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 • T asks • 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 or 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 or 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 or 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 Give the trainee a current copy Anticoagulant Therapy Sign & date training records when read • Has read local guidelines on Direct Trainee to where guidelines intranet. • 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 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 • Each full page has a signoff at the bottom
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 of each page as it is run through – signature of trainer in first column in training record. Item 1 2 3 4 Addition of new wc patient on to 15/4/12 system
How are you going to Teach /Assess ? Item 1 2 3 4 Addition of new wc wc patient on to system 15/4/12 18/4/12 Competence level 2 -Can do but needs supervision- • Interim step in training whilst knowledge/skill is consolidated Trainer Initial and date
How are you going to Teach /Assess ? Item 1 2 3 4 Addition of new wc wc wc TD patient on to system 15/4/12 18/4/12 24/4/12 26/4/12 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
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