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As of September, nine patients have been screened and identified as potential candidates for outpatient management in the outpatient program for uncomplicated DVT/PE begun about six months ago by Duke University Medical Center in Durham, NC. The program is still in its pilot phase.
"When DVT/PE patients are treated as outpatients, their lengths of stay can be cut from 4.9 days to 12 to 24 hours," says Lori H. Postal, RNC, MS, facilitator in the department of disease management at Duke. The staff is monitoring the cost and quality outcomes of those cases before rolling the program out to the whole institution. Among the indicators they are looking at are ease of obtaining meds, complications, and managing the nomograms of warfarin as an outpatient.
"We're excited about our outpatient program," says Postal. "Some patients still prefer to be admitted, but most patients prefer to be at home with self-administration of their meds or with home care." If a patient opts for self-management, he or she is instructed to self-administer two injections of enoxaparin, one at 8 a.m. and one 8 p.m., and then to go to an anticoagulation clinic to give a blood specimen for an INR test. The patient is then given instructions on how to take his or her warfarin. The patient is referred to a dedicated pager number to use if there are any signs of bleeding, such as vomiting blood, blood in the urine, or black stools.
If a patient requires home health management, a nurse administers the morning and evening shots of enoxaparin and draws blood. The nurse contacts the doctor to determine the daily dose of warfarin and is available if there are signs of bleeding.
A patient is eligible for the program only if he or she does not have:
• a history of two or more episodes of DVT or PE;
• presence of current active bleeding process, active peptic ulcer disease, or familial bleeding disorders;
• concurrent symptomatic pulmonary embolism;
• inability to receive outpatient enoxaparin because of associated comorbid conditions;
• potential for noncompliance — mental confusion, inability to care for self, poor vision, no support;
• inability to attend follow-up visits or obtain home care because of geographic inaccessibility;
• known history of an inherited hypercoagulable disorder;
• history of cerebral vascular accident known to be hemorrhagic;
• recent surgery within one week (potential for bleed);
• recent trauma within two weeks (potential for bleed);
• severe uncontrolled hypertension — SBP > 180 or DBP > 110;
• renal failure (SCr > 2.0 mg/dl) and/or hepatic failure.
Pregnant or lactating women and women of childbearing potential who are not covered by a medically recognized contraceptive method are also ineligible.
For more information, contact Lori H. Postal, RNC, MS, facilitator, department of disease management, Duke University Medical Center, Durham, NC. Telephone: (919) 416-5216.