INR Service

Undernutrition Service

Patients taking warfarin require INR (International Normalised Ratio) monitoring, this is done by analyzing blood samples obtained via a finger pinprick. The INR service monitors ~3700 patients.

Patients who are at risk of undernutrition or are undernourished require monitoring for weight, appetite and compliance with prescribed oral nutritional supplements (ONS). The dietetic service monitors ~1000 patients.

Prevailing Pathway

Most patients attend clinic for testing, others submit samples to clinic through Pharmacies, GP surgeries or District Nurses. Patients also answer basic safety questions (relating to bleeding symptoms, missed Warfarin doses and medication changes). All samples are analysed by INR clinic staff; if the INR reading is out of range, Warfarin doses are adjusted. Patients are then given their next appointment date. The frequency of monitoring is dependent on time with the service and time within INR range.

Dieticians visit patients in their own homes or in residential settings. Patient weights are recorded, dietary history assessed, and recommendations made; which may include provision of ONS. Follow-up is arranged at 3-month intervals in line with the pathway;

patients usually receive three follow-ups but sometimes more. Patients are followed up in outpatient clinic or in own home.

Digital Pathway

Digitally enabled INR self-testing pathway.

Digitally enabled monitoring of patient weight, appetite and compliance with ONS.

Using a lancet device, patients produce a blood sample which they analyse using a Roche self-monitoring device. Patients then submit the reading and respond to safety questions through an automated phone call or an on-line portal; the data is directly sent to the patient’s clinic.

Care homes record and submit information to the dietetic service via a secure web portal. Patients resident in their own homes receive an automated phone call asking for responses to questions about appetite and compliance and to enter their weight.

If a response is not received an alert is sent to clinic prompting follow-up by a clinician.

If a response is not received an alert is sent to clinic prompting follow-up by a clinician. In the case of care homes, the home receives an email reminder after 24 hrs.

INR readings are analysed using anticoagulation software which calculates the next warfarin dose and test date. If readings are normal, the automated process continues, and the patient is notified via a second message (automated phone call or email). Any irregular readings or adverse answers alert the clinic and direct contact is made with the patient.

ONS compliance, weight changes and BMI are assessed using software aligned to the “Malnutrition Universal Screening Tool” (“MUST”); if readings are outside of the pre-determined parameters, a healthcare professional is alerted, and contact is made to make changes to treatment.

Duration

Ongoing.

100 days.