Beyond Warfarin Clinic : Pharmacistmanaged. Anticoagulation Care Services

Transcription

1 Beyond Warfarin Clinic : Pharmacistmanaged Comprehensive Anticoagulation Care Services Nancy L. Shapiro, PharmD, FCCP, BCACP, CACP Clinical Associate Professor Clinical Pharmacist and Coordinator, Antithrombosis Clinic University of Illinois at Chicago College of Pharmacy nlasack@uic.edu 1

2 Objectives Discuss strategies used in the United States to implement antithrombotic stewardship methods that provide quality anticoagulation management in the setting of the traditional anticoagulants, as well as the DOACs. Creating clinical care guidelines on anticoagulants (such as warfarin, low molecular weight heparins, direct oral anticoagulants, and unfractionated heparin) Using electronic prescribing alerts, prescribing reports, and electronic rules in your electronic health record to aid appropriate prescribing and optimize clinical management of anticoagulants 2

3 Centralized Anticoagulation Management Services» Supported by multiple organizations Anticoagulation Forum Institute for Safe Medication Practices American College of Chest Physicians» Benefits Better Outcomes: improved TTR & reduced ADE Lower costs from reduced hospital and ED visits Higher patient satisfaction Witt DM, et al. Chest 2005:127: Entezari-Maleki T, et al. J Clin Pharmacol 2016:56: Rudd KM, et al. Pharmacotherapy 2010:30: Bungard TJ, et al. Pharmacotherapy 2012:32:

4 What is Stewardship? The job of supervising or taking care of something, such as an organization or property. Examples in clinical pharmacy: Antimicrobial stewardship Opioid/pain management stewardship Antithrombotic Stewardship 4

5 Antithrombotic Stewardship Services Antithrombotic Stewardship Services Inpatient Anticoagulation Services Outpatient Anticoagulation Practice Formulary, Pathways, Protocols, Order Sets, Provider Education, Cost Avoidance Chronic Warfarin ATC and Home INR DOAC monitoring Inpatient warfarin, UFH, LMWH, Argatroban, Reversal agents, Peri-Procedure Bridging, Outpt VTE, Pt education, Transitions of care Consults High Risk Pts Pregnancy Pediatrics Cancer ESRD Obesity Combination Tx 5

6 Antithrombosis Clinic Team 6

7 UI-HEALTH CLINICAL CARE GUIDELINES & PROTOCOLS 7

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9 Items Included in the ATC Protocol Procedures for consultation and referral Appointment scheduling Physician contact Emergency procedures Patient records Laboratory procedures Clinic procedures Clinical privileges Initial and Follow-up visits Discharge from clinic Patient Education Process for handling critical and questionable INRs 9

10 Anticoagulation Clinic Procedures - Protocol» Patient interview adherence alcohol use Rx medications OTC medications symptoms of bleeding symptoms of embolism diet Heparin/LMWH injection DOAC 10

11 Clinic Policy Areas Garcia DA et al. Ann Pharmacother

12 Using technology in record keeping Garcia DA et al. Ann Pharmacother 2008;42:

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14 Recommendations for Surgical Interruption UI-Health DOAC Guideline Drug Renal Function CrCl (ml/min) Low Bleeding Risk Surgery High Bleeding Risk Surgery Dabigatran CrCl > days before 3 days before CrCl days before 3-4 days before CrCl <30 3 days before 5-6 days before Rivaroxaban CrCl > days before 1-3 days before Resumption of Therapy: Low Bleeding Risk Surgery* Resumption of Therapy: High Bleeding Risk Surgery* 1 day after #^ 2-3 days after # CrCl days before 2-3 days before CrCl days before 2-3 days before Apixaban CrCl > days before 2-3 days before CrCl days before 2-3 days before Edoxaban CrCl > days before 2-3 days before Discontinue edoxaban at least 24 hours before invasive or surgical procedures 1 day after #^ 2-3 days after # 1 day after #^ 2-3 days after # 1 day after 2-3 days after *Ensure adequate hemostasis is achieved before resuming anticoagulation #When initiating a DOAC after an orthopedic procedure for VTE prophylaxis, refer to Section. II (FDA-Approved Dosing) 14

15 Procedure Bleeding Risk Minimal Bleeding Risk Low Bleeding Risk (2 day risk of major bleed <2%) High Bleeding Risk Procedures (2 day risk of major bleed 2%) Minor dermatologic procedures (e.g. excision of basal and squamous skin cancers, actinic keratosis, and premalignant or cancerous skin nevi) Cataract procedures Dental cleanings, fillings Minor dental procedures (simple dental extractions, restorations, prosthetics, endontonics) Cutaneous/lymph node biopsies Shoulder/foot/hand surgery Coronary angiography Gastrointestinal endoscopy +/- biopsy Colonoscopy +/- biopsy Abdominal hysterectomy Hemorrhoidal surgery Bronchoscopy +/- biopsy Epidural injections with INR < 1.2 Pacemaker battery change Arthroscopy Cancer surgery Major orthopedic surgery Reconstructive plastic surgery Transurethral prostate resection, bladder resection, or tumor ablation Nephrectomy, kidney biopsy Colonic polyp resection Bowel resection Purcutaneous endoscopy gastromy (PEG) placement, endoscopic retrograde cholangiopancreatography (ERCP) Cardiac, intracranial, or spinal surgery Surgery in high vascular organs (kidneys, liver, spleen) Any major operation (procedure duration > 45 minutes) Pacemaker or cardioverter-defibrillator device implantation J Thromb Thrombolysis Aug;36(2):

16 DOAC MONITORING EXAMPLES FROM OTHER INSTITUTIONS 16

17 Sylvester KW, et al. Journal of Thrombosis and Thrombolysis (2018) 45:

18 USING PRESCRIBING REPORTS TO AID DOAC MONITORING 18

19 UI-Health DOAC Monitoring Service Process» Prescribing report is ed daily, containing a list of electronic DOAC prescriptions from the day prior» On average, reviewed by ATC staff 3 half days a week» New prescription Call patient to provide initial education and ensure DOAC started Contact provider if necessary» Refill Call patient if history of nonadherence or drug intolerance documented Contact provider if necessary If patient is due for labs, will forward note to provider» Redcap Calendar utilized for follow up 19

20 Note Template Direct Oral Anticoagulation (DOAC) Screening If continued DOAC monitoring by the Anti-Thrombosis Clinic (ATC) is desired, please place a formal consult order (AMB Anticoagulation Consult) in Cerner. Patient has been screened for eligibility for based on indication, contraindication, renal function, weight and drug indications. is currently an appropriate choice for anticoagulation in this patient and the dosing is accurate. ( ) Unable to reach patient over the phone to verify medication access and adherence and provide patient education. One message was left for the patient which was not returned. OR ( ) Spoke to patient/ caregiver over the phone and verified medication adherence. Provided patient education on indication, side effects, adherence, monitoring, drug interactions and transitions of care. zzmedications zzcc1 zzcbc zzlfts Follow-up appointment: Next CC1 due: ( )Annually [CrCl >60] ( )Q6months [CrCl 30-60, Age > 75, drug interactions] ( )Q3months [CrCl 15-30, h/o fluctuating CrCl, recent change in dose due to renal function] ( ) Not needed as patient on HD (apixaban only) Next CBC due: ( )Annually ( )Q6months [low baseline H/H, previous bleed, drug interactions, age >75] ( ) Within 1-2 months due to elevated bleeding risk 20

21 DOAC Monitoring Service Preliminary Results Uppuluri E, Shapiro NL. 14th National Anticoagulation Forum. Los Angeles, CA. April 20,

22 DOAC Monitoring Service Number of patients spoken to New: 97 (97/265= 36.6%) Refill: 52 (52/526= 9.8%) Number of interventions New: 70 (70/265=26.4%) Refill: 70 (70/526= 13.3%) Uppuluri EM, McComb MN, Huang S, Wang K, Shapiro NL. Presented at the UI-Health Safety Forum October

23 More Recent Intervention Status N=70 N=86 Uppuluri EM, McComb MN, Huang S, Wang K, Shapiro NL. Presented at the UI-Health Safety Forum October

24 UI-Health DOAC Monitoring: Next Steps» Create new prescribing alerts Drug interaction alerts No refills on starter packs» Increase service to provide coverage daily Minimize delay in acting on interventions» Incorporate workflow into the ATC protocol?» Expand to provide inpatient oversight Catch problems early, before they leave the hospital 24

25 Next steps: Overseeing DOAC Orders While Patient is in the Hospital MedMined Surveillance Advisor 25

26 Inpatient DOAC Stewardship» Review order for appropriateness of use Indication Dose Renal Function Drug Interactions Access for prescription drug coverage» Contact service for orders that need to be addressed/changed» Resolve problems before the patient leaves the hospital 26

27 ELECTRONIC CONSULTS, ORDER SETS, SPECIALTY FLOWSHEETS, ALERTS, POWERNOTES 27

28 ATC Electronic Consult 28

29 Using a Powernote in ATC 29

30 Using a Powernote in ATC 30

31 Powernote working view 31

32 Powernote working view 32

33 DVT Prophylaxis Order Set 33

34 Sample Anticoagulation Orders 34

35 Specialized Anticoagulation Flowsheet 35

36 Alerts for ED visits, Hospital Admission, Discharge 36

37 Alerts for changes in renal fxn, weight 37

38 Other Sample Protocols 38

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40 UI-Health Decision Tree for Mgmt of Major Bleeding from CCG G

41 UI-Health Antithrombotic Reversal in Adult Patients CCG G May

42 UI-Health Antithrombotic Reversal in Adult Patients CCG G May

43 Conclusions» This is an exciting time to work in the field of antithrombotic therapy» It is time to embrace the idea of Antithrombotic Stewardship across all health settings Use technology to help us Ensure consistent processes Access better quality reporting Achieve better outcomes 43