Summary
To guard against the accidental administration of a novel oral anticoagulant (NOAC) to a patient for which one would not be suitable, silicone wrist alert bands were developed. An educational grant enabled the purchase 600 bands, coloured either red or blue, to give to patients beginning NOAC treatment following their stroke, in addition to their alert wallet card and written information. Only four months into the trial its success is evident. Only two patients declined a wrist band and all others continue to wear them - regardless of age. More importantly, increased patient compliance with treatment has been seen.
Challenge
The aim of NOACs is to reduce the incidence of ischaemic stroke for those people in atrial fibrillation, and one of their benefits over warfarin is the lack of requirement to monitor blood levels – but this has resulted in patients not considering these drugs with the same level of seriousness as vitamin K antagonists. Despite alert cards being issued and patients counselled prior to commencement of a NOAC, many lose the cards and forget the drug name by the time they are seen in clinic 4 weeks later. The reason for the formal study was a near-miss experienced while assessing a patient for thrombolysis: the patient was unable to speak as a result of the stroke, his wife had dementia and his son was not sure what he was taking although he had brought in his father’s current box of medication. This did not contain any blood thinners, although the patient was on a specific drug in its own dosset box, which the son had not found.
Objectives
To increase the understanding of the importance of this group of drugs by patients and thereby increase compliance and discussion of the drug (and its side effects) with family and healthcare providers.
Solution
An educational grant of £350 enabled the purchase of 600 silicone bands – 300 red, 300 blue. In order to increase patient control over their condition it was felt that a choice over colour would be more beneficial. Every patient who was commenced on a NOAC within the stroke service was offered a band and monitored regarding its success in continued wearing and conversation initiation with family, friends and healthcare professionals. This was monitored by discussion as part of their routine formal clinic appointment and by telephone consultation. The bands were either given in the ward (acute stroke unit) or clinic setting when the prescribing decision of NOACs was discussed with the patient. Within the clinic setting, if a patient had been commenced on a NOAC within the community, checking of the alert card occurred and a band was also offered at this time.
Results
The aim of the trial was to monitor the acceptability of patients to wearing a silicone band to identify a potential medical complication and to increase a patients’ understanding of the side effects of a drug – and the trial has been successful in this. To date 30 bands have been distributed and only 2 patients have now declined – 1 due to a latex allergy and the other due to a dislike of bands by the patients’ wife. Initially the trial involved only one practitioner issuing the bands, however this quickly increased to four with the two consultant stroke physicians and a stroke specialist nurse also issuing them. As part of ensuring GPs are kept up to date, a summary of the trial was included in the monthly communication paper to all GPs within the catchment area of Yeovil District Hospital Foundation Trust. Separate teaching and training to individual GP practices and to practice nurses has also included the use of the bands and there has been considerable support for the trial and the anticoagulation nurses within GP surgeries are keen to get involved, if a roll-out does occur. The aim now is to widen the trial to benefit a greater number of individuals.
Learnings
The trial has been small in size and therefore the workload is manageable and closely monitored. The funding from an educational grant has resulted in the company being aware, and interested in the outcomes, and the work has been discussed as part of the stroke steering group, so there is executive level support. These are the advantages of working in a small organisation. It is essential, however, that the roll-out is equally well prepared with staff having a good understanding of not only the drugs but the possible side-effects and the impact on the individuals at a practical level. Support and involvement of the pharmaceutical companies, Clinical Commissioning Groups and primary care providers is essential if mass-roll out is to occur. It is hoped, and envisaged, that this trial is the start of a journey of change and greater understanding of our patients.
Evaluation
All patients are seen post-discharge within 4-6 weeks, or typically 4 weeks post-clinic. At this follow-up appointment, patients are re-checked regarding the continued use of the band and also the correct storage of their alert card. This follow-up enabled the team to formally monitor the use, and perceived success, of the bands and greater understanding of the need to inform other healthcare providers of the use of NOACS.
