Massachusetts General Hospital Anticoagulation Management Service

1. Massachusetts General HospitalAnticoagulation Management Service Lynn B. Oertel, MS, ANP, CACP Clinical Nurse Specialist Presented November 4, 2008

2. Timeline of ATU/AMS

3. 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 anticoagulation therapy New http://www.jointcommission.org/

4. 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

5. 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 anti-thrombotic (anticoagulation) services that facilitate coordinated care management. http://www.qualityforum.org/

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

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

8. The Joint Commission Sentinel Alert – Sept 24, 2008 http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/

10. 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) Discharges: ~ 90/month Clinic overview

11. Time in Therapeutic Range • TTR calculated using Rosendaal method • Strict range limits, eg. 2 – 3 and 2.5 – 3.5 • Using ALL INR data (induction, interruptions, etc)

12. 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%

13. Communication and Education for Patients and Physicians

14. Key elements for improvedpatient management • Patient focused, primary nurse model • Physician Order Entry for AMS Consult Referral(nearly all data fields mandatory for submission, thus all critical info received) • Dawn AC(patient management system for maintenance and transition patients) • 3 Interfaces: • ADT Interface(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)

15. AMS Communication with Patients • 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 mailedwith same information. Dose info communicated via # pills – not mg.(finalizing plans to initiate email communications, when desired by patient) • Telephone assessments more common than face-to-face visits • Communication interventions are individualized to meet patient needs over time

16. Patient Satisfaction • “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.”

17. Nursing Implications for Anticoagulated Patients Achieving good outcomes is dependent upon: • 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

18. AMS Patient Education Slide ShowStandardized education curriculum content, individualized for patient-specific needs

19. Written materials support contentof slide show AMS Brochure

20. 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

21. 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

22. 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) Then, follow weekly dose instruction here

23. Compliance Process • 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

25. Reminder Letter for missed INR date Dedicated line for calls This information needed or email same information Auto-reschedule of INR Date

26. AMS Icon • 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

27. AMS icon … CAS, LMR and OnCall Phase II AMS Icon COMING NOVEMBER 7

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

29. AMS Consult Referral

30. AMS Consult Referral

31. Outpatient  Paper AMS Referral

32. Induction Pathways New Start – Warfarin Only New Start – Warfarin with LMWH New Start – Warfarin with Fondaparinux Bridging Pathways Resume – Warfarin Only Resume – Warfarin with LMWH Resume – Warfarin with Fondaparinux TransitionPathway Services

33. Communication Strategies Transition Pathways • Floor by floor roll-out • Multi-disciplinary approach (medicine, nursing, pharmacy, case management, target key leaders): • Grand rounds • Inservice education sessions • Print materials (newsletters) • Main Corridor events • Electronic resources • 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

34. Role Group Responsibilities Referring Physician Complete referral Order baseline lab work Submit AMS Rx AMS Nurse Reviews/confirms eligibility and seeks clarification, as needed “Meets and Greets” patient Written instructions for pt. Assumes anticoag management day after discharge Floor Nurse Obtain patient weight Conduct medication discharge teaching Completes discharge process and ensures patient leaves hospital with meds and instructions Case Management/ VNAs May/may not be involved Coordinates needs/services at home • Pharmacy • Delivers AMS Rx to floor

35. E-Z Guide

36. Resources • 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/SentinelEventAlert/ • Nursing Model for Anticoagulation Service –http://innovativecaremodels.com/

37. 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.