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Case Study Eight

Level 3 treatment review in patients receiving anticoagulant drug therapy in Barnet & Edgware

In 1999 an out –reach anticoagulant service was set up in four different localities in Barnet. A variety of junior doctors and consultants had led the clinic. Consequently there was disjointed supervision of patients with inconsistent education and advice given. Patients attended the clinic in the pathology department, the space was limited and there were long delays and queues.
A nurse-led service was implemented in 1997 but change needed to take place due to inadequate resources and funding took a very long time. In 1998 a Patient Group Direction (PGD) for the continuation of supply of warfarin was devised for the nurse-led service. Computer assisted dosage software that has all the information about the patients' anticoagulation therapy, aids decision making about drug dosage and next appointment date. The provision of the anticoagulation service has been funded by the local acute trust (Barnet & Chase Farm Hospitals), but since July 2002, the North Locality of North Barnet PCT and the trust have jointly funded and appointed the first consultant nurse in anticoagulation.
This service aims to:
  • Deliver a high quality that is safe and effective, patient-friendly, local and convenient anticoagulant monitoring service
    • Improve patient access
      • Provide advice and support patients taking a medicine with known risks
        • Make use of nurses skills e.g. patient counselling skills
        The anticoagulant service has over 2500 patients who have a choice of where they would like their blood taken. The service is decentralised in four different sites, this is to enable patients to have access to the service nearer to their home. Patients have the flexibility to attend the hospital or out reach clinics.
        The nurse-led clinic is an out-patient service provided to the Trust.
        Patients have their INR level measured by one of a team of accredited nurses. The nurse reviews with the patient:
        • Current oral anticoagulant therapy taking into account other medication for other disease morbidites but without specific review unless felt to be relevant to anticoagulant control or patient requests it
        • the results of blood level monitoring and adjusts the dosage of anticoagulant therapy
        • ensures specific dosage instructions are entered into patient held anticoagulant booklet and checks patient understanding of current dose of anticoagulants
        • discusses with the patient/carer any potential drug interactions e.g. particularly with alcohol, concomitant taking of antibiotics and herbal remedies.
        Subsequently treatment review is done but the patient can request to see the anticoagulant nurse for clinical medication review. Clinical medication review does occur when the patient contacts by telephone for advice or support. The anticoagulation nurse carries out clinical medication review over the telephone when the INR result is of concern. This is to discuss with the patient if there has been any changes to medication or medical condition that could have contributed to the sudden abnormal result.
        The patient is able to ask questions about their therapy and the nurse offers and records any advice given. Records are maintained containing all quality control data and patient data enables monitoring of quality standards and ensures that all patients are being seen at regular intervals.
        During the review all the medication the patient is on are taken into consideration. If there are any concerns about the other medication both the GP and the referring doctor will receive a letter about the other medication or any concern regarding the patient's anticoagulation therapy. For example if the patient is discharged on platelet aggregation drugs and anticoagulation therapy, this will be highlighted in the usual letter that is sent to the referring consultant and GP when the patient is first seen at the clinic.
        When the nurse-led service was set up in 1997, there were no systematic training and support mechanism. Training package for nurses and clerical support have been devised and implemented.
        Patient participation is integral to good management of anticoagulant therapy. Patients are involved in the decision making process. Patients are informed of risks and benefit of treatment offered and any alternatives offered in order for patients to make a fully informed decision. They are also encouraged to report any changes in medication or medical condition to the anticoagulation clinic. Drug interactions are discussed on their initial visit and the message is reinforced in the patient's hand held record.
        Patients hold their therapy record with all the information about their anticoagulant monitoring.
        A recent patient satisfaction survey demonstrated very high satisfaction with the service. Analysis of feedback from 35 patients identified:
        • 100% of respondents believed the service to be fast but safe, effective and efficient
        • 96% of respondents found the anticoagulant nurse was always able to 'completely help, understand and support their needs'
        • 97% were able to receive telephone advice about their therapy when they needed it
        • 100% of respondents were aware of their responsibility to keep Sister Packham informed of any changes in their medication or medical condition that could affect their anticoagulant therapy?
        In the past, some elderly patients were not commenced on anticoagulant therapy in spite of appropriate clinical indications because of the risks of complications and the difficulty in patients attending the hospital for monitoring. Improving the quality of monitoring and taking the service into the community has made it possible to give anticoagulant therapy to the elderly where appropriate.
        Patients are satisfied because there is help at the end of the telephone and they are aware that the anticoagulant team who know them deals their problems. Decentralising the anticoagulant service into the community has improved the service and reduced health inequalities for older people. 
        Contact Information
        Bunis Packham Consultant Nurse- Anticoagulation Barnet & Chase Farm Hospitals NHS Trust
        Tel: 0208 216 4890 0208 216 4000 bleep 493

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