UnChartThere’s been a discusssion on SupportCenter about Coumadin Plans.
Mal Riddell has offered his template:
Coumadin Plan TemplateMal’s process: We use a shortcut for our INR/PT patients that includes a 99211 charge for the most part. If I see them significantly, I delete the charge and add the appropriate charge after the visit. The template is a generic plan template and allows for changes in dose. The nurse loads the previous template in the current note (via the Shortcut) and adds the INR value. If it is within range, there is no change and the patient returns the following month. If needed, I can see the patient and make changes to the dose. I use a base of 5 mg tabs and alter the dose by ½ tab increments, based upon a weekly total dose.
Coumadin Algorithm
Personally, I do a coumadin algorithm process. In e-MDs, this lives as a pretty basic flowsheet. The rest of the process (remembering who is due, patient instructions, management decisions) are embedded in a set of paper documents below.
The Coumadin Documents based on the AAFP and Group Health Cooperative. These are my ‘Coumadin Algorithm’. Studies have shown that algorithmic coumadin management outperforms usual care — more time in therapeutic range and less complications. So I focus on the judgement issues (should you start? should you bridge for a procedure) and my nurse manages the rest.
Group Health uses a protocol driven approach. With that approach they have been able to reduce event rates in warfarin patients from 9.25% to 5.09% (as of 2007).
Group Health uses a custom relational database program called Dawn-AC to manage the anticoagulation for patients in western Washington. They use a systems approach to monitoring who needs testing, etc.
GH also has a protocol for initiating coumadin and bridging anticoagulation around procedures (in addition to monitoring). The scope of the protocol is broader than the AAFP published protocol.
The other benefit I’ve noticed is that having my nurse doing coumadin managment is a source of job satisfaction for her (she gets to do some real nursing) and the process is much quicker for patients than ‘routine management by a doctor.’
What parts does the doc do?
| Usual | AAFP | ME | |
|---|---|---|---|
| Recommending anticoagulation | x | x | x |
| Initiating medication | x | x | |
| Re-evaluating appropriateness | x | x | x |
| Approve ‘bridging’ plans for invasive procedures | x | x | x |
| Make ‘bridging’ plans | x | x | |
| Ordering Labs & Follow Up | x | ||
| Dosing Changes | x |
