Madison, Wisconsin
UW Health Anticoagulation Stewardship Program
UW Health created an Anticoagulation Stewardship Program (ASP) because of concerns about organizational performance related to safety, quality and regulatory compliance measures for blood thinning medications. The pharmacist-led, interdisciplinary ASP team is responsible for performance improvement efforts for blood thinning medications and any condition that may increase the risk of developing blood clots in all care settings across the health system and in all phases of the medication-use process.
ASP team responsibilities include leading and coordinating all performance improvement work related to the use of blood thinning medications across the health system. The ASP pharmacist serves as a leader and a staff member for key UW Health anticoagulation oversight committees. The ASP team does not provide direct patient care but rather provides leadership, coordination and implementation strategies to achieve best practices by front-line staff who are responsible for the use of blood thinning medications. Given the broad scope of the program, new interdisciplinary committees were chartered to review clot prevention systems and clinical tools and to remove barriers to implementation. Clinical tools developed include practice guidelines and order sets that have been configured into the UW Health electronic medical record. These order sets include standardized orders for medications and other therapies to prevent and treat clots in hospitalized patients. The program was officially launched in fall 2009 with a focus on two high-priority performance improvement projects, inpatient clot prevention and outpatient warfarin management.
Computerized tools and staff educational programs were implemented to help prevent the development of blood clots in hospitalized patients. Data were collected before and after the tools and education program were put into place. A significant reduction – from 24 percent to 8 percent – was found in all medical inpatients who were not receiving clot prevention regimens. The same was true in surgical inpatients who were not receiving a clot prevention regimen; they went from 20 percent to 3 percent. A significant reduction in post-operative blood clots was also observed: from 11.6 per 1,000 cases to 6.6 per 1,000 cases. Reductions in clots are estimated to have reduced excess hospital days and saved over $1 million in hospital costs.
An outpatient clinical guideline, protocol and educational program were developed for the management of warfarin use by outpatients. This program is now used in 39 primary care clinics across UW Health, covering more than 3,000 patients who take warfarin. An assessment of the initial pilot clinics found that processes significantly improved after the program was established. Additionally, results from the tests used to monitor warfarin effectiveness and safety were in the desired range 73 percent of the time as compared to only 65 percent of the time before program implementation.
The ASP model is unique in its depth and scope and has resulted in improvements in clot prevention in the hospital setting and appropriate use of blood thinning medications in the outpatient setting. It provides a model for improving anticoagulation quality and safety in an era of limited health care resources. In addition, the model is aligned with evolving health care models, including medical homes and accountable care organizations.