1. Implementation of local guideline by interactive workshop improves anticoagulation therapy and patient safety Puhakka J, Helsinki Health Centre, GP Suvanto I, Helsinki Health Centre, Head nurse Sipilä R, Centre for pharmacotherapy development ROHTO, Medical Advicer 13-16.5.2009 Nordic Congress of Family Practice

2. 13.-16.5.2009 Nordic Congress of Family Practice2 ROHTO-activities in Helsinki Health Centre 26 Primary health care units (PCU) Facilitator pairs at each PCUs + Aim: To promote rational pharmacotherapy To improve clinical practices Interactive workshops at PCUs

3. 13.-16.5.2009 Nordic Congress of Family Practice3 Background – anticoagulation therapy Bleeding complications are common and often serious (Landefeld & Beyth Am J Med 1993) The risks of complications are related to INR control (White et al. Arch Intern Med 2007) High interaction potential (Raunio H. Suom Laakaril 2005) Warfarin frequently prescribed to elderly patients with polypharmacy Concomitant prescriptions for potentially interacting medicines are common in primary care (Snaith et al. 2008 Am J Cardiovasc Drugs) Warfarin therapy documentation unclear High volume of these patients in Töölö INR test is the most prevalent laboratory test in Helsinki Health Centre

4. 13.-16.5.2009 Nordic Congress of Family Practice4 Aim Implementation of Helsinki Health Centre anticoagulation To improve recording of warfarin therapy to the electronic patient records To develop shared clinical practices, and to clarify division of professional tasks Enhance knowledge on anticoagulation therapy Evaluate the changes in clinical practices

5. 13.-16.5.2009 Nordic Congress of Family Practice5 Setting Helsinki Health Centre 26 primary care units 564 500 inhabitants Coverage 42.3% (outpatient treatment) 322 GPs, 525 Nurses, 270 other staff Töölö Health Care Unit 27 000 population Coverage 32.9 % Chief physician and 11 GPs, 8 outpatient consulting nurses, 14 other staff

6. 13.-16.5.2009 Nordic Congress of Family Practice6 The steps of Rohto-workshop Analysis and understanding Outline of present practices Baseline audit Feedback of the results Objectives of change Solutions based on city’s anticoagulation guideline Evaluation and feedback Follow-up audit Participant feedback Audit results Change in practice Contract Problem in practice local facilitators GP-nurse pair Supported and trained by ROHTO and regional coordinator Act as change agents for rational pharmacotherapy Information Picture modified from Rohto

7. 13.-16.5.2009 Nordic Congress of Family Practice7 Implementation methods Baseline audit A random sample of hundred patients visiting laboratory for INR control during one week Data collected from electronic patient records Is indication recorded Planned duration of the therapy Target level of the therapy Workshop Multiprofessional (21 participants: 10 GPs, 11 nurses + other) Follow-up audits every six months New indicator: Warfarin recorded as permanent medication to the electronic patient record Feedback of the results on weekly staff meetings and separately for GPs and nurses

8. 13.-16.5.2009 Nordic Congress of Family Practice8 Results 1 Feedback from participants 6 / 13 WS participants reported an intention to change their clinical practices 3 no need to change INR within therapeutic range for 66%, 65%, 77% and 66% in the cases After the workshop treatment information was generally better recorded

9. 13.-16.5.2009 Nordic Congress of Family Practice9 Results 2 : recordings Table I. Percentage of indicators recorded in electronic patient records

10. 13.-16.5.2009 Nordic Congress of Family Practice10 Results3: Control intervals Table II. Percentage of patients in different categories of control intervals (weeks) in two follow-up audits

11. 13.-16.5.2009 Nordic Congress of Family Practice11 Conclusions Interactive workshop combined to repeated audits and feedback can lead to improved patient data recordings Changing clinical practices requires time and effort These changes may lead to improved patient safety Control intervals are still short in relation to INR levels and city’s anticoagulation guideline Effect of the implementation and shared clinical practices on treatment control is still unclear

12. 13.-16.5.2009 Nordic Congress of Family Practice12 Thank you for your attention!