Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-10T13:28:57.204Z Has data issue: false hasContentIssue false
  • English
  • Français

Comparison of a Frail-Friendly Nomogram with Physician-Adjusted Warfarin Dosage for Prophylaxis after Orthopaedic Surgery on a Geriatric Rehabilitation Unit

Published online by Cambridge University Press:  31 March 2010

Susan Freter  and
Susan K. Bowles
Susan Freter*
Affiliation:
Department of Medicine, Dalhousie University
Susan K. Bowles
Affiliation:
College of Pharmacy, Dalhousie University
*
Requests for offprints should be sent to: / Les demandes de tirés-à-part doivent être addressées à : Dr. Susan Freter, Centre for Health Care of the Elderly, Room CHVMB-1-1308, QEII Health Sciences Centre, 5955 Veterans Memorial Lane, Halifax, NS B3H 2E1. (susan.freter@cdha.nshealth.ca)
Get access Rights & Permissions [Opens in a new window]

Abstract

Warfarin dosing for thromboprophylaxis in post-operative patients is time-consuming. Warfarin-dosing nomograms can be used in post-operative arthroplasty patients, but warfarin requirements are lower in frail older people. We modified an existing post-arthroplasty nomogram to a frail-friendly version and evaluated its performance in a frail elderly post-orthopaedic surgery on a geriatric rehabilitation ward to determine if it would improve quality indicators for oral anticoagulation. On a geriatric rehabilitation unit, post-operative orthopaedic patients were assigned to either physician-adjusted warfarin dosing or the nursing-administered nomogram. The proportion of days within target INR values was significantly higher in the nomogram group (77%, 95% CI 74% to 81%) compared to the physician-adjusted group (53%, 95% CI 46% to 60%), with no major bleeding or thromboembolic complications. The number of warfarin-related telephone calls to physicians was significantly reduced by tenfold. Use of a frail-friendly nomogram improved quality and efficiency of patient care on a geriatric rehabilitation unit.

Résumé

Le dosage de la warfarine pour la thromboprophylaxie chez les patients qui viennent d'être opérés prend beaucoup de temps.

Des nomogrammes permettant de doser la warfarine peuvent être utilisés pour les patients qui ont été subi une arthroplastie, mais les besoins en matière de warfarine sont moins élevés chez les personnes âgées frêles. Nous avons modifié un nomogramme existant utilisé pour la post-arthroplastie pour l'adapter aux personnes frêles, et nous avons évalué sa performance après des opérations orthopédiques sur des personnes âgées frêles dans une unité de réadaptation gériatrique, afin de déterminer si cela améliorerait la qualité des indicateurs pour l'anticoagulothérapie orale. Dans une unité de réadaptation gériatrique, nous avons attribué aux patients ayant subi une opération orthopédique soit un dosage de warfarine ajusté par le médecin, soit un nomogramme administré par les infirmières. La proportion de jours passés dans le cadre des valeurs du RIN était sensiblement plus élevé dans le groupe avec nomogramme (77 %, 95 % IC 74 %-81 %) que dans le groupe ou` le médecin effectuait les ajustements (53 %, 95 % IC 46 %-60 %) sans qu'il n'y ait de complications majeures de type hémorragique ou thromboembolique.

Le nombre d'appels téléphoniques destinés aux médecins au sujet de la warfarine a été divisé par dix. L'utilisation d'un nomogramme adapté aux personnes frêles a permis d'améliorer la qualité et l'efficacité des soins aux patients dans une unité de réadaptation gériatrique.

Keywords

agingpost-operativeanticoagulationwarfarinnomogramfrailgeriatric rehabilitationvieillissementPost-opératoireanticoagulantwarfarinenomogrammepersonnes frêlesréadaptation gériatrique
Type
Research Notes/Notes de recherche
Information
Canadian Journal on Aging / La Revue canadienne du vieillissement , Volume 24 , Issue 4 , Winter/Hiver 2005 , pp. 443 - 447
Copyright
Copyright © Canadian Association on Gerontology 2005

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Lieberman, J.R., & Geerts, W.H. (1994). Prevention of venous thromboembolism after total hip and knee arthroplasty. J Bone Joint Surg Am, 76, 1239–1250.Google Scholar
2.Harris, W.H., & Sledge, C.B. (1990). Total hip and total knee replacement. N Engl J Med, 323, 725–731.Google Scholar
3.Geerts, W.H., Pineo, G.F., Heit, J.A., Bergqvist, D., Lassen, M.R., Colwell, C.W., & Ray, J.G. (2004). Prevention of venous thromboembolism: the Seventh Annual ACCP Conference on Antithrombosis and Thrombolytic Therapy. Chest, 126(Suppl. 3), 338S–400S.Google Scholar
4.Nicolaides, A.N. (2001). Prevention of venous thromboembolism - International Consensus Statement: guidelines compiled in accordance with scientific evidence. Int Angiol, 20, 1–37.CrossRefGoogle ScholarPubMed
5.Kovacs, M.J., Anderson, D.A., & Wells, P.S. (2002). Prospective assessment of a nomogram for the initiation of oral anticoagulation therapy for outpatient treatment of venous thromboembolism. Pathophysiol Haemost Thromb, 32, 131–133.Google Scholar
6.Kovacs, M.J., Cruickshank, M., Wells, P.S., Kim, H., Chin-Yee, I., Morrow, B. et al. (1988). Randomized assessment of a warfarin nomogram for initial oral anticoagulation after venous thromboembolic disease. Homeostasis, 28, 62–69.Google Scholar
7.Kovacs, M.J., Rodger, M., Anderson, D.R., Morrow, B., Kells, G., Kovacs, J. et al. (2003). Comparison of 10-mg and 5-mg warfarin initiation nomograms together with low-molecular weight heparin for outpatient treatment of acute venous thromboembolism. Ann Intern Med, 138, 714–719.CrossRefGoogle ScholarPubMed
8.Poller, L., Shiach, C.R., MacCallum, P.K., Johansen, A.M., Munster, A.M., Magalhaes, A. et al. (1998). Multicentre randomised study of computerised anticoagulant dosage. Lancet, 352, 1505–1509.Google Scholar
9.Burns, N. (2004). Evaluation of warfarin dosing by pharmacists for elderly in-patients. Pharm World Sci, 26, 232–237.Google Scholar
10.Dager, W.E., Branch, J.M., King, J.H., White, R.H., Quan, R.S., Musallam, N.A. et al. (2000). Optimization of in-patient warfarin therapy: impact of daily consultations by a pharmacist-managed anticoagulation service. Ann Pharmacother, 34, 567–572.CrossRefGoogle Scholar
11.Ellis, R.F., Stephens, M.A., & Sharp, G.B. (1992). Evaluation of a pharmacist-managed warfarin monitoring service to coordinate in-patient and out-patient therapy. Am J Hosp Pharm, 49, 387–394.Google Scholar
12.Rivey, M.P., Wood, R.D., Allington, D.R., Stratton, T.P., Eriksson, C.C., & Stenson, T.A. (1995). Pharmacy-managed protocol for warfarin use in orthopedic surgery patients. Am J Health Syst Pharm, 52, 1310–1316.Google Scholar
13.MacDonald, D., Bhalla, P., Cass, W., Gollish, J., Brighton, R., Gorenstein, F. et al. (2002). Computerized management of oral anticoagulant therapy: experience in major joint arthroplasty. Can J Surg, 45, 47–52.Google ScholarPubMed
14.Anderson, D.R., Wilson, S.J., Blundell, J., & Petrie, D. (2002). Comparison of a nomogram and physician-adjusted dosage of warfarin for prophylaxis against deep-vein thrombosis after arthroplasty. J Bone Joint Surg Am, 84, 1992–1997.CrossRefGoogle ScholarPubMed
15.Ageno, W., Johnson, J., Nowaki, B., & Turpie, A.G. (2002). A computerized generated induction system for hospitalized patients starting on oral anticoagulant therapy. Thromb Haemost, 83, 849–852.Google Scholar
16.Hylek, E.M. (2001). Oral anticoagulants: pharmacologic issues for use in the elderly. Clin Geriatr Med, 17, 1–13.CrossRefGoogle ScholarPubMed
17.Roberts, G.W., Helboe, T., Nielsen, CBM, Gallus, A.S., Jensen, I., Cosh, D.G. et al. (2003). Assessment of an age-adjusted warfarin initiation protocol. Ann Pharmacother, 37, 799–803.CrossRefGoogle ScholarPubMed
18.Gedge, J., Orme, S., Hapton, K.K., Channer, K.S., & Hendra, T.J. (2000). A comparison of a low-dose warfarin induction regimen with the modified Fennerty regimen in elderly inpatients. Age Ageing, 29, 31–34.CrossRefGoogle ScholarPubMed
19.Ansell, J., Hirsh, J., Dalen, J., Bussey, H., Anderson, D., Poller, L. et al. (2001). Managing oral anticoagulant therapy. Chest, 119, 22S–38S.CrossRefGoogle ScholarPubMed
20.Messieh, M., Huang, Z., Johnson, L.J., & Jobin, S. (1999). Warfarin responses in total joint and hip fracture patients. J Arthroplasty, 14, 724–729.CrossRefGoogle ScholarPubMed
21.Chatap, G., Chaibi, P., Giraud, K., Sadji, F., & Vincent, J.P. (2001). Oral anticoagulation in older patients: establishment and validation of a new posologic warfarin regimen. Press Med, 17, 475–480.Google Scholar
22.Hirsh, J., Dalen, J., Anderson, D.R., Poller, L., Bussey, H., Ansell, J. et al. (2001). Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest, 119, 8S–21S.CrossRefGoogle ScholarPubMed
23.Lieberman, J.R., Wollaeger, J., Dorey, F., & Thomas, B.J. (1997). The efficacy of prophylaxis with low-dose warfarin for prevention of pulmonary embolism following total hip arthroplasty. J Bone Joint Surg Am, 319–325.Google Scholar