1 © 2008 TMIT Dale Bratzler, DO, MPH Michael Gulseth, PharmD, BCPS Dan Ford Hayley Burgess, PharmD, BCPP Charles Denham, MD Preventing Venous Thromboembolism

1© 2008 TMIT

Dale Bratzler, DO, MPHMichael Gulseth, PharmD, BCPS

Dan FordHayley Burgess, PharmD, BCPP

Charles Denham, MD

Preventing Venous Thromboembolism and Improving the Safety of Anticoagulation Therapy

March 5, 2008

2© 2008 TMIT

NQF Safe Practices for Better Healthcare: A Consensus Report

• 30 Safe Practices

Criteria for Inclusion

• Specificity

• Benefit

• Evidence of Effectiveness

• Generalization

• Readiness

3© 2008 TMIT

NQF Safe Practices Maintenance Committee Safe Practice Update Process

• SWOT analysis of each practice

Comprehensive literature search

Expert technical advisory support from more than 250 experts

Participation by The Joint Commission, CMS, and AHRQ Input from hospitals and facility involved in 100,000 and

5M Lives Campaign

“Feedback from the Field” - Hospitals that reported publicly through The Leapfrog Group and TMIT National Research Test Bed

4© 2008 TMIT

Harmonization – The Quality Choir

5© 2008 TMIT

Culture SP 1

Information Management & Continuity of Care

Medication Management

Healthcare-Assoc. Infections

Condition- & Site-Specific Practices

Consent & Disclosure

Culture

Workforce


2007 NQF Report

6© 2008 TMIT

Information Management & Continuity of Care

Medication Management

Healthcare-Associated Infections

Condition- & Site-Specific Practices


Wrong-siteSx Prevention

Periop. MIPrevention

Press. Ulcer Prevention

DVT/VTE Prevention

Anticoag. Therapy

Asp. + VAP Prevention

Central V. Cath.BSI Prevention

Sx-Site Inf.Prevention

Contrast Media Use

Hand HygieneInfluenza

Prevention

PharmacistCentral Role

Med. Recon.

Std. Med. Labeling & Pkg.

High-AlertMeds.

Unit-DoseMedications

Evidence-Based Ref.

Culture

CPOE

OrderRead-back

Abbreviations Discharge

System

CriticalCare Info.

LabelingStudies

Culture Meas.,F.B., & Interv.

Structures& Systems

ID Mitigation Risk & Hazards

Team Training& Team Interv.CHAPTER 1: Background

Summary, and Set of Safe Practices

CHAPTERS 2-8 : Practices By Subject

Nursing Workforce

ICU CareDirect

Caregivers

Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care

CHAPTER 2: Creating and Sustaining a Culture of Patient Safety

• Leadership Structures & Systems• Culture Measurement, Feedback, and Interventions• Teamwork Training and Team Interventions• Identification and Mitigation of Risks and Hazards

CHAPTER 5: Information Management & Continuity of Care

• Critical Care Information• Order Read-back• Labeling Studies• Discharge Systems• Safe Adoption of Integrated Clinical Systems

including CPOE• Abbreviations

CHAPTER 6: Medication Management• Medication Reconciliation• Pharmacist Role• Standardized Medication Labeling & Packaging• High-Alert Medications• Unit-Dose Medications

CHAPTER 7: Healthcare-Associated Infections• Prevention of Aspiration and Ventilator-

Associated Pneumonia • Central Venous Catheter-Related Blood Stream

Infection Prevention • Surgical Site Infection Prevention• Hand Hygiene• Influenza Prevention

CHAPTER 8: Condition- & Site-Specific Practices• Evidence-Based Referrals• Wrong-Site, Wrong-Procedure, Wrong-Person

Surgery Prevention • Perioperative Myocardial Infarct/Ischemia

Prevention• Pressure Ulcer Prevention• DVT/VTE Prevention • Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention

Informed Consent

Life-Sustaining Treatment

Disclosure

CHAPTER 3: Informed Consent & Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure


2007 NQF Report

7© 2008 TMIT

New Safe Practice Considerations

• Methicillin-resistant Staph aureus (MRSA)

• Urinary Tract Infections (UTI)

• Handover/Hand-off

• Second Patient

• Organ Donorship

8© 2008 TMIT

Preventing Venous Thromboembolism and Improving the Safety of Anticoagulation Therapy

Objectives: • Describe the impact of Venous Thromboembolism (Safe

Practice 28) complications as it relates to the nation's healthcare patient population.

• Prepare for pay for performance requirements and review national measures.

• Describe the requirements for the Joint Commission National Patient Safety Goal 3E and Anticoagulation Therapy (Safe Practice 29).

• Discuss strategy and stepwise process for planning, design, and implementation of an inpatient anticoagulant service.

9© 2008 TMIT

Safe Practice 28: Reduce the occurrence of venous thromboembolism

Safe Practice• Evaluate each patient upon admission, and regularly

thereafter, for the risk of developing VTE/DVT. Utilize clinically appropriate, evidence-based methods of thromboprophylaxis.

Additional Specifications• Document the VTE risk assessment and prevention plan in

the patient’s record.• Explicit organizational policies and procedures should be in

place for the prevention of VTE.Applicable Clinical Care Settings• Short and long-term acute care hospitals, long-term care

facilities, and nursing homes.

10© 2008 TMIT

Safe Practice 29: Ensure that long-term antithrombotic (anticoagulation) therapy is effective and safe

Safe PracticeEvery patient on long-term oral anticoagulants should be monitored

by a qualified health professional using a careful strategy to ensure an appropriate intensity of supervision.

Additional Specifications

• Explicit organizational policies and procedures should be in place regarding antithrombotic services that include at least documentation of:• indication for long-term anticoagulation;• target INR range;• duration of long-term anticoagulation and/or a review date;• a longitudinal record of INR values and warfarin doses; and• timing of the next INR appointment.

Applicable Clinical Care Settings

• This practice is applicable in all care settings

11

Prevention and Treatment of Venous Thromboembolism

Development of National Performance Measures

Dale W. Bratzler, DO, MPH

QIOSC Medical Director

Dale W. Bratzler, DO, MPH

QIOSC Medical Director

Oklahoma Foundation for Medical Quality

12

Prevention of Venous Thromboembolism

• Recent estimates show that– more than 900,000 Americans suffer VTE

each year• about 400,000 of these being DVT• About 500,000 being manifest as PE

– In about 300,000 cases, PE proves fatal; it is the third most common cause of hospital-related deaths in the United States.

Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment Group. [Abstract] American Society of Hematology Annual Meeting, 2005.

Is pulmonary embolism the most common cause of death in the US?

13

Prevention of Venous ThromboembolismIntroduction

• VTE Remains a major health problem– In addition to the risk of sudden death

• 30% of survivors develop recurrent VTE within 10 years

• 28% of survivors develop venous stasis syndrome within 20 years

– Incidence increases with age

Goldhaber SZ. N Engl J Med. 1998;339:93-104.

Silverstein MD, et al. Arch Intern Med. 1998;158:585-593.

Heit JA, et al. Thromb Haemost. 2001;86:452-463.

Heit JA. Clin Geriatr Med. 2001;17:71-92.

Heit JA, et al. Mayo Clin Proc. 2001;76:1102-1110.

14


• The majority (93%) of estimated VTE-related deaths in the US were due to sudden, fatal PE (34%) or followed undiagnosed VTE (59%)

Heit JA, Cohen AT, Anderson FA on behalf of the VTE Impact Assessment Group. [Abstract] American Society of Hematology Annual Meeting, 2005.

For many patients, the first symptom of VTE is sudden death!

How many of those patients with sudden death in the hospital or after discharge attributed to an acute coronary

event actually died of acute pulmonary embolism?

15

National Body Position Statements

• Leapfrog1:

PE is “the most common preventable cause of hospital death in the United States”

• Agency for Healthcare Research and Quality (AHRQ)2:

Thromboprophylaxis is the number 1 patient safety practice

• American Public Health Association (APHA)3:

“The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis.”

1. The Leapfrog Group Hospital Quality and Safety Survey. Available at: www.leapfrog.medstat.com/pdf/Final/doc2. Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ, 2001. Available at:

www.ahrq.gov/clinic/ptsafety/3. White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at:

www.alpha.org/ppp/DVT_White_Paper.pdf

16

Medical “Injuries” During Hospitalization

Postoperative DVT or PE:• 2nd commonest medical “injury” overall

• 2nd commonest cause of excess length of stay

• 3rd commonest cause of excess mortality

• 3rd commonest cause of excess charges

Zhan et a. JAMA 2003;290:1868

17

Annual cost to treat VTE

• $11,000 per DVT episode per patient• $17,000 per PE episode per patient• Recurrence increases hospitalization costs

by 20%• Complications of anticoagulation• Time lost from work

– Quality of life: venous stasis and pulmonary HTN

18

Consequences of Surgical Complications

• Dimick and colleagues demonstrated increased costs of care:– infectious complications was $1,398– cardiovascular complications $7,789– respiratory complications $52,466– thromboembolic complications $18,310

Dimick JB, et al. J Am Coll Surg 2004;199:531-7.

19

Inherited risk factors for DVT

Group 1 disorders• Protein C deficiency (2.5-6%)• Protein S deficiency (1.3-5%)• Antithrombin deficiency (0.5-

7.5%)

Group 2 disorders• Factor V leiden (6%)• Prothrombin (G20210A)

(5-10%)• Elevated VIII, IX, XI• Hyperhomocysteinemia• Arteriosclerosis

20

Acquired Risk FactorsRisk Factor Attributable Risk

Hospitalization/Nursing home 61.2

Active malignant neoplasm 19.8

Trauma 12.5

CHF 11.8

CV catheter 10.5

Neurologic disease with paresis 8.2

Superficial vein thrombosis 4.3

Varicose veins/stripping 6

Many others….

Being in the hospital is the greatest risk factor for VTE!

21

Risk Factors for VTE

• Previous venous thromboembolism

• Increased age

• Surgery

• Trauma - major, local leg

• Immobilization - ? bedrest, stroke, paralysis

• Malignancy & its Rx (CTX, RTX, hormonal)

• Heart or respiratory failure

• Estrogen use, pregnancy, postpartum

• Central venous lines

• Thrombophilic abnormalities

Most hospitalized patients have at

least one additional risk factor fo

r

VTE

Therefore, most patients in the hospital need VTE prophylaxis!

22

VTE is a Disease of Hospitalized and Recently Hospitalized Patients

1000

100

1

10

Hospitalized patients Community residents

Recently hospitalized

Heit JA. Mayo Clin Proc. 2001;76:1102

Ca

ses

per

10,0

00 p

ers

on-

year

s

VTE 100X more common in hospitalized patients!

23

Risk of DVT in Hospitalized Patients

Patient group DVT incidence Medical patients 10 - 20 % Major gyne/urol/gen surgery 15 - 40 % Neurosurgery 15 - 40 % Stroke 20 - 50 % Hip/knee surgery 40 - 60 % Major trauma 40 - 80 % Spinal cord injury 60 - 80 % Critical care patients 15 - 80 %

No prophylaxis + routine objective screening for DVT

24


• Despite the well known risk of VTE and the publication of evidence-based guidelines for prevention, multiple medical record audits have demonstrated underuse of prophylaxis

Anderson FA Jr, et al. Ann Intern Med. 1991;115:591-595.Anderson FA Jr, et al. J Thromb Thrombolysis. 1998; 5 (1 Suppl):7S-11S.

Bratzler DW, et al. Arch Intern Med. 1998;158:1909-1912.Stratton MA, et al. Arch Intern Med. 2000;160:334-340.

25

Thromboprophylaxis Use in Practice1992-2002

Prophylaxis Patient Group Studies Patients Use (any)

Orthopedic surgery 4 20,216 90 % (57-98)

General surgery 7 2,473 73 % (38-98)

Critical care 14 3,654 69 % (33-100)

Gynecology 1 456 66 %

Medical patients 5 1,010 23 % (14-62)

How many patients with COPD, CVA, heart failure, pneumonia, etc do you have in your hospital that are not on DVT prophylaxis?

26

Seventh ACCP Consensus Conference on Antithrombotic Therapy

Chest 2004;126:338S-400S

Prevention of Venous

Thromboembolism

W. Geerts, chair

G. Pineo

J. Heit

D. Bergqvist

M. Lassen

C. Colwell

J. Ray

27

Benefit: risk favors routine prophylaxis

• Major orthopedic surgery

(THR, TKR, HFS)

• Major trauma

• Spinal cord injury

• Major general, gyne, urologic surgery

• Major neurosurgery

• Medical patients with additional risk factors

• Most ICU patients

Benefit: risk uncertain- local practice or

individual prophyl.

• Laparoscopic surgery

• Vascular surgery

• Cardiac surgery

• Elective spine surgery

• Arthroscopic surgery

• Burns

• Isolated lower extremity fracture

Benefit: risk favors no prophylaxis

• Surgical patients:

- brief duration

- fully mobile

- no additional RFs

• Medical patients:

- fully mobile

- no additional RFs

• Long distance travel

Prevention of Venous ThromboembolismLow-, moderate-, or high-risk

Focus of New Measures

How many of these patients do we actually

admit to the hospital anymore?

28

Prophylaxis Modalities

• Mechanical– Graduated compression stockings (GCS) (e.g., “white

hose”)– Sequential compression devices

• Venous foot pumps (currently recommended only for orthopedic surgery in patients with bleeding risk)

In most studies, less effective than pharmacologic prophylaxis and patient

compliance rates are generally low.

Rates of compliance with mechanical forms of prophylaxis in many studies is less than 50% - has become a new target

of malpractice litigation.

29

Pharmacologic Prophylaxis

• Low-dose unfractionated heparin (LDUH)

• Low-molecular weight heparin (LMWH)

• Fondaparinux

• Warfarin

30

Development of National Performance Measures

to Prevent and Treat VTE

31

Why the need for performance measures?

• Despite widespread publication and dissemination of guidelines, practices have not changed at an acceptable pace– There are still far too many needless deaths

from VTE in the US

• Reasonably good evidence that using performance measures for accountability can accelerate the rate of change

32

33

Venous ThromboembolismStatement of Organization Policy

“Every healthcare facility shall have a written policy appropriate for its scope, that is evidence-based and that drives continuous quality improvement related to VTE risk assessment, prophylaxis, diagnosis, and treatment.”

34

Venous ThromboembolismCharacteristics of Preferred Practices

General• Protocol selection by multidisciplinary teams• System for ongoing QI• Provision for RA/stratification, prophylaxis,

diagnosis, treatment• QI activity for all phases of care• Provider education

35


(cont.)

Risk Assessment/Stratification• RA on all patients using evidence-based policy• Documentation in patient record that done

Prophylaxis• Based on assessment & risk/benefit,

efficacy/safety• Based on formal RA, consistent with accepted,

evidence-based guidelines

36


(cont.)

Diagnosis• Objective testing to justify continued initial therapy

Treatment and Monitoring• Ensure safe anticoagulation, consider setting• Incorporate Safe Practice 29 • Patient education; consider setting and reading

levels• Guideline-directed therapy• Address care setting transitions in therapy

37

Surgical Care Improvement ProjectFirst Two VTE Measures Endorsed by NQF

• Prevention of venous thromboembolism• Proportion who have recommended VTE

prophylaxis ordered

• Proportion who receive appropriate form of VTE prophylaxis (based on ACCP Consensus Recommendations) within 24 hours before or after surgery

These measures are NQF-endorsed

Limited to surgical patients – NQF endorsed, required reporting to Medicare for Annual Payment Update, and will be

posted to Hospital Compare soon.

38

84.880.5

98.6 97.2

0

20

40

60

80

100

Recommended VTE Prophylaxis Timely VTE Prophylaxis

Pe

rce

nt

National Average* Benchmark

Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).

Surgical Care Improvement ProjectHospital Voluntary Self-Reporting, Qtr. 2, 2007

39

54.6

48.6

98.6 97.2

0

20

40

60

80

100

Recommended VTE Prophylaxis Timely VTE Prophylaxis

Pe

rce

nt

Low performers Benchmark

Benchmark rates were calculated for all HQA reporting hospitals in the US based on discharges using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).

Ongoing Gaps in PerformanceHospital Voluntary Self-Reporting, Qtr. 2, 2007

40

7 Refined Measures Recommended for Endorsement by Steering Committee

• Risk Assessment/Prophylaxis domain• Prophylaxis w/in 24 hours of admission or

surgery, OR a documented risk assessment showing that the patient does not need prophylaxis

• Prophylaxis/documentation w/in 24 hours after ICU admission or surgery

Discards any “requirement” for a documented risk assessment – allows programs of default prophylaxis.

41

7 Refined Measures Recommended for Endorsement by Steering Committee

• Treatment and Monitoring domain• IVC filter appropriate indication

• Documented acute VTE with a contraindication to anticoagulation; or chronic thromboembolic pulmonary hypertension

• Measure recommended for quality improvement only

• Patients w/overlap of anticoagulation therapy• At least five calendar days of overlap and discharge

with INR > 2.0, or discharge on overlap therapy

• Patient receiving UFH with dosage/platelet count monitoring by protocol/nomogram

• Nomogram/protocol incorporates routine platelet count monitoring+

42

7 Refined Measures Recommended (cont.)

• Treatment/Monitoring Domain (cont.)

• Discharge instructions consistent with Joint Commission safety goals (Follow-up Monitoring, Compliance Issues, Dietary Restrictions, Potential for Adverse Drug Reactions/Interactions)

• Outcome• Incidence of potentially-preventable VTE – proportion

of patients with hospital-acquired VTE who had NOT received VTE prophylaxis prior to the event

• Incorporate the new “present on admission” codes

43

Strategies to Improve VTE Prophylaxis

• Hospital policy of risk assessment for all admitted patients??– Most will have risk factors for VTE and should

receive prophylaxis– Preprinted protocols for surgical patients– Electronic reminders (Kucher – NEJM 2005;352:969)

– Default prophylaxis (opt out)

44

1 point each • age 41-60• minor surgery planned• major surgery past month• varicose veins• inflamm bowel disease• current leg swelling• obesity (BMI > 25)• acute MI• CHF past month• sepsis past month• serious lung disease past month• COPD• medical patient at bedrest• other_____________________

2 points each • age 60-74• arthroscopic surgery• malignancy (current or previous)• major surgery (> 45 min)• laparoscopic surgery (> 45 min) • confined to bed (> 72 hrs)• plaster cast (< 1 month)• central venous access

3 points each • age > 70• previous DVT, PE• family H/O VTE• factor V Leiden• prothrombin 20210A• elevated homocysteine• lupus anticoagulant• elevated ACA• HIT• other thrombophilia

5 points each • hip / knee arthroplasty• hip/pelvis/leg fracture (< 1 month)• stroke (< 1 month) • multiple trauma (< 1 month)• acute spinal cord injury (< 1 mo)

Women only (1 point each)• BCP or HRT• pregnancy / postpartum (< 1 mo)• H/O unexplained stillbirth, > 3 spontaneous abortions, premature birth with toxemia, IUGR

Caprini – Dis Mon 2005;51:70

45

No individual risk assessment protocol has ever been validated in a clinical trial. While it seems intuitive that more points equates to greater risk of VTE, that has never been proven in a study, and we certainly have no idea if you need more prophylaxis for more points!

46

Should VTE prophylaxis be the default

for all hospitalized patients?

47

Summary

• VTE is very common, often unrecognized, and a common cause of hospital morbidity and death

• The vast majority of hospitalized patients are at risk for VTE

• New national performance measures will focus on evidence-based prevention and treatment of VTE

If your organization is serious about Patient Safety, you have to address VTE prevention and treatment!

48© 2008 TMIT

PATIENT ADVOCATE

Dan Ford

Vice President

Furst Group

49© 2008 TMIT

NQF Safe Practice 29 and NPSG 3E: How to Accomplish in the Hospital

Michael P. Gulseth, Pharm. D., BCPS

50© 2008 TMIT

Objectives

• Compare and contrast NQF safe practice #29 to NPSG 3E

• Describe strategies to accomplish this in the hospital

• Identify key articles supporting inpatient anticoagulation services

51© 2008 TMIT

Safe Practice 29

• Every patient on long-term oral anticoagulants should be monitored by a qualified health professional using a careful strategy to ensure an appropriate intensity of supervision.

52© 2008 TMIT

Policies and Procedures Should Require Documentation of:

• Indication for long-term anticoagulation

• Target INR range

• Duration of long-term anticoagulation and/or a review date

• A longitudinal record of INR values and warfarin doses

• Timing of the next INR appointment

53© 2008 TMIT

Joint Commission NPSG 3E Rationale

• Anticoagulation is a high risk treatment, which commonly leads to adverse drug event due to the complexity of dosing these medications, monitoring their effects, and ensuring patient compliance with outpatient therapy. The use of standardized practices that include patient involvement can reduce the risk of adverse drug events associated with the use of heparin (unfractionated), low molecular weight heparin (LMWH), warfarin, and other anticoagulants.

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

54© 2008 TMIT

Expectations/Timeline

• As of April 1, 2008, the [organization]’s leadership has assigned responsibility for oversight and coordination of the development, testing, and implementation of NPSG Requirement 3E.

• As of July 1, 2008, an implementation work plan is in place that identifies adequate resources, assigned accountabilities, and a time line for full implementation of NPSG Requirement 3E by January 1, 2009.

• As of October 1, 2008, pilot testing in at least one clinical unit is under way.

• As of January 1, 2009, the process is fully implemented across the organization.

• So what are the expectations by January 1, 2009?http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

55© 2008 TMIT

Implementation Expectations

• The organization implements a defined anticoagulant management program to individualize the care provided to each patient receiving anticoagulant therapy.

• To reduce compounding and labeling errors, the organization uses ONLY oral unit dose products and pre-mixed infusions, when these products are available.

• When pharmacy services are provided by the organization, warfarin is dispensed for each patient in accordance with established monitoring procedures.

• The organization 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 drug interactions.


56© 2008 TMIT


• For patients being started on warfarin, a baseline International Normalized Ratio (INR) is available, and for all patients receiving warfarin therapy, a current INR is available and is used to monitor and adjust therapy.

• When dietary services are provided by the organization, the service is notified of all patients receiving warfarin and responds according to its established food/drug interaction program.

• When heparin is administered intravenously and continuously, the organization uses programmable infusion pumps.


57© 2008 TMIT


• The organization has a policy that addresses baseline and ongoing laboratories tests that are required for heparin and low molecular weight heparin therapies.

• The organization provides education regarding anticoagulation therapy to prescribers, staff, patients, and families.

• Patient/family education includes the importance of follow-up monitoring, compliance issues, dietary restrictions, and potential for adverse drug reactions and interactions.

• The organization evaluates anticoagulation safety practices.


58© 2008 TMIT

Roles of the Inpatient Anticoagulation Program

• Providing anticoagulant dosing– Dosing heparin, LMWH, warfarin, argatroban, etc.

• Assuring regular monitoring and patient evaluation– Designing policies to assure coagulation labs are drawn when

needed; consulting on individual patients

• Provision of repeated patient education– Assuring hospital education on warfarin, LMWH, etc.

• Communicating with other patient care providers that are involved in the patient’s care– Helping surgeons and hospitalists communicate regarding the

risks vs. benefits of therapy and picking the right option

• Meeting transitional care needs

59© 2008 TMIT

Roles of the Inpatient Anticoagulation Program

• Helping with changes from heparin to LMWH and vice versa

• Setting up short stay/outpatient VTE treatment programs• Assuring the systematic prophylaxis of VTE• Evaluating available anticoagulant products for formulary

– Not just about cost• Assuring smooth transitions in care• Assisting in determining the appropriateness of care

– Picking the right parenteral antithrombin agent for the disease, renal function, patient history, etc.

• Evaluating the safety of the dispensing and administration procedures used by the facility

• And many more…..

60© 2008 TMIT

So how do you get there?

• The organization implements a defined anticoagulant management program to individualize the care provided to each patient receiving anticoagulant therapy.– Identify a qualified professional and start an

anticoagulation program that covers both outpatients and inpatients

– Also use that leader to evaluate and improve other practices to assure the safety of anticoagulant use

– Where do you start?

61© 2008 TMIT

Step 1: Review the literature and network with others

• Take a close look at the articles already presented– Which hospitals seem similar to your situation?– Which articles deal with issue that your hospital is

struggling with?• Closely evaluate the Bond and Raehl article

– Can be used to postulate a financial benefit to the hospital

• Talk to colleagues at other hospitals who have services like you are contemplating– Site visits are a very good idea to see a service first

hand

Dager WE, Gulseth MP. Implementing pharmacist anticoagulation management in the inpatient setting.

Am J Health-Syst Pharm. 2007; 64: 1071-1079.

64© 2008 TMIT

Bond and Raehl analysis

• Bond and Raehl evaluated the potential impact of pharmacist management of heparin and warfarin

• 1995 Medicare and the National Clinical Pharmacy Services Databases from 955 hospitals comparing data from hospitals that have the service to those that don’t

Pharmacotherapy 2004; 24(8): 953-963.

65© 2008 TMIT

If a hospital did not have a heparin service:

• 11.41% higher death rates– 6.37% vs. 7.19%

• Length of stay was 10.05% higher– 7.79 days vs. 8.66 days

• Medicare charges were 6.6% higher– $1145 more per patient

• Bleeding complications were 3.1% higher– 8.84% vs. 9.12%


66© 2008 TMIT

If a hospital did not have a warfarin service:

• 6.2% higher death rates– 6.66% vs. 7.1%

• Length of stay was 5.86% higher– 8.04 days vs. 8.54 days

• Medicare charges were 2.16% higher– $370 more per patient

• Bleeding complications were 8.09% higher– 8.41% vs. 9.15%


67© 2008 TMIT

Step 2: Plan the Anticoagulation Service

• Successful programs will have support from:– Pharmacy– Medical staff– Hospital administration– Nursing

• Think about things from their perspective and assure those issues are addressed



68© 2008 TMIT

Step 3: Gain Formal Approval of the Program

• The pharmacy and therapeutics committee will likely need to approve all programs, protocols, and guidelines– What policies and procedures are needed?



69© 2008 TMIT

Step 4: Launch the Program and Address Unanticipated Issues

• Be sure to do careful planning prior to launch, but

• Be careful not to “over plan”– Not having the service in place could be the

bigger issue– Piloting is an excellent way to avoid this

• Once “bugs” are worked out, expand to other areas



70© 2008 TMIT

Step 5: Monitor Program Quality and Strive for Improvement

• Don’t let quality issues go– Address system issues that need to be

addressed– Provide individual, one on one, feedback

when individual pharmacists do not perform adequately and strive to improve their skills

• Be sure to credit your staff when care is improved



71© 2008 TMIT

Step 6: Expand into New Arenas as the Patient Need Arises

• Look for the next opportunity to improve care

• What is the department’s role with rVIIa?• How is vitamin K being utilized?• Is an inpatient “antithrombosis” program

the next step?



72© 2008 TMIT

• Managing Anticoagulation Patients in the Hospital; the Inpatient Anticoagulation Service

• Published by ASHP June, 2007

• Available at www.ashp.org

73© 2008 TMIT

Managing Anticoagulation Patients in the Hospital

• Part 1: Program Design and Implementation– Chapter 1: Introduction to the Inpatient Anticoagulation

Service– Chapter 2: Literature Review Supporting Inpatient Pharmacy

Management of Anticoagulation– Chapter 3: Anticoagulant Safety: Identification of the Gaps– Chapter 4: Planning of the Inpatient Anticoagulation Service– Chapter 5: Winning Support for the Inpatient

Anticoagulation Service– Chapter 6: Justifying the Program to Hospital

Administration: The Financial Perspective– Chapter 7: Pharmacist Education and Training– Chapter 8: Patient Education Needs– Chapter 9: Monitoring and Maintaining Program Quality

74© 2008 TMIT

Managing Anticoagulation Patients in the Hospital

• Part 2: Anticoagulant Knowledge 101– Chapter 10: Essential Warfarin Knowledge– Chapter 11: Heparin, Low Molecular

Weight Heparin, and Fondaparinux – Chapter 12: Essential Direct Thrombin

Inhibitor Knowledge – Chapter 13: Helpful References and

Preparing for the Future

75© 2008 TMIT

In closing…..

• Anticoagulation services will likely become as fundamental of a service as kinetics

• Pharmacists need to be recognized as providers

76© 2008 TMIT

PATIENT ADVOCATE

Dan Ford

Vice President

Furst Group

77© 2008 TMIT

78© 2008 TMIT

Q & A

Documents

1 © 2008 TMIT Dale Bratzler, DO, MPH Michael Gulseth, PharmD, BCPS Dan Ford Hayley Burgess, PharmD, BCPP Charles Denham, MD Preventing Venous Thromboembolism