AnticoagulantsReducing the riskAmanda Powell & Sue WoollerMay 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

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National Patient Safety AgencyPatient 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 AgencyPatient Safety Alert 18 (March 2007)

Safety Indicators NPSA/BCSHBritish Journal of Haematology (2007)

136 (1); 26-29

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

0 500 1000 1500 2000

Survival to stroke (days)

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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/BCSHBritish Journal of Haematology (2007)

136 (1); 26-29

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: 828-831Questions 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: 828-831NICE CG36Patients 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)

www.nice.org.uk/

British Committee for Standards in Haematology http://www.bcshguidelines.com/

Welsh Medicines Resource Centre (WeMeRC) http://www.wemerec.org

BMJ learning http://learning.bmj.com

Coagucheck Website http://www.coaguchek.net/uk/