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David patterson: Continuing development of the community based anticoagulant and stroke prevention services

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David patterson: Continuing development of the community based anticoagulant and stroke prevention services

  1. 1. Continuing development of the community based anticoagulant and stroke prevention services Progressing towards A STROKE PREVENTION SERVICE (AF AND AC) Transition from successful pilot services towards more robust and expanding services 21 November 2011 Professor David Patterson, Professor Dipak Kalra, Department of Cardiovascular Medicine and Pharmacy, Whittington HealthCentre for Health Informatics and Multiprofessional Education, University College London
  2. 2. Electronic Health Record (EHR) Supporting clinical shared care across organisations Building on ~20 years of European research Conforms to the latest international standards Robust medico-legal and confidentiality features Standards for clinical knowledge capture enable meaningful clinician developer interaction and rapid development Implemented as a web based system Incorporates decision support and alerts Cardiovascular modules•HeartBeat AC: anticoagulation - in live use• HeartBeat HF: heart failure - ready for live use• HeartBeat AF: atrial fibrillation - clinical engagement commencing
  3. 3. Clinical Governance report Derived automatically from the EHR Each site can run its own report at any time All reports include anonymous service-wide comparisons Reviewed at quarterly Clinical Governance Board meetings
  4. 4. North Central London Community BasedAnticoagulant and Stroke Prevention Services PROGRESSING TOWARDSA STROKE PREVENTION SERVICE (AF AND AC)• Enhancing our ability to prevent patients developing strokes• Progressed from a doctor delivered service in hospital toward an increasingly community based service• Delivered by practice nurses, community pharmacists and GPs, supported by a state of the art information and advisory system which uses an Electronic Health Record• A strong focus on education and on clinical governance• Our services have been shown to be safe and very well received by the patients, by the commissioners of health services and by the community staff
  5. 5. Forgetful, elderly person with diabetes, atrial fibrillation, heart failure and mild aortic valve stenosis, who lives alone in poor housing and requires anticoagulation• Multiple chronic conditions• Multiprofessional care• Shared information needs - across boundaries• Interface with other organisations: – Social services – Housing – Voluntary sector – Ambulance/car services – Primary/secondary/tertiary care
  6. 6. Development of advisory systems for warfarin dose and follow-up interval guidance• CONTEXT - 1• In latter part of 20th Century – warfarin management was a doctor delivered service in hospital environment• Regarded as dull and unchallenging• Often performed by the most junior doctor with little experience of anticoagulation
  7. 7. Development of advisory systems for warfarin dose and follow-up interval guidance• CONTEXT - 2• And yet• Developing realisation that warfarin was potentially a dangerous drug influenced in its effects by many factors such as diet and use of other drugs• Increasing evidence that there was an unacceptably high morbidity and death directly related to warfarin• Very poor communication between health professionals when introducing a new drug or starting new treatment for a patient
  8. 8. [1] Evaluation of a decision support system for initiation and control of oral anticoagulation in a randomised trial[2] Validation of an algorithm for oral anticoagulant dosing and appointment scheduling• [1] The computerised decision support system was safe and effective• It improved the quality of initiation and control of warfarin by trainee doctors• [2] The algorithm performs better than inexperienced clinicians and as well as experienced clinicians for the non-difficult patients• Algorithm better at recognising the more difficult case than the non- expert (ie to see doctor)• Analysis of combination of dose and interval recommendation showed remarkable similarity between experts and algorithm
  9. 9. 3 2 1INR -Target INR 0.5 0 -0.5 -1 -2 -3 95% 2.0 - 3.0 2.5 - 3.5 3.0 - 4.0 3.0 - 4.5 90% Therapeutic range 75% 50% 25% 10% 5%
  10. 10. 400 0 therapeutic range 3000 2000 1000 0 1 00 1.50 2.00 2.50 3.00 3.50 4.00 4.55 5.00 5.50INR value - patients with therapeutic range 2.0 - 3.0 Total 18881 (full tail at high values not shown)
  11. 11. All therapeutic ranges 100 Above range 80 60Percentage In therapeuticof INR results range 40 20 Below range 0 0 36 Months into anticoagulation therapy
  12. 12. North Central London Sector
  13. 13. ANTICOAGULANT AND STROKE PREVENTION SERVICES atHOSPITALS AT: WHITTINGTON AND NORTH MIDDLESEX HOSPITALSPHARMACIES AT: HIGHBURY BARN, N5 BOOTS (WOOD GREEN), N17POLYCLINIC AT: ENFIELD (1 GP CENTRE/POLYCLINIC), N9GP PRACTICES AT:HIGHGATE GROUP PRACTICE, N6 DUKES AVENUE, N8SOMERSET GARDENS, N15 TYNEMOUTH ROAD, N17MORRIS HOUSE, N22 GOWER STREET, WC1HAMPSTEAD GROUP PRACTICE, NW3 JAMES WIGG PRACTICE NW5MUSEUM PRACTICE WC1B KEATS GROUP PRACICE NW3PARK END SURGERY NW3 PARLIAMENT HILL SURGERY NW5REGENTS PARK MEDICAL CENTRE NW1 ROSSLYN HILL SURGERY NW3BRONDESBURY MEDICAL CENTRE NW6 AMPTHILL SQUARE NW1ADELAIDE ROAD, NW5 ROMAN WAY MEDICAL CENTRE, N7RITCHIE STREE GROUP PRACTICE, N AMWELL GROUP PRCTICE, WC1ELIZABETH AVENUE, N1 RISE HEALTH CENTRE, N19KILLICK STREET, N1HOSPITAL OUTREACH SERVICES TO: GOODINGE HEALTH CENTRE, N7 RIVER PLACE HEALTH CENTRES, N1TORRINGTON SPEEDWELL HEALTH CENTRE, N12 EDGWARE COMMUNITY HOSPITAL, HA8 STANDARD CLINICAL OPERATING PROCEDURE
  14. 14. CLINICAL GOVERNANCE BOARD Anticoagulation & Stroke Prevention Service• MEMBERSHIP• PATIENTS• HOSPITAL CONSULTANTS – CARDIOLOGY AND HAEMATOLOGY• ANTICOAGULANT PRACTITIONER FROM EACH OF THE 5 PCTS (GP OR PRACTICE NURSE)• ANTICOAGULANT PRACTITIONERS FROM HOSPITAL(S) OUTPATIENT SERVICE• SENIOR PHARMACIST WITH EDUCATIONAL REMIT• SENIOR PHARMACISTS WITH CLINICAL GOVERNANCE REMIT• COMMISSIONER FROM EACH PCT• CLINICAL LEAD FROM EACH PCT• ACADEMIC HEALTH INFORMATIST• ACADEMIC BEHAVIOURAL SCIENTIST AND STATISTICIAN• ACADEMIC LEGAL AND EDUCATIONAL ADVISOR• IM&T REPRESENTATIVE FROM WHITTINGTON HOSPITAL
  15. 15. Generic Ingredients of our integrated services together with Our package of support• Education and training for practitioners – Formally defined syllabus – Training sessions including practical skills and use of the information system – Formal assessment, required certification, periodic reassessment• Clinical information system – Electronic Health Record supporting clinical shared care across different organisations – Disease management system - anticoagulation; heart failure; atrial fibrillation etc etc – Clinical management advisory system• Clinical support – Direct contact with senior clinicians, able to access the same EHR from different sites• Clinical governance – Clinical standard operating procedures and site specific operating procedures – Quality assurance processes and monitoring – Review and comparison of outcomes – Multidisciplinary clinical governance board
  16. 16. Comments from Patients• Site 1 –Very satisfied with everything –Always on time and always most helpful –I can not fault anything. I only wish I did not have to come –Nothing at this time –Very very good –Appointments always on time treatment well explained –All your staff are excellent –Very competent• Site 2 –To continue this same way as at present –I am very happy with the service given here, many people take up this choice –No Complaints at all –All very satisfied –I am very satisfied with the anticoagulant service –Delighted with the service, I got to compliment you on your lovely polite staff
  17. 17. Quality and safety principles of our integrated care service • the patient will receive monitoring care in the most convenient and safe place for them • the practitioner will be demonstrably well trained, up to date and able to offer a high quality service • the EHR of the patient will be available in a timely manner to all of the practitioners caring for the patient, wherever located • clinical governance arrangements will be implemented and learning processes enhanced • hospitals will continue to play key roles in clinical support, education of staff, clinical governance and service development • the patient or customer is central to the planning and delivery of services
  18. 18. CLINICAL GOVERNANCE BOARD Anticoagulation & Stroke Prevention Service• MEASURES OF SATISFACTORY QUALITY AND SAFE PERFORMANCE• PATIENT FEEDBACK/QUESTIONNAIRES FROM EACH PCT• TRAINING, EDUCATION AND PERFORMANCE OF ANTICOAGULANT PRACTITIONERS (OSCE AND RE-ACCREDITATION) FOR ALL PRACTITIONERS• ANTICOAGULANT CONTROL (BY SITE -- BY WHOLE SERVICE – BY PCT --- BY PRACTITIONER -- BY TIME - BY THERAPEUTIC RANGE ETC)• INFORMATION GOVERNANCE (ACCESS CONTROL; SECURITY; BACKUP POLICIES)• QUALITY CONTROL OF CLINICAL PREMISES - ANNUAL VISITS –• QUALITY CONTROL OF EQUIPMENT – POCT EQUIPMENT AND NEW REGULATIONS – SEEKING CPA ACCREDITATION FOR COMMUNITY SERVICE• THE ANNUAL REVIEW OF PATIENT – NOW BEING PILOTED• USE OF ROOT CAUSE ANALYSIS (RCA) AND COGNITIVE WORK ANALYSIS (CWA) IN “NEAR MISSES” OR UNTOWARD INCIDENTS• REAL TIME ANALYSIS OF PERFORMANCE
  19. 19. Link with secure mobile device
  20. 20. Make solutions simple and intuitive
  21. 21. North Central London Integrated Care Model Whittington Hospital and its collaborating Hospitals Collaborative GP Practices development Consultant-led and of EHR Community Cardiology Pharmacies systems Service CHIME (UCL) The Consultant-led Community Cardiology Services provides protocol-led and formally-evaluated collaborative care, initially for anticoagulant and cardiovascular diseases.

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