Harrison Memorial Hospital Cynthiana, KY. Rachel Harney, PharmD Director of Pharmacy ADEs Related to Coumadin March 1, 2018

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1 Harrison Memorial Hospital Cynthiana, KY Rachel Harney, PharmD Director of Pharmacy ADEs Related to Coumadin March 1, 2018

2 About Us HMH is a regional healthcare facility licensed to operate 61 beds 20 private med/surg rooms 6 ICU rooms 12 bed ER including 4 trauma rooms 7 labor and delivery rooms 7 chemotherapy/infusion suites 4 FT pharmacists, 3 FT certified technicians, several PRN pharmacists for after hours calls

3 What were our concerns? Anti-coagulation safety in response to NSPG 3E Sub and supra therapeutic INR levels upon admission Heparin dosing complexities Poor compliance in warfarin patients to dietary recommendations after discharge Poor compliance in warfarin patients to follow-up appointments and lab work

4 How did we begin? Started a pharmacist driven Anticoagulation Care Clinic (ACC) Recently celebrated the 5 year anniversary Still see between patients per month Has helped in-hospital management and discharge continuity of care ACC patients are flagged so ACC pharmacists can dose and discuss with providers during inpatient stay and dose and counsel patients at discharge

5 Anticoagulation Care Clinic Developed polices and procedures based on outpatient warfarin clinics from around the state Discussed at length with community physicians to ensure referrals 5 physician groups Tested 3 different POC INR machines I-Stat Coagucheck Coagusense Test patients thru billing to ensure payment

6 Anticoagulation Care Clinic Drafted collaborative care agreement and gathered all needed pharmacist/physician and patient signatures (ongoing process when new patient enrolled) The Pharmacy Practice Act allows pharmacists to practice under a Collaborative Practice Agreement with individual physicians. Pharmacist may participate in the practice of managing and modifying drug therapy according to a written protocol between the specific pharmacist and the individual physician(s) who is/are responsible for the patients care and authorized to prescribe drugs. By signing this document, the named physicians agree that the named pharmacists may enter into a Collaborative Practice for their patients.

7 Anticoagulation Care Clinic Two primary pharmacists Takes care of patients/completes progress notes Handles the scheduling of patients (Mon Fri 8-4) Calls in all prescriptions Communicates results/plan with physicians Back up pharmacists for vacations, etc Every pharmacist signs collaborative care agreement for every patient

8 Problems? Administration questioned financial viability of an anticoagulation care clinic Referral process from physician offices QI checks on POC machine Patients coming for scheduled appointments

9 What else? Every inpatient at HMH receiving enoxaparin, heparin or warfarin is monitored daily for dose changes, continuation of home therapy, lab values, possible drug interactions, etc.

10 Enoxaparin adjustments? Every inpatient at HMH receiving enoxaparin is monitored daily for changes in renal function or condition Pharmacists can automatically adjust enoxaparin doses based on renal function or fluctuations in patient weight

11 Heparin dosing? A dosing protocol was developed by pharmacy and approved by the medical staff Allows pharmacy to do all dosing and lab monitoring on all inpatients receiving heparin Every inpatient at HMH receiving heparin is monitored by a pharmacist until medication discontinuation

12 Warfarin monitoring? Pharmacy does NOT dose warfarin automatically, a provider consult request is required Every inpatient receiving warfarin at time of admission is monitored daily, even if warfarin is not restarted as an inpatient Monitoring of INRs, possible drug interactions, SUBtherapeutic INRs when bridge therapy may be indicated, etc. Discharge counseling is completed on every patient discharging home on warfarin

13 Problems? HMH does not have 24 hour pharmacy services On-call pharmacists are available by phone 24 hours/day Patients being admitted with supra-therapeutic INRs from outside facilities These patients are monitored even more carefully for signs and symptoms of high INRs, if reversal agents are needed, when home doses should be restarted, etc

14 Problems? Therapeutic patients being started on medicines as inpatients that could cause changes in INR Provider education with memos, discussions at medical staff meetings and reminder posters being placed in provider work rooms listing TOP 10 INTERACTIONS More aggressive suggestions from pharmacy to providers; more phone calls, more face to face discussion with providers during rounding times

15 Problems? Interdepartmental communication- discussions with nursing, pharmacy and dietary concerning what information and how the information would be distributed to patients Pharmacists or nursing or dieticians counsel all warfarin patients concerning dietary intake of vitamin K and written education is given to every patient being discharged on warfarin (sometimes all 3 disciplines) Pharmacy, nursing and dietary stress the importance of follow-up appointments, dietary consistency and lab work

16 Results ADEs due to warfarin 25.00% 20.00% 20.00% 18.18% 16.67% 15.00% Percentage 10.00% 11.11% 9.09% 5.00% 3.57% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 1/28 2/10 0/3 1/9 0/12 2/11 0/4 1/6 0/4 0/8 0/8 1/11 0/8 baseline Values/Month

17 Results ADEs due to warfarin 14.00% 12.50% 12.00% 10.00% Percentage 8.00% 6.00% 4.00% 2.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0/8 1/8 0/6 0/6 0/11 0/5 0/6 0/8 0/6 0/4 0/8 0/ Values/Month

18 Results ADEs due to warfarin 12.00% 11.00% 10.00% 8.00% Percentage 6.00% 4.00% 2.00% 0.00% 0.00% 0.00% 0/4 1/9 0/ Values/Month

19 Key Tips for Success! Be diligent! Outstanding record keeping Open communication between physicians and pharmacists Helping patients understand the importance of follow-up