Every patient is assigned a primary nurse who is accountable to the patient and family for the initial and ongoing assessment and development of a patient-specific plan of care. An associate nurse serves as backup to the primary for continuous coverage.
The primary nurse meets with the patient in the hospital to discuss the transition process and provide anticoagulation education. At this point, the nurse begins treatment to get the patient to therapeutic range, which takes 7-14 days and may involve interfacing with home care RNs.
Once the patient is in therapeutic range, s/he meets with the nurse for one hour for medication and anticoagulation management teaching. After this visit, the RNs primarily interact with patients via mail and phone. AMS RNs try to see patients if/when they come in to MGH, but this is rare, usually only occurring if a patient is having a difficult time managing medications (more common with the elderly where it is dementia-related).
The Nursing Model for Anticoagulation Management at MGH currently staffs nine FT RNs, who manage a panel of 400-500 patients each, for a total of about 4000 patients. Approximately, 80 percent of the patients are stable; they receive monthly blood tests and remain on same dosing schedule. Only 20 percent require more frequent monitoring and regular RN interaction.
The RN positions are Monday through Friday salaried positions, with weekend rotations. Each primary RN partners with associate RNs for support. In addition, 2 patient service coordinators (clerical secretaries) serve as support staff.
Knowing the patient is key to ensuring effective anticoagulation management. The nurse weighs relevant clinical and behavioral characteristics that influence patterns of absorption, distribution, metabolism, and elimination of warfarin. By staying in close contact with patients and considering the influence of poly-pharmacy, life style issues, compliance, procedures and significant bleeding and clotting events, the nurse is able to more effectively interpret laboratory levels and make dose adjustments that ensure therapeutic efficacy and avoid life-threatening adverse events.
This patient-centric approach to therapeutic warfarin monitoring enhances computer algorithms to support individualized dose decisions.
The nurse patient relationship is central to a therapeutic anticoagulation experience. The nurse together with the patient and her/his family collaborate with multiple disciplines, in the wide range of communities in which they are treated to deliver safe, effective anticoagulation care.
MGH invested in a computer system that imports data directly from the laboratory and makes suggestions for dosing and testing intervals. The system allows MGH to track all patients who live throughout New England and even further; labs can be sent in from anywhere. The system includes important information on each patient including medication interactions, which allows patients to be stratified based on risk for adverse events. The primary RN reviews, authorizes, and prints out the dosing instructions.
In cases where there is no change or a minimal change in dosing, instructions are sent by mail to the patient (on average 350 dosing instructions per day are mailed out). In cases where there is a significant change to dosing, the primary nurses will call the patient and bring him or her into the clinic or ER, depending on what is needed.
In addition, the model deploys technology to improve RN-MD communication. They invested in pagers for immediate response, and established a general email account for physicians to easily reach the team. An AMS icon is prominently displayed on MGH’s outpatient/inpatient electronic medical record; clicking on this icon yields important information on who the primary AMS RN is, the patient’s latest labs, and direct links to contact AMS. Finally, the system emails physicians for annual renewal orders and assessments or to confirm completion of therapy.
