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
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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
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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).
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This combined with the Warfarin treatment chart and the DAL
provides the information required for the safe transfer of care.
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All patients must have a confirmed appointment made with a
monitoring clinic prior to discharge
Cwm Taf Referral form
15
M222222
A Smith
RGH
R. Alcolado
Green Field
4.10.13
X
JH 4/10
X
X
X
X
X
X
X
lifelong
√
JH 4/10
JH 4/10
JH 4/10
National Patient Safety Agency
Patient Safety Alert 18 (March 2007)
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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
National Patient Safety Agency
Patient Safety Alert 18 (March 2007)
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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.
Safety Indicators NPSA/BCSH
British Journal of Haematology (2007)
136 (1); 26-29
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Proportion of patient-time in range
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Percentage of INRs > 5·0
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Percentage of INRs > 8·0
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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
Warfarin group
Cumulative survival
1.0
71–100%
61–70%
51–60%
41–50%
31–40%
<30%
Non Warfarin
0.9
0.8
0.7
0.6
0
500
1000
1500
Survival to stroke (days)
Morgan CL et al. Thrombosis Research 2009;124:37–41
2000
Safety Indicators NPSA/BCSH
British Journal of Haematology (2007)
136 (1); 26-29
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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: 828-831
Questions to ask when considering oral anticoagulation
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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: 828-831
NICE CG36
Patients at high risk of bleeding with Warfarin
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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?
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The Iceberg Challenge
Resources
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National Institute of Clinical Excellence (NICE)
www.nice.org.uk/
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British Committee for Standards in Haematology
http://www.bcshguidelines.com/
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Welsh Medicines Resource Centre (WeMeRC)
http://www.wemerec.org
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BMJ learning
http://learning.bmj.com
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Coagucheck Website
http://www.coaguchek.net/uk/