Anticoagulation therapy is safety goal for 2008

Growing number are taking these drugs

One of the new National Patient Safety Goals recently published by The Joint Commission addresses a situation emergency medicine experts say is becoming increasingly common: Patients on anticoagulation medication. Goal 3E for 2008 states: "Reduce the likelihood of patient harm associated with the use of anticoagulation therapy."

"There are a large number of people now presenting to the ED who are on these medications," says James J. Augustine, MD FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group based in Canton, OH. "These medications come in a number of versions in three big classes, ranging from aspirin — including the baby aspirin many people take prophylactically every day — to Coumadin [warfarin] to heparin," Augustine says. "A lot of people we see now are on them, and anyone at risk for coagulation in the heart, lung, or brain can be put on them."

The potential for patient harm is significant, notes Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission. "The types of medications used [to reduce coagulation risk] place the patient at risk for underdosing as well as overdosing," he explains. "Underdosing creates a situation where the disease is not adequately managed, while overdosing creates increased risk for bleeding and other various complications."

Accordingly, it is important for these medications to be maintained in a therapeutic range, both for inpatients and outpatients, he says. "This goal does not replace existing clinical guidelines developed by other professional societies, but focuses rather on trying to ensure there are adequate processes and systems in place to make sure the patient is identified and followed, the staff is educated appropriately, and any adverse outcomes are evaluated on a regular basis," Angood explains.

Modifying approaches

Because of the increased number of patients who may present while taking such a medication, "we have to modify our diagnostic approaches and be very careful in administering other medicines that prolong the effects of Coumadin," warns Augustine. "The patient can have significant harm from that medication overlap."

For example, ED staff may think they are doing the patients a favor by putting them on certain antibiotics, he says. "We may be resolving some infection problem, but when they are back at home, there could be at significant risk for a bleed in the head," Augustine says.

Accordingly, "this raises a big concern in regards to medication reconciliation," he says. Furthermore, the large number of people older than age 40 taking one baby aspirin a day "makes them susceptible to bleeding, and when we do a diagnostic work-up, we have to remember that," Augustine advises.

A classic example of a problem involved with patients on anticoagulation therapy would be patients on warfarin falling and striking their head, he says. "They could have a slow bleed, and be worsening over the hours — either at home or waiting in the ED," Augustine says. "You have to know how to avoid potential safety problems related to their care; you also have to know when the right window exists to find the bleed on the CT scan."

Angood agrees and outlines several strategies members of The Joint Commission staff think should be in place in this area. "[Anticoagulation therapy] processes should be defined and [the issue] established as a distinct management program, with recognition of different types of therapies," he says. "The ways they are administered — oral, IV, and so forth — should involve protocol-driven strategies with well-established laboratory parameters for therapeutic range, and policies for testing and management." There also should be education programs for staff and patients, he says.

Augustine, who recently attended a Joint Commission technical advisory committee meeting on the new National Patient Safety Goals, summarizes the agency's expectations thus: "They are looking for expert care of patients on anticoagulants — both in the hospital and when they leave the hospital to go home," he says.

Sources/Resource

For more information on anticoagulation therapy, contact:

  • Peter Angood, MD, Vice President and Chief Patient Safety Officer, The Joint Commission, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000.
  • James J. Augustine, MD, FACEP, Director of Clinical Operations, Emergency Medicine Physicians, 4535 Dressler Road, Canton, OH 44718. Phone: (330) 493-4443. E-mail: JAugustine@emp.com.

Go to www.jointcommission.org/npsg for the specific National Patient Safety Goals for each of The Joint Commission's accreditation and certification programs.