Presentation on theme: "Using DAWN AC to Facilitate a Quality Improvement Project Wenatchee Valley Medical Center Lisa Vaughn RN CACP Clinical Manager Anticoagulation Services."— Presentation transcript:
Using DAWN AC to Facilitate a Quality Improvement Project Wenatchee Valley Medical Center Lisa Vaughn RN CACP Clinical Manager Anticoagulation Services
Current Problem Bleeding is the major complication of anticoagulation therapy. Patients on concurrent antiplatelet and warfarin therapy are 2.75 times more likely to have a clinically significant hemorrhage. Each ACC location had patients overdue for annual fecal occult blood, urinalysis and hematocrit. Poor documentation of patient counseling, non compliance with labs or to communicate with the primary care physician. No policy to address the individual patient risk/benefit of concurrent warfarin and antiplatelet therapy or to document the physicians assessment.
Process Identify goals Obtain baseline metrics Develop policy and procedure To meet current goals Establish ongoing/permanent process Educate staff, physicians and patients Developed tools in DAWN AC Identify patients Communicate with physicians Physician assessment of risk/benefit of duel therapy Document in EMR Document in DAWN AC
Project Statement / Goal: Complete assessment of risk/benefit of concurrent warfarin and aspirin therapy. Decrease the risk of major bleeding event by completing ACC required labs. Increase the revenue by completing required lab tests 1. 95% of ACC patients will have either completed ACC required annual lab tests (hematocrit, fecal occult blood and urine dipstick analysis) or have documentation of refusal. Refusal was addressed by the case manager and communicated to the referring physician or PCP % of patients on aspirin therapy will be reviewed and assessed by their physician re: the bleeding risk vs benefit of concurrent warfarin and antiplatelet therapy.
Resources Outcomes Associated With combined Antiplatelet and Anticoagulant Therapy Samuel G Johnson, Kristina robbers, Thomas Delate and Daniel M Witt Chest 2008; 133; Republished online January 15, 2008: DOI /chest Warfarin and Antiplatelet Combination Use Among Commercially Insured Patients Enrolled in an Anticoagulant Management Service Samuel G. Johnson, Daniel M. Witt, Todd R Eddy, Thomas Delate and for the Clinical Pharmac Anticoagulation Service Study Group Chest 2007; 131; DOI.1378/Chest Combining Antiplatelet and Anticoagulant Therapy David R. Holmes, Dean J. Kereiakes, Neal S. Kleiman, David Moliterno, Giuseppe Patt, Cindy L Grines Journal of American Cardiology – JACC White Paper Vol. 54, No
Policy and Procedure Anticoagulation Clinic Policy and Procedure # 19 TITLE: Antiplatelet Risk Assessment Review Implemented: 2/1/09 POLICY: It is the policy of Wenatchee Valley Hospital (WVH) and Wenatchee Valley Medical Center (WVMC) that the Anticoagulation Clinic will require a physician to review the risk vs benefit of concurrent antiplatelet and warfarin therapy on every patient known to be taking antiplatelet medications. It is known that the bleeding risk is increased significantly with the concurrent use of antiplatelet and warfarin therapy.
DAWN Tool – List View Identify all Referring MDs List View Patients By Referring MD Active Treatment Plans ACC LocationDiagnosis
DAWN Tool - Drug Tab Documents Aspirin Use
Reconciled Patient Profile with DAWN Drug Tab
DAWN Tool - Report Identify Patients on ASA
DAWN Tool - Treatment Plan Summary Risks: Antiplatelet Therapy
DAWN Tool –Reviews Track When Antiplatelet Risk Assessment is Due Annual Reviews Antiplatelet Risk Assessment Interval Set at 365 Days Next Review Date Set at Today's Date
DAWN Tool – Reviews Tracks Required Antiplatelet Assessment
ANNUAL REQUIREMENTS OverdueCase Manager Annual Review Antiplatelet Risk Date Range DAWN Tool - LIST VIEW
DAWN Tool - List View Identifies Patients with Review Due
DAWN Tool – Letters Letters Patients Purpose of Annual Labs SAFETY Prevention and Treatment of Epistaxis Fall Prevention Referring MD Annual Update of Treatment Plan Antiplatelet Risk Assessment
DAWN Tool - Letters Antiplatelet Assessment Letter to MD
DAWN Tool – Letters Antiplatelet Risk Assessment Documented Letter was sent Documents physician order Documents case manager noted order Scanned into Documents in DAWN
DAWN Tool - Documents Records MD Review
DAWN Tool - Coded Comment Documents in Progress Note and Time Saver.so = SOAP Format Progress Note Antiplatelet Therapy On ASA.asl = Aspirin 81mg daily.ash = Aspirin 325mg daily No ASA.no = None
Challenges Identified Multiple ACC locations for all staff Story boards One EMR DAWN AC Physicians Journal articles Communication with medical director Lunch Risk/benefit very individual
More Challenges Increase staff use of List Views List View Filters Filter defaults to Overdue Increase case manager involvement Production reports Reminders Accurate documentation
Discontinue ASA ASPIRIN Discontinue Delete Review Delete Risk Antiplatelet Therapy Scan Assessment Letter into Documents Case Manager Cosigns Assessment Letter Confirm with Patient Case Manager Cosigns Assessment Letter Confirm with Patient Discontinue in EMR Continue Reset Review 365 Days Scan Assessment Letter into Documents
Goal: # 2 95% of ACC patients will have either completed ACC required annual lab tests (hematocrit, fecal occult blood and urine dipstick analysis) or have documentation of refusal. Refusal was addressed by the case manager and communicated to the referring physician or PCP.
DAWN Tool -Reviews Tracks Annual Required Labs
ANNUAL REQUIREMENTS OverdueCase Manager Annual Review FOB Hct UA Date Range LIST VIEW – Annual Required Lab Tests
DAWN Tool – List View Annual Requirements - Overdue Labs
Barriers Identified Non compliant patients Patients did not understand importance and purpose of annual labs Busy practices
DAWN Tool - Letters Annual Labs Letter to Educate Patient
Patient Letter The goal of the Anticoagulation Clinic is to prevent any thromboembolic (strokes, deep vein thrombosis, or pulmonary embolism) and/or bleeding events by carefully monitoring the warfarin level and by periodically checking urine, blood and stool for signs of hidden bleeding There are three lab tests that are required by the Anticoagulation Clinic. 1) Hematocrit ( the percentage of red blood cells found in the serum) is done to check for anemia which could be a sign of bleeding. 2) Urinalysis which tests your urine specimen for visible and microscopic blood. 3) Fecal Occult Blood which tests your stool specimens for blood which is not always visible. This is also an important screening test to detect colon cancer. Since the primary adverse effect of warfarin is bleeding, our goal is also to detect bleeding early enough to avoid complications. These lab tests can possibly show signs of bleeding before you feel any symptoms. Any abnormal test results will be immediately forwarded to your primary care provider. When we ask you to obtain these labs please realize our intention is to keep you safe and healthy.
DAWN Tool – Reminders Assists Case Manager
List View - Reminders
DAWN Tool - User Profile Facilitates Staff in Assisting Each Other Ancillary Staff given access to other organizations List View 1. Check CMR to see if labs completed by another provider 2. Make lab slips ahead of appointment times 3. Phone Reminders
Progress – ASA Use
Progress – Overdue Annual Labs
DAWN AC Facilitates Consistancy CONSISTANT PATIENT EDUCATION DOCUMENTATIONMETRICSPROCEDURES
FACILITATES Identifying Patients Obtaining Metrics Educating Patients Communication With Referring MD Documentation Measuring Progress Problem Solving Communicate Multiple Locations DAWN AC