Inpatient Anticoagulation Management Services to Improve - - PowerPoint PPT Presentation

Inpatient Anticoagulation Management Services to Improve Transitions of Care

Andrea Resseguie PharmD, RPh, CACP Advanced Practice Clinical Specialist Anticoagulation Management Service

• List Inpatient Anticoagulation Management

Services (AMS) at Brigham & Women’s Hospital

• Review Inpatient AMS workflow

– AMMO

• Discuss importance of inpatient AMS to improve

transitions of care

Learning Objectives

• AMMO = Anticoagulation Management for Post-

Orthopedic Surgery Inpatients

• HAT = Hemostatic and Antithrombotic

Stewardship

Inpatient Anticoagulation Management Services

Major Orthopedic Surgery (Total Hip Replacement, Total Knee Replacement)

AMMO

Ventricular Assist Device (VAD)

HAT

High Risk Populations Followed Inpatient by AMS

• Inpatient physician orders consult
• Brigham and Women's Hospital (BWH) Department of

Pharmacy AMS

– Monitor & order warfarin every day

• AMMO = post orthopedic surgery patients requiring warfarin

– INR target range of 1.8 – 2.3 – Duration = 3 weeks

• HAT = VAD patients requiring warfarin

– INR target range dependent on VAD device – Duration = indefinite

Inpatient Anticoagulation Management Services cont.

AMMO Service Roles & Responsibilities

Individual Responsibilities Orthopedic Surgery Resident/ Responding Clinician

• Orders initial consult, warfarin dose day before

surgery, and warfarin dose day of surgery

• Communicate changes in patients’ clinical

conditions

• Cosign daily warfarin orders

AMMO Primary Pharmacist

• Process the consult (viewable through “Consult

Messages”)

• Enters new patient demographic into DAWN AC
• Write EPIC consult note
• Emails daily patient roster to pharmacists

AMMO Secondary Pharmacist

• Orders warfarin dose in EPIC
• Documents daily progress note into DAWN AC

EPIC

• Order consult
• AMMO primary RPh

review consult & write AMMO intake note

DAWN AC

• Add patients into

system

• AMMO Primary RPh

create daily inpatient roster

EPIC

• AMMO secondary

RPh monitor & order warfarin

DAWN AC

• AMMO secondary

RPh document daily progress note

AMMO Inpatient Workflow

EPIC Order Consult

• Required for consult

– Referring physician (Surgeon) – Primary indication for anticoagulation (Orthopedic surgery) – Type of surgery – Date of surgery – INR target range – Duration

EPIC

• Review consult
• Write AMMO intake note

DAWN AC

• Add patients into system
• Create daily inpatient roster

AMMO Primary RPh Workflow

EPIC Consult Review

BWH Department of Pharmacy Anticoagulation Management Service (AMS) Patient Name: _______________________ Patient MRN: _______________________ DOB Age Gender: ____________________ Date: _______ Time: _______ Consult Reason: Asked to assist in warfarin management for the Anticoagulation Management for Inpatient Post-Operative Orthopedic (AMMO) service Indication for Anticoagulation: Orthopedic Surgery Type of Surgery: *** Target INR: *** - *** Duration of Therapy: *** Referring attending MD: _________________ Consult Received: The BWH Department of Pharmacy Anticoagulation Management Service will manage the warfarin dosing for Patient _______________ while an inpatient. For daily progress notes and dosing instructions please click on the AMS indicator in the patient header and an anticoagulation report will display on the right side of the screen. For any questions or concerns, please feel free to contact the AMS service via email (BWHRxInpatientAMS@partners.org) or contact the covering floor pharmacist for any urgent matters.

AMMO Intake Note

DAWN AC: Adding AMMO Patients

If patient is NOT in Dawn AC

• Create new patient record
• Enter patient details (Name, MRN)
• Enter treatment plan details (Primary Diagnosis: Orthopedic Surgery, Start Date (POD -1), First seen date (POD 1), Next test date (POD 1))
• Duration: Select “short term,” and enter # of weeks
• Under the Referral tab, enter in Attending Surgeon (Referring MD)
• Set status to “Active Admitted”

If patient is ALREADY ACTIVE in Dawn AC

• Edit patient’s status
• Treatment Plan: change from “Admitted” to “Active admitted”
• Re-schedule patient for POD 1

If patient is ALREADY in system but INACTIVE

• Reactivate patient (Personal tab: change status from Inactive to Reactivate)
• Create New Treatment Plan (Primary Diagnosis: Orthopedic Surgery, Start Date (POD -1), First seen date (POD 1))
• Duration: Select “short term,” and enter # of weeks
• Under the Referral tab, enter in Attending Surgeon (Referring MD)
• Click “Admit,” then “Activate Admitted”
• Schedule patient for POD 1

Letters Tab: Select a custom message to send >>> Retrieve patient demographics from EMPI Once demographics have uploaded >>> Retrieve patient medications Write Note within Patient Profile: “AMMO following while inpatient for diagnosis (i.e. TKR) on date of surgery per physician (i.e. Dr. Wright). Your name

• DAWN AC home page >>> Patient List/Daily

Routines

• Status tab >>> filter for “active admitted”
• Send email containing inpatient roster to AMMO

secondary RPh

DAWN AC: Create Daily Inpatient Roster

EPIC

• Monitor & order warfarin

DAWN AC

• Document daily progress note

AMMO Secondary RPh Workflow

Warfarin Initiation Dosing Protocol (INR Range 1.8 – 2.3)

POD INR Dose 1 <1.2 No change 1.2-1.3 No change or decrease by 1 mg 1.4-1.5 HOLD or decrease by 1-3 mg >1.5 HOLD 2 <1.3 Increase by 2 mg 1.3-1.5 Continue or increase by 1 mg

• If dose was held and INR is <1.5, restart at last dose

1.6-2.0 No change or decrease by 1-2 mg

• If INR increased 0.4-0.5 in 24h, decrease by 1 mg
• If INR increased by >0.5, decrease by 2 mg
• If dose was held and INR <1.8, average last 3 doses & add 1-2 mg.
• If dose was held and INR 1.8-2.3, average last 3 doses

>2.0 Decrease by 1 mg *Hold if INR increased by 0.6 in 24h 3 <1.3 Increase dose by 2 mg 1.3-1.5 No change or increase by 1 mg

• If dose was held, average previous doses and cont. or increase by 1mg

1.6-2.0 No change or decrease by 1-2 mg

• If INR increased by 0.4-0.5 in 24h, decrease by 1 mg
• If INR increased >0.5 in 24h, decrease by 2 mg
• If dose was held, average previous doses and cont. or increase by 1mg

>2.0 Decrease by 1 mg or HOLD if INR increased 0.6 in 24h

• If dose was held, average previous doses and decrease by 1mg or hold

Ordering Warfarin Within EPIC

Holding Warfarin Within EPIC

• Nursing Communication

– Comments Section = “PLEASE HOLD WARFARIN DOSE THIS EVE (MM/DD/YYYY). Call pharmacy with any questions on warfarin”

DAWN AC: Daily Progress Note Documentation

• Enter INR
• Document daily progress note within treatment

notes

DAWN AC: Daily Progress Note Documentation cont.

.POD1

• Date/time:
• POD 1
• PMH:
• SH:
• Meds:
• Hct:
• Blood products:
• POD 0 INR/warfarin dose:
• Plan/rationale:
• Signature:

.POD

• Date/time:
• POD #
• Meds:
• Hct:
• Plans/Rationale:
• Signature:

Coded Comments

• Select next retest date
• Accept & authorize

DAWN AC: Daily Progress Note Documentation cont.

DAWN AC: LMWH Documentation

Inpatient AMMO patient discharged

Home with no VNA services Home with VNA services Rehab Facility

AMMO Transition of Care

• Definition = movement of patients between

health care practitioners, settings, and home as their condition and care needs change

• Problems with transition of care may lead to

adverse events and higher hospital readmission rates and costs

Transition of Care

• AMS RPh responsible for determining

disposition & maintaining outpatient care for the remaining duration of anticoagulation therapy

– PT/INR tested day after discharge & Q Mon/Thurs – Reinforce education & counseling points

• AMS RPH will enter any missing or pertinent info

upon discharge into DAWN AC

AMMO Transition of Care cont.

Transition of Care Barriers & Solutions

• Clinicians effectively & completely communicate important

information in a timely fashion among themselves or to patient/ caregiver

• Culture promotes successful hand-off (teamwork, respect)
• Standardized procedures in conducting successful hand-off

Communication

• Resolve conflicting recommendations, confusing medication regimens,

and unclear instructions

• Include patient/ caregiver in planning related to the transition process
• Sufficient understanding of medical condition or the plan will more

likely buy into the importance of following the care plan

Patient Education

• Having a clinical entity take responsibility to assure that the patient’s

health care is coordinated across various settings and among different providers

• Steps are taken to assure that sufficient knowledge and resources will

be available to the patient upon discharge

Accountability

• No gap in AMS coverage

– Inpatient >>> Outpatient

• Standardized AMMO training
• Multidisciplinary communication, collaboration and

coordination, including patient/caregiver education, from admission through transition

• Clinician involvement and shared accountability during all

points of transition

• Timely follow-up, support and coordination after the

patient leaves a care setting

Summary of AMMO Transition of Care

• Allows for efficacy/ safety monitoring

– TTR – Thrombosis – Bleeding

• Patients that have thrombosis

– INR Range of 2.0 – 3.0 – Duration of 3 months – Ensure follow up with outpatient provider to asses long term anticoagulation needs

Summary of AMMO Transition of Care cont.

?

Questions