coo orrddiinnaattorr wwoorrkk ppllaann - fa-ciliter sept l2012... · if not, consider change...

F A - C I L I T E R — C o o r d i n a t o r W o r k P l a n

D a t e : M a y 2 3 , 2 0 1 2

(FA-CILITER PROGRAM — Atrial Fibrillation in an Integrated Clinic to Limit Thromboembolic Events)

CCoooorrddiinnaattoorr WWoorrkk PPllaann

Is the patient medically stable AND available for 1 hour of assessment and counseling?

Yes No Visit 1

□ Complete the demographic sheet.

□ Complete the data sheet (Visit 1).

□ Ask the patient to complete the FA-CILITER Quality of Life Questionnaire.

□ Obtain resting ECG.

□ Obtain laboratory test values (hemoglobin, platelet count, glycemia, serum creatinine,

creatinine clearance1, glomerular filtration rate2, ejection fraction, echocardiogram,

thyroid function and electrolytes).

□ Calculate CCS-SAF score.

□ Calculate CHADS2 and CHADS2-VASC score.

□ Calculate HAS-BLED score.

□ Determine whether there are any reversible causes of atrial fibrillation.

□ Counseling patient on AF management, patient educational material, website, visit card.

□ Schedule date for next telephone call.

□ Send an information letter to the patient’s physician(s) and pharmacist(s) concerning the

patient’s participation in the FA-CILITER program.

1 Creatinine clearance: (140-age) x weight (kg) x constant (1.23 for males, 1.04 for females)/serum creatinine

(µmol/L). 2 MDRD formula: 186 x (creatinine/88.4)

-1.154 x (Age)

-0.203 x (0.742 if female) x (1.210 if Black African) or glomerular

filtration rate estimated by the local laboratory.

Give the patient the FA-CILITER Program summary and record the patient’s contact

information for future follow-up.

Give the patient the FA-CILITER Program pamphlet and ask the patient if he/she agrees to participate in the

FA-CILITER Program and proceed with Visit 1, if possible.

May 23, 2012

CHADS2 Score

Congestive heart failure 1

Hypertension 1

Age ≥ 75 years 1

Diabetes mellitus 1

Prior Stroke or TIA 2

Score _____ /6

May 23, 2012

CHADS2-VASC Score

Congestive heart failure 1

Hypertension 1

Diabetes mellitus 1

Prior Stroke or TIA 2

Age ≥ 75 years

Age ≥ 65 years

2

1

Female Sex 1

Vascular disease (peripheral or coronary artery disease) 1

SCORE _____ /9

May 23, 2012

Absence of coronary artery disease or

stable coronary artery disease

□ CHADS2 ≥1

Or

□ CHADS2 = 0 with age ≥65 years or woman with

peripheral vascular disease

□ ANTICOAGULANT3

□ If the patient is not anticoagulated, inform the

FA-CILITER physician

For patients on warfarin 3 Recommendations CCC 2012: Novel oral anticoagulant is preferable to warfarin.

May 23, 2012

INR therapeutic and stable?

□ If yes, maintain on warfarin

□ If not, consider change warfarin to dabigatran

If use dabigatran

Inform the FA-CILITER physician of creatinine clearance and glomerular filtration

□ Normal renal function : dabigatran à 150 mg bid

□ Abnormal renal function4,5 :

□ If ClCr ≤30 ml/min, change to warfarine

□ If ClCr de 31-60 ml/min, consider dabigatran at 110 mgbid

□ If patient is older than >80 years, dabigatran at 110 mgbid

Other anticoagulant

Note reason for use of other anticoagulant

□ CHADS2 = 0 and woman or peripheral vascular disease : consider Aspirin

□ For patients with GFR <15 ml/min and on dialysis, CCC 2012 do not recommend

routine use of oral anticoagulants or ASA in these patients.

4 The above suggestion of dose for dabigatran is based on the product monography et the RE-LY study. Of

note, creatine clearance can over-estimate the GFR (as measured by MDRD) by 10-20%. To inform the FA-CILITER physician (creatinine clearance and glomerular filtration).

5 Canadian Cardiovascular Society 2012 recommends use of GFR to evaluate kidney function. Dabigatran

150 bid ou 110 bid can be used for patients with GFR 30-59 ml/min

May 23, 2012

Recent Acute Coronary Syndrome or

Percutaneous Coronary Intervention

CHADS2 ≤1 CHADS2 ≥2

ASA & clopidogrel ASA & clopidogrel &

anticoagulant6

If CHADS2 ≥2 and not anticoagulated,

inform the FA-CILITER physician

6 Recommendations CCC 2012 : Warfarin is preferred over novel oral anticoagulant

May 23, 2012

For patients on warfarin

INR therapeutic and stable?

□ If yes, maintain on warfarin

□ If not, consider change warfarin to dabigatran

If use dabigatran

Inform the FA-CILITER physician of creatinine clearance and glomerular filtration

□ Normal renal function : dabigatran à 150 mg bid

□ Abnormal renal function7,8 :

□ If ClCr ≤30 ml/min, change to warfarine

□ If ClCr de 31-60 ml/min, consider dabigatran at 110 mgbid

□ If patient i solder than >80 years, dabigatran at 110 mgbid

Other anticoagulant

Note reason for use of other anticoagulant

□ CHADS2 = 0 and woman or peripheral vascular disease : consider Aspirin

□ For patients with GFR <15 ml/min and on dialysis, CCC 2012 do not recommend

routine use of oral anticoagulants or ASA in these patients.

7 The above suggestion of dose for dabigatran is based on the product monography et the RE-LY study. Of

note, creatine clearance can over-estimate the GFR (as measured by MDRD) by 10-20%. To inform the FA-CILITER physician (creatinine clearance and glomerular filtration).

8 Canadian Cardiovascular Society 2012 recommends use of GFR to evaluate kidney function. Dabigatran

150 bid ou 110 bid can be used for patients with GFR 30-59 ml/min

May 23, 2012

HAS-BLED Score

Hypertension (>160 mmHg systolic)? Yes +1

Kidney disease (dialysis, serum creatinine >200 µmol/L)? Yes +1 Liver disease (cirrhosis, bilirubin >2x normal limit, AST/ALT/AP >3x normal limit)? Yes +1

Prior stroke or TIA? Yes +1

Prior major bleeding or predisposition to bleeding? Yes +1

Labile INR (INR <60% of time in the therapeutic range)? Yes +1

Age ≥65 years? Yes +1 Drugs that increase bleeding risk (anti-platelet agents, non-steroidal anti-inflammatory drugs)? Yes +1

Excessive use of alcohol? Yes +1

SCORE

_________/9

□ If HAS-BLED score > CHADS2 score

OR

□ HAS-BLED score ≥3

□ Notify FA-CILITER physician

(The risk of bleeding may outweigh the benefit of anticoagulation therapy.)

May 23, 2012

Identifying the Reversible Causes of Atrial Fibrillation

Determine whether any of these underlying conditions may have triggered or worsened the AF:

_____Hypertension

_____Hyperthyroidism

_____Consumption of alcohol (provide alcohol cessation advice)

_____Consumption of drugs or stimulants (e.g., caffeine, medications for the relief of flu-like

illnesses)

_____Acute coronary syndrome

_____Cardiac surgery

_____Non-cardiac surgery

_____Acute respiratory disorder

_____Infection

_____Other (specify) ______________________________________________

If any of these conditions are present, are not being treated or remain

uncontrolled, notify the FA-CILITER physician and/or family physician.

May 23, 2012

Telephone Call at Month 1, Month 3 and Month 6

□ Complete sheets for Month 1, 3 and 6 visits.

□ Review treatment compliance.

o Encourage compliance.

o Determine whether there has been a change in treatment.

□ Answer the patient’s questions.

□ If the patient cannot be reached, call the family or another contact person.

□ Complete and forward the follow-up letter to the family physician and pharmacist, if

applicable.

□ Recalculate CHADS2, CHADS2-VASC and HAS-BLED scores.

□ If these scores have changed, review anticoagulation therapy with the FA-CILITER

physician.

Final Visit at Month 12

□ Complete final visit data sheet.

□ Review medications.

□ Review treatment compliance.

o Encourage compliance.

o Determine whether there has been a change in treatment.

□ Answer the patient’s questions.

□ Provide patient with advice on future care.

□ Obtain resting ECG.

□ Recalculate CHADS2, CHADS2-VASC and HAS-BLED scores.

□ If these scores have changed, review anticoagulation therapy with the FA-CILITER

physician.

□ Re-determine patient’s renal function.

□ Send a letter to the cardiologist, family physician and pharmacist, explaining that the

FA-CILITER Program has been completed.

□ Complete the Quality of Life and CCS-SAF questionnaires.

May 23, 2012

Stroke

□ Notify the FA-CILITER physician and/or cardiologist and/or patient’s family physician (if

applicable).

Major bleeding (requiring a transfusion, emergency room visit or hospitalization, or resulting in

a change in medication or death)

□ Notify the FA-CILITER physician and/or cardiologist and/or patient’s family physician (if

applicable).

Unscheduled patient call(s) or visit(s)

□ Record reason and intervention performed.

□ Notify the FA-CILITER physician and/or cardiologist and/or patient’s family physician.

Patient death

□ Obtain reason and date of death from family.

□ Obtain death certificate (if possible).

□ Notify the FA-CILITER physician.

F A - C I L I T E R — C o o r d i n a t o r W o r k P l a n

D a t e : M a y 2 3 , 2 0 1 2

Quality of Life Questionnaire (To be completed by the patient)

Date: ____________ (day/month/year)

□ At the initiation of the FA-CILITER Program

□ At the completion of the FA-CILITER Program

Please rate your current health status on the following scale.

Please rate your current state of well-being on the following scale.

Worst health status Best health status

Worst feeling of well-being Best feeling of well-being

May 23, 2012

Work* Have your AF symptoms affected your work?

Has your treatment for AF affected your work?

I have not worked lately due to reasons unrelated to AF.

*: Work includes remunerative work, volunteer work or training.

Social Life Have your AF symptoms affected your social life/leisure activities?

Has your treatment for AF affected your social life and/or your leisure activities?

Family Life and Household Responsibilities Have your AF symptoms affected your family life and household responsibilities?

Has your treatment for AF affected your family life and household responsibilities?

Not at all Mildly Moderately Somewhat Severely






May 23, 2012

Missed days of work (approximate estimate)

How many days of work have you missed in the last 6 months or how many days have you not been able to carry out your normal responsibilities due to your AF symptoms?

Productivity (approximate estimate)

How many days in the last 6 months did you have reduced productivity due to your AF symptoms?

May 23, 2012

CCS-SAF Scale

The Three Steps

• Step 1 – Symptoms • Palpitation • Dyspnea • Dizziness, pre-syncope or syncope • Chest pain • Weakness or fatigue

• Step 2 – Association • Are these symptoms present during an AF

episode? • Determine if these symptoms are associated

with an AF episode (or if they are due to another cause).

• Step 3 – Functionality • Determine if the AF symptoms (or their

treatment) affect the patient’s functionality (subjective quality of life).

• Give a score of 0-4 based on the criteria listed in the table.

May 23, 2012

Table 1: Canadian Cardiovascular Society Severity of Atrial Fibrillation Scale

SAF Class Effect on patient’s general quality of life (QoL)

0 Asymptomatic with regard to AF

1 Symptoms attributable to AF have a minimal effect on patient’s general QoL

Minimal and/or rare symptoms, or

Single AF episode without syncope or heart failure

2 Symptoms attributable to AF have a minor effect on patient’s general QoL

Mild cognizance of symptoms in patients with persistent/permanent AF, or

Rare episodes (e.g., less than a few per year) in patients with paroxysmal or intermittent AF

3 Symptoms attributable to AF have a moderate effect on patient’s general QoL

Moderate cognizance of symptoms most days in patients with persistent/permanent AF, or

More frequent episodes (e.g., more than every few months) or more severe symptoms, or both, in patients with paroxysmal or intermittent AF

4 Symptoms attributable to AF have a severe effect on patient’s general QoL

Very unpleasant symptoms in patients with persistent/paroxysmal AF and/or

Frequent and highly symptomatic episodes in patients with paroxysmal or intermittent AF and/or

Syncope believed to be caused from AF and/or

Heart failure secondary to AF

May 23, 2012

APPENDIX — Example of Letter to Family Physician – First Visit (Name of city) _______ (Date)__________________ SUBJECT: Optimization of your patient’s medical treatment for atria fibrillation Dr. __________________ (treating physician), Mr./Ms._______________________ (pharmacist) Your patient, Mr./Ms. _________________________ is currently taking part in [name of institution]’s FA-CILITER (Atrial Fibrillation in an Integrated Clinic to Limit Thromboembolic Events) Program.

FA-CILITER is a multidisciplinary care program whose mission is to optimize care, follow-up and education to prevent thromboembolic complications in patients with atrial fibrillation. This program does not include INR monitoring follow-up.

We would like to share our opinion about your patient’s anticoagulation therapy with you:

This patient has a low risk of stroke and does not require an anticoagulant.

This patient has a high risk of stroke and we have initiated anticoagulation therapy with ____________________.

This patient was taking warfarin; however, given that:

His/her INR levels are labile, we have switched the warfarin to dabigatran.

INR monitoring is difficult, we have switched the warfarin to dabigatran.

Due to _____________________________________________________, we have switched the warfarin to dabigatran ________mg BID.

This patient was taking dabigatran; however, due to his/her renal disease, we have switched the dabigatran to warfarin.

May 23, 2012

This patient was on anticoagulation therapy; however, given his/her high risk of bleeding due to __________________________________, we have discontinued the anticoagulation therapy.

We have initiated ASA at a dose of __________________ per day.

We also suggest the continuation of treatment with these medications: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ We suggest the discontinuation of these medications: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ We suggest making changes to these medications: ______________________________________________________________________________ ______________________________________________________________________________ Other suggestions: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Enclosed you will find information that may help you with the follow-up of your patient:

□ Hospitalization summary or ER visit note

□ Copy of anticoagulant prescription

□ FA-CILITER pamphlet

□ FA-CILITER visit card

May 23, 2012

If you have any questions about the FA-CILITER Program and/or information about your patient, please contact Mr./Ms. _________________________ (FA-CILITER Program Coordinator) at ______________________________________________. We thank you for your cooperation and the attention afforded this letter. Sincerely,

____________________________________ Physician

____________________________________ Coordinator

May 23, 2012

APPENDIX — Example of FA-CILITER Program Follow-up Letter

(Name of city) _______ (Date)__________________ SUBJECT: Your patient’s telephone follow-up call at _____ months Dr. __________________ (treating physician), Mr./Ms. ________________________ (pharmacist) Your patient, Mr./Ms. _________________________, is a participant in the [name of institution]’s FA-CILITER (Atrial Fibrillation in an Integrated Clinic to Limit Thromboembolic Events) Program.

FA-CILITER is a multidisciplinary care program whose mission is to optimize care, follow-up and education to prevent thromboembolic complications in patients with atrial fibrillation. This program does not include INR monitoring follow-up.

As part of the FA-CILITER Program, we wish to share your patient’s health status with you.

He/she is asymptomatic.

He/she suffers from class _______ angina.

He/she suffers from class _______ dyspnea.

He/she suffers from class ______ palpitations.

He/she visited the ER on _____________ (date) for ____________________ (reason).

He/she was hospitalized from ___________ to _____________ because _____________________________.

He/she suffered a transient ischemic attack (TIA) on ____________________________.

He/she suffered a stroke on _______________________.

He/she experienced ________________ bleeding.

May 23, 2012

Development of new diseases or a new lifestyle since the last FA-CILITER follow-up

High blood pressure

Heart failure

Diabetes mellitus

Coronary artery disease

Peripheral artery disease

Liver disease

Excessive consumption of alcohol

Regular administration of anti-inflammatory drugs

Regular administration of anti-platelet agents

Medical Treatment

□ He/she is not receiving anticoagulation therapy because ________________.

□ Optimal anticoagulation is being achieved with ______________.

□ His/her anticoagulation therapy has been discontinued because _______________. We suggest the continuation of treatment with these medications: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ We suggest the discontinuation of these medications: ______________________________________________________________________________ ______________________________________________________________________________ We suggest making changes to these medications: ______________________________________________________________________________ ______________________________________________________________________________

May 23, 2012

Other suggestions: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Enclosed you will find information that may help you with the follow-up of your patient:


□ Other document ____________________ If you have questions about the FA-CILITER Program and/or information about your patient, please contact Mr./Ms. __________________________ (FA-CILITER Program Coordinator) at ______________________________________________. Thank you for your cooperation and the attention afforded this letter. Sincerely,

____________________________________ Physician

____________________________________ Coordinator

May 23, 2012

APPENDIX —Example of FA-CILITER Program Completion Letter

(Name of city) _______ (Date)__________________ SUBJECT: Your patient’s final visit at _____ Months Dr. __________________ (treating physician), Mr./Ms. ________________________ (pharmacist) Your patient, Mr./Ms. _________________________, is a participant in the [name of institution]’s FA-CILITER (Atrial Fibrillation in an Integrated Clinic to Limit Thromboembolic Events) Program. We would like to inform you that your patient has completed the FA-CILITER Program. Symptoms

He/she is asymptomatic.

He/she suffers from class _______ angina.

He/she suffers from class _______ dyspnea.

He/she suffers from class ______ palpitations.

He/she visited the ER on _____________ (date) for ____________________ (reason).

He/she was hospitalized from ___________ to _____________ because _____________________________.

He/she suffered a transient ischemic attack (TIA) on ____________________________.

He/she suffered a stroke on _______________________.

He/she experienced ________________ bleeding.

May 23, 2012

Development of new diseases or a new lifestyle since the last FA-CILITER follow-up

High blood pressure

Heart failure

Diabetes mellitus

Coronary artery disease

Peripheral artery disease

Liver disease

Excessive consumption of alcohol

Regular administration of anti-inflammatories

Regular administration of anti-platelet agents

Medical Treatment

□ He/she is not receiving anticoagulation therapy because ________________.

□ Optimal anticoagulation is being achieved with ______________.

□ His/her anticoagulation therapy has been discontinued because _______________ We suggest the continuation of treatment with these medications: ______________________________________________________________________________ We suggest discontinuation of these medications: ______________________________________________________________________________ ______________________________________________________________________________ We suggest making changes to these medications: ______________________________________________________________________________ ______________________________________________________________________________ Other suggestions: ______________________________________________________________________________ ______________________________________________________________________________

May 23, 2012

Enclosed you will find information that may help you with the follow-up of your patient:


□ Other document________________________________ It was our pleasure to care for the patient during the past year. We hope that the patient has benefited from our advice and services. We have asked him/her to continue his/her medical follow-up with you. If you have questions about the FA-CILITER Program and/or information about your patient, please contact Mr./Ms. __________________________ (FA-CILITER Program Coordinator) at ______________________________________________. Thank you for your cooperation and the attention afforded this letter. Sincerely,

____________________________________ Physician

____________________________________ Coordinator

coo orrddiinnaattorr wwoorrkk ppllaann - fa-ciliter sept l2012... · if not, consider change...

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