Medication Safety Anticoagulation Management.ppt
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Transcript of 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
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
http://www.inrpro.com/http://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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www.crhealthcarealliance.org
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
http://www.inrpro.com/http://www.inrpro.com/ -
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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
www.crhealthcarealliance.org
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
www.crhealthcarealliance.org
mailto:[email protected]://www.crhealthcarealliance.org/http://www.crhealthcarealliance.org/mailto:[email protected]