RN Anticoagulation Therapy Management Model: Improving Patient Care and Safety in the Ambulatory Care Setting

Purpose:
To develop and implement a comprehensive, evidence-based and standardized ambulatory anticoagulation therapy management program within a large integrated healthcare system utilizing an RN-led model to improve patient safety, effectiveness, access and customer satisfaction.

Relevance/Significance:
Deaths occured in the post-acute setting related to anticoagulation therapy(AT). Reporting of safety events inconsistent. Evidence-based protocols for warfarin AT implemented in 2011; utilization inconsistent. Education/training not provided for staff managing AT patients. Patient education materials not standardized; no process in place to ensure information current/evidence-based (EB). EMR documentation inconsistent/not defined. Management of AT patient fragmented/lacked standardization.

Strategy and Implementation:
Increased access for over 8000 patients & over 700 providers by establishing 17 RN-run anticoagulation clinics (AC) in VA & Northeastern NC. Developed/implemented innovative RN-led AC with virtual PharmD support, allowing RN to autonomously assess, educate, and safely provide AT management based on protocols and PharmD consultation. Established warfarin & new AT medication EB protocols. Established standardized computer-based staff/provider education, and standardized patient education materials. Developed/implemented robust RN documentation using standardized EMR template. Created virtual AT program for home-testing/home health patients. Established EMR provider referral process, reminder list to track patients' International Normalized Ratios (INR) monitoring schedule adherence, “time in therapeutic range” (TTR) report to monitor by patient/clinic & effectiveness of AT management. Implemented adverse event reporting/tracking processes to measure clinical and patient outcomes.

Evaluation:
In 18 months, AC increased from 3 to 17 & patient volume 2300 to 9000. 25 RNs/3 PharmDs managed 83,950 patient encounters. PharmDs intervened 13,729 (22%) due to RN escalation; over 76 ED visits avoided. TTR = 66%. Reporting/tracking safety/adverse drug events, patient education, & RN education improved 100%. RN/PharmD EMR workflow/documentation standardized across the post-acute setting.

Implications for Practice:
TTR needs to be separately calculated for orthopedic (short-term)warfarin patients. RNs and PharmDs practice to the full scope of licensure through use of effective and evidence-based AT patient management strategies. An RN-led AT patient management model is innovative, safe, & patient-focused.