Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Improving the Safety and Efficacy of Warfarin Therapy in a Metropolitan Private Hospital: A Multidisciplinary Practice Improvement Project

Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Improving the Safety and Efficacy of Warfarin Therapy in a Metropolitan Private Hospital: A Multidisciplinary Practice Improvement Project

Article excerpt

BACKGROUND

Warfarin therapy is widely prescribed for the prevention and treatment of venous and arterial thrombosis and embolism (Gallus, Baker, Chong, Ockelford, & Street, 2000; Hirsh, Guyatt, Albers, Harrington, Schünemann, & for the American College of Chest Physicians, 2008; Institute for Clinical Systems Improvement [ICSI], 2006). In our organisation we have seen the number of inpatients on warfarin significantly increase over the last 10 years. This is, in part, due to strong evidence of its benefit in patients with atrial fibrillation (Gallus et al., 2000; Hirsh et al., 2008; ICSI, 2006). This has led to warfarin now being one of the top 20 most prescribed drugs in Australia, with over 2 million prescriptions issued each year (Department of Health and Aging, 2008).

Effective warfarin therapy, however, is very complex to manage. The average daily dose required can differ dramatically from person to person varying from 0.5 to 15 mg/day (Gallus et al., 2000). This wide gap in individual responses to dosage requirements can be due to a number of factors including age, weight, cardiac or liver impairment, diet, or drug interactions (ICSI, 2006). In order to manage warfarin safely it must be closely monitored and titrated to avoid under or over-dosage and despite its wellproven efficacy as an anticoagulant it does come with considerable risks. Indeed, it is potentially a very hazardous drug with reports suggesting major bleeding in approximately 1-2% of cases and intracranial bleeding in 0.1-0.5% (Gallus et al., 2000).

This combination of a potentially dangerous drug with a complex therapeutic regimen considerably increases the likelihood of adverse events. In a systematic review of the literature Runciman, Roughead, Semple, and Adams (2003) identified that between 2 and 4% of all hospital admissions in Australia are related to adverse drug events and that anticoagulant medication, such as warfarin, is the second most common drug class implicated (second only to chemotherapy agents). Warfarin is also in the top five most cited medications in NSW Public Hospitals incident reports (Clinical Excellence Commission [CEC], 2006).

The catalyst for this project was an invitation in 2007 from the NSW Therapeutic Advisory Group (TAG) and the NSW Clinical Excellence Commission (CEC) to trial their new Medication Safety Self Assessment for Antithrombotic Therapy (MSSA-AT). This tool was initially developed in the United States by the Institute of Safe Medication Practices and had recently been adapted for the Australian context by NSW TAG and the CEC (Clinical Excellence Commission [CEC], 2007a). The self assessment required a multidisciplinary team to rate the organisation's compliance with best practice initiatives, discussing each initiative until a consensus was reached on the level of organisational implementation (from not implemented to fully implemented). On completion of the self assessment our overall score was calculated at only 44% (of the maximum possible score). On reviewing the results it was agreed that warfarin therapy management was the priority area for improvement.

AIM

The primary project aim was to improve the safety and efficacy of warfarin therapy through the application of the best available evidence on warfarin management. A number of objectives were set in order to achieve this aim. These included the comprehensive audit of current warfarin therapy management practices against evidence-based best practice; benchmarking of these results with comparable organisations; identification and prioritisation of areas for practice improvement and; sustaining practice change.

SETTING

The project was conducted over a 12-month period in a 250 bed acute care private hospital in metropolitan Australia. The hospital has over 20,000 separations annually and caters for all surgical and medical specialties excluding obstetric and paediatric care. The case mix is 70% surgical and 30% medical and 45% of the patient population is over 65 years of age. …

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