By Brian Ward
The Joint Commission (TJC) announced revisions to its anticoagulant therapy National Patient Safety Goal (NPSG) December 7. NPSG 03.05.01 has eight new or revised elements of performance (EP).
All the changes are listed in R3 Report 19 and will take effect July 1, 2019. The update applies to all TJC-accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory healthcare program.
The report explains that while this NPSG has made a positive impact on patient safety over the years, there’s been a rise in adverse events because of an increase in the use of direct oral anticoagulants (DOAC).
EP 1: Protocols for starting and continuing anticoagulant treatment must be evidence-based
Anticoagulant medicines are considered high-risk for a number of reasons. The dosing is complex, patients often don’t follow instructions, and providers can fall through on monitoring.
Facilities need to ensure their protocols are updated to cover all types of anticoagulants, including DOACs.
EP 2: Anticoagulation reversal and bleeding management protocols must be evidence-based
Anticoagulants prevent blood from clotting, which makes bleeding the most common complication. The severity and location of the bleeding varies case by case. Facilities should have protocols that cover multiple bleeding scenarios.
Protocols also need to cover indicators of when anticoagulation treatment needs to be reversed—either by stopping the treatment or prescribing a clotting agent. This includes information on which reversal agents go with which anticoagulant medication.
EP 3: Perioperative management protocols for oral anticoagulants must be evidence-based
Anticoagulant use has to be carefully monitored during surgery. Facilities need to have protocols for when to stop, restart, or bridge an anticoagulant during surgery.
EP 4: Have a written policy on the need for laboratory tests to adjust and monitor anticoagulant therapy
In the report’s EP rationale, TJC notes that baseline and ongoing tests can be used to monitor anticoagulation medications and ensure the dosage is appropriate.
The written policy should cover testing for anticoagulants like heparin and warfarin, as well as DOACs.
EP 5: Establish a process to respond to adverse drug events and evaluate and improve anticoagulation safety practices
There are two parts to this EP. The first requires a facility to have a process for dealing with adverse drug events (ADE) and their outcomes. The process must cover identifying, responding to, and reporting ADEs.
The second part says that facilities must evaluate their anticoagulant safety practices. The evaluation is to reveal how effective these practices are and pinpoint ways to improve. Possible improvements should be acted upon.
Note: Anticoagulant medicines are the fourth most common cause of ADEs.
EP 6: Provide education to patients and families on their anticoagulant treatment
The patient education this EP mandates is fourfold:
- Sticking to one’s medication schedule and dosing instructions
- The necessity of attending follow-up appointments and lab tests
- How anticoagulants interact with other drugs and food
- The risk of an ADE
Educating patients and their families on these topics will make it more likely they’ll comply with providers’ instructions and avoid ADEs.
EP 7: If available, facilities should only use pre-filled syringes, premixed infusion bags, or oral unit-dose products
These products reduce the chance of dosing errors and improve patient safety.
Note: These products should only be used on children if they’ve been specifically designed for children.
EP 8: Use programmable pumps when administrating heparin intravenously and continuously
This EP was an existing TJC requirement; it’s just been renumbered. Programmable pumps make medication administration more consistent and accurate.