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 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

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 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 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.

Goal is to reduce incidence of surgical complications nationwide by 25% by 2010 SCIP VTE1 – Surgery patients with recommended VTE prophylaxis ordered SCIP VTE1 – Surgery patients with recommended VTE prophylaxis ordered SCIP VTE2 – Surgery patients who received VTE prophylaxis within 24 hours after surgery SCIP VTE2 – Surgery patients who received VTE prophylaxis within 24 hours after surgery see Other Resource: About the Project

OSG Call to Action – Sept 15,

The Joint Commission Sentinel Alert – Sept 24,

Clinic overview Patients = Patients = Mean age = 69 yrs, SD 13.65, range Mean age = 69 yrs, SD 13.65, range Common indications for treatment: Common indications for treatment: AF 57%AF 57% VTE 15%VTE 15% Heart Valves 9%Heart Valves 9% INR intensity ranges INR intensity ranges 2 – 3 87%2 – 3 87% 2.5 – 3.5 9%2.5 – 3.5 9% By request, selected othersBy request, selected others Admissions: Admissions: ~75/month + Reactivated patients ~ 60% new referrals from inpatient (POE Consult referral) Discharges: Discharges: ~ 90/month

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

Percent INR tests out-of-range 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 for Patients and Physicians

Key elements for improved patient management Patient focused, primary nurse model Patient focused, primary nurse model Physician Order Entry for AMS Consult Referral (nearly all data fields mandatory for submission, thus all critical info received) 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) Dawn AC (patient management system for maintenance and transition patients) 3 Interfaces: 3 Interfaces: ADT Interface (electronic notification for AMS patient admissions/discharges)ADT Interface (electronic notification for AMS patient admissions/discharges) Outbound message Interface (AMS icon/communication facilitator)Outbound message Interface (AMS icon/communication facilitator) Results Interface (electronic INR entry into Dawn AC from lab system)Results Interface (electronic INR entry into Dawn AC from lab 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 Patients One-time face-to-face educational visit with patient & family and primary nurse 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 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 communications, when desired by patient) Thereafter, written instructions are mailed with same information. Dose info communicated via # pills – not mg. (finalizing plans to initiate communications, when desired by patient) Telephone assessments more common than face- to-face visits Telephone assessments more common than face- to-face visits Communication interventions are individualized to meet patient needs over time Communication interventions are individualized to meet patient needs over time

Patient 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 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. 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. 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. 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 Knowledge of patient risk v. benefit of treatment 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. 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 Monitoring Tracking and patient follow-up Effective communication and coordination of multiple care providers Effective communication and coordination of multiple care providers Patient & Family Education, include health literacy assessment, modification of risks, standardize curriculum & education materials Patient & Family Education, include health literacy assessment, modification of risks, standardize curriculum & education materials Achieving good outcomes is dependent upon:

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)Identify signs and symptoms of VTE (or bleeding) Describe action to take if occursDescribe action to take if occurs Identify warfarin managerIdentify warfarin manager Recite instructions for follow-up including: daily dose schedule, confirmation of pill size, date of next INRRecite instructions for follow-up including: daily dose schedule, confirmation of pill size, date of next INR Describe plans for blood testing and future monitoringDescribe plans for blood testing and future monitoring Describe management and disposal of medications, especially sharps disposal per town regulationsDescribe management and disposal of medications, especially sharps disposal per town regulations

2. Reminder of pill size Dose Instruction Letter 1. INR result and Target Range 3. New weekly dose instructions (repeat schedule until next dose letter arrives) 4. Date for next INR test

…may see a message to skip 1 or 2 days (patients generally recd a phone call at the time) Dose Instruction with skip If INR is high… Then, follow weekly dose instruction here

Compliance Process Automated follow-up support by Dawn AC, details developed by AMS Automated follow-up support by Dawn AC, details developed by AMS Five Stages – a letter mailed to patients at each stage underscoring safety concerns Five Stages – a letter mailed to patients at each stage underscoring safety concerns Formal discharge letter sent with delivery confirmationFormal discharge letter sent with delivery confirmation Collaboration with referring physicians (possibly case management) at critical milestones Collaboration with referring physicians (possibly case management) at critical milestones ed formal notices at Final and Discharge Stages ed formal notices at Final and Discharge Stages Customized letters/ s in Dawn AC Customized letters/ s in Dawn AC Highly efficientHighly efficient Batch printed or edBatch printed or ed Excellent documentation trailExcellent documentation trail

NonCompliance Process DNA StageINR rescheduled in…RN ReminderMD I if no INR 3 DAYS after scheduled date, then next INR in….2 weeks 2 if no INR 1 DAY after scheduled date, then next INR in …1 week 3 if no INR 1 DAY after scheduled date, then next INR in …1 week Final if no INR 1 DAY after scheduled date, then next INR in … 1 week Discharge Notice sent via Certified Mail Patient Discharged (DNA = Did Not Attend)

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

AMS Icon Indicates patient is an active patient in AMS Indicates patient is an active patient in AMS Appears on electronic medical records (1 in-patient, 2 out-patient systems) 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 Click on icon, new window displays critical data elements about the patient from AMS database

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

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

Outpatient Paper AMS Referral

Transition Pathway Services Induction Pathways New Start – Warfarin Only New Start – Warfarin Only New Start – Warfarin with LMWH New Start – Warfarin with LMWH New Start – Warfarin with Fondaparinux New Start – Warfarin with Fondaparinux Bridging Pathways Resume – Warfarin Only Resume – Warfarin Only Resume – Warfarin with LMWH Resume – Warfarin with LMWH Resume – Warfarin with Fondaparinux Resume – Warfarin with Fondaparinux

Communication Strategies Transition Pathways Floor by floor roll-outFloor by floor roll-out Multi-disciplinary approach (medicine, nursing, pharmacy, case management, target key leaders):Multi-disciplinary approach (medicine, nursing, pharmacy, case management, target key leaders): Grand rounds Grand rounds Inservice education sessions Inservice education sessions Print materials (newsletters) Print materials (newsletters) Main Corridor events Main Corridor events Electronic resourcesElectronic resources POE POE CAS alerts CAS alerts All user (select user group) Broadcast messages All user (select user group) Broadcast messages Web page presence with multi-source access to key anticoag-specific documents via hyperlinks Web page presence with multi-source access to key anticoag-specific documents via hyperlinks

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

E-Z Guide

Resources Your Guide to Coumadin/Warfarin Therapy – Agency for Healthcare Research and Quality, Your Guide to Coumadin/Warfarin Therapy – Agency for Healthcare Research and Quality, Important information to know when you are taking: Coumadin and Vitamin K - Important information to know when you are taking: Coumadin and Vitamin K - Are you at risk for a DVT Blood Clot - Are you at risk for a DVT Blood Clot - OSG Call to Action, Sept 15, OSG Call to Action, Sept 15, The Joint Commission Sentinel Alert, Sept 24, entinelEventAlert/ The Joint Commission Sentinel Alert, Sept 24, entinelEventAlert/ Nursing Model for Anticoagulation Service – Nursing Model for Anticoagulation Service –

Conclusion Collaborative communication strategies across disciplines are needed to support and reinforce the patients treatment plan. Collaborative communication strategies across disciplines are needed to support and reinforce the patients treatment plan. Patient education about prevention, disease process and treatment is vital for successful outcomes. Detailed written reinforcements are critical elements. Patient education about prevention, disease process and treatment is vital for successful outcomes. Detailed written reinforcements are critical elements.