Efficient operation of a high-volume anticoagulation clinic

A pharmacist-operated anticoagulation clinic at a Department of Veterans Affairs (VA) medical center is described. An anticoagulation clinic established by the pharmacy service at the Denver VA Medical Center cares for 600 patients by using 1.35 fulltime-equivalent pharmacists. The pharmacists are privileged by medical staff to write prescriptions for warfarin, adjust warfarin dosages, and conduct appropriate laboratory monitoring. A protocol has been developed to standardize care. Patients referred to the clinic are scheduled for a same-day warfarin class and laboratory so that International Normalized Ratios (INRs) are available for the patient's appointment with the pharmacist; the patient's understanding of the material presented in the class is assessed during this appointment. The pharmacist determines the therapeutic range and duration of treatment and schedules a follow-up appointment. A locally developed computer program imports patient data from the hospitalwide computer system and simplifies scheduling and tracking of patient-related information. At any point in time, approximately 67% of clinic patients are in the therapeutic range, 13% are above range, and 20% are below range. From January to December 1994, 1.1% of clinic patients were admitted to the medical center for bleeding compared with 2.0% of patients receiving usual care, and 0.9% of clinic patients had thromboembolic complications compared with 3.1% of usual care patients. A computer program, clinical privileging of pharmacists, and a clinic protocol have helped a pharmacist-operated anticoagulation clinic to provide efficient care to veterans.