key: cord-1024374-9fiktlr4 authors: Kish, Katie; Lekic, Sanela title: Implementation of warfarin to direct oral anticoagulant conversion initiative in pharmacist‐run anticoagulation clinics during COVID‐19 pandemic date: 2021-06-08 journal: J Am Coll Clin Pharm DOI: 10.1002/jac5.1470 sha: 0776be4a4d1ace6f29a90ef290258089c8b0ef10 doc_id: 1024374 cord_uid: 9fiktlr4 Due to community transmission of coronavirus disease 2019 (COVID‐19), social distancing and stay‐at‐home orders were implemented statewide in an effort to limit the spread of disease. This posed unique challenges for patients on medications requiring close and continued monitoring by clinic staff, such as anticoagulation clinics. Thus, innovative measures were implemented at Cleveland Clinic Health System (CCHS) to maintain the health and care of ambulatory patients. An initiative to evaluate patients for warfarin to direct oral anticoagulants (DOAC) conversion was used in the pharmacist‐run anticoagulation clinics. This article describes how patients were screened for eligibility, the education to pharmacists, the utilization of student learners in the process, and the workflow for provider notification of conversion. Follow up monitoring, challenges encountered, and future directions are also described. Project leads were identified within the PAC team. Leads created a "DOAC conversion checklist" which outlined eligibility criteria for DOACs (Table 1) . 7 Patients were deemed appropriate for conversion if all the questions in the checklist were answered "YES." The purpose of this checklist was to prevent inappropriate recommendations, such as when a patient had a precaution or a contraindication DOAC use. Once the patients were identified through one of the methods above, the option of conversion was discussed with the patient. Shared decision-making was used to engage the patient in discussion. Patients were educated on risks versus benefits of the anticoagulants, possible differences in cost, and key counseling points. Pharmacists also discussed current guideline recommendations for atrial fibrillation and venous thromboembolism, which list DOACs as first-line therapy over warfarin. [8] [9] [10] Affordability was a major driver for most patients, as DOACs are not available in the United States through generic formulations and often result in high copayments on many insurance plans. If a patient met eligibility criteria for conversion and discussed the option with a pharmacist, the pharmacist documented the outcome in the EHR. A standardized template was created that outlined the "DOAC conversion checklist" so that other providers could view the pharmacist's assessment in the EHR (Figure 1) . A free text area was included for pharmacists to enter any additional patient-specific factors or considerations. In early stages of this initiative, medication orders were pended to the referring provider for review and approval. While DOACs are included in the PAC consult agreement, physicians were not accustomed to pharmacists independently making the decision to convert a patient from warfarin to DOAC. As experience was gained throughout this initiative, PAC solicited input from CCHS providers who expressed interest in pharmacists independently initiating the warfarin to DOAC conversion under the existing consult agreement. Pharmacists contacted the patient to discuss the next steps and to facilitate safe conversion. Patients were scheduled for telephonic follow-up with the PAC team one month from conversion date, and were added to a shared EHR list for tracking purposes. Physicians were informed of patients who transitioned from warfarin to DOAC via the EHR. Project leads developed education to pharmacists on this topic. A step-by-step guidance document on how to pursue conversions was created that included the "DOAC conversion checklist" as mentioned above (Table 1) . 7 This checklist included: indication for anticoagulation, renal and hepatic function, drug-drug interactions, body weight, and adherence. The step-by-step document also described differing insurance types and expected coverage and copayments. A sample script for introducing DOACs and providing education to the patient was included for pharmacists to utilize ( Table 2 ). The checklist and step-by-step document were shared with the pharmacist team via email and through two live (virtual) one hour training sessions. Project leads remained available for questions on patient-specific cases. Due to an influx of questions by the pharmacists to the team leads, a frequently asked questions document was created and available on a shared drive for recurring DOAC questions, such as consideration for thrombophilia and off-label indications. If pharmacists had uncertainty regarding a patient's "eligibility criteria," pharmacists were encouraged to enter encounters into the EHR and route to referring provider and or specialist provider (if applicable) for their input. Advanced Pharmacy Practice Experience (APPE) students who were on rotation at CCHS were displaced from scheduled rotations during COVID to maintain social distancing. Health system administrators reassigned rotations so that learners could support the anticoagulation conversion initiative starting mid-April 2020. A total of approximately 30 students were assigned to this initiative through the end of May 2020. APPE students continued to report on-site due to limitations with access to patient-protected information off-site. There was a postgraduate year 1 (PGY1) pharmacy resident on Introduction: This is a type of anticoagulant we call a DOAC or "direct acting oral anticoagulant." As I mentioned, the benefit is that we do not have to monitor your blood levels as frequently. Your doctor will still want to check your kidneys, liver, and/or blood counts every few months or at least yearly. Compliance: With that said, it is imperative you do not miss doses because it is shorter acting than warfarin and one missed dose could lead to poor outcomes. Administration: Based on discussion with patient and review of chart, DOAC chosen (often apixaban or rivaroxaban based on local formularies). The administration instructions, including instructions for missed doses, from the package insert was shared with patient. Side effects: This is a very well tolerated medication, similar to that of warfarin in that you want to watch for signs and symptoms of bleeding or unusual bruising and contact provider immediately if that occurs. Cost: The main barrier to using these medications can be cost. If cost is an issue, please contact the anticoagulation clinic immediately so that we can identify a solution. PAC rose to the challenge of implementing a significant initiative in the face of a global pandemic. To continue providing the same care as pre-pandemic was not an option. Administration and pharmacy leads worked to create and modify a way to suggest warfarin to DOAC conversion in eligible patients. This initiative is likely to permanently expand the scope of practice within the pharmacist-run F I G U R E 2 Standardized template for DOAC follow-up documentation in EHR. CrCl, creatinine clearance; DOAC, direct oral anticoagulant anticoagulation clinics at CCHS. Other institutions could also adapt this approach as they work to expand their scope of practice in their anticoagulation clinics to include DOAC monitoring. WHO Director-General's opening remarks at the media briefing on COVID19 Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: Interim clinical guidance from the anticoagulation forum Incorporating Comprehensive Management of Direct Oral Anticoagulants into anticoagulation clinics Evaluation of a pharmacist-led outpatient direct oral anticoagulant service Implementation of a direct Oral anticoagulation screening service at a Large Academic Medical Center Provided by a pharmacist-managed Antithrombosis clinic as a method to expand antithrombotic stewardship efforts Management of Outpatient Warfarin Therapy amid COVID-19 pandemic: A practical guide Michigan Anticoagulation Quality Improvement Initiative Anticoagulation Toolkit Version AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report American Society of Hematology 2020 guidelines for management of venous thromboembolism: Treatment of deep vein thrombosis and pulmonary embolism How to cite this article: Kish K, Lekic S. Implementation of warfarin to direct oral anticoagulant conversion initiative in pharmacist-run anticoagulation clinics during COVID-19 The authors would like to acknowledge the entire Pharmacy Anticoagulation Clinic team for their resilience and willingness to adapt during the pandemic. The authors especially want to thank Pharmacy Anticoagulation Clinic leadership, Julia Mulheman, Pharm.D., CACP, and Erick Sokn, Pharm.D., MS, BCPS for their unwavering guidance throughout the pandemic. The authors declare no conflicts of interest.