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Near Patient Testing - Improving warfarin monitoring

Dr Anthony Kelly describes the successful community INR scheme three Worcestershire practices set up.

Specialist anticoagulation nurse Karen Read (left), with Dr Anthony Kelly and nurse manager Debbie Turner (Photograph: UNP)
Specialist anticoagulation nurse Karen Read (left), with Dr Anthony Kelly and nurse manager Debbie Turner (Photograph: UNP)

My practice, the Spa Medical Practice, and the other two practices in Droitwich, Worcestershire, run a town-wide INR service for patients on warfarin.

The Droitwich Anticoagulation Service, under which Warfarin patients receive a regular blood test, was set up in 2008 under practice-based commissioning (PBC).

The three practices appointed specialist anticoagulation nurse Karen Read to provide this comprehensive service. It is available Monday to Friday at the medical centre where my surgery is based.

Dangers of warfarin
Our practices look after 30,000 patients. The service came about as a result of concerns with the poor interface between primary and secondary care and the inherent dangers this posed to our patients taking warfarin.

The old system required sampling in primary care, dosing in secondary care and transmission of this information from secondary care to primary care and then on to the patient.

The chances of errors cropping up were all too apparent.

Our aim was to offer standardised and clinically effective anticoagulation management by means of near patient testing (NPT) and computer software decision support.

We spent several months developing the service specification and operational guidelines. Patient safety was our prime consideration and we needed to ensure good quality control and quality assurance through the development of clear referral pathways.

We sought the support of a consultant haematologist at the outset and went live in September 2008 using CoaguChek sampling machines and INRstar software.

In the anticoagulation clinic, after the NPT, Karen takes a history from the patient to establish any changes in their health status or medication before advising them about warfarin dosing. She then sets a review date.

Patients seen in the clinic include all those already being prescribed warfarin in the community, patients requiring the initiation of warfarin treatment and all patients discharged from hospital with conditions requiring the monitoring of warfarin medication. The more complicated cases requiring ongoing, regular venous sampling continue to be managed in secondary care.

Each of the three practices appointed a named clinical lead and any issues are addressed by liaison between Karen and these individuals.

Patients have access to Karen between appointments, allowing them to report adverse events, change of medication or to get advice before dental treatment.

Homebound population
The service has been working well since its launch with a 15 per cent increase in activity. It accommodates 99 per cent of the population requiring monitoring. This figure also includes the town's housebound population on warfarin who are now managed by an additional nurse we recruited.

The service also supports a small number of patients who 'self test' at home. Clinical responsibility remains with Karen as specialist nurse although she teaches them how to self-manage when they are travelling abroad.

The expertise shown by our nurses and the good communication networks that have been established have resulted in high confidence in the quality of the service we provide.

This was reflected in the positive results obtained following a patient satisfaction survey carried out earlier this year when we asked for feedback regarding convenience of appointment time, access to urgent advice and the overall quality of service provided. We are also happy that we have greatly improved the safety of the service and that there have not been any adverse events.

Education of patients and carers is important for the safe monitoring of oral anticoagulant therapy.

All patients who commence warfarin receive pre-treatment counselling and we organised a patient information day which was very well attended.

At this event, information related to all aspects of anticoagulation management was distributed to patients who also had the opportunity to ask questions. The day produced excellent feedback from patients who said that they had gained new insight and understanding of their treatment.

The Droitwich Anticoagulant Service has been very proactive. It is keen to share its success and to demonstrate that anticoagulation therapy can be safely undertaken and managed in primary care - a recent study day was arranged for healthcare professionals interested in developing anticoagulation services in primary care.

The course was well attended and feedback from the meeting was very positive.

The service has been approached by other community nurses involved in anticoagulation management seeking advice and support. As a result, an anticoagulant network group was set up to provide support for nurses from GP practices across Worcestershire. The aim of this group is to provide support and to share information.

  • Provides a service to town-wide population of 30,000 patients.
  • The service was established in 2008 and provides 99 per cent of the warfarin monitoring in the town.
  • It supports self-testing at home and recently expanded to include monitoring of housebound warfarin patients.
  • Dr Kelly is a GP in Worcestershire.

These further impact points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Organise a meeting with your practice nursing team to review how well local anticoagulant monitoring services work. Focus in particular on safety aspects.
  • Write a report of the meeting and implement within a set time limit any changes at practice level that will improve how it looks after warfarin patients.
  • Contact other local practices/your PBC group and secondary care clinicians with proposals for improving the patient pathway. Hold a meeting to discuss.

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