Background Inaccurate anticoagulant reconciliation at the preadmission stage of an elective surgical patient-care pathway can lead to either thromboembolic incidents on admission or could increase the risk of perioperative bleedings. The hospital pharmacist can therefore play an opportune role in the management on anticoagulant therapy around elective surgery.

Purpose To implement an evidence based protocol for managing of oral anticoagulant therapy around elective surgery.

Materials and methods A multidisciplinary team was formed consisting of a haematologist, an anaesthesiologist, a physician assistant, a communication specialist and a hospital pharmacist. A Pubmed search was performed on the following terms: anticoagulant therapy, surgery, and bleeding risk. Studies were reviewed and a protocol was set up. Two flows were made dependant on the anticoagulant therapy of the patient. A communication plan as well as appropriate materials, such as patient cards, and preprinted prescription was made for implementing the new protocol.

Results Literature studies has lead us to a number of important studies. One of which was a review article by Kearon et al.1 Two main risks are of importance; first the risk for thromboembolic accidents and second the risk for bleeding during surgery. The CHA2DS2-VASc score is leading for determining the risk of thromboembolic events2. The risk for bleeding during operation is dependent on the operation and therefore the range of operations were divided into several scales. In case the CHA2DS2-VASc score was four or higher and the bleeding risk during operation was high two different paths were laid out depending on the anticoagulant therapy of the patient. In the Netherlands two oral anticoagulants are used: acenocoumarol and fenprocoumon. In case of acenocoumarol, this therapy is stopped 3 days before the elective surgery and tinzaparine subcutaneous injections are given until 24 h before surgery. When fenprocoumon is used as anticoagulant therapy, fenprocoumon will be stopped 5 days in advance of surgery. The dose of the tinzaparine is dependent on the weight of the patient. After surgery tinzaparine is restarted as well as the acenocoumarol. The tinzaparine is given until the target INR is reached. Information material was made for patients, doctors and healthcare providers, this includes patient information, patient cards and preprinted prescription material for the doctors. At this moment the authors are in the phase of measuring the effects of our interventions.

Conclusions Pharmacy involvement has led to a useful and practical guideline and material for the management of bridging anticoagulant therapy around elective surgery and will therefore improve patient safety.