Lessons from the implementation of a near patient anticoagulant monitoring service in primary care

To evaluate the implementation of a primary care, nurse-led, near patient anticoagulant monitoring service. Action research workshops, supported by questionnaires and clinical audit, to define the strengths and weaknesses of the service and the effectiveness of the computerised decision support system used to set the dosage of anticoagulant and time interval to the next appointment. 13 general practices that implemented anticoagulant monitoring in a primary care organisation in south east England. 18 practice nurses, 72% of whom had over 20 years' clinical experience; the university-based investigators and managers from the primary care organisation. The nurses felt that the patients preferred the practice-based service, finding it more personal and accessible. However, circumstances arose where the nurse's intuition had to override the software's advice. The nurses found it stressful when they were unclear whether their decision making represented acceptable variation or dangerous practice. An audit tool was developed to measure the extent to which there was variation from the software's recommendation, and patterns of variation emerged. Most evident was that nurses responded to uncertainty by practising cautiously, shortening the interval until the next visit and slightly reducing the recommended dose of warfarin. The group, by sharing their experiences through a structured series of workshops, developed an understanding of when it might be appropriate to vary from the decision support software's recommendations and how this could be audited. The technological solution modelled on hospital practice proved hard to implement in primary care.