Managing >8 INRs in an Anticoagulation clinic. Sean OBrien - PowerPoint PPT Presentation

Managing >8 INR’s in an Anticoagulation clinic. Sean O’Brien Anticoagulation Specialist BMS Blackpool Hospitals Trust

Managing >8 INR’s in an Anticoagulation Clinic � Overview of service (ADAS) � Vitk Policy at Blackpool � Overview of Study, including exclusions � Patients by Clinic (location) � Patients by >8 reason � Demographics � Treatment options and outcomes � Domiciliary patients � Potential Savings, (Patient and Trust) � Key learns and improvements. � Any Questions?

Service overview. � ADAS is a consultant lead “point of care” service � The service is staffed by State Registered Specialist Biomedical Scientists who run and validate the DAWN dosing software during clinics � We use KC4 4 channel analysers with Coaguchek XS as a back up. � Near patient testing performed by Medical laboratory assistants � 6200 active patients � 16 outreach clinics dosing up to 550 patients daily � 750 domiciliary patients

Staff resource � 1 ADAS manager � 2 full time Specialist BMS’s � 1 Full time DVT nurse � 14 rotational Haematology BMS’s � 20 Medical Laboratory assistants � 2 fiat Multiplas, 1 Berlingo and 5 Clio’s!

Typical clinic resource � 2 Specialist BMS’s to dose � 4 Lab assistants to clerk patients and capillary sample � 2 KC4 analysers with Coaguchek XS back up � 1 Fiat Multipla to get us all there! � Suitable premises, these vary from Small surgeries to large out-patient departments in PFI health centres.

Vitk policy at Blackpool

Vitk policy. � Patient presents with >8 on KC4 � Repeat test on Coaguchek to confirm � Check referral for Vitk sign off. � BMS to consult patient for any potential reasons � If patient is actively bleeding/bruising send to A/E � If not, administer 2mg/0.2ml paediatric Vitk � Arrange 24 hour Follow up with patient at ADAS � Advise patient re bleeding/bruising � Send episode report to Haematology Consultant

Overview of study � Search for all >8 INR’s from April 2012/2013 � Filter into Clinics (Location) � Filter into Reasons for <8 INR � Demographics � Has VITk been administered � Follow up INR � Exclusions Domiciliary patients 1. “In patient” added history 2.

Results of search � 74 >8 INR’s found � 5 Excluded due to Hospital “added history” � 48 Clinic INR’s � 21 Domiciliary INR’s

Location Clinic location 12 10 8 6 4 2 0 south shore fleetwood Bispham cleveleys lytham garstang overwyre poulton thornton Kirkham

Reasons..

Reason for >8 Reason for <8 20 18 16 14 12 10 8 6 4 2 0 Drug interaction Alcohol No known reason Compliance Hospital overdose overdosed on initiation

Reason by % reason by % 45 40 35 30 25 20 15 10 5 0 Drug interaction Alcohol No known reason Compliance Hospital overdose overdosed on initiation

Drug by type Drug by type 12 10 8 6 4 2 0 Antibiotics Gout medication Multiple new meds Chemotherapy Tramodol NSAIDS paracetomol

Ages Age 12 10 8 6 4 2 0 30-40 41-50 51-60 61-70 71-80 81-90

Sex Sex Male, 21 Female, 23

Treatment options and outcomes � 45 patients were given Vitk in clinic � 1 patient was admitted due to active bleeding. � 1 patient was sent to A/E with headache and was found to have intracranial bleed and admitted � 1 patient was sent to Preston for Vitk. (Garstang Patient) Not admitted

Post Vitk INR’s � Range 1.5 - 6.6 � Mean INR 3.3 � Mean Target INR 2.8

Domiciliary Patients Reasons for >8 Domiciliary treatment options 12 8 10 7 8 5 6 4 2 0 Antibiotics No reason compliance Overdosed on Unstable Given initiation Vitk Given admitted Omitted

Potential savings. � 45 Potential hospital admissions saved � Estimated £119 - £219 per A/E visit = £5355 - £9855 � Estimated £200 for overnight AMU up to £9000 � Cost of a major bleed? Throw a dice in the air! � PCC Average cost £640 � Red cells £122.09 � Platelets £208.09 � Lets not forget the cost to the patient and family

Key learns and improvements � We are actually pretty good at what we do?... � 7 in 10,000 INR’s >8 � We have the Vitk dose right, mean 24 hour INR 3.3 � No complications with all 45 recipients � Our initiation is safe � More education needed re Drug changes � Only 1 surgery actually refers patients starting ABX. � Hospital dosing education � More GP surgeries now stock Vitk

Any questions?