MANAGING THE INR CLINIC : IJN EXPERIENCE Anticoagulation Workshop 21 st August 2015 KAMALESWARY ARUMUGAM PRINCIPAL PHARMACIST LEE LEE HO1 NURSE MENTOR, INR CLINIC
HISTORY & OVERVIEW OF THE INR CLINIC
HISTORY Established in July 2003 by Dr. Lam Kai Huat It is for better management of warfarin therapy by a team of health professionals fully trained in anticoagulation management Laboratory dept priority was given to warfarin patients and the old blood bank location was used as the INR clinic Pharmacy dept pharmacists guided staff nurses in educating warfarin patients as well as provide warfarin dose adjustments & dispensing warfarin from the clinic Emergency dept Patients with out of range INR referred to M.O. Since then: our INR clinic has further expanded to 3 permanent clinic rooms and the patients numbers have increased steadily over the last 10 years Dispensing of Warfarin has been centralised Pharmacy Outpatient Block B
HISTORY Protocol and policy has been developed to standardise anticoagulant management Staff nurses and pharmacists were sent to Singapore GH to attend Anticoagulation workshop 2005 onwards Pharmacy/INR Clinic collaborate with IJN College to organise the first Oral Anticoagulation workshop in August 2010 In 2014, we started training our own nurses and pharmacists and a second Anticoagulation workshop was successfully conducted in September 2014
INR CLINIC ORGANISATION CHART
INR CLINIC LOCATION & OPERATING HOURS The INR clinic is located on Ground Floor, Block B, IJN The clinic is operated based on normal working hours 8:00am to 5:00pm, 5 days a week (Monday to Friday), excluding public holiday During the lunch hour (Monday to Thursday 1:00pm-2:00 pm; Friday 12:30pm-2:30pm), the clinic is closed
OBJECTIVES To assist physicians in the management of patients on oral anticoagulation therapy To provide service continuity and enhance patient care through education, monitoring and close follow-up to patients who require anticoagulation therapy To serve as an information resource regarding warfarin for patients and family/care provider To conduct research regarding anticoagulation therapy and related areas
SCOPE All IJN Out-patients who are scheduled for INR test in IJN All IJN POCT patients Patients newly started on warfarin therapy in the ward, physicians shall refer patient to the INR clinic upon discharge Physicians will have to document the patient s indication for anticoagulation, intended duration of anticoagulation, and targeted INR in the patient warfarin record book upon referral
INR CLINIC WORKFLOW
MANPOWER REQUIREMENT The INR clinic is staffed by full time nurses 5 days a week: From 2003 2014: 2 staff nurses From March 2014 onwards: 3 staff nurses A pharmacist is on-site from 8:00am to 1:00pm (Monday to Thursday) and 8:00am to 12.30pm (Friday) to provide support for the anticoagulation services in dose adjustments and general management of the clinic The physician provides support of the clinical services and medical authority in management of the clinic services
MANPOWER REQUIREMENT
ROLES & RESPONSIBILITIES OF THE INR CLINIC NURSES & PHARMACISTS Conduct interview using INR Clinic Patient Assessment Form Evaluate patient s response to warfarin therapy through the INR results and information gathered from patient s interview Adjust dose according to patient specific response (INR trend, compliance issues and outcomes from initial assessment interview) Complete documentation in warfarin record book, patient assessment form Schedule appointments
PATIENT ASSESSMENT FORM
SPECIFIC ROLES & RESPONSIBILITIES OF THE INR CLINIC NURSES At the end of the day transfer information into INR clinic database in Trakcare Ensure Prescriptions Slips are collected for endorsement by physician at the end of the day Administer Vitamin K & SC Anticoagulant to patients, if indicated Teach patients to self-administer SC Anticoagulant Arrange for patient admission, if indicated
PROTOCOL
DOSE ADJUSTMENTS Dosage adjustment and duration of recall are generally done referring to Appendix 4
DOSE ADJUSTMENTS Dosage adjustment and duration of recall are generally done referring to Appendix 4 The pharmacist or nurse is authorised to adjust warfarin dosage using a doctor s standing instruction on the Prescription Slip The prescription will be counter-signed by the appointed physician later on
DOSE ADJUSTMENTS In general, the pharmacist or nurse manage all patients with INR of 1.4 to 5.0 If INR <1.4 refer to physician (unless AVR & MVR) If INR >4.0: check for any sign and symptoms of bleeding and determine any cause or triggers for the increase in INR where there s unexplained increase in the INR, the patient management & therapy is discussed with a physician if deemed appropriate, patient s INR of 5.0 & there is a significant factor attributing to the increase in INR, the pharmacist or nurse can manage the patient anticoagulation therapy provided that there is no actual or suspected signs or symptoms of bleeding
REFERRAL TO PHYSICIAN The patient are referred to a physician in the following situation: Actual or suspected signs and symptoms of severe haemorrhage regardless of INR value Actual or suspected signs and symptoms of thromboembolism INR values >5.0, with or without signs and symptoms of haemorrhage Patients with prosthetic valve replacement: mechanical aortic valve with INR 1.6 or mechanical mitral valve with INR 1.7 When Anticoagulation patient consistently Symposium & Workshop miss appointments 2015 or remain non-compliant to therapy
POCT
HOME MONITORING In 2006, Dr. Lam took a step forward, introducing the patient selfmanagement of INR (POCT Point of Care Test) Patients perform POCT at home and contact the INR clinic for warfarin dosage adjustment The home monitoring program for patients is ongoing low numbers currently Advantages: Convenience time & cost saved from travelling to hospital Compliance to treatment is better Improved quality of life
STAFF COMPETENCY
COMPETENCY ASSESSMENT Formally started in 2015 All nurses & pharmacists working in the INR Clinic must undergo competency assessment Yearly assessment 3 components: Peer review Case presentation Written assessment Must pass all 3 components
PEER REVIEW
PEER REVIEW
PEER REVIEW Assessed on 8 elements: Introduction to consultation Patient interview Review of INR result & action taken INR monitoring Provision of information for ongoing care Knowledge application Communication skills Documentation of clinic activities
COMPETENCY ASSESSMENT Case presentation: 2 subtherapeutic & 2 supratherapeutic cases & management Presented to Pharmacists & Nurses who work in the INR clinic, students & interns Written assessment knowledge based Must have attended Anticoagulation Workshop/Training
STATISTICS
PATIENT VISITS 11 YEARS DATA INR CLINIC PATIENT VISITS - 11 YEARS DATA 25000 20589 20000 18141 NO OF PATIENT VISITS 15000 10000 10060 10748 11317 13044 15017 15810 16478 16817 16935 5000 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 YEAR
INR CLINIC VISITS BY INDICATION (YEAR 2014) Other indications, 2339, 11% PE/DVT, 426, 2% Valve Repair, 492, 2% AF, 6513, 32% Valve Replacement, 10819, 53%
TTR Time in therapeutic range = TTR Percentage of time when patient has an INR in the prescribed range when stroke & bleeding risk is lowest Good TTR is INR in the range 2-3 >70% of the time Calculation is done based on Traditional method Ref: http://www.nps.org.au/ data/assets/pdf_file/0004/222277/medicinewise-news-feb-2012-managing-inr-figure.pdf
INR RESULTS FOR TARGET RANGE 2.0-3.0 (YEAR 2014) 3.3-5.0, 984, 9% above 5, 97, 1% below 1.8, 2011, 18% 1.8-3.2, 7818, 72%
FUTURE PLANS
ANTICOAGULATION SOFTWARE Many available on the market Designed to help establish a more efficient, effective and safer way of managing patients Complete anticoagulation decision support package covering induction, maintenance, bridging, novel oral anticoagulants and VTE diagnosis assessment
ANTICOAGULATION SOFTWARE PRODUCT SPECIFICATIONS/FUNCTIONS Generate letters/reports for internal/external physicians caring for patient Increase efficiency Reduce repetitive tasks Monitor patients who missed appointments Reduce potential errors in transcribing Able to track patient load/day Countercheck dose & dosing interval Objectives Easy data retrieval for future research Alert any drug interactions Benchmark clinic against other organisatons for further improvement Highlight high risk patients for further management Individual TTR report for better management Report yearly patient visits & patient numbers Overall clinic TTR reporting
WITHOUT ANTICOAGULATION SOFTWARE Generate letters/reports Manual for external process physicians caring for patient Increase efficiency Reduce repetitive tasks Monitor patients who missed appointments Reduce potential errors in transcribing Manual Able to track patient process load/day Countercheck dose & dosing interval Objectives Manual Easy data retrieval for future process research Alert any drug interactions Benchmark clinic against other organisatons for further improvement Highlight high risk patients for further management Individual TTR report for better management Report yearly patient Manual visits & patient process numbers Manual process Overall clinic TTR reporting
ANTICOAGULATION SOFTWARE BENEFITS Generate letters/reports for internal/external physicians caring for patient Increase efficiency Reduce repetitive tasks Monitor patients who missed appointments Reduce potential errors in transcribing Able to track patient load/day Countercheck dose & dosing interval Objectives Easy data retrieval for future research Alert any drug interactions Benchmark clinic against other organisatons for further improvement Highlight high risk patients for further management Improve patient safety Individual TTR report for better management Report yearly patient visits & patient numbers Overall clinic TTR reporting
ANTICOAGULATION SOFTWARE BENEFITS Generate letters/reports for internal/external physicians caring for patient Increase efficiency Reduce repetitive tasks Monitor patients who missed appointments Reduce potential errors in transcribing Able to track patient load/day Countercheck dose & dosing interval Increase efficiency Objectives Easy data retrieval for future research Alert any drug interactions Benchmark clinic against other organisatons for further improvement Highlight high risk patients for further management Individual TTR report for better management Report yearly patient visits & patient numbers Overall clinic TTR reporting
ANTICOAGULATION SOFTWARE BENEFITS Generate letters/reports for internal/external physicians caring for patient Increase efficiency Reduce repetitive tasks Monitor patients who missed appointments Reduce potential errors in transcribing Improvement on all processes Able to track patient load/day Objectives Countercheck dose & dosing interval Easy data retrieval for future research Alert any drug interactions Benchmark clinic against other organisatons for further improvement Highlight high risk patients for further management Individual TTR report for better management Report yearly patient visits & patient numbers Overall clinic TTR reporting
PATIENT PROFILE
RISK STRATIFICATION & TTR INDICATOR
DRUG INTERACTIONS & EVENTS
DOSE SETTING CLEAR
SUMMARY INR Clinic is successfully managed by MDT In the last 11 years patient numbers have increased significantly Process improvements have been made in the clinic Future plans include implementation of an anticoagulation software to increase patient safety & efficiency
THANK YOU