Category: Professional Posters
Purpose: New elements of performance (EP) for the Joint Commission National Patient Safety Goal (NPSG) for anticoagulation therapy are to be initiated on July 1, 2019 with specific focus on direct oral anticoagulants (DOACs). Based on this new goal, it is important to determine if DOAC utilization meets EP for this NPSG at our facility. This study assessed medication reconciliation, ordering, dispensing, and administration activities of apixaban, dabigatran, and rivaroxaban for venous thromboembolism (VTE) treatment and stroke risk reduction in patients with nonvalvular atrial fibrillation (AF).
Methods: The study was a retrospective, process improvement analysis of patients for whom apixaban, dabigatran or rivaroxaban was prescribed by a hospitalist at a large community hospital from June 2018 to November 2018. The protocol was approved by the institutional review board. Inclusion criteria were patients 18 years and older that were prescribed apixaban, dabigatran or rivaroxaban by a hospitalist and had a diagnosis of deep vein thrombosis (DVT), pulmonary embolus (PE) or AF. Patients were excluded if prescribed a DOAC for prophylactic anticoagulation indications. Measures assessed included appropriate DOAC dosing during the transition from outpatient to inpatient, appropriate management during transition from parenteral anticoagulant to DOAC, DOAC scheduling/administration compliance, inpatient DOAC dosing and significant drug interactions. Patients were assessed for proper dosing for AF and VTE with apixaban, rivaroxaban, and dabigatran based on renal function, weight, and age. Data collection included the following: date of admission, length of hospital stay, weight (kg), date of birth, allergies, physician in charge, dosing of DOAC and parenteral anticoagulant used, indication for anticoagulation, past medical history, home medications, inpatient medications, dates and times of DOAC administration, dates and times of parenteral anticoagulation administration, aPTT, INR, serum creatinine, hemoglobin, hematocrit, platelets, albumin, and bilirubin. Creatinine clearance was assessed using the Cockcroft Gault equation. Actual body weight was used in this calculation.
Results: The study included 98 patients, 52 females and 46 males. The mean age was 64.4 years old (range 20 to 100 years). DOAC indications included DVT (16), PE (26), and AF (56). Sixty-one patients were ordered a DOAC prior to admission. Upon admission, 2 apixaban patients (1 patient had dose adjusted) and 1 rivaroxaban patient (dose adjusted) were not receiving the correct medication dose based on labeling. In total, 85 patients received apixaban, 8 patients received rivaroxaban, and 5 patients received dabigatran. Three apixaban patients, 1 rivaroxaban and 1 dabigatran patients had dosages that varied from recommendations provided in labeling for the respective indications. Thirteen patients were started on a parenteral anticoagulant (unfractionated heparin (UFH)-8 patients; enoxaparin-5 patients) prior to DOAC initiation. There was delay in initiation of the DOAC in all 8 patients administered UFH and 4 of the 5 patients administered enoxaparin. Two dabigatran patients did not have appropriate overlap with a parenteral agent. Overall, there were 713 administrations of a DOAC. The percentage of patients who missed, received late, or refused a DOAC was 14.9%. Twenty three percent of patients were not administered their rivaroxaban dose with a meal. Two medications were contraindicated with DOAC use.
Conclusion: Data retrieved concerning medication reconciliation, ordering, dispensing and administration of DOACs at a large community hospital admitted to the hospitalist’s service provided information for improvements. The study results highlight gaps in compliance with the new NPSG for anticoagulation therapy. The most significant findings concern transitioning patients from parenteral anticoagulants to a DOAC and dosing rivaroxaban close to meals to enhance efficacy. Opportunity for policy and protocol enhancement with pharmacist involvement in facilitating improvements will be completed. Educational efforts for hospitalists, pharmacists, and nurses will be initiated to improve their understanding of DOAC clinical characteristics when ordering and administrating these medications.