Using DAWN AC to Facilitate a Quality Improvement Project

Wenatchee Valley Medical Center

Lisa Vaughn RN CACPClinical Manager Anticoagulation Services

Current Problem

Bleeding is the major complication of anticoagulation therapy. Patients on concurrent antiplatelet and warfarin therapy are 2.75 times more likely to have a clinically significant hemorrhage.

Each ACC location had patients overdue for annual fecal occult blood, urinalysis and hematocrit.

Poor documentation of patient counseling, non compliance with labs or to communicate with the primary care physician.

No policy to address the individual patient risk/benefit of concurrent warfarin and antiplatelet therapy or to document the physician’s assessment.

Process

Identify goals Obtain baseline metrics Develop policy and procedure

To meet current goals Establish ongoing/permanent process

Educate staff, physicians and patients Developed tools in DAWN AC Identify patients Communicate with physicians Physician assessment of risk/benefit of duel therapy Document in EMR Document in DAWN AC

Project Statement / Goal:

Complete assessment of risk/benefit of concurrent warfarin and aspirin therapy.

Decrease the risk of major bleeding event by completing ACC required labs.

Increase the revenue by completing required lab tests

1. 95% of ACC patients will have either completed ACC required annual lab tests (hematocrit, fecal occult blood and urine dipstick analysis) or have documentation of refusal. Refusal was addressed by the case manager and communicated to the referring physician or PCP.

2. 100% of patients on aspirin therapy will be reviewed and assessed by their physician re: the bleeding risk vs benefit of concurrent warfarin and antiplatelet therapy.

Resources

Outcomes Associated With combined Antiplatelet and Anticoagulant Therapy

Samuel G Johnson, Kristina robbers, Thomas Delate and Daniel M Witt

Chest 2008; 133;948-954. Republished online January 15, 2008:

DOI 10. 1378/chest.07-2627

Warfarin and Antiplatelet Combination Use Among Commercially Insured Patients Enrolled in an Anticoagulant Management Service

Samuel G. Johnson, Daniel M. Witt, Todd R Eddy, Thomas Delate and for the Clinical Pharmac

Anticoagulation Service Study Group

Chest 2007; 131;1500-1507

DOI.1378/Chest 06-2374

Combining Antiplatelet and Anticoagulant TherapyDavid R. Holmes, Dean J. Kereiakes, Neal S. Kleiman, David Moliterno, Giuseppe Patt, Cindy L Grines

Journal of American Cardiology – JACC White Paper

Vol. 54, No 2 2009

Policy and Procedure

Anticoagulation Clinic Policy and Procedure # 19

TITLE: Antiplatelet Risk Assessment ReviewImplemented: 2/1/09

POLICY: It is the policy of Wenatchee Valley Hospital (WVH) and Wenatchee Valley Medical Center (WVMC) that the Anticoagulation Clinic will require a physician to review the risk vs benefit of concurrent antiplatelet and warfarin therapy on every patient known to be taking antiplatelet medications. It is known that the bleeding risk is increased significantly with the concurrent use of antiplatelet and warfarin therapy.

DAWN Tool – List ViewIdentify all Referring MDs

List View

Patients By Referring MDActive Treatment Plans

ACC Location Diagnosis

DAWN Tool - Drug Tab Documents Aspirin Use

Reconciled Patient Profile with DAWN Drug Tab

DAWN Tool - Report Identify Patients on ASA

DAWN Tool - Treatment Plan Summary Risks: Antiplatelet Therapy

DAWN Tool –ReviewsTrack When Antiplatelet Risk Assessment is Due

Annual Reviews

Interval Set at

365 Days

Antiplatelet Risk Assessment

Next Review Date Set at Today's Date

DAWN Tool – ReviewsTracks Required Antiplatelet Assessment

ANNUAL REQUIREMENTS

Overdue Case Manager Date Range

Annual Review

Antiplatelet Risk

DAWN Tool - LIST VIEW

DAWN Tool - List View Identifies Patients with Review Due

DAWN Tool – Letters

Letters

Patients Referring MD

Purpose of Annual Labs

SAFETY

Prevention and Treatment of Epistaxis

Fall Prevention

Annual Update of Treatment Plan

Antiplatelet Risk Assessment

DAWN Tool - Letters Antiplatelet Assessment Letter to MD

DAWN Tool – LettersAntiplatelet Risk Assessment Documented Letter was

sent

Documents physician order

Documents case manager noted order

Scanned into Documents in DAWN

DAWN Tool - Documents Records MD Review

DAWN Tool - Coded Comment Documents in Progress Note and Time Saver

.so = SOAP Format Progress Note

Antiplatelet Therapy

On ASA No ASA

.asl = Aspirin 81mgdaily

.ash = Aspirin325mg daily

.no = None

Challenges Identified

Multiple ACC locations Email for all staff Story boards One EMR DAWN AC

Physicians Journal articles Communication with medical director Lunch

Risk/benefit very individual

More Challenges

Increase staff use of List Views List View Filters Filter defaults to Overdue

Increase case manager involvement Production reports Reminders

Accurate documentation

Discontinue ASA

ASPIRIN

Discontinue Continue

Delete ReviewReset Review

365 Days

Scan Assessment Letter into Documents

Scan Assessment Letter into Documents

Delete RiskAntiplatelet Therapy

Case Manager Cosigns

Assessment Letter

Case Manager Cosigns

Assessment Letter

Confirm with Patient

Confirm with Patient

Discontinue in EMR

Goal: # 2

95% of ACC patients will have either completed ACC required annual lab tests (hematocrit, fecal occult blood and urine dipstick analysis) or have documentation of refusal. Refusal was addressed by the case manager and communicated to the referring physician or PCP.

DAWN Tool -Reviews Tracks Annual Required Labs

ANNUAL REQUIREMENTS

Overdue Case Manager Date Range

Annual Review

FOB

UA

Hct

LIST VIEW – Annual Required Lab Tests

DAWN Tool – List ViewAnnual Requirements - Overdue Labs

Barriers Identified

Non compliant patients

Patients did not understand importance and purpose of annual labs

Busy practices

DAWN Tool - Letters Annual Labs Letter to Educate Patient

Patient Letter

The goal of the Anticoagulation Clinic is to prevent any thromboembolic (strokes, deep vein thrombosis, or pulmonary embolism) and/or bleeding events by carefully monitoring the warfarin level and by periodically checking urine, blood and stool for signs of hidden bleeding

There are three lab tests that are required by the Anticoagulation Clinic. 1) Hematocrit ( the percentage of red blood cells found in the serum) is done to

check for anemia which could be a sign of bleeding. 2) Urinalysis which tests your urine specimen for visible and microscopic blood. 3) Fecal Occult Blood which tests your stool specimens for blood which is not

always visible. This is also an important screening test to detect colon cancer.Since the primary adverse effect of warfarin is bleeding, our goal is also to detect

bleeding early enough to avoid complications. These lab tests can possibly show signs of bleeding before you feel any symptoms. Any abnormal test results will be immediately forwarded to your primary care provider.

When we ask you to obtain these labs please realize our intention is to keep you

safe and healthy.

DAWN Tool – RemindersAssists Case Manager

List View - Reminders

DAWN Tool - User ProfileFacilitates Staff in Assisting Each Other

Ancillary Staff given access to other organizations List View

1. Check CMR to see if labs completed by another provider

2. Make lab slips ahead of appointment times

3. Phone Reminders

Progress – ASA Use

Antiplatelet Risk Assessment

0

50

100

150

200

250

300

350

400

450

500

March J une August

2009

ASA in DRUG tab On ASA Total Discontinued

Progress – Overdue Annual Labs

Total Overdue Labs

Al l Locations

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Active Enrollment February March April May J uly August

DAWN AC Facilitates Consistancy

PROCEDURESPROCEDURES

METRICSMETRICS

DOCUMENTATIONDOCUMENTATION

PATIENTEDUCATION

PATIENTEDUCATION

CONSISTANTCONSISTANT

CommunicateMultiple

Locations

Problem Solving

MeasuringProgress

Documentation

Communication With

Referring MD

Educating Patients

Obtaining Metrics

Identifying Patients

FACILITATES

DAWN AC