Pharmacy Department, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore.
J Clin Pharm Ther. 2011 Oct;36(5):585-91. doi: 10.1111/j.1365-2710.2010.01216.x. Epub 2010 Nov 12.
Anticoagulation consultations provided by a pharmacist-staffed inpatient service, similar to the experience reported in outpatient anticoagulation clinics, can potentially improve anticoagulation control and outcomes. At Tan Tock Seng Hospital, a 1200-bed acute care teaching hospital in Singapore, pharmacist-managed anticoagulation clinics have been in place since 1997. Pharmacist-managed services were extended to inpatient consultations in anticoagulation management from April 2006. Our objective was to assess the effect of implementing a pharmacist-managed inpatient anticoagulation service.
This was a single-centre cohort study. Baseline data from 1 January 2006 to 31 March 2006 were collected and compared with post-implementation data from 1 April 2006 to 31 March 2007. Patients newly started on warfarin for deep vein thrombosis, pulmonary embolism or atrial fibrillation in general medicine and surgery departments were included. The three endpoints were as follows: (i) percentage of international normalized ratios (INRs) achieving therapeutic range within 5 days, (ii) INRs more than 4 during titration and (iii) subtherapeutic INRs on discharge.
A total of 26 patients in the control period were compared with 144 patients who had received dosing consultations by a pharmacist during the initiation of warfarin. The provision of pharmacist consult resulted in 88% compared to 38% (P < 0·001) of INR values achieving therapeutic range within 5 days. There was a reduction in INR values of more than 4 during titration from 27% to 2% (P < 0·001), and subtherapeutic INR values on discharge without low molecular weight heparin from 15% to 0% (P < 0·001). The mean time to therapeutic INR was reduced from 6·5 to 3·9 days (P < 0·001) and mean length of stay after initiation of warfarin from 11 to 7·7 days (P = 0·004).
Inpatient anticoagulation care and outcomes were significantly improved by a pharmacist-managed anticoagulation service. The time to therapeutic INR was achieved appropriately and efficiently without compromising patient's safety.
类似于门诊抗凝门诊所报告的经验，由药剂师提供的住院服务的抗凝咨询可以潜在地改善抗凝控制和结果。在新加坡的 1200 张病床的急性护理教学医院 Tan Tock Seng 医院，自 1997 年以来一直设有药剂师管理的抗凝诊所。自 2006 年 4 月以来，药剂师管理的服务已扩展到住院患者的抗凝管理咨询中。我们的目的是评估实施药剂师管理的住院患者抗凝服务的效果。
这是一项单中心队列研究。从 2006 年 1 月 1 日至 3 月 31 日收集基线数据，并将其与 2006 年 4 月 1 日至 2007 年 3 月 31 日实施后的数据进行比较。包括在普通医学和外科部门开始使用华法林治疗深静脉血栓形成，肺栓塞或心房颤动的患者。三个终点如下：（i）在 5 天内达到治疗范围的 INR 百分比，（ii）在滴定过程中 INR 超过 4，（iii）出院时 INR 低于治疗范围。
在对照期内比较了 26 名患者，他们在开始使用华法林时接受了药剂师的剂量咨询。与接受药剂师咨询的患者相比，88％的 INR 值在 5 天内达到治疗范围，而 38％（P <0·001）的 INR 值达到治疗范围。在滴定过程中，INR 值超过 4 的比例从 27％降至 2％（P <0·001），而没有低分子肝素的出院时低于治疗范围的 INR 值从 15％降至 0％（P <0·001）。达到治疗性 INR 的平均时间从 6.5 天缩短至 3.9 天（P <0·001），华法林开始后平均住院时间从 11 天缩短至 7.7 天（P = 0·004）。
通过药剂师管理的抗凝服务，住院患者的抗凝治疗和结果得到了显著改善。达到治疗性 INR 的时间恰到好处，并且不会影响患者的安全性。
