June Ward Haemophilia / Anticoagulant Nurse Ward 34 day area Ninewells Hospital juneward@nhs.net

Warfarin reduces rate of stroke Warfarin remains one of the most dangerous medicines causing harm Tayside has one of the most sophisticated services offering near patient testing, primarily nurse- led services with some pharmacy practitioners Standardised training, agreed shared dosing protocols, audit of practice Acute services and community settings 5700 patients all ages, abilities and literacy needs

Why we got involved & what we expected  Engagement & collaboration between teams DCAS, P&K, NWS, Phyllis & her team Reviewed existing information available video / concertina leaflet Feedback to Scottish Patient Safety Programme - influencing change to future patient information booklet Patient involvement- focus groups Measure our impact

Reminders / Training for staff re Teachback methods, site visits by Phyllis & Angela Adapting new patient checklist Review new patient knowledge at 1st & 2nd visit Patient focus groups

Improving self-management with high risk medication Focus groups main themes: Change name to ‘Warfarin’ rather than ‘Oral Anticoagulant Therapy’ Pages on patient information booklet with unnecessary information make the book too long One or two books - record book and information book - preferences varied Alert card - too big and needs to be more robust

Improving self-management with high risk medication “The books are good for back up but I found the spoken help I got at the beginning most useful” “I forgot to take it [Warfarin] at 6 o’ clock and wasn’t sure if I could take it at midnight” “I didn’t understand why it was important to take it at 6 o’ clock” Yellow Book being updated to simplify recording and information pages Checklists being tested by Anticoagulation Team with tick box to ensure use of Teach-back at appropriate points T √

Results Question and expected answer Response rate comments Why do you use warfarin Expected: to keep my blood thin, prevent clots or stroke 12/12 (100%) to thin my blood, Blood clots, combat blood clots caused by AF, mechanical heart valve, irregular heart beat, for blood, heart 2. Your target range Expected: 2-3, 2.5-3.5, 3-4.5 8/12 (67%) 1 don’t know, 1 not valid range, others valid range 3. Duration Expected: 3 mths , 6mths longterm / lifelong 11/12 (92%) 10 pts longterm/ lifelong 1 1 year 4. Which foodstuffs to limit Expected: spinach, broccoli, kale, sprouts, cranberry & pomegranate juice, dark green leafy veg 9/12 ( 75%) Eggs, pomegranate, sprouts, greens, grapefruit, cranberries, pomegranite, dark green leafy veg, excess garlic, YES 5. Alcohol limits Expected: 2 units per day 12/12 ( 100%) No more than daily advised 2 units, none, 1-2 units, 2 units per day, little one, very little 2 units weekly 6. Use aspirin / NSAIDS with warfarin? Expected: avoid unless advised by doctor 9/12 (75%) 9 avoid don’t use 7. Inform clinic starting new medicines Expected: Contact clinic to arrange review 11 yes contact clinic 8. Inform dental, surgeons, pre procedures Expected: Inform them use of warfarin 10/12 (83%) 10 yes inform 9. Who to contact if unexpected bleeding problem Expected: GP, NHS 24, warfarin clinic 10/ 12 ( 83%) GP, Doctor or NHS, Hospital or doctor, 999, warfarin nurse, cardiology, Warfarin team, YES 10. How long have you used warfarin 3 weeks – 5 years 11. Comments on clinic 6/12 ( 50%) Staff are friendly and helpful, everything lovely, very informative, its perfect, best ever, treatment very good and team excellent.

What next? Continue focus on teach-back methods within teams Review education / patient knowledge at agreed time frames: 1st , 2nd visit, 3 months, 6 months, annually Await new warfarin book??? DVD’s , Internet?? Our patients who attended focus groups are engaged and would like to be involved in future projects Feedback to our staff > motivated and engaged