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improving performanceFigure 1. An example of an INR recordfrom practice management software. A MicrosoftOffice Excel spreadsheet could be produced easilywhich would allow the exercise to be reduced to asimple matter of data entry.AcknowledgmentsI would like toacknowledge the work ofmy son Kyle Wright whoperformed the statisticalanalysis for this study whilehe was an undergraduatestudent in mathematics.FundingNo funding was receivedfor this study.Conflict of interestNone declaredIndividual mean INRWith one patient showing a rise in mean INRand another a fall and the majority showingno change, it can be concluded that the changein method did not have a significant impact onmean INR.Lessons and messagesMachin suggests that a reasonable standard forgood control of warfarin therapy is an INRwithin the therapeutic range 60% of the time. 5The British guidelines for anticoagulation controlquote 50%. 6 It would appear that this standardcan be achieved in my practice either by using myad hoc approach (65.3%) or by my nurses usingthe ‘British Columbia Health Service’ standardisedprotocol (69.3%).This is a study with a small number of patientsin a single practice. Factors such as ethnic mix,educational status and socioeconomic status maylimit the ability for these results to be generalisedto other general practices in NZ.While it is likely that most doctors would followthe same general principles, the effectiveness ofan individual doctor’s ad hoc approach will beunknown unless the practice data is audited. Theraw data for a practice audit is easily obtainedThe switch in my practice away from the heavilydoctor-intensive ad hoc system to the entirelynurse-led system was motivated by a desire to improvepractice efficiency and free up doctor time.Our experience was that this was achieved. Thedoctor was liberated from any part in the process.The nurse’s time was used more efficiently by nolonger having to act as a liaison with the doctor.Patients were able to get their instructions morequickly and were able to discuss the adjustmentwith the nurse making the clinical decision.Nobody was more pleased by the change than ourreceptionist who no longer had to inform patients‘the doctor hasn’t had time to look at your resultsyet, can you phone back later?’. This improvedefficiency is likely to be even greater in a grouppractice where several doctors may be involved inthe warfarin adjustment process.Changing from one system to the other can bedone quickly and with a minimum of planning.While new anticoagulant drugs not requiringsuch rigorous monitoring are under trial elsewherein the world, it is likely that we in NZ arestill several years away from having a safe andeffective alternative to using warfarin.References1. Lafuente-Lafuente C, Mahe I, Extramiana F. Management ofatrial fibrillation. BMJ. 2010;340:40–45.2. New Zealand Guidelines Group. The management of peoplewith atrial fibrillation and flutter. 2005.3. Nair A, Hazell W, Sutton T, Pillai S. Antithrombotic therapy inatrial fibrillation: an assessment of compliance with guidelines.N Z Med J. 28 Jan 2005; 118(1208).4. Guidelines and Protocol Advisory Committee. Initiation andmonitoring of warfarin therapy. British Columbia Medical Association.2004;1–8.5. Machin SJ. Medico legal problems associated with oral anticoagulantservices. In: Fitzmaurice DA and Murray ET, editors.Oral anticoagulation management and stroke prevention:the primary care perspective. Newmarket: Hayward MedicalCommunications. 2002;50–57.6. Baglin T et al. Guidelines on oral anticoagulation. Br J Haematol.1998;101:374–387.322 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE
improving performanceInfluenza H1N1 2009 in Canterbury: a casestudy in pandemic response co-ordinationDaniel Williams BA, MBChB, Dip Obs, MPH, FNZCPHM; 1 Annabel Begg BMedSci, MBChB, MPH,FNZCPHM; 1 Kim Burgess MBChB, DPH; 2 Michele Hider BA, Cert Journalism APR; 1 Lance Jennings PhD,FRCPath; 1 Mary Martin-Smith BScN, MSc; 1 Paul McCormack MBChB, FRNZCGP; 3 Jon Mitchell BA, PGDip(Geography and Planning), Grad Dip (Emergency Management); 4 Alan Pithie; 1 Phil Schroeder MBChB, DipObs, FRNZCGP; 5 Anja Werno MD FRCPA 1AbstractBackground and context: Reviews of overseas pandemic responses have suggested thatstronger links between primary care and other parts of the health sector are required. The influenza A(H1N1) 2009 (‘H1N1 09’) pandemic was the first real test of New Zealand’s pandemic preparedness.Assessment of problem: In the six months from May to October 2009, there were 595 confirmedcases of H1N1 09 in Canterbury, with 187 hospitalisations and three deaths. This paper describes the waya range of Canterbury agencies worked together in a co-ordinated health-led response aimed at minimisingthe impact of H1N1 09 in the community and maintaining effective health care services for bothinfluenza and non-influenza patients.Strategies for improvement: Key strategies included sector-wide response co-ordination, intelligenceand communications, a combined public health/primary care response during the ‘containment’phase, and universal red/green streaming supported by dedicated ’flu centres and an 0800 call centreduring the ‘manage it’ phase.1Canterbury District HealthBoard, Christchurch,New Zealand2New Brighton Village HealthCare, Christchurch3Independent HealthConsultant, Christchurch4Canterbury Civil Defenceand Emergency ManagementGroup, Christchurch5Rolleston Medical Centre,ChristchurchLessons: Despite the considerable impact of the H1N1 09 virus in Canterbury, health care serviceswere not overwhelmed. The key lesson learned from the Canterbury H1N1 09 response has been theimportance of preparing and working together across the sector.Keywords: Influenza, human; pandemic; primary health care; public health; mass media; civil defenceBackgroundThere are important overlaps between the essentialfunctions of primary care and public health. 1Prior to 2009, Canadian and Australian reviewssuggested that stronger links between primarycare and other parts of the health sector, particularlypublic health, were required. 2,3Canterbury is New Zealand’s second largestgeographic region, with the second biggestpopulation (522 000 at the 2006 census).Canterbury agencies had a history of workingtogether on pandemic preparedness prior to2009, including responding to SARS (2003),avian influenza (2004), and two major nationalpandemic exercises in 2006 and 2007. An intersectoralpandemic planning group includingkey sector leaders continued to meet monthlyfollowing the 2007 exercise. All agencies werefamiliar with the National Pandemic ActionPlan 4 (see Text Box 1) and the Co-ordinatedIncident Management System (CIMS) 5 andhad their own response plans in place (seeText Box 2).Assessment of problemCanterbury’s H1N1 09 response was initiatedon 25 April. The ‘keep it out’ and ‘stamp it out’phases of the response lasted until 19 June, whenCorrespondence to:Daniel WilliamsClinical Director,Community and PublicHealth DivisionCanterbury District HealthBoard, P O Box 1475Christchurch 8140,New Zealanddaniel.williams@cdhb.govt.nzVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 323
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