Nurse Anticoagulation Basics. Darren Triller, PharmD Foundation for Quality Care Teleconference February 13, 2013

Transcription

1 Nurse Anticoagulation Basics Darren Triller, PharmD Foundation for Quality Care Teleconference February 13, 2013

2 CMS Leads a national healthcare quality improvement program, implemented locally by an independent network of QIOs in each state and territory. IPRO The federally funded Medicare Quality Improvement Organization (QIO) for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS). 2

3 The QIO Program Largest federal program dedicated to improving health quality at the local level, Trustworthy partners for the continual improvement of healthcare for all Americans, Focuses on three broad aims: Better patient care, Better population health, Lower healthcare costs through improvement. 3

4 As the QIO for New York State, IPRO works to achieve the goals of the national QIO program by Convening communities of providers, practitioners and patients across the state to: Share knowledge, Spread best practices, Achieve rapid, wide-scale improvements in patient care. 4

5 The QIO Program supports patients by: Providing information to help you better manage your own healthcare, Reviewing quality of care complaints, Working with local healthcare providers to make healthcare safer and patient-centered, Listening to you and learning from your experiences, Helping to remove roadblocks between you and better healthcare. 5

6 The QIO Program supports providers by: Managing and sharing evidence-based best practices, knowledge and tools for improving health quality, efficiency and value. Serving as a change agent for rapid, widespread and significant improvements that contribute to broader national healthcare goals. Facilitating collaborative learning and action that results in better, more patient-centered care. Encouraging beneficiaries to take a more active role in their own healthcare. 6

7 QIO Program Priorities Beneficiary- and Family-Centered Care Improving Individual Patient Care by Reducing Healthcare-Associated Infections in Hospitals Healthcare-Acquired Conditions in Nursing Homes Adverse Drug Event and through Quality Reporting Integrating Care for Populations and Communities Improving Health for Populations and Communities 7

8 Objectives Briefly review available anticoagulants and their uses Identify key components of physical assessment of all anticoagulated patients Discuss additional nuances of effective warfarin monitoring and management

9 Why do we care?

10 Warfarin Events in LTC Adverse events: 18.8 per 100 patient months 5.4 preventable events per 100 mos Potential events: additional 6.6 per 100 mos Serious/life threatening/fatal events: 2.5 per 100 mos 57% were preventable

11 Perfect Storm High risk drugs Increased utilization Cardiovascular disease (AF) Surgical/interventional procedures New drugs coming into market Pressure to reduce costs, hospitalizations Underutilization of known best practices 12-20% of LTC residents users Residential facilities uniquely positioned to provide highest quality care

12 Risk of Stroke from AF

13 CHADS 2 Score Ann Intern Med. 16 December 2003;139(12):

14 Annual Event Rate, (%) SPAF III Results: Event Rate Per Year in High-Risk Cohort (N=1,044) %* Aspirin (325 mg/day) plus fixed-dose warfarin (INR, ) Adjusted-dose warfarin (INR, 2 3) 5 * P= N= % 2.4% 2.1% 0.9% 0.5% 0 Ischemic Stroke or Systemic Embolism Major Bleeding Intracranial Hemorrhage SPAF Investigators. Lancet. 1996SPAF Investigators. Lancet. 1996;348: Slide courtesy of Elaine Hylek

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17 ROCK High Quality Care Hard place

18 Types of drugs Antiplatelets Anticoagulants Injectable anticoagulants Oral anticoagulants

19 Antiplatelet Drugs Block activation and clumping of platelets Impact on clotting processes is less than anticoagulants Still carry risk of bleeding, and that risk is increased when used in combinations Examples Aspirin Plavix (clopidogrel), Effient, Brilinta NSAIDS (ibuprofen, naproxen)

20 Anticoagulants Block one or more clotting factors Prolong time to form clot Highly effective in treating existing clots (DVT) Highly effective in preventing clots (e.g. Afib, postorthopedic surgery) Increase risk of bleeding more than antiplatelet drugs

21 Injectable Anticoagulants Heparins Heparin Low molecular weight heparins Lovenox Fragmin Innohep

22 Oral Anticoagulants Warfarin (Coumadin, Jantoven) New Agents Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis)

23 Monitoring Antiplatelet drugs: Some use of testing in cardiac catheterization setting Injectable anticoagulants Heparin: PTT LMW Heparins: No testing Oral anticoagulants Warfarin: PT/INR New agents: No testing

24 Physical Assessment Incredibly important Under or overtreatment can be catastrophic Timely response can save lives Nursing staff perfectly positioned to identify issues over time via relationship with patient

25 True or False: The approach to the physical assessment of an anticoagulated patient depends on the drug used?

26 Purpose Today Acknowledge head to toe assessment is standard Identify and focus in on key findings in the anticoagulated patient Later identify nuances of warfarin

27 Domain #1: Visible bleeding Blood is red (amazing!)- anywhere Pink- urine, undergarments Black- tarry stool Black and blue- bruising

28 Most bleeding episodes visible

29 Domain #2: Stroke Anticoagulants protect against thromboembolic stroke Increase risk of hemorrhagic stroke Assessment standard for stroke Thromboembolic (i.e. anticoagulant failure) Hemorrhagic (adverse drug event) (Also consider severe headache, mental status changes, etc )

30 Stroke Symptoms Stroke symptoms include: SUDDEN numbness or weakness of face, arm or leg - especially on one side of the body. SUDDEN confusion, trouble speaking or understanding. SUDDEN trouble seeing in one or both eyes. SUDDEN trouble walking, dizziness, loss of balance or coordination. SUDDEN severe headache with no known cause.

31 Domain #3: Indirect signs/symptoms You know your patient best. Do they pass the look test? Malaise? Headache, mental status changes? Limp? Other Clinically relevant blood loss contributes to Decreased blood volume (hypovolemia) Decreased oxygen carrying capacity (hypoxia) Inappropriate fluid accumulation in body cavities (pain, discomfort)

32 Assessing Hypovolemia Vital signs (acute onset, change from your known baseline) Tachycardia Hypertension Orthostatic hypotension Tachypnea Dehydration (less acute) Thirst, dry eyes, dry mouth Skin turgor Decreased urine output, constipation

33 Assessing Hypoxia Tachypnea Reduced O2 saturation Tachycardia Hypertension Ischemia (e.g. angina, MI) Cyanosis Mental status changes, lethargy, dizziness Nausea ( Also consider S/S pulmonary embolism - anticoagulant failure)

34 Inappropriate Fluid in Compartment Left flank pain and hypotension developed in a 62-year-old woman during treatment with intravenous heparin (900 U per hour) and warfarin (7.5 mg per day) for deep venous thrombosis. Coagulation studies showed a prothrombin time of 15.5 seconds, an international normalized ratio of 1.29, a partial-thromboplastin time of 102 seconds, and a platelet count of 132,000 per cubic millimeter. Computed tomography showed a large, mixed-density mass in the left side of the abdomen suggestive of a large retroperitoneal hematoma. N Engl J Med 2000; 342:702March 9, 2000

35 Domain # 4:Falls! Primary cause: Hypoxia, e.g. Secondary harm: Head injury Process Incident reports Thorough evaluation

36 Domain #5: Misc Heightened awareness/surveillance New patients Initiation of anticoagulants Change in clinical status Procedures Events

37 Nuances of Warfarin INR range Factors affecting INR and bleeding risk New user Changes in clinical condition (fever, HF exacerbation, e.g.) New drugs added (especially antibiotics) Drugs discontinued Diarrhea Change in diet PRN med use (NSAIDs, aspirin, acetaminophen)

38 Warfarin and Infection/Antibiotics Infections are associated with warfarin/inr instability Fever Dehydration Change in diet, metabolism, drug clearance Antibiotics directly or indirectly interact with warfarin Directly block metabolism, increase INR Indirectly affect INR through diarrhea, vitamin K intake Short courses of abx may be overlooked in routine INR testing 38

39 Warfarin and Antibiotics Patients who use warfarin-potentiating drugs had significantly more hemorrhagic events The majority of warfarin users (80%) took at least one interacting medication The highest likelihood of hemorrhagic events was found among patients who took: Anticoagulants Antibiotics Antiplatelet drugs Analgesics 39

40 Warfarin/Antibiotic Quality Measure Percentage of warfarin users prescribed an interacting antibiotic who receive INR testing within 3-7 days of initiation of the antibiotic (National Quality Forum Measure #0056) Quality care thus requires more frequent monitoring when antibiotic starts (i.e. in addition to routine monitoring) Also consider continued monitoring AFTER antibiotic stopped. 40

41 Necessary System Components Updated policies and procedures Maintenance (e.g. routine monitoring interval) Acute responsiveness Key elements Patient identification Drug selection Indications Contraindications Dosing Monitoring (routine and acute) Response Documentation Outcomes Quality Improvement

42 General Approach for Facility Make ALL staff aware of findings to report Administrative staff Aides Provide formal training to nursing staff RN LPN Update training and processes often 42

43 Approach for Nursing Routine comprehensive evaluation of anticoagulated pt performed AND documented (e.g. weekly) Ongoing surveillance and responsiveness

44 Progression of Surveillance Scheduled Assessment Scheduled routine assessment and documentation Objective assessment and response if ANY findings Heightened awareness Ongoing subjective surveillance (i.e. look test ) Response to findings Objective assessment and response if ANY findings

45 Appropriate Response Immediate notification of objective findings Nursing supervisor Physician on call Organized documentation All findings Communications Responses/orders (Include stat INR for warfarin) Assure cohesive care (e.g. next shift) Follow up

46 AMDA Recommendation Medical directors may wish to implement a facility policy that staff members may not remove an antibiotic from the facility s emergency medication supply without first confirming whether or not the patient for whom the antibiotic is intended is receiving warfarin and then obtaining the practitioner s direction or seeking the advice of a pharmacist. American Medical Directors Association, Antithrombotic Therapy in the Long Term Care Setting,

47 Case #1 Mrs. Simmons is a frail, 86yo woman receiving warfarin for chronic AF. Her monthly INR was drawn 2 days ago, and was 2.8. She has history of OA and HTN, and today develops a UTI. She is prescribed SMZ/TMP DS BID x 10 days. 47

48 Case #1 Mrs. Simmons is a frail, 86yo woman receiving warfarin for chronic AF. Her monthly INR was drawn 2 days ago, and was 2.8. She has history of OA and HTN, and today develops a UTI. She is prescribed SMZ/TMP DS BID x 10 days. What risk factors does she have for bleeding? warfarin, age, HTN, analgesics? Abx? Frail? What is a reasonable approach to her care at this point? Alert practitioner, perhaps switch antibiotics, get INR every 3-5 days until stable 48

49 Case #2 Mr. Canoli is an 88 year old male receiving drug therapy for AF (warfarin), Type II DM, and mild dementia. He is typically very active, good natured, and talkative. This morning he declines breakfast and refuses to get out of bed. He is terse with the aide, and is overheard arguing with his deceased wife. 49

50 Case #2 Mr. Canoli is an 88 year old male receiving drug therapy for AF (warfarin), Type II DM, and mild dementia. He is typically very active, good natured, and talkative. This morning he declines breakfast and refuses to get out of bed. He is terse with the aide, and is overheard arguing with his deceased wife. What might be going on with Mr Canoli? Hypoglycemia? Infection? Bleeding-related complication? What are reasonable steps to take? Objective evaluation: Physical, BG, alert practitioner of any findings Check INR and follow until stable 50

51 Summary Anticoagulants are frequently used, highly effective agents Inherent risks require robust systems of care Nurses are uniquely positioned to monitor and respond All anticoagulants require similar elements of routine assessment and ongoing surveillance Signs and symptoms of bleeding may be overt or subtle Subtle changes warrant objective evaluation Objective findings warrant immediate, organized responses

52 This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM

53 For more information Darren Triller, PharmD Senior Director (518) IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY Template 1/13/2012