Improving Anticoagulant Compliance With Neuraxial Anesthesia Drs. Matt Lyman, Corey Tingey, and Ken Howard With help from Drs. Gravlee and Marshall

The Problem  Anticoagulation recommendations prior to surgical procedures are not consistent with anticoagulation  guidelines for neuraxial anesthesia.  Patients often not provided guidelines prior to operative day, altering optimum care plan.

Scope of the Problem Occurs mainly in patients receiving novel oral anticoagulants (NOA) including rivaroxaban, dabigatran apixaban Surgical and neuraxial guidelines differ most with these medications.  Insurance data studies imply rapid adoption of  NOA in recent years for A-fib and other diseases. Graph adapted from N.R. Desai, MD, MPH et al. AJM, 2011, V.127, P. 1075–1082.

Scope of the Problem Difficult to know exact incidence of neuraxial anesthetics deemed ineligible.  Incomplete documentation that this was the reason not to offer neuraxial anesthesia. 

Stakeholders Patient: Preoperative clinic: Surgeon: Unable to receive neuraxial anesthesia for pain relief. Increased pain and loss of the benefits of neuraxial anesthetic.  Frustration if anticoagulant timing is found to be inadequate or inappropriate to receive optimum care.  Preoperative clinic:   Usually unaware of neuraxial recommendations in the setting of anticoagulation.  "Misinformation" given to patient. Frustrating for providers if they are not sure which guidelines to use. Surgeon:  Some surgeons prefer neuraxial anesthesia in certain surgeries  May cancel an elective case if patient is unable to have a neuraxial anesthetic (e.g. thoracotomy) 

Stakeholders OR Anesthesiologist: Acute Pain Providers: Potentially make intraoperative planning and pain management more difficult in OR and PACU. Acute Pain Providers:  Inability to offer patient indicated neuraxial pain management, and explaining to patient on day of surgery why they are unable to receive it.  Difficulty in pain management post-operatively with limited options.

Measures of Improvement Outcome measures Process Measures Balancing measures Amount of anti-coagulated patients that were not given neuraxial anesthesia Number of patients considered for neuraxial anesthesia in surgical clinic Potential for increased rates of infection with increased procedures Number of anti-coagulated patients that received optimal neuraxial anesthesia How many patients were screened for their specific type of anticoagulation in relation to their potential procedures? Potential for autonomic (sympathetic) derangements or dose mismanagement during epidural use Patients given partial or modified (regional) anesthesia in place of neuraxial. Number of providers screened for correct management of anticoagulation in pre-anesthesia clinic. Risk of thrombosis or related consequences from being off of anticoagulation How many patients were provided perioperative instructions about their anticoagulation

SMART Goals and Objectives 1: Patient education via surgical team. Goal: Give patient correct information on when to alter/stop anticoagulation Objective: Avoid stopping patient anticoagulant at an inappropriate time, educating providers if needed. 2: Patient education about management in the pre- anesthesia clinic. Objective: Avoid stopping patient anticoagulant at an inappropriate time, educating clinics if needed.

SMART Goals and Objectives 3: Stopping or altering anticoagulation, identify which patients need bridging, etc Overall goal: Altering anticoagulation when indicated while avoiding adverse thrombotic events. Objectives: Maximize patient benefit from possible neuraxial anesthetic; maintaining patient safety. 4: Improve communication about neuraxial anesthesia in preoperative area if anticoagulant has not been held. Overall goal: Improve patient satisfaction by improving communication Objective: Review anticoagulation status and last anticoagulant prior to discussing plausibility.

Plan, Do, Study, Act Plan Do Improving patient compliance with anticoagulation prior to neuraxial procedures via discussion with anesthesia preop clinic about proper adherence to ASRA recommendations Do Record compliance in AIP preop by partnering with APS team Create a plan with anesthesia preop clinic on how to handle patients on anticoagulation that are candidates for neuraxial procedures

Plan, Do, Study, Act Study Act Record patient compliance in AIP preop Record patients seen in anesthesia preop clinic and determine if this is reflected in compliance once patients arrive in AIP preop Act Begin recording patients in anesthesia preop clinic Once sufficient data obtained, present data to certain surgical clinics (urology, thoracic, etc) Gradual expand project to involve more surgical subspecialties

Results from APS Preop Data Date range 1/20/17 – 4/14/17 Total of 22 patients recorded 6/22 (27%) did not have anticoagulation held appropriately 4/22 patients presented for spinal, 18/22 for spinal or CSE

Results from APS Preop Data Rivaroxaban (Xarelto): 10 patients, 8 held appropriately Apixaban (Eliquis): 4 patients, 1 held appropriately Plavix: 4 patients, 3 held appropriately SQH: 2 patients, 2 held appropriately Lovenox: 1 patient, held appropriately Dalteparin: 1 patient, held appropriately

Results from APS Preop Data 8/22 (36%) were seen in anesthesia preoperative clinic, of those 3 did not have their anticoagulation held appropriately Patient 1: spinal for circumcision, recommended by outside physician to hold apixaban for 48h. Preop clinic did not change rec. Case proceeded without spinal Patient 2: Epidural for diaphragmatic plication, rivaroxaban last taken 48h prior to surgery, seen in preop <48h prior to surgery. Case cancelled Patient 3: Epidural for dx laparoscopy, pelvic exploration. Apixaban taken 60h prior to surgery (2/2 BID dosing), seen in preop clinic 48h prior to surgery at which point Apixaban was being held. No epidural performed