Warfarin is being used in the management of increasing numbers of patients and conditions including patient’s post-myocardial infarction, atrial fibrillation, DVTs and other disorders. While it is a very effective drug in these conditions, it can also have serious side effects, e.g. severe haemorrhage. These side effects are related to the International Normalised Ratio (INR) level, which measures the delay in the clotting of the blood caused by the warfarin. While the “normal” INR is 1, the specific range of INR values depends on the disease and the clinical conditions. Warfarin monitoring aims to stabilise the INR within set limits to help prevent serious side-effects while maximising effective treatment.

This national enhanced service will fund:

Development and maintenance of a register: Practices should be able to produce an up-to-date register of all anti-coagulation monitoring service patients, indicating patient name, date of birth, the indication for, and proposed length of treatment, including the target INR. 

Call and recall: The hospital call and recall service will be used, but the practice will need to check patients are being appropriately monitored each time a prescription is issued and at medical reviews, by checking the patient-held ‘yellow booklet’ and ensuring that the patient has a follow-up appointment in the anti-coagulation monitoring clinic. (Local clarification: this should include systems for management of patients who fail to attend for anticoagulation monitoring or practice prescriptions).

Professional links: To work together with other professionals when appropriate. Any health professionals involved in the care of patients in the programme should be appropriately trained.

Communication from primary care to anti-coagulation clinic: Practices participating in the NES should inform the hospital anticoagulation clinic of any relevant changes in their patients' medical conditions. For example, it is important to notify the clinic if a patient has started new medication, if they have any significant adverse effects from the Warfarin, if they have moved away or died, or if their circumstances have changed and warfarin is less appropriate (for example, if they start having repeated falls).

Record-keeping: To maintain adequate records of the performance and result of the service provided, incorporating appropriate known information, as appropriate. This may include the number of bleeding episodes requiring hospital admission and deaths caused by anti-coagulants.

Questionnaire: A questionnaire has replaced the usual audit in this short contract, this is a much shorter tool to gain an overview of the care provided for patients against the above criteria, including untoward incidents.