Use of Pre-visit Patient Questionnaire
for Education and Self-Reporting
of Adverse Events
UCLA Anticoagulation Management Service
Jason S. Fish, MD, MSHS
Anticoagulation Management Service
UCLA Division of GIM and HSR
UK Users Group Meeting
October 5, 2010
UCLA
Anticoagulation Management Service
UCLA Labs
Physicians
NPs
Outside Labs
AMS
Home
Monitoring
Nursing
Homes
Staff
Home
Health
Two AMS Programs
Westwood
Santa Monica
Management
PCP
5 Physicians
Labs
Phlebotomy
Point of Care-Fingerstick
Computer System
DAWN AC
DAWN AC
Education
PCPs
initially
Staff routinely over the
phone
Computer
Current Enrollees
1010
303
Program:
informed consent and
education
Consult prior to entry
Staff routinely face to face
Safety and Quality of Care
Joint Commission National Patient Safety Goal
Goal 3E: “Reduce the likelihood of patient harm
associated with the use of anticoagulation therapy.”
Goal: a single management service or concerted
effort for the entire institution
UCLA Department of Medicine
Commitment to
Increased safety
Efficiency with reduction of duplicative efforts
Evidence Based Practices
Goals of Anticoagulation Management
Determine appropriateness of care
Manage anticoagulation dosing
Provide systematic monitoring and
patient evaluation
Provide ongoing education
Communicate with other providers
involved in the patient’s care
Sources: Ansell 2005, Wilson 2003, Ansell 2003
Sample of Online Tutorial
Limitations of
Current Healthcare System
Challenges of Open System of Healthcare
Tracking medication changes in real time
Tracking changes in health status
Coordinating care across multiple providers
Limitations of DAWN AC
System does NOT consider when dosing:
History of adverse events (recent/remote)
Other medications
Change in health status
Preparation for surgery
Risk Status (bridging or GI bleeding risk)
How Can We Address
These Limitations?
Option 1:
Do NOT address them and hope for the best
Option 2:
Hire staff to track patients across healthcare
settings
Difficult to implement and very costly
Option 3:
Develop patient education and reminder
system
UCLA Patient Education
All new patients undergo AMS consult to
determine appropriateness of care and educate
patient on anticoagulation risks and benefits as
well as review the online tutorial
All patients receive education pamphlets on
anticoagulation
But, does any of this work? Literature suggests
probably not too much benefit
UCLA Patient Education
What if we make concerted effort to remind
patients of important educational points at every
encounter?
Each visit for INR, patient completes questionnaire
with 15 key, evidence based questions
Key Reminders
Collects self-reported adverse events
On dosing reports, patient receive key reminders
about changes in medication
Patient Questionnaire
Questionnaire and DAWN AC
Questionnaire and DAWN AC
2009-10 Data
POCT site with patient education
% Time INR in Range by Site
% Time INR in Range
80.00
75.00
70.00
IMS
Cardiology
65.00
SM
60.00
55.00
50.00
November
February
May
August
November
February
Status Quo
2010 Data: All Sites with POCT
and Patient Education
Site 1: Average >70%
Site 2: Trending to 70%
80.00
70.00
Goal: > 70%
60.00
IMS-POCT
50.00
IMS-Combined Non-POCT
40.00
Cardiology
30.00
SM
20.00
10.00
Introduction of POCT/Patient Education Site 2
be
r
Se
pt
em
t
Au
gu
s
Ju
ly
Ju
ne
ay
M
Ap
ril
M
ar
ch
0.00
Status Quo
Next Steps
Develop Adverse Event tracking
Physician Feedback
Gratitude
Syd Stewart
Louise Pearson
Heather Stevenson
4S – DAWN AC
4S – DAWN AC
4S – DAWN AC
Brandon Koretz, MD
AMS Staff
UCLA Medical Director