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SE2EOj, Anticoagulation and VTE Prevention - Education Subcommittee October 7 2010.pdf
Venous Thromboembolism Prevention and Anticoagulation Safety Education Committee
Joint Commission National Patient Safety Goals (2010)
GOAL 3: Improve the safety of using medications
Requirement
NPSG.03.05.01: ANTICOAGULATION –
Reduce the likelihood of patient harm
associated with the use of anticoagulation
therapy.
Responsible
Committee/
Person
Pharmacy
Service
Raja Zeitany
Mark Baje
Physician
Director
Alpesh Amin
Policy
Measurement
Required?
Documentation
Required?
NO
YES
Gaps
EP-7: Education program for staff,
patients and families, with the
following components
Importance of follow-up
monitoring
Compliance
Drug-food interactions
The potential for adverse
drug reactions and
interactions
EDUCATION SUBCOMMITTEE
ROLES/RESPONSIBILITIES
Patient, family education
Staff education
Educational materials
Outcomes and deliverable should address
therapeutic and prophylactic management
OUTCOMES/DELIVERABLES
Implementation of an inpatient education
program for patients and families
Implementation and documentation of
appropriate staff education
Implementation of educational
materials/resources
DUE
Patient education plan: Sept 2010
Staff education plan: Sept 2010
Roll-out of education: Sept - Oct 2010
Patient Personal Recovery Plan: Oct 2010
Roll-out of the PPRP: Oct 2010
ACTIONS TAKEN:
10/7/10: Donna Grochow, Lynn Willis, Bobbie Jingle, Victoria Malonzo, Jung-Ah Lee
Action Items:
1. Education Proposal and Timeline: Continue with proposed timeline
2. Personal Recovery Plan:
a. Committee consensus determined that there was no need for a Personal Recovery Plan
3. Staff Education Materials:
a. Develop self-learning module:
i. To introduce VTE and anticoagulation to staff
ii. Identify UC Irvine specific screening tools
iii. Identify UC Irvine specific treatment regimens
iv. Identify UC Irvine patient education tools
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4.
5.
6.
7.
v. Utilize Computer Based Training: Stop the Clot®: What Every Healthcare Professional Should Know Patient Education Materials
vi. Utilize AACN Venous Thromboembolism Prevention educational module
Research Component:
Nurse Survey: Donna Grochow to send out to staff on 10/18.
Discharge Summary-Quest
a. Reviewed what is available in Quest. Discharge instructions adequate in Quest. Only 2 meds listed: Lovenox (Enoxoparin) & Coumadin (Wafarin)
b. New medications will be added to list as needed per Quest team.
Lovenox kits: Victoria to follow-up with Raja
9/9/10: Donna Grochow, Maurcie Espinoza, Lynn Willis, Carolyn Lem, Marianne Lovejoy, Victoria Malonzo
Action Items:
1. Committee agreed to change meeting to monthly-Donna Grochow will resend outlook invitation
2. Education Proposal and Timeline: Review at next meeting
3. Staff Education Materials: Donna Grochow will bring self-learning module for review, AACN Venous Thromboembolism Prevention education to be utilized
as foundation for nursing education.
a. Develop self-learning module:
i. To introduce VTE and anticoagulation to staff
ii. Identify UC Irvine specific screening tools
iii. Identify UC Irvine specific treatment regimens
iv. Identify UC Irvine patient education tools
4. Utilize Computer Based Training: Stop the Clot®: What Every Healthcare Professional Should Know Patient Education Materials
5. Research Component:
a. Nurse Survey: Donna Grochow to send out to staff. AHRQ video is primarily directed at patients receiving treatment.
6. Discharge Summary-Quest
a. Carolyn Lem and Bobbie Jingle to review what is currently available in the Quest Discharge Summary-Will report at next meeting.
7. Lovenox kits: Victoria to follow-up with Raja
8/26/10: Donna Grochow, Victoria Malonzo, Marianne Lovejoy, Carolyn Lem, Bobbie Jingle and Lynn Willis.
Action Items
1. Staff Education Materials: Still pending-Will be available for review at 9/9/10 meeting.
2. Patient Education Materials: Jung-Ah to provide link to Donna Grochow. Donna Grochow to send out to staff. AHRQ video is primarily directed at patients
receiving treatment.
3. Lovenox kits: Victoria to follow-up with Raja.
8/19/10: Donna Grochow, Victoria Malonzo, Marianne Lovejoy, Carolyn Lem, Kathleen Nguyen and Lynn Willis.
Action Items
1. Staff Education Materials: Still pending
2. Patient Education Materials: Jung-Ah to provide link to Donna Grochow. Donna Grochow to send out to staff. AHRQ video is primarily directed at patients
receiving treatment.
3. Process Flow: Revised during meeting.
4. Lovenox kits: Victoria to follow-up with Raja.
5.
Anticoagulation Program Implementation Schedule: The group discussed the how the pending action items would fit into the current Nursing Education
priorities and the impact on the implementation schedule. All agreed that both components of the staff education and full implementation of the
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6.
patient education handouts could be accomplished by October. Lynn Willis revised the Education Subcommittee portion of the implementation
schedule during the discussion. ACTION: Donna Grochow to present changes to Steering Committee.
Personal Recovery Plan: The team discussed incorporating the patient personal recovery plan into the October full implementation of the patient
education plan. Marianne Lovejoy stated that the VTE team was preparing to update the Clinical Pathway and that the personal recovery path
(PRP) should parallel those changes. The team agreed that the Clinical Pathway and PRP should be developed in parallel and that the PRP
should be part of the October implementation. ACTION: Marianne Lovejoy to assist Donna and Lynn with the development of the PRP.
8/12/10: Donna Grochow, Jung-Ah Lee, Bobbie Jingle, Lynn Willis and Carolyn Lem
Action Items
a.
b.
c.
d.
Staff Education Materials: see below
Patient Education Materials: See below
Process Flow: see below
Lovenox kits: Paula to follow-up
2. Staff Education Materials: The IRB approved the staff education survey. Jung-Ah has survey ready and would like to have it available for 30 days with
weekly reminders. She is hoping for 500 responses. There was some discussion about whether staff was inundated with surveys and if a sufficient
response rate would be possible. There was also some discussion about whether it would be appropriate to delay the training for 30 days. Donna
explained that the training could be separated into two parts: 1] diadactic/theory of anticoagulation, and 2] nursing role in patient education. Donna
explained that the nursing role in patient education should be part of the roll-out of the new teaching plans and should not be delayed. All agree that the
training could be separated and if the survey was designed to test generalized knowledge that having it available for 30-days would be reasonable and
would yield usable results. ACTION: Jung-Ah to email survey link to Donna. Donna to speak with Karen Grimley about sending out survey emails. Donna
to complete staff education module.
3. Patient Education Materials: Donna shared drafts of the patient education materials. Carolyn Lem brought additional information. There was additional
discussion on the content of the patient handouts and appropriate populations. There was also discussion about the AHRQ video and whether it was
useful for patient education on both prophylaxis and treatment or just one of the populations. Finally, there was discussion about access to the patient
education materials and whether they would be ready in time for the roll-out of the new teaching plans. Donna explained that the initially the ideal location
for the handouts would be on the Nursing SharePoint which is currently used to house other patient education materials. ACTION: Carolyn to email
Donna additional information for the patient education handouts. Donna to finalize patient education materials. All should review AHRQ video.
4. Process Flow: ACTION: Lynn to revise based on today’s discussion.
5. Donna to send invites for future meetings. Marianne Lovejoy to be added as a alternate for Lynn Willis
7/14/10: Donna Grochow, Marianne Lovejoy, Jade Yang, Gwen VanServellen, Jung-Ah Lee, Bobbie Jingle, Brooke Baldwin, Marra Williams, Kathleen Nguyen,
Victoria Malonzo, Paula Luna and Lynn Willis
1. Actions Items:
a. Staff Announcement: Done
b. VTE materials from Dr. Dangodara to Donna and Marianne: Done
c. Staff Education Materials: See below
d. Process Flow: See below
e. Lovenox kits: deferred to August. Paula will work with Raja
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2. Patient Education Materials: Donna presented two flyers, one generalized and one specific to medications. Group agreed that there should be a
medication hand-out should be specific to each medication and that there should be a combo-sheet with LMWH and Coumadin. Group also agreed that
the dietary information should be included on appropriate medication handouts. There was discussion about the best way to access the handouts once
finalized. Group agreed that the nursing SharePoint would be the ideal location since the primary responsibility for patient/family education would fall to
nursing. There was also some discussion about whether the AHRQ video was appropriate for both the treatment and prophylaxis groups. ACTION: Jade
to provide food-drug interaction information for the patient education flyer. Team to review handouts and provide input to Donna by end of business today.
Donna to compile edits and send out next iteration for review by Friday. Team to review AHRQ video and confirm that it is appropriate for both groups.
3. Staff Education Materials: Donna presented a draft of the staff education module. There was a discussion about roll-out of the module in consideration of
the pending Joint Commission visit. All agreed that it would be difficult for nursing to do the module next week, but a 1 page reminder sheet on Monday
would be appropriate. Jade requested that the module be completed by Monday so that she can start her staff training regardless of Joint Commission
presence. ACTION: Jade to provide staff education material on food-drug interaction. Donna to finalize first iteration of staff education module and send
out to the team. Team to respond with changes within 1 day. Donna to finalize module by Monday.
4. Process Flow: Process flow was discussed in context with the above. ACTION: Lynn to redraft process flow.
6/28/10: Dr. Amin, Donna Grochow, Paula Luna, and Lynn Willis
1. Patient Education Materials:
a. Team was aware that the AHRQ video was available in the on-demand system. ACTION: Lynn and Donna to work with Andrea Herbert on an all
staff announcement
b. Team reviewed a “Preventing Blood Clots” document by Donna Grochow geared toward VTE prevention at discharge.
c. Team reviewed Preventing and Treating Blood Clots with Anticoagulant Medications document prepared by Kathleen Nguyen. Team agreed that
a single document for each medication would be more appropriate. Team also agreed that these handouts ideally would be given at the time the
medication is initiated and also at discharge.
d. Team discussed whether a single page document for VTE prevention during hospitalization would be helpful or whether a personal recovery path
would be more appropriate. Team agreed that the educational materials for VTE prevention we very dependent on the final QUEST order sets.
ACTION: Donna to get VTE materials from Dr. Dangodara.
2. Staff Education: Team agreed the 4 components of staff education should be: 1] General information about anticoagulation, 2] VTE prevention, 3]
Treatment of VTE, and 4] Patient Teaching. ACTION: Donna to work on staff education module. Lynn to draft process flow.
6/22/10: Focus group on education: Donna Grochow, Jade Yang, Kathleen Nguyen, Victoria Malonzo, Brooke Baldwin, and Lynn Willis
After much discussion, the group agreed to the following
1. Target Audience for education: 1] patients and families, 2] Staff: Nurses, Dieticians and Pharmacists
2. Components of staff education: 1] Clinical knowledge of anticoagulation management and VTE prevention and treatment, and 2] what to teach the patients
3. Approach to staff education: 1] Pre-learning packet/module and 2] 1:1 by Nurse Educators and Unit Managers during patient education.
4. Approach to patient/family education: 1] videos, 2] handouts, and 3] 1:1 with a focus on teach back
ACTION ITEMS:
1. Kathleen to provide basic staff level information on anticoagulants
2. Jade to provide basic staff level information on food:drug interactions and Vitamin K restrictions
3. Lynn to provide information on current VTE risk assessment in TDS
4. Donna and Brooke to develop staff module
5/14/10: Dr. Amin, Donna Grochow, Jade Yang, Kathleen Nguyen, Jung-Ah Lee, Gwen Van Servellen, Maurice Espinoza, Victoria Malonzo, Paula Luna and Lynn
Willis. Guests: Marra Williams
1. Patient Educational Materials: The team reviewed the two pamphlets from AHRQ, “Your Guide to Preventing and Treating Blood Clots” and “Blood Thinner
Pills: Your Guide to Using Them Safely.” There was much discussion about whether the pamphlets covered the core topics that were important to UCI
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patients and would align with our process. There was also discussion about LMWH and the best approach to patient/family education. Cost was also
discussed. Lastly, implementation timing was discussed. Final decisions were:
Educational materials and training for Staff will roll out on July 6 with a goal of full implementation of the educational plan for patients/families by
July 15, 2010
AHRQ pamphlets would be used to start the program. Feedback from nursing and patients/families on their value will be sought during the first 36 months of implementation. Depending on feedback UCI will either continue to use these pamphlets or develop an internal version. ACTION:
Marra to order pamphlets.
AHRQ video will be used. It will be available on demand in the Douglas Hospital. There is loaner vcr equipment available for patients in the
Tower until the on-demand system can be fully implemented there. ACTION: Marra to order videos and put into on demand system.
The kits available from the pharmaceutical manufacturer will be used for Lovenox teaching. ACTION: Victoria and Raja to work on having the kits
available as an item that can be order from Pharmacy.
Insufficient information is in the materials on heparin and other medications might be better explained. ACTION: Kathleen to work with Donna on
a supplemental sheet to add to the pamphlets.
Donna will include the cost of the pamphlets etc in her budget for this year. Moving forward a budget for educational materials should be
proposed.
A Clinical Pathway and Patient Recovery Plan would be ideal tools in the long-run. ACTION: Lynn and Donna to meet with Tania Bridgeman
2. Physician and Staff Education:
Staff Education: The AACN Venous Thromboembolism Alert was reviewed. There was discussion about the need for staff education and the best
approach to education. Based on the AACN Alert, nursing education should incorporate clinical information on anticoagulation safety, VTE
prevention, as well as information on what to teach to patients and families. Because of the complexity of the topic, the proposed approach will
include a self-direct module as well as in-person education. ACTION: Donna to lead a focus group with Pharmacy, Nutrition and Nursing on roles
and content. Lynn to schedule session.
Physician Education: Dr. Amin suggested several areas that should be covered for physician education preferably in a video or CBT type format.
Anna is familiar with a module that may already be available. ACTION: Anna to provide module. Next Subcommittee meeting to focus on
physician education
3. Process Map: reported provide by D. Grochow for J. Skau. Process map is in progress and will be aligned with the teaching plan following the focus group
meeting.
5/18/10: Dr. Amin, Donna Grochow, Bobbie Jingle, Jade Yang, Kathleen Nguyen, Jung-Ah Lee and Lynn Willis, Mo Espinoza, Marra Williams, Parmis Khatibi,
Marianne Lovejoy.
1. Steering Committee update: Dr. Amin updated the Subcommittee on the addition of the VTE prophylaxis component to the overall mission of the
Anticoagulation Safety Program noting that one of the outcomes/deliverables for the VTE subcommittee is a gap analysis of our process compared to the
th
8 ACCP Consensus Guidelines. Dr. Amin also shared that he would be presenting the Anticoagulation Safety Program to the new Medication
Management Committee on Wednesday. ACTION: Lynn to refer gap analysis to VTE subcommittee.
2. Process map: Deferred. J. Skau not present
3. Patient Education: Marra and Donna presented educational materials from various sources including AHRQ noting that the AHRQ products including the
videos are free. There was much discussion on the approaches to patient education next steps. Key points included:
The “Ask me 3” approach” which focuses on addressing: 1] How does this affect me?, 2] Why is it important?, and 3] What can we do about it?
The use of the common approaches to patient education: 1] written material, 2] videos, and 3] 1:1 teaching. The group agreed that the use of all
three modalities was preferred. The group suggested the use of flip-charts for the 1:1 teaching to provide consistency.
The group also agreed that the education should address treatment, prophylaxis and the transition to outpatient care
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4. The group discussed the QUEST Screens and the current TDS VTE screens as well as the orders for VTE. None of the subcommittee members felt
certain about the process. ACTION: Request VTE and QUEST subcommittees provide additional information at the next Education Subcommittee
meeting.
5. The group also discussed the various VTE prophylaxis measures that are being collected. The Education Subcommittee felt that a better understand of
the measures as well as the current VTE prophylaxis ordering process would be helpful. ACTION: VTE subcommittee to present to the Steering
Committee the criteria and current performance in the various VTE related measure sets (SCIP, CHART, NSQIP). VTE subcommittee to outline the
current VTE prophylaxis risk assessment (i.e. TDS screens), ordering process and education process.
5/4/10: Dr. Amin, Terry Donnely (for Victoria Malonzo), Paula Luna, Donna Grochow, Jean Skau, Bobbie Jingle, Jade Yang, Jung-Ah Lee and Lynn Willis. Guests:
Jessica Schmick, Dietary Intern and Gwen Van Servellen, Professor Emeritus, UCLA School of Nursing and Research Professor, Program in Nursing Science,
UCI.
1. Introduction of new members and guests
2. Jung-Ah presented overview of RWJ grant on nursing education as a method to reduce preventable VTE. Members were asked to assist with the grant
application. ACTION: Deadline to submit materials to Jung-Ah is May 21, 2010 for inclusion in grant application.
3. Process map: Meeting to design ideal educational process was scheduled for May 5, 2010. However, several key members are not available. ACTIONS:
Jean Skau to reschedule. Process map to be reviewed and next meeting.
4. Food-Drug Interaction Policy: Jade noted that the information from the process map was needed to complete the updates to this policy. Other revisions
have been made. ACTION: Jade to send policy to Education Subcommittee for review and input.
5. Educational Materials: Donna Grochow presented that she had collected a significant number of samples from various commercially available sources.
After meeting with Marra Williams in Patient Education, Donna recommended the development of a UCI specific educational package. The package will
be primarily directed at the inpatient, but will including information about transition of care. The materials will cover heparin, warfarin and LMWH. The
materials will be supplemented by the closed circuit tv. ACTION: Donna to have draft of educational materials ready for review at the next meeting. Jean
Skau to provide information on timeline of availability of closed circuit tv in the Tower.
6. ACTION: Lynn Willis to send Committee structure and implementation timeline to subcommittee members.
4/19/10: Dr. Amin, Terry Donnely (for Victoria Malonzo), Paula Luna, Brooke Baldwin (for Donna Grochow), Jean Skau, Chris Johnson, Bobbie Jingle, Mary Owen,
Jade Yang and Lynn Willis
1. Educational Materials: Deferred to next meeting
2. Process Map: Jean Skau and Chris Johnson present the process mapping for what happens after Coumadin is ordered. Key points were:
Some gaps in process
Few decision points in process
Order of steps might not be correct
Each stakeholder seems to work in parallel and in a vacuum
Per Pharmacy Protocol and per MD protocol may not have the same critical value process
Not clear if pharmacy is following all patients and if so at what level. Inconsistent location for pharmacy oversight documentation
Process is not ideal
ACTION: Jean Skau and Chris to develop and map ideal process by next meeting. Participants will include: Brooke Baldwin, Jade Yang, Carolyn Lem,
Mark Baje, Kathleen Nguyen, Amy Breschiami and Jackie Stromberg.
4/5/10: Dr. Amin, Raja Zeitany, Victoria Malonzo (for Linda Hardham), Donna Grochow, Karen Grimley, Paula Luna, Jade Yang, Carolyn Lem, Jung-Ah Lee, Chris
Johnson (for Jean Skau) and Lynn Willis
1. Background and thoughts from previous meeting summarized to update new team members. Team was reminded that goal is to provide the Steering
Committee with recommendations and an implementation plan for anticoagulation education.
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2. Discussion about patient population: DECISION: Education should be provided for all patient receiving anticoagulation therapy and/or long-term
anticoagulation prophylaxis even.
3. Discussion on components of education and best expertise. Group agreed on the following:
Drug Food Interactions: Dieticians
Drug Drug Interactions: Pharmacy
General Inpatient Education, including Risks: Nursing
Transition and Authorization: Case Management
4. Discussion on available educational materials. Paula Luna brought a sample of a commercially available “go-home kit” for Lovenox. Raja mentioned that
he has a DVD available. Carolyn Lem shared several examples of outpatient materials and suggested that these might be adaptable for the inpatients.
Donna shared the revised teaching plan which is now ready for implementation. Group agreed that an assessment of all educational materials including
cost should be done. ACTION: Donna and Carolyn to review available educational materials from various internal and external sources and provide an
assessment including cost. Evaluation due at the next Subcommittee meeting.
5. Discussion on roles and responsibilities of 4 key participants (Dieticians, Pharmacy, Nursing and Case Management). Group agreed that there are
opportunities to improve clarity and that process mapping would be valuable. ACTION: Chris Johnson and Jean Skau to process map current
anticoagulation education from admission through discharge including transition to home/next provider. Process mapping work group will include:
Kathleen Nguyen (Pharmacy), Beth Asano (Dietician), Cinda Parker (Diet Clerk), Joanne Bailey (Nursing), Jackie Stromberg (Case Management) as well
as a bedside nurse from SICU. Process map is due at the next Subcommittee meeting.
6. Additional ideas on overall education plan:
Dr. Amin suggested the group consider feasibility of inpatient group classes
Raja suggested a tiered-trigger based education where all might get the DVD and additional education would be provided based on triggers
3/11/10: Dr. Amin, Raja Zeitany, Linda Hardham, Brooke Baldwin, Mary Owen, Jade Yang, Carolyn Lem, Jung-Ah Lee, and Lynn Willis
1. Dr. Amin provided an overview on the structure of the Anticoagulation Safety Team, including membership of the Steering Committee and Education
Subcommittee, as well as the program components (P&T approved protocols, Program Evaluation, and Education).
2. Jade Yang explained the current process for food-drug interaction education by Dietary Services for patients on Coumadin
Dietary Services does not provide food-drug interaction (Vitamin K foods) to patients on Coumadin unless Dieticians are seeing the patient for other
reasons. If they are seeing the patient for other reasons, the will then reinforce the information on Micromedix related to consistent vitamin K rich
foods
New orders for Coumadin go to the Diet Office where they are addressed by the Tray Line
The Diet Office monitors vitamin K intake and will let the patient know if he/she is ordering too much vitamin K rich food
The Diet Office monitors vitamin K intake and does not necessarily consult with a Dietician during this process
3. Carolyn Lem shared that patient’s seen in the outpatient Anticoagulation Clinic attend an educational session.
4. There was discussion regarding the role of nursing in anticoagulation education and the current nursing knowledge base. Linda Hardham suggested that
the Education Subcommittee add a Nurse Manager. ACTION: Linda to nominate a Nurse Manager to the Subcommittee
5. There was discussion about the development of a Clinical Pathway for anticoagulation management. A suggestion was also made to develop a personal
recovery plan for patients which would complement the education. ACTION: Subcommittee to consider incorporating these tools into the education
program.
6. There was some discussion about whether the Steering Committee should be deciding about the content and implementation of the education program.
Dr. Amin clarified that goal of the Education Subcommittee is to develop an education program, with implementation plan, for patients, families and staff
which encompasses the 4 components required by the NPSG and also addresses the transition from hospital to home, and bring the plan forward to the
Steering Committee for approval.
7. The Education Subcommittee will meet every two weeks until the education plan has been submitted to the Steering Committee. ACTION: Lynn to work
with Viviana to get the meetings scheduled.
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