Inpatient Anticoagulation Management Services to Improve Transitions of Care

Inpatient Anticoagulation Management Services to Improve Transitions of Care Andrea Resseguie PharmD, RPh, CACP Advanced Practice Clinical Specialist Anticoagulation Management Service

Learning Objectives List Inpatient Anticoagulation Management Services (AMS) at Brigham & Women s Hospital Review Inpatient AMS workflow AMMO Discuss importance of inpatient AMS to improve transitions of care

Inpatient Anticoagulation Management Services AMMO = Anticoagulation Management for Post- Orthopedic Surgery Inpatients HAT = Hemostatic and Antithrombotic Stewardship

High Risk Populations Followed Inpatient by AMS AMMO Major Orthopedic Surgery (Total Hip Replacement, Total Knee Replacement) HAT Ventricular Assist Device (VAD)

Inpatient Anticoagulation Management Services cont. Inpatient physician orders consult Brigham and Women's Hospital (BWH) Department of Pharmacy AMS Monitor & order warfarin every day AMMO = post orthopedic surgery patients requiring warfarin INR target range of 1.8 2.3 Duration = 3 weeks HAT = VAD patients requiring warfarin INR target range dependent on VAD device Duration = indefinite

AMMO Service Roles & Responsibilities Individual Responsibilities Orthopedic Surgery Resident/ Responding Clinician AMMO Primary Pharmacist AMMO Secondary Pharmacist Orders initial consult, warfarin dose day before surgery, and warfarin dose day of surgery Communicate changes in patients clinical conditions Cosign daily warfarin orders Process the consult (viewable through Consult Messages ) Enters new patient demographic into DAWN AC Write EPIC consult note Emails daily patient roster to pharmacists Orders warfarin dose in EPIC Documents daily progress note into DAWN AC

AMMO Inpatient Workflow EPIC DAWN AC EPIC DAWN AC Order consult AMMO primary RPh review consult & write AMMO intake note Add patients into system AMMO Primary RPh create daily inpatient roster AMMO secondary RPh monitor & order warfarin AMMO secondary RPh document daily progress note

EPIC Order Consult Required for consult Referring physician (Surgeon) Primary indication for anticoagulation (Orthopedic surgery) Type of surgery Date of surgery INR target range Duration

AMMO Primary RPh Workflow EPIC Review consult Write AMMO intake note DAWN AC Add patients into system Create daily inpatient roster

EPIC Consult Review

AMMO Intake Note BWH Department of Pharmacy Anticoagulation Management Service (AMS) Patient Name: Patient MRN: DOB Age Gender: Date: Time: Consult Reason: Asked to assist in warfarin management for the Anticoagulation Management for Inpatient Post-Operative Orthopedic (AMMO) service Indication for Anticoagulation: Orthopedic Surgery Type of Surgery: *** Target INR: *** - *** Duration of Therapy: *** Referring attending MD: Consult Received: The BWH Department of Pharmacy Anticoagulation Management Service will manage the warfarin dosing for Patient while an inpatient. For daily progress notes and dosing instructions please click on the AMS indicator in the patient header and an anticoagulation report will display on the right side of the screen. For any questions or concerns, please feel free to contact the AMS service via email (BWHRxInpatientAMS@partners.org) or contact the covering floor pharmacist for any urgent matters.

DAWN AC: Adding AMMO Patients If patient is NOT in Dawn AC Create new patient record Enter patient details (Name, MRN) Enter treatment plan details (Primary Diagnosis: Orthopedic Surgery, Start Date (POD -1), First seen date (POD 1), Next test date (POD 1)) Duration: Select short term, and enter # of weeks Under the Referral tab, enter in Attending Surgeon (Referring MD) Set status to Active Admitted If patient is ALREADY ACTIVE in Dawn AC Edit patient s status Treatment Plan: change from Admitted to Active admitted Re-schedule patient for POD 1 If patient is ALREADY in system but INACTIVE Reactivate patient (Personal tab: change status from Inactive to Reactivate) Create New Treatment Plan (Primary Diagnosis: Orthopedic Surgery, Start Date (POD -1), First seen date (POD 1)) Duration: Select short term, and enter # of weeks Under the Referral tab, enter in Attending Surgeon (Referring MD) Click Admit, then Activate Admitted Schedule patient for POD 1 Letters Tab: Select a custom message to send >>> Retrieve patient demographics from EMPI Once demographics have uploaded >>> Retrieve patient medications Write Note within Patient Profile: AMMO following while inpatient for diagnosis(i.e. TKR) on date of surgery per physician (i.e. Dr. Wright). Your name

DAWN AC: Create Daily Inpatient Roster DAWN AC home page >>> Patient List/Daily Routines Status tab >>> filter for active admitted Send email containing inpatient roster to AMMO secondary RPh

AMMO Secondary RPh Workflow EPIC Monitor & order warfarin DAWN AC Document daily progress note

Warfarin Initiation Dosing Protocol (INR Range 1.8 2.3) POD INR Dose <1.2 No change 1 1.2-1.3 No change or decrease by 1 mg 1.4-1.5 HOLD or decrease by 1-3 mg >1.5 HOLD 2 <1.3 Increase by 2 mg 1.3-1.5 Continue or increase by 1 mg If dose was held and INR is <1.5, restart at last dose 1.6-2.0 No change or decrease by 1-2 mg If INR increased 0.4-0.5 in 24h, decrease by 1 mg If INR increased by >0.5, decrease by 2 mg If dose was held and INR <1.8, average last 3 doses & add 1-2 mg. If dose was held and INR 1.8-2.3, average last 3 doses >2.0 Decrease by 1 mg *Hold if INR increased by 0.6 in 24h 3 <1.3 Increase dose by 2 mg 1.3-1.5 No change or increase by 1 mg If dose was held, average previous doses and cont. or increase by 1mg 1.6-2.0 No change or decrease by 1-2 mg If INR increased by 0.4-0.5 in 24h, decrease by 1 mg If INR increased >0.5 in 24h, decrease by 2 mg If dose was held, average previous doses and cont. or increase by 1mg >2.0 Decrease by 1 mg or HOLD if INR increased 0.6 in 24h If dose was held, average previous doses and decrease by 1mg or hold

Ordering Warfarin Within EPIC

Holding Warfarin Within EPIC Nursing Communication Comments Section = PLEASE HOLD WARFARIN DOSE THIS EVE (MM/DD/YYYY). Call pharmacy with any questions on warfarin

DAWN AC: Daily Progress Note Documentation

DAWN AC: Daily Progress Note Documentation cont. Enter INR Document daily progress note within treatment notes

Coded Comments.POD1.POD Date/time: POD 1 PMH: SH: Meds: Hct: Blood products: POD 0 INR/warfarin dose: Plan/rationale: Signature: Date/time: POD # Meds: Hct: Plans/Rationale: Signature:

DAWN AC: Daily Progress Note Documentation cont. Select next retest date Accept & authorize

DAWN AC: LMWH Documentation

AMMO Transition of Care Home with no VNA services Inpatient AMMO patient discharged Home with VNA services Rehab Facility

Transition of Care Definition = movement of patients between health care practitioners, settings, and home as their condition and care needs change Problems with transition of care may lead to adverse events and higher hospital readmission rates and costs

AMMO Transition of Care cont. AMS RPh responsible for determining disposition & maintaining outpatient care for the remaining duration of anticoagulation therapy PT/INR tested day after discharge & Q Mon/Thurs Reinforce education & counseling points AMS RPH will enter any missing or pertinent info upon discharge into DAWN AC

Transition of Care Barriers & Solutions Communication Clinicians effectively & completely communicate important information in a timely fashion among themselves or to patient/ caregiver Culture promotes successful hand-off (teamwork, respect) Standardized procedures in conducting successful hand-off Patient Education Resolve conflicting recommendations, confusing medication regimens, and unclear instructions Include patient/ caregiver in planning related to the transition process Sufficient understanding of medical condition or the plan will more likely buy into the importance of following the care plan Accountability Having a clinical entity take responsibility to assure that the patient s health care is coordinated across various settings and among different providers Steps are taken to assure that sufficient knowledge and resources will be available to the patient upon discharge

Summary of AMMO Transition of Care No gap in AMS coverage Inpatient >>> Outpatient Standardized AMMO training Multidisciplinary communication, collaboration and coordination, including patient/caregiver education, from admission through transition Clinician involvement and shared accountability during all points of transition Timely follow-up, support and coordination after the patient leaves a care setting

Summary of AMMO Transition of Care cont. Allows for efficacy/ safety monitoring TTR Thrombosis Bleeding Patients that have thrombosis INR Range of 2.0 3.0 Duration of 3 months Ensure follow up with outpatient provider to asses long term anticoagulation needs

Questions?