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Tell us about the excellent care that happens in your service and help others learn from your experiences. Please share your example of an innovative and successful solution to challenges in patient care or service management. Examples should be specific and focus on one particular aspect of your service.

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The Massachusetts General Hospital, Boston, Massachusetts

Corin R Gigler, BSN, RN, CACP
Walter J Moulaison Jr, MSN, MBA, RN
([email protected])

Anticoagulation Management Service: Overseeing Patient Compliance within the AMS

The Massachusetts General Hospital Anticoagulation Management Service (MGH AMS) takes a patient-centric approach to therapeutic warfarin monitoring. Overseeing patient compliance with treatment is an important part of this approach. Noncompliance management is a 5-tiered process. The first 2 steps of the process are completed by the administrative staff in the clinic. Therefore, valuable nurse time can be directed to the more challenging issues identified by the nurse as barriers to compliance should patients move on to steps 3 and beyond. Our multi-disciplinary approach, using both administrative and professional resources is an important aspect in how AMS accomplishes the noncompliance process.

The MGH AMS depends on database queries using, Dawn AC© to create “watch” lists for monitoring patient compliance according to the framework outlined in table 1. In fiscal year 2012, approximately 87% of scheduled tests were completed as instructed. Of the 13% requiring reminders, 73% were first notices indicating no INR was received 3 days after a scheduled test. Although this is a significant percentage, it is important to note that more than 55% of these patients heed the reminder and proceed to test their INR as instructed. Those that still do not test receive a second notice after which 48% of these patients then test. First and second notices are intended as helpful interventions to promote compliance and decrease the numbers of higher level noncompliance notices.

* 4S Dawn Clinical Software, 4S Information Systems Ltd., 4 The Square, Milnthorpe, Cumbria England UK LA7 7QJ Mass general center of excellence submission.doc

The most therapeutic aspect of the anticoagulation experience at MGH AMS is the relationship a patient has with his nurse. Though the MGH AMS relies on a robust noncompliance process, we work collaboratively with patients, families and referring physicians to provide for the highest quality patient care and safety through consistent direct communication to avoid noncompliance. The goal is to improve adherence, not discharge patients. Every effort is made to maintain patients who need our service within our program, however, chronic noncompliance may require agreed upon patient-specific strategies and unfortunately discharge from service may be necessary. Data collection over several years demonstrates positive outcomes from a consistent process and collaborative effort to improve patient compliance with INR testing. The result is decreased numbers of final notices and rarely, discharge from AMS service (figure 1).

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