Managing the Risks of Direct Oral Anticoagulants

The Joint Commission: Sentinel Event Alert

While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring different strategies than those for patients on warfarin (Coumadin®) and heparin. Unlike the more widely available reversal agents for warfarin and heparin, reversal agents for DOACs are lesser known and may not be available in every care setting. Also, some DOACs have no FDA-approved reversal agent at this time. Therefore, bleeding complications can be severe if these patients are not assessed according to guidelines on the management of DOACs. Intracranial hemorrhage is the most serious emergent bleeding risk.

In response to an increase in adverse events related to these widely prescribed medications, this alert provides guidance on the safe use and management of DOACs to all medical practitioners and health care organization leaders, particularly chief medical officers, pharmacists, emergency department clinicians, and quality and safety officers.

Anticoagulation FORUM: Numerous Resources and Expert Guidance

Anticoagulation FORUM

  • Education & Guidance
  • Webinars and Events
  • Centers of Excellence
  • Anticoagulation Stewardship

Established more than 25 years ago, the Anticoagulation Forum is the largest organization of its kind helping practitioners improve patient care by providing current and relevant information on best practices. The flagship program, the Anticoagulation Centers of Excellence, embodies our commitment to the clinical application of evidence-based practices and improved patient outcomes. Expert Guidance is provided by the Board of Directors, who are regularly relied upon for their expert opinion. Their contributions to research and guideline development have influenced all aspects of anticoagulation therapy.

Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement

Agency for Healthcare Research and Quality (AHRQ)

Pulmonary embolism resulting from deep vein thrombosis—collectively referred to as venous thromboembolism—is the most common preventable cause of hospital death. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of one of the most important problems facing hospitalized patients, hospital-acquired venous thromboembolism.

Preventing Hospital-Associated Venous Thromboembolism (VTE)

Agency for Healthcare Research and Quality (AHRQ)

AHRQ has an Appendix of Tools and Resources to Support Talking Points To Attract Administration Support for Venous Thromboembolism Prevention Programs:

  • Hospitalized patients are at high risk for venous thromboembolism (VTE).
  • Venous thromboembolism leads to substantial inpatient costs, morbidity, and mortality.
  • Effective, safe, and cost-effective measures to prevent hospital-associated VTE exist.
  • A gap between current practice and optimal practice exists.
  • VTE prevention is incorporated into public reporting, medical guidelines, Federal regulations, and national quality initiative priorities.
  • Reliably preventing VTE in the hospital is inherently complex.
  • Essential elements are needed for effective and safe prevention of VTE in the hospital.
  • A roadmap is in place.
  • Summary—Push for Support:

Opioid Stewardship: IPRO HQIC, Learning and Action Network (LAN)

IPRO Hospital Quality Improvement (HQIC), Learning and Action Network (LAN) webinar on the All-Cause Harm focus are of Opioid Stewardship: April 26th 2021.

IPRO HQIC presented aggregate baseline data on the Opioid Stewardship Hospital Baseline Assessment and heard from a rural hospital on promoting the safe use of opioids (prescribing policy, scripted communication tools, alternatives to opioids, tracking prescribing practices, referral network for pain management, and MAT therapy).

In addition, IPRO HQIC highlight many salient opioid stewardship resources on processes that support the inclusion of patient and family engagement and health equity (stigma) in opioid stewardship efforts. These resources further support IPRO HQIC hospital efforts in All-Cause Harm reduction.

Recording, Slides and All-Cause Harm Resource available.

HHS Releases New Buprenorphine Practice Guidelines, Expanding Access to Treatment for Opioid Use Disorder

Health and Human Services (HHS) April, 2021

In an effort to get evidenced-based treatment to more Americans with opioid use disorder, the Department of Health and Human Services (HHS) is releasing new buprenorphine practice guidelines that among other things, remove a longtime requirement tied to training, which some practitioners have cited as a barrier to treating more people.

Signed by HHS Secretary Xavier Becerra, the Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder exempt eligible physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and certified nurse midwives from federal certification requirements related to training, counseling and other ancillary services that are part of the process for obtaining a waiver to treat up to 30 patients with buprenorphine.

Direct Oral Anticoagulant: DOAC Playbook

Anticoagulation Forum

Although DOACs require less intensive dose management than warfarin, they are not devoid of potential complications. Anticoagulants have consistently ranked as the class of medications most frequently leading to emergency room visits and hospital admissions for adverse drug events. This toolkit explains how to use DOACs safely and effectively requires that all aspects of anticoagulation therapy are addressed, including appropriate patient selection, dosing, monitoring, transitions between therapies and between care settings, periprocedural guidance, management of risks (including DOAC associated
bleeding), drug-drug interaction management, ongoing assessment of patient and family educational needs, and incorporation of evidence-based practices into workflow.

Creating a Culture of Safety for Opioid Prescribing: Handbook for Healthcare Executives

Centers for Disease Control and Prevention (CDC)

Healthcare executives have an important role in creating a culture for safer opioid prescribing. This handbook contains insights and advice from healthcare executives and quality improvement leaders from four different health systems representing urban, suburban and rural settings. They share their experiences engaging internal and external stakeholders, working across interdisciplinary teams, leveraging data to inform efforts, implementing training and educational efforts, and much more. Sections include:

  • The Value of Evidence-Based Opioid Prescribing
  • Collecting and Using Data
  • Engaging with External Stakeholders
  • Establishing Policies and Standards that Support Safer Opioid Prescribing Practices
  • Training and Educating Providers
  • Supporting the Continuum of Care

Partnering with Patients and Families to Strengthen Approaches to the Opioid Epidemic

Institute for Patient and Family Centered Care (IPFCC)

This whitepaper showcases the many opportunities for patients, families, and individuals with lived experience to collaborate in shaping and implementing policies and programs related to the opioid epidemic. While work in this area is evolving, several “spotlight examples” provide a starting point for thinking about new strategies and opportunities and reflect existing structures that can be utilized and expanded to accelerate the process of building meaningful partnerships.

All-Cause Harm Resource

This resource explains what All-Cause Harm is, why it is important and then dives into each of the processes it takes to prevent All-Cause Harm. Eight priority focus areas for the Hospital Quality Improvement Contract (HQIC) are illuminated and strategies to monitor compliance are provided.

All-Cause Harm Resource, Recording and Slides from the IPRO HQIC All-Cause Harm “launch” on March 29th, 2021.

Your Guide to Controlling & Managing Pain After Surgery

MHA Keystone Center

Provides education to patients related to:

  • Understanding surgical pain
  • Understanding pain after surgery
  • Questions to ask before surgery, after surgery and before discharge
  • Tools to help manage pain
  • Keeping track of pain medications and frequency
  • Common pain medication side effects