An integrated team approach to Near Patient INR Testing in the community in South Dublin

Background: The international normalised ratio (INR) blood test determines clotting times in people taking warfarin (a medicine that prevents blood clots). The need to integrate a near patient testing service was identified for warfarin patients attending St. James’s Hospital (SJH). The management team from South Dublin Community Intervention Team (CIT) and SJH Warfarin clinic met. A new service pathway was created to test INR by near patient finger prick testing. This was located in a combination of home visits and visits to the local CIT clinic. Aims and objectives: The near patient test warfarin management pathway assists patients with monitoring their INR levels to ensure that they remain within a desired therapeutic range. This involves INR monitoring, education support (diet and medication compliance). The service is located in the home or in the local CIT clinic. Methods: In April 2019, the service was implemented. Patients appropriate for near patient INR testing were selected from SJH outpatient warfarin clinic. This was based on their geographical location, age, mobility, frailty and difficulty in attending face-to-face appointments at the hospital. A weekly master list of patients requiring home visits for INR monitoring is emailed to CIT. CIT schedules home visits or visits to the CIT clinic. At the home visit, the nurse conducts a full nursing assessment, including Near Patient INR testing, vital signs, and medication monitoring. Abnormal INRs result in hospital notification and a venous sample is taken and sent to SJH lab. The warfarin clinic team contacts the patient when the lab results are available and instructs them on treatment changes. This may be changing the warfarin dose or immediate hospital admission. A weekly master list of patients seen by CIT is emailed to the warfarin clinic in SJH. The referring consultant reviews all blood results. Analysis: The warfarin management pathway with St. James’s hospital and CIT has increased from 665 in a 12 month period in 2019-2020, to 1556, over 12 months in 2022-23. Feedback from patients has shown high satisfaction levels. The service has improved patient engagement in management of their Warfarin. Further analysis of the service highlights the need for further research and audit to gain valuable information on clinical outcomes, patient and carer and consultant perspectives with this integrated service. Conclusion: The care offered by CIT to the patient is specifically tailored to the patient’s needs. The CIT / SJH management of warfarin patient care has been shown to be safe, cost saving, and time efficient and acceptable to patients. Less INR specimens require lab processing, giving lab and clinical staff more time and reducing attendances at the warfarin outpatients clinic. The CIT services offers health promotion and education, in addition to fundamental nursing care for Warfarin patients requiring INR management. The CIT holistic approach to the management of Warfarin patients’ needs enables the patient to become more autonomous with their care, meeting the objectives of Slaintecare.