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

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Information about Cameron Wilson, The Queen Elizabeth Hospital: Nurse initiated Warfarin...
Health & Medicine

Published on March 10, 2014

Author: informaoz



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:

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 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.

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.

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.

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).

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.

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).

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.

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.

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.

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.

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.

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

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.

THE PLAN Next steps: > Reinforce existing standardised TQEH guideline. > Daily testing achievable in hospital and HITH settings. > Improve medical compliance with the guideline.

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.

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.

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.

Coagchek Technology/POC Machines

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.

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.

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

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.

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.

Therapeutic Drugs Committee + Patient Advisory Group Review and Recommendations DOCUMENTATION PROCESS: > INR recorded with warfarin dose in medication chart and progress notes.

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.

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.

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).

> 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.

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.

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.

References 1. NSW Health Safety Notice 006/07: “Guidelines for prescribing, dispensing and administering warfarin”. /sabs/pdf/sn20070412.pdf 2. Australian Commission for Safety and Quality Health Council (ACSQHC 2011): Australasian Clinical Indicator Report 2004–2011 13th Edition. cal_indicators_report_web.pdf

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