Improving the reliability of care in high risk areas.

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

Incidence of major bleeding in patients prescribed warfarin ranged from 0% to 16%, and the incidence of fatal bleeding was 0% to 2.9%.

Warfarin

Patient Story

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

Improving Reliability Using Data and Care Bundles

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 No (%) of patients with element recorded

Name and date of birth 36 (100)

Phone number 36 (100)

Diagnosis 31 (86)

Planned duration 18 (50)

Target INR 21 (59)

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…’

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

‘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)

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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

How does this apply to Warfarin management?

Process Map

Warfarin Bundle

Is there evidence that the last advice re warfarin dosing given to patientfollowed current Lothian Guidance/ INR Star/ RAT?

Is there evidence that the last advice re the interval for blood testing given topatient 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 patientfollowed 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.

Warfarin Bundle

Is there evidence that the last advice re the interval for blood testing given topatient 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.

Warfarin Bundle


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


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


There is good evidence that improved patient knowledge and understanding of the use of warfarin improves anticoagulation controlTang 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 patientfollowed current Lothian Guidance/ INR Star/ RAT?

Is there evidence that the last advice re the interval for blood testing given topatient followed current Lothian Guidance/ INR Star/ RAT?




Overall compliance out of 5

Its about what you do with the data…….

Like What?

• Practice meeting • Notice board• Process mapping • Ask patients• Try changing something….• Measure the effect.

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….

Bundle Compliance

Warfarin Bundle Compliance

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Overall Lothian Orchard

Lothian Practice Experience

“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?

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Conan Doyle Wave 1 Lothian Results <1.5 & >5

Potential to free up appointments

How well are we doing in NHS Lothian?

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

Questions?

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)

How to access the bundle data collection spreadsheet

Collecting your data

Entering your data

Automatically generated reportMonth

Warfarin dose Target INR

Advise recorded

INR within 7 days

Patient Education

Overall Compliant

June 60 50 50 60 50 20

July 50 50 50 70 50 10

August 80 60 50 80 40 30

September 90 80 70 80 50 30

October 80 100 70 90 40 40

November 80 80 60 80 50 50

December 80 90 70 80 70 50

January 70 90 90 90 80 60

Automatically generated Graphs

Warfarin dose

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INR within 7 days

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Warfarin Overall Compliance

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Example of Data

Composite Tayside

Composite Measure for 8 practices - Sept10-May11

35%

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Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13 Wk 14 Wk15 Wk16 Wk17 Wk18

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

Achievement – Wave 1

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Care Bundle Wave 1 & 2 Practices

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Care Bundle Wave 1 & 2 Practices

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Wave 1& 2 Achievements

Composite Measure for Wave 1 & 2 Practices June 2010-April 2012

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Wave 1 Wave 2

Patient Measure introduced July2011

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

Tayside Vision Guideline

Side Effects

Reliable systems

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

Medication Reconciliation

Medication Reconciliation • Unreliable at admission

• Inaccurate and delayed at discharge,

• Unreliable systems in place in primary care for updating

“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.org

http://www.ihi.org/

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?

Utilising I.T.

• Implementation of READ Codes for Medicines Reconciliation

• Development of Guideline/Macros on Clinical System

Meds rec data – NHS Greater Glasgow and Clyde

DVD Margaret

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

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 practiceHow many of these tests were not received by the practice………

Have a look at the bundles ?Comments /QuestionsCould you use them in your workplace?

Improving the reliability of care in high risk areas.

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