cameron wilson, the queen elizabeth hospital - the queen elizabeth hospital - warfarin mangement in...
DESCRIPTION
Cameron Wilson, The Queen Elizabeth Hospital delivered the presentation at the 2013 Hospital in the Home Conference. The Hospital in the Home Conference is a nurse oriented program packed with comprehensive case studies to improve HITH services and maximise hospital efficiency throughout Australia. For more information about the event, please visit: http://www.communitycareconferences.com.au/HITHeventTRANSCRIPT
The Queen Elizabeth
Hospital
Warfarin Management
in HITH
Warfarin Registered Nurse initiated dosing,
Coagchek „Point of Care‟
technology, and an Age-adjusted
Nomogram.
The Queen Elizabeth Hospital:
Hospital in the Home Service
Summary
› Registered Nurse led team.
› No Medical or Allied Health component.
› Medical Governance = Ward Home
Teams.
› Ranging up to 45 patient visits per day.
› Staffing levels: flex up and down
according to patient loads and acuity.
> TQEH HITH saw over 10,000 patients last
year.
> 3,666 INR tests completed in the
community- point of care & venepuncture.
> Average- 1 in 3 HITH patients had an INR*
test.
> Average time to reach therapeutic INR: 11-
12 days in 2007-08*.
*INR test: The International Normalised Ratio is the test for blood clotting.
*As per HITH 3 monthly random auditing over 12 months (>200 pts)- from commencement to two
stable therapeutic INR results and warfarin doses.
2012 HITH Statistics
The Australian Council on Healthcare
Standards (ACHS) 2011 report:
> Medication use remains the most common
intervention in health care.
> Medication errors and adverse reactions
result in an estimated 140,000 annual
hospital admissions.
> Most adverse drug events are preventable.
Warfarin and Medication
Safety Trivia
Australian Commission for Safety and Quality
Health Council* (ACSQHC 2011 Report):
> Listed Warfarin as 5th most notified
medication for reported events.
> Widely used drug with a narrow therapeutic
index.
> Potentially serious adverse reactions eg.
spontaneous bleeding. * Reference- ACSQHC Report (2011).
Warfarin and Medication
Safety Trivia
> Warfarin use is increasing with the ageing
population.
> Uncertainty surrounding newer
anticoagulants.
> Remains the drug of choice for many co-
morbidities: AF, DVT/PE, CVA (thrombus),
cardiomyopathy and AVR/MVR.
> The new National Inpatient Medication
Chart (NIMC) new design incorporated
Warfarin risk.
Safety and Concerns
> A non-standardised approach to Warfarin
dosing was apparent.
> “Clinical judgement was deemed better
than guidelines”.
> Length of stay (LOS) was inconsistent, and
poor vs Warfarin guideline.
> Very low medical compliance with TQEH
Warfarin Guideline (<2% in 2008).
TQEH HITH Audits Results
> Increased time to reach therapeutic INR
levels.
> Increased LOS in HITH.
> Guideline*: 4-6 days to achieve therapeutic
INR in 60% of patients vs TQEH clinical
judgement (11-12 days).
> Increased number of venepunctures and
laboratory (lab) testing.
*In combination with age adjusted Nomogram, a standard baseline INR, and daily testing from commencement.
TQEH HITH Audits Results
& Warfarin Concerns
> Long INR wait times for lab tests.
> Increased patient discomfort with repeat
venepuncture.
> Reliance on HITH RN to assist in dose
prescription.
> Increased incidence of over-coagulation
and bleeding.
> Increased readmission and intervention.
> Extended Hospital and HITH LOS.
Further Consideration
> Large patient variance in therapeutic
doses.
> Range: 0.5mg to 28mg per patient
daily.
> External influencing factors on
Warfarin stabilisation: medication
interactions, dietary intake, Vitamin K
stores, diarrhoea, low albumin levels.
> Patient compliance, cognition &
CALD.
Out of our control?
> Commonly used medication +
inconsistent prescribing + high
adverse event reporting = High risk
for patients + increased risk of
readmission + poor use of HITH and
hospital resources.
> All brought to attention by a HITH RN
Kate Swanson in 2008.
Time for change!
> Increase patient safety and
decrease reported incidents.
> Efficient use of hospital resources
and decreased LOS.
> Adherence to Hospital Guidelines
and evidenced based practice.
Goals for change
Business Case:
Interdisciplinary work group formation to
review current practice.
Key stakeholders:
> HITH RN: Kate Swanson
> Head of Pharmacy: Sharon Goldsworthy
> Head of Haematology: Dr Simon McRae
> IMVS Pathology Manager: Neil Pascoe
> Safety and Quality Manager: Jane Burgess
> CTCU Manager: Elizabeth Sloggett
> VTE RN: Donna King
Clinical Practice
Improvement
> Investigate ways to improve patient safety
> Improve overall efficiency of Warfarin
stabilisation.
HOW?
Evidence based literature discoveries:
> A standardised approach to prescribing
decreases risk of bleeding and erratic INR.
> Daily INR testing at the commencement of
therapy is recommended.
THE PLAN
Next steps:
> Reinforce existing standardised TQEH
guideline.
> Daily testing achievable in hospital and
HITH settings.
> Improve medical compliance with the
guideline.
THE PLAN
Next steps:
> Letter from Director of Medical Services, Dr
Sally Tideman, to all key medical staff and
heads of units.
> Education at Intern orientations.
> Counselling and education at
commencement of Warfarin.
> Establish a „Nurse initiated protocol‟ for INR
stabilisation using the standardised
algorithm.
THE PLAN
> Investigation of Point of Care (POC)
technology.
> Review POC accuracy, cost and
safety/effectiveness vs lab testing.
> Safe product selection: Coagchek and
partnership with SA Pathology (IMVS).
> Review role of POC to decrease
venepuncture and patient discomfort.
Standardised approach and
POC testing
> Develop a safe HITH nurse-initiated
warfarin protocol.
> Prompt dose adjustment during patient
(HITH) visit.
> No need for Medical Governance for first
4 days.
> Protocol: rapidly attains stable
therapeutic INR.
Standardised approach and
POC testing
Coagchek Technology/POC Machines
> Warfarin dose: 4pm daily during loading
phases.
> INR taken between 7am–9am the next
morning.
> INR performed daily for the first 5 days.
> Some patients may require dose
adjustment at protocol completion.
> Patients with serum albumin<30g/l may
be very sensitive to warfarin.
HOSPITAL IN THE HOME
WARFARIN PROTOCOL
> The goal of warfarin initiation is to
rapidly attain a stable therapeutic INR
without over-anticoagulation.
> If baseline INR is 1.4 or more then
careful consideration must be given to
warfarin initiation.
HOSPITAL IN THE HOME
WARFARIN PROTOCOL (continued)
Warfarin Age-Adjusted Nomogram Dose according to age (mg)
Day INR 50 years
51–65
years
66–80
years 80
years
1 1.4 10 9 7.5 6
2 (16hrs after 1st dose) 1.5
1.6
10
0.5
9
0.5
7.5
0.5
6
0.5
3 (16hrs after 2nd dose) 1.7 10 9 7.5 6
1.8–2.3 5 4.5 4 3
2.4–2.7 4 3.5 3 2
2.8–3.1 3 2.5 2 1
3.2–3.3 2 2 1.5 1
3.4 1.5 1.5 1 1
3.5 1 1 1 0.5
3.6–4.0 0.5 0.5 0.5 0.5
4 0 0 0 0
4 (16hrs after 3rd dose) 1.5 Refer to medical point of care
1.6 8 7 6 5
1.7–1.8 7 6 5 4
1.9 6 5 4.5 3.5
2.0–2.6 5 4.5 4 3
2.7–3.0 4 3.5 3 2.5
3.1–3.5 3.5 3 2.5 2
3.6–4.0 3 2.5 2 1.5
4.1–4.5 omit next dose, then
2 1.5 1 0.5
4.5 Hold & refer to medical officer
PATIENT ELIGIBILITY:
> Baseline INR of <1.4 (on commencement).
> Loaded as per age adjusted protocol.
ELIGIBILITY OF RN TO INITIATE
ORDER:
> Warfarin administration learning package
completion.
> Coagchek Competencies completion.
Therapeutic Drugs Committee
+ Patient Advisory Group
Review and Recommendations
EXPECTATIONS OF RN WHO
INITIATED TREATMENT:
> Achieve stable INR within 7 days of
commencement.
> Report to home team if INR>4.5 or <1.6 on
day 4 of protocol.
DURATION THAT AN RN MAY
CONTINUE TO INITIATE ORDER:
> 14 days post commencement of warfarin.
Therapeutic Drugs Committee
+ Patient Advisory Group
Review and Recommendations
DOCUMENTATION PROCESS:
> INR recorded with warfarin dose in
medication chart and progress notes.
Therapeutic Drugs Committee
+ Patient Advisory Group
Review and Recommendations
> Input from all key stakeholders = approval
granted.
> HITH Nurse Initiated age-adjusted Warfarin
Protocol implemented.
> SA Pathology and NATA approved for POC
Quality Control.
> ACHS commendation for Coagchek
program.
Approval!
> Instant INR results through POC use.
> Safe implementation of a nurse initiated
dose with daily testing.
> Reproducibility and reliability of POC tests
allow greater possibility of early discharge
to GP.
> Lyell McEwen and Modbury Hospitals also
adopted the protocol.
Approval!
> Increased use of the Warfarin protocol:
45% vs 2% in 2008.
> Reduction in lab testing and
venepuncture.
> Decrease in HITH length of stay (6.8
days).
> Reduction in total INR tests per pt (<7
tests).
> Reduction in time to achieve therapeutic
INR (8 days).
2012 Audit Results
> Increase in visit efficiency: instant result,
immediate dose, no phone calls or lag time
with lab follow up.
> Increased patient safety and satisfaction.
> Higher Protocol use = Less time to
therapeutic INR.
> Reduction in over-anticoagulation during
“loading” phase.
Nurse initiated warfarin protocol was
published in:
a. The Pulse (monthly TQEH newsletter).
b. Pharmacy Tablet.
c. Intern Newsletter.
d. Intern Handbook.
> Laminated copies of the protocol placed
in all ward medication folders.
Reinforcements +
Sustainability
> RN competencies and learning
package mandatory for HITH RN‟s.
> Presentation by HITH/Pharmacy at
intern education sessions.
> Education for ALL patients
commenced on Warfarin.
> 3 monthly random patient auditing.
> Weekly quality control checks: POC
vs lab testing.
Reinforcements +
Sustainability
1. NSW Health Safety Notice 006/07: “Guidelines
for prescribing, dispensing and administering
warfarin”.
http://www0.health.nsw.gov.au/resources/quality
/sabs/pdf/sn20070412.pdf
2. Australian Commission for Safety and Quality
Health Council (ACSQHC 2011): Australasian
Clinical Indicator Report 2004–2011 13th
Edition.
http://www.achs.org.au/media/50245/achs_clini
cal_indicators_report_web.pdf
References