Virtual anticoagulation clinic improves safety

A "virtual anticoagulation clinic" is being credited with dramatic improvements in patient safety at Abington (PA) Memorial Hospital, which recently won the John M. Eisenberg Patient Safety Award from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Any hospital or other health care provider wishing to improve patient safety can emulate the effort, the project’s leader says. Morbidity and mortality from less-than-optimal medication administration can be a major contributor to your overall patient safety statistics, he says.

The project reduced morbidity and mortality by addressing a difficult medication issue facing any health care provider, says Doron Schneider, MD, associate program director for the internal medicine residency program at Abington and a project leader. Abington tackled the difficult issue of monitoring patients on anticoagulant medications, such as warfarin, that are notoriously difficult to use properly.

"They are inherently risky, because too little can lead to strokes and pulmonary emboli, but too much and they can bleed," Schneider says. "It is very difficult to dose correctly because people metabolize it differently, and there are many food and drug interactions."

Needed to standardize

Because there is no standardized way to provide the medication, hospitals nationwide have come to accept a high degree of morbidity. The team at Abington thought they could reduce the morbidity and mortality by standardizing some of the process involved with delivering the drug.

"We set out to create a process that would work within the construct of an office environment, with no additional staffing," he says. "We restructured the existing staff to systematically deliver that medicine in a more consistent way."

Abington put together a team of three physicians, a representative from the hospital’s performance improvement committee, and a pharmacist. A key component of their plan turned out to be a virtual anticoagulation clinic — a web site that provides resources and tools for monitoring patients on anticoagulation medications. Among other things, the web site provides standardized patient education materials.

"Because of the complexities of interactions with warfarin and over-the-counter medications, and food, we needed to educate people in a standardized way to make sure they got the right information," Schneider says. "We developed host of materials for patients explaining interactions and symptoms to watch for. All the materials can be downloaded from the virtual clinic."

A patient education tracking form also was created. The patient signs the form, acknowledging that he or she received the information about the risk of bleeding and signs to watch for.

Coordinator in office has big role

The project also involved recruiting an office-based anticoagulation coordinator in each doctor’s office participating in the project. This person is not a physician, but rather a nurse or sometimes even an administrator in the office. The coordinator plays a key role in monitoring the patient’s level of anticoagulation medication — perhaps the most important, but sometimes the most challenging, part of treating a patient with these medications.

Patients’ blood levels must be monitored frequently, creating a headache for scheduling and a great deal of work for physicians who must check the lab results and adjust the drug dosage if the blood levels are not in the therapeutic range. The amount of work could overwhelm the physician, increasing the chance that an important lab result could be overlooked and the health care provider would be held liable for the oversight.

"There are always lot of lab results coming into the office for monitoring," Schneider says. "Instead of having all those come into the office to each individual physician, we have all of them come to the anticoagulation coordinator in that office, and she uses a protocol based on national guidelines and consensus statements to manage that patient independently of the physician. If the patient’s values are within a defined range, she can make a dose adjustment."

The coordinator puts a sticker on the lab slip indicating that he or she reviewed the results and adjusted the dose accordingly. At the same time, the coordinator checks the patient for any signs of bleeding or stroke, and schedules the next lab test.

"If the results are outside the mildly abnormal range, the physician is notified immediately," Schneider says.

System recommends clinical path

The virtual clinic on the web also provides a database in which all the patient’s clinical and demographic information is entered. The computer automatically recommends the correct dosage and when the patient should return for another lab test. The physician always has the ability to override the computer’s advice.

In addition, the system automatically reminds the physician or anticoagulation coordinator about patients who are late for scheduled testing.

Abington has used the system for more than a year now, so what is the effect on patient safety? Schneider says the hospital was able to increase the percentage of patients with ideal anticoagulation dosing from 55% to about 80%. He calls that a "dramatic improvement."

"We’ve had 495 patient-years of therapy, and the complication rate was .01 per patient year," Schneider says. "We had one major bleed, and that was in a patient whose physician did not consistently take the recommendations from the computer. Having a greater percentage of patients in the therapeutic range is directly tied to patient safety."

Schneider says the key to making such a project work is finding participants who are not just willing, but eager. The physicians who kick off the project must be enthusiastic enough to bring in more skeptical colleagues. And he adds that the anticoagulation coordinators, not the physicians, are the linchpins of the entire system.

The same sort of system could be implemented for monitoring the use of any medication, Schneider says. Start-up costs were minimal.

"This did not slow the physicians down at all. In fact, they appreciate the ability to off load much of this responsibility to another willing individual in the practice," he says. "There also was very little extra cost associated with this. We estimated the costs at about $3 per year per patient."