The Queen Elizabeth
Hospital
Warfarin Management
in HITH
Warfarin
Registered Nurse initiated dosing,
Coagchek „Point of Care‟
technology, and an Age-adjusted
Nomogram.
The Queen Elizabeth Hospital:
Hospital in the Home Service
Summary
› Registered Nurse led team.
› No Medical or Allied Hea...
2012 HITH Statistics
> TQEH HITH saw over 10,000 patients last
year.
> 3,666 INR tests completed in the
community- point o...
Warfarin and Medication
Safety Trivia
The Australian Council on Healthcare
Standards (ACHS) 2011 report:
> Medication use ...
Warfarin and Medication
Safety Trivia
Australian Commission for Safety and Quality
Health Council* (ACSQHC 2011 Report):
>...
Safety and Concerns
> Warfarin use is increasing with the ageing
population.
> Uncertainty surrounding newer
anticoagulant...
TQEH HITH Audits Results
> A non-standardised approach to Warfarin
dosing was apparent.
> “Clinical judgement was deemed b...
TQEH HITH Audits Results
& Warfarin Concerns
> Increased time to reach therapeutic INR
levels.
> Increased LOS in HITH.
> ...
Further Consideration
> Long INR wait times for lab tests.
> Increased patient discomfort with repeat
venepuncture.
> Reli...
Out of our control?
> Large patient variance in therapeutic
doses.
> Range: 0.5mg to 28mg per patient
daily.
> External in...
Time for change!
> Commonly used medication +
inconsistent prescribing + high
adverse event reporting = High risk
for pati...
Goals for change
> Increase patient safety and
decrease reported incidents.
> Efficient use of hospital resources
and decr...
Clinical Practice
Improvement
Business Case:
Interdisciplinary work group formation to
review current practice.
Key stakeh...
THE PLAN
> Investigate ways to improve patient safety
> Improve overall efficiency of Warfarin
stabilisation.

HOW?
Eviden...
THE PLAN
Next steps:
> Reinforce existing standardised TQEH
guideline.
> Daily testing achievable in hospital and
HITH set...
THE PLAN
Next steps:
> Letter from Director of Medical Services, Dr
Sally Tideman, to all key medical staff and
heads of u...
Standardised approach and
POC testing
> Investigation of Point of Care (POC)
technology.
> Review POC accuracy, cost and
s...
Standardised approach and
POC testing
> Develop a safe HITH nurse-initiated
warfarin protocol.
> Prompt dose adjustment du...
Coagchek Technology/POC Machines
HOSPITAL IN THE HOME
WARFARIN PROTOCOL
> Warfarin dose: 4pm daily during loading
phases.
> INR taken between 7am–9am the n...
HOSPITAL IN THE HOME
WARFARIN PROTOCOL
(continued)
> The goal of warfarin initiation is to
rapidly attain a stable therape...
Warfarin Age-Adjusted Nomogram
Dose according to age (mg)
Day

INR

50
years

51–65
years

66–80
years

80
years

1

1....
Therapeutic Drugs Committee
+ Patient Advisory Group
Review and Recommendations
PATIENT ELIGIBILITY:
> Baseline INR of <1....
Therapeutic Drugs Committee
+ Patient Advisory Group
Review and Recommendations
EXPECTATIONS OF RN WHO
INITIATED TREATMENT...
Therapeutic Drugs Committee
+ Patient Advisory Group
Review and Recommendations
DOCUMENTATION PROCESS:
> INR recorded with...
Approval!
> Input from all key stakeholders = approval
granted.
> HITH Nurse Initiated age-adjusted Warfarin
Protocol impl...
Approval!
> Instant INR results through POC use.
> Safe implementation of a nurse initiated
dose with daily testing.
> Rep...
2012 Audit Results
> Increased use of the Warfarin protocol:
45% vs 2% in 2008.
> Reduction in lab testing and
venepunctur...
> Increase in visit efficiency: instant result,
immediate dose, no phone calls or lag time
with lab follow up.
> Increased...
Reinforcements +
Sustainability
Nurse initiated warfarin protocol was
published in:
a. The Pulse (monthly TQEH newsletter)...
Reinforcements +
Sustainability
> RN competencies and learning
package mandatory for HITH RN‟s.
> Presentation by HITH/Pha...
References
1. NSW Health Safety Notice 006/07: “Guidelines
for prescribing, dispensing and administering
warfarin”.
http:/...
Cameron Wilson, The Queen Elizabeth Hospital: Nurse initiated Warfarin dosing in combination with Coaguchek ‘Point of Care...
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Cameron Wilson, The Queen Elizabeth Hospital: Nurse initiated Warfarin dosing in combination with Coaguchek ‘Point of Care’ technology

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Cameron Wilson, Hospital @ Home Casefinder - Community & Transitional Care Unit, The Queen Elizabeth Hospital delivered this presentation at the 2013 Hospital in the Home conference. This 2-day event is a nurse oriented program to improve HITH services and maximise hospital efficiency. For more information about the annual event, please visit the conference website: http://www.communitycareconferences.com.au/hospitalinthehome

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Cameron Wilson, The Queen Elizabeth Hospital: Nurse initiated Warfarin dosing in combination with Coaguchek ‘Point of Care’ technology

  1. 1. The Queen Elizabeth Hospital Warfarin Management in HITH
  2. 2. Warfarin Registered Nurse initiated dosing, Coagchek „Point of Care‟ technology, and an Age-adjusted Nomogram.
  3. 3. The Queen Elizabeth Hospital: Hospital in the Home Service Summary › Registered Nurse led team. › No Medical or Allied Health component. › Medical Governance = Ward Home Teams. › Ranging up to 45 patient visits per day. › Staffing levels: flex up and down according to patient loads and acuity.
  4. 4. 2012 HITH Statistics > TQEH HITH saw over 10,000 patients last year. > 3,666 INR tests completed in the community- point of care & venepuncture. > Average- 1 in 3 HITH patients had an INR* test. > Average time to reach therapeutic INR: 1112 days in 2007-08*. *INR test: The International Normalised Ratio is the test for blood clotting. *As per HITH 3 monthly random auditing over 12 months (>200 pts)- from commencement to two stable therapeutic INR results and warfarin doses.
  5. 5. Warfarin and Medication Safety Trivia The Australian Council on Healthcare Standards (ACHS) 2011 report: > Medication use remains the most common intervention in health care. > Medication errors and adverse reactions result in an estimated 140,000 annual hospital admissions. > Most adverse drug events are preventable.
  6. 6. Warfarin and Medication Safety Trivia Australian Commission for Safety and Quality Health Council* (ACSQHC 2011 Report): > Listed Warfarin as 5th most notified medication for reported events. > Widely used drug with a narrow therapeutic index. > Potentially serious adverse reactions eg. spontaneous bleeding. * Reference- ACSQHC Report (2011).
  7. 7. Safety and Concerns > Warfarin use is increasing with the ageing population. > Uncertainty surrounding newer anticoagulants. > Remains the drug of choice for many comorbidities: AF, DVT/PE, CVA (thrombus), cardiomyopathy and AVR/MVR. > The new National Inpatient Medication Chart (NIMC) new design incorporated Warfarin risk.
  8. 8. TQEH HITH Audits Results > A non-standardised approach to Warfarin dosing was apparent. > “Clinical judgement was deemed better than guidelines”. > Length of stay (LOS) was inconsistent, and poor vs Warfarin guideline. > Very low medical compliance with TQEH Warfarin Guideline (<2% in 2008).
  9. 9. TQEH HITH Audits Results & Warfarin Concerns > Increased time to reach therapeutic INR levels. > Increased LOS in HITH. > Guideline*: 4-6 days to achieve therapeutic INR in 60% of patients vs TQEH clinical judgement (11-12 days). > Increased number of venepunctures and laboratory (lab) testing. *In combination with age adjusted Nomogram, a standard baseline INR, and daily testing from commencement.
  10. 10. Further Consideration > Long INR wait times for lab tests. > Increased patient discomfort with repeat venepuncture. > Reliance on HITH RN to assist in dose prescription. > Increased incidence of over-coagulation and bleeding. > Increased readmission and intervention. > Extended Hospital and HITH LOS.
  11. 11. Out of our control? > Large patient variance in therapeutic doses. > Range: 0.5mg to 28mg per patient daily. > External influencing factors on Warfarin stabilisation: medication interactions, dietary intake, Vitamin K stores, diarrhoea, low albumin levels. > Patient compliance, cognition & CALD.
  12. 12. Time for change! > Commonly used medication + inconsistent prescribing + high adverse event reporting = High risk for patients + increased risk of readmission + poor use of HITH and hospital resources. > All brought to attention by a HITH RN Kate Swanson in 2008.
  13. 13. Goals for change > Increase patient safety and decrease reported incidents. > Efficient use of hospital resources and decreased LOS. > Adherence to Hospital Guidelines and evidenced based practice.
  14. 14. Clinical Practice Improvement Business Case: Interdisciplinary work group formation to review current practice. Key stakeholders: > HITH RN: Kate Swanson > Head of Pharmacy: Sharon Goldsworthy > Head of Haematology: Dr Simon McRae > IMVS Pathology Manager: Neil Pascoe > Safety and Quality Manager: Jane Burgess > CTCU Manager: Elizabeth Sloggett > VTE RN: Donna King
  15. 15. THE PLAN > Investigate ways to improve patient safety > Improve overall efficiency of Warfarin stabilisation. HOW? Evidence based literature discoveries: > A standardised approach to prescribing decreases risk of bleeding and erratic INR. > Daily INR testing at the commencement of therapy is recommended.
  16. 16. THE PLAN Next steps: > Reinforce existing standardised TQEH guideline. > Daily testing achievable in hospital and HITH settings. > Improve medical compliance with the guideline.
  17. 17. THE PLAN Next steps: > Letter from Director of Medical Services, Dr Sally Tideman, to all key medical staff and heads of units. > Education at Intern orientations. > Counselling and education at commencement of Warfarin. > Establish a „Nurse initiated protocol‟ for INR stabilisation using the standardised algorithm.
  18. 18. Standardised approach and POC testing > Investigation of Point of Care (POC) technology. > Review POC accuracy, cost and safety/effectiveness vs lab testing. > Safe product selection: Coagchek and partnership with SA Pathology (IMVS). > Review role of POC to decrease venepuncture and patient discomfort.
  19. 19. Standardised approach and POC testing > Develop a safe HITH nurse-initiated warfarin protocol. > Prompt dose adjustment during patient (HITH) visit. > No need for Medical Governance for first 4 days. > Protocol: rapidly attains stable therapeutic INR.
  20. 20. Coagchek Technology/POC Machines
  21. 21. HOSPITAL IN THE HOME WARFARIN PROTOCOL > Warfarin dose: 4pm daily during loading phases. > INR taken between 7am–9am the next morning. > INR performed daily for the first 5 days. > Some patients may require dose adjustment at protocol completion. > Patients with serum albumin<30g/l may be very sensitive to warfarin.
  22. 22. HOSPITAL IN THE HOME WARFARIN PROTOCOL (continued) > The goal of warfarin initiation is to rapidly attain a stable therapeutic INR without over-anticoagulation. > If baseline INR is 1.4 or more then careful consideration must be given to warfarin initiation.
  23. 23. Warfarin Age-Adjusted Nomogram Dose according to age (mg) Day INR 50 years 51–65 years 66–80 years 80 years 1 1.4 10 9 7.5 6 2 (16hrs after 1st dose) 1.5 10 9 7.5 6 1.6 0.5 0.5 0.5 0.5 1.7 10 9 7.5 6 1.8–2.3 5 4.5 4 3 2.4–2.7 4 3.5 3 2 2.8–3.1 3 2.5 2 1 3.2–3.3 2 2 1.5 1 3.4 1.5 1.5 1 1 3.5 1 1 1 0.5 3.6–4.0 0.5 0.5 0.5 0.5 4 0 0 0 0 1.5 Refer to medical 1.6 8 7 6 5 1.7–1.8 7 6 5 4 1.9 6 5 4.5 3.5 2.0–2.6 5 4.5 4 3 2.7–3.0 4 3.5 3 2.5 3.1–3.5 3.5 3 2.5 2 3.6–4.0 3 2.5 2 1.5 3 (16hrs after 2nd dose) 4 (16hrs after 3rd dose) 4.1–4.5 care omit next dose, then 2 4.5 point of 1.5 1 Hold & refer to medical officer 0.5
  24. 24. Therapeutic Drugs Committee + Patient Advisory Group Review and Recommendations PATIENT ELIGIBILITY: > Baseline INR of <1.4 (on commencement). > Loaded as per age adjusted protocol. ELIGIBILITY OF RN TO INITIATE ORDER: > Warfarin administration learning package completion. > Coagchek Competencies completion.
  25. 25. Therapeutic Drugs Committee + Patient Advisory Group Review and Recommendations EXPECTATIONS OF RN WHO INITIATED TREATMENT: > Achieve stable INR within 7 days of commencement. > Report to home team if INR>4.5 or <1.6 on day 4 of protocol. DURATION THAT AN RN MAY CONTINUE TO INITIATE ORDER: > 14 days post commencement of warfarin.
  26. 26. Therapeutic Drugs Committee + Patient Advisory Group Review and Recommendations DOCUMENTATION PROCESS: > INR recorded with warfarin dose in medication chart and progress notes.
  27. 27. Approval! > Input from all key stakeholders = approval granted. > HITH Nurse Initiated age-adjusted Warfarin Protocol implemented. > SA Pathology and NATA approved for POC Quality Control. > ACHS commendation for Coagchek program.
  28. 28. Approval! > Instant INR results through POC use. > Safe implementation of a nurse initiated dose with daily testing. > Reproducibility and reliability of POC tests allow greater possibility of early discharge to GP. > Lyell McEwen and Modbury Hospitals also adopted the protocol.
  29. 29. 2012 Audit Results > Increased use of the Warfarin protocol: 45% vs 2% in 2008. > Reduction in lab testing and venepuncture. > Decrease in HITH length of stay (6.8 days). > Reduction in total INR tests per pt (<7 tests). > Reduction in time to achieve therapeutic INR (8 days).
  30. 30. > Increase in visit efficiency: instant result, immediate dose, no phone calls or lag time with lab follow up. > Increased patient safety and satisfaction. > Higher Protocol use = Less time to therapeutic INR. > Reduction in over-anticoagulation during “loading” phase.
  31. 31. Reinforcements + Sustainability Nurse initiated warfarin protocol was published in: a. The Pulse (monthly TQEH newsletter). b. Pharmacy Tablet. c. Intern Newsletter. d. Intern Handbook. > Laminated copies of the protocol placed in all ward medication folders.
  32. 32. Reinforcements + Sustainability > RN competencies and learning package mandatory for HITH RN‟s. > Presentation by HITH/Pharmacy at intern education sessions. > Education for ALL patients commenced on Warfarin. > 3 monthly random patient auditing. > Weekly quality control checks: POC vs lab testing.
  33. 33. References 1. NSW Health Safety Notice 006/07: “Guidelines for prescribing, dispensing and administering warfarin”. http://www0.health.nsw.gov.au/resources/quality /sabs/pdf/sn20070412.pdf 2. Australian Commission for Safety and Quality Health Council (ACSQHC 2011): Australasian Clinical Indicator Report 2004–2011 13th Edition. http://www.achs.org.au/media/50245/achs_clini cal_indicators_report_web.pdf

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