Anticoagulants Reducing the risk Amanda Powell & Sue Wooller May 2014

How safe is your INR monitoring service??

The Iceberg Challenge

Reducing the risks: Oral anticoagulants Improving Medication Safety 2004, DoH All patients taking anticoagulants should be monitored carefully Responsibilities of health care team should be clearly defined There should be regular service audits Report stresses the critical importance of effective communications when patients move from one care setting to another On discharge, drug regimen /treatment plan need to be communicated in a timely and reliable way to ensure safe and seamless transfer Staff should ensure that patients understand their discharge medicines

Communication between primary and secondary care?

The Warfarin care pathway Developed to try to ensure the patient is safely initiated on Warfarin and that a patient’s care is safely transferred from secondary care to primary care No patient on Warfarin is to be discharged from the trust without having a completed Warfarin care pathway. (section 2 to be completed for all patients and section 1 and 2 for newly started patients). This combined with the Warfarin treatment chart and the DAL provides the information required for the safe transfer of care. All patients must have a confirmed appointment made with a monitoring clinic prior to discharge

Cwm Taf Referral form M A Smith lifelong √ X X X X X X X Green Field RGHR. Alcolado X JH 4/10

National Patient Safety Agency Patient Safety Alert 18 (March 2007) Ensure all staff caring for patients anticoagulant therapy have the necessary work competences Review and update procedures and clinical protocols for anticoagulant services to ensure they reflect safe practices Audit anticoagulant services using BSH/NPSA safety indicators as part of the annual medicines management audit programme Ensure that patients prescribed anticoagulants receive appropriate verbal and written information Promote safe practice with prescribers and pharmacists to check that patients’ INR is being monitored regularly and that the INR level is safe before issuing or dispensing repeat prescriptions for oral anticoagulants

Promote safe practice for prescribers co-prescribing one or more clinically significant interacting medicines for patients already on oral anticoagulants - make arrangements for INR tests and inform monitoring clinic. Pharmacists to ensure precautions have been taken. Ensure that dental practitioners manage patients on anticoagulants according to evidence based therapeutic guidelines. Amend local policies to standardise the range of anticoagulant products used incorporating characteristics identified by patients as promoting safer use. Promote the use of written safe practice procedures for the administration of anticoagulants in social care settings. Minimise and risk assess the use of MDS. National Patient Safety Agency Patient Safety Alert 18 (March 2007)

Safety Indicators NPSA/BCSH British Journal of Haematology (2007) 136 (1); Proportion of patient-time in range Percentage of INRs > 5·0 Percentage of INRs > 8·0 Percentage of INRs > 1·0 INR unit below target (e.g. percentage of INRs < 1·5 for patients with target INR of 2·5) Percentage of patients suffering adverse outcomes, categorised by type, e.g. major bleed Percentage of patients lost to follow up (and risk assessment of process for identifying patients lost to follow up).

Why time in therapeutic range (TTR) matters Survival to stroke (days) Cumulative survival 71–100% Warfarin group 61–70% 51–60% 41–50% 31–40% <30% Non Warfarin Morgan CL et al. Thrombosis Research 2009;124:37–41

Safety Indicators NPSA/BCSH British Journal of Haematology (2007) 136 (1); Percentage of patients with unknown diagnosis, target INR or stop date Percentage of patients with inappropriate target INR for diagnosis, high and low Percentage of patients without written patient educational information. Percentage of patients without appropriate written clinical information, e.g. diagnosis, target INR, last dosing record.

Who is at risk? BMJ 2002; 325: Questions to ask when considering oral anticoagulation Is there a definite indication? Is there a high risk of bleeding? Will current medication/disease interfere with control? Is compliance/attendance at clinic a problem? Will there be regular review of risks/benefits of anticoagulation?

Who is at risk? BMJ 2002; 325: NICE CG36 Patients at high risk of bleeding with Warfarin Age >75 years Uncontrolled hypertension Alcohol excess Poor compliance/clinic attendance Bleeding lesions/ history of bleeds Bleeding tendency (e.g. thrombocytopenia) or concomitant NSAIDs and antibiotics Instability of INR and INR above 3 Have a history of poorly controlled anticoagulation therapy. Are on multiple other drug treatments (polypharmacy) Are taking antiplatelet drugs

The future? NOACs? CDDS? Coaguchek XS+? Patient self monitoring?

The Iceberg Challenge

Resources National Institute of Clinical Excellence (NICE) British Committee for Standards in Haematology Welsh Medicines Resource Centre (WeMeRC) BMJ learning Coagucheck Website