Implementing and Integrating a Virtual Nurse-Led Anticoagulation Clinic Care Team

Eighteen registered nurse (RN)-run anticoagulation clinics providing in-person patient care identified a need to standardize practice and implement innovative staffing models to assure provision of expert anticoagulation services continue. The nation is facing a nursing shortage and models of care utilizing nurses to their full scope of practice are essential. Rapid changes made during the pandemic demonstrated nurses could manage patients on warfarin virtually without impacting quality and safety.
Transitioning to a virtual model of care for nursing staff and integrating the teams provided many benefits to patients and staff. Patients can complete a point-of-care (POC) INR test anywhere within our health system, followed by a virtual visit with an anticoagulation nurse, resulting in increased access closer to their home or work. Patient appointment availability is no longer limited by nurse staffing. Confirmatory venous draws for POC INRs greater than five were often refused when nurses completed the POC test. Patients now receive their POC in a lab setting, resulting in almost 100% compliance with venous confirmatory draws. Virtual desk staff were implemented, assuring administrative work is completed by the right role. Seven nursing FTEs were converted to non-licensed roles of administrative and lab staff. Basic patient education was transitioned into an interactive class format. Facility use has decreased within the virtual model, reallocating 23 rooms to be utilized for revenue generating purposes by providers.
Assuring two nurse-led anticoagulation programs successfully integrated from rural and urban-based locations into one virtual program was a significant accomplishment. Use of a nursing leadership team was key to the success of the project. The nursing education specialist, clinical nurse specialist, and nurse manager each leveraged their expertise. Nursing staff workgroups were established to ensure that nursing voices were heard. A nurse-led unit council and an education committee were imperative to the success. Strategically timed mandatory education sessions provided small, consistent change and level setting for all staff. Nurses identified that the education sessions helped keep the focus on what is best for patients and started the transition from separate unit-based thinking to a team approach. The charge nurse team and strong interprofessional collaboration were also essential to a successful transition. Teambuilding and managing the stress of staff were identified as opportunities for improvement. A workgroup to help with team building was established before integration, but lack of staff interest led to deprioritization of this work. The group became very active a month after integration but could have been prioritized sooner. More proactively and effectively managing the emotional needs of staff and alleviating their fears may have led to decreased stress.
This anticoagulation program has demonstrated nurses providing warfarin dosing and INR management per protocol in a virtual environment results in patients with high time in therapeutic range and compliance. The efficiencies gained from transitioning to a virtual model of care, combined with assuring RN practice at the top of licensure, will provide sustainability of the anticoagulation program for the benefit of both staff and patients alike.