Inpatient Anticoagulation Management Services to Improve Transitions of Care Andrea Resseguie PharmD, RPh, CACP Advanced Practice Clinical Specialist Anticoagulation Management Service
Learning Objectives • 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
Inpatient Anticoagulation Management Services • AMMO = Anticoagulation Management for Post- Orthopedic Surgery Inpatients • HAT = Hemostatic and Antithrombotic Stewardship
High Risk Populations Followed Inpatient by AMS Major Orthopedic Surgery AMMO (Total Hip Replacement, Total Knee Replacement) Ventricular Assist Device HAT (VAD)
Inpatient Anticoagulation Management Services cont. • 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
AMMO Service Roles & Responsibilities Individual Responsibilities Orders initial consult, warfarin dose day before • Orthopedic Surgery surgery, and warfarin dose day of surgery Resident/ Responding Communicate changes in patients’ clinical • Clinician conditions Cosign daily warfarin orders • Process the consult (viewable through “Consult • Messages”) AMMO Primary Enters new patient demographic into DAWN AC • Pharmacist Write EPIC consult note • Emails daily patient roster to pharmacists • AMMO Secondary Orders warfarin dose in EPIC • Pharmacist Documents daily progress note into DAWN AC •
AMMO Inpatient Workflow EPIC DAWN AC EPIC DAWN AC •Order consult •Add patients into •AMMO secondary •AMMO secondary system RPh monitor & order RPh document daily •AMMO primary RPh warfarin progress note review consult & •AMMO Primary RPh write AMMO intake create daily note inpatient roster
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
AMMO Primary RPh Workflow EPIC •Review consult •Write AMMO intake note DAWN AC •Add patients into system •Create daily inpatient roster
EPIC Consult Review
AMMO Intake Note 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.
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: Create Daily Inpatient Roster • DAWN AC home page >>> Patient List/Daily Routines • Status tab >>> filter for “active admitted” • Send email containing inpatient roster to AMMO secondary RPh
AMMO Secondary RPh Workflow EPIC •Monitor & order warfarin DAWN AC •Document daily progress note
Warfarin Initiation Dosing Protocol (INR Range 1.8 – 2.3) POD INR Dose <1.2 No change 1.2-1.3 No change or decrease by 1 mg 1 1.4-1.5 HOLD or decrease by 1-3 mg >1.5 HOLD <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 • 2 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 <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 3 • 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
DAWN AC: Daily Progress Note Documentation cont. • Enter INR • Document daily progress note within treatment notes
Coded Comments .POD1 .POD • Date/time: • Date/time: • POD 1 • POD # • PMH: • Meds: • SH: • Hct: • Meds: • Plans/Rationale: • Hct: • Signature: • Blood products: • POD 0 INR/warfarin dose: • Plan/rationale: • Signature:
DAWN AC: Daily Progress Note Documentation cont. • Select next retest date • Accept & authorize
DAWN AC: LMWH Documentation
AMMO Transition of Care Inpatient AMMO patient discharged Home with Rehab no VNA Facility services Home with VNA services
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
AMMO Transition of Care cont. • 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
Transition of Care Barriers & Solutions •Clinicians effectively & completely communicate important information in a timely fashion among themselves or to patient/ Communication caregiver •Culture promotes successful hand-off (teamwork, respect) •Standardized procedures in conducting successful hand-off •Resolve conflicting recommendations, confusing medication regimens, Patient and unclear instructions •Include patient/ caregiver in planning related to the transition process Education •Sufficient understanding of medical condition or the plan will more likely buy into the importance of following the care plan •Having a clinical entity take responsibility to assure that the patient’s health care is coordinated across various settings and among different Accountability providers •Steps are taken to assure that sufficient knowledge and resources will be available to the patient upon discharge
Summary of AMMO Transition of Care • 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
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