title: Expedited discharge in trauma patients requiring anticoagulation for deep venous thrombosis prophylaxis: the LEAP Program.
abstract: OBJECTIVE
  With rising health care costs, methods to decrease length of hospital stay without compromising care are necessary. One area that extends length of stay in trauma patients is inpatient anticoagulation to a therapeutic international normalized ratio. The 1998 American College of Chest Physicians guidelines recommend thromboprophylaxis with low-molecular-weight heparin (LMWH) and oral warfarin in this population. The LMWH Expedited Anticoagulation Program (LEAP) was created with the following goals: to decrease the number of inpatient warfarin days and to reduce overall number of hospital days.
  
  
  METHODS
  Inpatient anticoagulation was initiated with warfarin and LMWH. LEAP included early multidisciplinary collaboration to ensure third-party approval, outpatient primary care physician follow-up, and LMWH self-injection before discharge. Patients were discharged on LMWH (discontinued by primary care provider when a therapeutic international normalized ratio was attained) and warfarin (continued until resolution of orthopedic injuries). From August 2000 to August 2001, adult patients were included in the prospective study. Primary inclusion criteria were blunt acetabular fracture, bilateral lower extremity fracture, and contralateral upper and lower extremity fractures. Patients with similar injuries receiving warfarin for deep venous thrombosis prophylaxis between June 1999 and June 2000 were the control population. Anticoagulation care was similar for the study and control subjects.
  
  
  RESULTS
  There were 182 patients evaluated for LEAP inclusion. After initial evaluation, 108 patients were enrolled in LEAP (Injury Severity Score of 13). There were 69 control subjects (Injury Severity Score of 13). The average number of inpatient warfarin days was decreased from 8.8 days to 5.0 days in the control and study populations, respectively (p < 0.0001). The average length of hospitalization was shortened from 17.3 days in the control group to 12.9 days in the study (LEAP) population (p < 0.002).
  
  
  CONCLUSIONS
  LEAP has successfully decreased the number of inpatient days on warfarin and total hospital days for trauma patients requiring deep venous thrombosis prophylaxis. These results have substantially decreased health care costs and increased available hospital beds in this era of high hospital occupancy.
authors.affiliation: Department of Pharmacy, Regional Medical Center at Memphis, Tennessee 38103, USA. gbridges@the-med.org
authors.forename: Gail G
authors.initials: GG
authors.lastname: Bridges
authors.forename: Marilyn D
authors.initials: MD
authors.lastname: Lee
authors.forename: J Kimble
authors.initials: JK
authors.lastname: Jenkins
authors.forename: Mark A
authors.initials: MA
authors.lastname: Stephens
authors.forename: Martin A
authors.initials: MA
authors.lastname: Croce
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Fabian
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D016022:Case-Control Studies; D005260:Female; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use*; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D020246:Venous Thrombosis / Q000209:etiology / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use*; D014947:Wounds and Injuries / Q000145:classification / Q000150:complications*
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D014859:Warfarin