Primary Care Pharmacy November 1999 Vol 1 No 1 p

Looking at anticoagulation services

By Sheena Macgregor, MSc, MRPharmS

An audit tool has been developed by a team of pharmacists

Audit is a method whereby objective data can be critically examined to assess, evaluate and improve patient care via a systematic approach. Many pharmacists have a role in primary care to facilitate the implementation of national guidelines and to ensure that medicines are used appropriately and safely to maximise health gain for patients. Audit of current services, which are either undertaken by other primary health care professionals or by pharmacists themselves, can identify areas of practice which are in need of review and improvement. Audit templates, which have already been piloted, can provide a useful basis for adaptation to suit local needs. This article looks at a template for audit of anticoagulation.
In the United Kingdom it has been estimated that 300,000 patients are prescribed oral anticoagulants. The number of patients suitable for anticoagulation is increasing, with evidence that patients with non-rheumatic atrial fibrillation benefit. This increase in patient numbers has created pressure on existing hospital clinics, leading to a move to find alternative models of service provision within primary care. Models may vary from pharmacist or nurse-led clinics using near-patient testing in the GP surgery1 or community pharmacy,2 to nurses taking blood samples in the GP surgery, which are then sent to a central haematology laboratory for INR determination, the results being faxed, telephoned or electronically sent back within a few hours. Results are then interpreted and patients telephoned with instructions for dosage adjustment. Audit of anticoagulant care frequently indicates less than optimum therapeutic control and lack of standardisation of care within British Society for Haematology guidelines.3
An audit of an individual practice provides an opportunity to address quality issues identified, and to ensure consistency of the standards of care provision to patients. The audit tool described here was developed by a team of pharmacists from a range of specialties including hospital, community and quality assurance (see below). It covers critical components of the service, including documentation, procedures, INR monitoring and instrumentation. The service quality, efficiency and effectiveness are also evaluated. Initially, we developed practice standards based on the British Society for Haematology guidelines. This also produced a framework for continuous quality improvement of anticoagulant care, which could be reviewed in the light of changes in evidence or national guideline recommendations on a regular basis. The pharmacists involved used the outcomes for peer review sessions.

The audit process

A series of eight standards are assessed using a checklist approach. The auditor randomly selects a sample of either 25 per cent of the patients managed or 50 patients, whichever is smaller, and completes each individual audit checklist. Records for the previous six months are reviewed.

References

Acknowledgements

The audit tool was developed by: Gillian Cruickshank, quality of service pharmacist, Dundee teaching hospitals NHS trust (now practice pharmacist, Dundee), Elizabeth King, senior clinical pharmacist, Perth and Kinross NHS trust, Andrew McGuire, practice pharmacist, Dunkeld, and Sheena Macgregor, senior prescribing adviser, Borders primary care trust

Sheena Macgregor is senior prescribing adviser, Borders primary care trust