Report from the Anticoagulation Working Group



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Evidence for NICE shared learning award

Dr. Janet Shirley, Royal Surrey County Hospital NHS Trust

Contents

Report from the Anticoagulant Working Group, September 2007 page 2

Final report from the anticoagulant working Group, March 2008 page 7

Report for the Thrombosis Committee, Part 2 of the Hospital page 15

Transfusion Committee, august 2008

Report from the Anticoagulation Working Group

Reporting to: Clinical Governance Committee

Author: Dr. Janet Shirley

Date: September 2007

Contents Page

Executive summary 1

Introduction 2

Progress 3

NICE clinical guideline no. 46 3

NPSA patient safety alert no. 18 4

Department of Health report 5

Recommendations 5

References 5

Appendix 1 6

Executive Summary

Three pieces of NHS guidance were published in March and April 2007:

• NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

• National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’

• Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

An Anticoagulation Working Group was convened. The group is chaired by Dr. Christopher Tibbs, Medical Director, and includes representatives from medical specialties, nursing, pharmacy, audit, IT and pathology. The aim of the working group is to review the guidance and agree the recommendations, decide how to implement them and look at the resources required.

Good progress has been made with:

• Updating current trust guidelines

• Producing new guidelines

• Providing verbal and written patient information

• Reviewing anticoagulant clinic procedures

• Promoting safe prescribing practices

• Standardising the anticoagulant drugs across the trust

• Liaising with dental and primary care practitioners to promote safe practices

• Planning the audit requirements

The next steps required include:

• Implementing the new guidelines across the trust

• Developing training and competency assessments for clinical staff in thromboprophylaxis and anticoagulation

• Auditing current practice and the implementation of the new guidelines

The main barriers to progress identified are:

• Lack of IT progress

• Lack of sufficient audit and training support

The Anticoagulation Working Group therefore recommends that the trust:

• Purchases and installs an anticoagulant dosing support software package

• Employs a thrombosis practitioner to provide training, competency assessment and audit

Report from the Anticoagulation Working Group

1.0 Introduction

1.1 Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. It causes approximately 60,000 deaths per annum in the UK. The figures for the Royal Surrey County Hospital NHS Trust are 32 in 2005/6 and 38 in 2006/7. The majority of these VTE related deaths were in medical inpatients with four being in surgical patients. There is a lot of evidence that the use of appropriate thromboprophylaxis significantly reduces deaths from VTE.

1.2 The Anticoagulant Working Group was convened in May 2007 to look at how the trust would implement three pieces of NHS guidance.

1. NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’ Published April 2007, implementation required by July 2007.

2. National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’ Published March 2007, action plan needed by July 2007 and implementation required by March 2008.

3. Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’ Published March 2007, no implementation date, guidance only at this stage.

1.3 Membership of the group:

Christopher Tibbs, Medical Director, Chair

Janet Shirley, Consultant Haematologist

Paul Chappell, BMS3

Bhulesh Vadher, Chief Pharmacist

Helen Wilson, F1/F2 programme director

Bill MacAllister, Consultant Respiratory Physician

Helen Wilson, Foundation Programme Director

Jenny Faulkner, Matron

Claire Richardson, Matron

Sarah Westwell, Consultant Oncologist

Matthew Solan, Consultant Orthopaedic Surgeon

Mike Cavaye, IT Representative

Helen Brady, Audit and Service Improvement Manager

Jane Fagan, Clinical Governance Co-ordinator, Secretary

1.4 The purpose of the group is to:

• Agree the recommendations in the guidance

• Decide how to implement the guidance

• Look at the resources required for implementation of the guidance

1.5 It was decided that the most practical way of carrying out the work was to divide into three subgroups, each one to review one of the guidance documents and report back on progress at intervals to the whole group.

2.0 Progress so far

2.1. NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

2.1.1 This guideline recommends that all surgical inpatients should:

• Be assessed for their risk factors for venous thromboembolism (VTE)

• Before surgery be given written and verbal information on the:

o Risks of VTE

o Effectiveness of prophylaxis

• Be given prophylaxis for VTE appropriate for their risk factors and the type of surgery involved

• On discharge be given written information about the signs and symptoms of VTE and the type of prophylaxis to be continued at home

2.1.2 In response to this guidance the following have been completed:

• Updated guidance on thromboprophylaxis for surgical inpatients in the ‘Local Clinical Guidelines (The red book), 17th Edition, August 2007

• Patient information: Advice on reducing the risk of a blood clot

• Guideline for thromboprophylaxis for inpatients undergoing surgery

• Guideline for the use of graduated compression stockings

2.1.3 Problems identified:

• The orthopaedic surgeons do not all agree with the NICE guideline. They are awaiting a position statement from the British Orthopaedic Association. The group recommends that the trust should follow the NICE guideline for all surgical inpatients.

• The guideline recommends thigh length graduated compression stockings. The evidence for the superiority of thigh length stockings compared to knee length stockings is not compelling and there is a lot of evidence that patient compliance is poor with thigh length stockings. Indeed this is the experience at the trust. The group recommends that the wording in the ‘Guideline for the use of graduated compression stockings’ should allow nursing staff to use knee length stockings.

• Training is required for medical and nursing staff. This has significant resource implications.

• Implementation of the guidance requires regular audit and again this has significant resource implications.

2.1.4 Next steps

1. Approval of the new trust guidelines, ‘Guideline for thromboprophylaxis for inpatients undergoing surgery’ and ‘Guideline for the use of graduated compression stockings’ at the Clinical Governance Committee

2. Implementation across the trust of the new guidelines

3. Training of staff in the new guidelines

4. Regular audit of the implementation of the NICE guideline no. 46

5. Approval by the Patient Information Group of the patient information leaflet, ‘Advice on reducing the risk of a blood clot from surgery.’

6. Providing patients with the leaflet at pre-assessment

2.2 National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’

2.2.1 This alert contains recommendations with significant implications for teaching and training within the trust and for clinical audit. The main recommendations contained within it are:

1. Ensure that all staff caring for patients on anticoagulant therapy have the necessary work competences. Any gaps in competence must be addressed through training to ensure that all staff may undertake their duties safely.

2. Review and update written procedures and protocols for anticoagulant services to ensure they reflect safe practice and that staff are trained in these procedures.

3. Audit anticoagulant services using the British Society of Haematology/NPSA safety indicators. The audit results should inform local actions to improve the safe use of anticoagulants and should be communicated to clinical governance and drug and therapeutic committees.

4. Ensure that patients prescribed anticoagulants receive appropriate written ad verbal information.

5. Promote safe practice with prescribers and pharmacists to check that patients’ blood clotting (INR) is being monitored regularly and that the INR level is safe before issuing and dispensing repeat prescriptions.

6. Promote safe practices for co-prescribing clinically significant interacting medicines for patients already on oral anticoagulants.

7. Ensure that dental practitioners manage patients on oral anticoagulants according to evidence based guidelines.

8. Amend local policies to standardise the range of anticoagulant products used.

9. Promote the use of written safe procedures for the administration of anticoagulants in social care settings.

2.2.2 An action plan has been produced (appendix 1) to address these recommendations. Significant progress has been made with most of them. Currently the trust has a score of 25.2 out of 56. It is hoped that by the implementation date of 31st March 2008 all the recommendations will have been achieved.

2.2.3 Problems identified

1. There is a significant resource required to deliver the training and competency assessments to the relevant clinical staff (this includes all doctors, pharmacists and nursing staff). All the educational supervisors will need to be competent in order to train and assess their junior doctors. Pharmacy staff and nurses will also require training and assessment.

2. The safety alert contains significant audit requirements. Not all of these can be delivered using the trust’s current systems. Unlike most other trusts in England there is no computerised system for prescribing and recording anticoagulant treatment. This means that audits will have to be conducted using labour intensive manual systems. Also it is not possible to correlate pathology INR results with which patients are on anticoagulant therapy. Two manual audits are planned that will capture most of the information required as a ‘one off’ but it will not be possible to carry out regular audits to monitor progress without IT support. There are technical problems with linking the anticoagulant software package installed at Frimley Park Hospital with the IT systems at the Royal Surrey. The IT department are trying to find a way round this. Once this has been solved a business case will need to be developed to fund it.

2.2.4 Next steps

1. Produce a training package for clinical staff.

2. Produce competency assessment tools for clinical staff.

3. Plan and deliver training and competency assessments.

4. Carry out the two planned audits.

5. Obtain and install a computerised anticoagulant dosing and recording package.

2.3 Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

2.3.1 This report recommends:

• A documented mandatory VTE risk assessment of every hospitalised patient on admission.

• All medical patients should be considered for thromboprophylaxis measures.

• All surgical/orthopaedic patients should be managed according to the NICE guideline.

2.3.2 This is therefore an extension of what is required for surgical inpatients under NICE guideline number 46. The recommendations in this report are not mandatory at the present time and have no required implementation date. The Anticoagulant Working Group decided to wait until good progress had been made with the other two pieces of guidance before looking at this one. The first meeting of the subgroup for this guidance is scheduled to take place in October 2007.

3.0 Recommendations

The Anticoagulant Working Group recommends the following actions to the trust:

1. The trust accepts this report as representing the progress made with these three pieces of NHS guidance.

2. The trust recognises that every effort has been and is being made to comply with and implement the guidance within current resources.

3. To enable the audit requirements to be met further resource is provided:

• an anticoagulant dosing and recording software package is purchased and installed

• a dedicated person is identified to carry out the audits

4. To enable the training and competency assessment requirements to be met further resource is provided:

• a dedicated person is identified to carry out this work

5. Items 3 and 4 above could be delivered by the appointment of a thrombosis practitioner with a remit similar to that of the trust’s transfusion practitioner. Staff with a nursing, pharmacy or laboratory background would have suitable knowledge and skills for such a post. Most trusts in England employ an anticoagulant practitioner to manage the anticoagulant clinic. At the Royal Surrey this work is currently managed by the consultant haematologists. Therefore the trust does not have someone in post who can take on this work.

6. A regular report should be made to the Clinical Governance Committee detailing progress with implementation and presenting audit results.

4.0 References

1. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’ NICE clinical guideline no. 46, April 2007.

2. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’ National Patient Safety Agency, 28 March 2007.

3. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’ Chief Medical Officer, Department of Health, March 2007.

Final Report from the Anticoagulation Working Group

Reporting to: Clinical Governance Committee

Author: Dr. Janet Shirley

Date: March 2008

Contents Page

Executive summary 1

Progress 2

NICE clinical guideline no. 46 2

NPSA patient safety alert no. 18 3

Department of Health report 5

Risk assessment 5

Recommendations 6

References 6

Appendix 1, Summary of progress on Action Plan

for Implementation of NPSA alert and NICE guidance 7

Executive Summary

This is the second and final report from the Anticoagulant Working Group, chaired by Dr. Christopher Tibbs, on the implementation of the three pieces of NHS guidance published in March and April 2007:

• NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

• National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’

• Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

Work has been completed on:

• Updating current Trust guidelines

• Producing new guidelines

• Providing written patient information

• Reviewing anticoagulant clinic procedures

• Promoting safe prescribing practices

• Standardising the anticoagulant drugs across the Trust

• Liaising with dental and primary care practitioners to promote safe practices

• The audit requirements in the NPSA alert for 2007/08

• Rolling out the Trust thromboprophylaxis policy

• Training the junior doctors

• Developing the competency assessments for medical staff in thromboprophylaxis and anticoagulation

• Putting forward the business case for a thrombosis practitioner to support audit and training in anticoagulation and thromboprophylaxis across the Trust and to support the haematology consultants in delivering the service

Work is in progress on:

• Installing the software for computerised assisted dosing support to the anticoagulant clinic

• A baseline audit of thromboprophylaxis across the Trust

Work outstanding is:

• Auditing the implementation of the new guidelines across the Trust

• Ongoing audit of anticoagulation and thromboprophylaxis

• Training nursing and pharmacy staff in anticoagulation and thromboprophylaxis

• Competency assessing all staff involved in anticoagulation and thromboprophylaxis

The main barrier to further progress is:

• Lack of sufficient audit, training and competency assessment support

It is highly likely that one of the new targets in the Annual Health Check for 2008/09 will be ‘VTE prophylaxis in the form of risk assessment on admission to hospital’. This work will not be possible without extra support and the Anticoagulation Working Group therefore recommends that the Trust employs a thrombosis practitioner. A risk assessment indicates that there is a significant risk to the Trust if the appointment is not made.

Report from the Anticoagulation Working Group

1.0 Progress

1.1. NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

1.1.1 In response to this guidance the following have been completed or are in progress:

• Updated guidance on thromboprophylaxis for surgical inpatients in the ‘Local Clinical Guidelines (The red book), 17th Edition, August 2007 – completed.

• Patient information: ‘Advice on reducing the risk of a blood clot for inpatients undergoing surgery’ – completed.

• Guideline for thromboprophylaxis for inpatients undergoing surgery - completed.

• Guideline for the use of graduated compression stockings – completed.

• Baseline audit of thromboprophylaxis with low molecular weight heparin across the Trust - in progress.

• Training of F1 ad F2 doctors currently in post – completed.

• Implementation of the Trust thromboprophylaxis policy completed by:

o Circulating the new guideline for surgical patients to all consultant surgeons and relevant ward sisters.

o Providing thromboprophylaxis posters for all ward areas.

o Desk top alert on the Trust computers.

o Risk assessment tool developed for patients attending surgical pre-assessment.

o All patients attending pre-assessment to be given the patient information leaflet, ‘Advice on reducing the risk of a blood clot from surgery’.

1.1.2 Problems identified:

• Ongoing training and competency assessment is required for medical, pharmacy and nursing staff. This has significant on-going resource implications.

• The Trust is not using TED stockings. The brand being used is Carolon. This was chosen following a Surrey and Sussex NHS Supply tender on behalf of the trusts in Surrey and Sussex. The clinical studies on graduated compression stockings have been carried out on TEDS and the Anticoagulation Working Group has concerns about how clinically effective other brands are because there is limited independent clinical comparison between the main anti-embolism stockings. Carolon stockings meet the compression standards required by the British Standard BS 7672, 1993, are CE marked and meet the Medical Devices Directive standards. To change back to TED stockings would increase costs by about 18.5% or £11,382 per annum.

• Training is required for staff in applying anti-embolism stockings, particularly for the thigh length stockings which should be used where possible.

• Implementation of the guidance requires regular audit and again this has significant resource implications.

• The orthopaedic department have reached agreement on how they will manage thromboprophylaxis for their patients. Whilst inpatients will be managed according to the NICE guidance the extended thromboprophylaxis will consist of aspirin or Warfarin rather than low molecular weight heparin. This may put pressure on the anticoagulant clinic which has limited capacity.

1.2 National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’

1.2.1 This alert contains nine main recommendations. Progress against the action plan (appendix 1) for each is outlined below:

10. Ensure that all staff caring for patients on anticoagulant therapy have the necessary work competences. Any gaps in competence must be addressed through training to ensure that all staff may undertake their duties safely.

• Training has been given to the FI and F2 doctors. It has not been possible to carry out training for pharmacy and nursing staff due to lack of resource. Competency assessments have been developed for the junior doctors but have not been implemented, again due to lack of resource. Competency assessments for other staff have not been developed. Score = 48.9%%

11. Review and update written procedures and protocols for anticoagulant services to ensure they reflect safe practice and that staff are trained in these procedures.

• The red book, ‘Local Clinical Guidelines’ has been updated in the August 2007, 17th edition to include all current recommendations and references. For training see above. Score = 94.4%

12. Audit anticoagulant services using the British Society of Haematology/NPSA safety indicators. The audit results should inform local actions to improve the safe use of anticoagulants and should be communicated to clinical governance and drug and therapeutic committees.

• Audits have been completed on patients on anticoagulants who have been readmitted with bleeding complications and the management of patients with INR>8.0. Audits are currently in progress on documentation in the anticoagulant clinic and the management of patients with INR >5.0. Regular ongoing audits on a yearly basis will be required and it will not be possible to undertake this without extra resource for audit. Audit results have yet to be communicated to staff.

Score = 69.1%.

13. Ensure that patients prescribed anticoagulants receive appropriate written ad verbal information.

• All patients on discharge are given the yellow book and the new patient information pack as recommended by the NPSA is gradually being introduced. All new patients attending the Trust anticoagulant clinic are also shown a video about their anticoagulant treatment. Verbal information is being provided on the wards by the doctors and pharmacists and in the anticoagulant clinic by the haematology consultants. Score = 90.0%

14. Promote safe practice with prescribers and pharmacists to check that patients’ blood clotting (INR) is being monitored regularly and that the INR level is safe before issuing and dispensing repeat prescriptions.

• Ward pharmacists are checking that patients on Warfarin have had a recent INR and that it is not too high before dispensing a further prescription.

Score = 75.0%

15. Promote safe practices for co-prescribing clinically significant interacting medicines for patients already on oral anticoagulants.

• Ward pharmacists are checking what other drugs patients on Warfarin are prescribed. Score = 62.5%

16. Ensure that dental practitioners manage patients on oral anticoagulants according to evidence based guidelines.

• The maxillofacial department is following the guidelines and the local dentists are aware of the guidance. Score = 100%

17. Amend local policies to standardise the range of anticoagulant products used.

• The pharmacy and haematology department have reviewed and standardised the range of anticoagulant products used. Score = 100%

18. Promote the use of written safe procedures for the administration of anticoagulants in social care settings.

• This is the responsibility of the PCT which is aware of the guidance and carrying out work to implement it. Score = N/A

1.2.2 Problems identified

3. There is a significant resource required to deliver the training and competency assessments to the relevant clinical staff (this includes all doctors, pharmacists and nursing staff). All the educational supervisors will need to be competent in order to train and assess their junior doctors. Consultants, pharmacy staff and nurses will also require training and assessment. To date only the junior doctors (F1 and F2 grades) have been trained and no staff have been assessed. The only member of staff available to train and competency assess at present is Dr. Janet Shirley, who is employed for four PAs. More resource will need to be provided to improve this.

4. The safety alert contains significant audit requirements. Not all of these can be delivered using the Trust’s current systems. Unlike most other trusts in England there is at present no computerised system for prescribing and recording anticoagulant treatment. It is hoped that this will be installed by April 2008 for the outpatient anticoagulant clinic but it will not support the audit of inpatients on anticoagulant therapy. The audits carried out so far have been conducted using labour intensive manual systems. Another problem is that it is not possible to correlate pathology INR results with which patients in the Trust are on anticoagulant therapy. In order to comply with the ongoing audit requirements of anticoagulant therapy in the Trust more audit resource will be required.

1.3 Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

1.3.1 Progress on the recommendations in this report is as follows:

• A documented mandatory VTE risk assessment of every hospitalised patient on admission.

o A risk assessment tool has been developed for patients attending surgical pre-assessment. It is planned to develop this for all inpatients, including medical and cancer patients.

• All medical patients should be considered for thromboprophylaxis measures.

o Thromboprophylaxis guidelines have been produced for all inpatients and are in the red book, ‘Local clinical guidelines’ 17th edition, August 2007.

o A patient information leaflet ’Advice on reducing the risk of a blood clot’ for medical and cancer inpatients.

• All surgical/orthopaedic patients should be managed according to the NICE guideline.

o Guidance in the red book and in the Trust ‘Guideline for thromboprophylaxis for inpatients undergoing surgery’ are in line with the NICE guideline with the proviso in 1.1.2 above about orthopaedic patients requiring extended prophylaxis.

• Hospitals may wish to set up Trust Thrombosis Committees, similar to those for managing hospital transfusion.

o It has been agreed that the Hospital Transfusion Committee will have a Part 2 to deal with thrombosis matters. This will save having an extra committee and make the best use of individuals’ time as the same people are involved in both areas.

2.0 Risk Assessment

A risk assessment of the Trust’s ability to comply with this guidance and meet the Annual Health Check proposal for VTE prophylaxis in the form of risk assessment on admission to hospital has been carried out. As can be seen from the table below there are currently significant risks to the Trust for patient injury, poor patient experience, complaints and external inspection which all have scores of 8-12 and moderate risk for adverse publicity with a score of 6. The Trust has had to deal with a number of patient complaints and serious untoward incidents involving thromboprophylaxis and the treatment of thrombosis over the past couple of years.

Frequency = 3 for all consequences to the risks below

|Risk |Consequence |Risk rating |

|Injury |4 |12 |

|Patient experience |4 |12 |

|Complaints |4 |12 |

|External body’s inspection |3 |9 |

|Adverse publicity |2 |6 |

3.0 Recommendations

The Anticoagulant Working Group recommends the following actions to the trust:

7. The Trust accepts this report as representing the progress made with these three pieces of NHS guidance.

8. The Trust recognises that every effort has been and is being made to comply with and implement the guidance within current resources.

9. To enable the audit requirements to be met a dedicated person is identified to carry out the audits

10. To enable the training and competency assessment requirements to be met a dedicated person is identified to carry out this work

11. To comply with the Annual Health Check requirement in the next financial year for VTE prophylaxis the Trust will need extra support in this area.

12. The support required could be delivered by the appointment of a thrombosis practitioner with a remit similar to that of the Trust’s transfusion practitioner.

A business case for a thrombosis practitioner has been developed and submitted to the Director of Nursing and Operations. Staff with a nursing, pharmacy or laboratory background would have suitable knowledge and skills for such a post. Most trusts in England employ an anticoagulant practitioner to manage the anticoagulant clinic. At the Royal Surrey this work is currently managed by the consultant haematologists. Therefore the Trust does not have someone in post who can take on this work.

4.0 References

4. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’ NICE clinical guideline no. 46, April 2007.

5. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’ National Patient Safety Agency, 28 March 2007.

6. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’ Chief Medical Officer, Department of Health, March 2007.

Appendix 1 Summary of action plan

|Action Plan for NPSA Patient safety Alert 18 and NICE CG 46 |Lead |Score |Deadline |Comments |

|1 Ensure all staff caring for patients on anticoagulant therapy have the necessary work competences. Any gaps |Janet Shirley, Jenny |48.89% |31/03/2008 |Extra resource is required for staff |

|in competence must be addressed through training to ensure that all staff may undertake their duties safely. |Faulkner ,Bhulesh | | |training. For doctors need to assess via |

| |Vadher | | |DOPS. Assessment tool for this needs to be |

| | | | |produced. Monitoring e-learning package |

| | | | |will also require extra resource |

|2 Review and, where necessary, update written procedures and clinical protocols for anticoagulant services to |Janet Shirley and |94.44% |30/09/2007 |All actions complete and further actions |

|ensure they reflect safe practice, and that staff are trained in these procedures. |Jenny Faulkner to | | |will require a computerised system |

| |include in training. | | | |

|3 Audit anticoagulant services using BSH/NPSA safety indicators as part of the annual medicines management |Janet Shirley, Helen |69.12% |31/03/2008 |This will involve a large manual resource |

|audit programme. The audit results should inform local actions to improve the safe use of anticoagulants, and |Brady, Bhulesh | | |if we are unable to provide an IT solution.|

|should be communicated to clinical governance, and drugs and therapeutics committees (or equivalent). This |Vadher, Clive White | | |Ideally this audit work should be carried |

|information should be used by commissioners and external organisations as part of the commissioning and |and Paul Chappell | | |out via dedicated person, supported by |

|performance management process. | | | |clinician with knowledge of |

| | | | |anticoagulation. The group still considered|

| | | | |the need for anticoagulation Nurse or |

| | | | |pharmacist with appropriate anticoagulation|

| | | | |soft ware essential in order to meet NPSA |

| | | | |guidance requirements |

|4 Ensure that patients prescribed anticoagulants receive appropriate verbal and written information at the | Bhulesh Vadher, |90.00% |30/09/2007 |0 |

|start of therapy, at hospital discharge, on the first anticoagulant clinic appointment, and when necessary |Janet Shirley | | | |

|throughout the course of their treatment. The BSH and the NPSA have updated the patient-held information | | | | |

|(yellow) booklet. | | | | |

|5 Promote safe practice with prescribers and pharmacists to check that patients’ blood clotting (International|Bhulesh Vadher to |90.00% |31/03/2008 |This is near completion and due to CRS |

|Normalised Ratio, INR) is being monitored regularly and that the INR level is safe before issuing or |look at prescribing | | |project is unlikely to be better then 75% |

|dispensing repeat prescriptions for oral anticoagulants. |procedures and Paul | | |until adopted as a CRS standard |

| |Chappell to look at | | | |

| |how to ensure INR | | | |

| |results are available| | | |

| |to pharmacy | | | |

|6 Promote safe practice for prescribers co-prescribing one or more clinically significant interacting | Bhulesh Vadher |62.50% |31/03/2008 |0 |

|medicines for patients already on oral anticoagulants; to make arrangements for additional INR blood tests, | | | | |

|and to inform the anticoagulant service that an interacting medicine has been prescribed. Ensure that those | | | | |

|dispensing clinically significant interacting medicines for these patients check that these additional safety | | | | |

|precautions have been taken. | | | | |

|7 Ensure that dental practitioners manage patients on anticoagulants according to evidence-based therapeutic |Janet Shirley to |100.00% |31/12/2007 |This is an action for Surrey PCT now to |

|guidelines. In most cases, dental treatment should proceed as normal and oral anticoagulant treatment should |liaise with Carrie | | |complete |

|not be stopped or the dosage decreased inappropriately. |Newlands | | | |

|8 Amend local policies to standardise the range of anticoagulant products used, incorporating characteristics |Janet Shirley, |100.00% |31/12/2007 |Products reviewed and change agreed by DTC.|

|identified by patients as promoting safer use. |Bhulesh Vadher | | | |

|9 Promote the use of written safe practice procedures for the administration of anticoagulants in social care |Janet Shirley |N/A |31/03/2008 |This is an action that needs to implemented|

|settings. It is safe practice for all dose changes to be confirmed in writing by the prescriber. A risk | | | |by Surrey PCT |

|assessment should be undertaken on the use of Monitored Dosage Systems for anticoagulants for individual | | | | |

|patients. The general use of Monitored Dosage Systems for anticoagulants should be minimised as dosage changes| | | | |

|using these systems are more difficult. | | | | |

|10 Impliement NICE guidance on Venous Thromboembolism Clinical Guideline 46 |Janet Shirley |61.50% |31/03/2008 |0 |

| | | | | |

Report for the Thrombosis Committee, Part 2 of the Hospital Transfusion Committee

Author: Dr. Janet Shirley

Date: August 2008

This is the second report to the Thrombosis Committee on the implementation of the three pieces of NHS guidance published in March and April 2007:

• NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

• National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’

• Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

Work has been completed on:

• Updating current Trust guidelines

• Producing new guidelines

• Providing written patient information

• Reviewing anticoagulant clinic procedures

• Promoting safe prescribing practices

• Standardising the anticoagulant drugs across the Trust

• Liaising with dental and primary care practitioners to promote safe practices

• The audit requirements in the NPSA alert for 2007/08

• Rolling out the Trust thromboprophylaxis policy

• Training the junior doctors

• Developing the competency assessments for medical staff in thromboprophylaxis and anticoagulation

• Putting forward the business case for a thrombosis practitioner to support audit and training in anticoagulation and thromboprophylaxis across the Trust and to support the haematology consultants in delivering the service. Funding has been agreed for 0.5 WTE which will support the anticoagulant service but is not sufficient to support the thromboprophylaxis service.

Work is in progress on:

• Installing the software for computerised assisted dosing support to the anticoagulant clinic. It is hoped to implement this during September 2008.

• A baseline audit of thromboprophylaxis across the Trust. This will be carried out during September and October 2008.

Work outstanding is:

• Auditing the implementation of the new guidelines across the Trust

• Ongoing audits of anticoagulation and thromboprophylaxis – the computerised anticoagulant package will enable audits of the outpatient management of anticoagulation to be carried out but auditing the inpatients will still be very time consuming and require significant audit resource.

• Training nursing and pharmacy staff in anticoagulation and thromboprophylaxis

• Competency assessing all staff involved in anticoagulation and thromboprophylaxis

• Appointing the 0.5 WTE Anticoagulant Practitioner for which funding has been agreed. Agenda for Change have had the relevant paperwork for two months and have not completed the grading.

The main barrier to further progress is:

• Lack of sufficient audit, training and competency assessment support

It is highly likely that one of the new targets in the Annual Health Check for 2009/2010 will be ‘VTE prophylaxis in the form of risk assessment on admission to hospital’. This work will not be possible without extra support.

Capacity in the anticoagulant Clinic

Since the beginning of this year problems have arisen with the number of patients being referred to the anticoagulant clinic. At present this is a consultant led clinic and has capacity for 20 patients to be seen by the consultant haematologist on a Friday morning. Until April 2008 the GPs in our area initiated anticoagulation in patients starting Warfarin for atrial fibrillation. Surrey PCT has decided to standardise anticoagulant provision across all of Surrey and are encouraging GPs to manage their own anticoagulant patients once they have been stabilised. They have put in place common protocols and training but have decided that none of the GPs should initiate anticoagulation under the new PCT arrangements. As our GPs will no longer be paid to do this and the PCT does not want them to do it all AF patients requiring anticoagulation are being referred to the hospital anticoagulant clinic. We are being swamped with referrals and cannot accommodate the number. This means that we are having to delay starting the AF patients on Warfarin because the patients already on Warfarin must take precedence.

This problem will be eased when we have an Anticoagulant Practitioner in post because we shall be able to put in place another clinic bringing weekly capacity to 25-30 patients (in general Anticoagulant Practitioners can see 10-15 patients per clinic). However this may not be sufficient as we have increased the number of patients seen in the clinic to 25 and still cannot see them all. It is putting a great strain on the clinic consultant, phlebotomy and laboratory staff trying to see this number of patients. It will probably be next year by the time someone is recruited to the post of Anticoagulant Practitioner and trained.

Dr. Robbins and I are trying to find some way in the short term of addressing the problem but it is not going to be easily solved as we do not have space in our current timetables to run a second clinic each week. When the Anticoagulant Practitioner is in post there will still be ongoing problems arranging to cover annual leave. The ideal solution would be to have two part-time practitioners who could cover each other. This would also enable them to manage the inpatient anticoagulation and thromboprophylaxis and take on much of the audit work and some training of staff.

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