Anticoagulation stewardship team oversight of enoxaparin‐warfarin bridging delivered by Hospital in the Home: a pre‐ and post‐implementation study
Suebsakul Pripanapong, Sing Ning Yeoh, Jahan Zaib, Simon Lim, Nadishani Ratnayake, Simone Taylor, Emma Leitinger, Benjamin Rogers, Elizabeth PotterAbstract
Background
Initiation or re‐initiation of warfarin often requires enoxaparin bridging, a period associated with increased bleeding risk. Anticoagulation stewardship (ACS) teams may improve the safety of anticoagulant management; however, their impact on bridging delivered by Hospital in the Home (HITH) is unknown.
Aims
To determine the impact of ACS‐guided anticoagulation management on bleeding, thrombosis and other outcomes in patients admitted to HITH for enoxaparin‐warfarin bleeding.
Methods
We conducted a pre‐ (November 2020–November 2022) and post‐implementation (April 2023–November 2024) comparative cohort study of patients referred to HITH for warfarin‐enoxaparin bridging. In the post‐implementation phase, the ACS team provided individualised bridging plans and weekly chart reviews. The primary outcome was a composite of bleeding (major or minor), thrombosis (venous thrombo‐embolism, stroke, acute myocardial infarction) or anticoagulation‐related readmission prior to HITH discharge. Secondary outcomes included the primary outcome assessed at 30 days following discharge and incidence of supratherapeutic international normalised ratio (INR).
Results
A total of 373 patients were identified, with 231 bridging episodes in the pre‐implementation period (59% male, median age 64 (50–77) years) and 205 bridging episodes in the post‐implementation period (59% male, median age 66 (54–77) years). Overall, there was no significant difference in the primary composite outcome following implementation, with rates of 10% and 12% respectively ( P = 0.46). After implementation, major bleeding was reduced (2.2% vs 0%, P = 0.03), as was supratherapeutic INRs during warfarin titration (33% vs 21%, P = 0.01). No significant outcome differences were observed in the 30 days after discharge from HITH.
Conclusions
ACS‐guided anticoagulation plans and routine reviews did not reduce a composite of bleeding, thrombosis or anticoagulation‐related rehospitalisation in patients managed in HITH. ACS may be associated with less major bleeding and fewer episodes of supratherapeutic INR.