Safeguard Patients on Anticoagulants During Care Transitions

You play a key role in ensuring safe use of anticoagulants during transitions of care.

Admission. Document doses and durations carefully.

Also confirm the indication, such as rivaroxaban 2.5 mg BID for peripheral artery disease... 10 mg daily for VTE prophylaxis...or 20 mg daily to prevent a stroke from atrial fibrillation or to treat a VTE.

Assess adherence and record the date and time of the most recent anticoagulant dose...to avoid extra doses, help interpret INRs, etc.

Check if any DOACs need dose adjustments based on kidney function.

If patients are transferred from another hospital on a heparin drip, continue it in units/hr or units/kg/hr...not mL/hr. Hospital concentrations may vary.

Inpatient transfers. Consider a validated tool, such as IMPROVE, to evaluate if VTE prophylaxis is still needed on transfer to the floor.

Keep your eyes open for duplicate therapy...such as active orders for VTE treatment AND prophylaxis. Don't overlap warfarin and a DOAC...except in the rare case of transitioning a DOAC to warfarin.

Ensure correct use around surgery. For instance, generally restart a DOAC 1 day after minor procedures...or 2 to 3 days after major ones.

Discharge. Help resolve access barriers. For example, DOACs often cost over $450/month...and aren't covered by all insurance plans.

If you don't have a "meds-to-beds" program or discharge pharmacists to help verify coverage, call the outpatient pharmacy to check.

Generally reserve manufacturer drug coupons for short-term DOAC use.

Educate patients...and confirm comprehension. Ensure outpatient follow-up is scheduled, especially for new starts...and give patients the name and contact information for who will manage anticoagulation.

If patients are transferring to another facility, note duration and any dose changes. For instance, document when to step down from apixaban 10 mg BID to 5 mg BID for patients starting VTE treatment.

Also record times of recent doses...and when the next is due.

Get our Safe Use of Anticoagulants toolbox for more best practices at discharge. And review our Transitions of Care Resource Hub and Transitions of Care Checklist for further guidance.

Key References

  • Jt Comm J Qual Patient Saf. 2018 Nov;44(11):630-640
  • Jt Comm J Qual Patient Saf. 2018 Nov;44(11):627-629
  • Medication pricing by Elsevier, accessed Nov 2021
Hospital Pharmacist's Letter. December 2021, No. 371222



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