Anticoagulation Services



Service improvement with Microsystems started in September 2012 and the service has change significantly in that time. As at January 2016 there were approximately 3200 active patients receiving care from the Nurse-led STH Anticoagulation Service, resulting in a daily patient caseload of 300. The case mix of patients on Warfarin has changed in the last 3 years and those who can switch to a direct acting agent eg Rivaroxaban, have been discharged to primary care. The patients who cannot be offered an alternative to Warfarin now fall into the complex and unstable category therefore their management is more complicated and frequent monitoring is required to achieve a safer time within the therapeutic range.


As a result of carrying out a ‘5Ps assessment’, the initial data indicated:
• A very high percentage of inpatient referrals received by the service were incomplete. This wasted a substantial amount of nursing time acquiring the necessary information. As of January 2016 this continues to require ongoing improvement albeit in third or fourth phase
• Telephone calls were not being dealt with by the most appropriate member of staff. Both STH staff and patients gave negative feedback about being able to talk to the right person in Anticoagulation clinic
• A large number of patients called the clinic out-of-hours leaving voicemails. This created a an additional workload for the team at the start of each day
• There was mismatch between capacity and demand. Nursing staff routinely working several hours overtime each day in order to cope with the demand on the service
• There was no process for formal annual reviews of patients to ensure they are on the most appropriate anticoagulant and treated in the most appropriate setting
• There was an average of 30 DNA patients per day, creating approximately an additional hour of nursing work per day


The team used the data to identify six key improvement themes:
• Theme 1 ‘Referrals’ – “We aim to improve the referral process for patients requiring specialist care from the Anticoagulation Clinic , B Floor, Royal Hallamshire Hospital”
• Theme 2 ‘Service User Queries & Advice’ – “We aim to identify and ensure the best use of existing resource in the Anticoagulation Clinic”
• Theme 3 ‘Clinic Capacity’ – “We aim to understand the true capacity and demand for specialist management of patients in the Anticoagulation Clinic”
• Theme 4 ‘Dosing’ – “We aim to improve the dosing process for patients in the Anticoagulation Clinic”
• Theme 5 ‘Environment’ “We aim to improve the patient experience by provision of sufficient consultation rooms to enable discussions with patients to be held in private. We aim to improve staff satisfaction through provision of sufficient work space and equipment, thus providing a working environment that maximises work flow and efficiencies”
• Theme 6 ‘IT’ “We aim to improve the use of computerised dosing software system to modernise the STH service”


To date a number of significant improvements have been made. Through a changing NHS picture the needs and focus of the service have evolved and service improvement methodology has enabled the team to develop and change the service as an engaged and empowered group.

Staff feedback: I think going to the meetings….they do open your eyes, because you do just think “we can’t do any more”, but then get to the point when you can’t just carry on and let other people just decide for us. If we want something doing, we’ve got to get involved

Future Progress

In 2016, the emerging picture for anticoagulation means a focus on:
• Improvement on the quality and timeliness of incoming referrals
• Clinic environment, particularly addressing patient privacy and dignity issues
• Annual therapy reviews for all anticoagulation patients
• Work with ‘Community phlebotomy’ Project to explore options for service delivery
• Work with commissioners to explore options for hub and spoke/single Sheffield Provider
• Invest in patient self-testing models
• Investigate IT solutions that have potential for substantial positive impact on the service




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