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

2. 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.

3. 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.

4. 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. 

5. 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) 

6. 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.

8. 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

9. 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.

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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