Multi centre audit of warfarin use in community hospitals · •Drug food interactions are common...
Transcript of Multi centre audit of warfarin use in community hospitals · •Drug food interactions are common...
Multi centre audit An evaluation of the safe prescribing
and administration of Warfarin in Community Hospitals
Lelly Oboh, Consultant Pharmacist, Care of Older People East & South East NHS Specialist Pharmacy Services
23rd September 2014
East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast
Medicines Use and Safety
©East & South East England Specialist Pharmacy Services
S
P S
MUS Team: Winner: RPS Pharmaceutical Care award 2013; Finalist: HSJ Patient safety in primary care award 2013; Winner: UKCPA/Guild Conference Best Poster award 2013; Winner: UKCPA Pain award 2012;
Winner: UKCPA Respiratory award 2012
Overview
• Background and context
• Criteria and Justification
• Methodology
• Results and discussions
• Key points and recommendations
Background Part of a collaborative evaluation study to measure
the number and clinical significance of pharmacy contributions in community health services
Aim of audit
• To evaluate the safe prescribing and administration of warfarin in community hospitals
• To make recommendations around the use of warfarin which could be addressed locally and nationally
Why Warfarin? (1,2) • Well established for preventing thromboembolism in
AF, prosthetic valves, DVT, PE, TIA etc
• Most frequently prescribed oral anticoagulant in UK
• Commonly implicated in preventable harms, hospital admissions and claims in NHS Most significant ADR is haemorrhage
– Usually INR >5
– Those on long term therapy
– Risk highest in first 3 months of treatment
• National drivers
1. Baglin, T P et al. Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency. British Journal of Haematology, 136, 26–29 2. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N Engl J Med 2011; 365:2002-2012
Problems with warfarin • Biological variation in drug handling sensitivity to
even small changes dosing must be individualised
• No. of people involved in care transfer of information, communication
• Regular blood monitoring disruption to lifestyle
• Under coagulation (haemorrhage) and over coagulation(thrombosis) ADR and fatalities
• Drug food interactions are common
• Renal excretion (problems in older people)
NPSA Alert 18 2007 Reasons for high incidents of harm*
1. Staff training and competencies inadequate 2. Poor documentation of reason and treatment plan at start
of therapy. 3. Co-prescribing and monitoring of interacting drugs not
considered. 4. Poor transfer of care & communication from hospital to GP 5. Insufficient support and monitoring in first 3 months and
for vulnerable groups. 6. Potential confusion due to different strength and
packaging 7. Inadequate audit of anticoagulant services and/or failure
to act on identified risks
*those particularly relevant to community hospital settings
NPSA Alert 18 2007 Actions that can make anticoagulant therapy safer
NHS and independent sector (by Mar 2008)
1. Properly trained staff
2. Review and / or update written procedures and clinical protocols safe practice
3. Annual Audit of anticoagulant services using BSH/NPSA safety indicators inform commissioning and performance mgt
4. Patients prescribed anticoagulants receive appropriate written & verbal information.
5. Promote safe practice for prescribers and pharmacists regularly monitor INR safe level before issuing or dispensing repeat prescriptions
6. Promote safe practice for co-prescribing interacting medicines
7. dental practitioners follow evidence-based guidelines.
8. Standardise the range of anticoagulant products used
9. Written safe practice procedures for administration in social care settings (incl.MCA).
Audit Criteria 1-6 Relate to having the right information to ensure safety
Criteria Justification
1. Clear indication for warfarin stated
in the patient notes
Warfarin is a high risk drug and there should be a clear
indication why the patient is on it- AF, mechanical heart
valves, DVT, PE
2. There is a Yellow (INR) book for the
patient
Yellow book should show the most current monitoring
information/dose to ensure safety
3. Target range for INR is stated in
the yellow book
Out of range: under and over coagulation can lead to ADRs
4. Duration of therapy OR stop date
is stated in the yellow book/patient
notes
To prevent unnecessary long term use. usually 6weeks to
6months or for life if CVS condition
5. Recommended date for next INR is
stated in the yellow book
Ensure regular monitoring is done
6. Date for next INR is overdue Ensure regular monitoring is done
Audit Criteria 7-12 Relate to information needed to ensure safe administration
Criteria Justification
7. Last INR is within the range stated in
the Yellow book
Out of range: under and over coagulation can lead
to ADRs
8. What is last recorded INR?
9. Dose on MAR/prescription chart is as
stated in Yellow book
Wrong dosing can lead to higher risks of ADRs
10. Dose given or reason for not given is
documented
Omitted drugs can lead to ADRs
11. Interacting drug started or stopped in
the last week
Interacting drugs can cause fluctuation in INR and
lead to ADRs. In some sensitive people a small
change in dose, adding or stopping interacting
drug, herbal supplements, food etc can lead to a
significant change in warfarin levels
12. If Yes to Q11, was INR done within 4-7
days of stopping or starting drug
Close monitoring is needed when interacting drugs
are co-prescribed
Audit Criteria 13-16 Relate to safe prescribing
Criteria Justification
13. Warfarin is prescribed by
milligrams (not number of
tablets)
To reduce the risks of giving the wrong dose
14. Least number of tablet
combination is administered
To reduce pill burden
15. Daily dosing only (not alternate
day dosing)
Alternate dosing increases risk of medicines error
16. Whole tablets only (not half
tablets)
Increases risk of medicines error
17. Patient suffered adverse effect
in last week e.g. bruising, nose
bleeds
ADR monitoring
Methodology and data collection
• Snapshot audit in any 2 week period (Nov 2013)
• Simple data collection form designed and piloted in 2 community hospital wards
• Slight amendments and final tool agreed
• Data collected as part of study patients identified as taking warfarin where selected to participate in audit
• One form completed per patient
Results
• 192 entries from 15 Trusts (23 Sites)
• 15 entries from prison setting excluded
• 177 entries analysed
Participating sites No.of entries %
Berkshire Healthcare NHS Foundation Trust (Prospect Park)- RWX 7 4%
Berkshire Healthcare NHS Foundation Trust (St Marks) - RWX 1 1%
Berkshire Healthcare NHS Foundation Trust (Upton) - RWX 5 3%
Berkshire Healthcare NHS Foundation Trust (West Berkshire) - RWX 4 2%
Berkshire Healthcare NHS Foundation Trust (Wokingham) - RWX 4 2%
Cambridgeshire Community Services NHS Trust - RYV 6 3%
CNWL Foundation Trust (Camden) - RV3 1 1%
CNWL Foundation Trust (Hillingdon) - RV3 1 1%
Ealing Hospital NHS Trust (Willesden) - RC3 3 2%
East Coast Community Healthcare (Northgate)- SE3 1 1%
East Coast Community Healthcare (Beccles) - SE3 1 1%
East Sussex Healthcare NHS Trust - RXC 19 11%
Epsom and St Helier University Hospitals NHS Trust - RVR 13 7%
Hounslow and Richmond Community Healthcare Trust - RY9 7 4%
Medway Community Healthcare - SE1 5 3%
NELFT - RAT 9 5%
Oxford Health NHS Foundation Trust RNU 64 36%
Oxleas NHS Foundation Trust - RPG 3 2%
Provide - SE2 5 3%
SEPT (Bedfordshire) - RWN 2 1%
Sussex Community Trust (B&H) 3 2%
Sussex Community Trust (Kleinwort) 1 1%
Sussex Community Trust (WSHT) 12 7%
TOTAL 177 100%
172, 97%
5, 3%
1. Clear indication for warfarin stated in the patient records (e.g. notes or yellow book)
Yes
No
48, 27%
129, 73%
2. There is a Yellow (INR) book for the patient?
Yes
No
*Results skewed as the Trusts with the highest number of entries answered “NO” to this question
40, 23%
14, 8%
123, 69%
3. Target range for INR is stated in the yellow book?
Yes
No
No Yellow book
• YES 23% vs 74% with yellow book in place • Inconsistencies in data about yellow book
50, 28%
20, 11% 107, 61%
4. Duration of therapy OR stop date is stated in the yellow book/patient notes?
Yes
No
No Yellow book
• YES 28% vs 71% with yellow book in place • Inconsistencies with data about yellow book
37, 21%
15, 8% 125, 71%
5. Recommended date for next INR is stated in the
yellow book?
Yes
No
No Yellow book
• YES 21% vs 71% with yellow book in place • Inconsistencies with data about yellow book
24, 65%
13, 35%
6. Date for next INR is overdue?
Yes
No
40, 23%
22, 12% 115, 65%
7. Last INR is within the range stated in the Yellow book?
Yes
No
No Yellow Book
• YES 23% vs 74% with yellow book in place • Inconsistencies with data
8. What is last recorded INR?
Last INR No of entries (177)
INR 0.9 or less 0
1.0 - 5.0 169
5.1 and above 2
Not recorded 6 (2 new starters, 4 not found)
• YES 16% vs 68% with yellow book in place • Inconsistencies with data
9. Dose on MAR /prescription chart is as stated in Yellow book?
26, 16%
12, 8%
121, 76%
Yes
No
No Yellow Book
158, 89%
19, 11%
10. Dose given or reason for not given is documented?
Yes
No
17, 10%
160, 90%
11. Interacting drug started or stopped in the last week?
Yes
No
16, 94%
1, 6%
12. If Yes to question 11, was INR done within 4-7 days of stopping or
starting drug?
Yes
No
174, 98%
3, 2%
13. Warfarin is prescribed by milligrams (not number of tablets)?
Yes
No
175, 99%
2, 1%
14. Least number of tablet combination is administered?
Yes
No
169, 95%
8, 5%
15. Daily dosing only (not alternate day dosing)?
Yes
No
171, 97%
6, 3%
16. Whole tablets only (not half tablets)?
Yes
No
6, 3% 0, 0%
171, 97%
17. Patient suffered adverse effect in last week e.g. bruising, nose bleeds?
Yes
No
Not recorded
Entries recording adverse effects did not correlate with INR being out of range, > 5 or below 1
Results: data limitations
• No yellow book in 105-129 cases (59-73%)
• “Not recorded in yellow book” is not same as “not recorded”
• Entries too few to analyse by Trust (bar Oxford)
• Inconsistencies in data entry within same organisations
• Not the full range of NPSA/BSH indicators
• ?? Self administration not considered
Summary of results CRITERIA. Records show….. Baseline
1 Clear indication for warfarin stated in the patient notes 97%
2 There is a Yellow (INR) book for the patient 27%
3 Target range for INR is stated in the yellow book 23%(74%)
4 Duration of therapy OR stop date is stated in the yellow book/patient notes 28% (71%)
5 Recommended date for next INR is stated in the yellow book 21% (71%)
6 Date for next INR is overdue 35%
7 Last INR is within the range stated in the Yellow book 23% (74%)
8 What is the last INR? -
9 Dose on MAR/prescription chart is as stated in Yellow book 16% (68%)
10 Dose given or reason for not given is documented 89%
11 Interacting drug started or stopped in the last week 10%
12 If Yes to Q11, was INR done within 4-7 days of stopping or starting drug 94%
13 Warfarin is prescribed by milligrams (not number of tablets) 98%
14 Least number of tablet combination is administered 99%
15 Daily dosing only (not alternate day dosing) 95%
16 Whole tablets only (not half tablets) 97%
17 Patient suffered adverse effect in last week e.g. bruising, nose bleeds 3%
Key points Positive
• Indication for warfarin stated
• Safe choice of products
• Monitoring of interacting drugs
Key points Improvements needed
• Appropriate records to ensure safe use and administration – Target
– Duration of treatment
– Date of next INR and action taken
– Previous INR Within range
– Dose required is given on MAR chart
• Recording reasons for omitted drugs
Conclusion and recommendations CONCLUSION • Patterns were generally similar across the different Trusts
Interpretation of data and recommendations can be applied across the patch
RECOMENDATIONS • Review local protocols/guidelines
– Ensure INR monitoring and dosing information is recorded in an easily accessible place (preferably the Yellow book)
– Reinforce need to record reasons omitted doses – Ensure appropriate action is taken in light of INR results
• Re-audit after 6-12months (incl. Standards) • Feed back results within organisation to improve care