Program Overview
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Educational Goal
The purpose of this program is to provide learners with up-to-date knowledge on the management of patients on either warfarin and non-vitamin K antagonist oral anticoagulants (NOAC) therapy. The brief didactic lecture is accompanied by three interactive patient simulation cases where the learner will have the opportunity to "manage" the patient and receive complete feedback on their actions and decisions in the form of a Performance Report. This robust feedback element is valuable in helping to improve the overall management of patients on anticoagulation therapy.
Target Audiences
The intended audience for this educational activity includes Emergency Medicine, Hospital Medicine, and Intensive Care physicians, Emergency Department and ICU nursing staff, ED and Hospital physician extenders (PAs and NPs), hospital-based pharmacists, critical care physicians and critical care nurse specialists, anesthesiologists, and nurse anesthetists. There may also be interest in this program from hospital-based providers in interventional cardiology, pulmonary medicine, surgery, and vascular medicine.
Needs Assessment and Gap Analysis
Oral anticoagulant drug use is more common than ever before, and will continue to rise in the future, particularly given the rapid growth in the prevalence of nonvalvular atrial fibrillation and venous thromboembolism associated with population aging demographics, longer lifespans with chronic disease, and obesity. Besides warfarin, non-vitamin K antagonist oral anticoagulants (NOACs) have been approved for both SPAF and prevention and treatment of VTE. These newer agents are advantageous with a short half-life, fewer food and drug interactions, a lack of requirement for monitoring of the international normalized ratio or other clotting studies, and are generally safer than warfarin in terms of major bleeding risk and, in particular, intracranial bleeding.
Still, uncontrolled or life-threatening hemorrhages (major bleeding) can occur on any oral anticoagulant, as do surgical/procedural emergencies in patients who are anticoagulated (bleeding concern). When this occurs, the resuscitative and reversal approaches differ based on the anticoagulant the patient is taking. Essentially every acute care hospital in the United States has an explicit reversal protocol for bleeding and bleeding concern in patients taking warfarin. These protocols are driven by the results of an easily- and rapidly-obtained International Normalized Ratio (INR) assay and the approach, based on clinical scenario and INR, is with vitamin K supplementation and, in severe cases, coagulation factor repletion. With the NOACs, there is no consistent quantitiative guidance that can be gained from laboratory studies as to the extent of anticoagulation with the anti-IIa anticoagulant dabigatran or the anti-Xa anticoagulants apixaban, edoxaban, or rivaroxaban.
In early 2016, the Hospital Quality Foundation conducted a telephone survey of emergency physicians, hospital pharmacists, and ED nursing directors at ten hospitals (2 in PA, 2 in CA, 1 in MS, 1 in MI, 2 in TX, 1 in FL, 1 in AZ) regarding these bleeding management issues. Only 50% of emergency physicians and only 34% of nursing directors expressed full comfort with managing dabigatran- and warfarin-related major bleeds and bleeding concerns. Feedback from lead hospital pharmacists, all 10 hospitals had specific protocols for warfarin management, but clinicians followed them explicitly only occasionally. Only 3 of the hospitals had specific protocols for the use of idarucizumab in dabigatran-related bleeding management. All respondents, regardless of discipline, expressed significant interest in using simulation cases for their own training and for the training of others in their departments.
Learning Objectives
Upon completion of the educational activity, the learner will be better able to:
1) Apply evidence-based approaches to the diagnostic and therapeutic management of patients with dabigatran- or warfarin-related major bleeding and pre-procedural bleeding concerns
2) Develop a specific treatment protocol for the evaluation and management of dabigatran- or warfarin-related major bleeding and pre-procedural bleeding concerns
3) Differentiate between vitamin K administration and immediate factor repletion in warfarin-treated patients with bleeding emergencies
4) Explain the mechanism of action and rationale for use of both idarucizumab and 4-factor prothrombin complex concentrate in the management of bleeding emergencies