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Care Signature Clinical Pathway guides patients, physicians on anticoagulant use before and after procedures

Say you’re a patient who’s been taking an anticoagulant prescribed by a cardiologist to treat and prevent complications from blood clots. 

You also regularly see a primary care physician, and recently began seeing an orthopedic surgeon for an upcoming total knee replacement.

You know that before surgery you might need to stop taking the anticoagulant to address the risk of bleeding, but this is weighed against the risk of developing a clot if the medication is interrupted. Each doctor gives you different information on when and how to stop the medication before the procedure. You also receive separate information on when to restart the medication.

“As physicians and surgeons, we might think our recommendations are easy to follow,” said Vanita Ahuja, MD, Yale Surgery quality liaison and associate director, Yale GME Distinction Pathway in Health Equity, Patient Safety and Quality Improvement. “But we, and the patient, might not all be on the same page.”

This is the type of scenario a Yale New Haven Care Signature Clinical Pathway (CSCP) on anticoagulants aims to address. The pathway, which launched last November, provides guidance on how to think about managing anticoagulants before certain procedures or surgeries, as well as managing patients during procedures or surgeries. The CSCP also addresses restarting anticoagulant medications after procedures. 

The CSCP includes guidelines for more than 700 surgical and non-surgical procedures, with more being added. 

It is one of more than 400 CSCPs YNHHS has developed so far for a wide range of clinical conditions and scenarios. The pathways act as a kind of GPS, recommending steps clinicians can take to diagnose, treat and monitor patients.

YNHHS performs about 150,000 surgical and non-surgical procedures a year; 10 percent to 15 percent of patients having these procedures take anticoagulants. Lack of consensus about managing these medications around procedures does more than confuse patients – it can lead to safety events, canceled procedures and longer lengths of stay. Proper management of anticoagulation therapy is a safety priority for hospitals accredited by The Joint Commission.

Kent Owusu, PharmD, program manager with YNHHS Care Signature, led the group of more than 50 physicians, surgeons, pharmacists and other staff from different disciplines throughout the health system in developing the anticoagulant CSCP. Participants conducted an extensive review of the latest medical literature and identified best practices. The group then convened other experts, including physicians and staff from throughout YNHHS, Northeast Medical Group, Yale School of Medicine and community providers, for consensus on what the CSCP should include. 

“This is the result of the hard work of many people,” Dr. Ahuja said. “I really appreciated how everyone came together for the good of the patient.”

She and Owusu said they’re particularly impressed by patients’ involvement in the work. Patient Family Advisory Committee (PFAC) members helped identify communication gaps between providers and between providers and patients. PFAC members also reviewed and improved pre-procedure patient instructions the Care Signature Clinical Pathway group had developed to ensure they’re consistent and easy to understand. 

“We started this effort because it impacted patient care,” Owusu said. “It was appropriate and mission-critical that we circled back to the patients we serve to endorse the final product.”

Staff can find this and other Care Signature Clinical Pathways in Epic or on the employee intranet.