An audit of two methods of anticoagulation monitoring in a general practice

BACKGROUND AND CONTEXT: Patients with atrial fibrillation (AF) and a five-year stroke risk >15% should be on long-term oral anticoagulant therapy with adjusted dose warfarin unless there is a clear contraindication. ASSESSMENT OF PROBLEM: Ad hoc adjustments of warfarin dose and anticoagulation monitoring by a general practitioner is less efficient than a standardised protocol administered by the practice nurses. This study was a retrospective audit of patient anticoagulation control before and after a change in method of warfarin adjustment. Measures were frequency of testing, time spent in the therapeutic range and mean International Normalised Ratio. RESULTS: Thirty-two patients were studied over a 12-month period. The method change resulted in important improvements in practice efficiency while maintaining the standard of anticoagulation control with no significant increase in frequency of venesection. STRATEGIES FOR IMPROVEMENT: General practices still using ad hoc adjustments of warfarin therapy can adopt a standardised nurse-managed protocol to achieve greater efficiency without adversely affecting patient care. LESSONS: A move from the heavily doctor-intensive ad hoc system to the entirely nurse-led system improved practice efficiency. The doctor was liberated from the process. The nurse no longer had to act as liaison with the doctor. The receptionist did not have to ask patients to ring back once the doctor had seen the results. Patients received their instructions more quickly and their care was not compromised.