title: Utility of a dedicated pediatric cardiac anticoagulation program: the Boston Children's Hospital experience.
abstract: Congenital heart disease is the leading cause of stroke in children. Warfarin therapy can be difficult to manage safely in this population because of its narrow therapeutic index, multiple drug and dietary interactions, small patient size, high-risk cardiac indications, and lack of data to support anticoagulation recommendations. We sought to describe our institution's effort to develop a dedicated cardiac anticoagulation service to address the special needs of this population and to review the literature. In 2009, in response to Joint Commission National Patient Safety Goals for Anticoagulation, Boston Children's Hospital created a dedicated pediatric Cardiac Anticoagulation Monitoring Program (CAMP). The primary purpose was to provide centralized management of outpatient anticoagulation to cardiac patients, to serve as a disease-specific resource to families and providers, and to devise strategies to evolve clinical care with rapidly emerging trends in anticoagulation care. Over 5 years the CAMP Service, staffed by a primary pediatric cardiology attending, a full-time nurse practitioner, and administrative assistant with dedicated support from pharmacy and nutrition, has enrolled over 240 patients ranging in age from 5 months to 55 years. The most common indications include a prosthetic valve (34 %), Fontan prophylaxis (20 %), atrial arrhythmias (11 %), cardiomyopathy (10 %), Kawasaki disease (7 %), and a ventricular assist device (2 %). A patient-centered multi-disciplinary cardiac anticoagulation clinic was created in 2012. Overall program international normalized ratio (INR) time in therapeutic range (TTR) is favorable at 67 % (81 % with a 0.2 margin) and has improved steadily over 5 years. Pediatric-specific guidelines for VKOR1 and CYP2C9 pharmacogenomics testing, procedural bridging with enoxaparin, novel anticoagulant use, and quality metrics have been developed. Program satisfaction is rated highly among families and providers. A dedicated pediatric cardiac anticoagulation program offers a safe and effective strategy to standardize anticoagulation care for pediatric cardiology patients, is associated with high patient and provider satisfaction, and is capable of evolving care strategies with emerging trends in anticoagulation.
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, USA.
authors.forename: Jenna M
authors.initials: JM
authors.lastname: Murray
authors.forename: Amy
authors.initials: A
authors.lastname: Hellinger
authors.forename: Roger
authors.initials: R
authors.lastname: Dionne
authors.forename: Loren
authors.initials: L
authors.lastname: Brown
authors.forename: Rosemary
authors.initials: R
authors.lastname: Galvin
authors.forename: Suzanne
authors.initials: S
authors.lastname: Griggs
authors.forename: Karen
authors.initials: K
authors.lastname: Mittler
authors.forename: Kathy
authors.initials: K
authors.lastname: Harney
authors.forename: Shannon
authors.initials: S
authors.lastname: Manzi
authors.forename: Christina
authors.initials: C
authors.lastname: VanderPluym
authors.forename: Annette
authors.initials: A
authors.lastname: Baker
authors.forename: Patricia
authors.initials: P
authors.lastname: O'Brien
authors.forename: Cheryl
authors.initials: C
authors.lastname: O'Connell
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Almond
mesh_terms: D000293:Adolescent; D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects*; D001900:Boston; D002648:Child; D002675:Child, Preschool; D005260:Female; D006330:Heart Defects, Congenital / Q000150:complications* / Q000503:physiopathology; D006801:Humans; D007223:Infant; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration / Q000706:statistics & numerical data*; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use*; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D014859:Warfarin