We SPY DAWN AC s Efficiencies

1. We �SPY� DAWN AC�s Efficiencies Marlene Robinson, RN, BSCN McMaster University Hamilton General Hospital Thrombosis Clinic October 2010

2. Background Hamilton General Hospital � Regional Trauma /Rehabilitation Centre � Cardiovascular Program Thrombosis Clinic � Inception- 1974 by Dr. Alexander Graham Turpie Populous: � CVA, AF � Venous Thromboembolism- PE/DVT � Valvular Disease � Thrombophilia � Warfarin: Resistant/Failure/Intolerance

3. Clinic Orientation

4. Clinic Organization Card System � limited patient information � duplicate cards being made/transcription errors � storage � lost cards � common phrase within the clinic � I can�t find Mr. Jones card� � expended energy in tracking unfound cards � filing at days end � cards were colour coded � Research � Peri-Operative Bridging � Out-Patient

5. Repetitive Behavior � Daily Workload � INR patient dosing prompted by lab notification � Inconsistent patient follow-up � Labor intensive � Organization � Absence of standardized processes for clinic operations � referral process � missed follow up appointments/end of treatment � missed INR�s � Communication � Inability to interface effectively within clinics scope Unaware of our inefficiencies!

6. Statistical Absence Respectfully; � Clinic/patient TTR best guess � Estimates only � patient indication for OAC/ actively taking OAC � patient alternative use; Sintrom, LMWH�s � overall clinic size � referral process � peri-operative bridging program � research patients � Inability to quantify outcomes data within out-patient population

7. Enter!!!! Dr. Alex Spyropoulos, MD,FACP Founder, Medical Director Clinical Thrombosis Centre Lovelace Health System Albuquerque, New Mexico Credentials: EXPERIENCED WILLING ABLE

8. Follow the �New� Leader

9. A Vision

10. Emerge from Darkness

11. Enlightened % Time in Range (TIR) Hamilton CTC (1,811 patient total) 70.4% % Time in Range for All Active Treatment Plans 1.5-2.5 (2.0 Target) 77.5% 2.0-3.0 (2.5 Target) 71.2% 2.5-3.5 (3.0 Target) 63.5%

12. Awareness % of INR�s >5 and < 1.5 2.0-3.0 (2.5 Target) %<1.5 8.73 %>5 1.25 2.5-3.5 (3.0 Target) %<1.5 2.36 % >5 2.76

13. �Spying�Our Future � centralized service for disease management � incorporating new anticoagulants (Dabigatran /Apixaban) � educational activities- externships/ medical students � expansion of the anticoagulation clinic � satellite clinics within our city/ province � incorporating special patient populations (RI, obesity, pregnancy etc) � utilizing DAWN AC for world wide benchmarking � performing outcomes research/national registries

14. HGH-Thrombosis Team Physicians: Dr. Sam Schulman, Dr. Alex Spyropoulos, Dr. John Eikelboom Administrative: Joan Murphy, Brandy Webster, Lynda Hill Out Patient Clinic Staff: Donna Carter, Heather George, Molly Naylor, Trish Bradshaw Bridging Peri- operative/Hospital Staff: Anna Mancuso-Bene, Jennifer Delaney, Joyce Coletti, Deb Magier, Thelma Mendoza, Ellen Nicholson, Christine Cockhill Research Staff: Lisa Rudd-Scott, Michelle Zondag, Erin Jamula

15. Summation Nature defines Dawn; � as the time that marks the beginning of twilight before sunrise� HGH -Thrombosis Clinic defines DAWN AC; �as the means of our progression from the darkness of inefficiency towards enlightened clinical anticoagulation management�