Abstract
Lack of alignment of care protocols among providers in health care is a driver of
increased costs and suboptimal patient outcomes. Perioperative anticoagulation management
is a good example of a complex area where protocol creation is a clinical challenge
that demands input from multiple experts. Questions regarding the need for anticoagulation
interruptions are frequent. Yet, due to layers of complexity involving analysis of
anticoagulation indication, surgical risk, and anesthesia-associated bleeding risk
as well as institutional practices, there is heterogeneity in how these interruptions
are approached. The recent perioperative anticoagulation guidelines from the American
College of Chest Physicians summarize extensive evidence for the management of anticoagulant
and antiplatelet medications in patients who undergo elective interventions. However,
implementation of these guidelines by individual clinicians is highly varied and often
does not follow the best available clinical evidence. Against this background, anticoagulation
stewardship units, which exist to improve safety and quality monitoring for the anticoagulated
patient, are of growing interest. These units provide a bridge for the implementation
of value-based, high-quality guidelines for patients who need perioperative anticoagulation
interruption. We use a case to pragmatically illustrate the problem and tactics for
change management and implementation science that may facilitate the adoption of perioperative
anticoagulation guidelines.
Keywords perioperative - anticoagulation - implementation - six sigma - nudge - guidelines
