Download Anticoagulation Management in the Ambulatory Surgical

Anticoagulation Management in the
Ambulatory Surgical Setting
2.7
DIANA HILL EISENSTEIN, MSN, RN, FNP-BC, CNOR
www.aorn.org/CE
ABSTRACT
Many people receiving maintenance anticoagulation therapy require surgery each
year in ambulatory surgery centers. National safety organizations focus attention
toward improving anticoagulation management, and the American College of Chest
Physicians has established guidelines for appropriate anticoagulation management to
balance the risk of thromboembolism when warfarin is discontinued with the risk of
bleeding when anticoagulation therapy is maintained. The guidelines recommend
that patients at high or moderate risk for thromboembolism should be bridged with
subcutaneous low-molecular-weight heparin or IV unfractionated heparin with the
interruption of warfarin, and low-risk patients may require subcutaneous lowmolecular-weight heparin or no bridging with the interruption of warfarin. The
guidelines recommend the continuation of warfarin for patients who are undergoing
minor dermatologic or dental procedures or cataract removal. The literature reveals,
however, that there is not adequate adherence to these recommendations and guidelines. Management of anticoagulation therapy by a nurse practitioner may improve
compliance and safety in ambulatory surgery centers. AORN J 95 (April 2012)
510-521. © AORN, Inc, 2012. doi: 10.1016/j.aorn.2012.01.018
Key words: anticoagulation therapy, thromboembolism risk, warfarin, vitamin K
antagonist.
M
illions of patients receive anticoagulants for the prevention of thromboembolic events.1 Maintenance anticoagulation therapy (ACT) is prescribed for a variety of
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medical diagnoses and conditions, including atrial
fibrillation, history of myocardial infarction, implantation of mechanical heart valves, indwelling
myocardial stents, history of thromboembolism,
and prevention of stroke.1,2
Each year, approximately 250,000 people receiving warfarin for long-term ACT will require
interruption of this therapy for surgical or other
invasive procedures.3 Continuation of ACT during
surgical or invasive procedures predisposes patients to increased bleeding risks because of warfarin’s long half-life (ie, two to three days). The
overall effect of warfarin can last up to five
doi: 10.1016/j.aorn.2012.01.018
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days.4 In addition, withholding this medication bestandardization and recommended the use of infore a procedure or surgery may result in subtheraternational normalized ratio (INR), which is a
2
peutic levels for up to a week. Interrupting anticoformula calculated to correct for differences in
agulation can result
thromboplastin rein the formation of
agents.4 The dependent control variable
thrombosis. This can
One goal of anticoagulation management
in many research
have devastating conduring the phases of perioperative care is
studies is the amount
sequences, such as
appropriate regulation of warfarin. Warfarin
has a narrow therapeutic range, and modest
of time individuals
embolic stroke,
changes in dose can lead to either thrombosis spend within therawhich results in mapeutic INR range.
jor disability or death or hemorrhage.
Warfarin has a narin 70% of patients.5
Health care providers
row therapeutic
must appropriately assess the patient’s ACT when
range, and modest changes in dose can lead to
surgical or other invasive procedures, whether
either thrombosis or hemorrhage.6 Most surgeries
can be performed without risk of serious hemorelective or emergent in nature, are required. The
rhage when the INR is less than 1.5.5
challenge is to balance the patient’s risk of expeOne of the goals of anticoagulation manageriencing a thromboembolism, arterial or venous,
ment during the phases of perioperative care is
when discontinuing a prescribed blood thinner
appropriate regulation of warfarin. All individuals,
with the risk of bleeding if ACT is maintained.
whether they are instructed to continue warfarin
at current or reduced dosages or to discontinue
PHARMACOLOGY
use of warfarin should undergo INR monitoring
Warfarin is the predominant maintenance vitaone to two days before the procedure.3 Medicamin K antagonist and the most widely pretions, particularly ACT, need to be resumed in an
scribed anticoagulant in North America.4 It acts
pharmacologically by inhibiting the enzymes
appropriate time frame.
responsible for the cyclic interconversion of
vitamin K in the liver. This converted or reGUIDELINES FOR ANTITHROMBOTIC
duced form of vitamin K serves as a cofactor in
THERAPY
The American College of Chest Physicians
the production of coagulation protein factors II
(ACCP) has developed evidence-based practice
(ie, prothrombin), VII, IX, and X. Suppressing
guidelines for antithrombotic therapy during the
the production of clotting factors prevents the
perioperative period.3 High-risk patients or painitial formation and propagation of a thromtients undergoing procedures for which there is an
bus. Warfarin has no effect on formed thrombi
4
increased risk of bleeding should be treated with
or previously circulating clotting factors.
Prothrombin time had been used for decades to
bridging therapy of subcutaneous or IV heparin or
monitor warfarin anticoagulation. Prothrombin
subcutaneous low-molecular-weight heparin. The
time measures the amount of time required for
ACCP recommends that health care providers
clot formation when laboratory personnel add calkeep patients on warfarin for minor dental, skin,
cium and thromboplastin to citrated blood. Comor eye procedures.3 When bleeding is a concern,
the ACCP recommends discontinuing warfarin at
mercially prepared thromboplastin reagents proleast five days before an invasive procedure.3,7
duce substantially different results because of
Patients not treated with bridging therapy will
variability in their sensitivity. The World Health
have subtherapeutic ranges in their INR and,
Organization recognized the need for monitoring
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therefore, have an increased risk of thromboembolic events. Health care providers should restart
the patient’s ACT within 12 to 24 hours after the
procedure or as soon as there are no signs of active bleeding.3 Management should be individualized and coordinated among the patient, nonmedical caregiver, primary care provider, surgeon, and
anesthesia professional in a timely and comprehensive manner.1
Anticoagulants are among the medications
most frequently implicated in adverse drug
events, many of which are preventable.8 National
hospital accreditation organizations and patient
safety groups have emphasized the need for
health care providers to develop strategies or
guidelines to reduce the risk and improve the safe
use of anticoagulants.9-11 During 2008, the US
surgeon general issued a nationwide action statement to reduce the number of cases of deep vein
thrombosis and pulmonary embolism in the
United States and urged health care organizations
to incorporate coordinated, multifaceted plans to
address the problem.9 The Joint Commission has
called for the reduction of harm associated with
ACT and recommends that health care providers
use approved protocols and management programs to
individualize care;
 evaluate and improve ACT safety practices;
and
 educate personnel, patients, and patients’ family members.10

The Institute for Safe Medication Practices
(ISMP) indicates that there may be a misunderstanding by the patient because of previous instructions to discontinue a medication before a
surgical or other invasive procedure,11 therefore,
the ISMP emphasizes that health care providers
should communicate clearly in instructing
patients when to discontinue and resume all
medications.
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SIGNIFICANCE FOR AMBULATORY
SURGERY CENTERS
A majority of surgical or other invasive procedures are being performed at ambulatory surgery
centers (ASCs).3 Patients on long-term ACT are
at increased risk of adverse outcomes without
proper ACT management during the phases of
their perioperative care. Even though the ACCP
has established clinical guidelines to support clinicians, it acknowledges that
there are gaps in the literature,
many observational studies are based on small
populations, and
 no standardized bridging anticoagulation protocols are presented.3


The ACCP guidelines recommend that practice
patterns be based on patient characteristics and
the type of procedure being performed.3
As evidence-based practice changes, it is difficult for individual health care providers to stay
abreast of new information. Recognized barriers
to clinicians’ compliance with current antithrombotic practice and guidelines include lack of familiarity with ACT guidelines, lack of awareness
of the significance of consistent ACT practices,
disagreement with ACT guidelines, and resistance
to change.12
Knowledge from research demonstrates that
warfarin can be safely interrupted in low- to
intermediate-risk patients during a short perioperative phase but that prolonged interruption or discontinuation of ACT for perioperative procedures
increases the patient’s risk for thromboembolic
events.7 Garcia et al7 reported a 0.4% incidence
of thromboembolic events when warfarin was
interrupted for five or fewer days; however, the
incidence of thromboembolic events increased to
2.2% when warfarin interruption extended beyond
seven days.
Warfarin is 1.5 times more likely to be
discontinued after an ambulatory procedure and
twice as likely to be discontinued after an overnight hospitalization for elective surgery.13
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PATIENT EDUCATION
Anticoagulation Therapy (ACT)
Overview
Anticoagulation medicine helps prevent blood clots from
forming and helps prevent postoperative complications
caused by clotting, such as heart attack, deep vein thrombosis, or pulmonary embolism. This medicine also may be
given if you are at risk for blood clots (eg, being obese,
immobile, on bed rest). Some medicines used for ACT include warfarin and heparin. Some medicines may be taken
as pills; others must be given as a shot.
How do health care providers know if the ACT is
working?
Depending on your health and the condition being treated,
your doctor will order a blood test called the international
normalized ratio (INR), which measures how long it takes
your blood to clot, to decide the proper medicine and dose.
It is very important to return to the hospital, clinic, or outpatient office as instructed by your doctor for repeated laboratory tests. An INR also will be performed before surgery. Your doctor will advise you whether to stop taking
your medication before surgery and when to resume taking
it after your surgery.
How do I take this medicine?
You should take the ACT medicine in the evening at the
same time every day or as directed by your doctor. Never
skip a dose. If you do miss a dose, you should take it as
soon as possible but never take two doses at the same time.
If you forget to take a dose and don’t remember until the
next day, call your doctor’s office for instructions.
What do I have to do differently if I am on ACT?
 This medicine can cause bleeding problems so you
should
 avoid playing potentially dangerous sports;
 use an electric razor to shave;
 use a soft toothbrush;
 use waxed dental floss gently;
 wear gloves for yard work and when using sharp
tools;
 wear shoes or nonskid slippers in the house;
 trim nails carefully; and
 be careful when using knives and scissors.
 Some foods interfere with ACT, so you must be careful
of what you eat. For instance, foods high in vitamin K
can change your INR range easily. You should avoid
eating large amounts of vitamin K-rich food at a single
meal. These include green, leafy, vegetables, such as
kale, collard greens, spinach, and turnip greens.
 Some medicines interfere with ACT, so never begin tak-
ing a new medicine without first talking to your doctor.
Some of these medicines include antibiotics; pain medicines; nonsteroidal anti-inflammatory drugs, such as ibuprofen; and diabetes medicines that are taken by mouth.
Popular herbs, such as ginseng, ginkgo biloba, garlic,
chamomile, and ginger, all may influence the INR and
increase bleeding time.
 You may be asked to use a medicine log or journal to
help track medicine usage and dosing.
 Never start or stop taking these medicines without first
talking to your doctor.
 Tell all health care providers, including your dentist and
pharmacist, that you are on ACT, so they can plan your
care accordingly.
 Your doctor may tell you to decrease your dose of ACT
or stop oral ACT medicine before surgery. He or she
may start you on a different medicine, such as heparin or
low-molecular-weight heparin. Ask your dentist if you
should take your ACT medicine differently before dental
procedures like removing a tooth. Some surgery, such as
skin surgery or a biopsy of soft tissue, can be done
safely without changing your ACT medicine, but it is
always best to check with your doctor.
 Carry or wear medical identification to let health care
providers know that you take ACT.
 Tell your doctor if you have any side effects from the
medicine; your doctor may change the dose or substitute
another medicine.
What are the signs and symptoms of side effects
of ACT?
Bleeding is the primary adverse effect of taking anticoagulation medicine. The most serious effect is bleeding in the
brain; signs of this include uncoordination, dizziness, new
headache, nausea, or vomiting. Signs of bleeding in the
stomach or intestines include vomitus that looks like coffee
grounds; dark, tarry, or red stools; weakness; dizziness;
thirst; or abdominal pain. Seek medical care if you experience any of these symptoms and even for simple things
like cuts that do not stop bleeding or fail to heal, or unexplained or prolonged bruising.
Resource
Anticoagulation therapy. The Heart Hospital Baylor. http://
www.thehearthospitalbaylor.com/handler.cfm?event⫽practice,
template&se⫽1&cpid⫽20127&ppe⫽Abstract%20%2D%
20Anticoagulant%20Therapy. Accessed October 14, 2011.
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Medication continuity is generally considered to
studies provide evidence that ACT management
be the responsibility of the patient. However, a
services are an effective method of improving
change in medication regimen, such as disconcare.14-16 Results of other research support the
use of nurse-managed ACT care.17-20 Services
tinuation of warfarin five days prior to a proceprovided by a perioperative nurse practitioner
dure, may be confusing to patients. In actuality,
(NP) would be an appropriate solution for the
restarting medications requires participation
13
assessment, management, interruption, and refrom health care providers and the patient. An
increased risk of unintended warfarin discontinsumption of ACT in the ambulatory setting. The
uation after elective procedures may be a result of
NP develops specific pathways from evidencethe health care provider discontinuing the warfarin
based guidelines and collaborates with other
before surgery but failing to instruct the patient to
health professionals. Also, the use of inpatient
restart the medication after surgery. With other medcomputer-based clinical decision support systems
ications, health care providers instruct patients to
has been proven to be advantageous with anticotake their medications the night before or the mornagulation management for surgical procedures.21
ing of the procedure and to continue taking them as
normal after surgery.13
IMPLICATIONS FOR HEALTH CARE
The ISMP contends that health care providers
Health care is interconnected to many other asprescribing initial ACT may transfer the responsipects of life as a natural consequence of the way
bility to resume discontinued medication therapy
in which the care
after an invasive proprovided affects peocedure to patients,
ple, communities,
nurses, pharmacists,
Services provided by a perioperative nurse
and society. The aror primary care phypractitioner would be an appropriate solution
eas that health care
sicians.11 Patients are for the assessment, management, interruption,
affects include, but
placed at high risk
and resumption of anticoagulation therapy in
are not limited to,
the ambulatory setting.
when communication
health policy, organiabout medications is
zation, and financing;
not clear.10,11 This
ethics; professional
translates to the posdevelopment; human diversity; social issues;
sibility of thromboembolism complications occurhealth promotion; and disease prevention.
ring at home during the first two weeks after surgery.3 These thromboembolic events can have
Health Policy, Organization, and Financing
devastating consequences that ultimately could result
Although the ACCP has recommended standards
in the patient’s death. It is essential, therefore, that
for ACT during the phases of perioperative care,
health care providers manage ACT appropriately
the World Health Organization Collaborating Cenduring the phases of perioperative care.
tre for Patient Safety Solutions emphasizes that imAlthough practice guidelines have been estabplementation of standards requires leadership suplished for the use of ACT during surgical and
port, with active physician, nursing, and pharmacist
other invasive procedures, there is limited reinvolvement.22 It is important for health care providsearch on patient outcomes and health care proers at ASCs to follow health policy and have a stanvider efficacy in the ASC.3 Consistent ACT mandardized system to document
agement in ambulatory settings is vital during the
 prescription and nonprescription medications
vulnerable perioperative phase to help prevent
before admission,
bleeding and thromboembolic events. Several
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ANTICOAGULATION MANAGEMENT
the patient’s instructions for the administration
of those medications proceeding the date of
the procedure, and
 an updated list that includes new medications
and those previously prescribed to be resumed
at the time of discharge.

Recommendations include the use of technological
support and electronic medical records to facilitate
medication reconciliation.22 Preoperative clinic visits
improve patient outcomes, specifically in patients
older than 60 years, and reduce procedure cancellations and delays, which translates to cost savings.23
Adverse events relating to ACT are costly, as indicated by the average cost of an inpatient recurrent
venous thromboembolic event (ie, $14,975).24
Ethical Decision Making
Noncompliance with current antithrombotic guidelines is a concern.12 Creating an anticoagulation
pathway in an ASC is an ethical decision to strive
for improved patient outcomes, prevent adverse
events, and eliminate inconsistent and unpredictable patterns of practice associated with anticoagulation.25 Aspects of care addressed by a pathway
would include
immediate initiation of anticoagulation after
surgery,
 postprocedure administration of ACT earlier in
the day,
 improved ACT management or coordination
by an NP rather than by various providers,
 use of a pathway by practitioners other than
NPs for consistency.25

Professional Role Development
Nurse practitioners are successfully moving from
the primary care setting to the perioperative environment. By using evidence-based guidelines, the
NP functions independently or collaboratively
with the surgeon and the anesthesia professional.
In the perioperative environment, the NP might
obtain the patient’s medical and surgical
history,
 perform a physical assessment,

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






perform the nursing and anesthesia
assessments,
provide patient teaching,
order and interpret diagnostic tests,
eliminate unnecessary tests,
act as a resource person for perioperative personnel and patients before and after surgery,
prescribe necessary medications related to
ACT, and
perform medication reconciliation.26,27
The role of the NP is well-suited to manage these
and other responsibilities in the ASC (Table 1).
By evaluating and assessing the patient, the NP
can identify individuals who need thromboembolism prophylaxis, which is often missed.27 Highrisk patients may need a referral to an inpatient
surgical setting rather than having the surgery
performed in an ASC.
Human Diversity and Social Issues
Health care providers need to adjust care to
meet the needs of the ever-changing patient population. Annual use of warfarin for preventative measures has increased 20% because of the expanding
population of older adults.19 Health care providers
should direct special attention toward the heterogeneity of culture, language, health beliefs, and risk
for disease among US geriatric patients, many of
whom have been prescribed ACT and require outpatient procedures.28 Approximately one-third of all
Americans will be classified as a minority or an
older adult in the near future.29 Previous research
suggests that African Americans and Spanishspeaking Hispanics achieve a therapeutic range of
INR less often than adults in other populations.30
Low literacy levels present yet another barrier to
health promotion. Written patient materials are
meant to provide information and promote health.
Research conducted to assess readability and to
assess the cultural sensitivity of written anticoagulation educational material in an African American
population found that, as age increased, reading
skills decreased and the mean reading level
was three to four grades below the reported
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TABLE 1. Nursing Care Plan for a Perioperative Patient on Anticoagulation Therapy
Diagnosis
Risk for injury
Nursing interventions













Ineffective family
therapeutic
regimen
management







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Interim outcome
statement
Confirms patient identity.
Verifies allergies.
Verifies operative procedure, surgical site, and
laterality.
Establishes IV access.
Reviews medication reconciliation sheet for current
medications, medication allergy interactions,
contraindications, medication-medication or herbalmedication interactions.
Verifies medication label.
Performs patient identification by using at least two
identifiers.
Ensures the seven rights of medication administration
are followed: right patient, right medication, right
dose, right route, right time, right reason, and right
documentation.
Administers correct dose by
 validating order as prescribed;
 obtaining accurate patient weight before surgery
by using a facility-approved conversion chart to
convert pounds to kilograms; and
 calculating weight-based dose accurately and
verifying the calculation with two licensed
individuals.
Assesses the patient’s preoperative hydration status
as appropriate (eg, weight, height, skin turgor, pulses,
hematocrit, blood urea nitrogen, albumin, serum
electrolytes, total protein, serum osmolality, specific
gravity levels).
Prioritizes nursing actions, such as correcting
hypovolemia, hypervolemia, and blood glucose levels.
Provides equipment and supplies based on patient’s
needs.
Evaluates response to medications.

Assesses psychosocial issues specific to the patient’s
medication management.
Identifies barriers to communication.
Determines knowledge level.
Includes patient or designated support persons in
perioperative teaching.
Provides instruction about prescribed medications.
Verifies patient’s and designated support person’s
ability to understand information.
Provides necessary time to process information.


Outcome
statement
The patient receives
correct medication(s)
in accurate doses, at
the correct time, and
via the correct route
throughout the
surgical experience.
Medication reconciliation records are
completed.

The patient receives
appropriately
administered
medication(s).
The patient or
designated support
person can state
the correct dose,
frequency of
administration, and
purpose of each
prescribed medication at time of
discharge.

The patient or
designated support
person
demonstrates
knowledge of
medication
management.
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TABLE 1. (continued)
Diagnosis
Interim outcome
statement
Nursing interventions













Obtains an interpreter if needed.
Provides alternatives to interpreter when appropriate
(written material, video, tape recording in primary
language).
Provides patient and designated support person with
written discharge and at-home instructions.
Reinforces information provided by other members of
the health care team.
Observes and evaluates return demonstrations of
perioperative instruction.
Clarifies information.
Encourages patient and designated support person
to describe in their own words their understanding of
instructions.
Encourages patient and designated support person
to communicate feelings regarding surgery and
expected outcomes.
Provides patient and designated support person time
to ask questions.
Communicates discharge instructions verbally and in
writing.
Encourages designated support person’s
participation in the instructional process.
Evaluates patient’s and designated support person’s
responses to perioperative instruction.
Evaluates response to instruction about prescribed
medications.
educational reading level.31 Additionally, when
developing ACT management services, health
care providers should take into account the Culturally and Linguistically Appropriate Services
standards developed by the US Health and Human Services Office of Minority Health.32
Health Promotion and Disease Prevention
One of the goals established by The Joint Commission is to reduce patient harm associated with
the use of anticoagulation medications.10 Implementation of case management and evidencebased guidelines pertaining to anticoagulation regulation during the phases of perioperative care
will promote health and reduce the risk of adverse
drug events.6 Focused perioperative management

Outcome
statement
The patient or
designated support
person describes
medication adverse
effects to report at
time of discharge.
by NPs with the use of current established guidelines and practices will provide the opportunity to
educate and reinforce patient knowledge on medication dosage, food and medication interactions,
preadmission and discharge instructions, risks of
thromboembolism, and bleeding complications.
Furthermore, establishing a rapport with patients
improves education and compliance.6
THEORETICAL FOUNDATIONS FOR
NURSING PRACTICE
Jean Watson’s theory of transpersonal caring,
which focuses on the moment-to-moment encounters of the person who is providing care and the
person who is being cared for, is an ideal theory
to apply to the management of ACT in an
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I. Initial Data
_____ 1.What is the patient’s name and hospital record number: ___________________________________
_____ 2.In what age range (in years) does the patient’s age fit?
A = 18 – 30
B = 31 – 40
C = 41 – 50
D = 51 – 60
E = 61 – 70
F = 70+
_____ 3.What is the patient’s gender?
A = Male
B = Female
_____ 4.What is the patient’s race?
A = Asian
B = Black
C = Hispanic
D = White
E = Other
_____ 5.What is the patient’s highest level of education?
A = High school diploma
B = 1 to 4 years post high school education
C = 5+ years post high school education
D = Other: _______________________________________________________________________
_____ 6.What is the patient’s preoperative diagnosis?
A = History of atrial fibrillation
B = History of deep vein thrombosis
C = Presence of a mechanical heart valve
D = Presence of myocardial stent
E = Other: _______________________________________________________________________
_____ 7.What is the planned invasive procedure to be performed? _________________________________
_____ 8.What is the date of the proposed invasive procedure? _____________________________________
_____ 9.What is the patient’s current warfarin dose? ____________________________________________
____10. What is the patient’s desired international ratio (INR) target range?
A = 1.5 to 2.5
B = 2.6 to 3.5
C = Other _______________
____11. Who was the initial ACT prescriber?
A = Advanced practice nurse
B = Anesthesia professional
C = Primary care provider
D = Surgeon
E = Other
____12. Who was the prescriber at the time of the surgical procedure?
A = Advanced practice nurse
B = Anesthesia professional
C = Primary care provider
D = Surgeon
E = Other
____13. What comorbidities did the patient present with? ________________________________________
II.
24 Hour Interview
Date of Interview__/__/____
A.
Adverse events
____14. Did the patient experience a thromboembolism?
A = No B = Yes
Time__/__/____
____15. Did the patient have any bleeding problems?
A = No B = Yes
____16. Did the patient experience any other problems?
A = No B = Yes
Specify _________________________________________________________________________
____17. Was the patient’s ACT restarted within 24 hours of procedure?
A = No B = Yes
____18. If no, did the interviewer instruct the patient to contact his or her primary care provider for ACT
management?
A = No B = Yes
Figure 1. Ambulatory Surgical/Invasive Procedure Anticoagulation Therapy Data Collection Form.
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B. Patient instructions
____18. Did the patient received instructions to restart ACT after the invasive procedure?
A = No B = Yes
____19. If yes, what time was the patient instructed to resume ACT?
A = In the evening on the day of the procedure
B = In the morning after the procedure
C = In the evening on the day after procedure
D = Other
____20. If yes, what time did the patient actually restart his or her ACT?
A = In the evening on the day of the procedure
B = In the morning after the procedure
C = In the evening on the day after procedure
D = Other
____21. Who gave the patient instructions to restart ACT?
A = Advanced practice nurse
B = Anesthesia professional
C = Primary care provider/prescriber
D = Surgeon
E = Other
III.
Week 2 Interview
Date of Interview__/__/____
A.
Adverse events
____22. Did the patient experience a thromboembolism?
A = No B = Yes
Time__/__/____
____23. Did the patient have any bleeding problems?
A = No B = Yes
____24. Did the patient experience any other problems?
A = No B = Yes
Specify _________________________________________________________________________
____25. Did the patient contact the ACT prescriber after the invasive procedure for any reason pertaining to ACT?
A = No B = Yes
____26. Is the patient currently taking ACT
A = No B = Yes
____27. If no, why not? ___________________________________________________________________
____28. Was an INR obtained since the last interview?
A = No B = Yes
IV.
Week 4 Interview
Date of Interview__/__/____
A.
Adverse events
____29. Did the patient experience a thromboembolism?
A = No B = Yes
Time__/__/____
____30. Did the patient have any bleeding problems?
A = No B = Yes
____31. Did the patient experience any other problems?
A = No B = Yes
Specify _________________________________________________________________________
____32. Did the patient contact the ACT prescriber contacted after invasive procedure for any reason
pertaining to ACT?
A = No B = Yes
____33. If yes, why? ___________________________________________________________________
____34. Is the patient currently taking ACT?
A = No B = Yes
____35. If no, why not? _________________________________________________________________
____36. Was an INR obtained since the last interview?
A = No B = Yes
Figure 1. Continued
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ambulatory setting.33,34 This theory expounds on
the act of caring with the concept of intentional
caring that produces a positive energy, resulting
in health and healing in the present and future.
Caring through the acts of listening, expressing
emotion, educating, and performing procedures
and treatments is a component of an ethically
aware practice that produces positive outcomes. A
consciousness of this theory has safety and economic advantages as well as system success. This
theory is explicitly suited for perioperative ACT
management by NPs because outpatient surgeries
and procedures predispose individuals and their
family members to increased levels of stress. The
NP provides management, treatment, counseling,
and education in a sensitive and caring manner to
promote health and prevent illness.
FUTURE RESEARCH
Research is needed to assess methods of interrupting and reestablishing use of anticoagulants in an
ASC to evaluate outcomes and adverse effects
and to determine compliance with existing ACT
guidelines. Anticoagulation services other than
primary care providers have shown statistically
significant improvements in patient outcomes.14-18
The role of the NP is expanding from primary
care to specialty areas. Research supports using
NPs to manage ACT and other services during
the phases of perioperative care. Therefore, it is
recommended that research be initiated to evaluate outcomes associated with NP-led ACT management in an ASC. A research tool that could be
used to collect data is shown in Figure 1. Health
care personnel would collect initial data beginning
24 hours before the patient’s surgery or procedure. The personnel would then collect ongoing
data in person or with the use of telephone interviews about outcomes pertaining to adverse
events, quality of care issues, compliance with
guidelines, comparison of providers, and differences in population groups at two weeks and four
weeks after surgery. A quantitative, prospective,
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cohort study would help clarify the effects of
ACT management provided by NPs.
CONCLUSION
National safety goals have drawn attention to anticoagulation standards and the needs associated with
them. Current research suggests that long-term ACT
does not need to be interrupted during minor procedures for dentistry, dermatology, and ophthalmology. Analysis of evidence also suggests that interrupting long-term ACT for minor surgery or other
invasive procedures is a recommended and acceptable practice when there is a significant risk of
bleeding. Prolonged discontinuation of ACT, however, may predispose individuals to unnecessary
risks of thromboembolism. Potential advantages of
anticoagulation management in the ASC by an NP
include





improved communication among health care
providers and patients,
increased awareness of the need for ACT
education,
improved health care provider and patient
compliance with perioperative ACT
guidelines,
an enhanced patient perioperative experience,
and
overall cost savings related to adverse events
and complications.
Perioperative ACT management by NPs appears
to be a practical and beneficial next step in reducing risks and complications of ACT when patients
are undergoing surgery.
References
1.
2.
3.
4.
Garcia DA, Witt DM, Hylek E, et al. Delivery of optimized anticoagulant therapy: consensus statement from
the Anticoagulation Forum. Ann Pharmacother. 2008;
42(7):979-988.
Gaines KK. Management of anticoagulation therapy for
invasive procedures. Urol Nurs. 2005;25(5):379-380.
Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American
College of Chest Physicians Evidence-Based Clinical
Practice Guidelines (8th edition). Chest. 2008;133(6
suppl):299S-339S.
Dipro JT, Talbert RL, Yee GC, Matzke GR, Wills BG,
Posey LM. Venous thromboembolism. In: Weitz M,
ANTICOAGULATION MANAGEMENT
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Davis K, eds. Pharmacotherapy: A Pathophysiologic
Approach. New York, NY: McGraw-Hill Companies,
Inc; 2008:347-352.
Kaplan BC, Trischwell DL, Longstreth WT Jr, et al. Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly. Neurology. 2005;65(6):835-842.
Venkatachalam V, D’Atillio K, Lewis A, Acevedo M. Anticoagulation in ambulatory care: an evidence-based review of
the literature. Prof Case Manag. 2007;12(2):106-111.
Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin
therapy. Arch Intern Med. 2008;168(1):63-69.
Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the
ambulatory setting. JAMA. 2003;289(9):1107-1116.
The Surgeon General’s Call to Action to Prevent Deep
Vein Thrombosis and Pulmonary Embolism. 2008. US
Department of Health and Human Services. http://www
.surgeongeneral.gov/new/pressreleases/pr20080915
.html. Accessed October 24, 2011.
Ambulatory Health Care. 2011 National Patient Safety
Goals. The Joint Commission. http://www.jointcommission
.org/ahc_2011_npsgs. Accessed October 24, 2011.
Orders to “continue previous meds” continue a long
standing problem. The Institute for Safe Medication
Practices. November 1, 2000. http://www.ismp.org/
Newsletters/acutecare/articles/20001101.asp. Accessed
October 24, 2011.
Caprini JA, Hyers TM. Compliance with antithrombotic
guidelines. Manag Care. 2006;15(9):49-66.
Bell CM, Bajcar J, Bierman AS, Li P, Mamdani MM,
Urbach DR. Potentially unintended discontinuation of
long-term medication use after elective surgical procedures. Arch Intern Med. 2006;166(22):2525-2531.
Chiquette E, Amato MG, Bussey HI. Comparison of an
anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, health care costs.
Arch Intern Med. 1998;158(15):1641-1647.
Witt DM, Sadler MA, Shanahan RL, Mazzoli G,
Tillman DJ. Effect of a centralized clinical pharmacy
anticoagulation service on the outcomes of anticoagulation therapy. Chest. 2005;127(5):1515-1522.
Biscup-Horn PJ, Streiff MB, Ulbrich TR, Nesbit TW,
Shermock KM. Impact of an inpatient anticoagulation
management service on clinical outcomes. Ann Pharmocother. 2008;42(6):777-782.
Shimabukuro TT, Kramer J, McGuire M. Development
and implementation of nurse-managed anticoagulation
program. J Healthc Qual. 2004;26(1):4-12.
Connor CA, Wright CC, Fegan CD. The safety and
effectiveness of a nurse-led anticoagulant service. J Adv
Nurs. 2002;38(4):407-415.
Hennessy BJ, Vyas M, Duncan B, Allard SA. Evaluation of an alternative model of anticoagulant care. Ir
J Med Sci. 2000;169(1):34-36.
Taylor FC, Gray A, Cohen H, Gaminara L, Ransay M,
Miller D. Costs and effectiveness of a nurse specialist anticoagulant service. J Clin Pathol. 1997;50(10):823-828.
Durieux P, Nizard R, Ravaud P, Mounier N, Lepage E.
A clinical decision support system for prevention of
venous thromboembolism: effect on physician behavior.
JAMA. 2000;283(21):2816-2821.
www.aornjournal.org
22.
WHO Collaborating Center for Patient Safety Solutions.
Assuring medication accuracy at transitions of care.
Patient Safety Solutions. 2007;1(6). http://www
.ccforpatientsafety.org/common/pdfs/fpdf/presskit/
PS-Solution6.pdf. Accessed October 24, 2011.
23. Ferschi MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations
and delays. Anesthesiology. 2005;103(4):855-859.
24. Bullano M, Willey V, Hauch O, Wygant G, Spyropoulos AC, Hoffman L. Longitudinal evaluation of health
plan cost per venous thromboembolism or bleed event
in patients with a prior venous thromboembolism event
during hospitalization. J Manag Care Pharm. 2005;
11(8):663-673.
25. Delmora BA, Hansen D, Money KA, Paplanus LM,
Sutton PR. An anticoagulation pathway for quality
management. Appl Nurs Res. 2000;13(2):105-110.
26. Barnett JS. An emerging role for nurse practitioners—
preoperative assessment. AORN J. 2005;82(5):825-834.
27. Kidik PJ, Holbrook KF. The nurse practitioner role in
evidence-based medication strategies. J Perianesth
Nurs. 2008;23(2):87-93.
28. Yeo G. How will the US healthcare system meet the
challenge of the ethnogeriatric imperative? J Am Geriatr Soc. 2009;57(7):1278-1285.
29. 2008 Older Americans: key indicators of well-being.
AgingStats.gov. Federal Interagency Forum on Aging Related Statistics. http://www.agingstats.gov/agingstatsdotnet/
Main_Site/Data/Data_2008.aspx. Accessed October 24, 2011.
30. Bhandari VK, Wang F, Bindman AB, Schillinger D.
Quality of anticoagulation control: do race and language matter? J Health Care Poor Underserved. 2008;
19(1):41-55.
31. Wilson F, Racine E, Tekieli V, Williams B. Literacy,
readability and cultural barriers: critical factors to consider when educating older African Americans about
anticoagulation therapy. J Clin Nurs. 2003;12:275-282.
32. National Standards on Culturally and Linguistically Appropriate Services (CLAS). US Department of Health &
Human Services, The Office of Minority Health.
http://minorityhealth.hhs.gov/templates/browse.aspx?
lvl⫽2&lvlid⫽15. Accessed October 24, 2011.
33. Watson J. Intentionality and caring-healing consciousness: a practice of transpersonal nursing. Holist Nurs
Pract. 2002;16(4):12-19.
34. Watson J. Caring theory as an ethical guide to administrative and clinical practices. JONAS Healthc Law
Ethics Regul. 2006;8(3):87-93.
Diana Hill Eisenstein, MSN, RN, FNP-BC,
CNOR, is a nurse practitioner at Cooper University Hospital, Camden, NJ, and a perioperative
staff nurse at Virtua-West Jersey Health System,
Berlin, NJ. Ms Eisenstein has no declared affiliation that could be perceived as posing a potential
conflict of interest in the publication of this
article.
AORN Journal
521
EXAMINATION
CONTINUING EDUCATION PROGRAM
2.7
Anticoagulation Management in the
Ambulatory Surgical Setting
www.aorn.org/CE
PURPOSE/GOAL
To educate perioperative nurses about managing anticoagulation therapy (ACT)
during the ambulatory perioperative period.
OBJECTIVES
1.
2.
3.
4.
Identify conditions for which ACT is appropriate.
Discuss the perioperative management of ACT.
Identify barriers to clinicians’ compliance with ACT.
Discuss advantages of appropriate management of ACT.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Maintenance ACT may be prescribed for
1. atrial fibrillation.
2. history of myocardial infarction.
3. implantation of mechanical heart valves.
4. indwelling myocardial stents.
5. history of thromboembolism.
6. prevention of stroke.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
2. When a patient on ACT requires a surgical or
other invasive procedure, the challenge is to
balance the patient’s risk of having a thromboembolism when discontinuing a prescribed
blood thinner with the risk of bleeding if ACT
is maintained.
a. true
b. false
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3. The predominant maintenance vitamin K antagonist used for the prevention of thrombosis in
North America is
a. streptokinase.
b. warfarin.
c. enoxaparin.
d. heparin.
4. Most surgeries can be performed without risk of
serious hemorrhage when the international normalized ratio is
a. less than 1.5.
b. 1.5 to 1.9.
c. 2.0 to 2.4.
d. greater than 2.5.
5. High-risk patients or patients undergoing procedures for which there is an increased risk of
bleeding should be
1. treated with bridging therapy of subcutaneous
or IV heparin.
2. continued on warfarin but in lower doses.
© AORN, Inc, 2012
CE EXAMINATION
3. transitioned to streptokinase.
4. treated with bridging therapy of subcutaneous
low-molecular-weight heparin.
a. 2
b. 3
c. 1 and 4
d. 2 and 3
6. Health care providers should restart the patient’s
ACT
1. as soon as the patient is discharged.
2. as soon as there are no signs of active
bleeding.
3. within 24 to 48 hours after the procedure.
4. within 12 to 24 hours after the procedure.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 3
d. 1, 2, and 4
7. Recognized barriers to clinicians’ compliance
with current antithrombotic practice and guidelines include
1. confusion because of contradictory ACT
guidelines published by regulatory agencies.
2. disagreement with established ACT guidelines.
3. lack of awareness of the significance of consistent ACT practices.
4. lack of familiarity with ACT guidelines.
5. resistance to change.
a. 1 and 3
b. 2, 4, and 5
c. 2, 3, 4, and 5
d. 1, 2, 3, 4, and 5
8. Methods for providing consistent ACT management in ambulatory settings include
1. ACT management services.
www.aornjournal.org
2. nurse-managed ACT care.
3. services provided by a perioperative nurse
practitioner.
4. use of inpatient computer-based clinical decision support systems.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
9. When using evidence-based guidelines and practices, the nurse practitioner caring for the patient
on ACT in the perioperative setting might
1. obtain the patient’s medical and surgical
history.
2. perform a physical assessment.
3. schedule procedures and ACT management by
using a strictly cost-effective approach.
4. provide patient teaching.
5. order and interpret diagnostic tests.
6. prescribe necessary medications.
a. 1, 3, and 5
b. 2, 4, and 6
c. 1, 2, 4, 5, and 6
d. 1, 2, 3, 4, 5, and 6
10. Potential advantages of appropriate management
of ACT during the perioperative phase are
1. improved communication among health care
providers and patients.
2. improved health care provider and patient
compliance with perioperative ACT guidelines.
3. an enhanced patient perioperative experience.
4. overall cost savings related to adverse events
and complications.
a. 2 and 3
b. 1 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
The behavioral objectives and examination for this program were prepared by Rebecca Holm, MSN, RN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
AORN Journal
523
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
2.7
Anticoagulation Management in the
Ambulatory Surgical Setting
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Identify conditions for which anticoagulation therapy (ACT) is appropriate.
Low 1. 2. 3. 4. 5. High
2. Discuss the perioperative management of ACT.
Low 1. 2. 3. 4. 5. High
3. Identify barriers to clinicians’ compliance with
ACT. Low 1. 2. 3. 4. 5. High
4. Discuss advantages of appropriate management of
ACT. Low 1. 2. 3. 4. 5. High
CONTENT
5. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
6. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
7. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
8. Will you change your practice as a result of reading this article? (If yes, answer question #8A. If
no, answer question #8B.)
www.aorn.org/CE
8A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regarding why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: ____________________________
8B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to
my practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make a
change.
4. Other: __________________________
9. Our accrediting body requires that we verify the
time you needed to complete the 2.7 continuing
education contact hour (162-minute) program:
_________________________________
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center
approves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this
activity for relicensure.
Event: #12512; Session: #0001; Fee: Members $13.50, Nonmembers $27
The deadline for this program is April 30, 2015.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each
applicant who successfully completes this program can immediately print a certificate of completion.
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© AORN, Inc, 2012