October 2004

Anticoagulant Solution Team Publishes Guideline and Supporting Toolkit


After a thorough study of sentinel and adverse events related to the use of anticoagulants in hospitals, Catholic Health Initiatives has developed a guideline related to the care of inpatients on heparin and warfarin. An anticoagulant is defined as a medication or substance that inhibits blood clot formation.

The guideline was developed by the Anticoagulant Solution Team (ACST), comprised of staff members from market-based organizations and supported by national staff. "This guideline has the potential to improve quality, prevent injury and save lives throughout the system," said Milt Hammerly, MD, director of integrative medicine and medical operations for Catholic Health Initiatives.

The guideline includes six critical processes for management of inpatients receiving heparin and/or warfarin:

1. Selection and Procurement
2. Storage and Availability
3. Ordering and Transcribing
4. Preparing and Dispensing
5. Administration
6. Monitoring

The ACST identified the processes and action steps that market-based organizations can take to achieve specified goals in each process.

To support implementation of the guideline, the ACST also developed a toolkit that includes supporting materials and a data tracking tool. The guideline and toolkit materials were reviewed, refined and approved through a pilot program at eight market-based organizations.

Market-based organizations are responsible for assessing their processes against the anticoagulant guideline. Market-based organizations that identify gaps can then plan and implement processes to meet the intent of the guideline. The ACST developed a list of measures to help market-based organizations evaluate the effectiveness of the guideline; Catholic Health Initiatives will also measure its effectiveness across the system.

For more information, contact Nancy Lima, director of clinical performance improvement at Catholic Health Initiatives, at nancylima@catholichealth. net.