Audit of NOAC patients previously on warfarin Sue Bacon - PowerPoint PPT Presentation

Audit of NOAC patients previously on warfarin Sue Bacon Anticoagulation Nurse Specialist North Bristol Trust

History of NBT AMS • Prior to 2009 dosing by haematologist/BMS/MLA – • Small team based at FHY using DAWN • Sept 2009 CNS recruited and haematologists took backstage • 2010 AMS merged with dosing at SMD hospital who used yellow books and dosed by haemtologists only, who then also disappeared • Workload increased! • 2011 VTE nurse recruited but only 1.5 days anticoag

North Bristol Trust • Shared care with GPs • Cover North Bristol and South Glos • Postal service • 5,200 patients approx • Used to dose about 500 plus a day but recently 450 daily (approx) • I WTE CNS and one PT (1.5 days) although fills in three days a week to cover annual leave etc • BMS ‘of the day’ • 2 band 2 MLA – admin and dosing within SOP

NOACS • Dabigatran (RELY 2009) - AF • Rivaroxaban (ROCKET and EINSTEIN) AF and VTE • Apixaban (ARISTOTLE and AVEROES) AF • Edoxaban – coming soon

Why audit NOACs? • To understand how many patients have transferred • To look at the transfer process and ensure best practice followed • Feedback the results to the GP surgeries to improve patient care

How? • Using the reporting function on the list view- with a little help from DAWN • Downloading the data into excel • Sorting by reason for stopping (could DAWN give us a drop down menu to make this easier?) – this has already been addressed

Results • Downloaded data for the last 2 years • 3438 patients stopped for a variety of reasons

anaemia apixaban dementia high INRs low platelets non compliant previscan acenocoumarol unwell NOAC allergy palliative pt choice falls bleed cancer error antiplatelet self test LMWH RIP moved DAB GP DNA RIV no reason End

Results re reasons for stopping • Dementia • Falls • Antiplatlets • Allergy to warfarin • High INRs • These reasons are not reasons for stopping anticoagulation in patients with AF and should perhaps be investigated

NOACs • Of the 3428 patients stopped over the two years:- • 461 patients onto NOACs:- • 1 - apixaban • 164 - dabigatran • 296 – rivaroxaban

Problems identified • No firm data as yet but those investigated – inappropriate management of transfer – ie low INRs • GPs stopping patients to transfer • INRs - <3 for RIV and AF • INRs - <2.5 for RIV and VTE • INRs - <2.0 for DAB and APIX • Most patients could just transfer immediately esp those not taking • Information available to all GP on the BNSSG website

Further problems picked up • Remember NOACs only licensed for NON- VALVULAR AF and only RIV for VTE • 22/164 dabigatran - not licensed VTE/cardiomypoathy/arterial embolus and mechanical valves or valve repair (3) • 10/296 rivaroxaban – arterial disease/cardiomyopathy/mechanical valves or repair (3)

Action? • Consultant to write to GPs about valves • CNS to check future letters from GPs • Further formal audit – junior docs?

Good paper:- • www.NOACforAF.eu • Practical guide on the use of NOACs • Free to download • Patient alert card • Booklet available soon