Massachusetts General HospitalMassachusetts General Hospital

Anticoagulation Management ServiceAnticoagulation Management Service

Lynn B. Oertel, MS, ANP, CACPLynn B. Oertel, MS, ANP, CACP

Clinical Nurse SpecialistClinical Nurse SpecialistPresented November 4, 2008Presented November 4, 2008

Timeline of ATU/AMSTimeline of ATU/AMS

2008 NPSG 2008 NPSG (selected)

1 - Improve accuracy of patient identification1 - Improve accuracy of patient identification

2 - Improve the effectiveness of 2 - Improve the effectiveness of communication among caregiverscommunication among caregivers

3 - Improve safety of using medications3 - Improve safety of using medicationsRequirement 3E: Reduce the likelihood of Requirement 3E: Reduce the likelihood of

patient harm associated with the use of patient harm associated with the use of anticoagulation therapyanticoagulation therapy

New

http://www.jointcommission.org/

2008 NPSG 2008 NPSG (selected)(selected)

8 - Accurately and completely reconcile 8 - Accurately and completely reconcile medications across the continuum of medications across the continuum of carecare

9 - Reduce the risk of patient harm resulting 9 - Reduce the risk of patient harm resulting from fallsfrom falls

13 - Encourage patients’ active involvement 13 - Encourage patients’ active involvement in their own care as a patient safety in their own care as a patient safety strategystrategy

15 - The organization identifies safety risks 15 - The organization identifies safety risks inherent in its patient populationinherent in its patient population

NQF Safety StandardsNQF Safety Standards

Safe Practice 17: Safe Practice 17: Evaluate each patient upon Evaluate each patient upon admission, and regularly thereafter, for the admission, and regularly thereafter, for the risk of developing DVT/VTE. Utilize clinically risk of developing DVT/VTE. Utilize clinically appropriate methods to prevent DVT/VTE.appropriate methods to prevent DVT/VTE.

Safe Practice 18: Utilize dedicated anti-Safe Practice 18: Utilize dedicated anti-thrombotic (anticoagulation) services that thrombotic (anticoagulation) services that facilitate coordinated care managementfacilitate coordinated care management..

http://www.qualityforum.org/

Goal is to reduce incidence of surgical Goal is to reduce incidence of surgical complications nationwide by 25% by 2010complications nationwide by 25% by 2010

SCIP VTE1 – Surgery patients with recommended SCIP VTE1 – Surgery patients with recommended VTE prophylaxis orderedVTE prophylaxis ordered

SCIP VTE2 – Surgery patients who received VTE SCIP VTE2 – Surgery patients who received VTE prophylaxis within 24 hours after surgeryprophylaxis within 24 hours after surgery

www.qualitynet.org, see Other Resource: About the Project

OSG Call to Action – Sept 15, 2008OSG Call to Action – Sept 15, 2008

http://www.surgeongeneral.gov/

The Joint Commission Sentinel Alert – The Joint Commission Sentinel Alert – Sept 24, 2008Sept 24, 2008

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/

Clinic overviewClinic overview Patients = 4100+Patients = 4100+ Mean age = 69 yrs, SD Mean age = 69 yrs, SD

13.65, range 20 - 10013.65, range 20 - 100 Common indications Common indications

for treatment:for treatment:• AF AF 57% 57%• VTE VTE 15% 15%• Heart Valves Heart Valves 9% 9%

INR intensity rangesINR intensity ranges• 2 – 3 2 – 3 87% 87%• 2.5 – 3.5 2.5 – 3.5 9% 9%• By request, selected By request, selected

othersothers

Admissions:Admissions:• ~75/month~75/month• + Reactivated patients+ Reactivated patients• ~ 60% new referrals ~ 60% new referrals

from inpatient (POE from inpatient (POE Consult referral)Consult referral)

Discharges:Discharges:• ~ 90/month~ 90/month

Time in Therapeutic RangeTime in Therapeutic Range

TTR calculated using TTR calculated using Rosendaal methodRosendaal method

Strict range limits, Strict range limits, eg. 2 – 3 and 2.5 – eg. 2 – 3 and 2.5 – 3.53.5

Using ALL INR data Using ALL INR data (induction, (induction, interruptions, etc)interruptions, etc)

INR Range 2.5 - 3.5

55

60

65

per

cen

t T

TR

780800820840860880900920

# IN

Rs

percent 64.4 62.5 63.7 59.6 59.4 58.8

INRs 902 834 847 914 877 867

Jan Feb mar Apr May June

INR Range 2 - 3

68

69

70

71

per

cen

t T

TR

60006200640066006800700072007400

# IN

Rs

percent 69.1 68.8 69.3 69.3 70.2 69.7

INRs 7206 6423 6634 7150 6973 6864

Jan Feb mar Apr May June

Percent INR Percent INR teststests out-of-range out-of-range

In Range (2 – 3) = 60%In Range (2 – 3) = 60%

Above 3 = 15%Above 3 = 15%

Below 2 = 25%Below 2 = 25%

Percent Very High…

≥ 5 = 0.8%

≥ 7.5 = 0.2%

Percent Very Low…

≤ 1.3 = 0.3%

Communication and Education Communication and Education for Patients and Physiciansfor Patients and Physicians

Key elements for improvedKey elements for improvedpatient managementpatient management

Patient focused, primary nurse modelPatient focused, primary nurse model Physician Order Entry for AMSPhysician Order Entry for AMS Consult Consult ReferralReferral

(nearly all data fields mandatory for submission, thus all critical (nearly all data fields mandatory for submission, thus all critical info received)info received)

Dawn ACDawn AC (patient management system for maintenance and (patient management system for maintenance and transition patients)transition patients)

3 Interfaces:3 Interfaces:• ADT InterfaceADT Interface (electronic notification for AMS patient (electronic notification for AMS patient

admissions/discharges)admissions/discharges)• Outbound message Interface Outbound message Interface (AMS icon/communication (AMS icon/communication

facilitator)facilitator)• Results InterfaceResults Interface (electronic INR entry into Dawn AC from lab (electronic INR entry into Dawn AC from lab

system)system) Hospital “buy in”Hospital “buy in”

• Information System support (2 FTEs)Information System support (2 FTEs)• Pharmacy support (AMS Discharge Rx)Pharmacy support (AMS Discharge Rx)

AMS Communication with PatientsAMS Communication with Patients One-time face-to-face educational visitOne-time face-to-face educational visit with patient with patient

& family and primary nurse& family and primary nurse Followed by Followed by telephone callstelephone calls to patient for short to patient for short

period to review subsequent INR values, current period to review subsequent INR values, current dose instructions, and date of next INRdose instructions, and date of next INR

Thereafter, Thereafter, written instructions are mailedwritten instructions are mailed with with same information. same information. Dose info communicated via # Dose info communicated via # pills – pills – notnot mg. mg. (finalizing plans to initiate (finalizing plans to initiate email email communications, when desired by patient)communications, when desired by patient)

Telephone assessments more common than face-to-Telephone assessments more common than face-to-face visitsface visits

Communication interventions are individualized to Communication interventions are individualized to meet patient needs over timemeet patient needs over time

Patient SatisfactionPatient Satisfaction

““My ranking of this program: First Class Service.”My ranking of this program: First Class Service.” ““The anti-coag service is great. I go to Florida 3 The anti-coag service is great. I go to Florida 3

months during the winter months and I am able months during the winter months and I am able to keep track of dosages and INR levels easily. to keep track of dosages and INR levels easily. My daughter calls in for me and lets me know if My daughter calls in for me and lets me know if there are any changes in dosage to be made.” there are any changes in dosage to be made.”

““I have nothing but praise and appreciation for I have nothing but praise and appreciation for the concern and care over the years.” the concern and care over the years.”

““Knowing your clinic keeps a very close check on Knowing your clinic keeps a very close check on my Coumadin levels gives me a sense of security. my Coumadin levels gives me a sense of security. Your reporting is prompt and directions clearly Your reporting is prompt and directions clearly stated.” stated.”

Nursing Implications for Nursing Implications for Anticoagulated PatientsAnticoagulated Patients

Knowledge of patient risk v. benefit of Knowledge of patient risk v. benefit of treatmenttreatment

Safe and quality care management Safe and quality care management Know Know goal therapeutic INR range and treatment goal therapeutic INR range and treatment plan. Utilize systematic, standardized plan. Utilize systematic, standardized protocols and decision support tools.protocols and decision support tools.

Monitoring Monitoring Tracking and patient follow-upTracking and patient follow-up Effective communication and coordination of Effective communication and coordination of

multiple care providersmultiple care providers Patient & Family Education, include health Patient & Family Education, include health

literacy assessment, modification of risks, literacy assessment, modification of risks, standardize curriculum & education materialsstandardize curriculum & education materials

Achieving good outcomes is dependent upon:

AMS Patient Education Slide ShowAMS Patient Education Slide Show Standardized education curriculum content, Standardized education curriculum content,

individualized for patient-specific needsindividualized for patient-specific needs

Written materials support contentWritten materials support contentof slide showof slide show

AMS Brochure

Patient EducationPatient Education To prepare for discharge, can patient …To prepare for discharge, can patient …

• Identify signs and symptoms of VTE (or bleeding)Identify signs and symptoms of VTE (or bleeding)• Describe action to take if occurs Describe action to take if occurs • Identify ‘warfarin manager’Identify ‘warfarin manager’• Recite instructions for follow-up including: daily dose Recite instructions for follow-up including: daily dose

schedule, confirmation of pill size, date of next INR schedule, confirmation of pill size, date of next INR • Describe plans for blood testing and future Describe plans for blood testing and future

monitoringmonitoring• Describe management and disposal of medications, Describe management and disposal of medications,

especially sharps disposal per town regulationsespecially sharps disposal per town regulations

2.2. Reminder of Reminder of pill sizepill size

Dose Instruction LetterDose Instruction Letter

1.1. INR result and INR result and Target RangeTarget Range

3.3. New weekly dose New weekly dose instructions (repeat instructions (repeat schedule until next dose schedule until next dose letter arrives)letter arrives)

4.4. Date for Date for next INR testnext INR test

…may see a message to skip 1 or 2 days (patients generally

rec’d a phone call at the time)

Dose Instruction with skipDose Instruction with skipIf INR is high…If INR is high…

Then, follow weekly Then, follow weekly dose instruction heredose instruction here

Compliance ProcessCompliance Process Automated follow-up support by Dawn AC, details Automated follow-up support by Dawn AC, details

developed by AMSdeveloped by AMS Five Stages – a letter mailed to patients at each Five Stages – a letter mailed to patients at each

stage underscoring safety concernsstage underscoring safety concerns• Formal discharge letter sent with delivery confirmationFormal discharge letter sent with delivery confirmation

Collaboration with referring physicians (possibly Collaboration with referring physicians (possibly case management) at critical milestonescase management) at critical milestones• Emailed formal notices at Final and Discharge StagesEmailed formal notices at Final and Discharge Stages

Customized letters/emails in Dawn ACCustomized letters/emails in Dawn AC• Highly efficientHighly efficient• Batch printed or emailedBatch printed or emailed• Excellent documentation trail Excellent documentation trail

         

  NonCompliance Process  

DNA Stage INR rescheduled in… RN Reminder MD Email

Iif no INR 3 DAYS after

scheduled date,then next INR in…. 2 weeks    

2if no INR 1 DAY after

scheduled date, then next INR in … 1 week    

3if no INR 1 DAY after

scheduled date, then next INR in … 1 week

√ 

Finalif no INR 1 DAY after

scheduled date, then next INR in … 1 week

√ √

DischargeNotice

sent via Certified Mail Patient Discharged 

√

         

(DNA = Did Not Attend)      

Reminder Letter for missed INR dateReminder Letter for missed INR dateDedicated Dedicated

line for callsline for calls

This This informationinformation

neededneeded

or email same or email same informationinformation

Auto-Auto-reschedule reschedule of INR Dateof INR Date

AMS IconAMS Icon

Indicates patient is an active patient in Indicates patient is an active patient in AMSAMS

Appears on electronic medical records (1 Appears on electronic medical records (1 in-patient, 2 out-patient systems)in-patient, 2 out-patient systems)

Click on icon, new window displays critical Click on icon, new window displays critical data elements about the patient from AMS data elements about the patient from AMS databasedatabase

AMS icon … CAS, LMR and OnCallAMS icon … CAS, LMR and OnCall

COMING NOVEMBER 7

Phase II AMS Icon

CPOE Consult ReferralCPOE Consult Referral

•Creates an electronic referral to AMS•Efficient, user-friendly, fast turn around•Ensures key clinical information provided since most fields mandatory

AMS Consult ReferralAMS Consult Referral

AMS Consult ReferralAMS Consult Referral

Outpatient Outpatient Paper AMS Referral Paper AMS Referral

TransitionTransition Pathway ServicesPathway Services

Induction PathwaysInduction Pathways

New Start – Warfarin New Start – Warfarin OnlyOnly

New Start – Warfarin New Start – Warfarin with LMWHwith LMWH

New Start – Warfarin New Start – Warfarin with Fondaparinuxwith Fondaparinux

Bridging PathwaysBridging Pathways

Resume – Warfarin Resume – Warfarin OnlyOnly

Resume – Warfarin Resume – Warfarin with LMWHwith LMWH

Resume – Warfarin Resume – Warfarin with Fondaparinuxwith Fondaparinux

Communication StrategiesCommunication StrategiesTransition PathwaysTransition Pathways

• Floor by floor roll-outFloor by floor roll-out• Multi-disciplinary approach (medicine, nursing, Multi-disciplinary approach (medicine, nursing,

pharmacy, case management, target key pharmacy, case management, target key leaders):leaders):

Grand roundsGrand rounds Inservice education sessionsInservice education sessions Print materials (newsletters)Print materials (newsletters) Main Corridor eventsMain Corridor events

• Electronic resourcesElectronic resources POEPOE CAS alertsCAS alerts All user (select user group) Broadcast email All user (select user group) Broadcast email

messagesmessages Web page presence with multi-source access to key Web page presence with multi-source access to key

anticoag-specific documents via hyperlinksanticoag-specific documents via hyperlinks

Role Group ResponsibilitiesRole Group Responsibilities

Referring PhysicianReferring Physician Complete referralComplete referral Order baseline lab workOrder baseline lab work Submit AMS RxSubmit AMS Rx

AMS NurseAMS Nurse Reviews/confirms eligibility Reviews/confirms eligibility

and seeks clarification, as and seeks clarification, as neededneeded

““Meets and Greets” patientMeets and Greets” patient Written instructions for pt.Written instructions for pt. Assumes anticoag Assumes anticoag

management day after management day after dischargedischarge

Floor NurseFloor Nurse Obtain patient weightObtain patient weight Conduct medication Conduct medication

discharge teachingdischarge teaching Completes discharge Completes discharge

process and ensures process and ensures patient leaves hospital patient leaves hospital with meds and with meds and instructionsinstructions

Case Management/ VNAsCase Management/ VNAs May/may not be involvedMay/may not be involved Coordinates Coordinates

needs/services at homeneeds/services at home

PharmacyPharmacy Delivers AMS Rx to floorDelivers AMS Rx to floor

E-Z GuideE-Z Guide

ResourcesResources Your Guide to Coumadin/Warfarin Therapy – Your Guide to Coumadin/Warfarin Therapy –

Agency for Healthcare Research and Quality, Agency for Healthcare Research and Quality, http://www.ahrq.gov/consumer/coumadin.htmhttp://www.ahrq.gov/consumer/coumadin.htm

Important information to know when you are Important information to know when you are taking: Coumadin and Vitamin K - taking: Coumadin and Vitamin K - http://ods.od.nih.gov/factsheets/cc/coumadin1.pdfhttp://ods.od.nih.gov/factsheets/cc/coumadin1.pdf

Are you at risk for a DVT Blood Clot - Are you at risk for a DVT Blood Clot - http://www.preventdvt.org/http://www.preventdvt.org/

OSG Call to Action, Sept 15, 2008 - OSG Call to Action, Sept 15, 2008 - http://www.surgeongeneral.gov/http://www.surgeongeneral.gov/

The Joint Commission Sentinel Alert, Sept 24, 2008 The Joint Commission Sentinel Alert, Sept 24, 2008 -- http://www.jointcommission.org/SentinelEvents/Senhttp://www.jointcommission.org/SentinelEvents/SentinelEventAlert/tinelEventAlert/

Nursing Model for Anticoagulation Service –Nursing Model for Anticoagulation Service – http://innovativecaremodels.com/http://innovativecaremodels.com/

ConclusionConclusion

CCollaborative communication strategies ollaborative communication strategies across disciplines are needed to support across disciplines are needed to support and reinforce the patient’s treatment plan.and reinforce the patient’s treatment plan.

Patient education about prevention, Patient education about prevention, disease process and treatment is vital for disease process and treatment is vital for successful outcomes. Detailed written successful outcomes. Detailed written reinforcements are critical elements.reinforcements are critical elements.