4/9/2013

Disclosure

Best Practice Initiative: Inpatient

Anticoagulation Stewardship

Dorcas Letting reports no relevant

financial relationships

Dorcas LettingLetting-Mangira, Pharm.D

Pharmacotherapist, Internal Medicine
PGY1 Residency Program Director
Summa Health System

Objectives

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 patients
anticoagulation management
Understand the challenges in transition of
patients on anticoagulation therapy
Understand the role of a technician in
anticoagulation management

Preventable 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 #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 #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

Patient 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.

Why Anticoagulants

6.2% of these patients required medical

intervention and 1.5% needed a prolonged hospital
stay

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

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):5325.
Winterstein AG, et. al. Am J Health Syst Pharm. 2002;59(18):17429.

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

Why Anticoagulants

Fanikos, et. al. analyzed medication errors

reported in a hospital and found 7.2% were due
to anticoagulants

Why do this
Patient safety concerns
Regulatory Compliance

Financial Implications

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/0620040329.pdf.

4/9/2013

Safety Practices Focus

Benefits of the program

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)

The Model for Improvement

Improvement Team

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

Characteristics position power, expertise,

credibility, leadership

Getting started

Improve patient care

- standardized practices
- reduced complications
- improve compliance
- Reduce cost
- Improve continuity of patient care
- Reduce inpatient mortality rates
- Improve patient experience

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

Warfarin Order Set

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

4/9/2013

Warfarin Discharge Order Set

Expectations for ALL patients

Defines a baseline INR as occurring within the

last 24 hours prior to the current order for
warfarin

Pharmacists to review the baseline INR prior to

dispensing the first dose of warfarin

INRs from any facility are acceptable

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

Consult 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

Resources

Challenges 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

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

Action 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.

4/9/2013

Total Number Warfarin Consults

Sept 2011 April 2012

Pharmacy Consult
Service (n=223)

Warfarin
n=205

PCK
n=3

Drug
SE
n=5

Drug
Interaction
n=1

Poly
Pharmacy
n=9

Medication
Adherence

September 2011 April 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

Communicate vision and request

resources

Outline

0
3 (7%)
38 (93%)
0

Anticoagulation Stewardship

Anticoagulation Stewardship
Program Business Case

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

Background and environmental analysis

Proposal
Benefits to the organization
Resource requirement
Financial analysis (ROI)
Key deliverable actions and timelines

Summa Health System (ACH)

Anticoagulation Stewardship Program

Objective: To improve anticoagulation

management and safety in warfarin patients
through patient education, increased
communication with providers, use of evidencebased 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

Anticoagulation Stewardship:
Pharmacy Technician

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.

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:
Pharmacy Technician

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

Responsibilities:

Communication with pharmacists, nurses and

patients (new consults, discharges etc)
Call back program
Research data collection/entry
Professional development maintain
pharmacy technician certification

Readmission Rate for Consult

Group

Number of SAMS Referrals

SAMS Referrals

25

Number of Referrals

20

15

10

10

10

12

25

18

22

15

July

August

September

October

November

December

January

4/9/2013

MEDMARX Top Therapeutic Classes chart

from 9/1/2010 to 12/31/2012 (your facility)

Current Challenges

1400

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 )

1200

1000
# of Errors

1600

800
1424

1319
1211

600

400

710

639

631

593

558

557

536

200

MEDMARX Top Generic Names chart

from 5/1/2010 to 12/31/2012 (your facility)

Future Enhancement

700

600

# of Errors

Anticoagulation transitions in the ED

Anticoagulation selection for new starts

Formal anticoagulation stewardship rounds
with a physician

Anticoagulation in pre-operative & preprocedural patients develop bridging protocol
and order set

Standardize Anticoagulation patient education
across all units (booklet, TV, Nursing/pharmacy)

500

400

621

300

532
434

200

349

319

304

282

258

100

254

244

Preventable 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 #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

Preventable 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?

References

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.

References

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.