Managing Warfarin Dosing In the Post-Acute Facility

by Flora Bessey, Pharm.D., BCGP

Those of us who have been in long-term care for a while have noticed the trend toward ever-higher levels of acuity being “pushed down” towards our facilities. Conditions that were nearly always the purview of acute care hospitals are now being routinely managed within our buildings, especially those with post-acute units. Complex medical conditions necessitate complex medication regimes, and often warfarin is a part of the equation.

Warfarin (in various forms) has been the go-to anticoagulant for over fifty years. It is highly effective, and very inexpensive. However, it is vitally important to draw regular labs and monitor the INR for each patient. Then, the dose must be adjusted based upon the “window” that the patient should maintain, based upon other diagnoses and other medications. In the acute care setting, the in-house hospital pharmacist reads the labs and adjusts the dosing for each patient. Physicians who practice within the hospital setting have grown used to this arrangement. For these and many other reasons, there has been a relatively slow uptake in use of the newer anticoagulants that do not require routine labs. It should also be noted that the newer medicines are not appropriate for mechanical heart-valve patients.

Therefore, we will continue to see warfarin patients within our post-acute facilities, especially those with a close relationship or even partnership with a neighboring hospital. How will we manage those patients? Or, more to the point, who will manage their warfarin regime? Already over-burdened hospitalists and medical directors? At one time, long-term care pharmacy providers offered this service; lately, few do. (Of interest, most long-term care pharmacy providers do offer dosing recommendations for many other drugs, including vancomycin and aminoglycosides). It is probable that they have opted out of warfarin recommendation because of the high incidence of adverse events and liability concerns.

This is another place where a consultant pharmacist can be of great value to a facility who accepts these types of residents. There are a few steps that need to be followed for the consultant pharmacist before taking on this responsibility.

First, it is important that the contract with the facility be updated to reflect this duty. Most standard CP contracts do not address this. Next, the pharmacist should make sure that professional liability insurance is updated to cover this. Finally, take copious notes or keep a journal on these residents: any admissions on warfarin; what recommendations are made around dosing; when the next lab is due to be drawn; etc.

Since much of our communications with our facilities is now via text message, make sure you are using a HIPAA-compliant text message medium. Also, back up ALL communications with the facility; there are applications that will do auto-backup to the “cloud.”

We will continue to see a rising level of acuity in our facilities, so it is incumbent upon us to search out ways to ensure the safety and care of these residents, as well as helping our buildings to maintain CMS compliance.


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