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

2. 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”

3. 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)

4. 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

5. 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

6. 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

7. 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?

8. Data from Albuquerque SNFs

9. Data from Albuquerque SNFs

10. Data from Albuquerque SNFs

11. 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

12. 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

13. Anticoagulation Team’s Documents

14. 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

15. 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

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

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