# Presentation: 624045

## 
Carla S. Huber, ARNP MS
Community Anticoagulation Therapy (CAT) Clinic
Cedar Rapids, IA 52401
515-558-4046
chuber@pcofiowa.com
www.crhealthcarealliance.org 

**Medication Safety: ****Anticoagulation Management**

**Carla S. Huber, ARNP MS**
**Community Anticoagulation Therapy (CAT) Clinic**
**Cedar Rapids, IA 52401**
**515-558-4046**
- _[chuber@pcofiowa.com](mailto:chuber@pcofiowa.com)_
- _[www.crhealthcarealliance.org](http://www.crhealthcarealliance.org/)_** **

## 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 for patients taking warfarin
List the advantages of a dedicated anticoagulation clinic

- 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 for patients taking warfarin
- List the advantages of a dedicated anticoagulation clinic

## Specific Aims
Education and training in principles of ISO 9001 quality management systems
Establish the anticoagulation clinic
Determine other uses of ISO framework within the healthcare community

- Specific Aims
- Education and training in principles of ISO 9001 quality management systems
- Establish the anticoagulation clinic
- Determine other uses of ISO framework within the healthcare community

## Slide 4

**Notes:**
Also, many studies that support organized management of blood thinning medications

## Safe Practices:
#1 - Creation of a healthcare culture of safety
#18 – Utilization of dedicated anti-thrombotic services that facilitate coordinated care management

- Safe Practices:
- #1 - Creation of a healthcare culture of safety
- #18 – Utilization of dedicated anti-thrombotic services that facilitate coordinated care management

## 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 for adverse drug events

- 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 for adverse drug events

- Source CDC

## 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.htm retrieved 1/22/07
Up to 60% of all medications prescribed are taken incorrectly or not at all
90% of elderly patients make some medication errors
35% of the elderly make potentially serious errors http://www.itaa.org/isec/events/presentations retrieved 1/12/07    

- 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.htm retrieved 1/22/07](http://www.webmd.com/content/article/6/1680_51638.htm%20retrieved%201/22/07)_
- Up to 60% of all medications prescribed are taken incorrectly or not at all
- 90% of elderly patients make some medication errors
- 35% of the elderly make potentially serious errors http://www.itaa.org/isec/events/presentations retrieved 1/12/07

**Notes:**
Recently pt’s. INR in range for 7 mos. Pt. picked up new prescription of warfarin that read take 5mg, M,F and 7.5mg other days/week, even though she had been taking 5mg four days/week and  7.5mg 3 days/week for 7 mos, INR up to 5.6.
Pt taking warfarin bid because her BP pill that she took in am that was peach in color and her warfarin was peach in color. So she was taking warfarin twice a day instead of BP in AM and warfarin in PM.

## 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

- 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

**Notes:**
Consistency in training and staff. Look at how differently physicians practice. Again no different than CHF or pneumonia guidelines.
Collecting data.

## 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 to anticoagulation events

- 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 to anticoagulation events

## 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

- 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

## An organized Quality Management System
“Say what you do”
Document what you do
“Do what you say”
Perform to your documentation
“Record Information”
Record the results of your work
“Audit effectiveness”
Audit the documentation of effectiveness

- An organized Quality Management System
- “Say what you do”
- Document what you do
- “Do what you say”
- Perform to your documentation
- “Record Information”
- Record the results of your work
- “Audit effectiveness”
- Audit the documentation of effectiveness

**Notes:**
How many of us work in settings where same policies are different for other departments, registration for instance. Or policies are written in different formats for different departments.

## The organization needs to identify and determine which additional procedures need to be documented to create consistent processes. 
Physicians’ Clinic of Iowa currently has over 400 documented policies and procedures. 
The Community Anticoagulation Therapy Clinic (CAT Clinic) currently has over 70 documented policies and procedures. 

- The organization needs to identify and determine which additional procedures need to be documented to create consistent processes.
- Physicians’ Clinic of Iowa currently has over 400 documented policies and procedures.
- The Community Anticoagulation Therapy Clinic (CAT Clinic) currently has over 70 documented policies and procedures.

**Notes:**
PCI found that each department had a different registration process, this was revised so same process used for all departments, when they went to Electronic medical record all dept’s had same process, saved time and resources

## Note the:

- Format and color

- Document number

- Purpose

- Definition

- Procedure or flowchart

## Slide 15

## Completed a process flow of current (2005) anticoag clinic processes
Lots of variation – several nurses providing information about dose changes to patients
Little use of evidence-based guidelines
Waiting for lab results
Pt. satisfaction low
Pt. education 15 minutes

- Completed a process flow of current (2005) anticoag clinic processes
- Lots of variation – several nurses providing information about dose changes to patients
- Little use of evidence-based guidelines
- Waiting for lab results
- Pt. satisfaction low
- Pt. education 15 minutes

## Provide patient education 60-90 minutes and ongoing 
Patients go to lab of their choice, POC testing, home INR monitor
INRs faxed to CAT Clinic or provided via web
Pt. notified of results same day and dosing decision made based on guidelines
Referring physician notified of all results and changes in warfarin therapy

- Provide patient education 60-90 minutes and ongoing
- Patients go to lab of their choice, POC testing, home INR monitor
- INRs faxed to CAT Clinic or provided via web
- Pt. notified of results same day and dosing decision made based on guidelines
- Referring physician notified of all results and changes in warfarin therapy

## Why use guidelines to manage anticoagulation?
To reduce gaps in knowledge 
To reduce safety issues surrounding anticoagulation
Both of the above promote standardization in the practice of managing patients taking warfarin

- Why use guidelines to manage anticoagulation?
- To reduce gaps in knowledge
- To reduce safety issues surrounding anticoagulation
- Both of the above promote standardization in the practice of managing patients taking warfarin

**Notes:**
No different than management of CHF, diabetes, HTN, MI

## Maintenance Therapy
Make small changes to warfarin – increase or decrease dose 5-15%, if INR between 1.0 and 5.0
Calculate the weekly dose and adjust according to the total weekly dose. If patient taking 5mg/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- may take 48 hours to see a change in INR

- Maintenance Therapy
- Make small changes to warfarin – increase or decrease dose 5-15%, if INR between 1.0 and 5.0
- Calculate the weekly dose and adjust according to the total weekly dose. If patient taking 5mg/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- may take 48 hours to see a change in INR

## Other medications – antibiotics, herbs, aspirin products, chemotherapy, NSAIDs, amiodarone (decrease warfarin by as much as 30%)
Diet – amount of vitamin K in foods
Alcohol – warfarin is synthesized in the liver
Exercise
Stress

- Other medications – antibiotics, herbs, aspirin products, chemotherapy, NSAIDs, amiodarone (decrease warfarin by as much as 30%)
- Diet – amount of vitamin K in foods
- Alcohol – warfarin is synthesized in the liver
- Exercise
- Stress

**Notes:**
Antibiotics can increase or decrease INRs so watch closely. Do not arbitrarily decrease or increase dose of warfarin while pt. is taking an antibiotic. Check INR 3-4 days after antibiotic started (if one that affects INR) and then 3-4 days after pt. stops antibiotic. Most common culprits, levaquin, flagyl, Cipro
ASA and NSAIDs inhibit platelet aggregation so can increase bleeding, NSAIDs can increase gastric irritation and increase risk of bleeding
Dietary Supplements like Ensure, Slim Fast may have high amounts of vitamin K

## Each time the patient has an INR (especially if elevated or low), ask about changes in medication, OTCs, alcohol, diet, stress, missed/extra doses
Each face-to-face or telephone visit is a great opportunity to reinforce (anticipatory guidance)
If dose is changed, ask pt. to repeat instructions; clarify dose vs. pill size (5mg = 1 pill)	

- Each time the patient has an INR (especially if elevated or low), ask about changes in medication, OTCs, alcohol, diet, stress, missed/extra doses
- Each face-to-face or telephone visit is a great opportunity to reinforce (anticipatory guidance)
- If dose is changed, ask pt. to repeat instructions; clarify dose vs. pill size (5mg = 1 pill)

**Notes:**
Brand name Coumadin and generic warfarin pills are different colors for different mg sizes. Doesn’t matter if brand or generic colors will be the same for the same mg. For instance 2.5mg size is green for brand and for generic.

## 

It takes time to educate – more than a 10 or 15 minute office visit

- It takes time to educate – _more_ than a 10 or 15 minute office visit

**Notes:**
Binge drinking typically causes elevation in INR
Chronic drinking typically causes decrease in INR so increased doses of warfarin needed
Alcohol consumption is a safety issue - falls

## Educate, Educate, Educate
Health Literacy – 50% of adult population reads below 8th grade level
Joint Commission National Patient Safety Goal #13 - Encourage patients’ active involvement in their own care as a patient safety strategy. 
Find patient friendly materials such as “Your Guide to Coumadin®/Warfarin Therapy” at www.ahrq.gov/consumer/coumadin.pdf 
Teach back – ask   “Just so I know I explained things correctly, can you tell me 3 signs of bleeding that you need to report to your Dr.”

- Educate, Educate, Educate
- Health Literacy – 50% of adult population reads below 8th grade level
- Joint Commission National Patient Safety Goal #13 - *Encourage patients’ active involvement in their own care as a patient safety strategy.*
- Find patient friendly materials such as “Your Guide to Coumadin®/Warfarin Therapy” at www.ahrq.gov/consumer/coumadin.pdf
- Teach back – ask   “Just so I know I explained things correctly, can you tell me 3 signs of bleeding that you need to report to your Dr.”

**Notes:**
Ask simple assessment questions like do you like to ready, are you happy with the way you read, how far did you go in school. This may lead to more conversation about how well they read.
How would you explain A Fib to a patient?

## www.ahrq.gov/consumer/coumadin.pdf 

- www.ahrq.gov/consumer/coumadin.pdf

## CAT Clinic utilizes a web-based electronic medical record www.inrpro.com 
Automatic list of patients due for INRs
Warfarin log – easy to read
Control Chart
Next apt. date
Sent to referring physician
Reports at the click of a button

- CAT Clinic utilizes a web-based electronic medical record www.inrpro.com
- Automatic list of patients due for INRs
- Warfarin log – easy to read
- Control Chart
- Next apt. date
- Sent to referring physician
- Reports at the click of a button

**Notes:**
How do you know how well your patients are doing with their INR range? How many dose changes? Are any patients overdue for lab tests? How many times have patients been hospitalized  or visited the ER for bleeding or clotting problems?

## Slide 26

## Slide 27

## www.inrpro.com 

- www.inrpro.com

## Slide 29

**Notes:**
Bleeding and clotting events, INRs>5
Code E934.2 and 709.92

## Slide 30

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

| Benchmark - JCAHO, Journal of Quality and Safety, Vol. 29 (12), 2003 and AC Forum 2007. |
| --- |

## CAT Clinic patients in tighter range

**Notes:**
Tighter should mean less clotting and bleeding events
Less INR, decreased cost 

## 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. 

## 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.

## Slide 35

## Slide 36

**Notes:**
Compliance score includes: missed/extra doses, less/more vit K, more ETOH intake, addition of antibiotic, NSAID, herbal supplements or amiodarone

## ISO Executive and Staff Training Modules
INRPro Database – www.inrpro.com 
Organized Document System – 70 documents
Compliance Assessment Scale
Patient Education – Your Guide to Coumadin®/Warfarin Therapy 
Staff Education Modules

**Toolkit Items****	**

- ISO Executive and Staff Training Modules
- INRPro Database – www.inrpro.com
- Organized Document System – 70 documents
- Compliance Assessment Scale
- Patient Education – *Your Guide to Coumadin**®**/Warfarin Therapy*
- Staff Education Modules

## 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 for patients taking warfarin
List the advantages of dedicated anticoagulation clinics

- 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 for patients taking warfarin
- List the advantages of dedicated anticoagulation clinics

## www.crhealthcarealliance.org Cedar Rapids Healthcare Alliance
www.chest.org Most 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

- www.crhealthcarealliance.org Cedar Rapids Healthcare Alliance
- www.chest.org Most 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

## 
Carla S. Huber, ARNP MS
CAT Clinic
600 7th Street SE
Cedar Rapids, IA 52401
319-558-4046
chuber@pcofiowa.com
www.crhealthcarealliance.org 

- Carla S. Huber, ARNP MS
- CAT Clinic
- 600 7th Street SE
- Cedar Rapids, IA 52401
- 319-558-4046
- chuber@pcofiowa.com
- www.crhealthcarealliance.org