Clinical Audit Intention

INR Testing

This audit will measure the frequency of INR monitoring for patients on warfarin.

INR testing is a key component in maintaining control of treatment with warfarin. It is important to maintain the warfarin response within the therapeutic window so that the patient has the benefit of anticoagulation without the risk of haemorrhage.

INR testing and the frequency at which this is done is critical for all patients on warfarin treatment. At initiation of treatment, INR testing is done weekly as the risk of bleeding is greatest in the first three months of treatment and in patients who have not received warfarin previously, Once stabilised, the optimal frequency of INR testing is usually between four to six weeks. In some stable patients this can be extended out to eight weekly.

More frequent monitoring will be required when the warfarin dosage is adjusted, medicines are prescribed that interact with warfarin, or during a concurrent illness.

Changes in the INR level in a usually stable patient may be due to a number of factors: major changes in diet or alcohol intake, drug interactions, systemic or concurrent illness, non-adherence to dosage regimen, or unknown causes. Monitoring should be adjusted accordingly.

The management plan for anticoagulation therapy should be detailed in the patient’s notes and should include: note that the patient is on warfarin and date this was commenced, condition for which warfarin has been prescribed, brand of warfarin, documentation of warfarin dose, target INR range, INR testing schedule, and planned duration of therapy.

For patients with adherence issues, or where they are not well managed on warfarin, there is an option to refer the patient to the oral anticoagulant counselling servicebeing offered by Community Pharmacy.

The Clinical Advisory committee of Manaia Health PHO has endorsed this Continuous Quality

Improvement (CQI) activity with the objective of improving patient safety through an audit of INR testing for patients currently being treated with warfarin.

The CQI activity is for a General Practitioner to audit records for patients on warfarin treatment according to a set of standards for compliance as detailed in the table. GPs are able to compare their individual data to that of their peer groups, or as an individual self audit activity with opportunity for improvement of their records, thereby improving patient safety during the process.

This activity has been endorsed and the participating GP can be awarded 10 Maintenance Of Professional Standard (MOPS) points via the on-line RNZCGP website.

For further information about claiming MOPS points or requesting participation certification please contact Linda Holman, Quality Leader, Manaia Health PHO or ph 438 1015.

INR Testing Audit – Endorsed CQI Activity

Audit 20 of your patients on warfarin treatment.

The audit is conducted retrospectively on patients identified to be on warfarin therapy. The result of the audit would be on what was documented in the PMS, any changing of the record would result as a non-compliant result for that category on the audit sheet.

There is space provided at the bottom of the audit sheets to allow for any comment to be noted. Explanation of the categories is below.

On completion of the first audit of patients on warfarin treatment, contact Linda Holman at Manaia Health PHO for the first cycle certificate. On completion of the second cycle [recommended 12 months later] contact Linda Holman for the second cycle certificate.

NHI / To identify the patient should you need to go back to the record and make further changes.
Note patient is on warfarin / To identify patient is on warfarin treatment
Date warfarin started / To identify when warfarin was first prescribed
Indication for warfarin / To identify need for anticoagulation
Planned duration of treatment / Period e.g. 13 weeks for some indications, or an indefinite period in the case of atrial fibrillation.
Brand of warfarin / Brands of warfarin are not interchangeable. Prescribe by brand name.
Documentation of warfarin dose / Current dose of warfarin clearly documented
Target INR range / Target range for INR to be documented , usually 2.0 – 3.0, but may vary depending on clinical situation.
INR testing schedule / Frequency will depend on the status of the patient. Once stabilised on warfarin, the frequency of testing can be extended four to six weekly (optimal), or in some cases to eight weekly.
Education need / To identify the patient who will benefit from counselling from community pharmacist
NHI
Note patient is on warfarin
Date warfarin started
Indication for warfarin
Planned duration of treatment
Brand of warfarin noted
Warfarin dose noted
Target INR range
INR testing schedule
Education need

Comments:

  • Data Analysis:

Missing Data / Totals / Average or %
Note patient is on warfarin / T= / Ave=
Date warfarin started
Indication for warfarin / T= / Ave=
Planned duration of treatment / T= / Ave=
Brand of warfarin noted / T= / Ave=
Warfarin dose
Target INR range / T= / Ave=
INR testing schedule / T= / Ave=
Education need / Yes / No