1. Local Enhanced Service Care bundles Dr Andy Kilpatrick, Clinical Lead

2. What is a care bundle?  A bundle is a structured way of improving the processes of care and patient outcomes.  A small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.  Have worked very well in acute care. Challenge is to find appropriate ones for Primary Care. Five nationally developed ones. (Institute for Healthcare Improvement definition)

3. Each practice will collect regular data (fortnightly or monthly) on the safety and reliability of one high risk process on a rolling program with the focus changing every 12 months. The area of focus will be determined by the Health Board annually: Year 1 - Safe and Reliable systems for prescribing and monitoring of Warfarin Year 2 - Safe and Reliable Medication Reconciliation following discharge Local Enhanced Service

4. QOF GMS Core Immunisation Targets Prescribing targets Formulary Adherence Clinical Audit GP Appraisal Revalidation Enhanced services QOF QP Patient Satisfaction How do we know how well we are doing in General Practice?

5. What about QOF data? ISD Publication – Quality & Outcomes Framework (QOF) of the new GMS contract - achievement, prevalence and exception reporting data 2011/12 Results – The average number of points achieved by GMS practices increased from 976.3 (out of a maximum of 1,000) in 2010/11 to 980.9 in 2011/12. 98.1% of points available achieved. How do we know how well we are doing in General Practice?

6. Is the QOF data as good as it could be? Combining QOF data with the care bundle approach may provide a more meaningful measure of quality in general practice A model that NICE are looking at. Looked at 9 practices which provided QOF data on particular QOF indicators Then looked at an overall composite measure of the indicators

7. QOF Data - CKD Chronic kidney disease (CKD) The % of patients on the CKD register: CKD3whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less CKD5with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE – I) or angiotensin receptor blocker (ARB) CKD6whose notes have a record of a urine albumin: creatinine ratio (or protein: creatinine ratio) test in the previous 15 months

8. Chronic kidney disease (CKD) Threshold (min-max %) Average for all 9 practices (%) CKD340-7076.9 CKD540-8098.8 CKD640-8089.2 Overall Composite100% Outcomes 69

9. QOF Data - Stroke Stroke/TIAThe percentage of patients with: STROKE6a history of TIA or stroke in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less STROKE8TIA or stroke whose last measured total cholesterol (measured in the previous 15 months) is 5 mmol/l or less STROKE10TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March STROKE12with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or an anti- coagulant is being taken (unless a contraindication or side- effects are recorded)

10. Outcomes Stroke / TIAThreshold (min – max %) Average for all 9 practices (%) STR 640-7091.5 STR 840-6086.7 STR 1040-8593.7 STR 1240-9096.6 Overall Composite100% 74.1

11. 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%. Da Silva MS, Sobel M. Anticoagulants: to bleed or not to bleed, that is the question. Semin Vasc Surg. 2002;15(4):256-267. Why begin with Warfarin Management? Do Care Bundles work in Primary care?

13. Warfarin bundle Is there evidence that the last advice re warfarin dosing given to patient followed current Guidance/ INR Star/ RAT? Is there evidence that the last advice re the interval for blood testing given to patient followed current 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? Patient education recorded every 6 months? Have all measures been met?

14. The use of a dosing algorithm can significantly improve anticoagulant control 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.

15. Exercise Review each of the elements of the Warfarin Care Bundle. How easy or difficult is it to check each element? Is there any help the programme team could provide?

16. Month and comments Patient Warfarin dose is prescribed according to local guidance? INR test is planned according to local guidance? Patient complying with dosage instructions? INR is taken according to previous recommendation ? Patient receives regular education? Overall Compliant 1 Comment 2 Warfarin care bundle Data Toolkit (Excel) http://www.healthcareimprovementscotland.org/our_work/patient_safety/spsp_pri mary_care_resources/data_collection.aspx

17. Each participating GP practice is to provide evidence to their Board of: 1)Data collected on monthly or two weekly basis. This will be done using a web-based tool to allow analysis of data and to aid practices in monitoring progress. The final nature of the tool is still to be determined. 2) On an annual basis a summary of practices reflections of the data. In the first year practices will need to collect eight months of data and produce a summary of reflections on the data and changes made to improve patient safety as a result of the analysis of the data.

18. Has the potential to free up appointments. Dec-10 – Dalkeith introduced the RAT system Aug-11 – Dalkeith started the Patient Safety project Test per patient before RAT = 2.2 average Test per patient after RAT = 1.4 average Saving = almost 100 appointments per month