April 9, 2014

Improving Safety for Patients on Warfarin Therapy

by Cathy Mellett, contributing writer, PRMC

Orthopaedic Surgery/Anticoagulation Service partnership helps meet National Patient Safety Goals for high risk medication

A partnership between the Department of Orthopaedic Surgery and the Anticoagulation Service improves patient safety for orthopaedic patients who are on high-risk/high-alert Warfarin therapy.


Brian Kurtz, PharmD, and Shelley Howells, LPN, from Anticoagulation Services, discuss a patient referral.

Post-operative Orthopaedic Surgery joint reconstruction patients typically receive anti-clotting medications such as Warfarin (Coumadin) to prevent deep vein thrombosis (DVT)—blood clots in the calf or thigh. This is a life-saving but high-risk/high-alert medication because staff must closely monitor the therapeutic levels in the blood.

In fact, the Joint Commission has made reducing the likelihood of patient harm associated with anti-clotting medications a National Patient Safety Goal.

Back in 2012, U-M faculty, staff — and most importantly patients — were dissatisfied with the level of management this high-risk population received. So, in January 2013, a multidisciplinary team formed to tackle the issue – as one of the inaugural “Lean – Train the Trainer” Projects under the Michigan Quality Initiative.

Using several lean tools, the team identified tasks within their control that they could change to improve the process to identify and monitor patients—and to get them started in the service.

“After several meetings, we aligned clerical work with clerical staff and significantly reduced the involvement of the clinic/phone triage nurses and Joint Service mid-level providers associated with managing these patients,” says Dorothy Nalepa, administrative manager of the Taubman Center Orthopaedic Surgery Clinic.

With the new process, clerical staff follow the patient from hospital discharge to the skilled nursing facility (SNF), if there is one, to the point of care when the Anticoagulation Service enrolls them into their service. If there is a gap in the process, they are immediately aware and are able to take corrective action.

The Anticoagulation team starts managing the patient during their inpatient hospitalization so that upon discharge there is a seamless transfer of care between the inpatient and outpatient Anticoagulation Services.


Malory Corl, medical assistant specialist for Joint Services, talks with nursing homes about patient discharges.

“The Anticoagulation Service, on both the inpatient and outpatient teams, is committed to managing anticoagulation care starting on the day of surgery until therapy completion. We also work closely with the Orthopedic Surgery department to create a seamless transition of care when patients leave the hospital,” says Brian Kurtz, PharmD, pharmacist with the Outpatient Anticoagulation Service.

Before the team launched its new process on January 9, 2013, it took an average of 3.4 days for a discharged patient to be enrolled with the Anticoagulation Service.

At the end of June 2013, with the new process in place, a total of 240 (74 percent) of the discharged-to-home patients were enrolled — with an average length of time to enrollment of 1.3 days—a 38.2 percent improvement.

Previously, patients who stayed at a skilled nursing facility (SNF) were not enrolled with the Anticoagulation Service following discharge from the facility, unless their enrollment period would exceed 14 days. Eliminating the 14-day requirement improved the patient’s continuity of care.

Since the new process began, a total of 85 patients (26 percent) discharged from an SNF were enrolled — with an average length of time to enrollment of 1.3 days.

Importantly, the group met its goals of:
• identifying 100 percent of post-operative Orthopaedic Joint Service patients discharged on Warfarin therapy,
• monitoring these patients until enrollment in the Anticoagulation Service, and
• improving faculty, staff and patient satisfaction.

The team has also added joint replacement patients from the Trauma Service to the process.

“The foundation of our success was the development of a true partnership between Orthopaedic Surgery and the Anticoagulation Service as well as an unwavering commitment to do what was in the best interest of the patient,” Nalepa says.

The Anticoagulation Service is looking to expand this process to other areas.

The following team members carried out this process improvement work:
Dorothy Nalepa, Administrative Manager, Orthopaedic Surgery
Carolyn Cole-Brown, Department Administrator, Orthopaedic Surgery
Andrew Urquhart, M.D., Associate Professor of Orthopaedic Surgery
Susan Sell, Project Senior Manager, Ambulatory Care Services
Hilary King, Nurse Manager, Ambulatory Care Services
Brian Kurtz, Clinical Pharmacist, Ambulatory Cardiology / Anticoagulation Management
Janice Norville, Director of Clinical Operations for CVM Special Programs
Faculty and Staff of the Orthopaedic Surgery Department
Faculty and Staff of the Anticoagulation Service Program