Dr Karl Graham describes how his practice has used new technology to standardise the advice and recall times for patients taking warfarin
For many years our practice has providing an anticoagulation service for our patients. The blood samples are taken at the practice and the local laboratory calculates the INR. Our GPs then provide the dosing information for patients.
I observed that dosing information was not being recorded in a consistent manner, that recall periods were not in line with current recommendations and that GPs were altering doses based purely on experience rather than using any standardised protocol. I felt patient care could be improved by standardising this process.
Researching our options
Two options seemed to be available. We could either choose a ready-made commercial software product or design our own guideline within our clinical system.
I investigated the commercial software option but decided that, at that time, either the options were too costly or did not integrate sufficiently with our clinical system. It was therefore decided to develop our own Vision template.
Vision has a powerful and flexible template develop tool known as ‘Vision Guidelines'. Guidelines can both display filtered patient data and allow consistent data entry using simple mouse clicks. Guidelines can also contain links to websites, a hugely powerful feature allowing easy access to current information.
What we did
The template has undergone a number of revisions but currently displays the following information:
• Indication for anticoagulation
• Anticoagulant drug
• Coagulation timeframe
• The last 10 INR results
• Current anticoagulation dose (confirmed by phlebotomist at time of blood sample)
• Protocol for initiation of anticoagulation in Primary Care (via Web-link)
• Protocol for anticoagulant dose adjustment (via Web-link)
• Current recall (used as a safety net to prevent excessive time between INRs)
The dosing process we currently use is as follows:
1. Patient attends surgery for blood sample
2. Current dose confirmed with patient and recorded using guideline
3. Sample sent to lab
4. Result received electronically
5. GP uses guideline to enter new dosing information and recall
6. Dosing information given to patient
A monthly search checks that there are no overdue recalls outstanding.
Effects of the change
The introduction of a template has resulted in a significant improvement in data quality and recording consistency. It has helped to ensure that anticoagulant dose advice and recall periods are standardised. A regular search for overdue recalls has highlighted when patients have missed a planned blood test. The overall result has been an improvement in patient care.
Dr Dr Karl Graham is a GP at Hedge End Medical Centre, Southampton
How we revamped our anticoagulation service