2025 Southeastern Residency Conference

Title: Impact of Daily Pharmacist Anticoagulation Review in a Rural Hospital

Authors: Grace Kenley, Lindsey Arthur

Objective: will be included in presentation

Self Assessment Question: will be included in presentation

Background:  Anticoagulants are used for a variety of indications which leads to their frequent administration in hospitalized patients. Whether utilizing anticoagulants for therapeutic indications or for venous thromboembolism (VTE) prophylaxis, dosing is highly individualized to each patient based on factors such as weight and renal function. As patients’ clinical statuses can fluctuate from admission to discharge, it is imperative to review the appropriateness of each anticoagulation regimen on a daily basis. The consequences of inappropriate anticoagulation regimens can be severe, including adverse events such as bleeding or thrombosis. Due to these risks, anticoagulants are included on the Institute for Safe Medication Practices (ISMP) list of high alert medications. The purpose of this study is to determine the impact of daily pharmacist review of anticoagulants within a newly implemented floor-based pharmacist model in a rural hospital.

Methods: A prospective cohort study will be conducted on patients admitted to the medical and telemetry floors at Self Regional Healthcare during the hours of 7:00 AM to 3:30 PM on weekdays between February 24th, 2025 through March 26th, 2025. Anticoagulation regimens, both treatment and prophylaxis, will be reviewed on each patient for appropriateness in terms of indication and patient specific factors such as renal function and weight. Patients not on any type of anticoagulation will be reviewed to determine if therapy is warranted. Patients will also be educated on the importance of anticoagulation if refusals are documented. The primary outcome is the number of anticoagulation recommendations made to ensure appropriate therapy. Secondary outcomes include number of dosage adjustments, number of frequency adjustments, number of anticoagulant initiations, number of anticoagulant discontinuations, number of bleeding events, number of thrombotic events, and number of patient educations performed. 

Results: Between February 24th, 2025 – March 26th, 2025, 1,046 patients were admitted to medical and telemetry-monitored floors. During this period, 67 anticoagulation recommendations were made. Of the 67 recommendations, 60 were accepted by providers, resulting in a 90% acceptance rate.  The most common rejection was the addition of SCDs for patients refusing chemoprophylaxis (4 of the 7 rejections). Results for secondary outcomes are as follows: 29 dosage adjustments, 6 frequency adjustments, 12 initiations, 3 discontinuations, 14 SCDs added on, 2 bleeding events, 1 thrombotic event, and 3 patient educations performed.  

Conclusion: Ultimately, having a pharmacist located on the floor increased the number of therapeutically appropriate anticoagulation recommendations which may lead to decreased adverse bleeding or thrombotic events.