1 increase the safety of warfarin therapy in the ambulatory setting patient safety, satisfaction...
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Increase the Safety of Increase the Safety of WarfarinWarfarin Therapy in the Therapy in the
Ambulatory SettingAmbulatory Setting
Patient Safety, Satisfaction & RevenuePatient Safety, Satisfaction & Revenue
Stephanie Dougherty, RN, BSNPatient Safety Fellow
Virginia Commonwealth UniversityVIPC&S May 15, 2003
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History and BackgroundHistory and Background
• 176 bed hospital with176 bed hospital with 12 Ambulatory 12 Ambulatory PracticesPractices and 145 physicians participating and 145 physicians participating in Integrated Delivery System in Integrated Delivery System
• CoumadinCoumadin - one of the top 10 most dangerous - one of the top 10 most dangerous drugs in the ambulatory setting. Literature states drugs in the ambulatory setting. Literature states combination bleeding and embolic events runs 2- combination bleeding and embolic events runs 2- 20 % in traditional office based management20 % in traditional office based management
• Adverse Event – lets Speak the Truth Adverse Event – lets Speak the Truth
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Half Full TheoryHalf Full Theory
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ObjectivesObjectives
• a.. Create a a.. Create a cultureculture in ambulatory care of in ambulatory care of patient safety based on open patient safety based on open communication communication and human factor conceptsand human factor concepts
• b.. Implement an evidence based, systems b.. Implement an evidence based, systems based, patient centered framework to based, patient centered framework to decrease variationdecrease variation in the management of in the management of Warfarin therapy in the ambulatory settingWarfarin therapy in the ambulatory setting
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ObjectivesObjectives
• c.. Increase c.. Increase patient educationpatient education, , awareness,awareness, and and patientpatient participationparticipation in managing in managing healthcare safetyhealthcare safety
• d.. Implement use of d.. Implement use of PPont-ont-OOf-f-CCare INR are INR testing equipment in ambulatory setting to testing equipment in ambulatory setting to decrease turn around time and increase decrease turn around time and increase patient/staff satisfactionpatient/staff satisfaction
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Begin…Begin…
• Pilot patient safety project atPilot patient safety project at two hospital two hospital owned Ambulatory practicesowned Ambulatory practices
• Began November to create the new Began November to create the new processprocess
• Conducted Failure Analysis - Flow Conducted Failure Analysis - Flow Diagram or Diagram or
What are we currently doing?What are we currently doing?
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Flow DiagramFlow Diagram
5-6 RN's to train
D/C from somefacility already on
Coumadin orCardiologist
Register-Sign in onNurse Unit
RN Chart in "Rack""Nurse of the Day"all blood work for
nurse visits
RN picks up chartand bring patient
back to lab
RN verify currentdose and
compliance withregimen
Any missed dosesrecorded on record
and reported toM.D.
RN/LPN/MA drawsINR
Paper log of PT/INR(See lab draw log)
PBFHC uses HMCthe "most" due to
Medicare for INR's
Lab voucher (onecopy stays with
chart) results arepending
Specimen andvoucher goes to
HMC lab
Extreme abnormalsare called from
HMC lab to PBFHC.Otherwise HMC labfaxes copy of results
to PB.
Faxed copy ofresults
Recorded lab logand placed with
chart in M.D. Box(UP box
distinguishes urgent
Verify M.D. ispresent for follow-up
M.D. decides dose,repeat visit & writes
orders.See yellow
AnticoagulationForm
Abnormals getplaced on podum for
immediate
He puts chart intoNurse Box or into
RN's hands
RN calls to contact patient.*Document where
communication is in process.May write on lab sheet result.Makes new appt. for follow-up.
Patient on phone:Set date now-front desk doesschedule. They want the RN
to set the date. There is arecall list the patient can go onso the patient does not have
to remember.
If out of wack-assess.Patient education-RN blood
drawConversation and assessment
& callls for nurse dosebooklet.
We tell the patient if they donot hear from us within 24 hrs.
they need to call us.
Changes in Rx-Md/RN callspharmacy
Cardiology managedINR's?
PB faxes results tocardiologist who thencontact the patients.
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DATADATA
• How are we managing our patient How are we managing our patient education? education?
• What best practice algorithm are we What best practice algorithm are we using?using?
• Is everyone doing the same thing - well?Is everyone doing the same thing - well?• ( reference slide re data collection pre implementation)( reference slide re data collection pre implementation)
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What We Found…What We Found…
• Found the following: Found the following: – Small “Snapshot Sample” of charts Small “Snapshot Sample” of charts
reviewed:reviewed:
Only 13 % were in target range 80% of the Only 13 % were in target range 80% of the timetime
– Use of a basic algorithm only at one practice Use of a basic algorithm only at one practice site- site- large amount of variation large amount of variation
– Interaction with patient usually a lab draw Interaction with patient usually a lab draw by nurse or technician – did not have a by nurse or technician – did not have a Coumadin focused assessment by nurse or Coumadin focused assessment by nurse or physicianphysician
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What We Found…What We Found…
– PT/INR results arrive 1-2 days after PT/INR results arrive 1-2 days after patient visitpatient visit
– Physicians review stack of charts a the Physicians review stack of charts a the end of the day for medication orders end of the day for medication orders
– Needed standard for patient Needed standard for patient assessment each visitassessment each visit
– Needed standardized education for Needed standardized education for patients or staff - not sure of hospital patients or staff - not sure of hospital based patient education is rememberedbased patient education is remembered
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What We FoundWhat We Found
– Nurse time not billed Nurse time not billed – Physician time not billedPhysician time not billed
– Heavy reliance on memoryHeavy reliance on memoryMany steps in the processMany steps in the process
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Culture and Patient Safety Culture and Patient Safety ConceptsConcepts
• Cultivate Patient Safety Thinking- initiate Cultivate Patient Safety Thinking- initiate culture change- understand basics of culture change- understand basics of error and why changes to Coumadin error and why changes to Coumadin management need to be accomplished-management need to be accomplished-story tellingstory telling
• Remove blameRemove blame
• Look for roots of error in system- fatigue, Look for roots of error in system- fatigue, memory, vigilance, memory, vigilance, production production pressurepressure
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Look Familiar?Look Familiar?
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Human Factors Human Factors EvaluationEvaluation• Evaluated the intrinsic properties and Evaluated the intrinsic properties and
constraints of the current systemconstraints of the current system
• Noise, interruptions, vigilance, increased Noise, interruptions, vigilance, increased reliance on memoryreliance on memory
• Cognitive factors: stress, workload, Cognitive factors: stress, workload, fatiguefatigue
• Communication between staffCommunication between staff
• Staff TrainingStaff Training
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Goals from ObjectivesGoals from Objectives
• Decrease reliance on memory- patient, Decrease reliance on memory- patient, nurse , physician, nurse , physician,
• Decrease variation in assessment , dosing, Decrease variation in assessment , dosing, education, use of pharmacieseducation, use of pharmacies
• Minimize workspace management-Minimize workspace management-streamline process, use evidence based streamline process, use evidence based medical toolsmedical tools
• Add Specific Color to the Coumadin Add Specific Color to the Coumadin Management Tools – recognition easier Management Tools – recognition easier than recallthan recall
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Goals from ObjectivesGoals from Objectives
• Increase patient participation and Increase patient participation and education- Patient becomes partner in co education- Patient becomes partner in co managing Coumadin treatmentmanaging Coumadin treatment
• Eliminate 1-3 three day wait for PT/INR Eliminate 1-3 three day wait for PT/INR Laboratory resultsLaboratory results
• Immediate results with Point of Care Immediate results with Point of Care technology testing equipment technology testing equipment (CoaguCheck)(CoaguCheck)
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KEEP IT SIMPLEKEEP IT SIMPLE
• Real – Relevant - Simple- and ‘Fun Real – Relevant - Simple- and ‘Fun (Gosbee)(Gosbee)
• Develop healthy respect for latent error in Develop healthy respect for latent error in any new system, process or designany new system, process or design
• Training to Anticipate error- Error will Training to Anticipate error- Error will emerge!!emerge!!
( so ..look for it!)( so ..look for it!)
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Obstacles to Patient Obstacles to Patient Learning Learning
• Difficulty comprehendingDifficulty comprehending
• Memory( heavy reliance on)Memory( heavy reliance on)
• ““Rushed”Rushed”
• Minimal connection with concept of Minimal connection with concept of personal responsibility for monitoring diet, personal responsibility for monitoring diet, exercise, travel, communication re: doses exercise, travel, communication re: doses missed, illness or activity, and missed, illness or activity, and concommitant medications concommitant medications
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Perceived Obstacles to change Perceived Obstacles to change
at the sitesat the sites
• Things are ok hereThings are ok here
• This is too much paperworkThis is too much paperwork
• Not another “program”Not another “program”
• What do you mean Patient Safety- we’re What do you mean Patient Safety- we’re safe!safe!
• The doctors will never go for thisThe doctors will never go for this
• The patients won’t like itThe patients won’t like it
• We are doing too much already We are doing too much already
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Overcome perception of Change…Overcome perception of Change…
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BEST PRACTICE BEST PRACTICE
• Process & ToolsProcess & Tools• AlgorithmAlgorithm• Patient education and increased Patient education and increased
understanding of responsibilityunderstanding of responsibility• Initial Nursing Assessment and Coumadin Initial Nursing Assessment and Coumadin
Visit Assessment- drives the discussion –Visit Assessment- drives the discussion –re: relevant questions on diet, lifestyles, re: relevant questions on diet, lifestyles, medications over the counter medications, medications over the counter medications, herbs, activity, illnessherbs, activity, illness
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ToolsTools
• Evidence Based AlgorithmEvidence Based Algorithm
• Anticoagulation Log Anticoagulation Log
• Visit AssessmentVisit Assessment
• Follow-up AppointmentFollow-up Appointment
• Pont-of- Care INR Testing Pont-of- Care INR Testing
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Tools to Decrease reliance on Tools to Decrease reliance on MEMORY and Facilitate EducationMEMORY and Facilitate Education
TOOLS: (see your handouts for copies)TOOLS: (see your handouts for copies)
• Announcement to PatientsAnnouncement to Patients Let the Let the patients (and staff!) know there is a patients (and staff!) know there is a change a coming’ - new Point of Carechange a coming’ - new Point of Care Testing and Benefits Testing and Benefits
• ““Blood for the lab tests is obtained via Blood for the lab tests is obtained via finger stick - No more venipuncture”finger stick - No more venipuncture”
• ““Test results are available withinTest results are available within minutes – minutes – No more waiting days for resultsNo more waiting days for results””
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Tools continued Tools continued
• ““Immediate adjustment of drug dosage, if Immediate adjustment of drug dosage, if needed – No more delay in appropriate needed – No more delay in appropriate therapy and a decreased risk of therapy and a decreased risk of complications”complications”
• ““Frequent interaction with our healthcare Frequent interaction with our healthcare professionals, which results in better professionals, which results in better control of therapy and increased control of therapy and increased opportunity to discuss your treatment or opportunity to discuss your treatment or education needs”education needs”
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Tools- AnnouncementTools- Announcement
• Announcement- handed out in the lab Announcement- handed out in the lab draw area 3-4 weeks before the first draw area 3-4 weeks before the first patient starts on the new INR Point of patient starts on the new INR Point of Care Testing/Education Care Testing/Education
• Generated interest and Generated interest and excitement for the changesexcitement for the changes
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Tools..Tools..
• Initial AssessmentInitial Assessment - leads - leads discussion with patient relative to discussion with patient relative to Coumadin and issues of concernCoumadin and issues of concern
• The Language we use through each piece The Language we use through each piece REINFORCES learningREINFORCES learning about Coumadin and about Coumadin and precatutionsprecatutions
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Tools..Tools..
• Patient ResponsibilityPatient Responsibility discussion and discussion and contractcontract
• Education checklistEducation checklist matching the matching the patient Guide to using Coumadin pamphlet patient Guide to using Coumadin pamphlet from Bristol-Myers, Squib guides the nurse from Bristol-Myers, Squib guides the nurse and patient education- eliminates reliance and patient education- eliminates reliance on memory on memory ((see handoutssee handouts))
• The education process reinforces learning The education process reinforces learning about Coumadin management for the about Coumadin management for the Patient AND the StaffPatient AND the Staff
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Point of Care TestingPoint of Care Testing
• Eliminates call back time – immediate Eliminates call back time – immediate results to patient, nurse and physicianresults to patient, nurse and physician
• Engaged practitioners in discussion on Engaged practitioners in discussion on memory, vigilance, pace, interruptionsmemory, vigilance, pace, interruptions
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Point of Care testing Point of Care testing • Our choice - CoaguChek S System ( Roche Our choice - CoaguChek S System ( Roche
Diagnostics- www.coaguchek.com)Diagnostics- www.coaguchek.com)• Human factors designed with multiple Human factors designed with multiple
benignbenign failure modes - Designed to failure modes - Designed to minimize human error minimize human error
• CLIA waived CLIA waived • A test A test systemsystem not impacted by lot –to –lot not impacted by lot –to –lot
reagent variability thereby minimizes the reagent variability thereby minimizes the chances of clinically significant changes in chances of clinically significant changes in test results. test results.
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Education to change Education to change culture culture • Incident - literature review & root cause Incident - literature review & root cause
analysis resultsanalysis results
• All Staff Educated on Anticoagulation All Staff Educated on Anticoagulation Management via American Heart Management via American Heart Association- Management of Oral Association- Management of Oral Anticoagulation Therapy Anticoagulation Therapy
((www.acforum.orgwww.acforum.org))
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National Quality ForumNational Quality Forum
• National Quality Forum- Patient Safety activity: National Quality Forum- Patient Safety activity:
• Increase safety of anticoagulation management is Increase safety of anticoagulation management is applicable to ambulatory setting. applicable to ambulatory setting.
• A recommended safe practice is to utilize A recommended safe practice is to utilize dedicated anticoagulation services that facilitate dedicated anticoagulation services that facilitate coordinated care management servicescoordinated care management services
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NQFNQF
• Examples of implementation:Examples of implementation:
• Staff Experienced in monitoring anticoagulation Staff Experienced in monitoring anticoagulation therapytherapy
• Reliable patient scheduling and trackingReliable patient scheduling and tracking
• Accessible, accurate and frequent prothrombin Accessible, accurate and frequent prothrombin time (PT)/ Independent Normalized Ration (INR)time (PT)/ Independent Normalized Ration (INR)
• Patient Specific decision support and Patient Specific decision support and interactioninteraction
• Ongoing patient educationOngoing patient education
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Narrow the holes of Swiss Narrow the holes of Swiss CheeseCheese
• Use of appropriate TechnologyUse of appropriate Technology
• Improved clinician knowledge and error Improved clinician knowledge and error awarenessawareness
• Continuous improvement Continuous improvement
• Evidenced based Medicine for the Evidenced based Medicine for the Anticoagulation AlgorithmAnticoagulation Algorithm
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New Improved ProcessNew Improved Process
Patient Registersand completes
visit assessment
Nurse reviewspatient informationand performs INR/
PT Test
INR results areimmediate
Review anddiscuss INR with
patient/family
MD evaluatesassessment and
INR results: writesorders
Next visitappointmentscheduled
• Dramatic increase in patient satisfaction
• More personal time between nurse and patient better education and relationship
• Patient ownership of Coumadin self management
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How much is this going to How much is this going to cost?cost?
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Financial AnalysisFinancial Analysis
Total Total NumberNumber of Tests of Tests
Practice Tests / Week Annual TestsPBFHC 15 780DVFHC 15 780RFHC 15 780CFHC 10 520
Total 55 2,860
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Financial AnalysisFinancial AnalysisMedicare ReimbursementMedicare Reimbursement
INR TestingINR Testing• Annual Tests: 2,860Annual Tests: 2,860
• Nurse Visits: $67,524.60Nurse Visits: $67,524.60
• INR Tests: $15,701.40INR Tests: $15,701.40
Annual Revenue: Annual Revenue: $83,226$83,226
Outside LaboratoryOutside Laboratory• Annual Tests: 2,860Annual Tests: 2,860
• Venipuncture: $8,580Venipuncture: $8,580
Annual Revenue: Annual Revenue: $8,580$8,580
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Financial AnalysisFinancial AnalysisSupply CostsSupply Costs
POC INR TestingPOC INR Testing• Annual Tests: 2,860Annual Tests: 2,860
• Strips: $14,128.40Strips: $14,128.40
• Control Costs: $1,086.80Control Costs: $1,086.80
• Lancets: $572Lancets: $572
Annual Supply Costs: Annual Supply Costs:
$15,787$15,787
Outside LaboratoryOutside Laboratory• Annual Tests: 2,860Annual Tests: 2,860
• Venipuncture Supplies: Venipuncture Supplies: $0.22$0.22
Annual Supply Costs: Annual Supply Costs:
$629$629
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Financial AnalysisFinancial AnalysisNursing CostsNursing Costs
INR TestingINR Testing• Annual Tests: 2,860Annual Tests: 2,860
• Time Cost (15 min. per Time Cost (15 min. per test): $715test): $715
• Annual Nursing Time: 715 Annual Nursing Time: 715 hrs.hrs.
• Salary w/ Benefits per hr.: Salary w/ Benefits per hr.: $22.32$22.32
Annual Nursing Costs: Annual Nursing Costs:
$15,959$15,959
Outside LaboratoryOutside Laboratory• Annual Tests: 2,860Annual Tests: 2,860
• Time Cost (20 min. per Time Cost (20 min. per test): $943.80test): $943.80
• Annual Nursing Time: 944 Annual Nursing Time: 944 hrs.hrs.
• Salary w/ Benefits per hr.: Salary w/ Benefits per hr.: $22.32$22.32
Annual Nursing Costs: Annual Nursing Costs:
$21,066$21,066
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Financial AnalysisFinancial AnalysisTotal Annual ExpensesTotal Annual Expenses
POC- INR TestingPOC- INR Testing• Supply Costs: $15,787Supply Costs: $15,787• Depreciation on INR Depreciation on INR
machines: $960machines: $960• Nursing Time: $15,959Nursing Time: $15,959• NJ State Lab NJ State Lab
Compliance: $460Compliance: $460• Increased Lab License Increased Lab License
Expense: $800Expense: $800
TOTAL Expense: TOTAL Expense: $33,966$33,966
Outside LaboratoryOutside Laboratory• Supplies for Supplies for
Venipuncture: $ 629Venipuncture: $ 629
• Nursing Time: $21,066Nursing Time: $21,066
TOTAL Expense: TOTAL Expense: $21,695$21,695
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Financial AnalysisFinancial AnalysisProfit / (Loss) StatementProfit / (Loss) Statement
INR TestingINR Testing• Annual Tests: 2,860Annual Tests: 2,860
• Revenue: $83,226Revenue: $83,226
• Expenses: $33,966Expenses: $33,966
Profit: Profit: $49,260$49,260
Outside LaboratoryOutside Laboratory• Annual Tests: 2,860Annual Tests: 2,860
• Revenue: $8,580Revenue: $8,580
• Expenses: $21,066Expenses: $21,066
Only Loss: Only Loss: $12,486$12,486
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Patient OutcomesPatient Outcomes
• Patient and Practitioners discovering Patient and Practitioners discovering relationships between the diets of patients relationships between the diets of patients with noted sometimes large variation in with noted sometimes large variation in INR results INR results
• The education and assessment time spent The education and assessment time spent with patient- we are finding new with patient- we are finding new medications added, missed doses, medications added, missed doses, changes in level of wellness changes in level of wellness
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Patient SatisfactionPatient Satisfaction
• 100% satisfaction100% satisfaction from the Patients from the Patients – – they were ASKING for the new processthey were ASKING for the new process
• If they need to be re stuck they are saying If they need to be re stuck they are saying –”it’s OK- go ahead. Better than the vein” –”it’s OK- go ahead. Better than the vein”
• New algorithm is being used as standard New algorithm is being used as standard among physicians and residents-among physicians and residents-
• Error in dosing already intercepted with Error in dosing already intercepted with the algorithmthe algorithm
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Patient OutcomesPatient Outcomes
• Patient and Nurse schedules next Patient and Nurse schedules next appointment appointment before patient leavesbefore patient leaves
• Missed appointments are tracked Missed appointments are tracked and followed up promptly- there have and followed up promptly- there have not been any missed appointments not been any missed appointments with this new process for the INR with this new process for the INR testing and assessmenttesting and assessment
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Patient Safety continuesPatient Safety continues
• Patient leaves with a copy of the new Patient leaves with a copy of the new orders and the new appointment orders and the new appointment datedate
• Patients are now Patients are now calling incalling in to discuss to discuss the addition of new antibiotics from the addition of new antibiotics from other MD’s and what to do about the other MD’s and what to do about the Coumadin doseCoumadin dose
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Physician SatisfactionPhysician Satisfaction
• Physicians are seeing the time spent on Physicians are seeing the time spent on the education and assessment of each the education and assessment of each patient and are pleased and impressed patient and are pleased and impressed with the patient’s positive reactionwith the patient’s positive reaction
• This process This process slows downslows down the Production – the Production – devotes timedevotes time to relationship-to relationship- and is and is creating an interactive patient safety creating an interactive patient safety dynamic with dynamic with patients patients at the center of at the center of the carethe care
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Go Global.. Go Global.. Speak the Truth SoftlySpeak the Truth Softly
• Original plan was for 3 owned sites to Original plan was for 3 owned sites to implementimplement
• Now up to 5 – plan to offer this to all 12 owned Now up to 5 – plan to offer this to all 12 owned practices and the 145 physicians in our practices and the 145 physicians in our Integrated Delivery System Integrated Delivery System
• Data collection underway to capture the Data collection underway to capture the successsuccess and other opportunities for and other opportunities for improvementimprovement
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About Patient Safety …Overcome this..!!! About Patient Safety …Overcome this..!!!
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AcknowledgementsAcknowledgements
• Dr.KryzkowskiDr.Kryzkowski- - who showed us that we have an opportunity to who showed us that we have an opportunity to improved safetyimproved safety
• Dr. Roksvaag, Dr, ShlimbaumDr. Roksvaag, Dr, Shlimbaum,, Dr. Kozakowski, Dr. Kozakowski, Lawrence Grand, Claire LongLawrence Grand, Claire Long and Dr. Pickoffand Dr. Pickoff– for – for showing leadership, support and blessingsshowing leadership, support and blessings
• Dr. Jacky FeinDr. Jacky Fein for her support in changing culture through for her support in changing culture through educationeducation
• Patty Musselman, Mary Shurts, Betty Cronce, Bonnie Patty Musselman, Mary Shurts, Betty Cronce, Bonnie AdaireAdaire – – for their belief in patient safety as a number one for their belief in patient safety as a number one priority and who supported this process over all the priority and who supported this process over all the obstacles obstacles
• Karen Swisher andKaren Swisher and Dr. Eric Silfen-Dr. Eric Silfen- for Patient for Patient Safety Fellowship and mentoringSafety Fellowship and mentoring
• Dr. Kim Thorne-Dr. Kim Thorne- Northbay Medical Center – who Northbay Medical Center – who shared with us all her successful clinic toolsshared with us all her successful clinic tools
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Thank you!Thank you!
Stephanie Dougherty. RN, BSN Stephanie Dougherty. RN, BSN Patient Safety Officer- Risk MangerPatient Safety Officer- Risk Manger
[email protected]@hunterdonhealthcare.orge.org