Protocols and programs help improve quality of anticoagulation therapy

Project saves money, reduces LOS

Shortly after the Joint Commission included anticoagulation therapy on its National Patient Safety Goals two years ago, Winter Haven Hospital's pharmacy services began a major project to improve its own handling of anticoagulation.

"We researched available protocols and found very little information for inpatient care," says Jovino Hernandez, PharmD, clinical coordinator of pharmacy services at Winter Haven Hospital.

So Hernandez and another clinical pharmacist Karen Siegel, PharmD, spearheaded a project to develop an inpatient warfarin protocol. This protocol received immediate and positive feedback from physicians, who now had one less problem to worry about, Hernandez notes.

"They no longer would be getting phone calls in the middle of the night because a pharmacist could follow warfarin therapy with the protocol," he adds.

The outcomes also have been encouraging.

The hospital's length of stay (LOS) for warfarin patients at baseline was 6.4 days. Since making the change, the LOS has dropped to a low of 5.5 days, Hernandez says.

"The protocol helps with our National Patient Safety Goals," he adds. "So even though it takes more pharmacist time, the administration sees the value of this, partly because of the LOS decline."

Here's how the hospital developed the protocol:

• Design protocol to fit hospital's patient population: The first step is to assess your hospital's patient population.

"Over 50% of our population is on Medicare, so it's a very old population," Hernandez says. "Most of our patients have comorbidities like congestive heart failure, for example."

He took these factors into consideration as he looked at potential models for the protocol and worked on the one that eventually would be used.

"We had to get a feeling for what our experiences were with warfarin therapy," Hernandez says.

• Form an anticoagulation team: This is necessary for the National Patient Safety Goals. The Winter Haven Hospital anticoagulation team is co-chaired by Siegel and a physician and also has members who are from nursing, the lab, hematology, and cardiology.

"Our main focus was on the safety goals and how to address them," Hernandez says. "Through our pharmacy and therapeutics [P&T] committee we found a high level of elevated INRs associated with warfarin."

The P&T committee sent the information to the anticoagulation team to see if they could come up with a strategy that would improve this issue.

The anticoagulation committee eventually developed protocols for other anticoagulant issues, including heparin induced thrombocytopenia (HIT) and enoxaparin.

"All of these are in place to follow best practices and decrease adverse drug reactions as much as possible," Hernandez says.

• Obtain physician agreement to have pharmacy dose warfarin: "We had the medical staff approve the warfarin protocol as our hospital's protocol," Hernandez says. "And physicians can sign the form if they want pharmacists to manage their patients' warfarin therapy."

So far every physician who was approached has signed the protocol, he adds.

"We're seeing 80% of patients who are on warfarin," Hernandez says.

The hospital's hospitalist was the first to sign the agreement. But over 1.5 years, other physicians signed it, as well, he adds.

• Educate all involved: "We had to educate everyone," Hernandez says.

The change entailed training pharmacists on dosing warfarin and having pharmacists shadow a clinical pharmacist.

"For physicians, the main education involved vitamin K associated with warfarin," Hernandez says. "This was a huge piece."

This also was a good example of how education on these changes and protocols is ongoing and evolving. Once the protocol was accepted and used, Hernandez followed outcomes data and saw that two things were occurring: First, use of the protocol did help reduce the number of elevated international normalized ratios (INRs), and, secondly, physicians still were prescribing a lot of vitamin K, resulting in an increased length of stay.

Physicians would see a high initial INR and then prescribe vitamin K as an antidote, even though the pharmacists were following the protocol and were carefully monitoring INR levels. Then the patient would have to stay in the hospital longer because of the effect of too much vitamin K, Hernandez explains.

"In most situations if the patient doesn't have an active bleeding problem or too high of INR, then you don't have to give the patient vitamin K," he says.

"But physicians would see that a patient had an elevated INR and give the patient a subcutaneous injection of vitamin K in the morning," he adds. "Then they'd look for INR results later that night and still not see the results they wanted, so they'd give the patient another dose of vitamin K."

By the next morning, the patient's INR level would be very low, resulting in an increased LOS while pharmacy tried to get the INR back to a therapeutic level.

This costs the hospital money. The typical warfarin patient's daily cost is $1,080 per day, so a small decrease of 0.4 days in the LOS would equal $800,000 in annual savings, Hernandez says.

Once physicians were educated about holding off on vitamin K orders, the LOS began to decline, he adds.

Also, the INRs declined by one-third since the change was implemented, Hernandez says.

"The staff's satisfaction with the program has increased because they can see improvements in warfarin protocols," he adds.