Anticoagulation stewardship team oversight of enoxaparin‐warfarin bridging delivered by Hospital in the Home: a pre‐ and post‐implementation study

BACKGROUND: Initiation or re-initiation of warfarin often requires enoxaparin bridging, a period associated with increased bleeding risk. Anticoagulation stewardship (ACS) teams may improve the safety of anticoagulant management; however, their impact on bridging delivered by Hospital in the Home (HITH) is unknown. AIMS: To determine the impact of ACS-guided anticoagulation management on bleeding, thrombosis and other outcomes in patients admitted to HITH for enoxaparin-warfarin bleeding. METHODS: We conducted a pre- (November 2020-November 2022) and post-implementation (April 2023-November 2024) comparative cohort study of patients referred to HITH for warfarin-enoxaparin bridging. In the post-implementation phase, the ACS team provided individualised bridging plans and weekly chart reviews. The primary outcome was a composite of bleeding (major or minor), thrombosis (venous thrombo-embolism, stroke, acute myocardial infarction) or anticoagulation-related readmission prior to HITH discharge. Secondary outcomes included the primary outcome assessed at 30 days following discharge and incidence of supratherapeutic international normalised ratio (INR). RESULTS: A total of 373 patients were identified, with 231 bridging episodes in the pre-implementation period (59% male, median age 64 (50-77) years) and 205 bridging episodes in the post-implementation period (59% male, median age 66 (54-77) years). Overall, there was no significant difference in the primary composite outcome following implementation, with rates of 10% and 12% respectively (P = 0.46). After implementation, major bleeding was reduced (2.2% vs 0%, P = 0.03), as was supratherapeutic INRs during warfarin titration (33% vs 21%, P = 0.01). No significant outcome differences were observed in the 30 days after discharge from HITH. CONCLUSIONS: ACS-guided anticoagulation plans and routine reviews did not reduce a composite of bleeding, thrombosis or anticoagulation-related rehospitalisation in patients managed in HITH. ACS may be associated with less major bleeding and fewer episodes of supratherapeutic INR.