At MGH, the Nursing Model for Anticoagulation Management took three years for planning and full implementation.  During that time, the implementation team developed new pathways for starting and managing anticoagulation therapy across health care settings.  New pathways were evaluated for quality and efficiency of care, and standard quality measures were developed, tabulated, and analyzed.

In addition, the team conducted a complete workflow assessment and redesign, including the development of new policies, procedures, and documentation guidelines.  Each staff member in the new model underwent extensive training and role restructuring.

The implementation team consisted of the ultimate nursing director of the program, clinical nurse specialist, and two IT consultants.  The staff was actively involved in the process.  And the team had great support from their medical director and associate chief nurse.

AMS looks for professional nurses who are organized and have excellent written and verbal communication skills.  Most have experience in cardiac, neurology or general medicine and understand the goals of anticoagulant therapy.  The most recent RN hires came from acute care floors; this had the benefit of increasing the team’s understanding and appreciation of patients coming from the hospital.

An RN clinical specialist is in charge of training new staff.  The clinical specialist has developed an orientation program and core competencies for program.  The orientation for new staff is individualized using a preceptor model and is completed on average in 10 weeks.

Nurses from the Nursing Model for Anticoagulation Management speak at RN Grand Rounds frequently to update all nursing staff on latest anticoagulation therapy.  This provides a good opportunity to reach many nurses and help them learn about the importance of efficient anticoagulation management.

Prior to patient discharge, a hospital provider submits an AMS referral through the electronic consult feature of the provider order entry system.  Referrals are received electronically in the clinic, and the team responds before patients leave the hospital.  In addition, the Nursing Model for Anticoagulation Management interfaces with hospital admission and discharge systems so that AMS is notified whenever an established AMS patient is admitted or discharged from the hospital. 

AMS also accepts referrals from outpatient physician practices directly into maintenance services.  The patients may be new warfarin starts or transfer of care for established patients.

The Nursing Model for Anticoagulation Management Service is an applicable model for large hospitals that would benefit from better management of patients on anticoagulation therapy.  In addition, some of the elements of the model, particularly the use of RNs as care managers for a specific care need and the creation of individualized care plans based on evidence-based algorithms and nursing clinical judgment, could easily be applied to the management of other patient conditions.