Implementation of a collaborative drug therapy management service for inpatients receiving direct thrombin inhibitors

The development and implementation of a collaborative drug therapy management (CDTM) service for inpatients receiving direct thrombin inhibitors (DTIs) are described.

A pharmacist-driven DTI protocol was established to help establish guidelines for the use and monitoring of DTIs to ensure the effective and safe administration of these high-risk medications. The CDTM service and DTI dosing protocol, including order form development, were completed over a two-year period. The DTI order form consisted of five main sections: practice points pertaining to the clinical diagnosis of heparin-induced thrombocytopenia (HIT), initiation of DTIs, nurse- and pharmacist-driven instructions for the monitoring of DTI therapy, information to safely transition a patient from a DTI to warfarin, and a scoring system for determining the probability of HIT. A CDTM service for the inpatient setting was developed to improve patient outcomes and reduce medication errors related to the monitoring and adjusting of DTI dosages. To implement this service, three major areas were addressed: the credentialing of pharmacists, the ordering process, and required documentation. Challenges encountered during protocol development were eliminating the use of lepirudin, developing a comprehensive order form for two DTIs, obtaining approval of the DTI dosing protocol by the medical executive committee, and developing and implementing a comprehensive nursing education program for the new order form and protocol.

A dosing protocol for DTIs was developed to improve the use of these high-risk medications within an institution. The protocol provided physicians with the option of deferring DTI dosing to a pharmacist with appropriate credentials.