Tools and resources

Adoption support resource – insights from the NHS

6 How to implement NICE's guidance on point-of care coagulometers for self-monitoring

6 How to implement NICE's guidance on point-of care coagulometers for self-monitoring

The experiences of NHS organisations have been used to develop practical suggestions for how to implement NICE guidance on point-of-care coagulometers for self-monitoring coagulation status.

Project management

It is the experience of the Health Technologies Adoption Programme that in order to gain maximum benefit, this technology should be adopted using a project management approach.

NICE has produced the into practice guide which includes a section on what organisations need to have in place to support the implementation of NICE guidance.

Measuring success

In order to demonstrate the benefits of adopting CoaguChek XS for self-monitoring coagulation status, it is important to take measurements before, during and after implementation. This will enable the benefits and impact achieved at a local level to be measured and built on. Some of these measures will not be routinely collected and consideration will need to be given to data collection methodology appropriate to the service. Suggested measures from the sites involved in developing this resource are:

  • Time in therapeutic range: 3 and 6 months before and 3 and 6 months after people begin to self-monitor.

  • Patient experience (pre-implementation and post-implementation).

  • Number of people offered self-monitoring and reasons for not offering it.

  • Take-up rate of self-monitoring and reasons for people declining.

  • Number and percentage of people completing training.

  • Number and percentage of people passing the assessment.

  • Number and percentage of people continuing to self-monitor at 3 and 6 months.

  • Testing frequency and associated costs.

  • Number and percentage of people requiring additional advice on dosing and frequency of contact.

  • All related clinical events, for example reported minor and major bleeds and thrombotic events.

Overcoming implementation challenges

A number of implementation challenges were reported by NHS sites using CoaguChek for self-monitoring coagulation status as set out in table 2.

Table 2: Reported implementation challenges when using point-of-care coagulometers for self-monitoring coagulation status

Implementation challenge

Solution

Capital and ongoing revenue costs

Prepare a business case including full cost considerations for INR self-monitoring compared with current service models across a complete service budget.

Consider leasing arrangements.

Clinical confidence

Select appropriate metrics to demonstrate clinical benefit, safety and demand.

Patient confidence

Develop training packages and information for service users.

Initially introduce self-testing. As confidence grows consider introducing self-management for appropriate people.

Business case development

Cost savings

NICE has published a costing statement that can be used by NHS trusts to assess the local impact of implementing NICE guidance on point-of-care coagulometers for self-monitoring coagulation status, based on the local population. The statement highlights that avoiding a small number of high-cost adverse events has the potential to make the initial investment cost saving if a whole system view is taken.

Service commissioning

Local enhanced service or any qualified provider agreements for anticoagulation services should take into account the:

  • initial investment in supporting self-monitoring including cost of equipment and training and support

  • reduction in ongoing support required once self-monitoring has been established

  • potential savings resulting from decreased adverse events.

A fully commissioned anticoagulation service within a whole system budget may be the only sustainable model in which to include a self-monitoring service. This would allow for savings made in improved outcomes (reduced cardiovascular events from improved time in therapeutic range) to be redirected towards anticoagulation management services.

Business case

The implementation team should treat the development of a robust business case as an early priority in the life of the implementation project.

Local arrangements for developing and approving business plans will vary and each organisation is likely to have its own template and process in place.

The following are examples of documents developed by sites using point-of-care coagulometers for self-monitoring which can be used to inform the development of local business plans.

Bury CCG Innovation Funding application

County Durham and Darlington NHS Foundation trust cost report

Education

County Durham and Darlington NHS Foundation Trust have developed a training pack for people, which details the criteria they must meet to be issued with a meter.

The manufacturer of CoaguChek XS provides online and telephone support for people. For further information please see training and support for CoaguChek XS system users.

Development of local documentation

The following are examples developed by NHS sites using point-of-care coagulometers for self-monitoring coagulation status which can be used to inform the development of local documentation.

International normalised ratio (INR) self-monitoring service algorithm (Bury clinical commissioning group [CCG])

INR dosage algorithm for self-management (Bury CCG)

INR monitoring service procedure document (County Durham and Darlington NHS Foundation Trust)

INR monitoring patient information leaflet (County Durham and Darlington NHS Foundation Trust)

INR monitoring registration form (County Durham and Darlington NHS Foundation Trust)

INR record sheet for patient use (County Durham and Darlington NHS Foundation Trust)


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