Division of Hospital Medicine

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Presentation transcript:

Division of Hospital Medicine Improving Handoffs of Patients taking Warfarin From UNMH Internal Medicine Teams to SNFs Percy Pentecost Division of Hospital Medicine UNMH

Goals : Make a case for this being a problem Map the process of Coumadin handoffs between the IM ward teams and SNFs Suggest 3 easy interventions Minimize additional work Not trying to: Be funnier than Lenny Change system “in one stroke”

Warfarin History Professor Karl Paul Link of U of W in Madison 1933: Farmer presents with dying cows Related to clover hay the cows were eating? Container of un-coagulated blood BIB farmer Anti-coagulant isolated from feed in 1941 WARFARIN patented as rat poison WARF = Wisconsin Alumni Research Foundation (Coumadin is the medication for humans)

Case Presentation November 2011: 88 year old Male with severe CHF, on Coumadin is admitted to UNMH with high INR after multiple falls at home He is discharged to SNF with plan to restart Coumadin with Lovenox bridging February 2011: Patient is readmitted with de-compensated CHF and INR = 9 Much confusion about plan for Coumadin (Notes contradictory) Patient dies on comfort care at UNMH

Pubmed Literature Search “Hand off” and “Skilled Nursing Facility”: 0 results “Transitions of Care” and “Skilled Nursing Facility”: 41 results “Transitions of Care” and “Long Term Care Facility”: 1 result “Warfarin “ and “Long Term Care Facility”: 13 results “Warfarin” and “Skilled Nursing Facility”: 5 results 0 of 60 Results relevant

Rush Pierce Search The Joint Commission Journal on Quality and Patient Safety (8/2008) “Deficits in Discharge Documentation in Patients Transferred to Rehab Facilities on Anticoagulation: Results of a Systemwide Evaluation” Treatment or prophylaxis for thromboembolic disease 5 acute care hospitals  30 sub-acute care facilities Boston; March 2005—June 2007 342 patients on Coumadin 16% of Coumadin patients with all required information in DC summary

Data from Albuquerque SNFs 12 SNFs in Albuquerque area 9 responses 3 Questions % of skilled pts come from UNMH? % of UNMH pts admitted on Coumadin? % time there is clear communication about Coumadin plan?

Data from Albuquerque SNFs

Data from Albuquerque SNFs

Data from Albuquerque SNFs

Process Map for Communication of Warfarin information to SNF Patient taking Warfarin in UNMH Anticoagulation Team (AT) Finds out patient to go to SNF No clear process for this Anticoagulation Team tries to identify SNF where pt will be going AT looks through EHR (CM notes mostly) to identify destination AT faxes notes and data sheet to SNF Uses available fax number No recipient identified Phone Number for calls with questions included in fax bolus

Process Map for Communication of Warfarin information to SNF Patient taking Warfarin in UNMH Anticoagulation Team (AT) Finds out patient to go to SNF No clear process for this Anticoagulation Team tries to identify SNF where pt will be going AT looks through EHR (CM notes mostly) to identify destination AT faxes notes and data sheet to SNF Uses available fax number No recipient identified Phone Number for calls with questions included in fax bolus

Anticoagulation Team’s Documents

Process Map for Communication of Warfarin information to SNF Patient taking Warfarin in UNMH Anticoagulation Team (AT) Finds out patient to go to SNF No clear process for this AT tries to identify SNF where pt will be going A T looks through EHR (CM notes mostly) to identify destination AT faxes notes and data sheet to SNF Uses available fax number No recipient identified Phone Number for calls with questions included in fax bolus

Recommendations : SNF order set to include Anticoagulation Team phone number Via drop down box for Coumadin patients To be used as starting point for SNF questions To be called 9 am--5 pm 7 days per week Names of destination SNFs in EHR—Redundantly DC Summaries DC Instructions Progress Notes (CM notes and provider notes) Coumadin data to be faxed to the attention of the DON at SNFs PP to provide this information on Wiki and update q 6 months

Add Anticoagulation Team’s phone number to SNF orders Drop down box “For questions about this patient’s UNMH Coumadin history, call 505-264-6970 between 9:00 A.M. and 5:00 P.M. 7 days a week.”

Questions? Here’s one: How does this song relate to Warfarin?