# Presentation: 624117

## Improving Safety with Anticoagulation in the Nursing Home Setting

- Jerry H. Gurwitz, MD
- Meyers Primary Care Institute
- University of Massachusetts Medical School, Fallon Foundation, and Fallon Community Health Plan
- Worcester, Massachusetts

## Improving Safety with Anticoagulation in the Nursing Home Setting

*AHRQ-funded Center of Excellence for Patient Safety Research and Practice at Brigham and Women’s Hospital*
*University of Massachusetts Medical School and Meyers Primary Care Institute*
*Collaboration with Qualidigm: QIO in Connecticut*

## Anticoagulation Therapy with Warfarin

**History of warfarin**
**Indications for therapy**
**Monitoring therapy**
**Effectiveness of therapy**

## Slide 4

## Slide 5

## History of warfarin

**1924- bleeding disease in cattle**
**1939- agent identified**
**1948- warfarin synthesized**
**Rodenticide - ? therapeutic use**
**1951- young army recruit**
**Rest is history**

## Anticoagulation Therapy with Warfarin

**Indications for therapy**
**Challenge: effectiveness and safety hinge on very careful dosing and monitoring**

## Case Study

**   ****E.G. is an 85 year-old female nursing home resident with a history of atrial fibrillation, stroke, dementia, and hypertension, who is receiving chronic therapy with warfarin.  Her primary care provider has been dosing her warfarin to maintain her at an INR of 2.0.**

## Case Study

**   ****One evening, a covering physician is called with a report that the patient has developed a fever.  The patient is initiated on empiric antibiotic therapy with cephalexin (500 mg po TID for 7 days) to treat a presumed urinary tract infection.      **

## Case Study

**   ****The next morning the primary care physician is called with the previous day’s INR, 1.75.  He increases the daily warfarin dose from 4 mg to 5 mg per day.  He is not notified of the cephalexin ordered the previous evening by the covering physician.**

## Case Study

**   ****One week later, the INR comes back at 13.8 and a covering physician is notified.  That evening’s warfarin dose is held.  The INR the following day is 16.1.  The warfarin continues to be held.  No vitamin K is administered.  **

## Case Study

**  ****The next day the patient passes a tarry stool.**

## Case Study

**   ****The following morning the patient’s hematocrit is 25 and her INR is 11.3.  The primary care physician is notified, and vitamin K 10 mg sc is administered for 3 days with a decrease in the INR to 0.9.  The physician writes that “**_***warfarin will not be reinitiated because anticoagulation has been difficult to control for unclear reasons***_**.”**

## Slide 14

## Nursing Homes and Residents		

- Nursing homes (90-360 beds)
- 2946 to 3212 residents/quarter
- 490 residents on warfarin

## Definitions of Quality Measures

- The proportion of time within the target therapeutic range
- Response to out-of-target range INR values – time until next INR
- Adverse warfarin-related events (AWEs)
- Potential adverse warfarin-related events (PAWEs) – INR > 4.5

## Warfarin Errors

**Warfarin Errors**

**Preventable**

**PAWEs**

## Quality of Warfarin Management

- INR Range

**Notes:**
Furthermore, we observed a clear dose-response relationship.  We found that the risk increased dramatically with increasing daily dose of metoclopramide.  In this figure, daily dose of metoclopramide is on the horizontal axis.  Risk for the initiation of levodopa therapy is on the vertical.  Those patients treated with more than 20 mg of metoclopramide per day had a risk of being initiated on levodopa therapy that was 5.3 times greater than patients not using this medication.  Keep in mind that metoclopramide’s labeling indicates that it can be prescribed in a dosage of up to 60 mg per day.

## Delayed follow-up in INR testing when INR > = 4.5

## AWEs and PAWEs (n=965)

| Category | Number | Percentage |
| --- | --- | --- |
| AWEs | 721 | 75% |
| PAWEs | 244 | 25% |
| Total | 965 | 100% |

## AWEs by Severity (n=721)

| Category | Number | Percentage |
| --- | --- | --- |
| Fatal/Life Threatening | 14 | 2% |
| Serious | 82 | 11% |
| Minor | 625 | 87% |

## Adverse Warfarin-Related Events (n=721)Preventable vs Non-Preventable

## Preventability of AWEs

- Of fatal, life-threatening
- & serious events

- Of minor events

**Preventable**
**57%**

**Preventable**
**24%**

**Notes:**
Focus on preventable events 
High percent of the more serious events were preventable
(Compare to only 43% in the hospital-based study)

## Rates		

- 18.6 events per 100 resident-months on warfarin
- 5.4 preventable events per 100 resident-months on warfarin
- 2.5 fatal/life-threatening/serious events per 100 resident-months on warfarin
- 1.4 preventable fatal/life-threatening/serious events per 100 resident-months on warfarin

##  Errors by Stage of Warfarin Management (among 208 preventable AWEs)

| Category | Number | Percentage |
| --- | --- | --- |
| Prescribing | 132 | 63% |
| Filling | 2 | 1% |
| Administering | 2 | 1% |
| Monitoring | 188 | 90% |

## Slide 26

##    Nursing Home

**   ****Nursing Home**

## CPOE with Clinical Decision Support at Baycrest Centre for Geriatric Care in Toronto, Ontario

## State of HIT in U.S. Nursing Homes		

- Telephones
- Fax machines
- Computers (rare)

##    Nursing Home

**   ****Nursing Home**

##    Nursing Home

**   ****Nursing Home**

- MDs

- Lab

- Pharmacy

- Nurse

- Patient

## ?

##    Nursing Home

**   ****Nursing Home**

- MDs

- Lab

- Pharmacy

- Nurse

- Patient

## Intervention

- Focus on prescribing and monitoring
- Intervention options
- Specialized anticoagulation service
-  HIT intervention employing CPOE with computerized clinical decision support
-  Non-technology based intervention focused on improving communication between nursing home and physician

## Slide 35