1. Warfarin Prescribing

2. 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?

3. Warfarin Management

4. 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?

5. Example of a Warfarin Prescribing template (Medtech version)

6. 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.

7. 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.

8. 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