Introducing DOACs to Your Anticoagulation Service LYNN OERTEL, MS, - - PowerPoint PPT Presentation

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Introducing DOACs to Your Anticoagulation Service LYNN OERTEL, MS, - - PowerPoint PPT Presentation

Sep 04, 2023 106 likes •298 views

Introducing DOACs to Your Anticoagulation Service LYNN OERTEL, MS, NP LYNN OERTEL, MS, NP LYNN OERTEL, MS, NP LYNN OERTEL, MS, NP- - - -BC, CACP BC, CACP BC, CACP BC, CACP ANTICOAGULATION MANAGEMENT SERVICE ANTICOAGULATION MANAGEMENT

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SLIDE 1

Introducing DOACs to Your Anticoagulation Service

LYNN OERTEL, MS, NP LYNN OERTEL, MS, NP LYNN OERTEL, MS, NP LYNN OERTEL, MS, NP-

  • BC, CACP

BC, CACP BC, CACP BC, CACP ANTICOAGULATION MANAGEMENT SERVICE ANTICOAGULATION MANAGEMENT SERVICE ANTICOAGULATION MANAGEMENT SERVICE ANTICOAGULATION MANAGEMENT SERVICE MASSACHUSETTS GENERAL HOSPITAL MASSACHUSETTS GENERAL HOSPITAL MASSACHUSETTS GENERAL HOSPITAL MASSACHUSETTS GENERAL HOSPITAL

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SLIDE 2

Challenges at the start….

Consensus / agreement among stakeholders that this is the ‘right thing’ to do Technical changes related to DOAC modules and hospital systems Staff hesitancy – ‘already busy enough’ Knowledge gaps and need for staff education No quality examples of ‘how to do’ this

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SLIDE 3

DOAC vs. warfarin within Loyal Cohort*

*Loyal Cohort = patients receiving primary care at MGH Source: MGH Fireman Vascular Center

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SLIDE 4

Clinical staff education curriculum

Blended learning experience Credit hours awarded (5.66 from Knight Center and 1 from online program)

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SLIDE 5

Required reading assignments

RUFF CT ET AL. THE AMERICAN JOURNAL OF MEDICINE (2016) 129, S1-S29 BURNETT AE ET AL. J THROMB THROMBOLYSIS (2016) 41:206–232

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SLIDE 6

Identify knowledge gaps and needs

Pre and Post knowledge assessments (AMS staff required to achieve 100% on post test)

  • 23 multiple-choice items
  • Post-assessment “open book”

20 40 60 80 100 120 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 score

GOAL Pre-assessment results

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SLIDE 7

DOAC Referral

Cascading options presented according to:

  • Indication
  • Drug/dose options
  • Transitioning, if applicable
  • Off label use statement

RN staff worksheet to confirm eligibility

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SLIDE 8

Standard Follow-up Plan

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SLIDE 9

DOAC List view

Date filter = Today Televox automated calls made 2 days prior to patient’s scheduled QNR F/U date

  • Patient’s response used

to indicate confirmation

  • f availability

F/U QNRs average 5-10 minutes

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SLIDE 10

Patient and Family Education Slideshow

Caveats:

  • MGH experience thus

far with warfarin patients transitioning to a DOAC

  • Education by phone

(packet mailed in advance)

  • Average time on phone

~ 22 minutes

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SLIDE 11

Updated Medication Guides

Find in: Partners Handbook or EED anticoag portal page

Spanish translations available. English and Spanish MGH Instructions can be accessed in Epic.

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SLIDE 12

Revision of existing Patient Agreement to incorporate DOACs

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SLIDE 13

DOACs At-a-Glance Reference

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SLIDE 14

DOAC POTENTIAL interacting drugs

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SLIDE 15

Follow-up QNRs: A broader assessment of patient is needed and

includes adherence and medication changes (as noted in QNR) but also:

Dawn F/U QNRs:

  • Adherence* – use 80% rule
  • Medication surveillance for potentially

interacting meds* that may require dose adjustment or avoid use

Dawn Lab QNRs*:

  • eGFR, Creatinine and Hct obtained per Standard

F/U plan (manual process now, future: via lab interface)

Adverse events – documented in Events Tab Procedures – documented in Procedures Tab

  • Hospitalized/ED visit for what reason and when
  • Interruption in DOAC therapy (and details) that AMS

unaware of?

  • Seen by MD other than ‘well’ visits
  • Any side effects? (assess if bruising increased on DOAC

when compared with warfarin experience)

  • Verification of change in dose as expected (for new VTE

type indications only: Apix on Day 8 of trt and Riva on Day 22 of Trt)

  • Check on refills provided with initial Rx – how many

refills?

  • Issues with drug procurement/financial concerns about

getting refills as needed? Above assessment captured and documented in Epic Tel Encounter

* - This information displayed in AMS icon via Outbound

Interface message along with next scheduled F/U date

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SLIDE 16

How do I make an assessment of DOAC adherence?

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SLIDE 17

Adherence

  • Adherence “reflects the manner

in which patients take their medications relative to the agreed regimen with the prescriber” (NICE, 2009)

  • Considered adherent if “take

medication as prescribed more than 80% of the time” (WHO, 2003)

.dadNO = During today's follow-up, patient reports missing _ doses over past _____. Importance of not missing any doses was reinforced and interventions explored to improve

  • adherence. Based on adherence concerns, follow-up in 1

month.. .dadYES = During a phone call follow-up today, patient accurately described dose and adherence with taking as prescribed.

(mark as non-adherent)

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SLIDE 18

AMS DOAC Icon

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SLIDE 19

Pilot evaluation to demonstrate value to

  • rganization

Adherence (patient reported) Renal Function or drop in Hct necessitating a dose change or avoid use Identification of Drug Interactions which may require a change in therapy Adverse events Optimal management of transitions/interruptions in care Patient experience