Implement Updated Safety Policies for Direct Oral Anticoagulants (DOACs)

You’ll see more focus on maximizing safe use of apixaban (Eliquis) or other direct oral anticoagulants (DOACs).

The Joint Commission is expanding the anticoagulation National Patient Safety Goal (NPSG) starting July 1, 2019. The biggest change will be the requirement of including DOACs in hospital policies.

Use these strategies to help keep patients safe when using DOACs.

During med histories, document the indication...and stay alert for different doses. For example, you may see rivaroxaban 20 mg/day to prevent stroke in atrial fib...or 2.5 mg BID for coronary artery disease.

Also note any recent start dates...to help you catch errors. For example, for VTE treatment, verify rivaroxaban is switched from 15 mg BID to 20 mg once daily after 3 weeks...or the apixaban dose is reduced from 10 mg BID to 5 mg BID after one week.

Check your protocol for timing of baseline labs...such as a CBC and serum creatinine within 24 hours of starting inpatient DOAC doses.

Question orders for a DOAC plus another oral or injectable anticoagulant...since overlap is rarely indicated and may be an error. Be aware that switching from a DOAC to warfarin is one case where it’s okay to consider overlap...but overlap should only be for a few days.

Verify a plan to hold the DOAC when a patient is scheduled for surgery or regional anesthesia...such as an epidural catheter placement.

For example, expect to hold apixaban at least 48 hours before a CABG...or longer in patients with renal impairment, since DOACs are cleared by the kidneys.

Also be prepared to give meds...such as Kcentra, idarucizumab (Praxbind), or Andexxa...to reverse and treat major DOAC bleeding.

At discharge, emphasize DOAC adherence since their effect wears off quickly. Verify patients know why and how long they’ll take their DOAC...and which prescriber will manage their outpatient anticoagulation.

Prepare yourself for changes you may see with the updated NPSG by using our toolbox, Safe Use of Anticoagulants.

Key References
  • www.jointcommission.org/assets/1/18/R3_19_Anticoagulant_therapy_FINAL2.PDF
  • Jt Comm J Qual Patient Saf 2018;44(11):630-40
  • J Thromb Thrombolysis 2016;41(1):206-32
  • J Am Coll Cardiol 2017;70(24):3042-67
Nurse’s Letter. Feb 2019, No. 350217


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