ADAS Anticoagulant Dosing and Advisory Service - PowerPoint Presentation

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ADAS Anticoagulant Dosing and Advisory Service

Sean O’Brien

ADAS Deputy Manager

Bev

Straker - Bennett Senior Specialist Anticoagulation BMS

August 2019

Service ProvisionADAS is a Consultant led service managed by the Pathology Directorate.

Provides POCT and

computer assisted dosing advice to

6000 registered

patients on oral anticoagulant

therapy.

The

service is

delivered

by Biomedical

Scientists, Medical Laboratory Assistants.

All clinics are community based.

Daily housebound patient service.

Community Clinic sites

Warfarin dosing for intermediate care units.

Management of pre procedure INR levels

.

Management of pre procedure INR levels.

Direct links with DVT service.

M

anagement of patients awaiting cardiovascular procedures

Comprehensive Initiation / Education

for all new starters

. (WARFARIN / DOAC’s)

INR monitoring / warfarin dosing

DOAC safety checks / 3 week follow up

Anticoagulant service DOAC concernsVariation in initiation in both primary and secondary care.

Inconsistent education for patients.

Patients presenting

to

ADAS

clinics for advice and confused.

Patients prescribed a DOAC with contraindications.

Patients on both warfarin and a DOAC !Patient not on either anticoagulant !Switches done without renal bloods or INR checks. NICE guidance not followed.Switches done when INR is above recommended level (

bleeding risks).Patients on the wrong doses of DOACs / no follow up checks. Phone calls to ADAS for DOAC advice and switch assistance.

Scenarios

Patient

admitted to CAT unit at BVH as her INR was >10

.

D

ischarged

a day later with an INR of 7.3 following vitamin

K

ADAS had no update referral / no follow up check / no E discharge letter to GPADAS performed a home visit 3 days later INR still >3

Patient had been sent home and started on Apixaban on discharge with an INR of 7.3!! No follow up in place, no education for patient / carers.

Worrying Scenarios

Clinic patient attended confused about her anticoagulation. Started on rivaroxaban 3 days previously.

INR performed just

for safety and

a closing INR for

records

INR

was >8Patient previously on 3mg warfarin daily and had been

Rx’d 15mg rivaroxaban. She had taken 15mg of Warfarin and Rivaroxaban Oral Vit K administeredConsulted with GP re stopping and restarting Riva when INR<2She and her carer had not received any information the drug switch or counselling on DOAC

Worrying Scenarios

Patient requires Anticoagulation

Medics to discuss options with patient following trust guidelines and prescribe appropriate Anticoagulant.

NEXUS referral made to Adas. DOAC or Warfarin

Anticoagulation Initiated by Medic

Anticoagulation Initiated / switched by Adas

Education on chosen Anticoagulant. Safety Checks performed. Patient registered on centralised database

Warfarin

INR checked. Dosed amended/initiated. Follow up appointments in clinics arranged.

DOAC

Patient seen for three week follow up appointment to discuss issues/side effects

Discharged to GP care.All carers informed of medication changes if a switch of Anticoagulant has occurredRegular monitoring TTR/VGR review. Reports sent to GP

Secondary Care Pathway for all Anticoagulants

E Discharge Flag

Common DOAC issues

No clotting

screen at initiation (INR / PTT)

Liver enzymes not assessed or raised above safe limits according to product data sheets

Patient weight < 40kg or >120kg – no data on efficacy

Renal function not appropriate for DOAC use <15 ml/min Apix / Riva / Edox and <30ml/min Dabigatran

E GFR being used instead of Cock Croft Gault assessment for dosage, using actual body weight

Patients switched who are higher range 3-4 warfarin – APA / Clot whilst on warfarin / mechanical valve

Apixaban patients on 2.5 mg BD instead of 5 mg BD, using 1 instead of 2 of the dose reduction criteriaRivaroxaban prescribed at 20mg OD when Cr Cl 15-49ml/min

Common DOAC issues Patients not taking Rivaroxaban with largest meal

BD doses not taken at appropriate intervals

Renal function regular checks and care / action if renal function is declining

Reviews of dosage if patients weight or renal function or age indicate a change in dose

VTE patients - end of acute treatment duration review, discussions re prophylaxis or switch down to prophylactic dose for recurrent VTE

Confused / vulnerable patients - ? Risk with no

monitoring and switches should be carefully

implemented Switches to DOAC can be assisted by ADAS – checks to ensure safe INR levels / appropriate startsADAS switches back to warfarin closely monitored

Benefits of the pathway

Centralisation of all anticoagulant patients (universal anticoagulant database).

Auditable, consistent, comprehensive education for all patients/carers.

Less

M

edic time/confusion on who is educating patients.

Safe medication switches.

Secondary safety check to ensure: no contraindications (drugs or conditions) bloodwork is done and results appropriate correct dosage appropriate treatment duration3 week DOAC review Compliance for NRLS (NPSA) / NICE recommendations.