1. Title slide Georgia Hospital Engagement Network Healthcare Acquired Condition Affinity Group June 19, 2013 Presenter: Dr. Teresa Pounds, PharmD, BCNSP Moderator: Tracy Rutland, RT(R), MBA/MHA HAC Affinity Lead

2. ANTICOAGULATION PERFORMANCE IMPROVEMENT INITIATIVES Dr. Teresa Pounds, PharmD, BCNSP

3. Objective Share strategies employed at AMC to decrease international normalized ratio - INR related adverse drug events – ADE via the following: Information Technology (IT) Efficient Utilization of Pharmacy Resources Concurrent INR Monitoring Patient Safety Committee Involvement

4. Background Atlanta Medical Center has been successful in its ability to avoid adverse drug events (ADE) associated with the use of anticoagulants such as warfarin. Due to the dedication of the pharmacy department in ensuring that patient safety is prioritized first while providing the best pharmaceutical care to its patients.

5. Points For Discussion Information Technology (IT) Efficient Utilization of Pharmacy Resources Concurrent INR Monitoring Patient Safety Committee Involvement 2- Year Snapshot

6. Information Technology (IT) Pharmacy collaborated with IT to generate a daily INR report INR > 4 report  Report automatically prints first thing in the morning INR drill down  Involves the investigation of INRs > 3  Outpatient vs inpatient incident of elevated INR  Appropriate induction dose of warfarin  Drug/food associated interactions

7. Daily INR Report

8. Efficient Utilization of Pharmacy Resources Decentralized clinical pharmacists  Performs INR drill down  Intervenes where necessary Pharmacy residents  Performs INR drill down  Intervenes where necessary 4-yr students  Performs INR drill down  Reports the information to a decentralized clinical pharmacist and pharmacy resident

9. Concurrent INR monitoring Clinical pharmacist at point of order entry and pharmacy residents  Ensures the ordering of initial INR prior to warfarin  Daily INR monitoring of patients on warfarin 4-th year pharmacy students perform these as well  Appropriate intervention as indicated

10. Concurrent INR Monitoring cont’d Staff education on improved methods of counseling the warfarin patient use of warfarin teaching guide presence of pyxis prompts ensure that nurses verify patients INR prior warfarin administration

11. Reporting Structure Anticoagulation subcommittee co-chaired by Dr. Pounds with representatives such as : Physicians Nurses Pharmacists Dietitians Risk management IT

12. Reporting Structure cont’d Patient Safety Committee (PSC)  Ensures accountability amongst parties responsible for daily INR monitoring  Monthly report sent to PSC  PI indicators

13. RESULTS Total Percent (%) of Patients achieving super-therapeutic INR levels (>4) while receiving warfarin (Coumadin ® ) therapy (Goal: 4) while receiving warfarin (Coumadin ® ) therapy (Goal: <5)