The Joint Commission is set to survey hospitals’ anticoagulant therapy programs in January 2009, a mere three months from now. As of October, facilities are supposed to have begun pilot testing in one unit to trial the program they should have developed throughout the past year.
The previous milestones that should have been met thus far include:
- April 1: Leadership makes one person or group responsible for implementing the National Patient Safety Goal (NPSG). The program begins development.
- July 1: A work plan is established and the resources necessary to build a functioning anticoagulation program are assessed.
Getting to this point requires the participation of an interdisciplinary team, says Al Lodwick, RPh, MA, a certified anticoagulation care provider and a speaker for Brentwood, TN–based Cross Country Education, a company that hosts educational seminars and leads continuing education courses for anticoagulation therapy. Lodwick also managed Warfarin full-time for 10 years as the manager of pharmacy clinical support services at St. Mary-Corwin Hospital in Pueblo, CO.
“The key to having a good program is having coordination amongst all of the healthcare professionals involved,” Lodwick says. “It’s important to have everybody on the same page working for it, rather than saying, ‘This is my turf, and what are you doing on it?’ “
Lodwick says he thinks The Joint Commission (formerly JCAHO) did the right thing in giving a full year to fully implement Goal #3E, although, through teaching his courses, he knows that not all hospitals are hitting the milestones as they should.
Start small, plan to grow
Another principle to use when designing your pilot testing and larger facilitywide anticoagulation plan is to start small and focus on improving one area.
“I recommend focusing on one thing and getting that working,” says Michael Gulseth, PharmD, BCPS, program director for anticoagulation services at Sanford-USD Medical Center in Sioux Falls, SD.
“For example, pick something like Warfarin, work on the issues, and get that rolled out,” Gulseth says. “Then work on low molecular weight heparin, work on those issues, and get that rolled out. Don’t try to bite it off all at once, because it will get overwhelming. At St. Mary’s, we just chipped away at various issues because we knew it was the right thing to do.” (Gulseth spent many years working at St. Mary’s Medical Center in Duluth, MN.)
However, it’s important to keep in mind when creating a program that you don’t have to start from scratch—many of the things your facility is already doing to manage patients taking anticoagulants can be worked into the new facilitywide process, Gulseth says. The Joint Commission has established guidelines, but it gives each facility the ability to decide what to include in its plans.
Use your pilot test to double-check work plan
To go along with starting small, Lodwick recommends pilot testing on a smaller unit to try out what works.
Lodwick and Gulseth say the pilot testing phase is a good time to evaluate the decisions that should have been made during the work plan phase and determine whether there are resources available within the facility to maintain a functioning anticoagulation therapy program beyond the pilot unit.
“Maybe you’re going to have to financially justify the increasing of staff,” Gulseth says. “I always recommend that facilities consider the staffing implications. This doesn’t mean that every place has to hire more people, but it may mean a reassignment of duties.” For example, perhaps pharmacy technicians and nursing assistants can carry heavier loads.
“I caution people not to put an extremely well-thought-out program in place and then not give people the time to actually do what is needed to keep patients safe,” he says.
Gulseth, who recently authored the book Managing Anticoagulation Patients in the Hospital, published by the American Society of Health System Pharmacists, recommends facilities also do the following to plan an anticoagulation therapy program that works:
- Take a look at the most current literature. What are programs similar to your facility contemplating?
- Network with other facilities similar to yours; perhaps take a site visit. It’s important to find out what other people are doing. If there’s a facility that is rolling out a program similar in design to yours, seeing that in action will help you visualize how your program should work.
- Create a planning team with adequate nursing, medical staff, laboratory, pharmacy, and any other critical provider representation.
- Find good physician champions to help navigate approval through the pharmacy and therapeutics committee and medical staff.
- Create the necessary policies and procedures to keep the program functioning; these will need to be approved by the pharmacy and therapeutics committee.
- Create a body to review the data from the measures of success set by The Joint Commission once the process has been rolled out to the entire facility. The goal is to continually improve your program, says Gulseth.
Go above and beyond
For those facilities that have a better handle on their pilot programs, Gulseth recommends focusing on a loftier goal than merely complying with the NPSG.
“As you see new opportunities arise, look at things like how vitamin K is being used at your facility, or what are you doing to assure the correct use of direct thrombin inhibitors in the treatment of heparin-induced thrombocytopenia,” he says. “I don’t think you should be aiming to meet the bare bones of the standard—do what is needed to assure the intent of The Joint Commission is met, and that’s probably going to go beyond what’s required.”
Lodwick says he thinks Goal #3E will be very useful in the long run.
When facilities are building their anticoagulation the-rapy programs, they should take a good look at how to make them safer from the start. However, safer does not always mean using less anticoagulants.
“My idea of safer anticoagulation doesn’t mean to use less of it, it means to use it more appropriately, and that may even mean more of it,” says Lodwick, who recently wrote the book Reducing the Harm Done by Anticoagulation: A Clinical Training Guide, which is self-published through his Web site.
“I think that as we put greater emphasis on this, healthcare providers are going to become more proficient in using Warfarin,” he says.
Editor’s note: Gulseth recommends reading an article he recently coauthored with William Dager in the American Journal of Health-System Pharmacy, “Implementing Anticoagulation Management by Pharmacists in the Inpatient Setting,” for more information on this topic.