PAGE NO 1. INTRODUCTION 3 2 WARFARIN INITIATION GUIDELINES WARFARIN FLOWCHART. 5 4 WDHB WARFARIN PATHWAY 6 5 WDHB GP REFERRAL FORM 7

Transcription

1 Guidelines for Primary Care Com mmunity-based Clinicians September 2011

2 IINDEX PAGE NO 1. INTRODUCTION 3 2 WARFARIN INITIATION GUIDELINES WARFARIN FLOWCHART. 5 4 WDHB WARFARIN PATHWAY 6 5 WDHB GP REFERRAL FORM 7 6 WDHB DISCHARGE PROCESS WDHB DISCHARGE FLOWCHART 9 8. TRANSFER OF CARE TO PRIMARY SERVICES WARFARIN COUNSELLING CHECKLIST WDHB POST EDUCATION EVALUATION FORM RECOMMENDED INR TESTING FREQUENCY FOR LOW DOSE INTITIATION PATIENT DOSING GUIDELINES BEST PRACTICE TOOL (BPAC) TOOL IN MEDTECH WARFARIN MONITORING WARFARIN INTITIATION PROTOCOL USING THE BPAC TOOL ONCE SIX INR LEVELS ARE RECORDED SUGGESTED DOSING AND REVIEW PROGRESS INR GRAPH LABORATORY MANAGEMENT SAMPLE REFERRAL LETTER REFERENCE/RESOURCES SUGGESTIONS PAGE.. 25

3 1.. WARFARIIN GUIIDELIINES IINTRODUCTIIO ION 06 September 2011 Dear Practice We are pleased to be able to provide you with this copy of our recently developed Warfarin manual. This document aligns with the Warfarin Flipchart which was developed jointly by WRPHO and WDHB as a resource for the both hospital staff and general practice teams and places a key focus on encouraging the use of electronic technology to consistently record and monitor patient Warfarin levels. We would especially like to acknowledge Paul Boden who willingly participated providing us valuable feedback and contributed suggestionss for improvement. The manual has been produced in a format that enables any changes to be made by sending out a replacement page. An electronic version of the manual will also be available on Mambo. WRPHO will add this resource to its internal Document Management System to ensure that it is reviewed and updated annually. New and updated inserts will be available electronically. We trust you find this manual useful and we welcome your comments and suggestions for future updates. The contact for this directory is Robyn Finucane, WRPHO Practice Facilitator or Jeanette Hague, Quality Coordinator. Andrea Thornton Rick Nicholson Robyn Finucane

4 2.. WARFARIIN IINIITIIATIION GUIIDELIINES NB: PATIENTS WITH STABLE INR RECORDINGS CONTINUE TREATMENT WITH THE LABORATORY SERVICE New pathway for Warfarin initiation developed for secondary to primary management. Purpose of guidelines is to provide a standardised, safe and efficient process for INR monitoring and Warfarin dosage in the INITIATION stage Clinical responsibility for Warfarin pathway in the primary sector relates to: New diagnosis for people requiring anticoagulants Unstable INR recordings Referral from WDHB, ED, Laboratory, regional secondary services Wellington Hospital post cardiac surgery (valve) Understanding of Warfarin pathway, INR monitoring, Warfarin dosage Warfarin is prescribed for: Acute DVT or PE Chronic Atrial Fibrillation Valve replacements Referral back to laboratory services when patient stable within therapeutic range Dabigatran Warning Acute haemorrhage associated with Dabigatran initiation causing hospital admissions Remember if transferring from Warfarin to Dabigatran: Stop Warfarin and DO NOT start Dabigatran until INR is less than 2 Check dose is correct for age: patients over 80 years of age require a lower dose Check renal function before starting Dabigatran

5 3.. WARFARIIN FLOWCHART Figure 1: Patient Discharge to Primary Care Flowchart WELLINGTON HOSPITAL Identifies patient requires Warfarin Same commenced Patient education occurs Discharge summary completed at time of discharge including all medications and INR/ dosing hx copy to patient, faxed to GP Referral to hospital pharmacy for medication Discharged GP notified Patient discharged back to WANGANUI HOSPITAL Discharged information sent to the ward? COPY TO GP WHANGANUI HOSPITAL Identifies patient requires Warfarin Same commenced Inpatient education commences NB: ED patients commencee their education with GP Discharged Discharge summary completed at time of discharge including all medications and INR/dosing hx COPY TO PATIENT*, faxed to GP, GP phoned(solo and rural ) Referral to PHARMACY* for medication GP* / PN appt made prior to discharge LABORATORY* form with GP name on it PATIENT DISCHARGED TO PRIMARY CARE Own home Rest home Other care facility DISCHARGE REFERRAL INFORMATION *GP Referral information provided to GP Continue monitoring INR / dosing until level stable GP to manage above using BPAC tool Patient dx information When review planned / made prior to discharge Medication information Education commenced/ continued *PHARMACY (COMMUNITY) Diagnosis (why on Warfarin) When next due for review (GP) When next due for blood test Medication information Education given Require Patient diagnosis list and other medication list Patient requires MUR or comprehensive medication review *PATIENT COPY Summary of Hx/diagnosis When due for review with GP When due for blood test Medication information Patient education *LABORATORY Summary of Hx/Diagnosis When due for GP Review When due for blood test Medication Information Education given

6 4.. WDHB WARFARIIN PATHWAY The WDHB Warfarin Pathway was recently developed as a standardised process. Before Initiating Warfarin Therapy Consider if the benefits of anticoagulation outweigh the risks for each patient e.g. bleeding Ensure INR, platelets and liver function tests are normal. If not seek senior/specialist advice Dosing Principles Warfarin should be prescribed on the regular medication chart and also the supplementary chart The initiating team must complete the indication for Warfarin, INR range, treatment, initial dose and duration of therapy If admitted on Warfarin, an INR must be performed within 24 hours of admission and documented in the Warfarin section of the medication chart. If INR not performed within 24 hours of admission, Warfarin not to be administered until an INR is available to guide dosing decisions Check the patient has received education and written Warfarin information prior to discharge Starting Warfarin Acute DVT or PE: Start Warfarin on the same day as heparin/enoxaparinn (use caution in renal impairment). Bridge Warfarin with heparin/enoxaparin for a minimum of 7 days or until the INR is within therapeutic range for at least 2 consecutive days Chronic AF and valve replacements: Start Warfarin alone (may overlap with prophylactic heparin) Post operative patients: Restart with their normal pre-operative maintenance dose DO NOT RELOAD Assess each patient for risk factors (see step 3) for increased sensitivity to Warfarin, therefore increased bleeding: If no risk factors exist, start at 5mg daily, monitor INR daily and adjust dose using nomogram over. If risk factors exist consider a smaller loading dose (2-4mg) and seek advice if necessary igh loading doses, such as 10mg, should not be used due to an increase in the risk of bleeding. Remember you cannot hurry Warfarin!

7 5.. GP REFERRAL FFORM FROM WDHB Figure 2: Sample WDHB Referral Form

8 6.. WDHB DIISCHARG GE PROCESS HOSPIITAL RMO/REGIIST TRAR TO GP The patient notes should include: The patient is on Warfarin Condition for which prescribed Target INR range Planned duration of treatment Brand and strength of Warfarin given Last three Warfarin doses Last three INR recordings Date of next INR test due Education Status The referring doctor MUST ensure the GP has been contacted before 4pm (1600hrs). All GPs and/or practice nurses must be contacted by phone and the information faxed. After 4 pm (1600hrs) on a Friday, WAM will be notified and will care for the patient until the next working day. It will be the responsibility of the WAM staff to notify the GP using the same process as WDHB discharge process. Discharge from Emergency Department (ED) When a patient has been diagnosed with a deep vein thrombosis and has been given their first dose of anticoagulation therapy, Clexane and Warfarin in ED, they will be discharged with EITHER a prescription for Clexane and Warfarin OR sufficient ampoules and tablets to last until the next working day. The patient will be advised to have follow up care with their GP the following day (or at WAM weekend days or public holidays). Clexane requires a Special Authority Number and this means that the prescription can only be collected from the hospital pharmacy. Clexane administration should be continued until the INR level is within therapeutic range. Anticoagulation education will not be and/or practice nurse. Discharge from Wanganui Hospital wards commenced by the ED staff but will be commenced with their GP A patient will be discharged back to their GP once their condition is stable and there are three INR recordings. Education on anticoagulation therapy will be commenced while they are in hospital by the hospital pharmacist and/or the registered nurse. The required documentation as outlined on page 8 will be faxed to the general practices whether from ED or the ward.

9 7.. DIISCHARGE PROCESS WDHB DIISCHARGE FLOWCHART Figure 3: WDHB Discharge Flowchart

10 8.. TRANSFER R OF CARE TO PRIIMARY SERVIICES High Risks Poor communication on discharge Tablet strengths may be inappropriate for maintenance therapy Other medications may interact with Warfarin, e.g. antibiotics Poor education on discharge or lack of understanding by patient To ensure these high risks are minimised, an education package has been developed and implemented in secondary service. The plan includes: Discussion on background of Warfarin Importance of Warfarin in child bearing females How and when to take Warfarin Potential adverse events and actions to take Interactions with other medications including non prescribed, herbal and Maori Rongoa (Maori medicine) Visiting the dentist Diet and exercise Sport activity awareness Follow up care with GP NOT laboratory services when discharged. A Warfarin flip chart is available for discussing with patients. clinicians and pharmacists to use an education tool when An education checklist must be completed prior to discharge. A copy will be given to the patient to take to their GP visit

11 9.. WARFARIIN COUNSELLIING CHECK LIIS IST (Doctors continue to the final page, Step 12) Date: / /. Pre-education checklist (for use by pharmacist or person undertaking patient education) Family member(s) or caregivers required Patient/caregiver speaks English Other language spoken Patient good cognition Warfarin Handbook given Y/N Y/N Y/N Y/N Patient has access to telephone Patient has transport to lab Patient has a regular GP First time Warfarin patient Family/support person educated Y/N Y/N Y/N Y/N Y/N Post-education checklist for educator (Please tick relevant boxes below) 1. Background on Warfarin: [ ] Generic vs brand name Warfarin [ ] Purpose of Warfarin for this patient (AF, coronary occlusion, DVT, PE) [ ] Anticipated length of treatment [ ] Mechanism of action [ ] Monitoring of Warfarin therapy explained (monitoring of blood and INR explained) 2. Female of childbearing age? Yes [ ] No [ ] [ ] Importance of avoiding pregnancy whilst on Warfarin 3. How to take Warfarin: [ ] When to take Warfarin (6pm recommended) [ ] Strategies discussed with patient on how to remember Warfarin dose (e.g. calendar or red anticoagulation book) [ ] What to do in the event of missed doses 4. Potential adverse events and action to take: [ ] Abnormal bleeding (e.g. Nose bleeds, gum bleeds, blood in urine or stool, black tarry stools or excessive bruising) [ ] Haemorrhage (e.g. severe stomach pain and SOB, headache or other pain, unexplained swelling) [ ] Other rare reactions (e.g. Skin rash, purple toes syndrome (onset 3-10 weeks)) 5. Influence of other medications (including non-prescription and herbal): [ ] Over the counter medications affecting clotting (e.g. NSAIDs, Aspirin) and herbal preparations [ ] Medicines for pain (Paracetamol preferred) [ ] Starting/stopping/increasing/decreasing doses of prescription medications

12 WARFARIIN COUNSELLIING CHECK LIIST ((ccontti inued)) 6. Visiting the dentist/doctor/pharmacy: [ ] Inform the dentist about Warfarin prior to any appointments [ ] Inform all doctors and pharmacistss you visit about Warfarin 7. Influence of diet and alcohol: [ ] Eat a balanced diet including some green leafy vegetables. Avoid foods that are high in fat. Major diet changes can affect INR levels. [ ] Alcohol (1-2 drinks per day unlikely to affect Warfarin) 8. Other issues: [ ] Avoid contact with sports or activities where there is a high risk of injury [ ] Always keep a sufficient supply of Warfarin on hand, especially when travelling abroad [ ] Keep out of reach of children 9. Advice for patient immediately post discharge: [ ] Dose of Warfarin the patient should take at the evening of discharge [ ] Ensure patient is told to contact GP to obtain Warfarin guidance and not the laboratory [ ] Patient needs to ring early morning to book an appointment with GP or WAM the following day 10. Notes and issues requiring attention prior to the patient s discharge: EDUCATION GIVEN BY: Pharmacist/Nurse (Please print): Signature:

13 10.. WDHB POST EDUCATIION EVALUATIION POST EDUCATION PATIENT LEARNING EVALUATION FORM person undertaking the patient education) Date: / / (for use by the pharmacist or Immediately after education, please ask the patient the following questions: What is the name of your medicine? What does Warfarin do? Why do you need to take Warfarin? For how long will you need to take your Warfarin? What dose of Warfarin are you on now? (if known) What steps will you take to find out how much Warfarin you need to take? What is the ideal range of your blood test results? When should you take your Warfarin? What side effects do you need to watch out for? What will you do if you have these side effects? What can happen if you take fewer tablets than you were told? What can happen if you take more tablets than you were told? What must you do before buying any over the counter medication or herbal medication from the pharmacy? What must you do before goingg to the dentist or having any medical treatment or surgery? What are the important issues to remember regarding Warfarin and food? What are the important issues alcohol? How much Warfarin should you take on the evening after discharge? When should you contact your Warfarin dose? to remember regarding Warfarin and GP or go to WAM to organise your next

14 11.. RECOMMENDEDD IINR TESTIING FREQUENCY FOR LOW DOSE IINTIITIIATIION Low Dose Protocol: Suitable for outpatients Safe Achieves therapeutic anticoagulant within 3-4 weeks Reduces the risk of over-coagulations For patients initiated with low-dose protocol (Warfarin initial dose 2 3 mg daily): Initially: When INR <4: Weekly When INR >4: Every 2-3 days until stable for two consecutive tests Then: fortnightly until stable for 2-3 consecutive tests Maintenance: Most patients can be extended to 4-6 weekly testing however a minority may require more frequent testing INR RANGE AND TREATMENT Ideal INR Range Indication (condition) Please tick Proposed duration of Warfarin therapy 2-3 [ ] Atrial fibrillation [ ] Cardioversion [ ] Mural Thrombus [ ] DVT [ ] PE [ ] Tissue valves Usually indefinite Short term pre/post Variable 3-6 months 6-12 months 6 weeks [ ] Mechanical Heart valve Indefinite 3-4 [ ] Mechanical Heart valves implanted pre 1990 [ ] Recurrent DVT while on Warfarin Indefinite Indefinite Other Please specify INR, indication, duration below

15 12.. PATIIENT DOSIING GUIIDELIINES NB : GPS CAN CONSULT WITH THE MEDICAL PHYSICIAN OR ED MEDICAL STAFF IF UNSURE OF TREATMENT AT ANY STAGE. A low dose protocol for Warfarin initiation (Janes, 2004) Day 1 Day 2-7 Day 8 Day 15 INR Obtain Baseline INR < > 3.0 Most patients will have received stable doses on day 8 and others will only need minor dose adjustments. Warfarin Daily Dose Notes 3 mg 3 mg 6 mg * * follow blue guide for 2nd week 5 mg 4 mg 3 mg 2.5 mg 2 mg Omit 1-2 days, reduce to 1 mg Stop Warfarin. Check causes, high INR protocol and need for Warfarin. Repeat INR in 3-5 days. Restart at 1 mg if indicated. When INR is stable extend dosing interval and transfer to maintenance guide. Day 15 < > Guide for patients on 6 mg on days 8 to 14 8 mg Check high INR protocol. Check doses taken. Omit 3 days and check INR 6 mg 5 mg 4 mg reduce dose by 1-2 mg Unusual, check adherence, medication etc. Increase to 10 mg Consider omitting 1-2 days Omit 2 days, check doses taken

16 PATIIENT T DOSIING GUIIDELIINES ((ccontti inued)) Guideline for Over Anticoagulation Clinical INR 5-8 without bleeding NR > 8 with minor bleeding High INR and major bleeding Guideline Stop Warfarin Test INR daily until stable Restart in reduced dose when INR < 5 Give vitamin K mg oral/sc, if INR there is high risk of serious bleeding 1. Stop Warfarin 2. Consider admission if clinically appropriate 3. Test INR daily until stable 4. Restart in reduced dose when INR < 5 5. Give Vitamin K 1-2 mg oral/sc 1. Stop Warfarin 2. Give Vitamin K 10 mg sc 3. Admit stat fails to fall, or if The guide is only valid if the patient has taken seven days of Warfarin before the day 8 INR. If doses have been omitted or the INR is performed early the dose may be seriously overestimated. Due to the high number of biological and other variables inherent in Warfarin therapy its use should be augmented by sound clinical judgement.

17 13.. BEST PRACTIICE TOOL ((BPAC)) TOOLL IIN MEDTECH WARFARIIN MONIITORIING COMPONENTS OF BPAC TOOL 1. Accessing Best Practice and INR Tool 2. Warfarin Initiation Protocol 3. Warfarin Safety Questions 4. Warfarin Dose Monitoring 5. Suggested Dosing and Review 6. Progress INR Graph It is important to note that you will be unable to use the BPAC INR tool until you have six INR results; however you will be able to access the Warfarin Initiation Protocol guidelines. 1. ACCESSING BEST PRACTICE AND INR TOOL To access Best Practice INR tool in MedTech, either: Select the Best Practice icon or Module Advanced Forms New Form Best Practice or Shift F3 (Opens New Form) Best Practice To access INR monitoring for the initiation stage in Best Practice: Log in to Best Practice (if you are unable to login, please contact either your Practice Manager/Administrator or contact Robyn Finucane Ph ) Select INR Monitoring Select the second INR Monitoring pop up DIAGRAM 4

18 14.. WARFARIIN IINTIITIIATIION PROTOCOL 2. WARFARIN INITIATION PROTOCOL Once the INR monitoring page opens, prompt boxes will appear if there are not six INR results in the patient inbox that can populate the results into the BPAC tool. Select OK until the page is clear of prompt boxes. If you have six INR results that aren t in the Patient Inbox, these can manually be added into the BPAC tool. PROMPT 1 PROMPT 2 PROMPT 3 To access the initiation protocol: Select Resources then select Warfarin initiation protocol ( as outlined in red below). This process opens the BPAC: Guide for using INR to manage Warfarin (see Page 13). THIS PROCESS OPENS THE BPAC: GUIDE FOR USING INR TO MANAGE WARFARIN (SEE PAGE 13).

19 15.. USIING THE BPAC TOOL ONCE SIIX IINR LEVELS ARE RECORDED 3. WARFARIN SAFETY QUESTIONS Please tick these boxes if appropriate 4. WARFARIN DOSE MONITORING When the diagnosis is entered the duration of the treatment is calculated giving the INR target range for that condition. The result will be extracted from the Patient Management System (PMS) or you can enter the INR result. The recommended dose and the date for the next recommended review will show immediately. If you wish to manually enter an INR result enter in the Override column.

20 16.. SUGGESTED DOSIING AND REVIIEW The patient dose calendar can be printed for your patient and saved to your outbox DOSING CALENDAR

21 17.. PROGRESS IINR GRAPH 5. PROGRESS INR GRAPH Tracks INR results over time compared to therapeutic range. Only INR results extracted from the PMS will be graphed. 6. EXAMPLE OF INR LAB RESULT GRAPH:

22 18. LABORATORY MANAGEMENT RETURN TO LABORATORY FOR MANAGEMENT CARE Once a patient has had three INR levels within the range of 2-3 and their condition is stable, the patient can be referred back to the laboratory for continuation of their Warfarin management. The laboratory service requires a referral letter to be completed (Medtech Outbox - Code WARF) and either faxed to the Laboratory or given with a laboratory request form to the patient. NOTE: This laboratory form has a one year expiry date and the patient will be referred back to the GP in twelve months for review and a new laboratory form completed. Sample Laboratory Form

23 19.. SAMPLE REFERRAL LETTER 08 Sep 2011 Medlab Wanganui Phone: [06] Wanganui Hospital Fax: [06] Heads Road Wanganui Re: Mr Accorp Test 25 Nomansland Wanganui NHI: ACC1939 DOB: 30 Oct 1964 Phone: Mobile: Consultant: Dr Joe Bloggs Has the patient consented to referral YES [ ] No [ ] Date therapy commenced: Date(s): Dose(s): INR(s): Duration of therapy: Reason for therapy: Date of last review: Other medications: Date(s): Dose(s): INR(s): Date(s): Dose(s): INR(s): Please Note: 1. The patient is referred for control of anti-coagulation therapy only 2. At the end of the period identified above, the GP initiating the Warfarin therapy must review the patient. No further advice will be given until a new referral form is completed. 3. The referring GP must deal with any clinical issues. Please do not ask laboratory staff to deal with clinical issues. CLINICAL RESPONSIBILITY REMAINS WITH THE REFERRING GP AT ALL TIMES

24 20.. REFERENCES Wanganui District Health Board Warfarin Pathway Best Practice programme via MedTech 32 and BPAC website: Counties Manukau District Health Board website: RESOURCES Warfarin DVD Starting on Warfarin Can order 5 at a time free of charge Warfarin patient handout Starting on Warfarin Can order 30 at a time free of charge Your anticoagulation treatment red booklet for management of INR results Can order as many as you want up to 50 free of charge Phone: GlaxoSmithKline Best Practice

25 22.. SUGGESTIIONS Please use this page to add your comments and suggestions to improve this manual.