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Anticoagulation

IHC, in cooperation with health care providers across the state, has developed the following Anticoagulation Toolkit. The toolkit is a compilation of resources to ensure effective and safe long-term anticoagulation therapy.

We would like to thank those individuals and organizations who have shared their materials and who have agreed to serve as mentors. Please contact IHC if your organization would like to contribute materials to this toolkit.

Project Description

Objectives

Anticoagulation therapy is a complex and labor-intensive intervention for which success depends upon correct dosing decisions, close attention to many details, and good communication among all parties involved. In a recent study anticoagulants were responsible for 121 of the 1523 adverse drug events, a third of which were considered preventable1. In a recent TMIT survey conducted by the Iowa Healthcare Collaborative (IHC), 116 Iowa hospitals rated anticoagulation as an extremely relevant problem within the state.

Recognizing this problem, IHC has produced an Anticoagulation Toolkit for health care providers. The objective of this initiative is to ensure effective and safe long-term anticoagulation therapy in all care settings in Iowa. IHC hopes this resource will offer more information on the issue as well as practical solutions.

Project Team

The project team includes health care providers representing the following participating facilities:

Goal

The goal of the team is to facilitate effective and safe long-term anticoagulation therapy in all care settings in Iowa.

Status

The team has gathered information on current anticoagulation processes of anticoagulation clinics both in Iowa and nationally. Following the American College of Chest Physicians (ACCP) Guidelines the team has posted protocol examples for health care providers attempting to improve anticoagulation monitoring and treatment in their respective clinics and facilities. The forms selected contain all of the data elements necessary to successfully manage patient anticoagulation therapy according to the National Quality Forum Safe Practices and the ACCP Anticoagulation Management Guidelines.


1 Gurwitz, JH, et al., Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting, JAMA. 289:1107-1116, March 5, 2003.

Tool Kit

The National Quality Forum (NQF) in Safety Objective #29 states that "Every patient on long-term oral anticoagulants should be monitored by a qualified health professional using a careful strategy to ensure an appropriate intensity of supervision."(1) NQF goes on to outline explicit organizational policies and procedures necessary for effective management of patients taking anticoagulants.(1) The IHC Anticoagulation Work Group has endorsed NQF’s recommendations. The Work Group has divided these recommendations into an easy step-by-step process. Below are organizational policies, procedures, forms and flowsheets that align and satisfy each recommendation.

Step 1: Policies and Procedures

 Explicit organizational policies and procedures should be in place regarding anti-thrombotic services that include at least documentation of: Below are policies and procedures that satisfy these requirements.

Intake/Indication for long-term anticoagulation
Policies, procedures, and forms, to document patient intake and indication for long-term anticoagulation therapy.


Target INR Range and Dosing Policies
Below are tables, policies, procedures, and forms to effectively monitor and document target INR and dosing. Note the Anticoagulation Work Group endorses the use of the American College of Chest Physician’s Guidelines for therapeutic target INR.(2)


Duration of long-term anticoagulation and/or a review date
Policies, procedures, flowsheets and forms to document duration of long-term anticoagulation and/or review date.


Timing of the next INR appointment
Organizational policies and procedures to effectively document and monitor timing of the next INR appointment.



Step 2: Staff Education

To ensure that long-term (anticoagulation) therapy is effective and safe, every patient should be monitored by a qualified health professional. To this end, IHC has compiled a list of employment protocols, job descriptions, and continuing education programs for health care professionals who want to develop the knowledge and skills necessary for effective, coordinated anticoagulant therapy management. Below please find on-line and in-person anticoagulation therapy certification programs endorsed by the ACforum.


Step 3: Reliable Patient Scheduling and Tracking

Below are forms, procedures, and policies to aid in the implementation of reliable patient scheduling and tracking.


Step 4: Patient Engagement and Compliance

Below are policies, procedures, and forms to facilitate patient engagement and compliance.


Step 5: Discharge Planning/Patient Education

Discharge planning and patient education should include 1) specific verbal and written patient education materials appropriate for each patient’s language and reading level with assessment of understanding; and 2) bridging therapy across care setting transitions. Below are discharge tools and patient education materials utilized by anticoagulation clinics across Iowa that satisfy these requirements.

Discharge Planning


Patient Education


Complete Policies
Below are complete policies from Iowa anticoagulation clinics containing all criteria necessary to run an effective long-term anticoagulation therapy program(Consultation and referral, appointment scheduling, clinic procedure, laboratory procedure, patient education, etc.)


Miscellaneous


References:
(1) www.qualityforum.org
(2) Chest Vol 126, Supplement, September 2004, www.chestjournal.org/content/vol126/3_suppl/


Success Stories

How to Promote



Business Case




Mentor Hospitals

Allen Memorial Hospital Anticoagulation Clinic, Waterloo, IA

Central Community Hospital, Elkader, IA

Community Anticoagulation Therapy (CAT) Clinic, Cedar Rapids, IA

Great River Medical Center, Burlington, IA

Guttenberg Hospital Anticoagulation Therapy Program, Guttenberg, IA

Madison County Anticoagulation Management Clinic, Winterset, IA

Mercy North Iowa, Mason City, IA

University of Iowa Hospitals and Clinics, Iowa City, IA

Veterans Administration Medical Center of Central Iowa, Des Moines, IA

Veterans Administration Medical Center, Iowa City, IA

Winneshiek Medical Center, Decorah, IA

Resources


Websites

DVT Anticoagulation Software Stroke *Codes
D: DVT Site
A: Anticoag Site
P: Patient-Specific Site
M: Medical / Health Care Professional Site
PM: Patient or Medical Site


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