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Improving the reliability of care in high risk areas. Why Focus on Warfarin Management?. Warfarin is the second most common cause of adverse drug events in emergency departments
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Why Focus on Warfarin Management? Warfarin is the second most common cause of adverse drug events in emergency departments Incidence of major bleeding in patients prescribed warfarin ranged from 0% to 16%, and the incidence of fatal bleeding was 0% to 2.9%.
Where are the risks in prescribing and monitoring patients on warfarin?
Getting started with data “Education, education, education” Tony Blair 1997 “It’s the economy, stupid” Bill Clinton 1991 No politician has yet said: “Data, data, data” “It’s the data, stupid”
Getting started with data Warfarin sheets audit
Care Bundle A care bundle is a set of evidence based interventions that when used together significantly improve outcomes
Peter Provonost (ITU physician at Johns Hopkins Hospital, Baltimore, Maryland ) Simple message: ‘Evidence Based practice… Culture Change… Measurement of change…’
Peter Provonost’s Care Bundle • A simple 5 item checklist protocol would greatly reduce infections when inserting a central venous catheter • Doctors should: • Wash their hands with soap. • Clean the patient’s skin with chlorhexidine antiseptic. • Put sterile drapes over the entire patient. • Wear a sterile mask, hat, gown and gloves. • Put a sterile dressing over the catheter site
‘An intervention to decrease catheter-related bloodstream infections in the ICU’ Pronovost P, et al. (December 2006) N. Engl. J. Med.355 (26): 2725–32.
Central line infection rate (per thousand line days) 92% reduction 2.34 0.18
What is a Bundle? Aim to ensure patients receive optimum care at every contact Structured way of improving processes of care to deliver enhanced patient safety and clinical outcomes
What is a Care Bundle? 4 or 5 elements of care Across Patients Journey Creates teamwork Mix of easy and hard All or nothing Small frequent samples
Bundle vs Audit Audit – identifies whether individual measures are being implemented Bundle - data collection tool to sample whether optimum care is being delivered
Warfarin Bundle Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT? Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT? Has patient been taking the advised dose since last blood test? INR is taken within 7 days of planned repeat INR?* Face to face education recorded every 6 months?* Overall compliance out of 5
Warfarin Bundle Is there evidence that the last advice re warfarin dosing given to patient followed current Guidance The use of a dosing algorithm can significantly improve anticoagulantcontrol Kim, Y.K. et al Journal of Thrombosis and Haemostasis,2010 8,101–106. Computerized dosing has been shown to increase the overall percentage time for which patients are in their target INR range and in some studies to reduce the frequency of testing of patients. Poller, L., Journal of Thrombosis and Haemostasis, (2008b) 6,935–943.
Warfarin Bundle Is there evidence that the last advice re the interval for blood testing given to patient followed current Guidance? The use of a dosing algorithm can significantly improve anticoagulantcontrol Kim, Y.K. et al Journal of Thrombosis and Haemostasis,2010 8,101–106. Computerized dosing has been shown to increase the overall percentage time for which patients are in their target INR range and in some studies to reduce the frequency of testing of patients. Poller, L., Journal of Thrombosis and Haemostasis, (2008b) 6,935–943.
Warfarin Bundle Has patient been taking the advised dose since last blood test? The practice has to ensure that the patient is informed of the correct advice regarding warfarin dosage for the patient to be able to comply with the advice. - Patient feedback
Warfarin Bundle INR is taken within 7 days of planned repeat INR?* Patient’s regular attendance for blood testing is associated with better anticoagulation control. Roswe AJ et al Circ Cardiovasc Qual Outcomes 2011 May 1; 4(3):276-82. Epub 2011 Apr 19.
Warfarin Bundle Face to face education recorded every 6 months?* There is good evidence that improved patient knowledge and understanding of the use of warfarin improves anticoagulation control Tang EO at al Ann Pharmacother. 2003 Jan; 37(1):34-9.
Warfarin Bundle Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT? Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT? Has patient been taking the advised dose since last blood test? INR is taken within 7 days of planned repeat INR?* Face to face education recorded every 6 months?* Overall compliance out of 5
Like What? Practice meeting Notice board Process mapping Ask patients Try changing something…. Measure the effect.
Practice Feedback • There is magic in graphs… There is magic in graphs. The profile of a curve reveals in a flash a whole situation – the life history of an epidemic, a panic or an era of prosperity. The curve informs the mind, awakens the imagination, convinces…. Henry D Hubbard, 1939
“The care bundle was useful because it identified gaps” “You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good”
Successes - Improved: Patient Care Systems Knowledge, Skills & Attitudes Safety Culture Team-working Patient Involvement Less Stress Efficiency
Less Stress for some staff in their job • “Staff member X who manages the register and the recall for these patients, it caused her an enormous amount of stress prior to the programme” • “ Now that the programme is much more streamlined and she feels more confident and has taken much more clinical responsibility”
Staff time-saving - patients being more proactive • “staff member X doesn’t have to continually phone people up every month, that is quite a time saver for her, patients are now more coming in cause they understand the consequences potentially of the side effects of the potential toxic drugs”.
Does Bundle Compliance = better results? Results <1.5 & >5
Care bundles • Shed new light on our current practice • Act as a catalyst for improvement in care • Can lead to increased awareness
What about other bundles?DMARDS Medication ReconciliationResults handling
DMARD Bundle Only those prescribed Methotrexate or Azathioprine Full Blood Count in the last 6 weeks Action from abnormal results recorded Documented review of blood tests prior to issue of last prescription Ever had pneumococcal vaccine Documented the patient has been asked about side effects fo their medication at their last blood test Compliance with full bundle (i.e. all of above)
