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Utility of a Dedicated Pediatric Cardiac Anticoagulation Program: The Boston Children’s Hospital Experience

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Abstract

Congenital heart disease is the leading cause of stroke in children. Warfarin therapy can be difficult to manage safely in this population because of its narrow therapeutic index, multiple drug and dietary interactions, small patient size, high-risk cardiac indications, and lack of data to support anticoagulation recommendations. We sought to describe our institution’s effort to develop a dedicated cardiac anticoagulation service to address the special needs of this population and to review the literature. In 2009, in response to Joint Commission National Patient Safety Goals for Anticoagulation, Boston Children’s Hospital created a dedicated pediatric Cardiac Anticoagulation Monitoring Program (CAMP). The primary purpose was to provide centralized management of outpatient anticoagulation to cardiac patients, to serve as a disease-specific resource to families and providers, and to devise strategies to evolve clinical care with rapidly emerging trends in anticoagulation care. Over 5 years the CAMP Service, staffed by a primary pediatric cardiology attending, a full-time nurse practitioner, and administrative assistant with dedicated support from pharmacy and nutrition, has enrolled over 240 patients ranging in age from 5 months to 55 years. The most common indications include a prosthetic valve (34 %), Fontan prophylaxis (20 %), atrial arrhythmias (11 %), cardiomyopathy (10 %), Kawasaki disease (7 %), and a ventricular assist device (2 %). A patient-centered multi-disciplinary cardiac anticoagulation clinic was created in 2012. Overall program international normalized ratio (INR) time in therapeutic range (TTR) is favorable at 67 % (81 % with a 0.2 margin) and has improved steadily over 5 years. Pediatric-specific guidelines for VKOR1 and CYP2C9 pharmacogenomics testing, procedural bridging with enoxaparin, novel anticoagulant use, and quality metrics have been developed. Program satisfaction is rated highly among families and providers. A dedicated pediatric cardiac anticoagulation program offers a safe and effective strategy to standardize anticoagulation care for pediatric cardiology patients, is associated with high patient and provider satisfaction, and is capable of evolving care strategies with emerging trends in anticoagulation.

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Acknowledgments

The authors would like to express their sincerest thanks to Drs. Jane Newburger, Roger Breitbart and James Lock; Michelle Hurtig MSN, RN, Juli-anne Evangelista NP and Karen Hinsley RN, along with all the medical staff from 8E, 8S and the Cardiology Clinic with the Department of Cardiology; and Drs. Ellis Neufeld, Alan Michelson, Cameron Trenor and Juliann Duzan RN of the Division of Hematology, for their enormous support of the CAMP Service over the past 5 years.

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Authors and Affiliations

  1. Department of Cardiology, Boston Children’s Hospital, Boston, USA

    Jenna M. Murray, Loren Brown, Rosemary Galvin, Karen Mittler, Christina VanderPluym, Annette Baker, Patricia O’Brien, Cheryl O’Connell & Christopher S. Almond

  2. Departments of Pharmacy and Medicine, Boston Children’s Hospital, Boston, USA

    Amy Hellinger, Roger Dionne & Shannon Manzi

  3. Divisions of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, USA

    Suzanne Griggs

  4. Division of Hematology, Boston Children’s Hospital, Boston, USA

    Kathy Harney

  5. Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA

    Jenna M. Murray, Amy Hellinger, Roger Dionne, Loren Brown, Rosemary Galvin, Suzanne Griggs, Karen Mittler, Kathy Harney, Shannon Manzi, Christina VanderPluym, Annette Baker, Patricia O’Brien, Cheryl O’Connell & Christopher S. Almond

  6. Division of Pediatric Cardiology, Stanford University, The Lucile Packard Children’s Hospital, 750 Welch Road Suite 325, Palo Alto, CA, 94304-5731, USA

    Jenna M. Murray & Christopher S. Almond

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  1. Jenna M. Murray
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  2. Amy Hellinger
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Correspondence to Christopher S. Almond.

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Murray, J.M., Hellinger, A., Dionne, R. et al. Utility of a Dedicated Pediatric Cardiac Anticoagulation Program: The Boston Children’s Hospital Experience. Pediatr Cardiol 36, 842–850 (2015). https://doi.org/10.1007/s00246-014-1089-x

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  • DOI: https://doi.org/10.1007/s00246-014-1089-x

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