1. Improving the reliability of care in high risk areas

2. 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%.

3. Warfarin Patient Story

4. Where are the risks in prescribing and monitoring patients on warfarin?

5. Improving Reliability Using Data and Care Bundles

6. 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”

7. Getting started with data Warfarin sheets audit No (%) of patients with element recorded Name and date of birth36 (100) Phone number36 (100) Diagnosis31 (86) Planned duration18 (50) Target INR21 (59)

8. Care Bundle A care bundle is a set of evidence based interventions that when used together significantly improve outcomes

10. Peter Provonost ( ITU physician at Johns Hopkins Hospital, Baltimore, Maryland ) Simple message: ‘Evidence Based practice… Culture Change… Measurement of change…’

11. 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 Peter Provonost’s Care Bundle

12. ‘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.

13. Central line infection rate (per thousand line days) 2.34 0.18 92% reduction

14. 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

15. 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

16. Bundle vs Audit Audit – identifies whether individual measures are being implemented Bundle - data collection tool to sample whether optimum care is being delivered

17. How does this apply to Warfarin management?

18. Process Map

19. 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

20. 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 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.

21. 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 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.

22. 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

23. 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.

24. 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.

25. 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

26. Its about what you do with the data…….

27. Like What? Practice meeting Notice board Process mapping Ask patients Try changing something…. Measure the effect.

29. Practice Feedback There is magic in graphs… Henry D Hubbard, 1939 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….

30. Bundle Compliance

31. Lothian Practice Experience

33. “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”

34. Successes - Improved: Patient Care Systems Knowledge, Skills & Attitudes Safety Culture Team-working Patient Involvement Less Stress Efficiency

36. 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”

37. 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”.

38. Does Bundle Compliance = better results? Results 5

39. Potential to free up appointments

40. How well are we doing in NHS Lothian?

42. Care bundles 1.Shed new light on our current practice 2.Act as a catalyst for improvement in care 3.Can lead to increased awareness

43. Questions?

44. What about other bundles? DMARDS Medication Reconciliation Results handling

45. 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 )

47. How to access the bundle data collection spreadsheet

48. Collecting your data

49. Entering your data

50. Automatically generated report Month Warfarin doseTarget INR Advise recorded INR within 7 days Patient Education Overall Compliant June6050 60 50 20 July50 70 50 10 August80605080 40 30 September90807080 50 30 October801007090 40 November80 6080 50 December80907080 70 50 January7090 80 60

51. Automatically generated Graphs

57. Example of Data

58. Composite Tayside * A new patient measure to be added in June will change the nature of the data with the composite likely to decrease initially.

59. Achievement – Wave 1 Wave 1& 2 Achievements Patient Measure introduced July2011

60. 1 Invite patients who have failed to comply by telephone 2 Send information stating reasons for why it is important to attend 3 Put a note on patients repeat prescription Ensure patients prescribed Methotrexate or Azathoprine attend a monthly review for blood monitoring Patients complying by attending blood monitoring will increase Using a variety of engagement methods 4 Restrict the amount of repeat prescription available to them to encourage attendance 5 Stop repeat prescription until they attend PDSA - Improve Compliance of Patients Attending Monthly Blood Monitoring Patients engaging

61. Tayside Vision Guideline

62. Side Effects

63. Reliable systems “The practice team are more aware of the need to adopt "failsafe" systems rather than assume 100% adherence to systems”

64. Medication Reconciliation

65. Unreliable at admission Inaccurate and delayed at discharge, Unreliable systems in place in primary care for updating

66. “The process of obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medication accurately communicated” (Institute for Healthcare Improvement, www.IHI.orgwww.IHI.org

67. Medication Reconciliation Measures Has the Immediate Discharge Document been workflowed on the day of receipt? Has medicines reconciliation occurred within 2 working days of the Immediate Discharge Document being workflowed to the GP/Pharmacist Is it documented that any changes to the medications have been acted upon? Is it documented that any changes to the medications have been discussed with the patient or their representative?

68. Utilising I.T. Implementation of READ Codes for Medicines Reconciliation Development of Guideline/Macros on Clinical System

69. Meds rec data – NHS Greater Glasgow and Clyde

70. DVD Margaret

71. Results handling No. ITEM YES NO 1. Test(s) results were reviewed by a practice clinician 2 working days of being received by the practice? 2. A definitive decision was recorded by a practice clinician on ALL test results within 7 calendar days of being received by the practice? 3. The decisions for ALL test results have been ‘actioned’ by the practice, including the patient being informed as instructed? (Where no actions are required record as Yes ) 5. All measured met

72. Results In addition please answer the following During the past month have you carried out a process to identify results which have not been returned to the practice How many of these tests were not received by the practice………

73. Have a look at the bundles ? Comments /Questions Could you use them in your workplace?