Coumadin Complaints

[pagandeva2000, LPN]

I relieve the regular Coumadin nurse for lunch, and this past week, we have come to a problem. First let me describe how we work this clinic. There is one nurse and a physician's assistant. The nurse does the fingerstick on the CoaguCheck to obtain the PT/INR. If the reading is 3.0 and above, it is an automatic blood draw that must be sent to the lab (results return in about two hours). We have to call messenger service to come for the STAT labs. We make the appointments for the patients when they are ready to leave (how soon they are seen depends on the results of the current INR...it may be two or three days, to a month), all new patients must return in one week. We also receive calls from telemetry and med-surg clerks with their discharges; orders from docs are that the patient is to be seen within two or three days from discharge (the phone is ringing off of the hook, mind you). We do patient teaching, and the teaching for the new patient is understandably extensive. The PA told us that if a patient calls or comes and tells you that they have no more meds, an appointment must be made within two days, so, we have PLENTY of walk ins. We have computerized scheduling. We are supposed to see 25 patients a day, but due to the walk ins and overbooking, we can see as many as 40.

Suddenly, last week, our access to overbook appointments was taken away from us by the clinical administrator. She says that too many people are overbooking. We have no clerks or anyone overbooking these appointments for Coumadin(in fact, the nurses who are working this clinic are the only ones overbooking). I asked the manager how are we to handle this situation; who can do the booking for us. I stated that this is not an M&M being prescribed to these people, they need to be monitored, and these appointments are ordered by the provider. She says "she'll see" about giving it back to us. Later on during the week, it is still not given. Phones still ringing off the hook, walk ins, same issues going on. This time, I send an email to the the clinic as well as the nursing administrator asking how this will be resolved. No answer. I decided then, that I would verbally tell these patients what day to return (as ordered by the physician), write it on their clinic cards, and then, DOCUMENT that patient was verbally informed of date of return as directed/ordered by provider and that appointment date was given to clinic manager for scheduling. I both; emailed as well as wrote down the medical record numbers of the patients with the date ordered by the prescriber and the time agreed by the patient. This way, I feel, it is documented by me that the patient is aware and understands that they should return on such and such date, and since there is no computer proof that an appointment was actually scheduled by anyone at that point, at least the chart states that this was referred to the person who does, in fact have actual control of who books what sort of appointments at this time. Also, email can be retrieved and be used as a legal document showing proof of contact. It also shows if the person opened it, if it was deleted, forwarded, or whatever else. This is why I emailed both, the clinic manager as well as nurse administrator.

One of the nurses that relieves as well told me that she used a password from one of the clerks to book those appointments. I told her that while I cannot control what she does, I would not do this, because policy dictates that staff is not to share passwords. If the person who can give access chose to take it away for whatever reasons, then, she must provide a resource for us to use legally in order to accomodate this situation. And, also, everything is okay with administration until something happens. This particular manager is not a nurse, she charts nowhere, so, the legal ramifications will not fall on her, it falls on nursing.

I am on vacation this week (thank goodness), and will not be thinking much of these idiots. But, do you guys think that I handled this properly, or is there anything else that should/could be done? Thanks!

[towntalker]

i think that patients on coumadin need closer monitoring than yu have described

i believe that everyone is playing with fire and that a pt who is under/over medicated will be the one to pay the price

[Indy, LPN, LVN]

It sounds like you handled it well. It's one of those things that makes me wonder just where the manager-type person's priorities are. Is her problem the wait times, the flood of appointments, the workload that the many appointments creates (paperwork wise from billing standpoint) or what? It's very hard to say 'cause I'm not her.

However, umm. This is a clinic and there's a physician in charge somewhere isn't there? Did he/she okay this, and does he/she even know?

It sounds to me like your coumadin clinic needs another office - like another branch- to handle some of the workload. I do like that you are covering the legal end of it so that the patient is monitored no matter what the manager won't let you do with the computer. But the higher ups need to know that it isn't just your license, it's the physician and/or DON who's responsible as well for the patient welfare, and suddenly disallowing monitoring appointments for patients they previously accepted responsibility for, is probably considered patient abandonment. Refer the patients if the clinic can't handle the load.

[pagandeva2000, LPN]

i think that patients on coumadin need closer monitoring than yu have described

i believe that everyone is playing with fire and that a pt who is under/over medicated will be the one to pay the price

Unfortunately, I don't know what else they can do to monitor the patients more than this, because this is a city hospital where the majority of our patients have either no insurance, are illegal, or have fee-scaled visits as low as $20. The volume is extremely high and out of control, even on the best of days. I am trying to keep the ones that are currently being treated in our clinic from being lost in the folds.

It sounds like you handled it well. It's one of those things that makes me wonder just where the manager-type person's priorities are. Is her problem the wait times, the flood of appointments, the workload that the many appointments creates (paperwork wise from billing standpoint) or what? It's very hard to say 'cause I'm not her.

However, umm. This is a clinic and there's a physician in charge somewhere isn't there? Did he/she okay this, and does he/she even know?

It sounds to me like your coumadin clinic needs another office - like another branch- to handle some of the workload. I do like that you are covering the legal end of it so that the patient is monitored no matter what the manager won't let you do with the computer. But the higher ups need to know that it isn't just your license, it's the physician and/or DON who's responsible as well for the patient welfare, and suddenly disallowing monitoring appointments for patients they previously accepted responsibility for, is probably considered patient abandonment. Refer the patients if the clinic can't handle the load.

I am not sure if the physician in charge knows all of this, I will find out when I get back. I heard she wishes to obtain another provider to relieve the volume for this one poor man, but we'll see how that goes. I don't know what the issue is with the manager, but I would have appreciated a meeting with her to hear the views of all involved. I appreciate both of your views and will update when I leave my santuary next week.