4/9/2013. Best Practice Initiative: Inpatient Anticoagulation Stewardship. Dorcas Letting reports no relevant financial relationships

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1 Disclosure Best Practice Initiative: Inpatient Anticoagulation Stewardship Dorcas Letting reports no relevant financial relationships Dorcas Letting-Mangira, Pharm.D Pharmacotherapist, Internal Medicine PGY1 Residency Program Director Summa Health System Objectives Become familiar with JC National safety goal for warfarin anticoagulation Understand the steps of implementing a new pharmacy service Review the tools available to optimize patient s anticoagulation management Understand the challenges in transition of patients on anticoagulation therapy Understand the role of a technician in anticoagulation management Preventable Disaster #1 46 yo comes to ED c/o disorientation, headache, and ataxia. History of HTN, hypothyroidism, PUD. Was on warfarin 6mg daily for DVT/PE, CT of head revealed subdural hematoma, cerebral edema. INR > 15. Patient did not recover What could we have done to prevent this outcome? Preventable Disaster #2 Patient in the hospital, on warfarin, started on TMP/SMX for uncomplicated cystitis. Three days later patient has gross blood in their stool and low blood pressure, INR checked and found to be 1 What recommendations could pharmacy give to help minimize this adverse event? Preventable Disaster #3 Patient with an in range INR, mitral mechanical heart valve admitted to hospital for a new hip fracture. Patient given 1mg oral vitamin K to lower INR for surgery the next day. After her surgery, she remains in the hospital for 7 days as the clinicians attempt to get her INR therapeutic (pt not a candidate for LMWH) What cost implications does this have to the hospital? What could we have done to minimize this? 1

Patient Safety Standards The hospital implements a defined anticoagulation management program to individualizethe care provided to each patient receiving anticoagulant therapy The hospital uses

2 Patient Safety Standards The hospital implements a defined anticoagulation management program to individualizethe care provided to each patient receiving anticoagulant therapy The hospital uses approved protocolsfor the initiation and maintenance of anticoagulation therapy appropriate to the medication used, to the condition being treated, and to the potential for medication interactions. Why Anticoagulants Fanikos, et. al. analyzed medication errors reported in a hospital and found 7.2% were due to anticoagulants 6.2% of these patients required medical intervention and 1.5% needed a prolonged hospital stay Winterstein, et. al. showed that 32.2% of preventable ADEs in a teaching hospital involved anticoagulants Double the amount caused by any other medication class Fanikos J, et. al. Am J Cardiol. 24;94(4): Winterstein AG, et. al. Am J Health Syst Pharm. 22;59(18): Why Anticoagulants Top 5 Reported Drug Errors #5. heparin #7. warfarin #12. enoxaparin Top 1 Drug Errors Causing Harm #3. heparin #4. warfarin Medication Errors Occurring in Patients Homes #1. warfarin #5. enoxaparin #7. heparin Why do this Patient safety concerns Regulatory Compliance Financial Implications 1. US Pharmacopeia US Pharmacopeia US Pharmacopeia pdf. 2

Safety Practices Focus Written guidelines/policies Standardized order set Standardized chart documentation Defined monitoring standards Document anticoagulation education Transition of care at the

3 Safety Practices Focus Written guidelines/policies Standardized order set Standardized chart documentation Defined monitoring standards Document anticoagulation education Transition of care at the point of discharge (order set) Benefits of the program Improve patient care - standardized practices - reduced complications - improve compliance - Reduce cost - Improve continuity of patient care - Reduce inpatient mortality rates - Improve patient experience The Model for Improvement What are we trying to accomplish Available resources/team members Design a step-wise approach Identify and create resources Identify parameters to measure success Prepare for modifications to improve implemented processes Build a case for coverage and expansion Improvement Team Characteristics position power, expertise, credibility, leadership Disciplines pharmacy, physicians, nursing, quality, information technology Goal assess/plan/implement a process to improve and maintain best practice with ongoing monitoring Objective create a pharmacist-driven warfarin management service Getting started Warfarin Order Set Identify a physician champion Creation of the warfarin order set Propose and implement a pilot Create policies for approval Education of the staff Pharmacists Nursing physicians Set expectations and communication tools 3

Warfarin Discharge Order Set Expectations for ALL patients Defines a baseline INR as occurring within the last 24 hours prior to the current order for warfarin INRs from any facility are acceptable

4 Warfarin Discharge Order Set Expectations for ALL patients Defines a baseline INR as occurring within the last 24 hours prior to the current order for warfarin INRs from any facility are acceptable Pharmacists to review the baseline INR prior to dispensing the first dose of warfarin Applies to new starts and continuation patients Pharmacists to review the patient record to assess the appropriateness of the dose Pharmacists will be able to independently order INR if needed Pilot Program: Pharmacy Consult Service Pharmacy consulted by medical staff for anticoagulation management Pharmacy Residents with preceptor guidance Receive consult calls Review patient case Documentation(initial consult note, daily notes) Communicate with provider to address urgent warfarin related issues Place orders (doses, INR) Summa Anticoagulation Clinic Patients -admitted to the hospital will be automatic consults Resources Pharmacy Consult policy (P&T/Medical Executive approved) Warfarin dosing normogram (P&T approved) Pharmacy Consult chart sticker Pharmacist Monitoring Form SAMS referral form (outpatient management) Tools Phone, pager, binder Education In-services and resources for difficult cases Reporting of safety & effectiveness data Challenges during the Pilot Communication knowing exactly when and where the patient is going after discharge Changes in discharge plan Knowing when patients are discharged from SNF or Rehab New referrals physicians/nurses slowly learning the process and inability to document in standing stone Non-SAMS patients on SAMS list in PLATO Action Plan Nursing in-services nursing units, PLATO super-user group and nurse practice council group presentations, PFE newsletter, Pharmacy newsletter Physician education Family practice and internal medicine departments, SPI group Communication with nurses/nurse managers/physicians to plan discharges Communication with SAMS staff patient list, follow up issues, weekend documentation.communication. 4

5 Pharmacy Consult Service (n=223) Total Number Warfarin Consults Sept 211 April 212 Warfarin n=25 PCK n=3 Drug SE n=5 Drug Interaction n=1 Poly Pharmacy n=9 Medication Adherence September 211 April 212 Warfarin Discharge Data Total Warfarin consults (# Patients) 25 SAMS Patients # 84 New SAMS Patients # 42 Non-SAMS Patients # 126 SAMS SNF/Rehab Discharges # 18 Average INR at 3 days for new SAMS pts INR < 1.8 Subtherapeutic INR (< 1.9) Therapeutic INR Supratherapeutic 3 (7%) 38 (93%) Anticoagulation Stewardship Program Business Case Communicate vision and request resources Outline Background and environmental analysis Proposal Benefits to the organization Resource requirement Financial analysis (ROI) Key deliverable actions and timelines Anticoagulation Stewardship Definition. My version Pharmacist-driven coordination of care designed to manage, measure and improve the use of anticoagulants by implementing processes to promote optimal and safe use of anticoagulant regimen to achieve best clinical outcome Summa Health System (ACH) Anticoagulation Stewardship Program Objective:To improve anticoagulation management and safety in warfarin patients through patient education, increased communication with providers, use of evidencebased dosing, and focus on transitions of care Team Players: Lead Pharmacist, Pharmacy residents, Pharmacy Technicians Clinical staff pharmacists cover the service on weekends/holidays 5

Modification to Pilot Program Focus on warfarin management portion of the consult service Warfarin order set changes Partnership with Internal Medicine center to provide warfarin management and

6 Modification to Pilot Program Focus on warfarin management portion of the consult service Warfarin order set changes Partnership with Internal Medicine center to provide warfarin management and outpatient transitions to patients on Medicine Teams Call back program to all discharged warfarin patients to follow up regarding INR checks. Anticoagulation Stewardship: Pharmacy Technician Job Description (expectations/qualifications) Experience interacting with patients Good communication skills Good computer skills (pass test Microsoft word, excel, access) Monday Friday (first shift) Training Computer programs Excel, Access, PLATO, Standing stone Anticoagulation Stewardship: Pharmacy Technician Responsibilities: Communication with pharmacists, nurses and patients (new consults, discharges etc) Call back program Research data collection/entry Professional development maintain pharmacy technician certification Successes Program growth 1 st quarter consults 4 th quarter consults Improved transitions of care Mean follow up days after discharge: Consult patients: 2.9 days Non-consult patients: 6.9 days Readmission Rate for Consult Group Number of SAMS Referrals SAMS Referrals 25 Number of Referrals July August September October November December January 6

7 Current Challenges 16 MEDMARX Top Therapeutic Classes chart from 9/1/21 to 12/31/212 (your facility) Coverage for time off 14 Training of weekend/holiday coverage pharmacists Coordination of follow up on weekends/holidays Work load (rapid growth) Transitions of care to other settings (SNF, Rehab, HC, PCP ) # of Errors MEDMARX Top Generic Names chart from 5/1/21 to 12/31/212 (your facility) Future Enhancement # of Errors Anticoagulation transitions in the ED Anticoagulation selection for new starts Formal anticoagulation stewardship rounds with a physician Anticoagulation in pre-operative & preprocedural patients develop bridging protocol and order set Standardize Anticoagulation patient education across all units (booklet, TV, Nursing/pharmacy) Preventable Disaster #1 46 yo comes to ED c/o disorientation, headache, and ataxia. History of HTN, hypothyroidism, PUD. Was on warfarin 6mg daily for DVT/PE, CT of head revealed subdural hematoma, cerebral edema. INR > 15. Patient did not recover What could we have done to prevent this outcome? Preventable Disaster #2 Patient in the hospital, on warfarin, started on TMP/SMX for uncomplicated cystitis. Three days later patient has gross blood in their stool and low blood pressure, INR checked and found to be 1 What recommendations could pharmacy give to help minimize this adverse event? 7

$Preventable Disaster #3 Patient with an in range INR, mitral mechanical heart valve admitted to hospital for a new hip fracture. Patient given 1mg oral vitamin K to lower INR for surgery the next day.$

8 Preventable Disaster #3 Patient with an in range INR, mitral mechanical heart valve admitted to hospital for a new hip fracture. Patient given 1mg oral vitamin K to lower INR for surgery the next day. After her surgery, she remains in the hospital for 7 days as the clinicians attempt to get her INR therapeutic (pt not a candidate for LMWH) What cost implications does this have to the hospital? What could we have done to minimize this? References Schillig J, Kaatz S et al. Clinical and Safety Impact of an Inpatient Pharmacist-Directed Anticoagulation Service. J Hosp Med 211;6: Dager WE, Branch JM et al. Optimization of inpatient warfarin therapy: impact of a daily consultation by a pharmacist-managed anticoagulation service. Ann Pharmacother 2;34: The Joint Commission. 29 National Patient Safety Goals. Available at: Accessed March 212. Holbrook A, Schulman S et al. Evidence-based Management of Anticoagulant Therapy: American College of Chest Physicians evidence-based clinical practice guidelines (9 th Edition) Chest 212;141(2):152S-184S. References Donovan J, Drake J et al. Pharmacy-managed anticoagulation: Assessment of in-hospital efficacy and evaluation of financial impact and community acceptance. J Thromb Thrombolysis 26;22:23-3 Boddy C. Pharmacist involvement with warfarin dosing for inpatients. Pharm World Sci 21;23: Ellis RF, Stephen MA et al. Evaluation of a pharmacy-managed warfarin monitoring service to coordinate inpatient and outpatient therapy. Am J Hosp Pharm. 1992;49:

Inpatient Anticoagulation Management Services to Improve Transitions of Care

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