medication safety anticoagulation management.ppt

8/11/2019 Medication Safety Anticoagulation Management.ppt

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September 10, 2008

Medication Safety:Anticoagulation Management

Carla S. Huber, ARNP MS

Community Anticoagulation Therapy (CAT)Clinic

Cedar Rapids, IA 52401

515-558-4046

[email protected]

www.crhealthcarealliance.org
mailto:[email protected]://www.crhealthcarealliance.org/http://www.crhealthcarealliance.org/mailto:[email protected]


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Objectives

Identify the challenges and barriers to

implementing medication safety tools Explain the importance of utilizing evidence-

based guidelines for managing warfarin

therapy

Explain the importance of education forpatients taking warfarin

List the advantages of a dedicated

anticoagulation clinic


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PIPS Grant

Specific Aims

Education and training in principles of ISO 9001quality management systems

Establish the anticoagulation clinic

Determine other uses of ISO framework within the

healthcare community


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% Warfarin of All ADE's 04/02 through 11/04

0%

5%10%15%20%

25%30%35%40%

Oct-02

Dec-02

Feb-03

Apr-03

Jun-03

Aug-03

Oct-03

Dec-03

Feb-04

Apr-04

Jun-04

Aug-04

Oct-04

%WarfarinADE's


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National Quality Forum (2004)

Safe Practices:

#1 - Creation of a healthcare culture of safety #18Utilization of dedicated anti-thrombotic

services that facilitate coordinated care

management


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Medication Statistics

60% of older Americans use five or more

different medications per week 20% of older Americans take 10 different

medications per week

Americans older than 65 have more than

175,000 emergency room visits/year foradverse drug events

Source CDC


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Medication Statistics

In the US age >65 comprise 15% of population and

buy 30% of all prescription drugs and 40% of OTC

meds http://www.webmd.com/content/article/6/1680_51638.htmretrieved 1/22/07

Up to 60% of all medications prescribed are taken

incorrectly or not at all

90% of elderly patients make some medicationerrors

35% of the elderly make potentially serious errors

http://www.itaa.org/isec/events/presentationsretrieved 1/12/07
http://www.webmd.com/content/article/6/1680_51638.htm%20retrieved%201/22/07http://www.webmd.com/content/article/6/1680_51638.htm%20retrieved%201/22/07http://www.itaa.org/isec/events/presentationshttp://www.itaa.org/isec/events/presentationshttp://www.webmd.com/content/article/6/1680_51638.htm%20retrieved%201/22/07http://www.webmd.com/content/article/6/1680_51638.htm%20retrieved%201/22/07


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Anticoagulation Clinics

Dedicated service to manage patients on

anticoagulation medications

Use evidence based guidelines to make dosing

decisions

Specially trained nurses, pharmacists

Decrease complications of anticoagulants and

decrease ER visits and hospital admissions

Pts. are in INR range greater percent of the time

Improve physician and staff efficiency


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Why dedicated anticoagulation clinics?

Use of evidence-based guidelines

American College of Chest Physicians Improved outcomes

Increased time in INR range

Decreased bleeding and clotting events

Decreased hospitalizations related toanticoagulation events


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Patient Safety Goal

Joint Commission 2009 National Patient

Safety Goal #3: Improve the safety of using medications

Anticoagulation therapy, 3.05.01

Reduce the likelihood of patient harm associated with

the use of anticoagulation therapy


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Policies and Procedures

The organization needs to identify and

determine which additional procedures needto be documented to create consistentprocesses.

Physicians Clinic of Iowa currently has over

400 documented policies and procedures. The Community Anticoagulation Therapy

Clinic (CAT Clinic) currently has over 70documented policies and procedures.


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Note the:Format and color

Document

number

PurposeDefinition

Procedure orflowchart


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Flow of current clinic processes

Completed a process flow of current (2005)anticoag clinic processes

Lots of variationseveral nurses providinginformation about dose changes to patients

Little use of evidence-based guidelines

Waiting for lab results Pt. satisfaction low

Pt. education 15 minutes


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Community Anticoagulation

Therapy (CAT) Clinic

Provide patient education 60-90 minutes andongoing

Patients go to lab of their choice, POCtesting, home INR monitor

INRs faxed to CAT Clinic or provided via web

Pt. notified of results same day and dosingdecision made based on guidelines

Referring physician notified of all results andchanges in warfarin therapy


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ACCP Guidelines

Why use guidelines to manage

anticoagulation? To reduce gaps in knowledge

To reduce safety issues surrounding

anticoagulation

Both of the above promote standardization in thepractice of managing patients taking warfarin


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Guidelines

Maintenance Therapy

Make small changes to warfarinincrease ordecrease dose 5-15%, if INR between 1.0 and 5.0

Calculate the weekly dose and adjust accordingto the total weekly dose. If patient taking5mg/day=35mg/week. If dose increased or

decreased by 10% = 3.5mg/week Check INR every 4 weeks at a minimum

Give the warfarin time to work- maytake 48 hours to see a change in INR


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What affects how warfarin works?

Other medicationsantibiotics, herbs,aspirin products, chemotherapy, NSAIDs,amiodarone (decrease warfarin by as muchas 30%)

Dietamount of vitamin K in foods

Alcoholwarfarin is synthesized in the liver Exercise

Stress


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What does all of this mean?

It takes time to educatemore than a 10 or

15 minute office visit


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www.ahrq.gov/consumer/coumadin.pdf
http://www.ahrq.gov/consumer/coumadin.pdfhttp://www.ahrq.gov/consumer/coumadin.pdf


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Medical Record

CAT Clinic utilizes a web-based electronicmedical record www.inrpro.com

Automatic list of patients due for INRs

Warfarin logeasy to read Control Chart

Next apt. date Sent to referring physician

Reports at the click of a button
http://www.inrpro.com/http://www.inrpro.com/


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www.inrpro.com


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Benchmark - JCAHO, Journal of Quality

and Safety, Vol. 29 (12), 2003 and

AC Forum 2007.

Median % of Time in INR Range (CAT Clinic) = 59%

Percent of Time Patients in INR Range

Rosendaal

0

10

20

3040

50

60

70

80

90

100

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Month

CAT Patients

Prior visits

benchmark

Good


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CAT Clinic patients in tighter range

Percent of Time Patients in INR Range +/- 0.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Aug-06

Sep-06

Oct-06

Nov

-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov

-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

CAT Patients

+/- 0.2

Prior visits+/- 0.2

Good


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This graph shows a decrease in the number of physician contacts (the

number of times the CAT Clinic nurse needs to contact the referring

physician). This number should decrease as patients are in INR range a

greater percent of the time.

Physician Contacts

0%

5%

10%

15%

20%

25%

30%

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Month

All patients Median

Good


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The graph shows the percent of INRs greater than 5. There have been two

associated major bleeds in 2007 (GI bleeding, requiring hospitalizations, one

pt. taking NSAID, another pt. taking ASA and started on Amiodarone) with the

INRs greater than 5.Benchmark 7%, Chiquette,

Amato, Bussey, 1999.

% of INRs > 5

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

3rdQ

200

4th

Q200

1stQ

200

2ndQ

200

3rdQ

200

4th

Q200

1stQ

200

2ndQ

200

Good


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Average Compliance Score

80

82.5

85

87.5

90

92.5

95

97.5

100

Ma

y-06

Ju

n-06

Jul-06

Au

g-06

Se

p-06

Oct-06

No

v-06

De

c-06

Ja

n-07

Fe

b-07

Mar-07

Apr-07

Ma

y-07

Ju

n-07

Jul-07

Au

g-07

Se

p-07

Oct-07

No

v-07

De

c-07

Ja

n-08

Fe

b-08

Mar-08

Apr-08

Ma

y-08

Ju

n-08

Ave. compliance % Average

Good


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Toolkit Items

ISO Executive and Staff Training Modules

INRPro Databasewww.inrpro.com Organized Document System70 documents

Compliance Assessment Scale

Patient EducationYour Guide to

Coumadin/Warfarin Therapy

Staff Education Modules


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Summary

Identify the challenges and barriers to

implementing medication safety tools

Explain the importance of utilizing evidence-

base guidelines for managing warfarin

therapy

Explain the importance of education forpatients taking warfarin

List the advantages of dedicated

anticoagulation clinics


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References

www.crhealthcarealliance.orgCedar Rapids

Healthcare Alliance

www.chest.orgMost recent anticoagulation

management guidelines

My Guide to Warfarin Therapy


Your Guide to Coumadin/Warfarin Therapy

www.ahrq.gov/consumer/coumadin.pdf

www.inrpro.com
http://www.crhealthcarealliance.org/http://www.chest.org/http://www.crhealthcarealliance.org/http://www.ahrq.gov/consumer/coumadin.pdfhttp://www.inrpro.com/http://www.inrpro.com/http://www.ahrq.gov/consumer/coumadin.pdfhttp://www.crhealthcarealliance.org/http://www.chest.org/http://www.crhealthcarealliance.org/


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Carla S. Huber, ARNP MS

CAT Clinic

600 7thStreet SE

Cedar Rapids, IA 52401

[email protected]

mailto:[email protected]://www.crhealthcarealliance.org/http://www.crhealthcarealliance.org/mailto:[email protected]

medication safety anticoagulation management.ppt

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