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?

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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

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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

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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….

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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

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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

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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.