Transcript Facilitating optimal discharge plans for high risk

Massachusetts General Hospital
Anticoagulation Management Service
Lynn B. Oertel, MS, ANP, CACP
Clinical Nurse Specialist
Presented November 4, 2008
Timeline of ATU/AMS
2008 NPSG
(selected)
1 - Improve accuracy of patient
identification
2 - Improve the effectiveness of
communication among caregivers
3 - Improve safety of using medications
Requirement 3E: Reduce the likelihood of
patient harm associated with the use of
New
anticoagulation therapy
http://www.jointcommission.org/
2008 NPSG (selected)
8 - Accurately and completely reconcile
medications across the continuum of
care
9 - Reduce the risk of patient harm
resulting from falls
13 - Encourage patients’ active involvement
in their own care as a patient safety
strategy
15 - The organization identifies safety risks
inherent in its patient population
NQF Safety Standards
Safe Practice 17: Evaluate each patient upon
admission, and regularly thereafter, for the
risk of developing DVT/VTE. Utilize clinically
appropriate methods to prevent DVT/VTE.
Safe Practice 18: Utilize dedicated antithrombotic (anticoagulation) services that
facilitate coordinated care management.
http://www.qualityforum.org/
Goal is to reduce incidence of surgical
complications nationwide by 25% by 2010
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SCIP VTE1 – Surgery patients with recommended
VTE prophylaxis ordered
SCIP VTE2 – Surgery patients who received VTE
prophylaxis within 24 hours after surgery
www.qualitynet.org, see Other Resource: About the Project
OSG Call to Action – Sept 15, 2008
http://www.surgeongeneral.gov/
The Joint Commission Sentinel Alert –
Sept 24, 2008
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/
Clinic overview
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Patients = 4100+
Mean age = 69 yrs, SD
13.65, range 20 - 100
Common indications
for treatment:
• AF  57%
• VTE  15%
• Heart Valves  9%

INR intensity ranges
• 2 – 3  87%
• 2.5 – 3.5  9%
• By request, selected
others

Admissions:
• ~75/month
• + Reactivated patients
• ~ 60% new referrals
from inpatient (POE
Consult referral)
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Discharges:
• ~ 90/month
Time in Therapeutic Range
INR Range 2 - 3

70
69
68
Jan
Feb
mar
Apr
May
June
percent
69.1
68.8
69.3
69.3
70.2
69.7
INRs
7206
6423
6634
7150
6973
6864
7400
7200
7000
6800
6600
6400
6200
6000
# INRs
percent TTR
71
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percent TTR
65
60
55
Jan
Feb
mar
Apr
May
June
percent
64.4
62.5
63.7
59.6
59.4
58.8
INRs
902
834
847
914
877
867
920
900
880
860
840
820
800
780
# INRs
INR Range 2.5 - 3.5
TTR calculated using
Rosendaal method
Strict range limits,
eg. 2 – 3 and 2.5 –
3.5
Using ALL INR data
(induction,
interruptions, etc)
Percent INR tests out-of-range
In Range (2 – 3) = 60%
Above 3 = 15%
Below 2 = 25%
Percent Very High…
≥5
=
0.8%
≥ 7.5 = 0.2%
Percent Very Low…
≤ 1.3 = 0.3%
Communication and Education
for Patients and Physicians
Key elements for improved
patient management

Patient focused, primary nurse model
Physician Order Entry for AMS Consult Referral
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Dawn AC
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3 Interfaces:

(nearly all data fields mandatory for submission, thus all critical
info received)
(patient management system for maintenance and
transition patients)
• ADT Interface
•
•
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(electronic notification for AMS patient
admissions/discharges)
Outbound message Interface (AMS icon/communication
facilitator)
Results Interface (electronic INR entry into Dawn AC from lab
system)
Hospital “buy in”
• Information System support (2 FTEs)
• Pharmacy support (AMS Discharge Rx)
AMS Communication with Patients
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One-time face-to-face educational visit with patient
& family and primary nurse
Followed by telephone calls to patient for short
period to review subsequent INR values, current
dose instructions, and date of next INR
Thereafter, written instructions are mailed with
same information. Dose info communicated via #
pills – not mg. (finalizing plans to initiate email
communications, when desired by patient)

Telephone assessments more common than faceto-face visits

Communication interventions are individualized to
meet patient needs over time
Patient Satisfaction
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“My ranking of this program: First Class Service.”
“The anti-coag service is great. I go to Florida 3
months during the winter months and I am able
to keep track of dosages and INR levels easily.
My daughter calls in for me and lets me know if
there are any changes in dosage to be made.”
“I have nothing but praise and appreciation for
the concern and care over the years.”
“Knowing your clinic keeps a very close check on
my Coumadin levels gives me a sense of security.
Your reporting is prompt and directions clearly
stated.”
Nursing Implications for
Anticoagulated Patients
Achieving good outcomes is dependent upon:
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Knowledge of patient risk v. benefit of
treatment
Safe and quality care management  Know
goal therapeutic INR range and treatment
plan. Utilize systematic, standardized
protocols and decision support tools.
Monitoring Tracking and patient follow-up
Effective communication and coordination of
multiple care providers
Patient & Family Education, include health
literacy assessment, modification of risks,
standardize curriculum & education materials
AMS Patient Education Slide Show
Standardized education curriculum content,
individualized for patient-specific needs
Written materials support content
of slide show
AMS
Brochure
Patient Education
To prepare for discharge, can patient …
• Identify signs and symptoms of VTE (or
bleeding)
• Describe action to take if occurs
• Identify ‘warfarin manager’
• Recite instructions for follow-up including: daily
dose schedule, confirmation of pill size, date of
next INR
• Describe plans for blood testing and future
monitoring
• Describe management and disposal of
medications, especially sharps disposal per town
regulations
Dose Instruction Letter
1. INR result and
Target Range
2. Reminder of
pill size
3. New weekly dose
instructions (repeat
schedule until next dose
letter arrives)
4. Date for
next INR test
Dose Instruction with skip
If INR is high…
…may see a message to skip
1 or 2 days (patients generally
rec’d a phone call at the time)
Compliance Process
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Automated follow-up support by Dawn AC, details
developed by AMS
Five Stages – a letter mailed to patients at each
stage underscoring safety concerns
• Formal discharge letter sent with delivery confirmation

Collaboration with referring physicians (possibly
case management) at critical milestones
• Emailed formal notices at Final and Discharge Stages

Customized letters/emails in Dawn AC
• Highly efficient
• Batch printed or emailed
• Excellent documentation trail
NonCompliance Process
INR rescheduled in…
DNA Stage
I
2
3
Final
Discharge
Notice
if no INR 3 DAYS after
scheduled date,
then next INR in….
2 weeks
if no INR 1 DAY after
scheduled date,
then next INR in …
1 week
if no INR 1 DAY after
scheduled date,
then next INR in …
MD Email
√
1 week
if no INR 1 DAY after
scheduled date,
then next INR in …
1 week
sent via Certified Mail
Patient Discharged
(DNA = Did Not Attend)
RN Reminder
√
√
√
Reminder Letter for missed INR date
Dedicated
line for calls
This
information
needed
Autoreschedule
of INR Date
AMS Icon
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Indicates patient is an active patient in
AMS
Appears on electronic medical records (1
in-patient, 2 out-patient systems)
Click on icon, new window displays critical
data elements about the patient from AMS
database
AMS icon … CAS, LMR and OnCall
Phase II AMS Icon
COMING NOVEMBER 7
CPOE 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 Referral
AMS Consult Referral
Outpatient  Paper AMS Referral
Transition Pathway Services
Induction Pathways
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New Start – Warfarin
Only
New Start – Warfarin
with LMWH
New Start – Warfarin
with Fondaparinux
Bridging Pathways
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Resume – Warfarin
Only
Resume – Warfarin
with LMWH
Resume – Warfarin
with Fondaparinux
Communication Strategies
Transition Pathways
• Floor by floor roll-out
• Multi-disciplinary approach (medicine, nursing,
pharmacy, case management, target key
leaders):
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Grand rounds
Inservice education sessions
Print materials (newsletters)
Main Corridor events
• Electronic resources
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POE
CAS alerts
All user (select user group) Broadcast email
messages
Web page presence with multi-source access to key
anticoag-specific documents via hyperlinks
Role Group Responsibilities
AMS Nurse
Referring Physician
Complete referral
Order baseline lab work
Submit AMS Rx
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Floor Nurse
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Obtain patient weight
Conduct medication
discharge teaching
Completes discharge
process and ensures
patient leaves hospital
with meds and
instructions
Reviews/confirms eligibility
and seeks clarification, as
needed
“Meets and Greets” patient
Written instructions for pt.
Assumes anticoag
management day after
discharge
Pharmacy
 Delivers AMS Rx to floor
Case Management/ VNAs
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May/may not be involved
Coordinates
needs/services at home
E-Z Guide
Resources
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Your Guide to Coumadin/Warfarin Therapy –
Agency for Healthcare Research and Quality,
http://www.ahrq.gov/consumer/coumadin.htm
Important information to know when you are
taking: Coumadin and Vitamin K http://ods.od.nih.gov/factsheets/cc/coumadin1.pdf
Are you at risk for a DVT Blood Clot http://www.preventdvt.org/
OSG Call to Action, Sept 15, 2008 http://www.surgeongeneral.gov/
The Joint Commission Sentinel Alert, Sept 24,
2008 http://www.jointcommission.org/SentinelEvents/S
entinelEventAlert/
Nursing Model for Anticoagulation Service –
http://innovativecaremodels.com/
Conclusion

Collaborative communication strategies
across disciplines are needed to support
and reinforce the patient’s treatment plan.

Patient education about prevention,
disease process and treatment is vital for
successful outcomes. Detailed written
reinforcements are critical elements.