1. Management of A.F. patients with the DawnAC induction module David Hirst MidYorkshire Hospitals NHS Trust

2. Fennerty v5 software Glasgow from table Integrated Glasgow v6 software

3. Referrals to clinic Out patient referrals In patients referred direct from wards

4. Out-patient referrals Up to 4 a week Written referral request mandatory Details transferred onto warfarin dosing chart and new patient manager etc. completed Warfarin prescription done by consultant haematologist

5. Out-patient referrals Wed am…details confirmed/updated, counselled Start warfarin (5mg) on Friday and attend for INR on days 5 and 8 (following Tuesday and Friday) Dosed by induction algorithm, results telephoned, yellow book returned Aspirin stops when INR therapeutic (if have written confirmation) Day8, transferred to maintenance

6. Ward referrals Dosing chart acts as referral request New patient manager, treatment plan completed INR, warfarin dose and date of next INR written on dosing chart and sent back to ward Patient counselled before discharge Patient may be discharged during induction

7. Ward referrals Day8, transferred to maintenance In-patient, continue with dosing chart with INR checks on a regular basis If discharged, further INRs at hospital or in community by dose/post using yellow book

22. Only 32/175 UK sites (18%) have integrated induction module…why? Expensive luxury…£1838 special offer Read algorithm from a table and enter results as treatment history Induction not done…work volume, staffing levels

23. Why use integrated induction package ? User friendly Seamless transition to maintenance Safety features (best practice) Government guidelines Litigation I’m on 10% commission…I wish

24. Safety features Human error…misread table Import results…reduce transcription error Calculation prevention Warnings

25. Calculation prevention No matching rule for day INR greater than cut-off (5.0) No matching rule for previous dose Dialogue box to enter dose, any miss days and interval…algorithm shown to aid decision No matching rule for INR No dialogue box…problem with algorithm

27. Warnings generated on calculation Large INR change (>=INR entered in setup) INR less than previous INR and low Review for transfer

28. Warnings with confirmation prompt Given on accepting dose and next test date for both manual and computer calculated values Dose increased for INR rising to within range or high Dose decreased for INR falling to within range or low Miss days greater than 2 Next test interval greater than protocol maximum

29. PRODIGY guidelines for warfarin therapy in AF www.prodigy.nhs.uk www.prodigy.nhs.uk An INR of 2.0 can usually be reached by giving warfarin 5 mg for 4-5 days. People on warfarin need regular monitoring of INR. Ideally this should take place in the setting of an organized anticoagulant clinic. If no clinic is available, monitor INR daily until the result has stayed in the therapeutic range for at least 2 consecutive days. Then check INR 2-3 times a week for 1-2 weeks, and then less often, depending on the stability of the results.

37. Analysis of induction algorithm Foxfire…258 induction records dosed on days 1,5,8 Time taken to 2 consecutive INRs 2.0- 4.0 post induction Was day8 dose accurate or did it overdose/underdose

40. Analysis summary Acceptable, covered by Aspirin Unacceptable, Aspirin stopped. Most sensitive to warfarin taking longer to induct. ?increase by 1mg No problem

48. What can be done? Tweak algorithm Warning when day8 INR < day5 Advise to restart aspirin Have higher post induction target INR Let INR fall to baseline and restart on a different algorithm ‘Intelligent’ algorithm