My remit as Senior Clinical Nurse Specialist for Nottingham University Hospitals NHS Trust was to re-design the Anticoagulation Services at the Queen’s Medical Centre and City Hospital in order to create a merged, safe and efficient service. Both services (prior to the recent hospital merger) were very different in their approach and under extreme pressures as a result of excessive workload and complex manual working pathways.

The two hospitals were both running DAWN AC version 6 in completely different ways (terminal services connection to system at the City Hospital) and had their own separate databases. Referral processing between the hospitals was a manual transcribing exercise resulting in considerable workload for both trained and support staff. Protocols and working pathways were different across the two sites. The commonality was that both sites used yellow books and printed the dose instructions onto stickers that were then attached to the patient’s book and posted the same day, whenever possible.

Very little of the dosing process was automated. The City Hospital was using the DAWN AC version 6 unidirectional interface for INR import but this required manual intervention and the import success was poor at approximately 45-55%. This was due to duplicate records, and considerable patient detail data mismatches between the Laboratory Information Management System (LIMS) system and DAWN AC.

The Queen’s Medical Centre did not have the import facility so therefore laboratory staff were required to transcribe the INR results into the yellow books and the dosing staff then transcribed the INR results into DAWN AC. Safety measures were in place to reduce the risk of transcription errors but incidents were still reported. In addition, sticking the labels into the wrong book and posting the book/s to the wrong patient also had a high incident rate.

Backed by clinical risk data, the promise of efficiency and capacity improvements the service was successful in their application for capital funding to finance the re-design of the service. This has enabled the design and implementation of the following service improvements:

• Upgrade to DAWN AC version 7 and the merging of the two databases.

• Purchase of an interface to enable INRs to be imported automatically from the Patient Administration System (PAS) system into DAWN AC version 7.

• Purchase of the required duplex printers, multi-functional device (scanner, fax, multi-bin printer etc), bar code readers, pressure sealers and additional computers.

• Design and purchase of the single sheet therapy records to replace the yellow books.

• Design and purchase of educational documentation (i.e. information leaflets, patient wallets and ID cards).

• Purchase of an interface to enable the dosing information to be transmitted back to the PAS for uploading into the General Practice (GP) systems – currently being implemented.

• Purchase of an interface to enable the automatic transmission of admission and discharge data and the automatic update of the DAWN AC database with demographic data/GP data from the PAS system – currently being implemented.

The service now benefits from a streamlined working pathway that has enhanced all key areas i.e. laboratory, anticoagulant clinic, remote dosing unit, clerical pool, general practice and patients. Many of the repetitive tasks e.g. sticking labels and transcribing results that previously have been associated with a high incident rate have been completely automated which has eradicated errors. In addition, the automation of these tasks has enabled junior and non-trained staff to be used instead of senior staff for some tasks e.g. laboratory biomedical scientists were required to transcribe the results into the yellow books. Workload for both trained and support staff has been reduced and therefore time has been used to enhance other areas of the service e.g. patient help-line and patient education.

The service has benefited considerably as a result of the redesign and is now able to concentrate on delivering quality patient care. Risk within the service has been substantially reduced and the service now has the opportunity to dedicate time to meeting the NPSA recommendations and implementing further service enhancements. These will include:

• Integrating the DAWN AC version 7 messaging centre into our patient/staff help-line service.

• Implementation of a ward-based dosing for discharge service utilising near patient testing technology and wireless remote dosing.

• Re-design of the service offered to residential and nursing homes.