Implementation of local guideline by interactive workshop improves

anticoagulation therapy and patient safety

Puhakka J, Helsinki Health Centre, GPSuvanto I, Helsinki Health Centre, Head nurse

Sipilä R, Centre for pharmacotherapy development ROHTO, Medical Advicer

13-16.5.2009 Nordic Congress of Family Practice

13.-16.5.2009 Nordic Congress of Family Practice 2

ROHTO-activities in Helsinki Health Centre

26 Primary health care units (PCU)

Facilitator pairs at each PCUs+

Aim:

To promote rational pharmacotherapy

To improve clinical practices

Interactive workshops at PCUs

13.-16.5.2009 Nordic Congress of Family Practice 3

Background – anticoagulation therapy

• Bleeding complications are common and often serious (Landefeld & Beyth Am J Med 1993)

• The risks of complications are related to INR control(White et al. Arch Intern Med 2007)

• High interaction potential (Raunio H. Suom Laakaril 2005)

• Warfarin frequently prescribed to elderly patients with polypharmacy

• Concomitant prescriptions for potentially interacting medicines are common in primary care (Snaith et al. 2008 Am J Cardiovasc Drugs)

• Warfarin therapy documentation unclear• High volume of these patients in Töölö• INR test is the most prevalent laboratory test in Helsinki Health

Centre

13.-16.5.2009 Nordic Congress of Family Practice 4

Aim

• Implementation of Helsinki Health Centre anticoagulation • To improve recording of warfarin therapy to the

electronic patient records• To develop shared clinical practices, and to clarify

division of professional tasks

• Enhance knowledge on anticoagulation therapy

• Evaluate the changes in clinical practices

13.-16.5.2009 Nordic Congress of Family Practice 5

Setting

• Helsinki Health Centre• 26 primary care units• 564 500 inhabitants• Coverage 42.3% (outpatient treatment)• 322 GPs, 525 Nurses, 270 other staff

• Töölö Health Care Unit • 27 000 population• Coverage 32.9 % • Chief physician and 11 GPs, 8 outpatient consulting nurses, 14 other

staff

13.-16.5.2009 Nordic Congress of Family Practice 6

The steps of Rohto-workshop

Analysis and understanding•Outline of present practices

•Baseline audit

•Feedback of the results

Objectives of change

Solutions•based on city’s anticoagulation

guideline

Evaluation and feedback•Follow-up audit

•Participant feedback

•Audit resultsChange in

practice

Contract

Problem in practice

local facilitatorsGP-nurse pair

• Supported and trained by ROHTO

and regional coordinator

•Act as change agents for rational pharmacotherapy

Information

Picture modified from Rohto

13.-16.5.2009 Nordic Congress of Family Practice 7

Implementation methods

• Baseline audit • A random sample of hundred patients visiting laboratory

for INR control during one week • Data collected from electronic patient records

• Is indication recorded• Planned duration of the therapy• Target level of the therapy

• Workshop• Multiprofessional (21 participants: 10 GPs, 11 nurses + other)

• Follow-up audits every six months• New indicator: Warfarin recorded as permanent medication to the

electronic patient record

• Feedback of the results on weekly staff meetings and separately for GPs and nurses

13.-16.5.2009 Nordic Congress of Family Practice 8

Results 1

• Feedback from participants• 6 / 13 WS participants reported an intention

to change their clinical practices • 3 no need to change

• INR within therapeutic range for 66%, 65%, 77% and 66% in the cases

• After the workshop treatment information was generally better recorded

13.-16.5.2009 Nordic Congress of Family Practice 9

Results 2 : recordings

Table I. Percentage of indicators recorded in electronic patient records

Baseline 6 months 12 months 18 months

Indication 54 73 82 93Target level 50 58 73 90Planned duration 54 46 58 78

Recorded as permanent medication 77 91

%

13.-16.5.2009 Nordic Congress of Family Practice 10

Results3: Control intervals

Table II. Percentage of patients in different categories of control intervals (weeks) in two follow-up audits

Control intervals (weeks) 12 months 18 months

< 2 32 132-3 30 65>3 38 22

%

13.-16.5.2009 Nordic Congress of Family Practice 11

Conclusions

• Interactive workshop combined to repeated audits and feedback can lead to improved patient data recordings

• Changing clinical practices requires time and effort

• These changes may lead to improved patient safety

• Control intervals are still short in relation to INR levels and city’s anticoagulation guideline

• Effect of the implementation and shared clinical practices on treatment control is still unclear

13.-16.5.2009 Nordic Congress of Family Practice 12

Thank you for your attention!