The Oxford clinical intranet: providing clinicians with access to patient records and multiple knowledge bases with internet technology.

The Oxford Clinical Intranet provides clinicians in primary and secondary care across Oxfordshire with: Access to information about their patients held on multiple remote disparate computer systems, including admissions and episodes, Laboratory Medicine reports, Radiology reports and hospital discharge letters. The patient records are managed using CSW Case Notes. Access to support and advisory information, developed both within the organization and collected from other sites and projects, a wide range of internal handbooks, directories and guidelines and links to external resources, including evidence-based resources, the Cochrane Collaboration and the NHS National electronic Library of Health. Automated retrieval and presentation of the support information that is contextually appropriate to the task being carried out by the clinician and the information held about the patient. For example laboratory reports are linked to handbooks and other reference sources using eLABook, a web-interfaced database subsystem. Internet technology has been used throughout, thus providing a thin-client architecture with cross-platform ability. Appropriate data standards have been used across the communicating systems and the intranet is compliant with the UK eGovernment Interoperability Framework. The intranet was developed at low cost and is now in routine use. This approach appears to be transferable across systems and organisations.

Reversal of asymptomatic over-anticoagulation by orally administered vitamin K.

Over-anticoagulation with warfarin is common. There is good reason to reverse significantly high international normalised ratios (INRs), however, in practice, there is wide variation in the means to achieve this. Randomised controlled trials have provided evidence for using low dose orally administered phytomenadione for the reversal of asymptomatic over-anticoagulation. We devised an oral regimen using the intravenous preparation of phytomenadione (vitamin K1). Patients with an asymptomatic INR between 8.0 and 11.9 (n = 166) received 2.5 mg and those with an INR of 12.0-20.0 (n = 36) or >20 (n = 21) received 5 mg. Median INRs for the three groups of patients on day 1 (approximately 14 h) after vitamin K administration were 3.5, 3.0 and 2.9 respectively. In the patients given 2.5 mg, 77% had INRs between 2.0 and 4.9 on day 1. In the patients given 5 mg, 52% of those presenting with INRs of 12.0-20.0 returned between 2.0 and 4.9 1 d after administration of vitamin K. In the INR >20 group 44% returned with an INR between 2.0 and 4.9. Warfarin was reintroduced once the INR was <5 and the majority of patients remained stable for the following 14 d. This regimen for non-urgent correction is therefore effective and returns patients to a safe INR level without over-reversing anticoagulation.