ADAS Anticoagulant Dosing and Advisory Service Bev Straker-Bennett / Sean O’Brien Senior Specialist Anticoagulation BMS’s Jan 2018

Service Provision ADAS is a Consultant led service managed by the Pathology Directorate. Provides POCT and computer assisted dosing advice to 6000 registered patients on oral anticoagulant therapy. The service is delivered by Biomedical Scientists, Nurses and Medical Laboratory Assistants. All clinics are community based. Daily housebound patient service.

Community Clinic sites

Additional provision Direct link to outpatient DVT service. Pre op management of patients awaiting Cardioversion or Ablation. Pre and Post op management of Colonoscopy patients. Pre op management of Cataract patients. Reversal of over Anticoagulated patients with Oral Vitamin K, including 24 hour follow up, within community clinics. DOAC’s Initiation / safety checks / drug switches, 3 week follow up

Cardioversion management Comprehensive Initiation / Education for all new starters. Warfarin and DOAC’s DOAC safety checks / 3 week follow up Fully compliant with NPSA recommendations   ADAS Blackpool Fylde Wyre BVH Wards Point of care Team Gastro- Enterology Colonoscopy Opthalmology Cataract patients Ambulatory DVT services. GP Led Cardiology Ablation Cardioversion management Comprehensive management of patients awaiting cardiovascular procedures Warfarin dosing for intermediate care units. Management of pre procedure INR levels. Direct links with DVT service. Pathway for LMWH developed by ADAS. Management of pre procedure INR levels.

Current DOAC concerns Variation in initiation between medics both primary and secondary care. Inconsistent education for patients Patients presenting to ADAS clinics for advice. Patients prescribed a DOAC with contraindications. Patients on both warfarin and a DOAC. Switches done without renal bloods or INR checks. NICE guidance not followed. Switches done when INR is above recommended level (bleeding risks). Patients on the wrong doses of DOACs / no follow up checks. GP’s / nurses phoning ADAS for DOAC advice and switch assistance.

Proposed Simple Safe Pathway for all Anticoagulants Patient requires Anticoagulation Proposed Simple Safe Pathway for all Anticoagulants Medics to discuss options with patient following trust guidelines and prescribe appropriate Anticoagulant. NEXUS referral made to Adas. DOAC or Warfarin Anticoagulation Initiated by Medic Anticoagulation Initiated / switched by Adas Education on chosen Anticoagulant. Safety Checks performed. Patient registered on centralised database Warfarin INR checked. Dosed amended/initiated. Follow up appointments in clinics arranged. DOAC Patient seen for three week follow up appointment to discuss issues/side effects Regular monitoring TTR/VGR review. Reports sent to GP Discharged to GP care. All carers informed of medication changes if a switch of Anticoagulant has occurred

Benefits of the pathway Centralisation of all anticoagulant patients (universal anticoagulant database). Auditable, consistent, comprehensive education for all patients/carers. Less Medic time/confusion on who is educating patients. Safe medication switches. Secondary safety check to ensure: no contraindications (drugs or conditions) bloodwork is done and results appropriate correct dosage appropriate treatment duration 3 week DOAC review Compliance for NRLS (NPSA) / NICE recommendations.