Patient safety is a major concern in the United States and around the world.  The release of the Institute of Medicine’s Report in 2001 bolstered efforts to improve patient safety across the board.  During the past few years, the Anticoagulation Management Service (AMS) at Massachusetts General Hospital (MGH) implemented a number of changes focused on patient safety and quality improvement for anticoagulated patients. 

At the MGH, the need to improve the quality in the care of anticoagulated patients was underscored with Dr. Elaine Hylek’s findings describing the real world anticoagulation practice with unfractionated heparin in 1998.  (Hylek, 2003)  Hylek’s provocative results provided the catalyst for a number of quality improvement initiatives at MGH including a hospital-wide program to facilitate timely and safer discharge plans for patients newly started or resuming anticoagulation therapy.  AMS developed several transition pathways to provide a seamless transition of care from the inpatient to outpatient arena.  The transition services support: a) induction of warfarin therapy for patients newly started on warfarin with or without a low molecular weight heparin (LMWH) or fondaparinux and b) resumption of warfarin and if the risk is high, bridging with LMWH or fondaparinux.  Another of  these initiatives included the implementation of a new patient management software system; Dawn AC.  The features of Dawn AC supported many of the changes already instituted as well as planned for AMS.  This overview will focus on how Dawn AC enabled the AMS staff to continue their high quality patient care and facilitate additional improvements.

The Anticoagulation Management Service was established at MGH in 1969 and was known then as the Anticoagulant Therapy Unit (ATU).  Within a few years, a custom-built software program was implemented to provide clinical decision support with the goal to make dose adjustments more uniform.  Key functionality of this software program included a dosing algorithm, patient tracking capability, and printed dose instructions that were mailed to patients on postcards. The design of the ATU application, however, created a task-and-function type work environment.  Each nurse was assigned a variety of independent tasks that pertained to the entire clinic population.  Later, an interface was added to identify AMS patients admitted or discharged from the hospital and a daily list was printed. 

In the ATU system, INR results were entered one-by-one into the system (primarily by secretaries but also nurses) and were processed at designated times during the work day.  The ATU’s database was essentially a ‘stand alone’ application.  Hospital clinicians did not have electronic access to ATU patient information and details contained therein.  This was a growing concern since many AMS patients have laboratory services performed by over 200 laboratories in the greater New England area and therefore, many INR results were known only to AMS.

The AMS is a nurse run clinic.  Currently, there are 9 nurses (or 7.6 full time equivalent positions and additional positions have been approved) and 2 fulltime secretaries. The management team is comprised of a nurse director (full time) and clinical nurse specialist (part time) along with a medical director who provides medical oversight and consultation.  AMS manages nearly 4000 patients who are referred for management of anticoagulation therapy, primarily with warfarin.  One of the more significant changes in AMS prior to the launch of Dawn AC was the implementation of a primary nurse model to manage the comprehensive needs of our patients.  In Dawn AC, each patient’s primary nurse is identified by the Preferred Clinic.  Customization of the list views and filters was instrumental in supporting this practice model. 

The implementation of Dawn AC v7.3 was noteworthy for a number of reasons and provided the means to capitalize on quality and safety concerns.  Dawn AC provided the means to dispense with paper records for our transition pathway patients.  These records were cumbersome and needed constant handwritten updates.  Furthermore, analysis of patient progress was extraordinarily time consuming.  Additionally, communication opportunities both within AMS and to the hospital community were markedly improved.  At the time of our launch, electronic interfaces with existing hospital information systems were developed and are described below:

1) Lab Results Interface

An interface to electronically enter INR values onto the patient’s Dawn AC record was developed.  Since nearly half of the AMS population went to a laboratory affiliated with the MGH hospital system, this interface would significantly decrease time on task spent to enter INRs and at the same time, improve safety and accuracy of laboratory results.  On average, 250 – 325 INRs were entered into the electronic ATU record.  The sources for these values were fax, telephone, and mailed reports.  Prior to Dawn AC, INR processing (via a printed data run) occurred at 3 designated times during the work day.  This had a significant impact for how the nurses and secretaries organized their work day and generated a huge amount of paper reports which needed to be filed.  This interface also changes how INR results were reviewed and processed as is was no longer fully dependent upon a manual entry or printed data run.  Therefore, the nurses could review their patient results via a list view at intervals best suited for their work day.  This interface created significantly better access to INR information and processing.

2)  Hospital Census Interface

An interface with hospital census and the AMS clinic population existed with the ATU system in the form of a daily printed list.  This interface was improved so that information about AMS patients and hospital admissions and discharges could be accessed and displayed throughout the day in real time.  Filters were programmed on the Patient Status List View to allow staff to identify newly admitted, admitted , or discharged patients.  When newly admitted, the primary nurse electronically creates a note into the patient’s electronic hospital record.  This note communicates key clinical information such as the patient’s INR range, duration of therapy, pill size, last 4 INRs and dose instructions, and AMS contact information.   These were key elements needed to safely plan a patient’s discharge.  The nurses monitor the discharge filter to learn when their patients are discharged.  A phone call assessment is conducted to review the treatment plan with specific emphasis on warfarin pill size, dose instructions and timing of next INR.

3)  AMS Icon Interface

A third interface with Dawn AC and hospital systems was continued and supports the display of the AMS icon.  This small red and white AMS image identifies patients who are managed by AMS and appears on hospital and out-patient electronic records.  Additionally, a click with the mouse over the AMS icon displays a new window containing details about the patient and his/her anticoagulation management. 

Thoughts from a national perspective

Nationally, the high costs resulting from medication-related errors in hospitalized patients are staggering, about $2 billion every year.  Anticoagulant drugs constantly appear on the high alert lists for medications frequently involved in medication errors and causing harm.  Additionally, we are also reminded that over 50% of patients with chronic atrial fibrillation are managed inadequately. 

In the United States, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) releases annual National Patient Safety Goals that are designed to promote specific improvements in patient safety and focus on system-wide solutions.  Many of the previously defined goals have addressed medication safety in general.  However, the 2008 National Patient Safety Goals released earlier this year contain language specific to anticoagulation.  Requirement 3E reads:  Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.  This goal has a 1 year phase-in period but hospitals in the United States should be prepared and expect to see JCAHO surveyors collecting evidence to support this goal. 

Another national organization, although relatively new, is the National Quality Forum (NQF).  The NQF was created to develop and implement a national strategy for health care quality measurement and reporting.  In 2006, NQF published a national concensus report on the prevention and care of venous thromboembolism (VTE).  Currently, performance measure development and testing is being done jointly with JCAHO.  NQF has representatives from many stakeholders including consumers, purchasers, provides, health plans, research experts and federal agencies.  Concensus-based national standards, specific to VTE, are likely to have significant implications for the future.

Lastly, the issue and importance of health literacy can not be overlooked.  Health literacy as defined by the Institute of Medicine in 2004 is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.  Health literacy is also an important factor when discussing quality and safety patient care issues.  According to the National Center for Education Statistics, the average American reads at 8 – 9^th grade levels and 1 in 5 American adults read at 5^th grade levels or below.  This is a sharp reminder about the importance to address the basic needs of patients and their families and to use this information to formulate an educational and treatment plan best suited to meet their needs.

Summary

As of the time of this presentation, our experience with Dawn AC is limited to six months.  Our staff is pleased with the application and find the list views and corresponding filters particularly helpful to manage patients in a timely and efficient manner.  High quality, safe and cost-effective care remain top priorities for AMS.  The contributions and dedication of our staff was key to meet the challenges of the significant changes within our clinic and the successful implementation of Dawn AC.  Additionally, the support of 2 full-time information technology staff were equally instrumental in the implementation of Dawn AC and the three interfaces.  The changes implemented thus far have placed AMS in a better position to address national objectives pertaining to future quality and safety concerns in our patient population.  Dawn AC is able to provide the framework and tools to organize, measure, and analyze efforts to support our future challenges. 

References

Institute of Medicine – www.iom.edu

Hylek EM.  Challenges to the effective use of unfractionated heparin in the     hospitalized management of acute thrombosis.  Arch Intern Med. 2003 Mar 10;163(5):621-7.

Joint Commission on Accreditation of Healthcare Organizations – www.jcaho.org

National Quality Forum – www.qualityforum.org

Partnership for Clear Health Communication is now at the National Patient Safety Foundation www.askme3.org  (or www.npsf.org)

National Center for Education Statistics (National Assessment of Adult Literacy) – www.nces.ed.gov