Community DVT Service. Phase 3: Anticoagulation at DVT Treatment Centres

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Amberly Black
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1 Community DVT Service Quick Reference Guide Phase - Anticoagulation Phase : Anticoagulation at DVT Treatment Centres If a Patient has had a positive Ultrasound Scan they attend one of the DVT Treatment Centres for Anticoagulation: The Default Protocol should be used for anticoagulation where appropriate. The Alternative Protocol should be used for the following patients: Elderly (over age ) Liver disease Alcohol abuse Body weight less than 0kgs Heart failure Multiple co morbidities Patients receiving drugs which may interact with or potentiate Warfarin Patients with Day 1 INR of 1.4 or above Whichever Protocol is selected, clinical judgement should be used in all cases and where there is uncertainty or concern doctors should discuss the appropriate dose with a haematologist. NB: Warfarin will be provided by DVT Treatment Centres to patients using the current prescription mechanism as there is no reimbursement arrangement with GP Care. Author: NC/PN Page 1 of Pages Aug 01

2 Default Warfarin Protocol This table should be used as a guide, in conjunction with clinical judgement DAY LFT, U&E FBC INR Test INR Level Dose (mg) 1 < Treat according to Alternative Protocol 10 < > 4.0 NONE 4 As per day < /8 alternate days / alternate days / alternate days / alternate days /4 alternate days Miss one day, then mg > 4. Discuss with haematology As per day *If Day INR is below.0, seek GP Advice re: increasing Warfarin dose INR continues to be tested on alternate days (, 9, 11, 1,...) and Warfarin dose adjusted according to Day table. Author: NC/PN Page of Pages Aug 01

3 EACH PATIENT WILL FOLLOW ONLY ONE OF THESE DAY DOSAGE PATHS, DEPENDENT ON INITIAL DAY INR VALUE. Alternative Warfarin Protocol This table should be used as a guide, in conjunction with clinical judgement DAY 1 LFT, U&E FBC INR Test 4 INR Level Dose (mg) < NONE < >. NONE < 1.8 >. NONE As per day DAY Dose (mg) 4 NONE 1 *If Day INR is below.0, seek GP Advice re: increasing Warfarin dose DAY INR Test INR Level Dose (mg) < 1.8 * >.0 < 1.8 * /4 alternate days.1 -. >. / alternate days < 1.8 4* /4 alternate days / alternate days >. < 1.8 * / alternate days / alternate days >. 1 < 1.8 * / alternate days / alternate days >. NONE <.0 1/ alternate days* /1 alternate days >. NONE 9 As per day 11 As per day On even numbered days (8, 10, 1, ) the patient should be advised to take the same Warfarin dose as calculated on the previous day, ie. as per last INR test. 1 As per day 1 As per day If patient is not stabilised by Day 1, INR continues to be tested on alternate days and Warfarin dose adjusted according to Day table Author: NC/PN Page of Pages Aug 01

4 Default & Alternative Warfarin Protocols INR testing to be performed on alternate days unless there are any clinical concerns; ie rapidly changing INR levels Anticoagulation Day 1 Patient weighed and Clexane dose calculated; Baseline Full Blood Count, including LFT, U&Es and serum Calcium, using existing procedures; DVT Treatment Centre staff to print results when available on ICE and attach to patient s treatment record for faxing to GP upon discharge. Blood test results should be reviewed by the DVT treatment centre doctor and then faxed to GP Care. Any abnormalities need to be actioned and notified to the patient s own GP. In normal circumstances all results will be forwarded to the registered GP practice by GP Care staff, but where there are abnormalities, it is the responsibility of the DVT treatment doctor to ensure these are dealt with appropriately. INR test using Near Patient Testing Coaguchek unit (refer to Page 8 for step by step guide); Clexane injection, unless already given by registered GP that day (dosage as per protocol for Phase 1); Patient provided with Oral Anticoagulation Therapy (OAT) Pack; Initiation of Patient on Warfarin: o Prescribe Day 1 dose, according to the appropriate Warfarin Loading Schedule. o Provide Patient with 8 day prescription of Warfarin tablets, ie. 8 of each strength of 1.0mg,.0mg and.0mg, to allow for variations in the ongoing dosage levels Ascertain DVT Treatment Centre of choice for patient. If the patient wishes to transfer to to an alternative centre: o Contact the chosen DVT Treatment Centre and establish an appointment time whilst the patient is still present; o Fax the Patient Record Card and Anticoagulation Record to GP Care Office advising them of the transfer and designated appointment time given to patient; o GP Care will then ensure the Treatment Centre to which the patient is transferred receives the complete patient record prior to their appointment. Anticoagulation Day Single daily Clexane injection (dosage as per protocol for Phase 1). NB: Patients can choose to self administer without attendance at DVT Treatment Centre provided that they have been shown how to administer the Clexane and that they feel confident with the procedure. Personal sharps bins available on request. Prescribe Day dose of Warfarin according to relevant Loading Schedule above If clinically indicated, INR testing can be performed on Day. Anticoagulation Day Single daily Clexane injection (dosage as per protocol for Phase 1). INR test using Near Patient Testing Coaguchek unit; Warfarin dosage is prescribed according to appropriate Loading Schedule above Anticoagulation Day 4 Single daily Clexane injection (dosage as per protocol for Phase 1). NB: Patients can choose to self administer without attendance at DVT Treatment Centre provided that they have been shown how to administer the Clexane and that they feel confident with the procedure Prescribe Day 4 dose of Warfarin according to appropriate Loading Schedule above Anticoagulation Day Single daily Clexane injection (dosage as per protocol for Phase 1). DVT Treatment Centre repeats Full Blood Count using existing procedures to test for thrombocytopenia; platelet count to be recorded on the Patient Record Card. Blood test results should be reviewed by the DVT treatment centre doctor and then faxed to GP Care. Any abnormalities need to be actioned and notified to the patient s own GP. In normal circumstances all results will be forwarded to the registered GP practice by GP Care staff, but where there are abnormalities, it is the responsibility of the DVT treatment doctor to ensure these are dealt with appropriately. NB: Where Day is on a weekend then the Full Blood Count should be performed by the DVT Treatment Centre on the next working day. Author: NC/PN Page 4 of Pages Aug 01

5 INR test using Near Patient Testing Coaguchek unit; o If the Patient has achieved a second consecutive INR reading of.0.0 (inclusive) and Warfarin dose is stable (i.e. current dose differs from previous dose by no more than mg) then: Patient is discharged back to their Registered GP who is responsible for getting the Patient onto the Pink/Yellow Slip system of INR testing/warfarin dosing via secondary care. Next INR test in 1 week or earlier if clinically indicated. o If the Patient has not achieved a second consecutive INR reading of.0.0 (inclusive), or Warfarin dose is not stable then: Warfarin is prescribed according to the appropriate Loading Schedule above; ie, as per Day Anticoagulation Day onwards INR Testing continues to be carried out on alternate days; ie Days, 9, 11, 1, 1. o If the Patient has achieved a second consecutive INR reading of.0.0 (inclusive) and Warfarin dose is stable (i.e. current dose differs from previous dose by no more than mg) then: Patient does not receive a Clexane injection and they are discharged back to their Registered GP who is responsible for getting the Patient onto the Pink/Yellow Slip system of INR testing/warfarin dosing via secondary care. Next INR test in 1 week or earlier if clinically indicated. o If the Patient has not achieved a second consecutive INR reading of.0.0 (inclusive), or Warfarin dose is not stable then: Patient receives another daily Clexane injection (dosage as per protocol for Phase 1) unless the INR level is. or above when the Clexane dosing should cease; Prescribe Warfarin Dosage according to the appropriate Loading Schedule above; ie as per Day Author: NC/PN Page of Pages Aug 01

6 Step by Step Guide Coaguchek INR Test To measure a patient s INR level the following steps should be performed: 1. Turn on Coaguchek Unit (the Unit ) and locate a Coaguchek Testing Strip (the Strip ) from the cylindrical container. Do not leave the lid of the container for longer than is necessary as the active part of the Strip can react with moisture in the air and begin to deteriorate;. Press the Initiate Test area on the Touch Screen;. Insert Strip into the slot at the front of the Unit with the arrows on the Strip pointing toward the Unit; 4. Wait for 4 seconds whilst the Strip warms up after which the unit will bleep. Note that the egg timer symbol will show for the duration of the warming up process as will a Cross sign indicating that the Strip is not yet ready for use;. You now have 180 seconds in which to perform the INR Test;. Extract a drop of blood by pricking the patient s finger. Note: Transfer of the drop of blood to the Strip will be made easier by: pricking at the end of the little finger (rather than mid way along a finger) and collecting a large drop by milking the finger;. Guide the patient s finger and touch the drop of blood to the side of the Strip at the point where the strip is transparent. Note that the blood will be drawn up the strip and the transparent area may eventually appear empty of blood; 8. The Unit will display the INR result within a further 4 seconds of placing the blood on the Strip. For further information please refer to the Roche Diagnostics Manual which should be held by each DVT Treatment Centre. If you are experiencing recurrent error messages and need assistance please call the Roche Helpdesk on Patient Treatment Record The Patient Treatment Record should be updated daily after each anticoagulation Patient visit. On Day 1: o Circle which Warfarin Protocol the patient will be following; Record the weight of the patient and the Clexane dose calculated; o Record that you have completed and handed the patient the OAT Pack; When the patient returns to the DVT Treatment Centre following attendance at OOH provider the patient s own copy of the Patient Treatment Record should be copied and used thereafter so that the complete record of anticoagulation is faxed to GP Care and the registered GP on discharge. On Day 1 and subsequent days: Annotate your name, Clexane batch no and dose administered, INR reading (if appropriate) and Warfarin dose. Anticoagulation Out of Hours The majority of patients with actual DVTs will receive care from an Out of Hours provider (Frendoc) on a weekend when DVT Treatment Centres are generally not operational; If Patient requires continuing Clexane injections and/or INR tests over the weekend then o DVT Treatment Centre advises Patient to go to Frendoc at Frenchay for appointments on each day; the Patient is advised to telephone Frendoc on after 08.00am on Saturday morning to ascertain the best time to attend. o DVT Treatment Centre faxes Patient Record Card and Treatment Record to Frendoc on by 8.00pm each Friday evening (or Thursday if Friday is a bank holiday) and gives the originals to the Patient; o GP Care provides Frendoc with a summary list of Patients expected to attend over the weekend by faxing Frendoc on by.00pm each Friday evening (or Thursday if Friday is a bank holiday); o Frendoc advises Patient to return to DVT Treatment Centre following the weekend for discharge or ongoing anticoagulation and faxes updated Patient Treatment Record to GP Care on by 9.00am on the next working day, giving the original Patient Treatment Record to the Patient; o GP Care then passes a copy of the Patient Treatment Record to the appropriate DVT Treatment Centre to ensure that patient treatment records are up to date. Author: NC/PN Page of Pages Aug 01

7 If a patient fails to call Frendoc to arrange an appointment or Does Not Attend for a scheduled appointment, Frendoc staff should attempt to contact the patient by telephone. Any action taken should be clearly documented on the Patient Treatment Record. Discharge Following Anticoagulation If the Patient has achieved two consecutive INR readings of.0.0 and the Warfarin dose is stable (i.e. current dose differs from previous dose by no more than mg) then they should be discharged from the Service; Patients will always be discharged by a DVT Treatment Centre who should notify the Patient s Registered GP; The discharge should always be made by a Duty Doctor and not by a nurse team by completing and signing Section of the Patient Record Card; Once discharged, the Patient s own completed Patient Record Card and Patient Treatment Record is copied and faxed to GP Care on and also faxed to the Patient s Registered GP; Once a patient has been discharged from the GP Care Service the Patient s Registered GP is responsible for: o o Considering potential secondary causes of the DVT; and Arranging ongoing warfarinisation and INR testing via the Pink Slip or Yellow Book systems operated by secondary care; or accepting responsibility for ongoing monitoring using in-house equipment and dosing protocol. Next INR test in 1 week or earlier if clinically indicated. Admission to Secondary Care - Interface Protocol with Secondary Care Patients who have complex medical problems - This group of patients will require specialist management and some will need admission to hospital. The referring GP may consider that hospital treatment is necessary at the time of presentation. Alternatively the specialist GP may decide that the patient is not suitable for community based treatment in which case he or she will make a referral to secondary care and will notify the referring GP of the decision by fax; Patients who suffer a complication of treatment - Patients attending the specialist practice for Clexane and Warfarin stabilisation will be temporarily under the care of the expert GP for this aspect of their treatment. In the event of a serious complication of Warfarinisation e.g. haemorrhage, the expert GP will arrange any necessary treatment and will notify the GP by fax and or telephone; Patients who develop intercurrent illness during Warfarinisation - Management of intercurrent illness remains the responsibility of the registered GP at all times. However the expert performer GP will be expected to notify the referring GP of any medical problems which arise during Warfarinisation in order to facilitate prompt treatment and prevent complications. Author: NC/PN Page of Pages Aug 01

Linda Cutter / Dr Charles Heatley. GP Practices and Community Pharmacies

Schedule 2 Part A Service Specification Service Specification No. 04 Service Anti-coagulation Monitoring Levels 3, 4 & 5 Commissioner Lead Provider Lead Linda Cutter / Dr Charles Heatley GP Practices and