1. Overview:
Recent FDA approval of Target Specific Oral Anticoagulants has made it more conve-
nient to treat acute venous thromboembolic events (VTE) in the outpatient setting,
With increasing health care costs and reduced reimbursement, it is imperative that
health care systems develop programs to enable more effective transitions of care.
Patients presenting to the emergency department (ED) with VTE may be able to be
safely discharged directly from the ED in appropriately selected patients utilizing a
comprehensive transition of care program.
We will outline the steps involved in implementing a comprehensive care transition
program:
Jeff Fast: Facilitating Anticoagulation for Safer Transitions and associated outcomes.
Objective:
Describe the key elements of care that help to assure safe transitions when treating
patients with acute VTE.
Identify challenges to assuring that patients will be able to access their treatment and
adhere to therapy.
Describe our experience with implementation of the program and its evolution.
Methods:
Step 1: Identification of Key Program Components
A multidisciplinary team consisting of pharmacists, physicians, nurses and case man-
agers identified the key components necessary for a comprehensive and consistent
transition of care process for patients with acute VTE seen in the ED. These included:
- Appropriate patient selection
- Appropriate anticoagulant selection
- Patient education
- Medication procurement
- Well defined outpatient follow-up plan
- Staff knowledgeable in the process
Step 2: Creation of Order Sets and Educational Materials
Patient Assessment and Selection:
In order to assure appropriate patient selection and enrollment the following were created:
- An order set with required labs and studies
- Eligibility criteria for patient enrollment
- Admission criteria
After assessment, a process was developed for consistent management:
1. An order for “Jeff Fast Enrollment” is entered in our CPOE computer system
2. A controlled setting was identified in the ED Observation Unit. Eligible patients
would be transferred to this area for program enrollment where nurse
practitioners, case managers and pharmacists see each patient prior to discharge.
Anticoagulant Selection:
Anticoagulant guidelines for use were developed
Patient Education:
Standardized patient education forms for each anticoagulant and the disease process
were created and made available on the intranet and in the ED computer system. All
educational materials are printed out for the patient as part of the discharge process.
Plans were made for patient education by a core group of nurse practitioners and
pharmacists in the ED Observation Unit, which is quieter and more conducive to the
learning process.
Discharge Planning Process:
A standardized discharge process was created and encompasses the following com-
ponents:
- a case management process was developed for insurance screening
- required prescription is to be called in to a designated pharmacy and as
sure is ready for pick up prior to discharge
- Outpatient appointment for follow up must be arranged within
3 – 5 days at either patient’s PCP or at our Vascular Center
- Process was created for communication of care plan by nurse
practitioners in the Observation Unit to designated PCP
Staff Educational Tools:
A formal educational program with slide presentation was created
Streamlined education documents for providers were developed:
- Clinician Education Guide
- Pocket Card: outlining necessary labs, history, inclusion / exclusion
criteria and anticoagulant selection
All materials were placed on the intranet for quick reference
Patient Tracking System:
Selection of the “Jeff Fast” order set in our CPOE system creates an ongoing list of
patients enrolled.
Our pharmacy program coordinator will check the list on a daily basis and make
follow up phone calls to the patients to insure:
- Medication adherence
- Timely follow up with designated practitioner
- Assess for development of any adverse events
Plans were made for our coordinator to:
- Schedule appointments with our Vascular Center staff, on an as needed
basis
- Collect outcome data, with follow up phone calls within 3 days and at 30
days post-discharge
- Administer a patient satisfaction survey
Step 3: Development of Assessment Tools
Telephone Questionnaire
Outcome Assessment Worksheet for data collection on:
- DVT location
- Did patient meet criteria for program inclusion?
- Medication adherence
- Bleeding, thrombosis, and other medication-related adverse events
- 30 Day readmission rate (ED visit or hospitalization)
Patient Satisfaction Survey
Step 4: Staff Education and Program Implementation
- A formal education program with slide presentation was created by Laura
Falconieri and presented to the ED staff in 2014 at the time of program implementa-
tion
Step 5: Assessment of Program’s Impact and Program Refinement
- Program implementation occurred January 2014
- Pre and post implementation data was collected (pre October 2013 – 2014)
and preliminary findings were published in the journal of Hospital Practice
in October 2014.1
- Follow up data on the program’s impact has been collected on an
ongoing basis
Program Flow Process
Jeff FAST DVT Discharge Program – Clinician Management Guide
Jeff Fast Pocket Guide
Patient Education Guide: DVT Process
Results:
Patients enrolled were identified from the CPOE order entry system for patients with
a “Jeff Fast” program enrollment order. A preliminary analysis of pre- and post-
program analysis was completed for the time periods of October to December 2013
(pre-implementation) and January to March 2013 (post-implementation).1 Preliminary
findings completed in 2014 showed no patients at the 3-5 day and 30-day follow up
time period had any issues with their anticoagulant, nor reported any significant
hemorrhagic associated adverse events. One patient was re-admitted after discharge
with a PE. Patient satisfaction with the program was high, at 100%.
Further data was collected on an ongoing basis for a one year time period of April
2014 through March 2015. The findings from this one year time period are as follows:
A total of 28 patients were identified from the CPOE system.
2 patients were excluded from the program due to lack of evidence of a VTE based
upon radiologic studies.
1 patient was not discharged from the ED, but was admitted for six days for
management of disease states unrelated to the VTE diagnosis (malignancy).
Gender:
Gender was relatively
equally distributed.
Age:
There was a wide range of patient age
from 21 to 88 years. The average
patient age was 52 years old.
Thrombosis Type:
Breakdown of type of VTE
location was as follows:
1 patient was diagnosed with a
superficial thrombus (muscular
branch).
1 patient was diagnosed with a
PE and was determined to be
eligible for enrollment after
observation for 24 hours. There
was no evidence of a deep vein
thrombosis (DVT), ECHO was
normal, the PESI score was low
at 12 and vital signs were stable.
2 Upper Extremity DVTs, one was associated with a central catheter and one was felt
to be due to repetitive upper extremity exercise.
7 patients had unilateral distal lower extremity DVTs
10 patients had unilateral proximally located DVTs
4 patients had unilateral combined proximal and distal DVTs
2 patients were diagnosed with extensive bilateral lower extremity thrombi
Insert Figure 3: Thrombosis Type
Comorbidities:
Most of these patients had
complicated histories /
comorbidities: many pre-
disposing to the
development of VTE. They
included:
Drug Selection:
Medications were selected
based upon renal / liver status,
considerations related to
comorbidities (such as
malignancy), patient preference
and prescription coverage. One
patient with a superficial
thrombosis was discharged on
ibuprofen. The remainder of the
patients with a DVT / PE was
treated with either enoxaparin,
an enoxaparin bridge to warfarin
or rivaroxaban.
Length of ED Stay:
Length of stay in the combined ED / Observation Unit ranged from 2 to 23.8 hours,
with an average time period of 4.9 hrs. Time period appeared to be unrelated to time
of presentation to the ED, but mainly depended upon complexity of the patient.
Longer times were required for monitoring patients with recent surgery, acute PE,
more extensive thrombosis and active malignancy. Difficulty with obtaining
outpatient medication, such as the requirement for prior authorization, was a
factor in delaying some discharges, but did not require hospital admission.
Readmission:
30 Day Readmission for VTE related complications to either the hospital or ED was 0%
Other Clinical Outcomes:
One patient experience a minor bleeding event of bleeding gums within the 30 day
follow up time period. This resolved without intervention and anticoagulation was
continued (enoxaparin bridge to warfarin patient).
There was no incidence of re-thrombosis or worsening symptoms related to VTE.
Patient Adherence:
By the 30-day follow-up call, 100% of patients had a follow-up outpatient appoint-
ment, with an average time to the follow-up of 4.4 days (range 1-7 days). Several
patients did require our coordinator to schedule a follow up appointment at our
Vascular Center within the initial 3 – 5 day follow up period, when patients did not
see their PCP for various reasons.
Patient Satisfaction:
Patient satisfaction with the program was 100%, with all patients at the 30-day call
indicating they would recommend the program.
Discussion:
Clinical outcomes for the enrolled patients were quite good, considering many had
significant comorbidities and some with extensive VTE disease. Many of these
complex cases were seen by our vascular consult service and determined to be safe
for discharge with a short follow up time period in the Vascular Center within a few
days.The educational components of this program were essential to ensuring a
successful transition-of-care program for patients with acute uncomplicated DVT.
Reassessment of the program is ongoing and dynamic to allow any necessary
changes to the program to ensure it remains current, sustainable, and patient / pro-
vider friendly.
This program has evolved to include:
Creation of an app that can be downloaded to a smartphone / tablet for increased
convenience of use.
Expansion to include other anticoagulants as they become available, such as
apixaban for the treatment of VTE.
Creation of acute care slots within the Vascular Center, so that patients can be
conveniently seen the following day, if necessary by a physician, nurse practitioner
or pharmacist after discharge from the ED.
Conclusions:
This program has been effective in safely transitioning patients with acute VTE from
the ED to the outpatient setting.
Positive feedback has been obtained from clinicians: they value having a guide that
helps clarify when a patient is appropriate for discharge, as well as the steps
necessary to assure appropriate care transitions.
Challenges we have faced include:
- Problems with medication coverage, especially with some Medicare Part D plans
- Difficulty with reaching a large number of staff on a continual basis to assure
all are educated and follow the guidelines. This is mainly due to the ongoing
rotation of house staff in the ED department. Fortunately the staff in the
Observation Unit is relatively stable and small, where the majority of the
enrollment process occurs.
The program has gained significant attention by hospital leadership and plans are in
place to program expansion throughout the health system.
This model is easily adaptable to other anticoagulants and other health systems.
References:
1. Falconieri, L, et al. Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency
department deep vein thrombosis discharge program. Hospital Practice;42(4):16-45.doi10.3810/
hp.2014.10.1140.
Special thanks to Laura Falconieri who worked tirelessly on implementation of this
program as her PGY2 residency project and Julia Spross who collects follow up
data on an ongoing basis as part of our quality control program.
Facilitating Anticoagulation for Safer Transitions: Outcomes from an Emergency
Department Deep Vein Thrombosis Discharge Program
Lynda Thomson, Glenn Oettinger, Robert Pugliese, Geno Merli, Julia Spross
Thomas Jefferson University Hospital, Philadelphia, PA, United States
Comorbidity
Dehydration / Elevated Hematocrit associated
with DM medication
PMH of PE
PMH of DVT
Cancer (no active treatment)
Recent Surgery (1 torn quadricepic repair,
3 spine surgeries, 1 facial surgery)
Advanced Cardiac Disease (cardiomyopathy)
Trauma (fall, ankle fracture)
Paraplegia
Infection (cellulitis)
Hormonal Use (oral contraceptive)
Ulcerative colitis
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