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4/9/2013
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Dorcas LettingDorcas Letting--Mangira, Pharm.DMangira, Pharm.DPharmacotherapist, Internal MedicinePharmacotherapist, Internal Medicine
PGY1 Residency Program DirectorPGY1 Residency Program DirectorSumma Health SystemSumma Health System
Best Practice Initiative: Inpatient Anticoagulation Stewardship
DisclosureDisclosure
� Dorcas Letting reports no relevant
financial relationships
ObjectivesObjectives
� 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 #1Preventable 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 #2Preventable 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 10
What recommendations could pharmacy give to
help minimize this adverse event?
Preventable Disaster #3Preventable Disaster #3
� Patient with an in range INR, mitral mechanical
heart valve admitted to hospital for a new hip
fracture. Patient given 10mg 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?
4/9/2013
2
Patient Safety StandardsPatient Safety Standards
� The hospital implements a defined anticoagulation management program to individualize the care provided to each patient receiving anticoagulant therapy
� The hospital uses approved protocols for the initiation and maintenance of anticoagulation therapy appropriate to the medication used, to the condition being treated, and to the potential for medication interactions.
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
Why AnticoagulantsWhy 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. 2004;94(4):532‐5.Winterstein AG, et. al. Am J Health Syst Pharm. 2002;59(18):1742‐9.
Why AnticoagulantsWhy Anticoagulants� Top 50 Reported Drug Errors
#5. heparin#7. warfarin#12. enoxaparin
� Top 10 Drug Errors Causing Harm#3. heparin#4. warfarin
� Medication Errors Occurring in Patients’ Homes
#1. warfarin#5. enoxaparin#7. heparin
1. US Pharmacopeia. www.usp.org/patientSafety/resources/top50DrugErrors.html.2. US Pharmacopeia. www.usp.org/products/medMarx.3. US Pharmacopeia. www.usp.org/pdf/EN/patientSafety/posters/062004‐‐‐‐03‐‐‐‐29.pdf.
Why do this …Why do this …
� Patient safety concerns
� Regulatory Compliance
� Financial Implications
4/9/2013
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Safety Practices FocusSafety 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 programBenefits 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 ImprovementThe 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 TeamImprovement 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 …Getting started …
� 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
Warfarin Order Set
4/9/2013
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Warfarin Discharge Order SetExpectations for ALL patientsExpectations 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 Pilot Program: Pharmacy
Consult ServiceConsult 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
ResourcesResources
� 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 PilotChallenges 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 PlanAction 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….….COMMUNICATION….
4/9/2013
5
Warfarinn=205
Drug SE
n=5
Drug Interaction
n=1
PolyPharmacy
n=9
Medication Adherence
PCKn=3
Pharmacy Consult Service (n=223)
Pharmacy Consult Service (n=223)
September 2011 – April 2012
Total Number Warfarin ConsultsTotal Number Warfarin Consults
Sept 2011 Sept 2011 –– April 2012April 2012
Warfarin Discharge Data
Total Warfarin consults (# Patients) 205
SAMS Patients # 84
New SAMS Patients # 42
Non-SAMS Patients # 126
SAMS SNF/Rehab Discharges # 18
Average INR at 30 days for new SAMS pts
INR < 1.8
Subtherapeutic INR (< 1.9)
Therapeutic INR
Supratherapeutic
0
3 (7%)
38 (93%)
0
Anticoagulation Stewardship Anticoagulation Stewardship
Program Program –– Business CaseBusiness 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 StewardshipAnticoagulation 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) Summa Health System (ACH)
Anticoagulation Stewardship Program Anticoagulation Stewardship Program
� Objective: To improve anticoagulation
management and safety in warfarin patients
through patient education, increased
communication with providers, use of evidence-
based dosing, and focus on transitions of care
� Team Players: Lead Pharmacist, Pharmacy
residents, Pharmacy Technicians
� Clinical staff pharmacists cover the service on
weekends/holidays
4/9/2013
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Modification to Pilot Program …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: Anticoagulation Stewardship:
Pharmacy TechnicianPharmacy 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:Anticoagulation Stewardship:
Pharmacy TechnicianPharmacy 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 Successes
� Program growth
◦ 1st quarter 2012 – 114 consults
◦ 4th quarter 2012 – 199 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 Readmission Rate for Consult
GroupGroupNumber of SAMS ReferralsNumber of SAMS Referrals
0
5
10
15
20
25
10 10 12 25 18 22 15
Nu
mb
er
of
Refe
rra
ls
SAMS Referrals
July August September October November December January
4/9/2013
7
Current ChallengesCurrent Challenges
� Coverage for time off
� 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 )
14241319
1211
710639 631 593 558 557 536
0
200
400
600
800
1000
1200
1400
1600
# o
f E
rro
rs
MEDMARX Top Therapeutic Classes chart
from 9/1/2010 to 12/31/2012 (your facility)
621
532
434
349319 304 282 258 254 244
0
100
200
300
400
500
600
700
# o
f E
rro
rs
MEDMARX Top Generic Names chart
from 5/1/2010 to 12/31/2012 (your facility)
Future EnhancementFuture Enhancement
� Anticoagulation transitions in the ED
� Anticoagulation selection for new starts
� Formal anticoagulation stewardship rounds
with a physician
� Anticoagulation in pre-operative & pre-
procedural patients – develop bridging protocol
and order set
� Standardize Anticoagulation patient education
across all units (booklet, TV, Nursing/pharmacy)
Preventable Disaster #1Preventable 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 #2Preventable 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 10
What recommendations could pharmacy give to
help minimize this adverse event?
4/9/2013
8
Preventable Disaster #3Preventable Disaster #3� Patient with an in range INR, mitral mechanical
heart valve admitted to hospital for a new hip
fracture. Patient given 10mg 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?
ReferencesReferences
� Schillig J, Kaatz S et al. Clinical and Safety Impact of an Inpatient
Pharmacist-Directed Anticoagulation Service. J Hosp Med
2011;6:322-328.
� Dager WE, Branch JM et al. Optimization of inpatient warfarin
therapy: impact of a daily consultation by a pharmacist-managed
anticoagulation service. Ann Pharmacother 2000;34:567-572.
� The Joint Commission. 2009 National Patient Safety Goals.
Available at: HTTP://www.jointcommission.org/NR. Accessed
March 2012.
� Holbrook A, Schulman S et al. Evidence-based Management of
Anticoagulant Therapy: American College of Chest Physicians
evidence-based clinical practice guidelines (9th Edition) Chest
2012;141(2):152S-184S.
ReferencesReferences
� 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
2006;22:23-30
� Boddy C. Pharmacist involvement with warfarin dosing for
inpatients. Pharm World Sci 2001;23:31-35.
� 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;49:387-394.
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