IHI Expedition Expedition: Improving Medication Safety from the - - PowerPoint PPT Presentation

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IHI Expedition Expedition: Improving Medication Safety from the - - PowerPoint PPT Presentation

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April 23, 2015 These presenters have nothing to disclose IHI Expedition Expedition: Improving Medication Safety from the Patients Perspective Session 5: Safe Management of Newly Released Anticoagulants and High-Alert Medications L. Hayley

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IHI Expedition

Expedition: Improving Medication Safety from the Patient’s Perspective Session 5: Safe Management of Newly Released Anticoagulants and High-Alert Medications April 23, 2015

These presenters have nothing to disclose

  • L. Hayley Burgess, PharmD

Jamie Anderson, PharmD, BCPS Frank A. Federico Joelle Baehrend

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Today’s Host

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Dorian Burks

Project Coordinator Institute for Healthcare Improvement

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Phone Connection (Preferred)

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T

  • join by phone:

1) Click on the “Participants” and “Chat” icons in the top right hand side of your screen. 2) Click the button

  • n the right hand side of

the screen. 3) A pop-up box will appear with the option “I will call in.” Click that

  • ption.

4) Please dial the phone number, the event number and your attendee ID to connect correctly .

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WebEx Quick Reference

  • Please use chat to

“All Participants” for questions

  • For technology

issues only, please chat to “Host”

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Enter Text Select Chat recipient Raise your hand

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5

When Chatting…

Please send your message to All Participants

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Expedition Director

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Joelle Baehrend

Director Institute for Healthcare Improvement

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Today’s Agenda

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  • Welcome & Introductions
  • Action Period Debrief
  • Safe Management of Newly Release

Anticoagulants and High-Alert Medications – L. Hayley Burgess, PharmD

  • Action Period Assignment
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Expedition Sessions

Session 1 – Improving Polypharmacy

Faculty : Robert Feroli, PharmD and Amanda Brummel, PharmD, BCACP

Session 2 – Health Literacy and Medication Safety

Faculty : Gail Nielsen, BSHCA, FAHRA

Session 3 – Improving Medication Adherence

Faculty : William Strull, MD

Session 4 – Medication Reconciliation

Faculty : Anne Myrka, RPh, MAT

Session 5 – Safe Management of Newly Released Anticoagulants and High- Alert Medications

Faculty : L. Hayley Burgess, PharmD

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Action Period Assignment Report Out

Assignment: Reflect on the audit and what you heard from Anne Myrka and identify two challenges and two affordances (things that help) in your medication reconciliation process. Report out: What did you learn? Please chat in any reflections on the exercise.

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Survey Results - Current State

Safe Management of New Anticoagulants: My hospital has a process to ensure the safe management of newly released anticoagulants and high-alert medications:

  • Do not know current status of this practice: 0%
  • Do not currently have this practice in place: 10%
  • Have a process that supports this practice: 50%
  • Process is reliably applied: 25%
  • Need further clarification on this practice: 15%

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Faculty

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Frank Federico, RPh

Executive Director, Strategic Partners Institute for Healthcare Improvement

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Faculty

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  • L. Hayley Burgess, PharmD

Director of Clinical Pharmacy and Medication Safety Hospital Corporation of America, Clinical Services Group

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Faculty

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Jamie Anderson, PharmD, BCPS

Clinical Pharmacy Specialist - Anticoagulation University of Kansas, School of Pharmacy

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Direct Acting Oral Anticoagulants

Medication Management Strategies

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Objectives

  • Introduce direct acting oral anticoagulants
  • Recall benefits and disadvantages to therapy
  • Learn strategies to positively impact

medication management processes

  • Procurement
  • Storage
  • Ordering
  • Administration
  • Monitoring
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A 68 year old male is admitted to the hospital and has rivaroxaban 20 mg PO DAILY from his home medication reconciliation.

Is your system set up for safe medication management of a NOAC

  • Indication specific
  • Monitoring
  • Storage
  • Case
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Clot Bleed

Anticoagulation Balancing Act

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Direct Thrombin Inhibitor: Pradaxa (dabigatran) Xa Inhibitors: Xarelto (rivaroxaban) Eliquis (apixaban) Savaysa (edoxaban) Vitamin K Antagonist: Coumadin (warfarin)

Emerging Therapies

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Afib – Stroke Prevention DVT/PE Treatment Postop VTE Prophylaxis

Indications

All direct acting

  • ral anticoagulants:

Additional indication

  • nly for:

Xarelto (rivaroxaban) Eliquis (apixaban)

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Fixed dosing No routine bloodwork Rapid onset Shorter half life Few food and drug interactions Lack of reversal agents Renally dosed BID dosing Cost Lack of data

Pros & Cons

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  • Procurement
  • Storage
  • Ordering
  • Administration
  • Monitoring

Medication Management

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  • Procurement
  • Manage formulary to avoid therapy disruption
  • Be prepared to convert to and from:
  • Parental agents
  • Warfarin
  • Direct oral anticoagulants

Pradaxa (dabigatran) Enoxaparin Warfarin Eliquis (apixaban)

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  • Storage
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  • Ordering

Create order sets for each indication

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  • Administration

May be given without regard to meals Crushable for NG Tube

  • Pradaxa (dabigatran)
  • Xarelto (rivaroxaban)

doses ≥ 15mg/day

  • Xarelto (rivaroxaban)

doses 10mg/day

  • All others
  • Xarelto (rivaroxaban)
  • Eliquis (apixaban)
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  • Monitoring

INR

  • No routine coagulation testing
  • Renal function
  • CrCl
  • SCr
  • CBC (hemoglobin, hematocrit)
  • Signs & symptoms of bleeding
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  • “Drugs work only when

patients take them.”

  • Is adherence dependent
  • n delivery of Care?
  • Monitoring of NOAC

helps with better patient adherence.

  • Monitoring
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  • Pharmacist-based activities

improved patient outcomes.

  • Pharmacist ensure appropriate

medication selection.

  • Pharmacist provide patient

education.

  • Pharmacist lead in patient

monitoring.

  • Monitoring
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Conclusion

  • Direct acting oral anticoagulants are an

emerging treatment option

  • Education is required
  • Appropriate medication management is vital
  • Procurement: Formulary – avoid disruption, know

conversion between agents

  • Storage: Per manufacturer, Pradaxa oddities
  • Ordering: Create order sets by indication
  • Administration: 5 Rights, crush, food
  • Monitoring: Renal function, bleeding
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Questions/Comments?

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  • Levy JH. Pharmacology and safety of new oral anticoagulants: the challenge of bleeding
  • persists. Clin Lab Med. 2014;34(3):443-52.
  • Levy JH, Levi M. New oral anticoagulant-induced bleeding: clinical presentation and
  • management. Clin Lab Med. 2014;34(3):575-86.
  • Dabigatran. In: Lexi-Drugs Online. Hudson (OH): Lexi-Comp, Inc.; [updated 03/30/15; accessed

04/02/15].

  • Rivaroxaban. In: Lexi-Drugs Online. Hudson (OH): Lexi-Comp, Inc.; [updated 04/02/15; accessed

04/02/15].

  • Apixaban. In: Lexi-Drugs Online. Hudson (OH): Lexi-Comp, Inc.; [updated 02/02/15; accessed

04/02/15].

  • Savaysa [package insert]. Daiichi Sankyo, Inc. Parsippany, NJ 07054 USA. January 2015.

http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/206316lbl.pdfAccessed April 2, 2015.

  • Boehringer Ingelheim Pharmaceuticals Medical Information. Pradaxa stability, storage,

dispensing, shipping and disposal.

References

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Questions/Discussion

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Raise your hand Use the chat

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Action Period Assignment

Assignment: Run a PDSA (small test of change)

– Test using a Warfarin protocol (or other high-alert med for which you

are not currently using a protocol)

  • 1. Educate staff about the small test of change.
  • 2. Either develop a protocol or use one developed by another organization.
  • 3. Identify who, what, where, and when of the test. (one physician, one

nurse, one patient, one day)

  • 4. Complete the test.
  • 5. Huddle with the team to discuss.

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Action Period Assignment – cont.

When preparing your test, include your predictions of what will happen. After you conduct the test, answer questions about your predictions. For example, in this case:

Physician will be able to use the protocol easily. Yes or No The protocol fits into the flow of our work. Yes or No The protocol does not add any time to the process. Yes or No

If the answer to any question is “No” find out why, modify the protocol and retest.

Share your test! Complete a PDSA worksheet and send to the listserv! http://www.ihi.org/resources/Pages/T

  • ols/PlanDoStudyActWorksheet.aspx

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Expedition Communications

  • All sessions are recorded
  • Materials are sent one day in advance
  • Listserv address for session communications:

medicationsafety@ls.ihi.org

  • To add colleagues, email us at info@ihi.org

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Thank You!

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Joelle Baehrend jbaehrend@ihi.org Dorian Burks dburks@IHI.org

Please let us know if you have any questions or feedback following today’s Expedition webinar.