Anticoagulation Clinic Description

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The Clinic provides 2 main patient services:

  1. "Bridging" administration of low-molecular weight heparin (LMWH) injections to high-risk patients to cover the few days' delay while warfarin tablets become effective (when initiated), or wear off (when purposely stopped before surgery)
  2. monitoring of patients' intensity of anticoagulation as determined by lab test results, and advising on changes to warfarin dosage

"Bridging" patients

  • referral / intake of new patients could be from the community but is mainly from hospitals where the patient has usually just had an artificial heart valve inserted. They may alternatively have had a stroke, or a clot to the leg or lung, or a hip replacement on a background of prior clotting. They might also have developed or had detected Atrial Fibrillation.
  • registration:
    • doctors unfamiliar with the system phone for information (could be put on web)
    • patient information is faxed to clinic. Paper form information includes
      • labels on which are patient name, DOB, health insurance #, last responsible doctor in hospital
      • reason, planned intensity, and planned duration for anticoagulation
      • last 3 days of dosing (LMW heparin, warfarin) and lab test results (mainly the INR)
      • not included (but would be helpful)
        • more demographics / contact info in Hospital Information System (HIS) which lacks an interface (inaccessible) from the community
      • pertinent lab test results are also trapped in the HIS
  • patients are seen daily from 8:30 - 10:00 am for an injection and a blood test (specimens are taken across the street to the hospital, thought might in future be tested on a point-of-care device) and are contacted later that day when the result of the test is available, on which basis the patient in then advised of the dosage of oral medication to take
  • process is repeated daily (including over the weekend), typically up to about 5 days, until the oral anticoagulant (warfarin) is "therapeutic" at which point the patient can be discharged from "bridging" but most often becomes (remains) an "Anticoagulation Monitoring" patient

"Anticoagulation Monitoring" patients

  • these may have been "bridging" patients who continued beyond their need for injections, or patients referred de novo at hospital discharge or from the community
  • registration is as outlined for "bridging" patients above
  • no physical visit by the patient is required for this service, they might never "come" to the clinic
  • in contrast to "Bridging" patients, "Anticoagulation Monitoring" patients do not have tests daily except in two cases, one being when "bridging" is again required, for example around surgery, or on the rare occasion when anticoagulation is so excessive as to justify daily testing (and possibly require the administration of vitamin K)

Anticoagulation Work Process

  • Seven participating nurses self-assign onto a paper sign-up sheet posted in the clinic, up to a month or two ahead. Self-assignment is to any number of Monday to Friday shifts, including (during a special project phase Jan-June 2006) statutory holidays and weekends. It is advantageous when this was the nurse who worked the Friday, or the day prior to a statutory holiday.

  • Clinic process:
    • the Daysheet binder is inspected for any patients due to arrive for bridging or to have an INR test done in the community
    • messages left by the prior day's nurse, and any telephone messages, are retrieved & reviewed
    • fax machine is checked for any referral correspondence, and for any lab results
    • lab data are retrieved via browser lookup with printing of new results
    • results are sorted by patient name and for each patient result
      • the patient "chart" (consisting of their referral sheet and Anticoagulation Flowsheets) is identified within the clinic binder of "active patients"
      • the test result(s) is/are copied onto the patient's flowsheet
      • the result is compared to the patient's "target range" and the flowsheet is color-coded, using a semi-adhesive Post-It (TM) flag, as being in-range or out-of-range
      • the patient is marked off against the schedule (see Daysheet below)
      • the "on duty" clinic doctor is consulted for an adjustment on
        • each "bridging" patient
        • each "monitoring" patient who is out of range or repeatedly "borderline"
        • patients due to end their anticoagulation, or who have been unable to be contacted, or about whom any other concerns or questions arise
      • each patient is contacted and advised of any change to their dosage as well as when they should next have an INR test
        • the patient's name is also copied onto an aggregate Daysheet, labelled in advance for each of the next 30 days and kept in a Daysheet binder
    • patients listed on the prior day's Daysheet but for whom no result is yet available are marked in highlight pen, contacted, and reminded to attend the lab. if they cannot be contacted, a note is left for the next day's staff.
    • the chart of patients who request (or whose doctors request) to no longer be managed through the clinic, and patients whose need for anticoagulation has ended, are moved to the Archive binder. In some cases, correspondence must be sent out to document and communicate the circumstances and the cessation of service through the clinic.

Process Summary (Operational, not limited to computing)

  • Referral
  • Registration
  • Prescribing of the warfarin (blood-thinner) +- tinzaparin (low-molecular-weight heparin for injection)
  • Test authorization (requisition) including designation of the clinical entities (doctors, clinics) that are to receive results
  • Test scheduling
  • Documentation of contact with patient and the advice given
  • Test specimen collection at clinic or at branch lab
    • Injections, if required, and documentation of giving same
  • Test result transmission, pick-up, and post-processing, including telephone review by doctor
  • Patient notification -> optional action -> test scheduling
  • Special cases
    • Critical-high INR results may require referral to hospital and administration of Vitamin K
  • Ancillary
    • Scheduling of nurses' work shifts
    • Scheduling of doctors' work shifts
    • Billing government for work done
    • Payment of nurses & any other costs
    • Maintaining emergency stock of tinzaparin
    • Maintaining point-of-care device, supplies, and training
    • Maintaining adequate pool of nurses
    • Maintaining referral materials and information for patients
    • Communicating clinic status with regard to week-end coverage

Informs: AnticoagulationClinic use case.


> todo: upload attachment containing Enrollment form, patient Flowsheet, and clinic Daysheet (problem with uploading has been noted on the WikiSupport page)
Topic revision: 01 Jan 2006, JamesBusser
 
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