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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 dosingStaff 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 # 2Take 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 # 3Tailor 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
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
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
wc15/4/12
wc18/4/12
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
wc15/4/12
wc18/4/12
wc24/4/12
TD26/4/12
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 doserNot possible at present )
Trainer asking questions of trainee
Observation of dosing 10 patients
Still asking questions of 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 session5 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 of 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?
http://www.youtube.com/watch?feature=player
_detailpage&v=-0Xa4bHcJu8
