Best Practices in Meeting Best Practices in Meeting NPSG 3E-Anticoagulation NPSG 3E-Anticoagulation

RequirementsRequirements

MaryAnne Cronin, PharmDMaryAnne Cronin, PharmDAssistant Director of PharmacyAssistant Director of Pharmacy

Glen Cove HospitalGlen Cove Hospital

Clinical Pharmacy PresenceClinical Pharmacy Presence

Addition of Clinical Pharmacist to the Addition of Clinical Pharmacist to the orthopedic and rehabilitative medicine orthopedic and rehabilitative medicine services in 2004 identified areas of services in 2004 identified areas of potential improvementpotential improvement

Review of all VTE in 2005 led to the Review of all VTE in 2005 led to the formation of a multidisciplinary formation of a multidisciplinary Anticoagulation SubcommitteeAnticoagulation Subcommittee

Orthopedic ServiceOrthopedic ServiceOrder sheet approved by Anticoagulation Order sheet approved by Anticoagulation Subcommittee in April 2005Subcommittee in April 2005Revised protocol applied immediately to Revised protocol applied immediately to orthopedic surgical population via patient orthopedic surgical population via patient care rounds and chart reviewscare rounds and chart reviews– Minimize warfarin monotherapyMinimize warfarin monotherapy– Begin LMWH POD#1 with non-epidural Begin LMWH POD#1 with non-epidural

analgesia and 6 hours after catheter removal analgesia and 6 hours after catheter removal with epidural analgesiawith epidural analgesia

– Bridge warfarin with LMWH until INR > 2.0 Bridge warfarin with LMWH until INR > 2.0 x 2 consecutive days AND warfarin x 2 consecutive days AND warfarin administered for at least 4 days.administered for at least 4 days.

What impact do you think the What impact do you think the implementation of a Prescriber Order implementation of a Prescriber Order Sheet had on our rate of venous Sheet had on our rate of venous thromboembolism in the ORTHOPEDIC thromboembolism in the ORTHOPEDIC SURGERY PATIENT over one year?SURGERY PATIENT over one year?

A.A. 12%12%B.B. 25%25%C.C. 35%35%D.D. 48%48%

Rate VTE Rate VTE Total Joint Replacement ProgramTotal Joint Replacement Program

Rate VTE Total Joint Replacement Program

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

Year

Per

cen

t R

ate

VT

E

Rate VTE 4.60% 2.40% 2.60%

2005 2006 2007

2005: n = 44/953

2006: n = 24/1003. 48% reduction 2005 to 2006.48% reduction 2005 to 2006.

2007: n = 28/1054. 43% reduction 2005 to 2007.43% reduction 2005 to 2007.

Pulmonary Embolism Pulmonary Embolism Total Joint Replacement ProgramTotal Joint Replacement Program

Rate of PE in Total Joint Replacement Program

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

Year

Per

cen

t R

ate

of

PE

Rate of PE 0.90% 0.40% 0.18%

2005 2006 2007

2005: 9/953 2006: 4/1003 2007: 2/10542005: 9/953 2006: 4/1003 2007: 2/1054

57% reduction 2005 to 2006. 80% reduction 2005 to 2007.57% reduction 2005 to 2006. 80% reduction 2005 to 2007.

WARFARIN MECHANISM OF ACTIONWarfarin 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.

WARFARIN MECHANISM OF ACTIONRapid 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.

Very High Risk TJR PatientsVery High Risk TJR Patients

History of VTEHistory of VTE

Clinically or genetically hypercoagulableClinically or genetically hypercoagulable

Morbidly obeseMorbidly obese

Monitored closelyMonitored closely

- Aggressive anticoagulation (LMWH on POD#1)- Aggressive anticoagulation (LMWH on POD#1)

- AntiFactor Xa levels for clinical efficacy in - AntiFactor Xa levels for clinical efficacy in special populationsspecial populations

Medical ServiceMedical Service

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

What impact do you think the What impact do you think the implementation of a Prescriber Order implementation of a Prescriber Order Sheet had on our rate of venous Sheet had on our rate of venous thromboembolism in the MEDICAL thromboembolism in the MEDICAL PATIENT over one year?PATIENT over one year?

A.A. 15%15%B.B. 25%25%C.C. 40%40%D.D. 60%60%

Rate VTE Medical Service Rate VTE Medical Service No ContraindicationNo Contraindication

Rate Hospital-Acquired VTE Medical Patients

0

0.2

0.4

0.6

0.8

Year

Per

cen

t R

ate

of

VT

E

Rate VTE 0.55 0.58 0.23

2005 2006 2007

2005: 28/5113 = 0.55%

2006: 30/5161 = 0.58%

2007: 11/4716 = 0.23% 60% reduction 2006 to 2007

Rehabilitative MedicineRehabilitative Medicine

Mandatory use of Thromboprophylaxis Mandatory use of Thromboprophylaxis Order Sheet improved rates of preventable Order Sheet improved rates of preventable VTE overallVTE overall

Patients admitted on warfarin monotherapy Patients admitted on warfarin monotherapy with subtherapeutic INRs bridged with with subtherapeutic INRs bridged with LMWH until INR> 2.0 unless surgeon LMWH until INR> 2.0 unless surgeon opposed therapyopposed therapy

Number Hospital-Acquired VTE RehabNumber Hospital-Acquired VTE RehabTotal Number "PREVENTABLE" VTE Rehab

0

10

20

30

Year

Nu

mb

er V

TE

Number VTE 26 11 9

2005 2006 2007

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

Rate Hospital-Acquired VTERate Hospital-Acquired VTEMedical ServiceMedical Service

Heparin 5000 units SC q12hr FailureHeparin 5000 units SC q12hr FailureRate VTE Medical Service Heparin q12h Failure

0

10

20

30

40

Year

Per

cen

t T

ota

l V

TE

fo

r th

e Y

ear

Rate VTE 32 6.7 0

2005 2006 2007

Lack of efficacy of Heparin 5000 units SC q12h for venous thromboprophylaxis supported by this 3-year data.

In addition to NPSG In addition to NPSG requirements, what other requirements, what other forces are impacting the forces are impacting the

prophylaxis and treatment prophylaxis and treatment of VTE? of VTE?

PROPHYLAXIS OF VTE: PROPHYLAXIS OF VTE: American College of Chest Physicians American College of Chest Physicians

(ACCP) 2008 Guidelines(ACCP) 2008 Guidelines

TREATMENT OF VTE: TREATMENT OF VTE: 2008 ACCP Guidelines2008 ACCP Guidelines

Patients Transferred AcutePatients Transferred Acute

Patients Requiring Acute Care for Treatment of VTE

Year Rehab (# pts)

Med-Surg (# pts)

Total Acute Days

Percent Percent reductioreductio

nn 

2005 9 5 80 

2006 7 4 66 17.5%17.5%  

2007 4 2 33 50%50%  

Conclusion: Conclusion: Meeting NPSG 3E RequirementsMeeting NPSG 3E Requirements

The Anticoagulation Subcommittee meets The Anticoagulation Subcommittee meets quarterly and is responsible for all issues quarterly and is responsible for all issues concerning safe and efficacious concerning safe and efficacious administration of anticoagulationadministration of anticoagulation

Hospital protocols and order sheets utilized Hospital protocols and order sheets utilized for anticoagulation prophylaxis and for anticoagulation prophylaxis and treatmenttreatment

Clinical Pharmacists round on each unit and monitor Clinical Pharmacists round on each unit and monitor for anticoagulation safety and efficacyfor anticoagulation safety and efficacy– INRs and PLTs INRs and PLTs – Morbid obesity (BMI>40) and low body weight (<45kg Morbid obesity (BMI>40) and low body weight (<45kg

female, <57kg male)female, <57kg male)– Renal functionRenal function– PMH (aggressive vs conservative)PMH (aggressive vs conservative)

Patients and/or family members educated by nursing Patients and/or family members educated by nursing and/or pharmacy prior to discharge on warfarin and and/or pharmacy prior to discharge on warfarin and enoxaparinenoxaparin– Discharge kit for enoxaparinDischarge kit for enoxaparin– Educational materials on safe administration of warfarinEducational materials on safe administration of warfarin– ““Coumadin Cookbook”Coumadin Cookbook”

Conclusion:Conclusion:Meeting NPSG 3E Requirements, Meeting NPSG 3E Requirements, cont.cont.