Program helps patients who take anticoagulants

Patient education helps avoid adverse outcomes

While an elderly man on warfarin was waiting to get blood drawn at his physician’s office, he was handed some educational materials about the drug. "The packet included warnings that the shape of the pill may change based on the manufacturer of the drug, but the color will never change," says Kim Shields, RN, clinical systems safety officer and team leader for the Virtual Anticoagulation Project at Abington (PA) Memorial Hospital.

After the prescription was filled, the man noticed that the pills, which always had been pink, were white. The pharmacy had mistakenly given the man 10 mg pills instead of the 1 mg he was prescribed, which could have resulted in a potentially fatal hemorrhagic event.

This "near-miss" scenario is just one success story from an innovative program at Abington Memorial, where a "Virtual Anticoagulation Clinic" has significantly reduced the morbidity and mortality of patients taking the anticoagulant drug warfarin. As a result of this successful initiative, the organization won the 2003 John M. Eisenberg Patient Safety Awards, given jointly by the National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations.

The medical, pharmacy, physician network, and performance assessment departments at the facility implemented a web-based program for outpatients that improves primary care physician management of patients taking warfarin.

The pilot study data for the program show that patients in appropriate therapeutic range improved from 51% to 70%, reports Keith Sweigard, MD, the facility’s chief of internal medicine.

Here are key aspects of the program:

Staff at physician offices are trained on an ongoing basis.

Staff at 29 physician practices have received initial training from the facility’s performance improvement nurse, consisting of a three-hour class. Each coordinator is given a self-learning packet and passes a competency test, with ongoing education provided via newsletters and intermittent classes.

Additionally, office performance is continuously assessed and feedback given to the clinicians, Sweigard says. "Networks can monitor each office’s performance and then use their resources to identify issues that may be causing less than optimal anticoagulation rates," he adds.

For example, when Sweigard noticed that one practice had failed to input patient international normalized ratio (INR) levels in a timely fashion, he arranged for one of the senior coordinators to work with the office to correct the problem.

"It can be difficult to oversee so many practices when you are not physically present all the time," Shields points out. "These reports are our tools to assess the process."

Dosing instructions provided to the clinicians are standardized and based on national guidelines, Sweigard explains. "This has resulted in improved results with less risk of bleeding or clotting," he says.

Potential adverse outcomes are avoided with patient education.

Patients are educated on how to handle issues such as missed doses and drug interactions. While still in the hospital, patients receive an educational packet, including a one-page information sheet, available in English, Korean, and Spanish.

"We tell patients to put it right on the refrigerator because it lists the essentials they need to know to be safe," Shields says.

Patients also are given a sheet listing prescription and over-the-counter medications, herbal supplements, and vitamins that interact with warfarin.

"One of the biggest problems with warfarin is that so many drugs interfere with the way it works, by either raising the INR or lowering it," she says.

"So patients have a tool to bring with them to the pharmacy or other health care providers that informs them of drug interactions," Shields adds.

Patient education about warfarin often is sorely lacking, and this can have a devastating impact on patient safety since it is a difficult drug to manage with a narrow therapeutic index, she says.

If blood levels are too high, there is a risk of major bleeding, whereas levels too low can fail to protect patients from blood clots, Shields explains.

"We promote that the patient has to be part of a team. They have to be very knowledgeable, because they are the first ones to alert us that something is not right," she says.

The web site allows patients to log in and see their own health record for warfarin therapy, Sweigard says. "At discharge, patients are told that their INRs and warfarin dosing will be faxed or entered into the program before discharge," he says. "Patients with mechanical valves may enter their own INR values and receive computerized decision support."

Patient knowledge is routinely assessed.

Following a teaching session, patients are asked 12 questions to determine their knowledge about warfarin, so that educators can "drill down" during future sessions on the areas that require reinforced education. "It’s one thing to educate someone, but that is only as good as the patient’s level of comprehension," Shields says.

An education documentation record is kept in the patient’s chart at the physician office. "When a patient is having blood drawn, the coordinators can refer to the documentation record that indicates where additional education is still needed," she adds.

Point-of-care testing is offered.

Dosage levels of warfarin are determined by blood test results reported as INR levels, and maintaining blood levels within therapeutic range is essential, as there is a narrow window of efficacy and safety, Shields emphasizes.

Therefore, the safest and best way to manage warfarin is with point-of-care testing, which is being implemented at one of the larger physician practices, she reports. "Instead of having venous blood drawn, it will be a finger stick with results available in one minute," she says.

The patient’s dose can be changed immediately if needed, with no lag time or having to call the patient back, she says. "We can act on INR results 24 hours sooner than if we had to send the blood work to a lab. It also requires less blood and is a lot less painful," Shields continues.

Patient care is individualized.

Patients are taught that foods high in vitamin K, such as leafy green vegetables, help the blood to clot and therefore can affect INR levels. "We tell patients, You can make modifications to your diet — just tell us in advance so we can adjust your warfarin dose as indicated,’" she says. "If patients have a glass of wine with dinner every night, we adjust the dose based on that."

This provides a better quality of life, so patients don’t feel that the drug controls their life, Shields continues.

"The most important thing is consistency. If patients are happier, they are more compliant and safer," she says.

Important information is pushed to the front page of the web site.

Patients who are late for follow-up blood tests and patients who should be off warfarin are listed on the front page of the web site, Sweigard notes.

"Patients have remarked that they feel more closely watched, which translates to improved patient satisfaction and safety," he says.

While many patients are on warfarin for life, others are only supposed to take the drugs for several months after orthopedic procedures such as total hip replacements. Sometimes, these patients would end up being on the drug longer than prescribed.

"You don’t want to keep patients on warfarin when they don’t need to be," Shields says. "So if we know there is a stop date, we put that in the computer." Previously, there was no way to track when patients were late in getting their blood work drawn, she states.

"We could have patients who didn’t come back for months, and we didn’t know it. Now with this new computer system, there is a screen that lists the patients, including the number of days late and their last INR results. This allows coordinators to contact the patient to schedule an appointment for overdue blood work." Shields adds.

[For more information on the Virtual Anticoagulation Clinic, contact:

Kim Shields, RN, Clinical Systems Safety Officer, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001-3788. Phone: (215) 481-4378. Fax: (215) 572-9087. E-mail: Web:

Keith Sweigard, MD, Chief of Internal Medicine, Abington Memorial Hospital, Abington Memorial Hospital, 1200 Old York Road, Abington PA 19001. Phone: (215) 481-4871. Fax: (215) 481-6790. E-mail: