OSHP NPSG3E Anticoagulation Workshop

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OSHP NPSG-3E Anticoagulation Workshop

• Susan Fugate, Pharm.D., BCPS, CACP
• University of Oklahoma College of Pharmacy
• INTEGRIS Baptist Southwest Anticoagulation
  Clinics

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INTEGRIS

• Baptist Medical Center
• 508 bed hospital
• Southwest Medical Center
• 368 bed hospital
• Anticoagulation Clinics
• Comprehensive outpatient warfarin management
• 1000 patients
• http//www.integris-health.com/integris/en-us/spec
  ialties/a-f/anticoagulation

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National Patient Safety Goals (NPSG)

• NPSG.03.05.01
• Reduce the likelihood of patient harm associated
  with the use of anticoagulation therapy
• Rationale
• High-risk treatment commonly leading to ADE due
  to complex dosing, follow-up monitoring,
  inconsistent compliance
• Standardized practices can reduce risk of ADEs
  associated with UFH, LMWH, and warfarin

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NPSG.03.05.01 Timeline

• 4/1/08 Responsibility assigned for oversight
  and coordination
• 7/1/08 Implementation plan in place
• 9/1/08 Pilot testing in at least 1 clinical unit
• 1/1/09 Full implementation

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NPSG.03.05.01Elements for Performance

• 1. The hospital implements a defined
  anticoagulation management program to
  individualize the care provided to each patient
  receiving anticoagulation therapy.
• Example
• Anticoagulation management services
• Anticoagulant committee to develop processes and
  protocols to be used throughout the institition

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NPSG.03.05.01Elements for Performance

• 2. To reduce compounding and labeling errors, the
  hospital uses only oral unit dose products,
  pre-filled syringes, or pre-mixed infusion bags
  when these products are available.
• Note For pediatric patients, pre-loaded syringe
  products should only be used if specifically
  designed for children.

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NPSG.03.05.01Elements for Performance

• 3. 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.
• Examples
• Warfarin protocols
• Pharmacist or nurse driven dosing
• Support structure to physician dosing
• UFH/LMWH
• Treatment dosing/indications
• Prophylactic dosing/indications

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31 hospital survey

• Surveyed ACCP Cardiology and Critical Care list
  serves
• 58 had 2 UFH order sets
• 23 had 3 UFH order sets
• Majority for DVT/PE and ACS
• 74 have been evaluated
• 45 had pharmarcy-managed anticoagulation
  services
• 97 used aPTT to monitor UFH

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NPSG.03.05.01Elements for Performance

• 4. For patients starting on warfarin, a baseline
  INR is available, and for all patients receiving
  warfarin therapy, a current INR is available and
  is used to monitor and adjust therapy.
• Examples
• Automatic INR order upon warfarin initiation in
  warfarin-naïve patients
• Automatic INR daily orders (prescriber may alter
  to no greater than weekly testing)
• Responsible party for review of INR prior to dose
  administration

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NPSG.03.05.01Elements for Performance

• 5. When dietary services are provided by the
  hospital, the service is notified of all patients
  receiving warfarin and responds according to its
  established food/medication interaction program.
• Examples
• Warfarin education booklet
• USDA vitamin K food list
• Dietary services provide education to all
  patients

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NPSG.03.05.01Elements for Performance

• 6. When heparin is administered IV and
  continuously, the hospital uses programmable
  infusion pumps in order to provide consistent and
  accurate dosing.

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NPSG.03.05.01Elements for Performance

• 7. The hospital has a written policy that
  addresses and ongoing laboratory tests that are
  required for UFH and LMWH therapies.
• Examples
• Therapeutic monitoring
• Safety monitoring
• May incorporate into medication use protocols

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NPSG.03.05.01Elements for Performance

• 8. The hospital provides education regarding
  anticoagulation therapy to prescribers, staff,
  patients, and families.
• Note Patient/family education includes the
  importance of follow-up monitoring, compliance
  issues, dietary, restrictions, and potential for
  ADRs and interactions.
• Examples
• AHRQ warfarin booklet (English/Spanish)
• LMWH discharge kits
• Prescriber/staff meeting in-services and
  newsletter update

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NPSG.03.05.01Elements for Performance

• 9. The hospital evaluates its anticoagulation
  safety practices, takes appropriate action to
  improve its practices, and measures the
  effectiveness of those actions on a regular
  basis.
• Examples
• Assessment of patient outcomes and therapeutic
  control

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Additional Joint Commission Expectations

• Standardized list of abbreviations
• Standardize and limit the of drug
  concentrations used
• Accurately and completely reconcile meds across
  the continuum of care
• Identify and at a minimum annually review
  look-alike/sound-alike drugs

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Additional Joint Commission Expectations

• Implement a standardized approach to hand off
  communications
• Measure, assess, and if appropriate, take action
  to improve timeliness of reporting receipt of
  critical tests results
• Encourage patients active involvement in their
  own care as a patient safety strategy

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Resources

• 2008 CHEST recommendations www.chestjournal.org
  
• AHRQ www.ahrq.gov
• USDA www.usda.gov
• Pharmaceutical industry websites/reps
• Managing Anticoagulation Patients in the
  Hospital 107 www.ashp.org

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Resources

• Anticoagulant toolkit http//www.purdue.edu/dp/rc
  he/pharmatap/toolkit.pdf
• Live WEBINAR NPSG 3E Myths Reality 8/21
  www.1.gotometting.com/register/862541958
• OSHP workshop summary
• www.oshp.net