Year

2011

Degree Name

Masters of Science - Research

Department

Faculty of Health and Behavioural Sciences

Abstract

Aim: This thesis reports on the study on the implementation of a warfarin-management strategy into residential aged care facilities (RACFs) providing high-level care. The research question investigated in the study was “does the development and implementation of a new warfarin-management strategy into RACFs enhance the outcome for high-level care residents and is it usable and acceptable to those responsible for warfarin management?” The evaluation of the acceptability, usability and safety implications of the strategy, which involved the introduction of a warfarin-specific medication chart in concert with education sessions, is also described.

Background: The study originated from the findings of previous research into the barriers to quality use of warfarin in RACFs from the perspectives of General Practitioners (GPs) and Registered Nurses (RNs) working in this setting which identified communication, monitoring, documentation and decision-support inadequacies in the systems employed. There is highlevel evidence for the efficacy of the anticoagulant warfarin in reducing the risk of thromboembolism; yet there is a paucity of evidence for its benefits in older, frail people with comorbidities and complex medication regimes for whom the risks of haemorrhage are higher than populations in the landmark studies. Hence the necessity for safe medication practices around warfarin in this setting. The safety of warfarin is paramount in the context of the changing environment of residential aged care and as a continuing option in the expanding pharmacological options for anticoagulation.

The literature confirmed that quality use of all medications and particularly warfarin is difficult to achieve in residential aged care. From the recommendations of the previous research, a standardised warfarin-specific medication chart was inductively developed by all healthcare disciplines with roles in medication management, and it is introduction of this as part of an overall management strategy and its evaluation, that was the focus of the study.

Methods: A mixed-methods approach was employed in the study, utilising a pre-test/posttest with intervention design. The multi-intervention design comprised of warfarineducation sessions for RACF staff, an explanation of the proposed warfarin-management strategy to prescribing GPs, dispensing pharmacists and RACF staff, the development and introduction of the warfarin-specific medication chart and ongoing participation in the implementation of the strategy as required. Descriptive statistics were used to assess the indicators of the quality use of warfarin and the safety implications of the warfarinmanagement strategy for high-level care residents receiving warfarin throughout the study, as well as its acceptance and usability. Additionally, thematic analysis of interviews with participant GPs and RNs responsible for warfarin management was used to evaluate the strategy. Potential and actual warfarin-related adverse events were also recorded from the participant residents’ medical histories and medication charts.

Findings: The study participants were 23 residents who received warfarin, nine GPs and the nurses from three Illawarra RACFs. Fifty-six nursing staff with a role in medication management participated in the warfarin education sessions delivered with the implementation of the strategy implementation. Data analysis demonstrated a trend towards an improvement in surrogate measures of quality use of warfarin when the posttest phase results were compared to those from the pre-test. Thematic analysis of semistructured interviews with the GPs and RNs found that the strategy provided more accurate and preferred documentation of essential information, formalisation of the roles in warfarin management, reduced time and improved workflow compared to previously used methods: all with the potential impact on improving the safety of warfarin. The other quality indicators analysed did not differ obviously throughout the study; however, instances were noted of changed nursing practices in response to the education sessions.

Conclusion: The warfarin-management strategy introduced into Illawarra RACFs was evaluated as being acceptable and easy to use as well as providing decision-support to improve warfarin prescribing, monitoring and administration, and potentially reduce warfarin-related adverse events and errors. In addition, this thesis describes the strategy implementation in the context of the changing environment of residential aged care and the expanding pharmacological options for anticoagulation and provides recommendations for further approaches to augment the strategy and to enhance the quality use of all medicines.

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