Objective: To determine how frequently hospital discharge is delayed to administer intravenous heparin to patients with diverse indications for oral anticoagulation (OAC) medications and how often these delays are potentially avoidable, as assessed by the prevalence of contraindications to outpatient use of low-molecular-weight heparin (LMWH).
Patients and methods: Records were reviewed from a random sample of 309 patients who received at least 1 dose of OAC medication while hospitalized at the Mount Sinai Hospital in New York City between January 1 and December 31, 1997. Medical records were abstracted to determine admission diagnoses; patient demographics and comorbid conditions; indications for anticoagulation; laboratory data; and treatment and discharge medications, including whether LMWH was prescribed. A delay was defined as the continuation of hospitalization solely to administer intravenous heparin. Predefined criteria were used to classify the delay of discharge as appropriate or avoidable on the basis of the patient's potential eligibility for outpatient treatment with LMWH.
Results: Discharge was delayed for 75 of 309 patients (24%; 95% confidence interval [CI], 19%-29%); during analysis of the avoidability of delay, 67 of the 75 medical records were available and showed that 32 of 67 delays (48%; 95% CI, 35%-60%) were avoidable. Of patients taking long-term OAC medications who were admitted for reasons unrelated to thromboembolism or bleeding, discharge was delayed for 18 of 146 (12%; 95% CI, 7%-19%); during analysis of the avoidability of delay, 16 of the 18 medical records were available and showed that 9 of 16 delays (56%; 95% CI, 30%-80%) were avoidable. Of patients admitted for acute venous thromboembolism who were not taking long-term OAC medications, discharge was delayed for 24 of 38 (63%; 95% CI, 46%-78%); during analysis of the avoidability of delay, 22 of the 24 medical records were available and showed that 11 of 22 delays (50%; 95% CI, 28%-72%) were avoidable.
Conclusions: For patients taking OAC medications, hospital discharge is frequently delayed so that intravenous heparin can be administered; approximately half of these delays could be avoided by outpatient use of LMWH. Studies of the safety, efficacy, and feasibility of outpatient use of LMWH for indications other than deep venous thrombosis are needed because timely discharge of these patients could substantially decrease health care costs.