Microsoft word - monitoringprocedurewarfarinuse.docx
MOC Online Clinical PIP Report
1. Describe, in detail, your primary role in this project
I took the lead in studying the problem and initiating a solution. I however could not take credit for defining the instigating problem. I was the principal designer of the Anticoagulation Form (i.e. the Form). Despite mandate
from hospital administration that some type of written documentation scheme be devised, I have been the only team member to actively monitor its use of the subsequently created Form. As a result, I have been the only team member to summarize the outcomes of the project.
2. Will this project be submitted by other ABPMR diplomates (team members)?
3. Dates of physician participation:
4. Clinical PIP Title
Monitoring of pre-procedure discontinuation and post-procedure re-initiation of Warfarin use relevant to the
performance of fluoroscopically guided neuraxial procedures.
5. Project Leader(s)
6. Brief Description of Clinical PIP
On 3 March 2008, a patient that I had performed a lumbar epidural steroid injection on 2 days earlier had a stroke. Review of her records indicated she had been off her Warfarin for 7 days as per our standard protocol and
approval by her prescribing physician. However, despite the patient’s later acknowledging we told her to restart her Warfarin (which she did), there was no specific written documentation that the patient was to restart or was even instructed to restart her Warfarin post-procedure.
Steven Palm MS, MD; Michelle Birch RN; Delores Pine RN; Michael Aspen RN; Daniel Willow LPN; Anthony
Cypress LPN; Stephanie Alder RN, Quality Resource Department; Teresa Cedar MD
To devise a simple but complete system (i.e. a single Form) that would allow for concise monitoring of written approval (i.e. signatures), by the prescribing physician, for a patient to discontinue Warfarin prior to a neuraxial
procedure. It would also, and even more importantly, provide a written acknowledgement (i.e. signatures) by the patient and/or their guardian that the patient was to resume use of Warfarin as indicated by the prescribing physician after a neuraxial procedure was performed.
Prior to creating the Form, the complete process from approval for Warfarin discontinuation through patient post-procedure discharge had to be evaluated. Identifying the lack of written acknowledgement for specified Warfarin re-initiation was very easy; it didn’t exist in the sentinel patient’s case or several other randomly chosen anticoagulated patients’ charts. Also, documentation methods for Warfarin discontinuation varied greatly in
multiple charts. The Form that was created provided signature space for acknowledgement of pre-procedure Warfarin discontinuation and post-procedure re-initiation. Case-by-case, initiating the Form’s use was responsibility of the nursing staff. Confirmation of the Form’s use was responsibility of the physicians. The Form was used in all cases involving pre-procedure Warfarin discontinuation. Appropriate filing of the Form was
responsibility of office and medical records staff. This was the weakest link in the process. 100% Form use was the goal.
10. What was the source of your data?
Other: Combination of patient paper chart, EMR and administrative data
11. What methods were used for data collection?
Retrospective chart review Electronic medical record
Prior to the implementation of the Form, methods of approval for discontinuation of Warfarin varied greatly. Review of patients’ office charts from 2007 until initial Form use revealed that 22 anticoagulated patients underwent 31 procedures. Approval as follows: Verbal-9; Written Prescriptions-5; Office Note-6; No Documentation-1; Multiple methods-3. If a patient had a procedure no more than one year earlier, staff accepted that Warfarin discontinuation
was "implied" on 11 occasions. Other than our "Post Procedure Discharge Sheet", that states the patient was to restart any prior medications as prescribed, there was no written record signed by patients who were told to restart their Warfarin. After implementation of the Form, 19 patients underwent a total of 24 procedures. 4 of 24 fully completed Forms (signatures of all required parties) could not be accounted for in the patients' office or hospital charts or in EMR. The pre-procedure portions were completed, but not the post-procedure portions.
13. Summary of Results/Lessons Learned
1. There was no written documentation in patients’ clinic charts indicating patients were specifically to restart or
were instructed to restart their Warfarin after a neuraxial procedure. This was also lacking in patients’ hospital charts. The Form has directly addressed this problem.
2. There were entirely too many inconsistent means of documentation acknowledging a patient could discontinue
3. Despite the goal of 100% utilization of the Form on cases involving Warfarin use, on 4 occasions fully
completed Forms never made it into patients’ clinic or hospital charts. It was believed to be due to inexperienced and inadequately trained office and medical records staff. Staff have been further educated.
4. Despite the quick identification of the documentation problem after the “sentinel event”, it still took
approximately 5 months to create, refine, receive hospital administration approval, and devise a method of implementing the Form. This process was entirely too long.
14. How did you change your practice as a result of this project
The project had a notable impact on how our office views all pre- and post-procedural anticoagulation in general. Warfarin discontinuation is no longer taken for granted simply because we abide by ASRA pre-procedural recommendations. Form use became mandatory in our office once it was put into effect. While “reconfirming” Warfarin discontinuation by other means is always acceptable, the Form is still the only recognized means by which Warfarin can be stopped. A procedure is not performed if the pre-procedural component of the Form is not
completed. On the complimentary side, a patient is not discharged from the recovery area if the post-procedural component of the Form is not completed. The Form is now not only mandatorily being filed in patients’ clinic charts but also in their hospital charts (to include EMR). In the future the Form may become mandatory for all hospital based procedures. The use of the Form is essentially 100% sustainable for the life of this clinic and hospital.
Robert Owen Newbury, M.D. Curriculum Vitae CURRICULUM VITAE PERSONAL DATA: Canadian, permanent resident of the United EDUCATION: POSTGRADUATE EDUCATION: Resident, Pathology (Anatomic and Clinical Robert Owen Newbury, M.D. Curriculum Vitae PROFESSIONAL EXPERIENCE: Children’s Hospital & Health Center Robert Owen Newbury, M.D. Curriculum Vitae Walw
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