As an individual clinician, it is hard to keep up with the latest evidence for peri-procedural management of anticoagulation therapy. Even when clinicians know what should be done, hospital policies often lag behind and are slow to change, making it challenging to provide the best care to every patient every time. The AC Forum, in partnership with Boston University School of Medicine Continuing Medical Education (BUSM CME) and IPRO, the Centers for Medicare & Medicaid Services designated Quality Improvement Organization for NYS, piloted an educational program meant to provide the most up-to-date information on peri-procedural anticoagulation management to providers while helping leadership amend policies to comply with the best available evidence.
In general, there are many patients who are chronically anticoagulated and need individualized care to manage anticoagulation peri-procedurally. Over 4 million people in the US are on anticoagulation medications, while more than 2.5 million Americans are chronically anticoagulated for indications that include venous thromboembolism (VTE), mechanical heart valve(s), and atrial fibrillation (AF). Approximately 10 percent of these patients require anticoagulation interruption on an annual basis due to surgical procedures. With rapid advances in the area of anticoagulation, there are often gaps in knowledge for both providers and systems with regard to effective perioperative anticoagulation management.
Due to the overwhelming numbers of patients who require interruption of anticoagulation, clinicians need to be able to perform appropriate risk assessments for these patients. With improved knowledge of the latest agents, along with more comprehensive thromboembolic and bleed risk assessment in the peri-operative setting, clinicians have the opportunity to improve the existing standards of care in this challenging area. Also, organizations need to change policies to support clinicians as they update their practices.
This pilot program was designed to see if experts in anticoagulation, education, and quality improvement from outside an institution could help with updating policies and improving care. For this pilot program, the partnership groups worked with two different hospitals, both at different stages of updating their current polices. One of the included hospitals had already started the process of updating their policies, while the other had not yet started and did not have a mechanism for reviewing and updating these policies. BUSM CME brought in AC Forum experts who worked with leaders at each organization to develop a plan tailored to the specific needs of their providers and their leadership.
For this pilot program, faculty was selected from members of the Board of Directors of the AC Forum. This included Scott Kaatz, DO, MSc, FACP, SFHM, Current President of AC Forum and Clinical Associate Professor at Wayne State University and a Hospitalist at Henry Ford Hospital in Detroit, MI, Eva Kline-Rogers, MS, NP, AACC, a Board Member of AC Forum, Cardiovascular Nurse Practitioner and manager for MCORRP (Michigan Cardiovascular Outcomes Research and Reporting Program) at the University of Michigan, in Ann Arbor, MI, and Allison Burnett, a Board Member of AC Forum and Assistant Clinical Professor at the University of New Mexico College of Pharmacy in Albuquerque, New Mexico. The clinical champions from each site included Maura Wychowski, PharmD, from Rochester General Hospital and Melinda Montoya, PharmD, from St. Vincent’s in Santa Fe.
The program started with interviews of key leaders from pharmacy, surgery, nursing, anesthesiology and other professions at each organization to assess the current policies at the institutions and the educational needs of the providers. Next, a survey was administered to the providers to assess their knowledge of anticoagulation resources within their institution, as well as their current knowledge anticoagulation guidelines and best practices. Then, based on the interviews and surveys, an educational lecture was developed to update the providers on the latest in managing anticoagulation peri-procedurally. Following the lecture, members of the BUSM CME team and AC Forum faculty met with each institution’s QI team to determine a plan of action for change within their hospital. Finally, BUSM CME and AC Forum faculty followed up with each institution to ascertain if they were able to update their policies and determine how the program impacted the care they deliver to patients. (Figure 1).
Figure 1. One Policy at a Time Process Map :
The first institution was a large teaching hospital in Upstate New York. When the leaders of the organization decided to participate in the program they felt that they had already made excellent progress in updating their current policies before the program, but wanted a way to get other stakeholders involved and to educate all their providers on why they were making these changes. Through the program, the group was able to engage stakeholders, particularly surgeons, who previously had been unaware of the changes, and to update these providers about the changes to their policies.
Over 75 providers were included in the education sessions, which included participants from multiple specialties and professions. The grand rounds lecture was followed by a multi-disciplinary lunch meeting which discussed barriers and ways to improve implementation of existing policies. After the program was completed, the local leaders for the project said that while the program did not help them update their policies, which had been updated prior to the program, they were able to receive guidance and reassurance that the changes they were making were based on the best available evidence and backed by leaders in the field. Also, and most importantly, the program was a spark to assemble the lunch time group, which included senior leadership, so policies and procedures could be more readily implemented. In addition, they felt that having experts outside the institution available to teach about the latest evidence and talk about the necessity for changing policies helped catch the attention of some stakeholder groups that were not previously engaged in the changes. Also, having an outside speaker helped boost attendance at their educational sessions.
The second institution in the program was a mid-size teaching hospital in the Southwest. This institution had not started making any changes to their policies and was relying on individual providers to modify their own practices to comply with the best available evidence. While this was a smaller organization with 25 people attending the sessions, the hospital is one of only a few trauma centers in the state and serves about a third of the population of the state.
The local leaders were brought together by the program to discuss the need to update their polices. An initial brainstorming session uncovered a current anticoagulation policy that included 30+ pages of hard to read text that mixed together policies and protocols and was difficult to use as a guide for practice. The group set up a plan to involve cardiologists, surgeons, OR coordinators, hospitalists, their anticoagulation service providers, pharmacists and independent physicians who run their outpatient clinics. The group designated a clinical champion to update the policies and protocols and make them easier to read and understand. The group also decided to create a plan to disseminate the new policies through educational sessions, meetings with leadership and a marketing campaign designed to target different stakeholder groups. In addition to the educational plans and meetings, the group also decided to create decision support systems and better communication between electronic health record systems for both inpatients and outpatients.
After the program was completed, the local leaders expressed their gratitude for the program. They really felt that these changes would not have been made without the help of the AC Forum, IPRO, and BUSM CME. Through the program they were able to create a plan to make system-wide changes to how they manage their patients on anticoagulation therapy peri-procedurally.
The partnership between AC Forum, IPRO, and BUSM CME was able to create a robust program that helped two different institutions update their policies for anticoagulation management. While AC Forum was able to provide the experts to guide the program, BUSM CME was able to provide the educational expertise and project management staff. IPRO was able to identify hospitals who would be open to participating in the program and in need of improving their practice in this area. The program was supported by educational grants from Daiichi Sankyo, Inc. (DSI) and Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). While DSI and BIPI provided the funding for the program they had no input in the content or design of the activity.