Prior to developing a full-fledged anticoagulation management program in order to meet the new Joint Commission National Patient Safety Goal (NPSG) 3E deadline of January 1, 2009 for full implementation, Central Iowa Health System had many of the necessary processes already in place but needed to revamp several of them in order to become fully compliant.

The Health System (which includes Iowa Methodist, Iowa Lutheran, and Blank Children’s Hospital, totaling 600-plus beds) previously had both warfarin- and heparin-dosing protocols in place that were managed by pharmacy. With the release of NPSG 3E, we recognized it was time to review our processes and pay particular attention to the new monitoring requirements. We needed to ensure that a baseline is recorded before any dose is prescribed and that a current lab value is always used for dosing and monitoring. Our goal was to build on the program components that were already in place, run test pilots with the new components, and become fully compliant by January 2009.

Getting Started
We assembled an anticoagulation committee in July 2008 that included administration, nursing, physicians and pharmacists, as well as our dieticians, who are given a report of all patients receiving warfarin under the new program. The committee developed new anticoagulation management processes for the test pilot, which included listing the labs that need to be ordered, providing examples of how orders should be written to include target lab values when applicable, and itemizing medications for which pre-printed order forms are available. In addition, the special ordering and monitoring requirements for the rehab and transitional care patients were addressed. Once patients in these areas demonstrate consistent labs and therapeutic response, their labs may be less frequent and orders for continuous therapy are acceptable.

One of the biggest challenges during the pilot stage was establishing effective communication among the many healthcare professionals across our institution. Even within our own department of over 40 pharmacists, having to cycle different pharmacists through the pilot floors (due to vacations, rotating schedules, etc.) was a challenge. Often a pharmacist new to the pilot floor would change the monitoring or recording procedures. This challenge underscored the need to establish and mandate consistent anticoagulation management procedures throughout the health system.

It is important to communicate what changes will be taking place early in the process. Staff education via departmental meetings, nursing leadership committees, physician group meetings, memos to medical staff, and one-on-one discussions are good ways to ensure the staff is confident and comfortable with the new anticoagulation dosing and monitoring requirements. We shared examples of valid anticoagulation orders and outlined exactly what labs had to be ordered and with what frequency. We also demonstrated the types of previously accepted orders that would no longer be valid, such as orders for daily warfarin as warfarin doses can now only be ordered on a one-time basis. Additionally, monitoring requirements for enoxaparin and dalteparin will depend on whether the dosing is therapeutic or prophylactic. To reinforce the importance of using pre-printed orders, samples of these were distributed during the educational sessions.

Selling the program is an important aspect of building acceptance among the staff. Overcoming staff skepticism toward new programs that cause additional work is always difficult. Physicians may see the additional, required lab monitoring as excessive and unnecessary. However, it is important to stress that from a patient safety standpoint, the monitoring is absolutely necessary, particularly when a patient enters a hospital and has dietary changes as well as new medications added to their daily regimen.

Lab preparation is another critical aspect of the program because the volume of orders will increase, as will requisite calls to physicians. Involve the lab early in the process so they can tailor their workflow to manage these increases.

How it Works
With our new program, prescribers use pre-printed order sheets that include the required labs and monitoring for all anticoagulation products. Pharmacy then reviews all of these orders for completeness. Pharmacy contacts the prescriber if the orders do not follow the new protocol, such as an order for warfarin written as “daily for seven days.” Our system allows pharmacists to review all lab requirements for patients receiving anticoagulants, so if a lab has not been ordered, we contact the physician and recommend ordering those labs. Pharmacists also conduct daily monitoring, verifying the lab orders and using a notes function in our order scanning system to record the outcome. For example, if the INR has a relatively large increase or decrease compared to the previous day, the last dose given is noted by the pharmacist and is helpful in determining any necessary dose changes. This process allows for trends to be noted and keeps all information in one location — there is no need to switch between pharmacy and lab screens within the operating system.

Achieving Compliance
One of the initial challenges faced with the new anticoagulation program is the amount of time pharmacy spends contacting physicians to change medication orders. As the prescribers become more familiar with the requirements and accept the need to write daily orders, for example, pharmacy’s time commitment should diminish.

From a distribution perspective, we did not see many changes as we had previously established standard concentrations and we continue to purchase pre-mix products. To provide the half-milligram warfarin doses that are not commercially available, pharmacy is splitting these and packaging them in unit dose so they are readily available on the floor.

Conclusions
Developing and implementing a successful anticoagulation management program that satisfies the Joint Commission requirement for NPSG 3E compliance is a process that should seek to involve all areas of the hospital team, including physicians, nurses, and pharmacists, as all of these areas will be affected. Take a fresh look at the processes you already have in place and be prepared to make tweaks and changes that may be necessary for compliance. Taking the time to fully review and understand both your current processes, and those required by the Joint Commission will make for a smoother transition for both you and your staff while bringing your organization into full compliance with the Joint Commission.

 
Brian D. Benson, RPh, PharmD, is the Pharmacy Operations Manager for Iowa Methodist and Blank Children’s Hospital in Des Moines, Iowa. He graduated from Drake University in 1996 and received his PharmD from the University of Kansas in 2006.