Increase the Safety of Warfarin Therapy in the Ambulatory Setting

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Increase the Safety of Warfarin Therapy in the
Ambulatory Setting

• Patient Safety, Satisfaction Revenue

Stephanie Dougherty, RN, BSN Patient Safety
Fellow Virginia Commonwealth University VIPCS
May 15, 2003
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History and Background

• 176 bed hospital with 12 Ambulatory Practices
  and 145 physicians participating in Integrated
  Delivery System
• Coumadin - one of the top 10 most dangerous drugs
  in the ambulatory setting. Literature states
  combination bleeding and embolic events runs 2-
  20 in traditional office based management
• Adverse Event lets Speak the Truth

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Half Full Theory
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Objectives

• a.. Create a culture in ambulatory care of
  patient safety based on open communication and
  human factor concepts
• b.. Implement an evidence based, systems based,
  patient centered framework to decrease variation
  in the management of Warfarin therapy in the
  ambulatory setting

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Objectives

• c.. Increase patient education, awareness, and
  patient participation in managing healthcare
  safety
• d.. Implement use of Pont-Of-Care INR testing
  equipment in ambulatory setting to decrease turn
  around time and increase patient/staff
  satisfaction

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Begin

• Pilot patient safety project at two hospital
  owned Ambulatory practices
• Began November to create the new process
• Conducted Failure Analysis - Flow Diagram or
• What are we currently doing?

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Flow Diagram
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DATA

• How are we managing our patient education?
• What best practice algorithm are we using?
• Is everyone doing the same thing - well?
• ( reference slide re data collection pre
  implementation)

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What We Found

• Found the following
• Small Snapshot Sample of charts reviewed
• Only 13 were in target range 80 of the time
• Use of a basic algorithm only at one practice
  site- large amount of variation
• Interaction with patient usually a lab draw by
  nurse or technician did not have a Coumadin
  focused assessment by nurse or physician

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What We Found

• PT/INR results arrive 1-2 days after patient
  visit
• Physicians review stack of charts a the end of
  the day for medication orders
• Needed standard for patient assessment each visit
• Needed standardized education for patients or
  staff - not sure of hospital based patient
  education is remembered

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What We Found

• Nurse time not billed
• Physician time not billed
• Heavy reliance on memory
• Many steps in the process

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Culture and Patient Safety Concepts

• Cultivate Patient Safety Thinking- initiate
  culture change- understand basics of error and
  why changes to Coumadin management need to be
  accomplished-story telling
• Remove blame
• Look for roots of error in system- fatigue,
  memory, vigilance, production pressure

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Look Familiar?
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Human Factors Evaluation

• Evaluated the intrinsic properties and
  constraints of the current system
• Noise, interruptions, vigilance, increased
  reliance on memory
• Cognitive factors stress, workload, fatigue
• Communication between staff
• Staff Training

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Goals from Objectives

• Decrease reliance on memory- patient, nurse ,
  physician,
• Decrease variation in assessment , dosing,
  education, use of pharmacies
• Minimize workspace management-streamline process,
  use evidence based medical tools
• Add Specific Color to the Coumadin Management
  Tools recognition easier than recall

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Goals from Objectives

• Increase patient participation and education-
  Patient becomes partner in co managing Coumadin
  treatment
• Eliminate 1-3 three day wait for PT/INR
  Laboratory results
• Immediate results with Point of Care technology
  testing equipment (CoaguCheck)

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KEEP IT SIMPLE

• Real Relevant - Simple- and Fun (Gosbee)
• Develop healthy respect for latent error in any
  new system, process or design
• Training to Anticipate error- Error will emerge!!
• ( so ..look for it!)

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Obstacles to Patient Learning

• Difficulty comprehending
• Memory( heavy reliance on)
• Rushed
• Minimal connection with concept of personal
  responsibility for monitoring diet, exercise,
  travel, communication re doses missed, illness
  or activity, and concommitant medications

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Perceived Obstacles to change at the sites

• Things are ok here
• This is too much paperwork
• Not another program
• What do you mean Patient Safety- were safe!
• The doctors will never go for this
• The patients wont like it
• We are doing too much already

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Overcome perception of Change
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BEST PRACTICE

• Process Tools
• Algorithm
• Patient education and increased understanding of
  responsibility
• Initial Nursing Assessment and Coumadin Visit
  Assessment- drives the discussion re relevant
  questions on diet, lifestyles, medications over
  the counter medications, herbs, activity, illness

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Tools

• Evidence Based Algorithm
• Anticoagulation Log
• Visit Assessment
• Follow-up Appointment
• Pont-of- Care INR Testing

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Tools to Decrease reliance on MEMORY and
Facilitate Education

• TOOLS (see your handouts for copies)
• Announcement to Patients Let the patients (and
  staff!) know there is a change a coming - new
  Point of Care Testing and Benefits
• Blood for the lab tests is obtained via finger
  stick - No more venipuncture
• Test results are available within minutes No
  more waiting days for results

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Tools continued

• Immediate adjustment of drug dosage, if needed
  No more delay in appropriate therapy and a
  decreased risk of complications
• Frequent interaction with our healthcare
  professionals, which results in better control of
  therapy and increased opportunity to discuss your
  treatment or education needs

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Tools- Announcement

• Announcement- handed out in the lab draw area 3-4
  weeks before the first patient starts on the new
  INR Point of Care Testing/Education
• Generated interest and excitement for the
  changes

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Tools..

• Initial Assessment - leads discussion with
  patient relative to Coumadin and issues of
  concern
• The Language we use through each piece
  REINFORCES learning about Coumadin and
  precatutions

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Tools..

• Patient Responsibility discussion and contract
• Education checklist matching the patient Guide to
  using Coumadin pamphlet from Bristol-Myers, Squib
  guides the nurse and patient education-
  eliminates reliance on memory (see handouts)
• The education process reinforces learning about
  Coumadin management for the Patient AND the Staff

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Point of Care Testing

• Eliminates call back time immediate results to
  patient, nurse and physician
• Engaged practitioners in discussion on memory,
  vigilance, pace, interruptions

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Point of Care testing

• Our choice - CoaguChek S System ( Roche
  Diagnostics- www.coaguchek.com)
• Human factors designed with multiple benign
  failure modes - Designed to minimize human error
  
• CLIA waived
• A test system not impacted by lot to lot
  reagent variability thereby minimizes the chances
  of clinically significant changes in test
  results.

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Education to change culture

• Incident - literature review root cause
  analysis results
• All Staff Educated on Anticoagulation Management
  via American Heart Association- Management of
  Oral Anticoagulation Therapy
• (www.acforum.org)

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National Quality Forum

• National Quality Forum- Patient Safety activity
• Increase safety of anticoagulation management is
  applicable to ambulatory setting.
• A recommended safe practice is to utilize
  dedicated anticoagulation services that
  facilitate coordinated care management services

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NQF

• Examples of implementation
• Staff Experienced in monitoring anticoagulation
  therapy
• Reliable patient scheduling and tracking
• Accessible, accurate and frequent prothrombin
  time (PT)/ Independent Normalized Ration (INR)
• Patient Specific decision support and interaction
• Ongoing patient education

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Narrow the holes of Swiss Cheese

• Use of appropriate Technology
• Improved clinician knowledge and error awareness
• Continuous improvement
• Evidenced based Medicine for the Anticoagulation
  Algorithm

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New Improved Process

• Dramatic increase in patient satisfaction
• More personal time between nurse and patient
  better education and relationship
• Patient ownership of Coumadin self management

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How much is this going to cost?
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Financial AnalysisTotal Number of Tests
Practice Tests / Week Annual Tests PBFHC 15 78
0 DVFHC 15 780 RFHC 15 780 CFHC
10 520 Total 55 2,860
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Financial AnalysisMedicare Reimbursement

• Outside Laboratory
• Annual Tests 2,860
• Venipuncture 8,580
• Annual Revenue 8,580

• INR Testing
• Annual Tests 2,860
• Nurse Visits 67,524.60
• INR Tests 15,701.40
• Annual Revenue 83,226

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Financial AnalysisSupply Costs

• Outside Laboratory
• Annual Tests 2,860
• Venipuncture Supplies 0.22
• Annual Supply Costs 629

• POC INR Testing
• Annual Tests 2,860
• Strips 14,128.40
• Control Costs 1,086.80
• Lancets 572
• Annual Supply Costs 15,787

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Financial AnalysisNursing Costs

• Outside Laboratory
• Annual Tests 2,860
• Time Cost (20 min. per test) 943.80
• Annual Nursing Time 944 hrs.
• Salary w/ Benefits per hr. 22.32
• Annual Nursing Costs 21,066

• INR Testing
• Annual Tests 2,860
• Time Cost (15 min. per test) 715
• Annual Nursing Time 715 hrs.
• Salary w/ Benefits per hr. 22.32
• Annual Nursing Costs 15,959

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Financial AnalysisTotal Annual Expenses

• Outside Laboratory
• Supplies for
• Venipuncture 629
• Nursing Time 21,066
• TOTAL Expense 21,695

• POC- INR Testing
• Supply Costs 15,787
• Depreciation on INR machines 960
• Nursing Time 15,959
• NJ State Lab
• Compliance 460
• Increased Lab License Expense 800
• TOTAL Expense 33,966

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Financial AnalysisProfit / (Loss) Statement

• Outside Laboratory
• Annual Tests 2,860
• Revenue 8,580
• Expenses 21,066
• Only Loss 12,486

• INR Testing
• Annual Tests 2,860
• Revenue 83,226
• Expenses 33,966
• Profit 49,260

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Patient Outcomes

• Patient and Practitioners discovering
  relationships between the diets of patients with
  noted sometimes large variation in INR results
• The education and assessment time spent with
  patient- we are finding new medications added,
  missed doses, changes in level of wellness

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Patient Satisfaction

• 100 satisfaction from the Patients they were
  ASKING for the new process
• If they need to be re stuck they are saying
  its OK- go ahead. Better than the vein
• New algorithm is being used as standard among
  physicians and residents-
• Error in dosing already intercepted with the
  algorithm

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Patient Outcomes

• Patient and Nurse schedules next appointment
  before patient leaves
• Missed appointments are tracked and followed up
  promptly- there have not been any missed
  appointments with this new process for the INR
  testing and assessment

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Patient Safety continues

• Patient leaves with a copy of the new orders and
  the new appointment date
• Patients are now calling in to discuss the
  addition of new antibiotics from other MDs and
  what to do about the Coumadin dose

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Physician Satisfaction

• Physicians are seeing the time spent on the
  education and assessment of each patient and are
  pleased and impressed with the patients positive
  reaction
• This process slows down the Production devotes
  time to relationship- and is creating an
  interactive patient safety dynamic with patients
  at the center of the care

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Go Global.. Speak the Truth Softly

• Original plan was for 3 owned sites to implement
• Now up to 5 plan to offer this to all 12 owned
  practices and the 145 physicians in our
  Integrated Delivery System
• Data collection underway to capture the success
  and other opportunities for improvement

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About Patient Safety Overcome this..!!!
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Acknowledgements

• Dr.Kryzkowski- who showed us that we have an
  opportunity to improved safety
• Dr. Roksvaag, Dr, Shlimbaum, Dr. Kozakowski,
  Lawrence Grand, Claire Long and Dr. Pickoff for
  showing leadership, support and blessings
• Dr. Jacky Fein for her support in changing
  culture through education
• Patty Musselman, Mary Shurts, Betty Cronce,
  Bonnie Adaire for their belief in patient
  safety as a number one priority and who supported
  this process over all the obstacles
• Karen Swisher and Dr. Eric Silfen- for Patient
  Safety Fellowship and mentoring
• Dr. Kim Thorne- Northbay Medical Center who
  shared with us all her successful clinic tools

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• Thank you!
• Stephanie Dougherty. RN, BSN
• Patient Safety Officer- Risk Manger
• dougherty.stephanie_at_hunterdonhealthcare.org