Anticoagulant center saves clinic $75,000
Anticoagulant center saves clinic $75,000
Even as researchers confirm the benefits of warfarin use, you may find yourself embroiled in a quandary. The anticoagulant carries with it a risk of complications and requires intense monitoring. Keep one step ahead: Consider developing a specialized anticoagulant center to absorb some of the burden.
The Veterans Affairs Medical Center in Louisville, KY, discovered having such a center is cost-effective and raises quality standards as well. Richard Vissing, PharmD, clinical pharmacist, estimates that the cost benefit of their clinic was $75,000 in 1996, and John Burke, chief of pharmacy, says that the figures haven’t been analyzed as yet but it will be in the same neighborhood for 1997.
"We estimate cost avoidance based on baseline and current data," he says, "and all indications point toward it proving to be as cost-effective last year."
The clinic has had a significant increase in patients. "When we began the clinic we had less than 300 on anticoagulation therapy," says Burke, "and now we have over 1,000. The new arrhythmia indications have added some, and there’s not as much risk for bleeding for those patients because of the lower dosage."
In 1992, 8.65% of anticoagulated patients at the center required hospitalization due to bleeding complications. While the national incidence of warfarin toxicity is unknown, says Vissing, "We thought this rate was too high. We wanted to know what was going on."
A team consisting of the assistant chief of staff of ambulatory care, the chief of pathology service, a clinical pharmacist, a community health nurse coordinator, and a primary care clinic physician pulled a random sample of patients and manually reviewed their charts, says Maureen Washburn, ND, RNC, CPHQ, utilization management nurse at the medical center.
No established protocol in place
While the team found that warfarin patients discharged from the cardiology service were given follow-up appointments at the prothrombin time (PT) clinic, no established protocol followed patients discharged from other services.
"Warfarin has many uses and is given to cardiac patients, those with deep vein thrombosis and, for short periods of time, to orthopedic surgery patients," Washburn explains. Difficulties arise after their care. Team members found that the following must occur to prevent noncardiac patients from being lost in the system:
• The patient must have a follow-up appointment.
• The patient’s medication profile has to be available at the time of the clinic visit to alert caregivers to the need for warfarin follow-up.
A flowchart of the existing process showed structural weaknesses. "A lot of decisions had to be made, and there was potential for a lot of rework," Washburn says.
First, the team developed a practitioner education program covering warfarin pharmacology, indications, and monitoring. It focused on the International Normalized Ratio (INR) method. INR is a monitoring measurement that reduces variations in laboratory reporting and prevents complications associated with anticoagulations."We do INR with every PT now." Vissing explains. "It takes into account variability and is more sensitive." (See related story on INR, p. 36.)
Next, team members developed a warfarin worksheet which reduced variation in the documentation of care and provided an ongoing tracking mechanism for all patients even those whose charts are not available at the time of their clinic visits.
After making those changes, the team created a flowchart for the new process and collected data on the warfarin toxicity rate. The rate fell in 1993 to 6.59%, but team members were not satisfied, Vissing says. It was confusing to have more than one PT clinic. "There was a lot of overlap as to who should go where. Also, there wasn’t a centralized approach to make sure no one fell through the cracks," he explains.
So team members established a central anticoagulation clinic staffed by clinical pharmacists. They rewrote the hospital’s policies and procedures to allow clinical pharmacists to adjust patients’ dosages and order tests. The clinic protocol includes:
• consistent follow-up after discharge;
• therapeutic dosage adjustment;
• consultation and referral;
• patient/family education;
• practitioner education;
• monitoring and evaluation of the program.
Once a week, Vissing makes sure every patient receiving warfarin has an appointment either at the clinic or for home care or is being monitored by a private physician. This 20 minutes per week is time well spent, he says, because it ensures everyone is monitored. (See the facility’s warfarin tracking sheet and follow-up process, pp. 34-35.)
The warfarin toxicity rate for 1996 was at 2.31%. "As additional indications for warfarin use are published and the number of patients on the therapy increases, this low rate means even more to us," he adds. (For data from 1992-1996, see bar graph on admissions due to bleeding, p. 36.)
The program has other benefits as well, Vissing says. Each patient who comes to the anticoagulation clinic for a PT check 4,229 in 1996 represents a physician appointment. "Warfarin patients just need to get their PT levels checked. They don’t really need to take up a physician’s time with that," Vissing explains.
The pharmacists staffing the anticoagulation clinic have been able to handle almost all clinic visits without referring patients to a physician. In addition, he says, "the patients love it. They get to see the same person each time, and that familiarity has led to a great deal of trust." Washburn concurs. Some of the clinic patients have opened up to the pharmacists about medical problems they probably would have kept to themselves had that trust not been there.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.