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Using DAWN AC to Facilitate a Quality Improvement Project
Wenatchee Valley Medical Center
Lisa Vaughn RN CACPClinical 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 physician’s 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.
2. 100% 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;948-954. Republished online January 15, 2008:
DOI 10. 1378/chest.07-2627
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;1500-1507
DOI.1378/Chest 06-2374
Combining Antiplatelet and Anticoagulant TherapyDavid 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 2 2009
Policy and Procedure
Anticoagulation Clinic Policy and Procedure # 19
TITLE: Antiplatelet Risk Assessment ReviewImplemented: 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 ViewIdentify all Referring MDs
List View
Patients By Referring MDActive Treatment Plans
ACC Location Diagnosis
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 –ReviewsTrack When Antiplatelet Risk Assessment is Due
Annual Reviews
Interval Set at
365 Days
Antiplatelet Risk Assessment
Next Review Date Set at Today's Date
DAWN Tool – ReviewsTracks Required Antiplatelet Assessment
ANNUAL REQUIREMENTS
Overdue Case Manager Date Range
Annual Review
Antiplatelet Risk
DAWN Tool - LIST VIEW
DAWN Tool - List View Identifies Patients with Review Due
DAWN Tool – Letters
Letters
Patients Referring MD
Purpose of Annual Labs
SAFETY
Prevention and Treatment of Epistaxis
Fall Prevention
Annual Update of Treatment Plan
Antiplatelet Risk Assessment
DAWN Tool - Letters Antiplatelet Assessment Letter to MD
DAWN Tool – LettersAntiplatelet 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 No ASA
.asl = Aspirin 81mgdaily
.ash = Aspirin325mg daily
.no = None
Challenges Identified
Multiple ACC locations Email 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 Continue
Delete ReviewReset Review
365 Days
Scan Assessment Letter into Documents
Scan Assessment Letter into Documents
Delete RiskAntiplatelet Therapy
Case Manager Cosigns
Assessment Letter
Case Manager Cosigns
Assessment Letter
Confirm with Patient
Confirm with Patient
Discontinue in EMR
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
Overdue Case Manager Date Range
Annual Review
FOB
UA
Hct
LIST VIEW – Annual Required Lab Tests
DAWN Tool – List ViewAnnual 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 – RemindersAssists Case Manager
List View - Reminders
DAWN Tool - User ProfileFacilitates 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
Antiplatelet Risk Assessment
0
50
100
150
200
250
300
350
400
450
500
March J une August
2009
ASA in DRUG tab On ASA Total Discontinued
Progress – Overdue Annual Labs
Total Overdue Labs
Al l Locations
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Active Enrollment February March April May J uly August
DAWN AC Facilitates Consistancy
PROCEDURESPROCEDURES
METRICSMETRICS
DOCUMENTATIONDOCUMENTATION
PATIENTEDUCATION
PATIENTEDUCATION
CONSISTANTCONSISTANT
CommunicateMultiple
Locations
Problem Solving
MeasuringProgress
Documentation
Communication With
Referring MD
Educating Patients
Obtaining Metrics
Identifying Patients
FACILITATES
DAWN AC