Summary

The Southern Health and Social Care Trust’s anticoagulant team developed guidelines to promote the safe use of Direct Oral Anticoagulants (DOACs) and assist clinicians in initiating the medicines. The team identified an opportunity to change first line treatment for patients presenting with a DVT from warfarin and a low molecular weight heparin (LMWH) to rivaroxaban. By changing the treatment, patients would benefit by not having to return to ED for daily injections until their INR was therapeutic. On implementation, an immediate drop in the number of ED DVT clinic attendances and a fall in the average number of patient visits was seen. The anticoagulant team also audited prescribing practices for patients newly started on DOACs in hospital and measured the impact that DOAC use had on inpatient stay on the acute stroke ward.  

Challenge

The anticoagulant team decided to offer rivaroxaban as first line treatment for DVT treatment - DOACs have been shown to be as safe and effective as warfarin in clinical trials and have several benefits. However, for reasons of intolerance, fear of warfarin or resistance to routine monitoring, many patients are either receiving anti-platelets or no anti-thrombotic treatment. 

Objectives

To change the first line treatment of DVTs in the ED from warfarin and LMWH to rivaroxaban, which was approved by NICE in July 2012 for the purpose. To audit the impact the change had on both patients and the ED, measuring the number of patient visits to the ED both before and after the change of treatment, as well as any cost difference. To audit the inpatient and discharge prescribing practices of the DOACs by the medical staff on all the wards over a six-month period and the length of hospital stay of patients on the Acute Stroke Ward - to allow a comparison to be made for patients commenced on warfarin compared with those on a DOAC. The data would be used in healthcare staff training sessions and to promote further safe and appropriate use of DOACs in the Southern Trust.

Solution

A diagnostic algorithm was designed, based on NICE guidelines, ensuring patients were assessed and diagnosed appropriately. If a DVT was confirmed, the anticoagulant pharmacist was contacted and followed a DVT treatment algorithm. The pharmacist took a detailed drug history from the patient, checking if the patient was on aspirin, on any medicines that may interact with anticoagulants or had any allergies. The patient’s weight, age and creatinine level were recorded and Creatinine Clearance was calculated using the Cockcroft Gault equation. This was to check if the patient was a suitable candidate for rivaroxaban. Baseline bloods were requested, a pregnancy test performed if appropriate and a Bone Profile was requested if the patient had an unprovoked DVT/PE. Patients who were commenced on rivaroxaban were counselled on their medication, given a supply of medication, give written information on the drug along with an alert card, and advised that they would be contacted by telephone approximately one month after starting treatment by the anticoagulant pharmacist. Patients on enoxaparin and warfarin were seen daily in ED until their INR was therapeutic, when care was transferred to the weekly anticoagulant clinic in the Out-Patient Department. The anticoagulant pharmacist was available to the ED each morning from Monday to Friday. Outside these hours, patients were treated with enoxaparin and given an appointment to return to ED to see the pharmacist. Letters were sent to each patient’s GP informing of the treatment plan, any changes in medication, future dose changes and required follow-up – these letters also were uploaded onto the Northern Ireland Electronic Care Record. 

Results

In 2012, before the introduction of rivaroxaban as first line treatment, 72 patients were diagnosed with a DVT and treated with enoxaparin and warfarin. There were a total of 457 patient attendances in total, with each patient attending on average 6.35 times. A total of 93 patients were diagnosed with a DVT in 2013, but the number of patient attendances dropped to 229, with the average patient attending the ED 2.46 times. In 2014, the use of rivaroxaban as a first line treatment had gained momentum and was used in the majority of cases. 86 patients were diagnosed with a DVT and in total for this year there were 134 patient attendances to ED. This meant that each patient diagnosed with a DVT attended ED on average 1.56 times. This initiative has greatly relieved the burden on the Clinical Decision Unit in ED and the initiative has been welcomed by staff working there. In the Acute Stroke Ward, patients commenced on a DOAC had a shorter inpatient stay than those commenced on warfarin. In total 11 patients were commenced on warfarin and length of stay was, on average, 6 days. There were 22 patients commenced on DOACs and these patients were discharged on average 4 days after admission. Patients on DOACs spent 33% less time as an inpatient and as result these medications have the potential to have a massive impact on the patient’s journey through the hospital. 

Learnings

It is important to be consistent with the advice provided and versatile when dealing different staff groups that require training. We also learned from experience the types of questions patients asked and how to respond to them. The biggest challenge was ensuring good communication between secondary and primary care after initiation and ensuring that patients received the relevant information and counselling when the drug was initiated and that this was documented in their notes. 

Evaluation

As part of the initiative, patients were contacted one month after starting the drug and asked some questions regarding their treatment. The feedback received was very positive with the vast majority of patients very happy with their treatment, in particular not having to return to ED for daily INR monitoring and daily injections. The clinician and patient feedback of this project was used to implement rivaroxaban as first line treatment for DVT and then PE across the trust for all inpatients. This included the value in standardising patient’s treatment, patient education, healthcare staff awareness and GP communication for the transfer of care. There were eight audit standards and information was obtained from patient notes and from the electronic discharge system.