Warfarin Prescribing

Aim and Measures Aim: 100% of patients on Warfarin will be managed within safe margins around the therapeutic target and 100% of practices will have developed consistent processes around INR testing Is there evidence that the last advice on warfarin dosing given to the patient followed current local guidelines or used computer-assisted decision making? Is the target INR and duration of treatment clearly documented in the notes? Since the last blood test, has the patient been taking the correct dose as ordered by the treating GP? Has the INR been taken within seven days of the planned date? Is it recorded that the patient has received education about warfarin in the past 12 months? Have all measures been met?

Warfarin Management

Discuss your Experience So Far What did your data show? What changes have you made? What have been you key successes? What have been the challenges? What are you going to do next?

Example of a Warfarin Prescribing template (Medtech version)

Key Change Ideas Allow time for changes to be checked, adjusting further if required, before rolling out to all staff to embed as usual practice Developing nurse and doctor champions in the practice gave all staff confidence in dealing with INR results and testing frequency Development of a manual process to ensure the practice has the ability to monitor and remind INR patients, especially the ones currently testing spasmodically Identify patients with stable INR results to have point of care testing done at the pharmacy Patients having education updates For each test: INR result, warfarin dose, when next text is due, GP signature, nurse signature when patient advised, any patient specific notes relevant to warfarin monitoring Front desk maintaining current contact details System for handling faxed INRs & ensuring acted on before clinic closed each day Drop down arrow added within screening term to show whether nurse or Dr can manage patient Collation of resources available for patient education i.e. flip chart, red book etc.

Key Change Ideas Moved from duplicate electronic process to single entry using the INR screening term Refined screening term to identify patients on warfarin Implementation of recall system to follow up INR timeframes Education check list prepared and embedded in form Changed the wording on the INR screening term within MedTech  from “Patient Info Given” tick box to “Patient Education Given” as a date field INR management IT tool and new protocol created using practice wide feedback, experience and knowledge All clinical staff used standardised guidelines Setting up policies around what time patients do tests Designating nursing time to follow up INR results daily & transition to nurse prescribing Cycle of education leading to patients involvement and better compliance Open discussion of best clinical person to manage specific groups of patients on warfarin Trial of Point of Care testing with local pharmacy.

Driver Diagram: Warfarin Management - Safety in practice AIM Measures Primary Drivers Secondary Drivers Change Idea Audit Results Electronic template Standard procedure Streamlined process Consistency Warfarin Guidelines Practice champions Appropriateness of Warfarin use Refined screening for patients in system Staff education Co morbidities To enhance patient safety around the Warfarin process and to maintain the optimal therapeutic range by 1st July 2016 Communication with practice Front desk update details Education updates Self management Education Education checklist Multiple language education packs Test at local pharmacy Compliance Use of 1mg tabs only Nurse led prescribing After hours response plan Receipt of results Timeliness Manual for timely checking by patients Frequency of test Electronic recall system Version 2