Anticoagulation COVID Response

Background: In response to the COVID-19 pandemic, our ambulatory care services division (ASD) primary care practices temporarily stopped in office care and adopted virtual visits. The transition to a virtual care model affected the ASD anticoagulation clinics located in the practices. Over 5000 patients needed continued anticoagulation services and monitoring. Approximately 60% of the patients required face-to-face visits.

Objective: The objective was to develop and implement a temporary solution to continue point-of-care testing and encourage patients who were able to adopt remote testing. The team’s top priorities were patient safety and comfort and nurse well-being and confidence, ultimately decreasing fear by providing care that is safe and efficient. ASD anticoagulation leaders needed a solution that would allow the team to continue point-of-care testing, maintain staff safety, and encourage fearful patients to continue international normalized ratio (INR) testing.

Methods: To ensure continuity of care for patients whose care required face-to-face visits, the team stood up seven centralized drive through tent locations and expanded home-testing capabilities. To deliver care in this new model the team took the following steps:
1. Encouraged patients who could enroll in home testing to do so and collaborated with a home-testing company to increase efficiency of enrolling new home-testing patients.
2. Utilized RNs not engaged in care at testing sites to enhance the anticoagulation services virtual team.
3. Established tent testing locations:
• Leadership assigned staff to dedicated tent teams for the duration of the project.
• RNs at tent sites donned proper PPE in accordance with Centers for Disease Control guidelines and our organization’s policy while working at tent sites.
• Tent site teams instructed patients to stay in their vehicles and wear a mask through the entirety of the visit.
• Patients were arrived in the electronic medical record (EMR) for their visits.
• While the patient remained in their vehicle the tent site RNs conducted a COVID-19 screening and completed an anticoagulation assessment.
• Virtually the team completed the visit in the EMR and managed the patient’s dosing.

Results: Warfarin management was successful; enrolled patients’ average time in therapeutic range (TTR) remain unchanged from pre COVID-19 averages. Prior to clinics closing in March 2020, the average TTR was 60.75%. In April and May 2020, the average TTR was 61%. In addition to maintaining TTR performance, the new workflows decreased appointment length of time from 20 minutes to less than 5 minutes. Shorter appointments reduced risk of exposure for patients and the nurses. Home testing also expanded; over 100 patients were transitioned to home testing. Lastly, the new process maintained staff safety; there were no reported cases of RNs exposed or diagnosed with COVD-19.

Conclusion: Our nurses skillfully collaborated to ensure safe, effective, and efficient care. Anticoagulation services temporarily closed 32 clinics for 8 weeks, quickly implementing innovative solutions to continue care for patients who could not receive care virtually. Patients continued to have their POC testing and warfarin therapy monitored, resulting in very little variation in TTR.