Request for information under the Freedom of Information Act

Transcription

1 Request for information under the Freedom of Information Act Thank you for your dated 6 July 2017 requesting information regarding patients diagnosed with atrial fibrillation. Please find detailed below your original request together with our response. Original Request: 1. Please confirm or deny whether your NHS Trust collects data on the number of patients diagnosed with atrial fibrillation who are treated with warfarin by i) gender and ii) age group. a. If confirmed, please provide the number of i) male and ii) female patients b. If confirmed, please provide the number of patients aged i) below 45 years old ii) years old, iii) years old, iv) years old, v) years old and vi) 85 years old and above It may first be useful to explain that Kent Community Health NHS Foundation Trust (KCHFT) provides wide-ranging NHS care for people in the community, in a range of settings including people s own homes; nursing homes; health clinics; community hospitals; minor injury units and in mobile units. The Trust would not diagnose patients with atrial fibrillation. Such a diagnosis would be made by the Trusts running the acute hospitals. Attached as Appendix A are the contact details of the acute hospitals in Kent and Medway, should you wish to redirect your request to them. KCHFT does not collect data on the number of patients diagnosed with atrial fibrillation and treated with warfarin. 2. Please confirm or deny whether your NHS Trust collects data on the time in therapeutic range (TTR) of patients diagnosed with atrial fibrillation who are treated with warfarin. a. If confirmed, please provide details of the number of patients with a TTR (calculated over a maintenance period of at least 6 months while excluding those initiated within the last 6 weeks, as per NICE Clinical Guideline 180 (CG180)) of i) per cent, ii) per cent, iii) per cent and iv) 34.9 per cent and below. KCHFT does not collect data on the time in therapeutic range of patients diagnosed with atrial fibrillation and treated with warfarin. 3. Please confirm or deny whether your NHS Trust collects data on the International Normalised Ratio (INR) values of patients diagnosed with atrial fibrillation who are treated with warfarin. a. If confirmed, please provide details of number of patients within the past six months recorded with i) two INR values higher than five, ii) one INR value higher than eight, or iii) two INR values less than 1.5. KCHFT does not collect data on the International Normalised Ratio (INR) values of patients diagnosed with atrial fibrillation and treated with warfarin. Chairman David Griffiths Chief Executive Paul Bentley Trust HQ The Oast, Unit D, Hermitage Court, Hermitage Lane, Barming, Nr Maidstone, Kent ME16 9NT Rating: GOOD

2 4. Please confirm or deny whether your NHS Trust collects data on the frequency of blood tests for purposes of INR readings of patients diagnosed with atrial fibrillation. a. If confirmed, please provide details of the average interval between blood tests for INR readings. KCHFT does not collect data on the frequency of blood tests for purposes of INR readings of patients diagnosed with atrial fibrillation. 5. Please confirm or deny whether your NHS Trust collects data on the number of patients diagnosed with atrial fibrillation who are treated with warfarin and self-monitoring or self-managing their anticoagulation therapy. a. If confirmed, please provide the number of patients diagnosed with atrial fibrillation who are treated with warfarin who are i) selfmonitoring and receiving dosing instructions from a healthcare professional; and ii) self-managing their anticoagulation. KCHFT does not collect data on the number of patients diagnosed with atrial fibrillation and treated with warfarin who are self-monitoring or self-managing their anticoagulation therapy. 6. Please confirm or deny whether your NHS Trust has conducted a root cause analysis of adverse events related to anticoagulation treatment in atrial fibrillation patients. a. If confirmed, please provide details of any root cause analysis of adverse events related to anticoagulation treatment in atrial fibrillation patients in the last 12 months. The Trust has not conducted a root cause analysis of adverse events related to anticoagulation treatment in atrial fibrillation patients in the last 12 months. 7. Please confirm or deny whether your NHS Trust has written clinical protocols in place for reassessing patients diagnosed with atrial fibrillation who have poor warfarin anticoagulation control (as defined by NICE CG180) to determine why their TTR/INR are unstable. a. If confirmed, please provide evidence of the protocol(s) The Trust has a clinical protocol for the atrial fibrillation/flutter service, which is attached as Appendix B. In particular sections 4.3, 5.0, 8.0, 9.0, and appendices 6, 7, 8, 9, 10, 11, 12 refer to NICE CG180. The Trust also has a policy for anticoagulation therapy, which is attached as Appendix C. 8. Please confirm or deny whether your NHS Trust has information, education and support tools available for patients diagnosed with atrial fibrillation to help them understand their treatment options and support adherence. a. If confirmed, please provide evidence of the information, education and support tools that you use. Management of warfarin dosing is usually undertaken in primary care. Some GP surgeries have an in-house anticoagulation service with their practice nurses. Some community pharmacies run anticoagulation services. Page 2 of 4

3 The Trust s atrial fibrillation/flutter service would be involved in managing patients symptoms and heart rate control. Staff will check patients level of control on warfarin and make recommendations to the GP depending on their findings. It is important to say that all community services will come into contact with patients in atrial fibrillation and therefore taking warfarin. Many housebound patients under the community nursing teams will have blood tests conducted by the nurses, but the community nurses will not be involved in adjusting doses. Information and support tools the Trust uses are: Page 3 of 4

4 Appendix A - Kent and Medway Acute Trusts Freedom of Information (FOI) contact details Dartford and Gravesham NHS Trust FOI Act Lead, 4th Floor, Information Dept, Dartford & Gravesham NHS Trust, Darent Valley Hospital, Darenth Wood Road, Dartford, Kent, DA2 8DA. Online form: East Kent Hospitals University NHS Foundation Trust FOI Administration Office Trust Offices Kent and Canterbury Hospital Canterbury Kent, CT1 3NG Online form: Maidstone and Tunbridge Wells NHS Trust Freedom of Information Officer, Trust Headquarters, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone, Kent, ME16 9QQ mtw-tr.foiadmin@nhs.net Medway NHS Foundation Trust Information Governance Team Medway NHS Foundation Trust Medway Maritime Hospital Windmill Road Gillingham Kent, ME7 5NY medwayft.foi@nhs.net Page 4 of 4

5 7402 Appendix B CLINICAL PROTOCOL FOR THE ATRIAL FIBRILLATION/FLUTTER SERVICE Document Reference No. AF001 Status Approved Version Number 2.1 Replacing/Superseded policy or documents Clinical Protocol For The Atrial Fibrillation/Flutter Service Number of Pages 47 Target audience/applicable to Cardiac Nurse Specialists Author Consultant Nurse for Older People Acknowledgements Health Care Assistant, Medicines Management Team Contact Point for Queries Consultant Nurse for Older People Date Ratified April 2015 Date of Implementation/distribution November 2016 Circulation Cardiac Nurses, Heads of Service, Lead nurses, Intranet Review date April 2018 Copyright

6 7402 Appendix B Atrial fibrillation/flutter clinical protocol SCOPE AND PURPOSE OF POLICY The arrhythmia service uses the National Institute for Health and Clinical Excellence (NICE) Clinical Guidance 180 Atrial fibrillation: the management of atrial fibrillation (2014) as the foundation for care of patients with atrial fibrillation. The Primary Care Atrial Fibrillation Pathway from the South East Coast Strategic Clinical Network will be followed (appendix 1). The arrhythmia service supports the process of better identification and management of atrial fibrillation/flutter in the community. Working with GPs to identify patients with irregular pulses, confirm or exclude atrial fibrillation, refer if necessary, make decisions on the need for anticoagulation, educate patients and work with them to decide on the management of their arrhythmia. Only nurses deemed competent in the management of arrhythmia may implement the aspects of management discussed within this document. The competencies associated with the care of patients with arrhythmia are included in the appendices. This document sets out the best practice expectations of Kent Community Health NHS Foundation Trust for identifying and managing atrial fibrillation/flutter in accordance with the agreed pathway of care. This CP does NOT cover acutely unwell patients. Risks addressed This policy is to ensure a thorough and safe assessment and management or referral of people with atrial fibrillation/ flutter who are managed within KCHT services. Governance Arrangements Directorate or Function Governance Group responsible for developing document Circulation group Authorised/Ratified by Governance or Function Group Authorised/Ratified On 30/04/15 Review Date Review criteria Adult Clinical Directorate Intranet, Policy Distribution Adult Directorate Governance Group 3 years from ratification This document will be reviewed prior to review date if a legislative change or other event dictates. Version 2.1 Page 2 of 47 November 2016

7 7402 Appendix B Atrial fibrillation/flutter clinical protocol Key References Department of Health (2014) National Institute for Health and Clinical Excellence [CG180] Atrial Fibrillation: The management of atrial fibrillation. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)(2010) Guidelines for the management of atrial fibrillation. European Heart Journal (2010) 31, doi: /eurheartj/ehq278 Department of Health (2009) Reference guide to consent for examination or treatment, second edition Department of Health (2014) NICE guidelines [CG138] Patient experience in adult NHS services: improving the experience of care for people using adult NHS services Department of Health (2012) NICE guidelines [CG144] Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing Related Policies/Procedures Title Reference Non-Medical Prescribing Policy MM011 v2 March 2013 Consent to examination and treatment policy CQS001 v Management of diagnostic testing and screening procedure CQ007 v1 March 2013 Policy for Anticoagulation Therapy MM012 v3.8 December 2013 Quality Standard Privacy Dignity and Respect CQS015 April 2012 Document Tracking Sheet Version Status Date Issued to/approved by 2 draft 02/04/15 Medicines Management Governance Group Comments/Summary of Changes Minor changes to wording. 2.1 draft 30/04/15 Helen Hatter Competencies reviewed 2.1 draft 30/04/15 Adult Quality Meeting Summary of Changes a. new section added to ensure compliance with equality and diversity requirements; b. sections 1-9 updated in line with Department of Health (2014) National Institute for Health and Clinical Excellence [CG180] Atrial Fibrillation: The management of atrial fibrillation. c.competency statement for novel anticoagulation therapy added. Version 2.1 Page 3 of 47 November 2016

8 7402 Appendix B Atrial fibrillation/flutter clinical protocol CONTENTS SCOPE AND PURPOSE OF POLICY INTRODUCTION 5 EQUALITY ANALYSIS ROLES AND RESPONSIBILITIES CRITERIA FOR REFERRAL TO ARRHYTHMIA SERVICE DIAGNOSIS AND ASSESSMENT PERSONALISED PACKAGE OF CARE AND EDUCATION REFERRAL FOR SPECIALISED MANAGEMENT ASSESSMENT OF STROKE AND BLEEDING RISKS INTERVENTIONS TO PREVENT STROKE RATE AND RHYTHM CONTROL TRAINING AND AWARENESS MONITORING COMPLIANCE AND EFFECTIVENESS OF THIS POLICY REFERENCES 11 PAGE GLOSSARY AND ABBREVIATIONS 11 Appendix 1 Primary Care Atrial Fibrillation Pathway 12 Appendix 2 Algorithm to Show Patient Pathway within Arrhythmia Nursing Service 13 Appendix 3 Anticoagulation Assessment for Atrial Fibrillation 14 Appendix 4 EHRA Score of Atrial Fibrillation Related Symptoms 15 Appendix 5 Atrial Fibrillation Oral Anticoagulation Card for non-vitamin-k anticoagulants 15 Appendix 6 Competence Statement for developing a management plan for a patient with Atrial Fibrillation/ Flutter Appendix 7 Competence Statement for implementing a management plan for AF/ Flutter 21 Appendix 8 Appendix 9 Competence Statement for introducing and titrating Beta blockers in Atrial Fibrillation/Flutter Competence Statement for introducing and titrating calcium channel blockers in Atrial Fibrillation/Flutter Appendix 10 Competence Statement for Introducing and Titrating Digoxin in Atrial Fibrillation/Flutter Appendix 11 Competence Statement for Assessment for Anticoagulation Therapy with Vitamin K Antagonist in Patients with Atrial Fibrillation /Flutter Appendix 12 Competence Statement for Assessment for Anticoagulation Therapy with Vitamin K Antagonist in Patients with Atrial Fibrillation /Flutter Appendix 13 Competence Statement for interpretation of an ECG Version 2.1 Page 4 of 47 November 2016

9 7402 Appendix B Atrial fibrillation/flutter clinical protocol 1.0 INTRODUCTION 1.1 Atrial fibrillation is the most common sustained cardiac arrhythmia, and estimates suggest its prevalence is increasing. If left untreated atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and the prevalence increases with age. The aim of treatment is to prevent complications, particularly stroke, and alleviate symptoms. Drug treatments include anticoagulants to reduce the risk of stroke and anti arrhythmics to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. 1.2 Equality, Diversity and Inclusion All patients, carers and staff should be given full assistance to ensure understanding. This assistance will take many forms and media is committed to ensuring that patients whose first language is not English receive the information they need and are able to communicate appropriately with healthcare staff. It is not appropriate to use children under the age of 16 to interpret for family members who do not speak English. There is an interpreter service available and staff should be aware of how to access this service The privacy and dignity rights of patients must be observed whilst enforcing any care standards e.g. providing same sex carers for those who request it in line with the Quality Standard for Privacy, Dignity and Respect is committed to ensuring that information is provided in accessible formats and communication support is met for people with a disability, impairment or sensory loss. The Accessible Information Standard (AIS) is a legal requirement of the Equality Act which applies to all organisations included within the Health and Social Care Act. Guidance on professional support services for the Trust is available in the Accessible Information Policy Staff must be aware of personal responsibilities under Equality legislation, given that there is a corporate and individual responsibility to comply with Equality legislation. This also applies to contractors when engaged by the Trust, for NHS business. 1.3 Equality Analysis is committed to promoting and championing a culture of diversity, fairness and equality for all our staff, patients, service users and their families, as well as members of the public Understanding of how policy decisions, behaviour and services can impact on people with protected characteristics under the Equality Act 2010 is key to Version 2.1 Page 5 of 47 November 2016

10 7402 Appendix B Atrial fibrillation/flutter clinical protocol ensuring quality and productive environments for patient care and also our workforce Protected Characteristics under the Equality Act 2010 are: Race Disability Sex Religion or belief Sexual orientation (being lesbian, gay or bisexual) Age Gender Re-assignment Pregnancy and maternity Marriage and civil partnership To ensure full involvement and understanding of the patient and their family in the options and decision making process about their care and treatment, all forms of communication (e.g. sign language, visual aids, interpreting and translation, or other means) should be considered and made available if required The privacy and dignity (human rights) of patients must be considered alongside any care standards, in recognition of the fundamental link between good health care and equality It is also important for the Trust to look to the future and ensure that it remains equitable to all, by considering elements that may be outside current legislation, such as financial deprivation, educational discrimination, class exclusion and many other elements The Equality Analysis for this policy is located on the public website: ROLES AND RESPONSIBILITIES 2.1 The heart failure and arrhythmia best practice group This group is held monthly and all heart failure and arrhythmia nurses working for KCHFT are invited. It is a forum to discuss evidence and critically evaluate case studies. This group decides how best practice can be implemented within the organisation. They will also decide on relevant audits that need to take place and update the competencies as necessary. 2.2 Heads of Service / Managers Are responsible for ensuring their staff are aware of the contents of this policy and have access to training to specialist advice through multidisciplinary meetings with Cardiologists and GPs with a Special Interest in Cardiology. Heads of service are responsible for ensuring staff have access to clinical supervision. 2.3 Specialist Role Staff delivering the arrhythmia service are responsible for working within their own clinical competence and evidencing this competence through meeting the AF competencies. The staff are also responsible for seeking appropriate education opportunities and keeping up- Version 2.1 Page 6 of 47 November 2016

11 7402 Appendix B Atrial fibrillation/flutter clinical protocol to-date with relevant guidance, policies and evidence. Staff must ensure that they attend clinical supervision at least 4 times a year. The staff delivering the arrhythmia service are an expert resource within KCHFT for other staff. They will provide relevant training as appropriate. 3.0 CRITERIA FOR REFERRAL TO ARRHYTHMIA SERVICE 3. 1 Inclusion Criteria a. Newly diagnosed atrial fibrillation or flutter; b. Strong clinical suspicion of AF i.e. irregular pulse; c. Documented evidence of AF; d. Patients identified via GP register searches or opportunistic screening; e. Recurrence of symptoms despite medical therapy 3.2 Exclusion criteria a. Patients who are haemodynamically compromised and acutely unwell or have had associated syncopal episodes should be referred directly to Accident and Emergency. b. Recent cardiac surgery (within 6 weeks) will be referred directly to Cardiologist; c. People with congenital heart disease which precipitates their AF. d. Pregnant women and children under the age 18 years. See Appendix 2: Algorithm to show patient pathway within Arrhythmia Nursing Service 4.0 DIAGNOSIS AND ASSESSMENT 4.1 Perform manual pulse palpation to assess for the presence of an irregular pulse that may indicate underlying atrial fibrillation in people presenting with any of the following: breathlessness/dyspnoea palpitations syncope/dizziness chest discomfort stroke/transient ischaemic attack. 4.2 Perform an electrocardiogram (ECG) in all people, whether symptomatic or not, in whom atrial fibrillation is suspected because an irregular pulse has been detected. 4.3 In people with suspected paroxysmal atrial fibrillation undetected by standard ECG recording it may be necessary to order: 24hour ambulatory ECG monitor in those with suspected asymptomatic episodes or symptomatic episodes less than 24 hours apart An event recorder ECG in those with symptomatic episodes more than 24 hours apart. Transthoracic echocardiography (TTE) may need to be ordered for people with atrial fibrillation for whom a baseline echocardiogram is important for long-term management or where there is a strong suspicion of underlying structural or functional heart disease (see NICE CG 180). Version 2.1 Page 7 of 47 November 2016

12 7402 Appendix B Atrial fibrillation/flutter clinical protocol 5.0 PERSONALISED PACKAGE OF CARE AND EDUCATION People with atrial fibrillation should be offered a personalised package of care. Ensure that the package of care is documented and delivered, and that it covers: Holistic assessment Stroke awareness and measures to prevent stroke Rate control Assessment of symptoms for rhythm control (see appendix 4) Who to contact for advice if needed Psychological support if needed Up-to-date and comprehensive education and information on: Cause, effects and possible complications of atrial fibrillation Management of rate and rhythm control Anticoagulation: practical advice on anticoagulation including risks and benefits in line with recommendation 'Venous thromboembolic diseases' (NICE clinical guideline 144 & 180) Support networks (for example, cardiovascular charities). 6.0 REFERRAL FOR SPECIALISED MANAGEMENT Refer people promptly at any stage if treatment fails to control the symptoms of atrial fibrillation and more specialised management is needed. 7.0 ASSESSMENT OF STROKE AND BLEEDING RISKS 7.1 Stroke risk Use the CHA2DS2-VASc stroke risk score (appendix 3) to assess stroke risk in people with any of the following: symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation atrial flutter a continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm 7.2 Bleeding risk Use the HAS-BLED score (Appendix 3) to assess the risk of bleeding in people who are starting or have started anticoagulation. Offer modification and monitoring of the following risk factors: uncontrolled hypertension poor control of international normalised ratio (INR) ('labile INRs') concurrent medication, for example concomitant use of aspirin or a non-steroidal anti- inflammatory drug (NSAID) harmful alcohol consumption Version 2.1 Page 8 of 47 November 2016

13 7402 Appendix B Atrial fibrillation/flutter clinical protocol 7.3 When discussing the benefits and risks of anticoagulation, explain to the person that: for most people the benefit of anticoagulation outweighs the bleeding risk for people with an increased risk of bleeding the benefit of anticoagulation may not always outweigh the bleeding risk, and careful monitoring of bleeding risk is important. Do not withhold anticoagulation solely because the person is at risk of having a fall. 8.0 INTERVENTIONS TO PREVENT STROKE Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist (See NICE CG 180 for further details. 8.1 Do not offer stroke prevention therapy to people aged less than 65 years with atrial Fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA2DS2-VASc score of 0 for men or 1 for women). 8.2 Antiplatelets Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation. 9.0 RATE AND RHYTHM CONTROL When to offer rate or rhythm control Offer rate control as the first-line strategy to people with atrial fibrillation, except in people: whose atrial fibrillation has a reversible cause who have heart failure thought to be primarily caused by atrial fibrillation with newonset atrial fibrillation with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm for whom a rhythm control strategy would be more suitable based on clinical judgement Advice in line with recommendation 'management of atrial fibrillation' (NICE clinical guideline 180) 10.0 TRAINING AND AWARENESS 10.1 Any Health professional wishing to implement these guidelines will need to demonstrate the necessary competencies detailed in the relevant competency statements (appendices 6-13) 10.2 The NMC Code places specific responsibilities on Registered Nurses, including: being personally accountable for actions and omissions in practice and able to justify decisions; always act lawfully whether those laws relate to your professional practice or personal life; recognising and working within the limits of their own competence; undertaking appropriate learning and practice activities that maintain and develop their competence and performance. (NMC 2015); ensure policy and associated policies are followed and that information is disseminated to relevant parties Version 2.1 Page 9 of 47 November 2016

14 7402 Appendix B Atrial fibrillation/flutter clinical protocol 10.3 Competency will be achieved through a range of methods being: learning from competent colleagues; attendance at approved training courses; on-the-job learning, workbook learning; feedback process; observation and critical analysis of everyday practice; observed structured clinical examination (OSCE); reflective diaries with self-assessment of competence Training sessions and workshops will assist in the acquisition of knowledge and demonstration of understanding. The assessment of clinical competency will support robust assessment through consideration of underpinning knowledge, policies, procedures and actions with overall competence being recorded MONITORING COMPLIANCE AND EFFECTIVENESS OF THIS POLICY The impact of the nurse led AF clinic will be monitored by auditing: number of patients referred to the service; total number of patients seen; number of males and females; age; number of patients presenting with persistent, paroxysmal, permanent or lone AF/flutter; number of patients referred for anticoagulation, 24hr monitors, ECHO and D/C cardioversion; medication changes for heart rate control and thromboprophylaxis; Atrial fibrillation/flutter clinical protocol adverse incidents/complaints; patient satisfaction survey; Auditing of this service is the responsibility of the service managers. The arrhythmia nurses will complete documentation in line with the organisations policies. The audit data will be collected through the database. What will be monitored? No of GP practices visited GP practices declined service How will it be monitored? Data collected on a quarterly basis Who will monitor? Arrhythmia nurses, Line manager Frequency 6 monthly No of AF registers reviewed Face to face reviews Number put on warfarin Number put on Novel oral anticoagulation therapy No. who declined anticoagulation Competency and training of staff Competency and training of staff Peer review and self-declaration of competencies Annually Version 2.1 Page 10 of 47 November 2016

15 7402 Appendix B Atrial fibrillation/flutter clinical protocol 12.0 GLOSSARY AND ABBREVIATIONS Abbreviation AF D/C ECHO KCHFT EHRA Meaning Atrial Fibrillation Direct current Echocardiogram European Heart Research Authority References European Society of Cardiology (ESC)(2010). Guidelines for the Management of Atrial Fibrillation Guidelines/GuidelinesDocuments/guidelines-afib-FT.pdf 24/5/11 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Heidbuchel H., Verhamme P., Alings M., AntzM., Hacke V., Oldgren J., Sinnaeve P., CammP. & Kirchhof P. (2013) EHRA Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. doi: /eurheartj/eht134 Nursing and Midwifery Council (2015) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC: London. Version 2.1 Page 11 of 47 November 2016

16 7402 Appendix B Appendix 1: Primary Care Atrial Fibrillation Pathway

17 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 2: Algorithm to Show Patient Pathway within Arrhythmia Nursing Service Patient with AF Normally treated by GP Normally referred to Cons Cardiologist Refer to Arrhythmia Nurse for Assessment Simultaneous referral to Arrhythmia nurse Assessment by ANS If appropriate will organise 24hr tape/echo Assess risk of stroke (using CHA2DS2- VASc2 score) Education & advice about AF Assess suitability for Rate/Rhythm control Assessment by ANS If appropriate will organise 24hr tape/echo Assess risk of stroke (using CHA2DS2VASc2 score) Education & advice about AF Rate Control Rhythm control Refer back to GP with recommendation regarding rate control: B-Blocker or Calcium Channel Blocker Anticoagulation therapy: Vitamin K antagonist or NOAC Follow up patient if require drug titration for rate control. Otherwise discharge to GP care. Refer to Cons Cardiologist Patients can be rereferred into service if condition changes or medications need reviewing Patients seen in clinic by Cardiologist & treatment plan formulated Referred to ANS for follow up & drug titration or discharge to GP V2.1 Page 13 of 47 March 2015

18 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 3: Anticoagulation Assessment for Atrial Fibrillation Thrombo-embolic risk for AF patients CHA2DS2VASc Assessment Clinical Indicator Score Relevant Score C Congestive Heart Failure or LVF ejection fraction 40% 1 H Hypertension 1 A Age 75yrs 2 D Diabetic 1 S Previous Stroke/TIA 2 V Vascular Disease 1 A Age 65 yrs 74 yrs 1 Sc Female 1 Total Interpretation of CHA2DS2VASc assessment: Total Risk of Antithrombotic therapy Indicated Score Stroke 0 Low *Do not offer antiplatelet solely for stroke prevention to people with atrial fibrillation. (new NICE 2014) Review stroke risk when patients reach 65 years or if they develop major/clinically relevant risk factors. 1 Moderate * Consider anticoagulation for men with a score of 1, taking bleeding risk into account (new NICE 2014) 2 or above High *Offer anticoagulation taking bleeding risk into account (new NICE 2014) This may be either a Novel Oral Anticoagulant or Vitamin K antagonist.. *Do not offer stroke prevention therapy to people aged under 65 years with Atrial Fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to CHADsVASc score of 0 for men or 1 for women) (new NICE 2014) *Discuss the options for anticoagulation with the patient and base the choice on their clinical features and preferences. (new NICE 2014) Bleeding risk for AF patients and the use of oral anticoagulants. HAS-BLED score Score Relevant Score Hypertension Systolic 160 mmhg 1 Abnormal Liver/Renal Disease (please assess renal function and egfr prior to using NOACs and 2 points for both adjust dose appropriately, monitor renal function 3-6 monthly after initiation) Stroke previous history of stroke, especially deep brain stroke 1 Bleeding previous history of bleed, anaemia or predisposition to 1 bleeding. Labile INR unstable INRs, or poor time (TTR less than 65%) in therapeutic range 1 Elderly 65 years of age 1 Drugs 1 point for taking antiplatelet (Aspirin/Clopidogrel) and /or alcohol intake of more than 8 alcoholic drinks per week. 2 points for both Total Points V2.1 Page 14 of 47 March 2015

19 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Please also consider these factors when making the decision for anticoagulation Confusion/dementia Falls -do not withhold anticoagulation solely because the person is at risk of having a fall (new 2014) Non-compliance with drugs & Clinic appointments Recent trauma/surgery within 4-6 weeks Other Interacting Medicines Interpretation of the HAS-BLED score: A score of 3 or more indicates an increased 1 year bleed risk on anticoagulation which would be sufficient to justify caution or more frequent evaluation. This can lead to an increased risk of an intracranial bleed, bleeding requiring hospitalisation or a haemoglobin drop 2g/L or a bleeding episode that requires transfusion. When discussing benefits and risks of anticoagulation, explain to the patient: For most people the benefit of anticoagulation outweighs the bleeding risk. For people with an increased risk of bleeding the benefit of anticoagulation may not always outweigh the bleeding risk and careful monitoring of bleeding risk is important (new NICE 2014) Assessing anticoagulation control and Vitamin K antagonists: Calculate the person s time in therapeutic range (TTR) at each visit: Use a validated method of measurement such as the Rosendaal method for computer-assisted dosing or proportion of tests in range for manual dosing. (Not applicable to Kent Community Health NHS Foundation Trust Arrhythmia Nursing service) Exclude measurements taken during the first 6 weeks of treatment. Calculate TTR over a maintenance period of at least 6 months (new NICE 2014) Reassess anticoagulation for a person with poor anticoagulation control shown by any of the following: 2 INR values higher than 5 or 1 INR value higher than 8 within the last 6 months. 2 INR values less than 1.5 within the past 6 months TTR less than 65% (new NICE 2014) Take into consideration and if possible address the following factors that may contribute to poor anticoagulation control: Cognitive function Adherence to prescribed therapy comorbidities Interacting drug therapy Lifestyle factors including diet and alcohol consumption (new NICE 2014) If poor anticoagulation control cannot be improved, evaluate the risks and benefits of alternative strokeprevention strategies and discuss these with the patient and forward information to GP and anticoagulation clinic. (new NICE 2014) V2.1 Page 15 of 47 March 2015

20 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 4 Appendix 5 V2.1 Page 16 of 47 March 2015

21 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 6 Competence Statement for developing a management plan for a patient with Atrial Fibrillation/ Flutter Summary This statement includes taking a history, recognising signs and symptoms of atrial fibrillation/ flutter, medication, cardiology investigations and management options in line with NICE guidance to ensure that the management plan is appropriate Scope Cardiac Nurses band 7, Links This competency has been linked to NHS Knowledge and Skills Framework Core 1, HWB1, 2, 3, 4, 5, 6 and 7 National Workforce Competences CHD HK1,HCS CARD 13&14, CHDFA3,EF3, HCS31,3100,399 Knowledge and Understanding Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability Demonstrate the application of: Atrial fibrillation/ Flutter clinical protocol Clinical and Diagnostic Test Policy Consent policy Chaperoning policy NICE CG 180 (2014) European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Clinical Knowledge Broad knowledge of cardiac conditions Anatomy and physiology of cardiovascular system relating to arrhythmia Clinical signs and symptoms of arrhythmias Components required of a cardiac history Cardiovascular related clinical examination skills Systematic approach to 12 lead ECG interpretation Systematic approach to interpretation of 24 &72 hour ECG monitoring Understand the indicators for referral to GPwSPI or Cardiologist Understanding of the indications for referral for anticoagulation Knowledge of rate and rhythm controlling medication their indications, contraindications, side-effects, dose, interactions and required monitoring. Ability to recognise sequelae of uncontrolled AF Performance criteria Positively identify the patient Clinically examine the patient and record clinical signs Consider the aetiology of arrhythmia Completion of arrhythmia assessment documentation and appropriate actions. Rationale for rate or rhythm control Rationale for anticoagulation Interpersonal Skills and Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal V2.1 Page 17 of 47 March 2015

22 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Behaviour Requirement Assessment consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Knowledge can be acquired by: Completion of arrhythmia module Completion of clinical examination course Attendance at cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a Community Cardiac Nurse specialist Band 7, who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac Nurse Specialist who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self-sign off review form and undertake reassessment every 3 years by an Assessor of Practice. Process of governance approval V2.1 Page 18 of 47 March 2015

23 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft RECORD OF COMPETENCE FOR DEVELOPING A MANAGEMENT PLAN FOR A PATIENT WITH ATRIAL FIBRILLATION/ FLUTTER KSF dimension to which this Competency applies 1, HWB1, 2, 3, 4, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 19 of 47 March 2015

24 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 5, 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform DATE Signature: Job Title: I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 20 of 47 March 2015

25 7402 Appendix B Appendix 7 Competence Statement for implementing a management plan for AF/ Flutter Summary This statement includes recognising symptoms of atrial fibrillation/ flutter and responses to treatment, the competence to recognise responses that are outside of management parameters and when to refer patient for review of management plan Scope Cardiac Nurse specialist band 6 &7 Links This competency has been linked to NHS Knowledge and Skills Framework Core 1, HWB1, 2, 3, 4, 5, 6 and 7 National Workforce Competences CHD HK1,HCS CARD 13&14, CHDFA3,EF3, HCS31,3100,399 Knowledge and Understanding Performance criteria Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability Demonstrate the application of; Clinical protocol for atrial fibrillation/flutter Clinical and Diagnostic Test Policy Medicines Policy NICE CG 180 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Clinical Knowledge Broad knowledge of cardiac conditions, Anatomy and physiology of cardiovascular system relating to AF/Flutter Clinical signs and symptoms of AF/Flutter Cardiovascular related clinical examination skills Rate and rhythm controlling medication including indications, contra-indications, side-effects, dose, interactions and required monitoring. Health education required by patients with AF/Flutter Indications for cardiology investigations Recognition of sequelae of uncontrolled AF/Flutter Positively identify the patient Review and interpret existing patient information and investigations Assess current signs and symptoms, examine the patient and record clinical signs. Determine whether the patient is stable, improving or deteriorating Assess response to last intervention Deliver care according to the management plan Involve the patient in reviewing the management plan if required and report any change in condition that will require modification of the plan to the appropriate person Safely recommend or prescribe medication changes in accordance with the plan and local guidance, explaining rationale, possible side-effects and monitoring requirements. Communicate action with GP Review health education as appropriate to the patient including selfmanagement strategies and lifestyle modifications Review exercise tolerance and advise accordingly Provide appropriate written information to the patient Review co-existing conditions within the context of AF/Flutter management Document interventions clearly within patient records

26 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Interpersonal Skills and Behaviour Requirement Assessment Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education and advice in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Knowledge can be acquired by: Completion of arrhythmia module Completion of clinical examination course Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a community Cardiac Nurse specialist Band 7, who has achieved level 4 in this competency The Assessor of Practice will be Principal Nurse Cardiology or a Community Cardiac Nurse Specialist who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self-sign off review form and undertake reassessment every 2 years by an Assessor of Practice Process of governance approval V2.1 Page 22 of 47 March 2015

27 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft RECORD OF COMPETENCE FOR IMPLEMENTING A MANAGEMENT PLAN FOR AF/ FLUTTER KSF dimension to which this Competency applies 1, HWB1, 2, 3, 4, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 23 of 47 March 2015

28 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform DATE Signature: Job Title: I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 24 of 47 March 2015

29 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 8 Competence Statement for introducing and titrating Beta blockers in Atrial Fibrillation/Flutter Summary This statement includes recognising the need to introduce beta blockers, the considerations to be made prior to commencing therapy, knowledge of possible sideeffects, patient monitoring required and review of effectiveness Scope Cardiac Nurse specialist band 7 Links This competency has been linked to NHS Knowledge and Skills Framework: Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 National Workforce Competences (NWC): CHD GB2, HK1 and HL1 CM A6, A7, F3 Knowledge and Understanding Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability Demonstrate the application of; Clinical protocol for atrial fibrillation/flutter Clinical and Diagnostic Test Policy Medicines Policy NICE CG 180 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Clinical Knowledge Broad knowledge of cardiac conditions, Anatomy and physiology of cardiovascular system relating to AF/Flutter Clinical signs and symptoms of AF/Flutter Cardiovascular related clinical examination skills Rate and rhythm controlling medication, indications, doses, side effects, interactions and required monitoring Health education required by patients with AF/Flutter Indications for cardiology investigations Recognition of sequelae of uncontrolled AF/Flutter Specific knowledge of the effect of beta blockers in the management of atrial fibrillation/ flutter including indications, contra-indications, side-effects, dose, interactions and required monitoring. Performance criteria Positively identify the patient Review and interpret existing patient information, assessment and management plan Clinically examine the patient and record clinical signs Determine whether it is clinically appropriate to initiate or titrate beta blockers based upon clinical assessment Recognise the target dose according to the management plan Demonstrate the limitations of optimising beta blockers in view of cardiovascular recordings Recommend or prescribe the dose of appropriate beta blocker, explain the V2.1 Page 25 of 47 March 2015

30 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Interpersonal Skills and Behaviour Requirement Assessment rationale to the patient, the action and benefits of the medication and possible side effects. Arrange appropriate review of patient Deliver health education as appropriate to the patient including selfmanagement strategies Provide appropriate written information to the patient Review effectiveness of beta blocker therapy and titrate up or down according to clinical assessment Demonstrate the rationale for changing beta blocker Demonstrate an understanding of the caution required in co-administration with other medications Communicate changes in medication to GP Identify intolerance to beta blockers and determine the appropriateness of stopping medication Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Knowledge can be acquired by: Completion of arrhythmia module Completion of clinical examination course Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a community Cardiac Nurse specialist Band 7, who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac Nurse Specialist who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self sign off review form and undertake reassessment every 2 years by an Assessor of Practice Process of governance approval V2.1 Page 26 of 47 March 2015

31 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft RECORD OF COMPETENCE FOR INTRODUCING AND TITRATING BETA BLOCKERS IN ATRIAL FIBRILLATION/FLUTTER KSF dimension to which this Competency applies Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 27 of 47 March 2015

32 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, at least 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform Signature: Job Title: DATE I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 28 of 47 March 2015

33 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 9 Competence Statement for introducing and titrating calcium channel blockers in Atrial Fibrillation/Flutter Summary This statement includes recognising the need to introduce calcium channel blockers, the considerations to be made prior to commencing therapy, knowledge of possible side-effects, patient monitoring required and review of effectiveness Scope Arrhythmia nurse specialist band 7 Links This competency has been linked to NHS Knowledge and Skills Framework: Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 National Workforce Competences (NWC): CHD GB2, HK1 and HL1 CM A6, A7, F3 Knowledge and Understanding Performance criteria Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability Demonstrate the application of; Clinical protocol for atrial fibrillation/flutter Clinical and Diagnostic Test Policy Medicines Policy NICE CG 180 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Clinical Knowledge Broad knowledge of cardiac conditions, Anatomy and physiology of cardiovascular system relating to AF/Flutter Clinical signs and symptoms of AF/Flutter Cardiovascular related clinical examination skills Rate and rhythm controlling medication, indications, doses, side effects, interactions and required monitoring Health education required by patients with AF/Flutter Indications for cardiology investigations Recognition of sequelae of uncontrolled AF/Flutter Specific knowledge of the effect of calcium channel blockers in the management of atrial fibrillation including indications, contra-indications, sideeffects, dose, interactions and required monitoring. Positively identify the patient Review and interpret existing patient information, assessment and management plan Clinically examine the patient and record clinical signs Determine whether it is clinically appropriate to initiate or titrate calcium channel blockers based upon clinical assessment Recognise the target dose according to the management plan Demonstrate the limitations of optimising calcium channel blockers in view of cardiovascular recordings V2.1 Page 29 of 47 March 2015

34 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Interpersonal Skills and Behaviour Requirement Assessment Recommend or prescribe the dose of appropriate calcium channel blocker, explain the rationale to the patient, the action and benefits of the medication and possible side effects. Arrange appropriate review of patient Deliver health education as appropriate to the patient including selfmanagement strategies Provide appropriate written information to the patient Review effectiveness of calcium channel blocker therapy and titrate up or down according to clinical assessment Demonstrate the rationale for changing calcium channel blocker Demonstrate an understanding of the caution required in co-administration with other medications Communicate changes in medication to GP Identify intolerance to calcium channel blockers and determine the appropriateness of stopping medication Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Knowledge can be acquired by: Completion of arrhythmia module Completion of clinical examination course Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a Community Cardiac Nurse specialist Band 7, who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac NS who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self sign off review form and undertake reassessment every 2 years by an Assessor of Practice Process of governance approval V2.1 Page 30 of 47 March 2015

35 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft RECORD OF COMPETENCE FOR INTRODUCING AND TITRATING CALCIUM CHANNEL BLOCKERS IN ATRIAL FIBRILLATION/FLUTTER KSF dimension to which this Competency applies Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 31 of 47 March 2015

36 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform DATE Signature: Job Title: I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 32 of 47 March 2015

37 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 10 Competence Statement for Introducing and Titrating Digoxin in Atrial Fibrillation/Flutter Summary This statement includes recognising the need to introduce digoxin, the considerations to be made prior to commencing therapy, knowledge of possible side-effects, patient monitoring required and review of effectiveness Scope Cardiac Nurse specialist band 7 Links This competency has been linked to NHS Knowledge and Skills Framework: Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 National Workforce Competences (NWC): CHD GB2, HK1 and HL1 CM A6, A7, F3 Knowledge and Understanding Performance criteria Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability Demonstrate the application of: Clinical protocol for atrial fibrillation/flutter Clinical and Diagnostic Test Policy Medicines Policy NICE CG 180 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Clinical Knowledge Broad knowledge of cardiac conditions, Anatomy and physiology of cardiovascular system relating to AF/Flutter Clinical signs and symptoms of AF/Flutter Cardiovascular related clinical examination skills Rate and rhythm controlling medication, indications, doses, side effects, interactions and required monitoring Health education required by patients with AF/Flutter Indications for cardiology investigations Recognition of sequelae of uncontrolled AF/Flutter Specific knowledge of the effect of Digoxin in the management of atrial fibrillation including indications, contra-indications, side-effects, dose, interactions and required monitoring. Positively identify the patient Review and interpret existing patient information, assessment and management plan Clinically examine the patient and record clinical signs Determine whether it is clinically appropriate to initiate or titrate digoxin based upon clinical assessment and digoxin levels Recognise the target dose according to the management plan Recommend or prescribe the dose of digoxin, explain the rationale to the patient, the action and benefits of the medication and possible side effects. V2.1 Page 33 of 47 March 2015

38 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Interpersonal Skills and Behaviour Requirement Assessment Arrange appropriate review of patient Deliver health education as appropriate to the patient including selfmanagement strategies Provide appropriate written information to the patient Review effectiveness of digoxin therapy and titrate up or down according to clinical assessment Demonstrate an understanding of the caution required in co-administration with other medications Communicate changes in medication to GP Identify intolerance to digoxin and determine the appropriateness of stopping medication Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Knowledge can be acquired by: Completion of arrhythmia module Completion of clinical examination course Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a Community Cardiac Nurse Specialist Band 7, who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac NS who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self-sign off review form and undertake reassessment every 2 years by an Assessor of Practice Process of governance approval V2.1 Page 34 of 47 March 2015

39 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft RECORD OF COMPETENCE FOR INTRODUCING AND TITRATING DIGOXIN IN ATRIAL FIBRILLATION/FLUTTER KSF dimension to which this Competency applies Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 The policies developed by Kent Community Health NHS foundation Trust describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 35 of 47 March 2015

40 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform DATE Signature: Job Title: I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 36 of 47 March 2015

41 7402 Appendix B Appendix 11 Competence Statement for Assessment for Anticoagulation Therapy with Vitamin K Antagonist in Patients with Atrial Fibrillation /Flutter Summary This statement includes the ability to correctly diagnose AF/flutter, to communicate effectively with patients in order to gain informed consent. And to be able to analyse the risks and benefits of anticoagulation therapy to patients. Scope Community Cardiac Nurses Bands 7, Links Knowledge and Understanding This competency has been linked to NHS Knowledge and Skills Framework HWB3, HWB7, HWB8 National Workforce Competences FE HCS CARD 5,10,12,14,FHHCSI 6, FFHCSI14 Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability NMC Code of Conduct Demonstrate the application of: Atrial fibrillation/ Flutter clinical protocol Anticoagulation policy Clinical and Diagnostic Test Policy Consent policy Chaperoning policy Medicines policy NICE CG 180 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Heidbuchel H., Verhamme P., Alings M., AntzM., Hacke V., Oldgren J., Sinnaeve P., CammP. & Kirchhof P. (2013) EHRA Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. doi: /eurheartj/eht134 Clinical Knowledge Broad knowledge of cardiac conditions Anatomy and physiology of cardiovascular system relating to arrhythmia Clinical signs and symptoms of arrhythmias Components required of a cardiac history Cardiovascular related clinical examination skills Systematic approach to ECG interpretation Risks and benefits of anticoagulation in AF and Flutter Use of risk scoring tools Specific knowledge of the effect of warfarin in the management of thromboprophylaxis in atrial fibrillation including indications, contra-indications, sideeffects, dose, interactions and required monitoring. Positively identify the patient

42 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Performance criteria Clinically examine the patient and record clinical signs Consider the aetiology of arrhythmia Completion of arrhythmia assessment documentation and appropriate actions. Interpersonal Skills and Behaviour Requirement Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Gives patient appropriate anticoagulation card Assessment Knowledge can be acquired by: Completion of arrhythmia module Completion of anticoagulation module Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a CCNS Band 7 who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac NS who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self-sign off review form and undertake reassessment every 2 years by an Assessor of Practice Process of governance approval V2.1 Page 38 of 47 March 2015

43 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Record of Competence for Assessment for Anticoagulation Therapy with Vitamin K Antagonist in Patients with Atrial Fibrillation /Flutter KSF dimension to which this Competency applies Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 39 of 47 March 2015

44 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform DATE Signature: Job Title: I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 40 of 47 March 2015

45 7402 Appendix B Appendix 12 Competence Statement for Assessment for Novel Oral Anticoagulant (NOAC) Therapy in Patients with Atrial Fibrillation /Flutter Summary This statement includes the ability to correctly diagnose AF/flutter, to communicate effectively with patients in order to gain informed consent. And to be able to analyse the risks and benefits of novel oral anticoagulation therapy to patients. Scope Community Cardiac Nurses Bands 7, Links Knowledge and Understanding This competency has been linked to NHS Knowledge and Skills Framework HWB3, HWB7, HWB8 National Workforce Competences FE HCS CARD 5,10,12,14,FHHCSI 6, FFHCSI14 Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability NMC Code of Conduct Demonstrate the application of: Atrial fibrillation/ Flutter clinical protocol Anticoagulation policy Clinical and Diagnostic Test Policy Consent policy Chaperoning policy Medicines policy NICE CG 180 European Society of Cardiology (ESC) (2012) focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation Developed with the special contribution of the European Heart Rhythm Association. doi: /eurheartj/ehs253 Heidbuchel H., Verhamme P., Alings M., AntzM., Hacke V., Oldgren J., Sinnaeve P., CammP. & Kirchhof P. (2013) EHRA Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. doi: /eurheartj/eht134 South West Medicines Information and Training and Regional Drug and Therapeutics Centre (Newcastle)(2014) Common Questions and Answers on the Practical Use of Oral Anticoagulants in Non-Valvular Atrial Fibrillation. Oral Anticoagulants in Non- Valvular Atrial Fibrillation. OralAntiCoagCompar isonoct14-finalversion Clinical Knowledge Broad knowledge of cardiac conditions Anatomy and physiology of cardiovascular system relating to arrhythmia Clinical signs and symptoms of arrhythmias Components required of a cardiac history Cardiovascular related clinical examination skills Systematic approach to ECG interpretation Risks and benefits of anticoagulation in AF and Flutter Use of risk scoring tools (eg SPARC - Stroke Prevention in Atrial Fibrillation Risk Tool)

46 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft SPARCtool - Atrial Fib Stroke Risk Tool.m Specific knowledge of the effect of NOACs in the management of thromboprophylaxis in atrial fibrillation including indications, contra-indications, sideeffects, dose, interactions and required monitoring. Performance criteria Positively identify the patient Clinically examine the patient and record clinical signs Consider the aetiology of arrhythmia Completion of arrhythmia assessment documentation and appropriate actions. Interpersonal Skills and Behaviour Requirement Assessment Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Gives patient appropriate anticoagulation card (Appendix 5) Knowledge can be acquired by: Completion of arrhythmia module Completion of anticoagulation module Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a CCNS Band 7 who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac Nurse Specialist who has achieved level 5 in this competency Duration Date Individual must complete 6 diagnostic assessments per year to retain competency completing the self-sign off review form and undertake reassessment every 2 years by an Assessor of Practice Process of governance approval V2.1 Page 42 of 47 March 2015

47 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Record of Competence for Assessment for Novel Oral Anticoagulation Therapy in Patients with Atrial Fibrillation /Flutter KSF dimension to which this Competency applies Core 1 and 3, HWB1, 2, 3, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 43 of 47 March 2015

48 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, 2 supervised practice session required Date No Level achieved Supervisor signature Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform DATE Signature: Job Title: I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 44 of 47 March 2015

49 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Appendix 13 Competence Statement for interpretation of an ECG Summary This statement includes recognising the need to record an ECG, appropriate communication with the patient to gain informed consent, the knowledge and skills to accurately interpret the ECG, and act on these results. Scope Community Cardiac Nurses Bands 6 and 7 Links Knowledge and Understanding Performance criteria Interpersonal Skills and Behaviour Requirement Assessment Duration This competency has been linked to NHS Knowledge and Skills Framework HWB8, National Workforce Competences HCS CARD 14 Legislation, regulations and guidelines (to include Organisational policies and Professional bodies requirements) Identify own responsibility / accountability Demonstrate the application of: Atrial fibrillation/ Flutter clinical protocol Clinical and Diagnostic Test Policy Consent policy Chaperoning policy Clinical Knowledge Broad knowledge of cardiac conditions Anatomy and physiology of cardiovascular system relating to arrhythmia Clinical signs and symptoms of arrhythmias Components required of a cardiac history Cardiovascular related clinical examination skills Systematic approach to ECG interpretation Understand the indicators for referral Positively identify the patient Clinically examine the patient and record clinical signs Consider the aetiology of arrhythmia Completion of arrhythmia assessment documentation and appropriate actions. Introduce self to patient Thoroughly explains the procedure ensuring patient s understanding and verbal consent Delivers health education in a clear and concise fashion using language understood by the patient Ensures patient comfort and dignity Asks for assistance if required / recognises own limitations Knowledge can be acquired by: Completion of arrhythmia module Attendance at Cardiology study days Shadowing and supervised practice Minimum of two clinical assessments will be observed in order to meet competency The Supervising Practitioner will be a CCNS Band 7 who has achieved level 4 in this competency The Assessor of Practice will be a Community Cardiac NS who has achieved level 5 in this competency Individual must complete 6 diagnostic assessments per year to retain competency completing the self-sign off review form and undertake reassessment every 2 years by an Assessor of Practice Date Process of governance approval V2.1 Page 45 of 47 March 2015

50 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft RECORD OF COMPETENCE FOR INTERPRETTATION OF AN ECG KSF dimension to which this Competency applies 1, HWB1, 2, 3, 4, 5, 6 and 7 The policies developed by describe the knowledge, skills and performance criteria required to provide safe and competent care. This record provides evidence of the development and maintenance of competence. Name of staff member: Job Title: Service: Base / Team / Ward: Name of Assessor of Practice: Job Title: Service: Base / Team / Ward: Evidence of Acquiring New/ Updated Knowledge Date Achieved Details Supervisor signature Supervisor print Name Practitioner signature Adapted from Policy for Assessment of Competency (EKHT 2007) *Level of Achievement Descriptor Scale Unable to perform activity Not Competent 0 Can perform activity but requires supervision and some assistance Not Competent 1 Can perform activity without assistance and/or direct supervision Probationer 2 Can perform activity with initiative/ability to problem solve Competent 3 Can perform with speed and fluidity. Possess substantial skills, knowledge and confidence Responsible for assessing continued competency in practice (Supervising Practitioner) Can perform with speed and fluidity. Acts as an Expert within field of practice Responsible for teaching and assessing initial competency in practice (Assessor of Practice) 4 5 V2.1 Page 46 of 47 March 2015

51 7402 Appendix B Atrial fibrillation/flutter clinical protocol draft Assessment of Competency Minimum achievement level 4, Date No Level achieved Supervisor signature 2 supervised practice sessions required Supervisor print Name Practitioner signature Specify further action to achieve competency (refer to Appraisal and Personal Development Plan): Completion of Competencies DATE I certify that the practitioner.. has achieved the competencies required to perform Signature: Job Title: DATE I agree to maintain my competency in the above skill and will notify my manager of any changes to my ability to perform this skill safely and competently Signature of Practitioner: Job Title: If you do not feel competent to continue to practice this skill or require additional support/ re-training please ensure you undergo a period of supported practice and this is detailed within your Personal Development Plan additional supporting evidence of up-date for any additional support need to maintain competency (specify): Please: Send one copy of this competency signatory sheet once completed to your line manager for reporting purposes. Retain the other for inclusion in your professional profile. V2.1 Page 47 of 47 March 2015

52 7402 Appendix C POLICY FOR ANTICOAGULATION THERAPY Document Reference No. MM012 Status Final Version Number 4.2 Replacing/Superseded policy or documents Policy for Anticoagulation Therapy v4.0 Number of Pages 45 Target audience/applicable to All staff dealing with patients receiving anticoagulant therapy Author Pharmacists Acknowledgements Medical Director, KCHFT Contact Point for Queries Chief Pharmacist Date Ratified 13 April 2017 Date of Implementation/distribution May 2017 Circulation Policy Dissemination / Intranet Review date January 2020 Copyright