Anticoagulation Safety

Transcription

1 Anticoagulation Safety 2/12/13 Latha Sivaprasad, MD, FHM, FACP Associate Chief Medical Officer Chief Patient Experience Officer Laura O Brien RN, MA, CCRN Clinical Nurse Specialist

2 Outline The journey Areas of improvement What is in the pipeline?

3 Let s Start at the very beginning. Why did Continuum need an Anticoagulation Program? 3

4 Anticoagulation=Safety Issue Anticoagulants are associated with nearly a tenth of hospital adverse drug events (ADEs) 117,700 ADEs per year related to anticoagulation therapy Medication errors associated to anticoagulation therapy represent an annual financial burden of up to $1 billion From January 1, 2001 through December 31, 2006 a total of 59,316 medication errors related to anticoagulants were reported to USP s MEDMARX 1. Elixhauser A. and Owens P. (AHRQ). Adverse Drug Events in U.S. Hospitals, HCUP Statistical Brief #29. April Agency for Healthcare Research and Quality, Rockville, MD. Available from: 2. Fanikos J, Stapinski C, Koo S, Kucher N, Tsilimingras K, Goldhaber SZ. Medication errors associated with anticoagulant therapy in a hospital. Am J Cardiol.2004; 94(4): U.S. Pharmacopeia. US Patient Safety CAPSLink. Jan USP Medication Error Analysis. Available from: 4

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6 Goals and Objectives of Continuum AC Taskforce 1. Use monthly data to drive safer care delivery as it relates to anticoagulation 2. Share best practices across sites 3. Make changes to our protocols based on updated guidelines and recommendations 4. Maximize PRISM function to decrease practice variability 5. Promote ongoing education to close knowledge gaps 6. Enhance collaboration between pharmacy and frontline providers

7 Metrics 1. Inpatients on Heparin with at least 1 PTT > Inpatients on Warfarin with at least 1 INR >5 3. % of pts with CrCl <30 who received greater than 1.25mg/kg of Enoxaparin 4. Patients on Heparin, Enoxaparin, or Warfarin with ICD-9 Codes suggestive of a bleeding complication 5. Appropriate dosing of Enoxaparin in PE/DVT and Renal Failure

8 AC Safety Timeline Assign Responsibility Policies finalized across Continuum Policy Development Timeline Finalized Resources Verified Policies Live In PRISM Ordersets created Pilot

9 PRISM Safety Enhancement (Heparin) 9

10 PRISM Safety Enhancement (Enoxaparin)

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13 Enoxaparin Rounding

14 AC Safety Timeline Assign Responsibility Policies finalized across Continuum Housewide policy Implementation Web-based training Policy Development Timeline Finalized Resources Verified Policies Live In PRISM Ordersets created AC Safety Rounds Pilot Oversight and tracking of ADR s, interventions, and med errors Update of card and ongoing education

15 Goals and Objectives of AC Safety Rounds Reduce the number of improper orders, adverse events, and medication errors associated with enoxaparin, warfarin, and heparin Use daily anticoagulation reports to affect current patient care real-time rather than use in retrospective analysis 15

16 What did we do? Pre-intervention Period Intervention Period 16

17 17 Process

18 18 Inclusion Criteria

19 19 Heparin

20 AC Safety Timeline Assign Responsibility Policy Development Timeline Finalized Resources Verified Policies finalized across Continuum Policies Live In PRISM Housewide policy Implementation Web-based training Integrate VTE Core Measures Integrating Pradaxa and Rivaroxaban Ordersets created Ordersets Modified AC Safety Rounds Pilot Oversight and tracking of ADR s, interventions, and med errors Update of card and ongoing education

21 Dabigatran (Pradaxa) FDA approved for non-valvular Afib to decrease stroke incidence Direct thrombin inhibitor Cardiology approval required Renal dosing Interactions with Rifampin Not to be used with indwelling epidural catheters No INR monitoring required (the plus)

22 Rivaroxaban (Xarelto) Oral anticoagulant FDA approved for post hip/knee dvt proph and treatment for DVT/PE Factor Xa inhibitor Some drug interactions Major plus is that it is oral and not injectable like LMWH

23 Outcomes

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28 DVT Prophylaxis Received SCIP Compliance Sample includes CABG; other Cardiac Surgery; Hip; Knee; Colon; Hysterectomy and Vascular Surgery

29 Areas of Improvement/Next Steps Appropriate use of Heparin in PE/DVT Underdosing of Heparin in PE/DVT AC metrics for the outpatient space New metrics for Rivaroxaban and Dabigatran Bleeding reports on Rivaroxaban and Dabigatran Protocols for reversal of newer agents

30 All the strong links.