor (dates and outcomes)

j. physician name, direct office telephone number, pager number, and fax number


Dean Anticoagulation Clinics

INDICATIONS AND THERAPEUTIC RANGES
Unless the desired INR range is specified by the primary physician on the patient referral form, the AC Clinic will use ranges for the corresponding indications below as recommended by the Commitee on Antithrombotic Therapy of the American College of Chest Physicians.


INDICATION

TARGET INR (RANGE)

DURATION

COMMENT

Atrial Fibrillation (AF)

Age < 65 no risk factors

Age < 65 with risk factors for stroke (Hx

TIA/stroke/TE; HTN, CHF,  LV fxn;

rheumatic mitral valve dz; valve replacement;

DM; CAD; thyrotoxicosis

Age 65-75 no risk factors

Age 65-75 with risk factors

Age > 75

Precardioversion (AF/flutter > 48 hrs in duration

Postcardioversion (in NSR)

None


2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)


Chronic


Chronic

Chronic


Chronic

Chronic


3 weeks

4 weeks

Aspirin alone

Or Aspirin

Weekly INRs

Add antiplatelet Rx



Cardioembolic Stroke

With risk factors for stroke (AF;CHF;LV

dysfxn; mural thrombus; Hx TIA/Stroke.TE)

Following embolic event despite therapeutic

anticoagulation

2.5 (2.0-3.0)


2.5 (2.0-3.0)

Chronic
Chronic







Left Ventricular Dysfunction

Ejection fraction <30%

Transient, following myocardial infarction

Following embolic event despite therapeutic

anticoagulation


2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)



Chronic


3 months

Chronic


Add antiplatelet Rx



Acute Myocardial Infarction (MI)

Following anterior MI

Following inferior MI with transient risks (AF;

CHF; LV dysfxn; mural thrombus, Hx TE)

Following initial tx with persistent risks

2.5 (2.0-3.0)

2.5 (2.0-3.0)
2.5 (2.0-3.0)

3 months


3 months
Chronic





Thromboembolism (DVT,PE)

Treatment/prevention of recurrence

Transient risk factors

Idiopathic

Presisitent risk factors (AT-III; protein C;

protein S deficiencies; Factor V Leiden;

malignancy

Antiphospholipid antibody syndrome

Following recurrent DVT/PE


2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

3.0 (2.5-3.5)

2.5 (2.0-3.0)




3-6 months

6 months

Chronic


Chronic

Chronic


May need higher range



Valvular Disease

Aortic valve disease with mitral valve disease; AF;

Hx systemic embolization

Mitral annular calcification with AF; Hx systemic

embolization

Mitral valve prolapse:

With AF; Hx systemic embolization

With Hx of TIA despite ASA Rx

S/p embolic event despite anticoagulation

Rheumatic mitral valve disease

With AF; Hx systemic embolization;

LA > 5.5cm

S/p embolic event despite anticoagulation


2.5 (2.0-3.0)


2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)


2.5 (2.0-3.0)
2.5 (2.0-3.0)

Chronic
Chronic

Chronic

Chronic


Chronic
Chronic
Chronic

Add antiplatelet Rx

Add antiplatelet Rx



Valve Replacement-Bioprosthetic

Aortic or mitral

with LA thrombus

with Hx systemic embolism

with AF

Following systemic embolism


2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)

2.5 (2.0-3.0)



3 months


>3 months

3-12 months

Chronic

Chronic



Followed by aspirin Rx

Followed by aspirin Rx

Followed by aspirin Rx
Add aspirin Rx


Valve Replacement – Mechanical

Aortic


Bileaflet

In NSR, normal EF, normal LA size

All others

Tilting disk

Ball and cage

Mitral


Bileaflet

Tilting disk

Ball and cage

With additional risk factors or following TE


2.5 (2.0-3.0)

3.0 (2.5-3.5)

3.0 (2.5-3.5)

3.0 (2.5-3.5)

3.0 (2.5-3.5)

3.0 (2.5-3.5)

3.0 (2.5-3.5)

3.0 (2.5-3.5)

3.0 (2.5-3.5)



Chronic


Chronic

Chronic


Chronic

Chronic


Chronic

Chronic


Chronic

Chronic


* 2.0-3.0 + aspirin81mg

* 2.0-3.0 + aspirin81mg

With aspirin
* 2.0-3.0 + aspirin81mg

* 2.0-3.0 + aspirin81mg

With aspirin

Add aspirin


*In patients with risks for hemorrhage.

Hx, history; TIA transient ischemic attack; TE, thromboembolism; HTN, hypertension; CHF, congestive heart failure;

, lowered; LV left ventricular; fxn, function; dysfxn, dysfunction; dx, disease; CAD, coronary artery disease;

AF, atrial fibrillation; NSR, normal sinus rhythm; MI myocardial infarction; tx, treatment; DVT, deep venous thrombosis;

PE pulmonary embolism; s/p, status post; LA, left atrium; EF, ejection fraction


6. All referrals to the AC Clinic must have a supervising Dean Medical Center physician

who is responsible for periodically assessing the patient’s continuing need for

anticoagulation therapy and management of medical/surgical problems.




  1. If difficulties arise, such as, lack of cooperation, continued non-adherence with

INR blood draws, the primary physician will be made aware of the issues by the

AC Clinic clinician. A note will be placed in the patient’s medical record

describing the problem, discussion with the primary physician, and agreed upon course

of action. If the issue continues to be problematic despite repeated efforts to rectify the

problem, the patient may be referred back to the primary physician for reevaluation.


  1. In addition to adherence issues, the AC Clinic clinician will notify or, if needed, refer the patient back to the primary physician or proceed to the hospital ER in the following circumstances:

a. consultation with a physician is requested by the patient

b. the AC Clinic clinician notes findings suggestive of another worsening medical

problem


c. there is evidence suggestive of gross hematuria, gastrointestinal, or other bleeding

d. there is evidence suggestive of worsening thromboembolic disease

e. assessment of continuing need for anticoagulation is warranted
9. Discontinuation of anticoagulation therapy will only occur by physician order. When the

desired length of treatment has been reached, the the AC Clinic clinician will refer the

patient back to the primary physician to evaluate the need for continued

anticoagulation. Discharge from the AC Clinic will occur by physician order when:


a. anticoagulation therapy is discontinued

b. the patient desires primary physician to manage anticoagulation

c. the primary physician decides to manage anticoagulation

d. the patient violates adherence policy (see B.3)


10. The AC Clinic clinician must provide consultation only with the patient via an inclinic appointment,

the telephone, US mail or MyChart. The AC Clinic clinician can leave a message on the patient’s

voice mail or answering machine or speak with a family member, activated power of attorney for

healthcare, or other designated person provided that the patient completes and signs the AC Clinic

verbal permission form (see below). The completed and signed formed must be scanned into Epic

by Medical Records.



PERMISSION FOR VERBAL COMMUNICATIONS

(print name of patient or place patient label here) (birthdate)


(street address) (city, state, zip code)


(phone number)


I permit Dean Health Systems, Inc. Anticoagulation (AC) Clinic personnel (“Health Care Providers”) to leave information regarding ongoing anticoagulation therapy on my voice mail or answering machine.
In addition this authorization allows the AC personnel to discuss health information, in person or by telephone with the following family members or friends involved in my medical care: (List family members/friends and state the person’s relationship to the patient).


Name

Phone Number

Relationship

1.








2.








3.








4.








Patient’s Signature: Date:


If this Release is signed by a representative on behalf of the patient, complete the following:
Representative’s Name:
Relationship to Patient:
If, at any time, I do not want this information to be left on my answering machine or I want to change the names of the people listed above, I must notify the Anticoagulation (AC) clinic:

  • by telephone at 608-252-8060, or

  • by mail at the address listed below, or

  • in person at the Anticoagulation Clinic at Dean Clinic.


INSTRUCTIONS: Please sign this form and send to the following location:



Dean Clinic

Attention: Anticoagulation Clinic

1313 Fish Hatchery Road

Madison, WI 53715

Rev 1/28/09



  1. Clinic Procedures - AC Clinics: For Dean Fish Hatchery Road AC Clinics see visio below;

For Riverview and Stoughton AC Clinic, see attached guidelines.






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