Numbers alone rarely tell the whole story, but for the University of Wisconsin (UW) Health in Madison, they offer a tantalizing glimpse of a remarkable transformation. Within one year:
• Postoperative venous thromboembolisms (VTEs) per 1,000 patients fell from 11.6 to 6.6.
• Within its 39 primary care clinics, the percentage of patients whose INR achieved target ranges increased from 64 percent to 72 percent.
• The percentage of all inpatients and surgical inpatients who did not receive VTE prophylaxis decreased from 24 percent to 8 percent and from 20 percent to 3 percent, respectively.
Another figure stands out: $50,000. That’s the amount accompanying the ASHP Foundation’s 2011 Award for Excellence in Medication-Use Safety. UW Health won the prize for its anticoagulation stewardship program (ASP), which was responsible for the impressive system-wide improvements.
“We were excited and humbled when we won,” said Philip Trapskin, Pharm.D., BCPS, clinical manager of patient care services and practice advancement at UW Health, who helped spearhead the ASP. “You work hard to help patients, not to win an award. In many respects, the real beneficiaries are the patients whose quality of care will improve because of our work.”
Ensuring Patients Receive VTE Prophylaxis
Dr. Trapskin and his colleagues initiated the program after they identified substantial inconsistencies and gaps in how anticoagulation agents were used and monitored across the organization.“About 20 percent of patients didn’t get VTE prophylaxis during their hospitalizations,” said ASP Coordinator Anne Rose, Pharm.D. “That’s a huge number of patients.” Compared with peer institutions, a higher proportion of the UW Health’s patients experienced postoperative thromboembolisms, which was costing the system an estimated $1.7 million annually.
Among the major goals of the ASP is to ensure that at least 90 percent of inpatients received appropriate VTE prophylaxis within
24 hours of admission and to reduce by at least 25 percent the observed-to-expected rate of preventable postoperative VTEs.
To reach those goals, the ASP reconciled existing inpatient order set content with evidence-based recommendations and configured all order sets into the electronic medical record. A pharmacist is required to assess every patient for bleeding risk and appropriateness of VTE therapy. Orders can be put into action only when all necessary information is recorded.
“We pay more attention now to which patients are appropriate for VTE prophylaxis, and we have more patient assessment tools available,” said Angela Hottman, Pharm.D., a clinical pharmacist who works in surgical pharmacy areas. “There was some initial pushback from physicians, who were not used to being questioned about VTE therapy. Now they’re used to us asking about prescribed VTE therapy and recommending changes, and they’re likely to listen to us. Some even approach us for advice.”
Documenting Outpatient Warfarin Dosing
The other focus of the ASP is anticoagulation therapy conducted at the primary care clinics, where about 3,000 patients receive their warfarin. Before the program began, patient assessments, dose management and documentation procedures varied considerably, often depending on individual physician preferences and which guidelines they favored.
“It was shocking that in only 70 percent of cases was there documentation of warfarin dosing, why the patient was on the drug, and what the target INR range was,” said Dr. Rose.
The ASP standardized care across the system to mirror the protocol in UW Health’s pharmacist-managed anticoagulation clinic, explained Erin Robinson, Pharm.D., lead pharmacist in the anticoagulation clinic.
“The program created overarching dosing and documentation guidelines for the primary care clinics,” she said. “The objective was to have nurses conduct the same level of patient assessment that pharmacists perform in the anticoagulation clinic.”
But that required substantially more time, and at first the nurses weren’t keen about the idea, said Dr. Robinson. Instead of leaving information about warfarin dosing on a patient’s voicemail, now they’d have to spend an extra 10 to 15 minutes asking them questions and formulating the proper dose adjustment. Soon, however, they noticed that this extra effort resulted in more accurate dosing and INR levels that were consistently within target ranges.
“Objections from nurses decreased steadily as outcomes improved, and patients appreciated the higher level of care they were getting,” said Dr. Robinson.
Making the Case for Change
Some institutional resistance to a program of this scope was inevitable. But the ASP leaders had baseline data that made a strong case for change. “We were able to say, ‘This isn’t working, but here’s what we can do to correct it,” says Dr. Robinson. Once a few small groups undertook successful pilot programs, others became convinced of the ASP’s value, and things grew from there.
Concerted and ongoing education and training for all front-line clinical staff proved essential to success. So did support from hospital administration, which supplied some seed resources. The administration fully embraced the program when they witnessed the magnitude of its results, which included saving the system an estimated $1.3 million. Deep integration of the information technology system was also crucial.
“These were large changes,” said Dr. Trapskin. “We employed a lot of the typical tools to help people manage major change and created a sense of urgency. You have to have confidence in your vision and believe that the goal will be worth the inevitable trials and tribulations. That perseverance and knowing that it’s the right thing to do for patients is so important.”