An outpatient anticoagulation protocol managed by a vascular nurse-clinician
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G R Seabrook1, D Karp, D D Schmitt
1Department of Surgery, Medical College of Wisconsin, Milwaukee.
Insights
Vascular nurse-clinician management of Coumadin therapy ensures safe and effective anticoagulation for patients with hypercoagulable states or prosthetic grafts. This approach achieves optimal therapeutic levels with low risks of bleeding or thrombosis.
Area of Science:
- Vascular Surgery
- Pharmacology
- Clinical Nursing
Background:
- Lifetime anticoagulation is an option for patients with hypercoagulable states or prosthetic arterial bypass grafts.
- Physicians may hesitate due to perceived risks of hemorrhagic complications from Coumadin (warfarin) therapy.
- Optimal anticoagulation intensity and duration are critical for managing thrombotic risks.
Purpose of the Study:
- To review a protocol for anticoagulant therapy managed by a vascular nurse-clinician.
- To assess the safety and efficacy of nurse-managed Coumadin therapy in high-risk patients.
- To evaluate the incidence of hemorrhagic and thrombotic events during outpatient anticoagulation.
Main Methods:
- A retrospective review of anticoagulant therapy managed by a vascular nurse-clinician.
- Coumadin prescribed for 1,891 patient-months to 93 patients.
- Therapeutic range: prothrombin time (PT) 1.5 to 2 times control (18-24 seconds).
Main Results:
- Mean prothrombin time was 19.8 +/- 1.8 seconds.
- 14% of PT measurements were outside the therapeutic range, prompting dose adjustments in 88% of patients.
- Low incidence of complications: 4 recurrent graft thromboses, 6 major and 11 minor hemorrhages.
Conclusions:
- Outpatient anticoagulant therapy can be safely administered at optimal intensity by vascular nurse-clinicians.
- This management strategy is associated with a low incidence of hemorrhagic and thrombotic events.
- Effective anticoagulation is achievable for patients with chronic risks of arterial or venous thrombosis.
Abstract:
Lifetime anticoagulation has become a therapeutic option for surgical patients with hypercoagulable states or prosthetic arterial bypass grafts. However, physicians may not achieve optimal anticoagulation or may attempt to limit the length of the therapy period because of the perceived morbidity from hemorrhagic complications of Coumadin therapy. A protocol for anticoagulant therapy monitored and regulated by a vascular nurse-clinician was reviewed. Coumadin was prescribed for 1,891 patient-months to 93 patients to maintain their prothrombin time 1.5 to 2 times control (range: 18 to 24 seconds). The mean (+/- SD) prothrombin time for the study population was 19.8 +/- 1.8 seconds. During follow-up, 472 (14%) of 3,479 prothrombin times measured were below the therapeutic range (n = 232) or prolonged (n = 240), prompting an adjustment in the Coumadin dose in 82 (88%) patients. Four patients developed recurrent vascular graft thrombosis while receiving anticoagulation. There were 6 major and 11 minor hemorrhagic complications. Patients with a chronic risk for arterial or venous thrombosis can have out-patient anticoagulant therapy administered at optimal intensity and regulated safely with a low incidence of hemorrhagic and thrombotic events.