Improving Handoffs of Patients taking WarfarinFrom UNMH Internal Medicine Teams to SNFs

Percy PentecostDivision 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

Suggest 3 easy interventions

Minimize additional work

Not trying to:

Be funnier than Lenny

Change system “in one stroke”

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)

Case PresentationNovember 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

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

Rush Pierce SearchThe 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

Data from Albuquerque SNFs12 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?

Data from Albuquerque SNFs

Data from Albuquerque SNFs

Data from Albuquerque SNFs

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

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

Anticoagulation Team’s Documents

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

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

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.”

Questions?Here’s one: How does this

song relate to Warfarin?