(Management Case Study) Implementation of a Pharmacy Managed Interprofessional Antithrombotic Stewardship Program at a Rural Academic Medical Center

Purpose: In 2018, our institution ranked in the lowest 2.5^th percentile for performance in the Vizient quality metric for percentage of hospital-acquired (HA) INRs greater than 5. In the same year, patients with HA-venous thromboembolic (VTE) events experienced an average increased length of stay of 7.84 days compared to patients without HA-VTE in the same DRG. To address quality concerns and ensure regulatory compliance, the Pharmacy Department led the development of novel resources to support these initiatives. This case describes the implementation of an antithrombotic stewardship program (ASP) to address the complex management of antithrombotic therapy.

Methods: The Pharmacy Department formed a steering committee to determine the program goals and resources necessary to meet the antithrombotic needs of the institution. Members of this committee included the director of pharmacy, cardiology physician leaders, and clinical anticoagulation specialists. The steering committee calculated the preliminary FTE requests, physical space requirements, and capital budget needs to support the program. It was determined that the interprofessional team members needed for a successful program should include representatives from the department of pharmacy, department of nursing, and the division of cardiology physicians. After consulting with external health systems and referencing published literature, the steering team carefully considered the daily workflow of the ASP team members which included daily patient review, high-level practice management and quality improvement, transitions of care, and patient education. The proposed training plan for these FTEs included collaboration with the following stakeholders: inpatient clinical pharmacists, the institution’s outpatient pharmacy, ambulatory anticoagulation specialists, care managers, inpatient and outpatient nurses, patient financial services, and inpatient cardiologists. With the program goals and resource needs in mind, the steering team presented a business plan to the hospital finance department for the 2021 calendar year budget cycle. This was offset by cost-savings opportunities from reducing HA-INRs greater than 5 and HA-VTE events at our institution.

Results: The business plan and FTE requests were approved for the 2021 budget. Two clinical specialist pharmacist FTEs and 1 clinical pharmacy technician FTE were approved under the Pharmacy Department cost center. A nurse specialist FTE was approved under the Nursing cost center. The Pharmacy Department financially offset 0.2 physician FTE, designated as the ASP Medical Director. The team was fully hired and implemented in October 2021, overseen by the Pharmacy Manager of Ambulatory Care and Transitions of Care. Dedicated office space for the pharmacists and technician was provided; nurses worked remotely. Education regarding the program and its work was provided to key internal and external stakeholders, including the Quality Department, physician groups, and pharmacists. The ASP team performed a needs assessment to prioritize work on program goals and outcome measures and developed daily workflow and larger-scale initiatives to support performance improvement in these domains. HA-VTE and HA-INR metrics are reported monthly with an interprofessional quality committee to monitor progress. The ASP team members have cared for over 250 patients since the program’s establishment. A full assessment of program impact on quality metrics and regulatory compliance, as well as a gap analysis for future opportunities, is planned in early 2023.

Conclusion: The Pharmacy Department led the successful justification and implementation of an interprofessional ASP at a rural academic medical center to address the complex management of antithrombotic therapy.