Wenatchee Valley Medical Center (WVMC) is one of the largest, most comprehensive medical centers in the Pacific Northwestern United States.  Our goal is to provide the highest quality of healthcare and service in a friendly and caring atmosphere.  The challenge is to make our work and our values come together.  An Anticoagulation Clinic (ACC) has proven to be an excellent way to meet the patient’s needs and fulfill the medical center’s goal.

The WVMC Anticoagulation Clinic was established within the Department of Cardiology with the goal to improve the quality of care for patients receiving anticoagulant therapy while freeing physicians from care that could be provided by a nurse. Consistent personal contact and patient education contributed to improved patient compliance and satisfaction. Nurses often take the initiative to assist patients with compliance by assisting with pill boxes, personal phone calls and frequent visits.   Our patients became our best advertising.  Soon other physicians were seeing the benefit of systematic and coordinated anticoagulation management. The service grew steadily and now serves patients from all departments at WVMC as well as other community clinics in the area.

WVMC ACC has now extended outside the Wenatchee campus to provide anticoagulation care for 1600 patients in four WVMC rural health clinics scattered across north central Washington State. The main anticoagulation clinic location in Wenatchee is now a hospital outpatient based service associated with Wenatchee Valley Hospital. DAWN AC allows the individual locations to operate as separate organization within a common data base with a standardized format for treatment plan parameters, patient letters, data entry procedures and quality assurance indicators.

The complexity of anticoagulation care warrants case management. WVMC case managers are a mix of physician assistants, nurse practioners and registered nurses. Care in the rural health clinics is done by physician assistants and nurse practioners.  Registered nurses provide the service in the outpatient hospital setting. Patients see the same case manager consistently through the duration of their therapy. Case managers establish close working relationships with patients and often possess specific knowledge of individual compliance, response to dose changes, dietary habits and comorbidity affecting the anticoagulation therapy. The role of the registered nurse as an anticoagulation clinic case manager has proven to be successful. Nurses monitor patient status and manage anticoagulation according to set procedures and protocol under the supervision of a medical director.  The use of a computerized support system, DAWN AC v7.1, has augmented the existing protocol for anticoagulation management. 

Anticoagulation case management requires a nurse to function with a high degree of autonomy, have critical thinking skills and have the ability to facilitate interdisciplinary teams in order to act as a care coordinator. This role has been very satisfying to the WVMC ACC nurses, and staff turnover has been minimal over the last 10 years. The use of portable INR monitors, specially trained nurses, an effective decision support system combined with staff and management support are crucial factors for the success of nurses in anticoagulation services[1]. The clinical performance of nurses using computerized decision systems designed to guide oral anticoagulation management has demonstrated to be at least as effective as traditional physician based anticoagulation management in maintaining INR in therapeutic range and avoiding adverse events[2] The quality of care provided by nursing staff at WVMC is shown in the measurement of quality indicators such as time in therapeutic range, bleeding and thromboembolic events and the use of vitamin K to reduce bleeding risk with elevated INR’s.

The establishment of the WMC Anticoagulation Clinic was guided by the publication of Consensus guidelines for coordinated outpatient oral anticoagulation therapy management[3]  Prior to implementing DAWN AC patient management was guided by the use of algorithms and a decision matrix based on current American College of Chest Physicians Guidelines for Anticoagulation Management and other published therapy guidelines. The warfarin management protocol has been updated at frequent intervals to stay current published practice guidelines and continues to augment the dose management provided by DAWN AC. The policies and procedures for anticoagulation management and INR testing are consistent throughout the five locations.

Patients are seen in the clinic and are scheduled appointment times in a patient management system called PLUS. This system facilitates the management of clinic based financial and patient information through out WVMC. 

INR testing is done by medical assistants using the Coaguchek XS point of care INR meter.  Point of care INR testing has been shown to decrease test turn around time, the use of clinic resources, and the risk in errors in handling and labeling. Patient satisfaction is increased with the convenience of a finger stick and immediate result reporting.

In 2005 WVMC had accumulated a want list for an anticoagulation documentation and management system. The search was instigated by the need to comply with the patient privacy requirements of HIPPA and coincided with the WVMC goal to establish an electronic medical record. The ability to integrate an anticoagulation management system within the existing WVMC practice management systems was imperative. Other desired features included: reliable data back up, good technical support, and room for additional growth.  Patient management audits had shown a need for improvement and standardization of documentation, improved communication with other care providers, standardization of patient education materials and the support of computer aided dosing and warfarin induction algorithms.  The nursing staff wanted a system to facilitate the documentation of physician review and participation in the patient care as well as a tool to communicate effectively with other care providers. The conversion from three separate CoumaCare databases to the DAWN AC system was implemented in July 2006.  DAWN Acv7:1 is currently used at all WVMC anticoagulation clinics. 

Soon after the implementation of DAWN AC the interface to the WVMC computerized medical record (CMR) was completed.  When a CMR user clicks on the link, it connects to the DAWN SQL server database and pulls the information directly from DAWN AC.  The DAWN data is displayed in an ACC page in the WVMC custom built web page.  The DAWN AC to CMR link is displayed for all patients in the DAWN AC system and specifies if the patient is active or inactive in the DAWN database.  DAWN AC records remain visible in the CMR when the patient is no longer active in DAWN AC.

The DAWN AC page is easily accessed with one login to the WVMC intranet and CMR.  The ACC page can be accessed from 3 different areas inside the CMR: the lab page, the patient demographics page and the patient profile page. The link provides all CMR users with the ability to view anticoagulation clinic records from DAWN AC in a read only format.  Health care providers needing access to the DAWN AC information included the primary care physician, specialists, surgeons, pre op nurses, hospital and emergency room providers, local assisted and extended care facilities, and other community clinics.  WVMC billing and Medicare compliance staff access DAWN AC data needed to support levels of care provided. 

The CMR link pulls information from the DAWN AC Treatment Plan and communicates the patient’s Indication for therapy, INR Goal, Diagnosis notes, Duration of therapy, ACC referring physician (GP), ACC location and ACC Case Manager.  Dosing history and Treatment Notes are included to clearly communicate the current INR and warfarin dosing.  The 20 most recent INR’s are displayed in a graph.  Events are noted in the CMR page as documented in the EVENTs tab in DAWN AC.

DAWN AC is also interfaced with the practice management system, PLUS. 

The PLUS to DAWN AC Admissions, Discharges, and Transfers (ADT) interface was felt to be an important tool in managing risk management issues such as frequency of patient follow up, DNA documentation, patient non compliance and insuring accurate patient identification and dosing instruction. The scheduling of patient appointments in PLUS confirms the correct patient, the correct date and the printing of the correct dose instruction.  Case managers are kept current on changes in patient scheduling by the automatic printing of updated patient letters including the new appointment.  The patient demographic information in PLUS is kept current by the medical center billing and reception staff.  This ensures the patient contact and demographic information is always current in DAWN AC. Appointments made in the PLUS system are sent to the DAWN AC clinic schedules and are visible in the clinic schedule, list view, and patient view page

Patient education documentation has improved with the use of DAWN AC.  Patient visit documentation templates created with coded comments and the scanning of signed patient education objectives into the Documents tab in DAWN AC efficiently documents teaching. Patient education information has been standardized and included in the Letters tab in DAWN AC.  Easy access to the patient handouts and documentation of the letter printing has increased the use of patient education materials and improved the consistency in documenting patient education.  The addition of patient handouts in Spanish has been a positive step in meeting the needs of the Hispanic patients.  Other letters included are: Treatment and Prevention of Epistaxis, Use of Over the Counter Medications, Safety and Fall Prevention and Non Attendance (DNA) letters. 

Documentation of physician review is easily accomplished in DAWN AC.  Vitamin K and low molecular heparin use is cosigned by the responsible physician via the CMR electronic signature and a simple cut and paste into DAWN AC. Physician signed forms such as ACC enrollment, annual review of the treatment plan, and annual review by the medical director are printed from the Letters tab. The signed forms are then scanned into the Documents tab of DAWN AC.  The unlimited storage of documents in DAWN AC ensures compliance with our Medical Records Department requirements.

DAWN AC efficiently supports the workflow at each WVMC location and assists the anticoagulation team in managing our patients. The Review tab is used by the case managers and their support staff to manage required reoccurring lab tests and physician reviews.  The list views conveniently track DNA’s and daily clinic schedules.

Anticoagulation management requires communication and coordination of care among all aspects of medicine. The risk of anticoagulation and the effectiveness of the therapy are influenced by the quality of the care delivered. Communication and coordination occurs when all care providers know the diagnosis, treatment plan, and ongoing care of the patient.  WVMC nurses, using DAWN AC, partnered with our existing clinical management systems are providing the high quality of care to our patients on anticoagulation therapy.