Cardiac Antithrombosis Management Program (CAMP)
It’s hard to believe that the Cardiac Antithrombosis Management Program (CAMP) was formed just five years ago. Since its humble beginnings, when it served around 40 patients, the program has grown by leaps and bounds. Today, 180 outpatients are enrolled in CAMP, with over 15 inpatients on any given day and an ever-expanding number of international patients.
“The program was created in response to a statement by the Joint Commission that said patients on high risk medications should undergo highly vigilant and standardized management,” explains Program Director Christina Vanderpluym, MD.
Congenital heart disease is one of the leading causes for pediatric stroke, therefore dedicating specialized attention and centralizing care of anticoagulation was paramount to improving outcomes and preventing complications in the cardiac population. In true Heart Center form, the program has innovated and expanded every year since. The program is coordinated by a full-time pharmacist (Amy Hellinger, PharmD), two nurse practitioners (Beth Hawkins, NP, and Courtney Ventresco, NP), and an administrative associate (Janell Acharya).
“I’m very proud of our expansion,” says Vanderpluym. “We’ve improved internal processes, so that patients are identified for needing antithrombosis therapy as early as possible. We don’t just follow Heart Center patients, we assist with the management of any patient with congenital or acquired heart disease who comes to Boston Children’s and needs anticoagulants.”
If a patient is referred here for a surgery and will need anticoagulant medication, the CAMP team is notified before the appointment date. During pre-op, the team assesses the patient and formulates a medication plan. They follow the patient through his or her stay, and assist with discharge planning. “We try to educate local providers, too,” says Vanderpluym.
Once the patient is home, CAMP is in charge of all anticoagulation monitoring and management. This involves frequent laboratory measurement and telephone check-ins at least once a week. “Certain medications and foods can interfere with Coumadin’s effectiveness,” says Vanderpluym. “Not that many of our patients would do this, but they can’t load up on spinach and negate the effect of Warfarin.”
For the first few weeks, patients need labs drawn every other day. After that, they only need labs twice a month. Many patients are monitored for just a few months, while other require lifelong monitoring.
CAMP care around the world
International patients present unique challenges. “Many of these patients live quite far from any doctor comfortable with anticoagulation management,” says Vanderpluym. “We’ve had patients in Panama, Colombia, Qatar, the United Arab Emirates, Iran, Switzerland—really all over the map.”
International patients are discharged with a home INR instrument. “They take a photo of the reading with their phones and send them to us. That way, there’s no interpretation issue,” says Vanderpluym.
Speaking of interpretation, Vanderpluym explains that CAMP works closely with Boston Children’s Interpreter Services for phone calls with families who don’t speak English. “We do a dry run of these calls while the patient is still here at the hospital to work out any kinks,” she adds.
An exciting new development in recent years has been incorporating genetic testing into treatment plans. Vanderpluym calls this “informedics” – using genetic data to inform medicine. This initiative is led by Shannon Manzi, PharmD, director of the Clinical Pharmacogenomics Service, as part of a hospital-wide study, called InforMED Kids, at Boston Children’s Hospital.
“We can now test a patient’s gene sequence and learn how their enzymes will metabolize the medication,” says Vanderpluym. “This way we can prescribe the optimum dose on the first try. What we do is test for two specific mutations related to Coumadin metabolism. If you have either, you may need a lower or higher dose of Coumadin than the average person.”
Upcoming clinical trials
Currently, most patients in CAMP are on Warfarin, the most commonly prescribed oral anticoagulant for this population. (There are adult patients in CAMP, too).
“Newer anticoagulant medications for adults don’t need the same type of rigorous monitoring,” says Vanderpluym. “We would love to make life easier for our patients and eradicate the need for frequent lab tests. In 2017, we’re launching two clinical trials to test new medications in pediatric patients. Both medications are novel oral anticoagulants that will not require frequent lab tests for monitoring.”
Trail #1: Apixaban
- For any patient over two years old with congenial or acquired heart disease
Trial #2: Rivaroxaban
- For patients who’ve had the Fontan procedure
If the at-home monitoring portion of CAMP could be mitigated with these medications, the program could focus more attention on patients in the hospital. “Strokes, clots and bleeding events are significant causes of morbidity and mortality in the hospital” she says. “It’s extremely important that we standardize the way we monitor and treat our patients on the floors.”
CAMP has already collaborated with hematology to standardize inpatient services for children with congenital and acquired heart disease. “They were very happy to incorporate us into their protocol,” Vanderpluym says. “We run a 24 hour, comprehensive service. With this approach, we can improve outcomes and optimize resource allocation to get patients home faster.”