Mara Znagoveanu

3rd year medical student

mz214@student.le.ac.uk

QUALITY
IMPROVEMENT
PROJECT
 Presentation Outline Background

Today's Topics Aims

Resources and research

Offering a DOAC to housebound patients on Warfarin, Results

if clinically suitable
Suggestions

Conclusion
Background

Description
Anticoagulant medication used for prophylaxis and
treatment of various condictions such as VTE, AF, PE

Dosing
Initial dose of 5-10 mg, subsequent doses calculated
using a patient's INR

Challenges
increased risk of haemorrhage
INR / dose affected by food, alcohol, medication
 NEXT

AIMS
Offering all housebound patients a
change from Warfarin to a DOAC, if
suitable

Desirable standard: 90%

Inclusion criteria:
housebound patients (home + care home)
diagnosed with atrial fibrillation

Exclusion criteria:
mechanical heart valve
creatinine clearance < 15 mL/min
 Resources and research

Identification
Selection
Using SystemOne to identify housebound patients
Identify patients who suffer from Atrial fibrillation out
who are currently undergoing Warfarin treatment
of those who are using Warfarin

Eligibility
Look at blood tests - creatinine clearnace most
important, but also FBC, LFTs, U&Es
Check whether the patients have a mechanical heart
valve.
Switch
Think about switching clinically suitable patients from
Warfarin to a DOAC after gaining their consent
Results
Out of the 12 housebound patients, currently on warfarin:

5 4 3
SUITABLE FOR
NOT SUITABLE ALREADY ON
DOAC - COULD
FOR DOAC DOAC
SWITCH NOW
Suggested improvements

01.OBTAIN RECENT BLOODS ( U&ES, LFTS AND Minimum monitoring frequency based on CrCl:
FBC) IF NOT ALREADY AVAILABLE(OBTAINED 12 monthly if CrCl > 60
WITHIN THE PAST 3 MONTHS) AND DETERMINE 6 monthly if CrCl between 45 and 59.9
CREATININE CLEARANCE 3 monthly if CrCl between 30 and 44.9

Considerations:
02.AT NEXT APPOINTMENT – CHECK INR, contraindications
RECORD WEIGHT AND CONFIRM LMSG CRITERIA dose adjustment
ARE MET interactions with other drugs

03. DOCTOR / PHARMACIST TO EXPLAIN Ensure patient / NOK is aware of:

DOAC TREATMENT TO PATIENT / NOK AND possible side effects
GAIN CONSENT FOR SWITCH importance of compliance
how to seek help / what to do in an emergency

Provide written instructions and involve family members /

04. PRESCRIBE DOAC AT APPROPRIATE
carers where possible to minimise the risk of patients taking
DOSE AND ADVISE PATIENT TO STOP
both warfarin and the DOAC concurrently
WARFARIN
Next steps
INITIATION
provide anticoagulation alert card
provide LMSG medicines leaflet
provide 28 day treatment
FOLLOW-UP
first review at 1 month
subsequent review scheduled based
on CrCl and requirements for re-
assessment
Implementation
and conclusions

In order to implement the new

medication:
I will give the pharmacy team the list of
the 5 housebound patients on warfarin
to investigate switching them to DOACs.

The pharmacist will be getting in contact

with these patients / their next of kin to
initiate the process of switching from
Warfarin to DOAC
THANK YOU FOR LISTENING

Time for questions, comments and

inquiries