Phone: (313)
592-3535
Fax: (313)
592-3538
Patient appointment hours:
Monday,
Tuesday, and Friday:
Wednesday
and Thursday:
Referral
Process for Enrollment of patients:
Consult Information:
·
Consults
may be made by Internal Medicine Residents and/or associated precepting
physicians
·
The
patient MUST be an active Internal Medicine Resident clinic patient (Primary Care
Clinic)
·
An
enrollment form must be fully completed
and signed by the resident who will serve as the primary care physician
responsible for the patient’s anticoagulation therapy.
·
Enrollment
forms can be obtained by emailing skarr@dmc.org,
by stopping by the Anticoagulation Clinic office (clinic room 286), or by
contacting the SGH Anticoagulation Service at (313) 592-3535.
·
Requests
for enrollment forms and consult information may be left on the voicemail for (313)
592-3535; however, no patient will be accepted into the SGH Anticoagulation
Clinic until a completed referral form has been received and the patient case
reviewed by the clinic pharmacist.
·
The
completed and signed enrollment form may be hand delivered to the
Anticoagulation Clinic office, or faxed to: 313-592-3538. If faxed, a call should be placed to ensure
that the fax was received.
·
Consults
are not accepted on a “STAT” basis.
Patients are seen by appointment only.
·
Once
a consult has been reviewed and the
patient accepted for enrollment into the SGH Anticoagulation Clinic, the
Internal Medicine resident will be notified by numeric or text page.
·
Until
notification is received that the SGH Anticoagulation Clinic will begin
monitoring a patient, the resident is responsible for managing anticoagulation,
including evaluating PT/INR results, making warfarin dose adjustments,
continuing or discontinuing low molecular weight heparin (Lovenox or Fragmin)
and scheduling return lab draws via venipuncture phlebotomy.
·
Consults
will be in effect for a total of 3-6 months (see discharge information on back
of page)
Criteria for Acceptance of Patients
into the Sinai-Grace Outpatient Anticoagulation Clinic:
·
The
patient must be an established clinic patient in the Primary Care Clinic
·
The
patient must:
o
Be
at least 18 years of age
o
Provide
contact information (primary and secondary telephone numbers and home address)
o
Can
be reached by telephone and has adequate transportation to/from the clinic
o
Not involved in any active substance
abuse
·
The
patient must have an indication for warfarin that is consistent with guidelines
published in The Seventh ACCP Conference
on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines,
2004, or consistent with usual medical practice (benefit of anticoagulation
outweighs the risk)
·
The
referring resident must have a plan in place to adequately manage warfarin
until the first SGH Anticoagulation Clinic visit is scheduled (usually within 7
days from referral date)
·
The
physician agrees for the clinic pharmacist to independently manage
anticoagulation with warfarin and/or low molecular weight heparin (LMWH) or
fondaparinux within clinic guidelines, including prescribing for these
medications in the physician’s name
·
The
physician agrees to be notified as per clinic protocol (INR >6.0, other
unusual situations)
·
The
patient is agreeable to having their anticoagulation managed by the clinic
pharmacist
·
The
patient must see his/her physician at least every six months (or more often—as
instructed by the resident)
Additionally, patients will be
discharged from the SGH Anticoagulation Clinic Service if the patient:
·
is
no longer receiving warfarin
·
repeatedly
fails to come in for INR visits--three no call, no shows without extenuating
circumstances. In this instance, a
letter will be sent to the physician and the patient to notify him/her that
they have been discharged from the clinic.
·
otherwise
misses several clinic appointments to warrant unsafe practice
·
decides
to transition their care to another physician outside of the Primary Care
Clinic
·
the
patient changes or disconnect phone numbers or moves without notifying the SGH
Anticoagulation Clinic and has missed appointments as a result
·
is
noted to be an active substance abuser without attempting rehabilitation
·
behaves
in a hostile or violent manner toward staff or is unwilling to following
instructions
·
has
a primary care physician who wishes to manage the anticoagulation themselves
·
has
a primary care physician who repeatedly adjusts warfarin or low molecular
weight anticoagulation after SGH Anticoagulation Clinic enrollment without
notifying the clinic pharmacist
·
has
stable (therapeutic) INR results for >2 months, the patient may be referred
back to their primary care resident* for anticoagulation management in order to
allow room in the clinic for new, unstable patients
·
has
been managed in the Anticoagulation Clinic for a total of six or more months,
despite sub- or supra-therapeutic INR results.
The patient will then be referred back to their primary care resident*
for anticoagulation
How to
transition anticoagulation and enroll in the Anticoagulation Clinic:
Transitioning Anticoagulation from Inpatient:
1. Order baseline labs (PT/INR, hepatic
function and renal function) prior to starting warfarin and/or LMWH
2. If INR is therapeutic, add up total
warfarin doses in mg and divide by the number of warfarin days for approximate
daily dose and subsequent weekly dosing regimen.
example: day 1 = 5 mg, day 2 = 6 mg, day 3 =
5 mg, day 4 = 7.5 mg; total is 23.5 mg/4 days = 5.9 mg per day. Give patient Rx for 6 mg, #30, take one daily
or as directed by doctor (do not give too many tablets or refills)
3. If INR is NOT therapeutic prior to
discharge, look at warfarin doses for previous days and INR trend to determine warfarin
daily dose for next several days. In
general, starting doses are:
a. 2.5 mg daily:
patients with impaired hepatic function, wt <45 kg or females over age 65
b. 5 mg daily:
usual starting dose for most patients and males over 65
c. 7.5 mg daily:
may be considered for age <35, weight at least 70 kg with normal hepatic
function.
d. If patient on antibiotic or other
interacting drug at discharge, consult with hospital/clinic pharmacist
4. Prior to discharge, instruct patient
to follow-up in Primary Care Clinic:
a. Within 3-4 days for therapeutic INR
b. Within 2-3 days for subtherapeutic
or supratherapeutic INR
5. Give patient primary care clinic
telephone number on discharge paperwork (313-592-3680) and remind them that
they need to schedule a follow-up with you immediately as described above
6. After 1st clinic visit
with patient post-discharge, you may refer them to the SGH Anticoagulation
Clinic. Complete SGH Anticoagulation
referral form, fax to (313) 592-3538 and call (313-592-3535) to confirm
receipt. No referrals will be accepted from the hospital on discharge—the
patient must be seen in the clinic first
7. Go under “Patient List” in CIS and
under “modify list” choose list on the left titled, “Patients referred to SG
Anticoagulation Clinic.” Move this over
to your active lists on the right. You
can now view all patients referred and add this new patient to the list of
referred patients so that you don’t lose track of them.
8. Expect notification of patient
acceptance for anticoagulation management within a few business days of sending
the referral. Clinic pharmacist will
then contact patient to set up an initial appointment with the SGH
Anticoagulation Clinic and take the patient off of the “Patients referred to SG
Anticoagulation Clinic” list in CIS.
Adjusting warfarin in the outpatient
setting:
1. If patient on warfarin for <1
week follow steps 2-4 above
2. If patient already on warfarin for
>1 week, follow dosing algorithms (see separate pages)
3. Complete SGH Anticoagulation
referral form as in #6 above