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Improving Handoffs of Patients taking Warfarin From UNMH Internal Medicine Teams to SNFs

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

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Improving Handoffs of Patients taking Warfarin From UNMH Internal Medicine Teams to SNFs

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  1. Improving Handoffs of Patients taking WarfarinFrom 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 • 12SNFs 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 Warfarininformation 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 • ATlooks 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 Warfarininformation 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 • ATlooks 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 Warfarininformation 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 Tlooks 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 505-264-6970 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?

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