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.

> 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: 11-

12 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.

2012 HITH Statistics

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).

Warfarin and Medication

Safety Trivia

> Warfarin use is increasing with the ageing

population.

> Uncertainty surrounding newer

anticoagulants.

> Remains the drug of choice for many co-

morbidities: AF, DVT/PE, CVA (thrombus),

cardiomyopathy and AVR/MVR.

> The new National Inpatient Medication

Chart (NIMC) new design incorporated

Warfarin risk.

Safety and Concerns

> 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

> 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.

TQEH HITH Audits Results

& Warfarin Concerns

> 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.

Further Consideration

> 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.

Out of our control?

> 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.

Time 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.

Goals for change

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

Clinical Practice

Improvement

> 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.

THE PLAN

> 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.

Standardised approach and

POC testing

Coagchek Technology/POC Machines

> 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

> 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.

HOSPITAL IN THE HOME

WARFARIN PROTOCOL (continued)

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

1.6

10

0.5

9

0.5

7.5

0.5

6

0.5

3 (16hrs after 2nd dose) 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

4 (16hrs after 3rd dose) 1.5 Refer to medical point of care

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

4.1–4.5 omit next dose, then

2 1.5 1 0.5

4.5 Hold & refer to medical officer

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.

Therapeutic Drugs Committee

+ Patient Advisory Group

Review and Recommendations

> 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.

Approval!

> 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).

2012 Audit Results

> 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.

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.

Reinforcements +

Sustainability

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

References