Ambulatory Oncology Care Anticoagulation Safety

Background: Peri-procedural anticoagulation management for ambulatory clinic patients can present a challenge for safe care coordination. Variance has been identified in clinical practice amongst the surgical oncology teams. Developing institutional standards for a large outpatient surgical oncology program has high priority for peri-procedural anticoagulation management. The primary objective in pre-operative regimens is identification and management of any potential risks to the patient. Recognition of the complexity of the peri-procedural anticoagulation management across surgical clinics incorporates patient safety regardless of variation in diagnoses, procedures, surgeons, and clinical staff. Peri-procedural anticoagulation care management in the ambulatory setting required specialized efforts to assure essential patient safety across multidisciplinary teams.

Method: A professional practice surgical oncology nurse reviewed the literature and began a clinic-wide assessment of current state. She worked together with the institution’s anticoagulation pharmacists to determine several key factors involved in peri-procedure anticoagulation management. These factors were: 1) the risk of bleeding related to the planned procedure, 2) the goal INR requested by the surgeon, 3) the patient’s historical response to specific anticoagulation taken, and 4) the medical reason for prescribed anticoagulant. All of which are crucial elements and contribute to the management plan development. Utilizing a multi-clinician team approach facilitated creation of the safest and most comprehensive anticoagulation standardization of a plan for our peri-procedural patients.

Findings: A standardized process has now been developed to assist teams with communication and engagement with patient’s prescribing provider/anticoagulation clinic. The process initiates when it is determined that surgery is necessary for a patient on anticoagulation therapy. The surgeon determines the risk of bleeding related to the planned surgery and goal INR for the day of surgery. Once the team determines the surgical date, the clinic staff sends this information. These orders to the prescribing provider include requests for “hold medication instructions” and bridging orders as needed. This communication is given to the patient, scanned into the patient medical record, and electronically added to the surgical procedure encounter information for review by the inpatient surgical and anesthesia teams.

Interpretation: Peri-procedural anticoagulation management must involve the surgeon and the clinically relevant historical patient information and case specific prescribing by a provider or anticoagulation clinic. This process assures a collaborative, individualized, and safe management plan for the patient. Standardization is essential to provide consistent institutional clinical processes and tools to anticipate care. These complex comprehensive steps are crucial for best integration of clinical and surgical teams ensuring the most excellent patient outcomes in peri-procedural anticoagulation in the ambulatory care setting.