An Evaluation of the BVH Initiation of warfarin for DVT. Sean O Brien Specialist Anticoagulation BMS Oct 2015

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1 An Evaluation of the BVH Initiation of warfarin for DVT Sean O Brien Specialist Anticoagulation BMS Oct 2015

2 Service Provision ADAS is a Consultant led service managed by the Pathology Directorate. Provides POCT and computer assisted dosing advice to 7000 registered patients on oral anticoagulant therapy. The service is delivered by Biomedical Scientists, Nurses and Medical Laboratory Assistants. All clinics are community based. Daily housebound patient service.

3 Community Clinic sites

4 Activity ADAS Activity NUMBER OF PATIENT VISITS Series Series

5 Additional provision Inpatient dosing for Rossall & Bispham Spire Healthcare Rehab units. Direct link to outpatient DVT service. Pre op management of patients awaiting Cardioversion or Ablation. Pre and Post op management of Colonoscopy patients. Pre op management of Cataract patients. Reversal of over Anticoagulated patients with Oral Vitamin K, including 24 hour follow up, within community clinics.

6 Comprehensive Education for all new starters. Fully compliant with NPSA recommendations Comprehensive management of patients awaiting cardiovascular procedures Cardiology Ablation Cardioversion management BVH Wards ADAS Blackpool Spire Bispham Rossal Nurse Led Units Warfarin dosing for intermediate care units. Fylde Ambulatory DVT services. GP Led Wyre Gastro- Enterology Colonoscopy Management of pre procedure INR levels. Direct links with DVT service. Pathway for LMWH developed by ADAS. Opthalmology Cataract patients Management of pre procedure INR levels.

7 The Warfarin Patients Journey DVT/PE Patient presents at A+E with suspected DVT/PE PCAU confirm diagnosis of DVT/PE. DVT nurse sees patient and starts patient on Warfarin 5mg + Fragmin cover for 8 days. Patient referred to ADAS via electronic referral and Appt made for day five at Blackpool Vic.

8 The Warfarin Patients Journey Patient attends ADAS on Day 5 for INR test. This includes a weekend service when day 5 falls on a Saturday or Sunday. Following INR result patient receives ADAS counselling, is dosed for 3 days using our locally agreed Induction Algorithm and advised re Fragmin cover. If patient has reached therapeutic range Fragmin is stopped. Counselling session includes appropriate clinic for continued follow up.

9 DVT Induction protocol Initiate warfarin 5mg daily for 4 days. Check INR on day 5 * If baseline INR >1.2, then check LFT s. If LFT s abnormal use 3 mg starting dose and adjust appropriately at day 5. Only follow the dosing algorithm below if the patient has taken 5mg for 4 days. DAY 5 INR WARFARIN DOSAGE =/< 1.4 8MG FOR 3 DAYS MG FOR 3 DAYS MG FOR 3 DAYS MG FOR 3 DAYS MG FOR 3 DAYS MG FOR 3 DAYS >3.7 MISS 1 DAY AND RETEST

10 Why Evaluate the protocol? Its never been evaluated, anecdotally it works? Does it work? Is it safe? Could it be used throughout the trust? Could we improve it?

11 Study Design 100 patients randomly selected, retrospectively, from DAWN database. Patient MUST have followed the protocol. Any patients who missed days or took the wrong dose were excluded. Start date searched between Where multiple episodes were in the treatment plan the first episode has been included only. Results taken from DAWN, Day 5, 8, and when INR > 2 Fragmin usage was not included.

12 Demographics Age Range 24-94

13 Results Average INR on day 5 = 1.9 Average INR on day 8 = 2.4 Average time to therapeutic range = 7.9. This result has limitations due to the INR only being tested at Day 5 and Day 8. Average dose of stable warfarin = 4.7

14 Results

15 Conclusions It works! Its safe, we had one >8 INR, at day 5. (stable dose 1mg) Could it be used throughout the trust? Watch this space. Can we improve it?

16 Future plans Trust investigating using new policy incorporating our algorithm. We are going to look at our AF algorithm, currently 3mg for 4/5 days. A pilot is starting at the end of October for an ADAS early discharge scheme for Cardiac patients. Exciting times indeed and an opportunity to get an upgrade next year too. Ultimately a move to inpatient dosing, we know it makes sense!