1. Introducing a Patient Safety Programme
Dr Gordon Black
NHS Lothian Clinical Lead SIPC Project

2. The NHS Lothian experience with Warfarin
Brief Background
How well do we manage Warfarin at the moment?
The SIPC warfarin journey
Where next?

3. Safety Improvement in Primary Care 1 (SIPC 1)

4. Aims To enable 80 Primary Care teams to:
Identify and reduce risk and harm to patients
Improve reliability of care for patients
On High Risk Medications
With Heart Failure

5. NHS Lothian took on the Warfarin workstream
Care Bundles
Trigger Tools
Climate Survey
Patient Involvement
PDSA’s
Process Mapping
Collaborative learning
NHS Lothian took on the Warfarin workstream

6. Can we do better with 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%.

7. Warfarin Video
Could this happen in your practice?

8. What is ‘normal’ practice
Worksheet 1 activity

9. Measuring Outcome for the project
We were able to get INR results for all practices in NHS Lothian from the labs
We decided to look at results ‘outwith’ an expected range <1.5 & >5

10. How well are we doing in NHS Lothian?
‘All’ GP practices
Results <1.5 & >5

11. SIPC Project Can we do any better?
Care Bundles )
Trigger Tools )
Climate Survey )
Patient Involvement )
PDSA’s )
Process Mapping )
Collaborative learning )
Overall aim was to reduce INR results above 5 by 30%

12. Practice Recruitment

13. Care Bundle Development
Bundles of care
4 or 5 elements
Across Patients Journey
Creates teamwork
Mixture easy and hard
All or nothing

14. Care Bundle Development
Reviewed literature / guidelines
Discussed with colleagues
Spoke to ‘Bundle experts’ from IHI
Spoke to patients

15. Patient Involvement 1. Lothian wide focus group
2. Practice specific focus groups

16. Patient Involvement
Lothian Wide Patient Focus Group – 20th August 2010
What would you change?
Once diagnosed, info on foods/ diet/ over-counter drugs which may affect INR.
Someone specific to sit down and give all the info and make sure patient understands.
Annual check-up.

17. Warfarin Bundle v1 Elements
Is the target INR recorded in patient’s notes
INR is taken within 7 days of planned repeat INR
Last INR recorded in yellow book
Face to face education recorded every 3 months

18. Warfarin Bundle v1 How well do you think you would do?
What elements would challenge your practice?

19. Warfarin Bundle
Weekly Data Collection Tool

20. Data Entry Charts

21. Bundle Feedback Not challenging enough Target INR always recorded
Yellow book wasn’t always applicable (if patients preferred their diaries, or the practice uses an online system such as INR Star)
No consistence with prescribing and interval for follow up appointment.

22. Warfarin Bundle v2 Needed to increase the level of challenge-
Listened to practices
Patient focus groups
Review of literature

23. Warfarin New 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 3 months?*
Overall compliance out of 5

24. Warfarin New 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?
How do you decide what dose of warfarin a patient needs and when they should return – if you asked one of your partners would they do the same?

25. INR Blood Tests Dalkeith Medical Practice Dr Richard Conlan
Kevin Lawrie (Practice Manager)
Hazel Thomson (Practice Nurse)

26. Can you improve efficiency?
Dec-10 – Dalkeith introduced the RAT system
Aug-11 – Dalkeith started the SIPC project
Test per patient before RAT = 2.2 average
Test per patient after RAT = 1.4 average
Saving = almost 100 appointments per month

27. Craigmillar Medical Practice
Our Experience
Craigmillar Medical Practice

28. Our Experience
Bundle changed to make it more relevant for the practices.
HCA collects the information for the last three.
GP then goes through records and collects information for the first two.
Generally all the bundles score highly.
Most difficult is face to face education every three months.

29. Warfarin Bundle Data Collection Tool Bundle Composite Patient 1
Overall Compliance Y N
No. out of 5
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 3 months?
Overall compliance with bundle (i.e. total number of patients who achieved ALL 5 composites) __ / 5
1. Is there evidence that the last advice re warfarin dosing given to patient followed current Lothian Guidance/ INR Star/ RAT?
2. Is there evidence that the last advice re the interval for blood testing given to patient followed current Lothian Guidance/ INR Star/ RAT?
3. Has patient been taking the advised dose since last blood test? Check with the patient that they have actually taken the correct dose.
4. INR is taken within 7 days of planned repeat INR. The planned date and actual date of next INR test must have been recorded.
5. Face to face education recorded every 3 months? This must include advice, questionnaires, leaflets etc.

30. What does our data tell us?

31. Improving Warfarin Management
Driving force was compliance with the bundle.
Practices then tried to improve their system:
PDSA’s
Process Mapping
Patient Involvement

32. Plan, Do, Study, Act

33. Improve Compliance of Using Guidelines When Treating Warfarin Patients
Ensure all GPs and nurses use the Lothian Guidelines when treating patients on warfarin
Review of records showing compliance will increase
Having guidelines within easy access for use backed up with educational event
Practices engaging with process
4 Monitor use of Guideline by developing template for computer system
3 Ensure the Lothian Guidelines are within easy reach for each GP to use
2 all doctors stating the importance and set up PLT around it
1 Review in the practice who uses the Lothian Guidelines

34. Process Map

35. Patient involvement
Each practice was asked to have some Patient Involvement activity.
Practice specific focus groups
Practice patient questionnaires
Simple asking 3 questions
Patient involvement with education leaflet

36. Now what? Bundles helped us understand our system.
Bundles raised awareness.
Bundles allowed us to make improvements to the system, both for staff and patients.

37. Bundle Compliance

38. Does Bundle Compliance = better results?

39. Does Bundle Compliance = better results?

40. BUT……
Control chart for INR <1.5 or >5

41. We do seem to have reduced blood testing!
Control chart for mean number of tests per patient per month

42. What about the Trigger Tool?
All practices were trained in the use of the Trigger tool
Practices were asked to do the tool every 3 months.
Results were collated to learn common themes.

43. Any thoughts about the use of the Trigger tool?

44. Experience with the Trigger Tool
Doctor Gordon Cameron
Milton Surgery, Edinburgh

45. Initial Apprehension
Trigger tool seemed a bit intimidating when we first had it presented to a large group at the study day
Much easier to use in practice and after a brief one on one session to get started
It’s a really effective tool for reflective analysis on patient safety and other clinical issues
Has created a lot of interest from other doctors in the practice as a tool for professional development and for appraisals

46. Not too time consuming after all
Initially seemed like it would take up lots of time to scan the notes and enter the data
In practice much quicker than I thought it would be
By the second time around I spent only 90 minutes on reviewing 20 sets of notes
The absence of triggers sometimes allows quicker scanning BUT – some of the most significant learning experiences were in patients who had NO TRIGGERS

47. “Dodging bullets ….”
No harm actually occurred in this instance so would never have been picked up without trigger tool analysis - events had happened six months before notes were reviewed
Patient on warfarin for stable long term AF
Co-prescribed aspirin – not intentionally
No FBC check in two years
Seen with gout (locum doctor) and co-prescribed two different NSAID’s in high dose in the space of ten days
No PPI cover given
Upward drift of INR during this period to a level just around 4.0
Gout resolved, NSAID’s stopped, INR back to 2.6 …. And were it not for the trigger tool review nobody would have been any the wiser !

48. Frequent Themes We used the trigger tool in in patients on warfarin
Common themes:
Missing Read Codes – e.g: Atrial fibrillation not coded in two patients who had it
Huge variations in what different doctors thought the “Allergy” codes in GPASS should be used for
some only recorded true allergies
others recorded all adverse reactions no matter how trivial
Practice doing well with Warfarin monitoring but much less well with checking Digoxin levels on a regular basis, checking occasional FBCs.

49. Trigger Tool vs SEA Significant Event Analysis
Can only be used to look at cases where harm has already occurred
Needs a lot of writing up
Very reliant on the clinician involved feeling able to share
Can be threatening
Trigger Tool Structured Case notes review
Can pick up near miss cases where no actual harm occurred
No formal writing up as such
Less threatening
A more powerful tool for changing personal ways of working

50. How trigger tool has changed our practice
We plan to encourage other partners and doctors in training to use it as part of appraisal
Specific changes made in response to things picked up during reviews:
Protocol now for recording adverse drug reactions
FBC checks at least once a year for all warfarin patients
Digoxin levels checked at least once a year
Better systems for highlighting possible drug interactions to the doctor who is deciding the next dose of warfarin
Much better at coding relevant read codes
Closer checking that locums are familiar with practice systems for warfarin patients

51. Patient Involvement (focus groups)
How does it all fit together?
PDSA
Patient Involvement (focus groups)
Labs Data
Process Map
Care Bundle
Trigger Tool

52. Where next?
In NHS Lothian we now have a proposed Locally Enhanced Service to spread the SIPC work across other practices.
We have LMC support for the LES.
We are currently awaiting a decision for
? National Patient Safety Programme 2013

53. What is happening in your Board?
To consider before Q & A session:
How aware is your board of this agenda
What is the current infrastructure to support this
What is your board going to do next?