Clinical activities

Duke Hematology Clinical Activities, Ara Metjian,

Outpatient Programs

Anticoagulation Management Service

The Anticoagulation Management Service(AMS) currently manages more than 650 patients on chronic oral anticoagulation therapy. The Anticoagulation Clinic, located in Clinic 2C in Duke South, is open five days a week and is staffed by a Physician Assistant, two Nurse Clinicians, and two Clinical Pharmacists. Medical oversight of the clinic is provided by faculty in the Hemostasis & Thrombosis Center. The Medical Director of the Anticoagulation Management Service is Dr. Thomas Ortel. 
 
Most patients are managed by use of a point-of-care capillary blood coagulation meter, but specialized coagulation testing and skill is available for managing outpatients on low molecular weight heparins, patients for whom the INR may not be accurate (e.g., certain patients with the antiphospholipid antibody syndrome), and complex medical patients on direct oral anticoagulants.

Additional services include developing therapeutic ‘bridges’ for patients on chronic anticoagulant therapy who need a surgical or interventional procedure that will require temporary discontinuation of the anticoagulant.
 
In addition to the outpatient program, there is also a pharmacist-based inpatient service to assist with the management of hemostatic therapies (e.g., recombinant factor VIIa), direct thrombin inhibitors (e.g., lepirudin, argatroban), and with outpatient management of patients with new venous thromboembolic events starting anticoagulant therapy.
 
Current staff for the Anticoagulation Management Service:

  • Kathy Vokaty, PA-C
  • Sarah Roberson, PA-C
  • Karen Baker, RN
  • Dawn Johnson, RN
  • Kimberly Hodulik, Pharm.D
  • Michelle Schoonover, Pharm.D
  • Cinnamon Leggett, LPN

Hemostasis & Thrombosis Clinic

The Hemostasis & Thrombosis Clinic is open five days a week and is staffed by five hematologists and one cardiologist. 

The Hemostasis & Thrombosis Clinic is located in Clinic 2C in Duke Clinic. Outpatient administration of factor concentrates, blood products and other parenteral agents is performed in the Duke Specialty Infusion Center, located in Clinic 2A on the same floor as the Hemostasis & Thrombosis Clinic.

Outpatient apheresis is available five days a week, adjacent to the Treatment Facility.
 
Many of the patients seen in the Hemostasis & Thrombosis Clinic are eligible for clinical trials. Our Clinical Research team reviews patients being seen in the clinic to make them aware of potential clinical trial opportunities. We are currently involved in a surveillance study through the Centers for Disease Control to determine the incidents of venous thromboembolism in Durham County, identifying all patients with venous thromboembolism.

Women's Hemostasis & Thrombosis Clinic

The Women’s Hemostasis and Thrombosis Clinic at Duke was formally organized in July of 2000 in response to the needs of women with bleeding and clotting disorders. Starting in 2002, the Centers for Disease Control and Prevention’s Division of Hereditary Blood Disorders recognized and began funding Duke’s Comprehensive Hemostasis and Thrombosis Center, in part because of the important work of the Women’s Clinic. The Women’s Clinic has a Gynecologic Program that serves the needs of women who have a bleeding disorder or are on anticoagulation and require management of menorrhagia. The Obstetric Program primarily serves the needs of women who have blood disorders and are pregnant or desire a pregnancy.
 
Since its inception in 2000, the Obstetric Program of the Women’s Hemostasis and Thrombosis Clinic has been supported by the Division of Maternal Fetal Medicine in the Department of Obstetrics and Gynecology and the Division of Hematology in the Department of Medicine. Both divisions recognize that women with clotting disorders are at an increased risk of thrombosis during pregnancy and an increased risk of poor pregnancy outcome. Many require anticoagulation during pregnancy. Anticoagulation in pregnancy requires vigilance and anticipation of the potential bleeding complications which may occur at the time of miscarriage or childbirth. Women with bleeding disorders are also at risk of bleeding complications. Pregnant women with bleeding and clotting disorders are best served by the combined expertise of a multidisciplinary team such has been assembled at Duke.
 
Current staff for the Obstetric Program:

  • Elizabeth Livingston, M.D. - maternal-fetal medicine specialist
  • Kathy Vokaty RN, PA – physician assistant from the Division of Hematology
  • Thomas Ortel M.D., Ph.D. – Medical Director of the Anticoagulation Clinic and back-up for the physician assistant
  • Laura Brown RN, NP – nurse practitioner, Raleigh office
  • Kristin Paulyson Nuñez M.S., C.G.C – genetic counselor
  • Geraldine Wahlay – patient education and nursing support

Services are provided at weekly sessions held at the Duke Perinatal office at 2801 Erwin Road, Durham, NC, 27705. 
 
Services include:

  • Preconception counseling
  • Genetic counseling – not only routine, but also specific to the needs of women with inherited disorders of bleeding and clotting and women at-risk for an affected child.
  • Obstetric ultrasound
  • Prenatal diagnosis
  • Antepartum testing
  • Labor, delivery and postpartum management
  • Sonohysterography
  • Collaboration and consultation with other specialties, particularly anesthesiology, neonatology, pediatric hematology, cardiology and pulmonary/critical care medicine

Pediatric Hematology Clinic

The Pediatric Hematology Clinic is held each Wednesday and is led by pediatric hematologist Dr. Nirmish Shah, as well as three physician extenders, a nurse coordinator, a sickle cell educator,  a Pediatric Hematology/Oncology fellow and a social worker.
  
The clinic provides comprehensive care for patients with bleeding and thrombotic disorders. Bleeding disorders include coagulation factor deficiencies such as hemophilia, von Willebrand disorder, platelet function disorders and acquired bleeding tendencies. Thrombotic disorders include evaluation and treatment of venous and arterial thrombosis and thrombotic thrombocytopenic purpura. Approximately two to four new patients with hemorrhagic or thrombotic disorders, and one to five return patients, are seen in this clinic each week. In addition, ~20 to 30 patients with hemophilia are followed for ongoing care.
 
The Pediatric Hematology Clinic is located in the Duke Children’s Hospital and Health Center, Fourth floor. Outpatient administration of recombinant factor products, blood products and other parenteral agents is performed five days a week in the Valvano Day Hospital, located on the same floor as the Clinic
 
All patients with inherited bleeding defects seen in the clinic are approached for participation in a patient registry sponsored by the Centers for Disease Control and Prevention. Dr. Shah's research interest include novel therapeutic options and hypercoagulability for sickle cell disease.

Inpatient Programs

Pharmacist-Based Hemostasis/Thrombosis Service

Inpatient management of patients with complex hemorrhagic and thrombotic disorders requires close supervision; anticoagulant therapy continues to contribute to adverse drug events. Management strategies include an expanding array of therapeutic options which must be managed in patients with multiple other medical conditions. Examples include: peri-operative and peri-procedural management of antithrombotic therapies, use of direct thrombin inhibitors in patients with heparin-induced thrombocytopenia and use of hemostatic agents in patients with bleeding complications (inherited as well as acquired).
 
To address this need, we have developed an inpatient service staffed by pharmacists which provides a consultative service for the management of hemostatic and antithrombotic therapies. The inpatient service works closely with the inpatient Hematology Consult Service, the Clinical Coagulation Laboratory, and the outpatient Anticoagulation Management Service (AMS), facilitating transition of patients followed by the AMS from inpatient to outpatient management.
 
Patients receiving direct thrombin inhibitors (DTIs), factor products, heparin agents and oral anticoagulants are identified by referral from the inpatient hematology consult service by direct consultation from other medical and surgical services, or by pharmacy computer report. Indication for these agents is reviewed to ensure appropriateness of therapy. Dosing and monitoring recommendations are made and patients are managed by the pharmacist based service while receiving these antithrombotic or hemostatic agents. Follow-up is arranged with the outpatient AMS upon discharge of the patient from the hospital if indicated.
 
Patients with new deep vein thrombosis who qualify for outpatient management or peri-procedural bridge therapies are identified through the ED, pre-op screening or the AMS. These patients are then educated regarding their disease state, medications and medication schedules. Transition to the outpatient AMS is facilitated, decreasing the length of hospitalizations for these patients.
 
Patients who are new to anticoagulation therapy are identified and counseled regarding anticoagulant indication, dose, diet, medication interactions, alcohol interactions, disease state interactions and symptoms of unusual bruising or bleeding.
 
This service started seeing inpatients beginning in September 2004. Our experience has confirmed that the inpatient pharmacist-based hemostasis and thrombosis service has been successful at enhanced continuity of care, standardization of care, decreased length of hospitalizations, improved patient education and confirming appropriate outpatient follow-up.
 
Staff: Michelle R. Schoonover, Pharm.D.
Kimberly L. Hodulik, Pharm.D.
 
Faculty Supervision: Thomas L. Ortel, M.D., Ph.D.
Ara Metjian, M.D.
Gowthami Arepally, M.D.