Service Specification s1

Introduction

Warfarin is being used in the management of increasing numbers of patients and conditions including post-myocardial infarction, atrial fibrillation, DVTs & other disorders. Details of current guidance re: warfarin use in various clinical conditions may be found within the British Journal of Haematology, Guidelines on oral anticoagulation with warfarin - 4th edition.

Warfarin is the number one drug which causes harm to patients in Scotland. Warfarin is a vitamin K antagonist, interferes with the operation of vitamin K in blood coagulation. The effect does not kick in immediately, and a single dose can be active from 2 to 5 days. Moreover, Warfarin interacts with a wide range of other common medications (such as aspirin or ibuprofen), as well as with many basic foodstuffs which patients may regard as safe such as kale or spinach. While it is a very effective drug in a wide variety of clinical conditions, warfarin can also have serious side effects, e.g. severe haemorrhage. These side effects relate to the International Normalised Ratio (INR) level, which measures the delay in the clotting of the blood caused by warfarin. While the “normal” INR is 1, the specific range of INR values depends on the disease and the clinical conditions. Monitoring aims to stabilise the INR within set limits to help prevent serious side-effects while maximising effective treatment.

Achieving a dosage that is both safe for the patient and sufficient to prevent thrombotic events therefore requires a disciplined approach to both blood testing and patient prescribing. This is fundamental to patient care and safety, and needs to include ongoing one-to-one patient education.

Additional information and resources can be found on the SPSP-Primary CareCommunity Knowledge website

Service Specification

An anti-coagulation monitoring service is designed to be one in which:

·  therapy should normally initiated in Primary or Secondary care, for recognised indications for specified lengths of time

·  maintenance of patients should be properly controlled

·  the service to the patient is convenient

·  the need for continuation of therapy is reviewed regularly

·  the therapy is discontinued when appropriate

Practice requirements

(i) Development and maintenance of a register: Practices should be able to produce an up-to-date register of all anti-coagulation monitoring service patients, indicating patient name, date of birth, the indication for and length of treatment, including the target INR.

(ii) Call and recall: To ensure that systematic call and recall of patients on this register is taking place. To ensure that INRs are taken at a frequency set by local guidelines or approved software, that the dose is set by the same manner and the patient retested within 7 days of the planned repeat INR.

(iii) Dosage and compliance: The practice will use local guidance or preferably computer assisted decision making to prescribe the dose or warfarin and set the interval to the next INR test. They will also check at testing that the patient has been taking the dose as set at the previous test.

The average dose of warfarin required daily is around 5 mg (range 1-9 mg) but may vary markedly because of several factors. Warfarin should be given once daily (5-6 pm is an ideal time) and is given as a tablet for oral administration. [Tablet strengths are 1 mg (brown), 3 mg (blue), 0.5 mg (white).] The use of the 5mg (pink) tablets is not recommended within NHS Borders due to the potential confusion with the 0.5mg tablet.

It is strongly recommended that a suitable, approved computerized program is utilised for the dosage regime for warfarin as well as the testing intervals. This has been shown to provide faster achievement of the desired level of anticoagulation together with more appropriate recall dates than any manual system. Locally approved systems include Bluebay Warfarin package, INRstar, RAT and Dawn.

(iv) Professional links: To work together with other professionals when appropriate. Any health professionals involved in the care of patients in the programme should be appropriately trained.

(v) Education and newly diagnosed patients: To ensure that all newly diagnosed patients (and/or their carers and support staff when appropriate) receive appropriate management and prevention of secondary complications of their condition including the provision of a patient-held anticoagulant booklet including written information on anticoagulant therapy. Patient understanding and compliance should be checked regularly and education reinforced at least 6 monthly. An example of an approved warfarin information sheet is provided in the Appendix for your use in conjunction with the yellow warfarin booklets. Information re: practice ordering of the ‘yellow books’ is also included.

(vi) Individual management plans: To prepare with the patient an individual management plan, giving the diagnosis, planned duration and therapeutic range to be obtained.

(vii) Record-keeping: To maintain adequate records of the performance and result of the service provided, incorporating relevant known information, as appropriate.

(viii) Training: Each practice must ensure that all staff involved in providing any aspect of care under this scheme have the necessary training and skills to do so.

(ix) Untoward events: Practitioners will undertake a Significant Event Analysis (SEA) for any hospitalisation or death occurring as a direct result of the patient being on warfarin i.e. haemorrhage or extreme INR result.

Practices using commercial INR measuring devices are responsible for ensuring adequate in house training, quality assurance and governance arrangements surrounding their use.

Funding

Each practice contracted to provide this service will receive payment according to the level at which they are working for individual patients:

Level 1 – laboratory outreach sampling, test and dose

Level 2 – Health Board or other externally funded phlebotomist or pharmacist etc., practice sample, laboratory test, practice dosing

·  Level 2 service £ 95.90 per patient per year

Level 3 – Practice-funded phlebotomist or pharmacist etc, practice sample, laboratory test, practice dosing

·  Level 3 service £ 106.56 per patient per year

Level 4 – Practice-funded phlebotomist or pharmacist etc, practice sample, practice test, practice dosing

·  Level 4 Service £ 115.20 per patient per year Most practices are currently paid at Level 3. We anticipate and encourage movement towards Level 4 payments with the practices obtaining commercial INR measuring devices (e.g. Coaguchek ©) and thereby offering a complete “in-house” service of recalling, testing and dose alteration within primary care. This has additional benefits of being able to advise the patient of their new dose and retest date whilst they are at the surgery being tested.

APPENDIX

Patient information leaflet and warfarin ‘yellow books’

The following generic Warfarin Patient Information leaflet can be used in conjunction with the patient-held warfarin yellow book. A link to this leaflet is also available on the Warfarin Enhanced Service RefHelp information page:

Practices can order copies of the yellow warfarin patient information booklets for free via the following company:

APS Group

E-mail or phone: 0131 629 9938

Please sign and return this completed form only to confirm your participation.

NHS Borders Enhanced Service Programme for

Primary & Community Services

NHS Borders Local Enhanced Service 2016/17

For Warfarin Anti-Coagulant Monitoring

Practice Name: ______

Practice No: ______

Signed for and on behalf of the Practice ______

Please print name and designation ______

Date ______

Notice Period

In the event of a practice being unable to maintain the service for the duration of the contract or wishing to opt out, an appropriate period of notice will be agreed with NHS Borders (normally 3 months).

The payments will be subject to the normal payment verification processes.

Forms should be returned to Louise Patterson-Coltman in BGH.

e-mail:

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