title: Impact of a Pharmacist-Directed Anticoagulation Service on the Quality and Safety of Heparin-Induced Thrombocytopenia Management.
abstract: BACKGROUND
  The use of anticoagulant medications is complex and prone to error in the inpatient setting. Patients with heparin-induced thrombocytopenia (HIT) must receive treatment with alternative anticoagulant agents to ensure optimal patient outcomes.
  
  
  OBJECTIVE
  To evaluate the impact of an inpatient pharmacist-directed anticoagulation service (PDAS) on the safety and efficiency of direct thrombin inhibitor use in patients with HIT.
  
  
  METHODS
  This was a quasi-experimental pre/postintervention study comparing patients with HIT managed with usual care to patients managed with a focused inpatient anticoagulation service. The primary endpoints of the study were the percent of time that the activated partial thromboplastin time (aPTT) remained within the therapeutic range and time to achievement of a therapeutic aPTT. Bleeding and appropriateness of warfarin initiation were evaluated as secondary endpoints.
  
  
  RESULTS
  A total of 193 patients were included in the study. Percent of time that aPTT was in the therapeutic range was 32% higher with the PDAS (p < 0.001) and time to therapeutic aPTT was shortened by approximately 12.5 hours in patients managed by the PDAS (p < 0.001). There was a trend for more bleeding events, regardless of severity, among control patients (p = 0.130). Rate of TIMI (Thrombolysis in Myocardial Infarction) major bleeding was lower in the PDAS group (p = 0.006), but there was no significant difference between groups in GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate/severe bleeding (p = 0.679). Appropriateness of warfarin initiation was also similar between groups.
  
  
  CONCLUSIONS
  Implementation of a focused inpatient PDAS was associated with improved efficiency of dosing, improved monitoring, and low bleeding risk.
authors.affiliation: Long To PharmD, at time of writing, PharmD Student, Wayne State University, Detroit, MI; now, PGY1 Resident, Medical University of South Carolina, Charleston, SC.
authors.forename: Long
authors.initials: L
authors.lastname: To
authors.affiliation: Jessica M Schillig PharmD BCPS, Pharmacy Specialist-Anticoagulation, Henry Ford Hospital, Detroit, MI.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Schillig
authors.affiliation: Brian D DeSmet PharmD MS, Pharmacy Specialist-Outcomes Research, Henry Ford Hospital.
authors.forename: Brian D
authors.initials: BD
authors.lastname: DeSmet
authors.affiliation: Philip Kuriakose MD, Senior Staff Physician, Henry Ford Hospital.
authors.forename: Philip
authors.initials: P
authors.lastname: Kuriakose
authors.affiliation: Edward G Szandzik BS MBA, Director of Pharmacy, Henry Ford Hospital.
authors.forename: Edward G
authors.initials: EG
authors.lastname: Szandzik
authors.affiliation: James S Kalus PharmD BCPS (AQ CV), Senior Clinical Pharmacy Manager, Henry Ford Hospital jkalus1@hfhs.org.
authors.forename: James S
authors.initials: JS
authors.lastname: Kalus
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D000991:Antithrombins / Q000627:therapeutic use; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006493:Heparin / Q000009:adverse effects*; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D013921:Thrombocytopenia / Q000139:chemically induced / Q000188:drug therapy*; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D014859:Warfarin; D006493:Heparin