Using DAWN AC to Facilitate a Quality Improvement Project

1. Using DAWN AC to Facilitate a Quality Improvement Project Wenatchee Valley Medical Center Lisa Vaughn RN CACP Clinical Manager Anticoagulation Services

2. 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.

3. 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

4. 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 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. 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.

5. 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 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 2 2009

6. 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.

7. DAWN Tool – List ViewIdentify all Referring MDs

8. DAWN Tool - Drug Tab Documents Aspirin Use

9. Reconciled Patient Profile with DAWN Drug Tab

10. DAWN Tool - Report Identify Patients on ASA

11. DAWN Tool - Treatment Plan Summary Risks: Antiplatelet Therapy

12. DAWN Tool –ReviewsTrack When Antiplatelet Risk Assessment is Due

13. DAWN Tool – ReviewsTracks Required Antiplatelet Assessment

14. DAWN Tool - LIST VIEW

15. DAWN Tool - List View Identifies Patients with Review Due

16. DAWN Tool – Letters

17. DAWN Tool - Letters Antiplatelet Assessment Letter to MD

18. DAWN Tool – LettersAntiplatelet Risk Assessment Documented Letter was sent Documents physician order Documents case manager noted order Scanned into Documents in DAWN

19. DAWN Tool - Documents Records MD Review

20. DAWN Tool - Coded Comment Documents in Progress Note and Time Saver

21. 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

22. More Challenges Increase staff use of List Views List View Filters Filter defaults to Overdue Increase case manager involvement Production reports Reminders Accurate documentation

23. Discontinue ASA

24. 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.

25. DAWN Tool -Reviews Tracks Annual Required Labs

26. LIST VIEW – Annual Required Lab Tests

27. DAWN Tool – List ViewAnnual Requirements - Overdue Labs

28. Barriers Identified Non compliant patients Patients did not understand importance and purpose of annual labs Busy practices

29. DAWN Tool - Letters Annual Labs Letter to Educate Patient

30. 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.

31. DAWN Tool – RemindersAssists Case Manager

32. List View - Reminders

33. DAWN Tool - User ProfileFacilitates Staff in Assisting Each Other Ancillary Staff given access to other organizations List View Check CMR to see if labs completed by another provider Make lab slips ahead of appointment times Phone Reminders

34. Progress – ASA Use

35. Progress – Overdue Annual Labs

36. DAWN AC Facilitates Consistancy

37. DAWN AC