Oh, I do like to dose beside the seaside....................... - - PowerPoint PPT Presentation

Oh, I do like to dose beside the seaside.......................

Wendy Cottee Lead BMS, Haematology Dept Worthing Hospital Western Sussex Hospitals Foundation NHS Trust

Worthing

• Our problems:
• Elderly retired population
• Lots of AF
• Adding 20 + patients to our database

per week ( & not taking many off)

• Limited number of staff who dose
• Need to train more staff
• Need for written competency
• (NPSA 2008)

Development of training & records documentation

• First
• Develop the training manual
• We needed documentation that we

could teach in sections to the different staff groups involved

Who are we training ?

• Senior MLA
• Practitioner BMS
• Specialist BMS
• Senior Specialist BMS
• Anticoagulant Nurse

Identify Scope of Practice

• Five levels of Practice
• Depends on :
• Grade
• Training
• Experience
• Confidence

What fits into that scope of practice?

• Break down what happens in the clinic

into sections

• Consider who will be allowed to do the

components

• (guided by IBMS)
• Ensure that trainee staff know and

adhere to their current scope of practice.

What will staff be doing?

• Level Zero -Admin of clinic only
• Tasks
• Entry of Demographics onto the computer system
• Taking and recording of telephone patient enquiries
• Correct actions resulting from those enquiries.
• Dealing with straightforward DNAs
• Dealing with Dosing letters to prepare for posting
• Telephoning dosage and dose changes as directed

by a dosing BMS (or Anticoagulant nurse), asking for appropriate information and feeding that information back to the doser

• Participation in Clinical Audit if required

What won’t they be doing?

• Exclusion criteria
• Level Zero staff will not be involved in

DAWN dosing nor manual dosing of patients

• Final grade for SMLA staff but first

stage of other staff training.

Levels of training :Level one

Level One : Basic dosing Staff Grade HCPC registered Practitioner Biomedical Scientists or Specialist Biomedical Scientists

• r A/C nurses in training

Tasks

• Staff deal with no dose changes, in cases where:
• The patient INR is in range and also was at last visit ,
• Dawn has provided a dose,
• NO change in medications or clinical information.
• To print dosage instructions and next test date
• To assist with telephoning Dose changes

generated by staff at level 2 /3.

• Plus the non-dosing tasks.
• Participation in clinical audit, where required

Levels of training :Level one

• Exclusion criteria:
• New medication
• Dose change
• Walked in for clinical reason
• Not fulfilling inclusion criteria
• Any letter operator feels unable to release

Levels of training :Level Two

• Staff Grade HCPC Reg Specialist Biomedical

Scientists & AC Nurse

• Tasks
• Staff would be expected to deal with dose changes

with INRs out of range, (but within the dosage limitations of the computer software), and next appointment dates, amending where necessary.

• Phone significant dose changes and release yellow

letters for posting.

• Plus Level One dosing
• Plus Non-Dosing tasks
• Participation in clinical audit, where required

Levels of training :Level Two

• Inclusion criteria:
• Dose changes due to fluctuation in INR with no

change in clinical circumstances except minor changes to medication, where experienced operator feels confident to release letter.

• Changes to next appointment date where necessary

Levels of training :Level Two

• Exclusion criteria:
• Dosing Letter / E Mail with any clinical information

included that may require Level 3 or 4 intervention

• Significant Medication changes (Drugs requiring

major intervention)

• INR : DAWN unable to dose i.e. >5 or <1.3
• Patients due for imminent cardioversion
• Patients due for other procedures
• Any dose that the operator feels unable to authorise,

should be referred to a higher level operator

Levels of training :Level Three

• Staff Grade Experienced Specialist Biomedical

Scientist, Senior Specialist Biomedical Scientist, Anticoagulant Nurse

• Tasks
• Involves authorising complex dosing where manual

intervention is required.

• More relevant where Dawn 4S will not provide a

suggested dose (INR <1.3 or >5.0) or where computer programme to be over-ridden.

• Use of local protocols for increasing / reducing dose-

flagging need for Vit K or Fragmin to Level 4

Levels of training :Level Three

• Continuation of inductions after initial induction

strategy by clinician, following protocols where they exist.

• Plus Level Two dosing
• Plus Level One dosing
• Plus Non-Dosing tasks

Levels of training :Level Three

• Inclusion criteria:
• Any patient with a significant and interactive change

in medication

• Any patient with attached significant clinical

information Including impending procedures

• Any patient listed as requiring manual dosage

“problem patients”

• Any patient for whom a Level 2 operator feels unable

to authorise a dose / interval

• All high INR’s (>5 < 9 without stated clinical

problems)

• Newly started anticoagulant patients following

protocols and some who are not………………..

Levels of training :Level Three

• Exclusion criteria:
• Any patient the Level 3 operator feels unable to dose
• r authorise
• Patients requiring clinical intervention
• LIMIT OF BMS SCOPE OF PRACTICE

Levels of Training Level 4

• Staff Grade
• Consultant Staff, Specialist registrar,
• Anticoagulant Nurse Prescriber or working to PGD
• Tasks
• Complex dosing referred by Level 3 doser
• Initial induction of anticoagulation & risk assessment
• Problem patients requiring complex manual dosing
• Dealing with peri-operative planning
• Patients who are bleeding

Levels of Training Level 4

• Patients experiencing thrombotic episodes whilst

anticoagulated

• Patients whose INRs are continually out of target

range (may need a clinic visit).

• Dealing with patients requiring Fragmin or Vitamin K
• r Beriplex
• Participation in clinical audit, where required

This level of training is provided by Clinician or Senior AC Nurse not BMS staff

So: The Manual # 1 Take the tasks that you want performed at the level : list them

Level ZERO Non – dosing tasks (administration) ITEM 1 Addition of new patient onto system 2 Addition of drugs to patient record 3 Addition of patient notes 4 Telephoning results to Patients and dealing with telephone queries 5 Dealing with DNAs 6 Dealing with Anticoagulant Clinic Paperwork

)

So : The Manual # 2

Take the task and break it down

• 1. Addition of new patient to system

Item to Check Training notes Checking referral information Checking for complete referral information. Pink forms and “cold” referrals via clinic clerks and secretaries. Use of LF-HAE-ACRejectForm Use of Sema Helix To be able to log in and look up patient details on Sema- to look up and check GP and patient contact telephone numbers including Next of Kin Also to be able to look up inpatient stays and discharge entries.

The Manual # 3

Tailor to grade & level Example is Level One)

• Concept of anticoagulation

therapy Item to Check Training notes

Has read BCSH Guidelines on Anticoagulant Therapy

Give the trainee a current copy Sign & date training records when read

Has read local guidelines on intranet.

Direct Trainee to where guidelines are kept on Intranet – sign & Date training records when read

Has taken BMJ online Training

Ask for evidence of completion - + pass

Now – the training records

• These mirror the manual – but with spaces for

signatures of trainer/trainee

• Each full page has a signoff at the bottom

PROCEDURE

• 1. Dealing with High Risk Patients

Item to Check In Training In Assessment Dealing with APLS patients Dealing with Mechanical Heart valve patients Dealing with patients with recent thrombotic events

Competency records - Level 2)

ITEM 1 2 3 4 Date 1 Dealing with High Risk Patients 2 Dealing with medications /other factors that potentiate 3 Dealing with medications /other factors that act as agonists 4 Dealing with INRS below range but >1.3

How are you going to Teach /Assess ?

• Explain the Training Competency Assessment to the

trainee

• Competence level 1- Unsure – has been shown but

not confident- initial and date – sign off at the bottom

• f each page as it is run through – signature of trainer

in first column in training record. Item 1 2 3 4 Addition of new patient on to system wc 15/4/12

How are you going to Teach /Assess ?

• Competence level 2 -Can do but needs supervision-

Interim step in training whilst knowledge/skill is consolidated Trainer Initial and date

Item 1 2 3 4 Addition of new patient on to system wc 15/4/12 wc 18/4/12

How are you going to Teach /Assess ?

Competence level 3 – Can do without supervision – Trainer Initial and date – sign off third column in training record Competence level 4 - Independent – can teach others- when so comfortable and confident with the procedure that they could (and would be happy to ) train other staff. Trainee to sign

Item 1 2 3 4 Addition of new patient on to system wc 15/4/12 wc 18/4/12 wc 24/4/12 TD 26/4/12

How did Dawn help us?

• We asked for the list view to be altered
• High (above range)
• Low (below range)
• In Range
• Helps for training purposes as we can select group of

patients to work with

Assessing competency : stages

PROCEDURE 6 Observation of dosing with Level 2/3 doser Item to Check In Training / Date In Assessment Observation of dosing 10 patients (ideally each session with a different doser Not possible at present ) Trainer asking questions of trainee Observation of dosing 10 patients Still asking questions

• f trainer

Usually at least 10 sessions of this

Assessing competency : stages

PROCEDURE 6 Supervised dosing with Level 2/3 doser Item to Check In Training / Date In Assessment Performance of dosing 10 patients within scope Trainer asking questions of trainee regarding patients on screen Vs Letter Performance of dosing 10 patients within scope Trainer asking questions of trainee Usually at least 10 sessions of this

Assessing competency : stages

PROCEDURE 8 Unsupervised dosing referring cases to Level 2/3 dosers Item to Check Date In Assessment Dosing Morning clinic session. Questions to trainee if required 5 of these No errors or excursions from scope Dosing Afternoon clinic session 5 of these Whole day dosing 5 of these

Ongoing assessment

• Use of Self audit form – staff encouraged to complete

form & reflect what the outcome was – and what would they do differently if desired outcome not achieved.

Self Audit Form

• BMS / Nurse NAME……………………………………………………………
• Present Dosing Level………………………………………
• Date………………………………………
• Are you satisfied with your dosing of this patient?………………………………
• If not, what have you learned from this audit? ……….…………………………

………………………………………………………………..

Dosing Date Patient no INR Range Dawn dose Your dose Reason to alter computer dose Next Test date Review date Current INR Patient back in range

Ongoing Competence

Patient No Dosing Practice acceptable (Adherence to protocols) If not acceptable- why not… 1 2 3 4 5

Level 3 Assessor name…………………………………….. BMS NAME (Assessed)……………………………………………………… Present Dosing Level……………………………………… Date……………………………………… Assessment of ongoing competency Fully competent at present level YES / NO Need for training review YES / NO Actions needed………………………....................................................... Signature of Assessor………………………................................…. Signature of Assessed BMS…………………………......……………. One copy in training File One copy in BMS’S / Nurse’s CPD folder

Ongoing Assessment

• Level 3 dosers randomly audit the work
• f each other and levels below – select

20 patients and check dosing was appropriate to case and achieved required outcome. If not then - discussion of the cases ? Retrain on elements if needed.

• Clinicians train and assess Level 4 1:1

Any Questions? Wendy.cottee@wsht.nhs.uk

http://www.youtube.com/watch?feature=player _detailpage&v=-0Xa4bHcJu8