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Anticoagulation service: improving the referral process.

ABSTRACT: Oral anticoaguIants are extremely common, and it is estimated that there are between 500,000 and 1 million people prescribed them in the UK.[1] These drugs are the most frequently named medication in fatal errors and litigation claims [2] and they require the implementation of additional safety controls.[3] Warfarin is the most commonly prescribed anticoagulant and it requires regular international normalised ratio (INR) monitoring and dosage adjustment to achieve the desired therapeutic range.[4] Under-anticoagulation can cause thrombosis and over-anticoagulation can lead to haemorrhage, both of which can be fatal.[5] At St. Peter's hospital there is an anticoagulation service providing regular international normalised ratio (INR) monitoring for patients on warfarin. However, the current referral system is paper-based and a baseline audit found that only 66% of patients were successfully referred to the service on discharge from hospital. This identifies a significant patient safety issue which could result in life-threatening consequences. An electronic referral form was developed within a pre-existing computer based ordering system with the aim of improving the referral rate. The electronic referral tool streamlined the referral process, making the form quicker and easier to fill out and removed the need for faxing lengthy paper forms. Key information on the form was made mandatory. After intervention a re-audit revealed that 84% of patients discharged on warfarin were referred to the clinic, which equates to an increase of 18%. The increased referral rate will improve patient safety and prevent unnecessary hospital admissions. There should be continued promotion of the importance of referring patients to the anticoagulation clinic. This can be delivered through inductions, teaching sessions, and re-audits. Future goals include an automated referral system triggered on patient discharge.

SUBMITTER: Davies T

PROVIDER: S-EPMC4645824 | biostudies-other | 2014

REPOSITORIES: biostudies-other

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Project description:BackgroundElectronic medical record-based interventions such as best practice alerts, or reminders, have been proposed to improve evidence-based medication prescribing. Formal implementation evaluation including long-term sustainment are not commonly reported. Preprocedural medication management is often a complex issue for patients taking antithrombotic medications.MethodsWe implemented a best practice alert (BPA) that recommended referral to an anticoagulation clinic before outpatient elective gastrointestinal (GI) endoscopies. Eligible patients were taking an oral anticoagulant (warfarin or direct oral anticoagulant [DOAC]) and/or antiplatelet medications. Patients referred to the anticoagulation clinic were compared to those managed by the ordering provider. Outcomes assessed included guideline-adherent drug management before endoscopy, documentation of a medication management plan, guideline-adherent rates of bridging for high-risk patients taking warfarin, and evaluation for sustained use of BPA.ResultsEighty percent of patients (553/691) were referred to the anticoagulation clinic during the initial 13-month study period. Most referrals came from gastroenterologists (397/553; 71.8%) followed by primary care providers (127/554; 22.9%). Patients referred had improved rates of guideline-adherent medication management compared to those who were not referred (97.4% vs 91.0%; P = .001). Documentation of medication plan was significantly higher in the referred group (99.1% vs 59.4%; P ≤ .001). There were no differences in rates of appropriate bridging for patients taking warfarin. Implementation of the BPA also resulted in sustained, consistent use over an additional 18 months following the initial study period.ConclusionImplementation of a BPA before elective outpatient GI endoscopies was associated with improved rates of guideline-adherent medication management and documented management plan, while streamlining preprocedural medication management.

Project description:Ethiopia has one of the world's poorest neonatal mortality rates (1). As a British paediatrician working for one year, the main aim was to improve neonatal care in a referral hospital's neonatal unit. An initial project looking at all admissions to the unit over the month of October 2012, revealed the death rate within the unit was 21% of all admissions. Of the 55 admissions only 43 (75%) had a temperature recorded at admission. 29 (67%) of these were hypothermic, and of these 29 initially hypothermic babies, 19 (65%) remained hypothermic or did not have another temperature documented during their stay. Only 33 (56%) had a heart rate and respiratory rate recorded on admission and only 11 (19%) had any further vital signs recorded during their stay. 19 of the admitted infants had a diagnosis of low birth weight and 10 (53%) of these either died or left against medical advice. With this information regular basic neonatal care teaching sessions for doctors and nursing staff were initiated. Vital signs charts were introduced and unit specific protocols were written. Continuous Positive Airway Pressure (CPAP) was trialled and found to be effective, and CPAP training was given to all nurses and doctors on the unit. A room was set aside to be used solely as Kangaroo Mother Care (KMC). The nurses were taken to a very effective neonatal unit as an 'experience sharing' trip to help with motivation and a grant was also obtained for basic equipment. After 6 months the project was repeated for all the admissions during February 2013. The death rate had progressively fallen and was 10% in February. 54 patients (98%) had a temperature taken on admission and of these, 27 (49%) were hypothermic. 25 (93%) of these hypothermic infants had subsequent temperatures documented which were normal. 54 (98%) had heart rate and respiratory rate recorded on admission and 50 (90%) had them recorded at least daily during their stay. Of the 22 babies with low birth weight (40%), only 4 (18%) died/left against medical advice. 4 received CPAP and 6 were treated with KMC.

Project description:The GMC states that, 'You must be satisfied that, when you are off duty, suitable arrangements have been made for your patients' medical care…including effective hand-over procedures' [1]. The medical weekend handover system at this tertiary referral centre involved multiple pieces of paper with no clear list of tasks, and no way to identify critically unwell patients. Patients could be missed from the ward round or could be difficult to identify under pressure. The authors felt this process could pose a threat to patient safety so decided to improve it. A questionnaire was distributed to all 11 medical SHOs with 100% response rate. Results showed that 72% thought the process was unstructured, 81% did not think the process was always safe, and 100% thought it could be improved. After discussions with senior medical management and with the approval of the trust audit committee, a new weekend handover proforma was designed, taking into consideration the results and comments from the questionnaire. The new proforma is accessible through a shared drive, which can be accessed by all medical SHOs in the hospital. Each team is able to copy their patients onto the combined ward-based list. There are columns for specific weekend jobs and registrar/SHO reviews. Any potentially unwell patients are highlighted in bold and discussed with the on-call SHO on Friday. All medical SHOs were given a post-implementation questionnaire after the new handover process had been in place for two months. Results of this showed that 100% of SHOs felt an improvement had been made, with 100% stating that the new system was more structured (64% always, 36% most of the time). The SHO's perception of patient safety increased from 81% generally unsafe, to 100% generally safe. The new handover has been well received and supported by the current SHO cohort. Improvements in the structure of handover have been made with perceived improvements in patient safety. Due to the success of the system, the handover proforma is being implemented in the trust's sister hospital.

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Anticoagulation service: improving the referral process.

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