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Best Practices in Meeting NPSG 3E-Anticoagulation Requirements

Best Practices in Meeting NPSG 3E-Anticoagulation Requirements. MaryAnne Cronin, PharmD Assistant Director of Pharmacy Glen Cove Hospital. Clinical Pharmacy Presence.

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Best Practices in Meeting NPSG 3E-Anticoagulation Requirements

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  1. Best Practices in Meeting NPSG 3E-Anticoagulation Requirements MaryAnne Cronin, PharmD Assistant Director of Pharmacy Glen Cove Hospital

  2. Clinical Pharmacy Presence • Addition of Clinical Pharmacist to the orthopedic and rehabilitative medicine services in 2004 identified areas of potential improvement • Review of all VTE in 2005 led to the formation of a multidisciplinary Anticoagulation Subcommittee

  3. Orthopedic Service • Order sheet approved by Anticoagulation Subcommittee in April 2005 • Revised protocol applied immediately to orthopedic surgical population via patient care rounds and chart reviews • Minimize warfarin monotherapy • Begin LMWH POD#1 with non-epidural analgesia and 6 hours after catheter removal with epidural analgesia • Bridge warfarin with LMWH until INR > 2.0 x 2 consecutive days AND warfarin administered for at least 4 days.

  4. What impact do you think the implementation of a Prescriber Order Sheet had on our rate of venous thromboembolism in the ORTHOPEDIC SURGERY PATIENT over one year? • 12% • 25% • 35% • 48%

  5. Rate VTE Total Joint Replacement Program 2005: n = 44/953 2006: n = 24/1003. 48% reduction 2005 to 2006. 2007: n = 28/1054. 43% reduction 2005 to 2007.

  6. Pulmonary Embolism Total Joint Replacement Program 2005: 9/953 2006: 4/1003 2007: 2/1054 57% reduction 2005 to 2006. 80% reduction 2005 to 2007.

  7. WARFARIN MECHANISM OF ACTION Warfarin acts by inhibiting levels of anticoagulant factors II, VII, IX, and X and procoagulant proteins C and S. Protein C promotes fibrinolysis. Factor VII and protein C have short half-lives (6 hrs). Although depletion of Factor VII  rise in INR, patient not protected from thrombosis until Factor X and Factor II levels fall substantially. The half-life of Factor X is ~40 hrs, and ~60-70 hrs for Factor II.

  8. WARFARIN MECHANISM OF ACTION Rapid reduction of Protein C leaves the patient hypercoagulable and places them at  risk for thrombosis with warfarin monotherapy. If the patient is not bridged with LMWH or unfractionated heparin (UFH), warfarin alone induces a protein C deficiency prothrombotic state.

  9. Very High Risk TJR Patients • History of VTE • Clinically or genetically hypercoagulable • Morbidly obese Monitored closely - Aggressive anticoagulation (LMWH on POD#1) - AntiFactor Xa levels for clinical efficacy in special populations

  10. Medical Service • Form approved by all necessary committees and Medical Board in Sept 2006 • Education provided to attendings, residents, NPs, PAs, RNs indicating that Thromboprophylaxis Order Sheet must be completed within 24 hours of patient admission • Initiative up and running by end of 2006 • Clinical interventions, phone calls, chart reviews completed by clinical pharmacy service • Daily reports sent to pharmacy indicating patients requiring re-order to maintain prophylaxis throughout hospitalization

  11. What impact do you think the implementation of a Prescriber Order Sheet had on our rate of venous thromboembolism in the MEDICAL PATIENT over one year? • 15% • 25% • 40% • 60%

  12. Rate VTE Medical Service No Contraindication 2005: 28/5113 = 0.55% 2006: 30/5161 = 0.58% 2007: 11/4716 = 0.23% 60% reduction 2006 to 2007

  13. Rehabilitative Medicine • Mandatory use of Thromboprophylaxis Order Sheet improved rates of preventable VTE overall • Patients admitted on warfarin monotherapy with subtherapeutic INRs bridged with LMWH until INR> 2.0 unless surgeon opposed therapy

  14. Number Hospital-Acquired VTE Rehab 2005: 26/1791 = 1.5% 2006: 11/2284 = 0.48% 68% reduction 2005 to 2006 2007: 9/2179 = 0.41% 73% reduction 2005 to 2007

  15. Rate Hospital-Acquired VTEMedical ServiceHeparin 5000 units SC q12hr Failure Lack of efficacy of Heparin 5000 units SC q12h for venous thromboprophylaxis supported by this 3-year data.

  16. In addition to NPSG requirements, what other forces are impacting the prophylaxis and treatment of VTE?

  17. PROPHYLAXIS OF VTE: American College of Chest Physicians (ACCP) 2008 Guidelines

  18. TREATMENT OF VTE: 2008 ACCP Guidelines

  19. Patients Transferred Acute

  20. Conclusion: Meeting NPSG 3E Requirements • The Anticoagulation Subcommittee meets quarterly and is responsible for all issues concerning safe and efficacious administration of anticoagulation • Hospital protocols and order sheets utilized for anticoagulation prophylaxis and treatment

  21. Conclusion:Meeting NPSG 3E Requirements, cont. • Clinical Pharmacists round on each unit and monitor for anticoagulation safety and efficacy • INRs and PLTs • Morbid obesity (BMI>40) and low body weight (<45kg female, <57kg male) • Renal function • PMH (aggressive vs conservative) • Patients and/or family members educated by nursing and/or pharmacy prior to discharge on warfarin and enoxaparin • Discharge kit for enoxaparin • Educational materials on safe administration of warfarin • “Coumadin Cookbook”

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