Anticoagulant Therapy: Strategies for Improving Patient Safety. Brought to you by the Washington Patient Safety Coalition September 9 th, 2009

Transcription

1 Anticoagulant Therapy: Strategies for Improving Patient Safety Brought to you by the Washington Patient Safety Coalition September 9 th, 2009

2 Goals of Presentation Raise awareness and understanding regarding use of FMEA to improve anticoagulation safety. Provide examples of multidisciplinary efforts to improve anticoagulation safety upon transitions in care. Demonstrate value of standardization of products & care processes, role definition and communication methods in improving medication safety.

3 General Topics / Presenters Heparin Products and Infusions Brent Albertson, PharmD,, BCPS Transitions in Care with Anticoagulation Eric Harvey, PharmD,, MBA, BCPS Coordinating Ambulatory Care for Anticoagulation Therapy Elisa Vila, RPh,, CACP

4 Standardizing Heparin Products and Concentrations: An FMEA-directed Improvement Process Brent Albertson, PharmD,, BCPS Advanced Pharmacy Practice Manager Providence Sacred Heart Medical Center & Children's Hospital

5 Providence Sacred Heart Medical Center & Children's Hospital SHMC 623 beds Children s s 120 beds

6 Heparin FMEA Need? Quaid & Texas events Heparin Recall JC Mock Survey Sean Dobbin Director of Pharmacy FMEA

7 Heparin FMEA - Process Leaders Brent Albertson Derek Barnhart, PharmD, Operations Manager Brent Carlson, RPh,, Purchasing Manager Assess Scope Heparin is located all over Many indications therapeutic, prophylactic, flush, line maintenance Process On the Fly (pharmacy centric) Ad Hoc Nurse managers, IV Therapy, & Central Supply Follow up with Tracer activities

8 Heparin FMEA - Process Resources Guidelines & Articles on venous access Key changes IV room change to one concentration Limit number of IV heparin infusion concentrations Heparin in NS, Double strength, unneeded heparin infusiobn uses 1000unit/ml & 5000 unit/ml look alike Drug dictionary descriptions with common uses Removal of heparin from central supply

9 Standardizing the Transition Between Inpatient and Outpatient Anticoagulation Services September 9, 2009 Eric Harvey, PharmD, MBA Pharmacy Quality Manager

10 Seattle Children s Hospital Pediatric referral center for the WAMI region (WA, AK, MT, ID) 250 inpatient beds 13,500 inpatient admissions >200,000 ambulatory clinic visits Pediatric teaching facility for UW School of Medicine

11 Outline Overview of Seattle Children s anticoagulation safety program Seattle Children s approach to standardizing the inpatient-to-outpatient transition for anticoagulation services Things that are working well and ongoing challenges

12 Program Overview 2008 TJC National Patient Safety Goal : Reduce harm associated with the use of anticoagulation 2009: Seattle Children s Hospital launches organization-wide anticoagulation safety program centered on pharmacist-prescribed anticoagulation dose adjustment and monitoring January - Inpatient services offered for patients on heparin, enoxaparin, warfarin April - Transition process for enoxaparin and warfarin patients moving from inpatient to outpatient implemented May Moved existing warfarin clinic outpatients to pharmacy-based service

13 Inpatient to Outpatient Transition Nursing-based discharge education No standard process followed Opportunity to standardize discharge education and transition to outpatient care at the same time One day event on Oct. 31, 2008 Std teaching materials Std documentation method Method for alerting educators of need to teach

14 Inpatient to Outpatient Transition Teaching materials Specific information packets for warfarin and enoxaparin Demonstration/practice kit for enoxaparin injections Defined roles for teaching Nursing Pharmacist Dietitian Standard documentation method Method for alerting educators of need to teach

15 Inpatient to Outpatient Transition Process steps 1. Orders in tx initiation order set

16 Inpatient to Outpatient Transition Process steps 2. D/C criteria order placed on nurse task list 3. Nurse posts bedside checklist

17 Inpatient to Outpatient Transition Process steps 4. Nursing contacts pharmacy (and dietitian) when patient and guardian ready for teaching 5. Pharmacist does teaching and documents in CIS and on bedside checklist 6. Patient discharged with follow-up scheduled

18 Successes and challenges +The educational materials are very well received by patients and families +Everybody likes having very clear roles and responsibilities +Transitions are flowing very smoothly, nobody has been missed/dropped -Difficult for nursing staff to give pharmacy adequate notice when a patient is ready for teaching

19 Questions

20 A Collaborative Process for the Management of VTE Prophylaxis Following Joint Replacement Surgery Elisa Vila, RPh,, CACP Anticoagulation Clinic/Lipid Management Clinic Evergreen Healthcare

21 EVERGREEN HEALTHCARE Kirkland, Washington EHMC is a 280 bed hospital with 16 primary and specialty care clinics 55,000 annual ED visits 4500 annual births Inpatient and outpatient hospice Home Health Service

22 Evergreen Healthcare Anticoagulation Clinic Outpatient service 38,000 annual visits >85% of visits are in clinic FTEs = 9 pharmacist, 4.5 support staff

23 ACC Standard of Care In clinic visit Optimal clinician assessment Reliable laboratory testing and quality control Education opportunities Instruction and follow-up Reimbursement

24 Alternate Management Approach Telephone management Difficulty obtaining lab results Wide variety of home nursing services with varying procedures. Inconsistent patient assessment Difficult communication Dosing errors Reimbursement

25 The Problem The standard of care for telephone managed patients was widely inconsistent and did not meet our quality expectations. The Orthopedic surgeons identified deficiencies in their management of DVT prophylaxis following joint replacement surgery and requested involvement from the Anticoagulation Clinic.

26 Evergreen Home Health 700 patient service 70 RNs along with PT, OT and social work Serving King and Snohomish Counties

27 Program Development Collaborative process with Evergreen Home Health, physician, ACC and laboratory involvement. Protocol development to define treatment parameters and various responsibilities at discharge. Standard discharge orders created for the Joint Replacement program.

28 Evergreen Joint Replacement Discharge Orders

29 Evergreen Joint Replacement Discharge Orders

30 Training Training provided to EHH nursing staff by ACC pharmacists. Coaguchek POC device training Assessment expectations Additional education provided to the team leaders and clinical manager. Responsible nursing manager identified to coordinate ongoing RN training.

31 Results INR results are immediately available. RN assessment is thorough and meets our expectations. Prompt identification of thromboembolic complications. Compliance concerns are addressed. Quality testing and assessment mechanisms are in place. Limited use of outside nursing services. Physician, patient and nursing satisfaction

32 For More Information on the Evergreen Program Don Briggs, RPh,, Manager, Pharmacy Clinical Services; Evergreen Healthcare Ph: ; Fax: Margo Hollenbeck, RPh,, CACP or Elisa Vila, RPh,, CACP Anticoagulation Clinic & Lipid Clinic Ph: ; Fax:

33 Information & Resources Washington Patient Safety Coalition Today s s slide set Tools from presenters Anticoagulation Safety Information IMSP.org (Institute for Safe Medication Practices; type in key word anticoagulation jointcommission.org (The Joint Commission); type in key word anticoagulation

34 Your turn. Questions

35 Thanks to Brent, Eric and Elisa! Please submit your evaluations