Bingener-Casey, Juliane

Introduction Safe management of warfarin in the inpatient setting can be challenging. At the Mayo Clinic hospitals in Rochester, Minnesota, we set out to improve the safety of warfarin management among surgical and non-surgical inpatients. Methods A multidisciplinary team designed a pharmacist-managed warfarin protocol (PMWP) which designated warfarin dosing to inpatient pharmacists with guidance from computerised dosing algorithms. Ordering this protocol was ultimately designed as an ‘opt out’ practice. The primary improvement measure was frequency of international normalised ratio (INR) greater than 5; secondary measures included adoption rate of the protocol, a counterbalance INR metric (INR <1.7 three days after first inpatient warfarin dose), and complication rates, including bleeding and thrombosis events. An interrupted time series analysis was conducted to compare outcomes. Results Among over 50 000 inpatient warfarin recipients, the PMWP was adopted for the majority of both surgical and non-surgical inpatients during the study period (1 January 2005 to 31 December 2011). The primary improvement measure decreased from 5.6% to 3.4% for medical patients and from 5.2% to 2.4% for surgical patients during the preimplementation and postimplementation periods, respectively. The INR counterbalance measure did not change. Postoperative bleeding decreased from 13.5% to 11.1% among surgical patients, but bleeding was unchanged among medical patients. Conclusion Our PMWP led to achievement of improved INR control for inpatient warfarin recipients and to less near-term bleeding among higher risk, surgical patients.

With various minimally invasive approaches in the field of surgery and new techniques entering rapidly, it is important to evaluate the effectiveness of these different practices. Information about the impact on both patient and provider can be gained through research investigations. Since the workload placed on the surgeon may influence patient outcomes, this study measured levels of stress and fatigue for the surgeon participating in an NIH randomized control trial of single incision versus 4-port laparoscopic cholecystectomy. Through the administration of the SURG-TLX for 22 Single-Incision Laparoscopic Cholecystectomies and 24 4-port cholecystectomies, physical workload was the only measure statistically different between 4-port and SILC (P=0.028). There was a significant difference in the duration (P=0.029) based on the procedure that was completed. Mental stress was highly correlated to many of the variables in the Surg-TLX and duration, degree of difficulty, and complexity were all highly correlated. This research shows how the SILC procedure can cause more stress on the surgeon. When the situation is combined with longer surgeries, higher complexity, and a higher degree of difficulty, the patient outcomes may be at risk.