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Madigan AMC’s Anticoagulation Clinic works its way through testing to cut the ribbon on May 4 on point-of-care testing for its Warfarin patients. (Photo Credit: U.S. Army photo) VIEW ORIGINAL

MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. – Blood is supposed to clot; that’s why a simple cut doesn’t lead to bleeding to death. But, as with so many things related to the human body, the left and right parameters that create a range of healthy functioning are pretty tight. From a heart attack to a car accident, the list of ailments and injuries that can throw things out of that range, to where the blood does not flow properly, is significant. That’s when a “blood thinner” is useful. Drugs that help the blood flow, like Warfarin, can require frequent testing to ensure the dosage is correct.

The Anticoagulation Clinic within the Cardiology Service has reached the finish line on a nearly two-year process that included research, requesting, justification, approval, equipment procurement, training and validation testing in order to implement point-of-care testing for patients on these drugs instead of a lab blood draw.

“Some people are very afraid about venous puncture,” noted Han Crimi, the clinic’s licensed practical nurse who performs the testing, “but a good fingerstick is easier, easy to accept.”

POC testing short cuts the process that used to involve going to the lab for a walk-in blood draw where a phlebotomist used a needle to collect blood from the patient’s arm, ran the necessary tests on it and called the clinic with the results. The clinic then called the patient, often leaving a message.

This process could take days and left room for errors and miscommunication. Now, patients can have their blood tested and dose adjusted, if needed, all within a regular clinic visit.

Once a patient on Warfarin is shown to the exam room, Crimi uses a screening form that she developed in conjunction with Natural Conyers, a pharmacy technician, to identify any possible changes in the patient’s condition. She follows these questions with a simple finger poke to collect a ladybug-sized drop of blood that she tests to determine how well their medication is managed.

“Thirty minutes for one patient, including the blood test and talking to the provider,” says Crimi of the time the process now takes and how it addresses problems. “We can catch it right at that time and adjust the dose right in the same day. So, it avoids a lot of accidents for the patient.”

Warfarin was one of the first anticoagulants on the market.

“It's the benchmark that all the other anticoagulants compare themselves to before they're brought out to market,” said Dr. Deborah Bair, a clinical pharmacist in the clinic.

Blood thinner, as this type of drug is often called, is a misnomer in that the blood is not being thinned. An anticoagulant, like Warfarin, reduces the amount of clotting proteins in the blood, allowing it to flow properly. Since it is designed to reduce clotting, it also must be monitored closely to ensure that the blood does clot, when necessary.

To ensure the medication is working properly, its monitoring tests how long it takes for the blood to clot. Results outside of the normal, and rather narrow, range could produce severe problems. If the time it takes to clot is too high, the patient is at risk for a potential bleed; too low and they could be looking at a clotting event, or a stroke. This time is measured in seconds.

“A lot of things that can affect Warfarin management, from new meds, medications discontinued, activity, smoking, drinking, diet – the medications to include over-the-counter and supplement vitamins. A lot of things can interfere, even stress,” said Bair.

Still, Warfarin offers some benefits that the newer anticoagulants generally do not.

“Miss a dose, you still have Warfarin in your system, so it has that aspect of a little buffer zone,” said Dr. Giao (Alex) Nguyen, also a clinical pharmacist with the clinic. “But with that said, you need more monitoring, you need them to have blood work all the time to check out what the levels are.”

Newer drugs that assist clotting are less forgiving, but they can be taken orally and require a lower level of management. Clinic patients on these medications are currently monitored by their primary care managers but will eventually be drawn into the Anticoagulation Clinic to have more specialized oversight.

The Warfarin panel of approximately 250 patients are in close communication with the clinic from the time they are diagnosed and referred for medication management.

“We always joke with our patients when we meet them the first time for the initial intake, we say we're going to get to know each other ‘very well,’” said Bair with harmony added by Kimberly Pikul, an advanced registered nurse practitioner with the clinic. “We talk to them, probably more than most other providers.”

This change in testing process has meant an overhaul of clinical processes. Each provider in the clinic used to have their own panel of patients they monitored. Now, they rotate as the provider monitoring Warfarin patients each week, making them all familiar with every patient.

Over the past few years, the clinic has been reducing the number of patients on Warfarin by evaluating each patient’s need and moving them to one of the newer drugs, or discontinuing their use if they no longer need the medication. Some patients, however, will continue to be long-term Warfarin patients. If they have deep vein thrombosis, pulmonary embolism or atrial fibrillation, for example, they may take the drug for decades.

The clinic often tests a patient multiple times a week when they are first put on the drug. The longest span the clinic providers feel comfortable letting a patient go between tests is six weeks.

The Anticoagulation Clinic is no stranger to time investment. They clearly make it in their patients and they made it in the process to bring point-of-care testing into implementation as well.

“This was a combined effort between Pharmacy, Cardiology and Decentralized Lab Services and our NCOICs and CNOICs,” said Pikul. “It was almost two years since we put the original memorandum in.”

With the potential to cut down the time to adjust dosing and reduce miscommunication, they feel it is worth the effort.

“We're hoping to decrease potential adverse events. So, reported events or just a decrease in emergency room visits and hospital visits,” said Bair.

She also hopes to see an uptick in patient satisfaction. She is managing a process improvement project that is collecting patient and provider feedback both before POC testing was implemented and after.

A long list of staff across a number of departments worked to put this new process in place. It is not hard to imagine that such a degree of support, and the time-saving aspect alone, will provide both the patient satisfaction and the therapeutic enhancements the clinic seeks.

Warfarin is sold under the brand names Coumadin and Jantoven.

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1 / 4 Show Caption + Hide Caption – Madigan AMC’s Anticoagulation Clinic goes live with their new point-of-care testing process that simplifies blood tests for patients on Warfarin. Left to right, Deborah Bair, PharmD; Giao (Alex) Nguyen, PharmD; Kimberly Pikul, advanced registered nurse practitioner; and Han Crimi, licensed practical nurse, cut the ribbon on May 4. (Photo Credit: U.S. Army photo) VIEW ORIGINAL
Patient testing
2 / 4 Show Caption + Hide Caption – Retired Chief Warrant Officer 3 Rossie Hammer, left, becomes the first patient to complete the dual testing of finger stick and venous draw to validate the protocol for point-of-care testing in the Madigan AMC Anticoagulation Clinic in the Cardiology Service. Han Crimi, licensed practical nurse, helps take his blood for testing as Tara Culbertson, medical laboratory technician, Deborah Bair, PharmD and Stephanie Sperry, MLT, in background, watch the process on Sept. 30, 2020. (Photo Credit: U.S. Army photo) VIEW ORIGINAL
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3 / 4 Show Caption + Hide Caption – Stephanie Sperry, medical laboratory technician, center, draws blood from retired Sgt. 1st Class Ramon Hizon as he helps the Madigan AMC Anticoagulation Clinic validate a new testing process on Sept. 30, 2020. Tara Culbertson, MLT, watches the process as Han Crimi, licensed practical nurse, in front, gathers supplies. (Photo Credit: U.S. Army photo) VIEW ORIGINAL
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4 / 4 Show Caption + Hide Caption – Chong Brock, left, a patient of the Madigan AMC Anticoagulation Clinic, helps the staff prepare a new protocol for the frequent blood tests needed for those on the anti-clotting drug Warfarin. She’s joined by, from left to right: Han Crimi, licensed practical nurse; Tara Culberton, medical laboratory technician; Kimberly Pikul, advanced registered nurse practitioner; Deborah Bair, PharmD; and Giao [Alex] Nguyen, PharmD at near the end of validation of the process on Nov. 19, 2020. (Photo Credit: U.S. Army photo) VIEW ORIGINAL

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