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Semin Thromb Hemost 2019; 45(02): 187-195
DOI: 10.1055/s-0038-1676320
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Utility of a Nurse-Led Pathway for Patients with Acute Venous Thromboembolism Discharged on Rivaroxaban: A Prospective Cohort Study

Ming Sheng Lim
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
,
Tishya Indran
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
,
Anita Cummins
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
,
Ashwini Bennett
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
,
Erica Wood
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
3   Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
,
Susan Brown
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
,
Zoe McQuilten
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
3   Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
,
Huyen Tran
,
Master Clin Epi
4   The Australian Centre for Blood Diseases, Monash University, Alfred Medical Research and Educational Precinct, Melbourne, Australia
5   Department of Clinical Hematology, The Alfred Hospital, Melbourne, Australia
,
Noel C. Chan
6   Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
7   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Sanjeev Chunilal
1   Department of Hematology, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
2   Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
› Author Affiliations
Further Information

Publication History

Publication Date:
19 December 2018 (online)

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Abstract

The highest risk of adverse events for patients with acute venous thromboembolism (VTE) is during the early anticoagulation period. However, no established model exists for early clinical monitoring of patients treated with non–vitamin K antagonist oral anticoagulants (NOACs). The authors' aim was to evaluate the utility of a nurse-led pathway to minimize adverse events in acute VTE patients starting on rivaroxaban. The rivaroxaban VTE treatment pathway is a prospective cohort study of consecutive patients with objectively confirmed VTE between July 2015 and May 2017. Primary outcome was the proportion of patients identified at major risk of adverse events (bleeding or recurrent VTE). Secondary outcomes were rates of interventions, major or clinically relevant nonmajor bleeding (CRNMB), recurrent VTE, and all-cause mortality at 90 days. Among 304 participants, 5% (n = 15) were identified to be at major and 9% (n = 28) at possible risk for adverse events. Appropriate interventions to prevent harm were required in 40 patients. Rates of major bleeding, CRNMB, recurrence, and all-cause mortality were 0.3% (95% confidence interval [CI]: 0.1–1.8), 7.2% (95% CI: 4.8–10.7), 1.0 (95% CI: 0.3–2.9), and 1.6% (95% CI: 0.7–3.8), respectively. In conclusion, following discharge of acute VTE patients, a nurse-led pathway identified one in seven (14%) patients at major or possible risk of adverse events. Preemptive interventions to reduce harm translated into the low rates of bleeding and recurrence. The authors' experience highlights the feasibility and importance of a structured clinical surveillance pathway for acute VTE patients initiating NOAC therapy.

Keywords

adverse drug event - clinical pathways - nurse-led pathway - rivaroxaban - venous thromboembolism

Contributions

S. Chunilal and A. Cummins were involved in the conception and design of the project. M.S. Lim, T. Indran, and A. Cummins were involved in data acquisition. M.S. Lim, S. Chunilal, and N.C. Chan were involved in data analysis and interpretation. M.S. Lim wrote the first draft of the manuscript. All authors contributed to critical revision of the manuscript and approved the final version of the manuscript.


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