Atrial Fibrillation (AF) has been recognised as one of the major causes of stroke, heart failure, sudden death and cardio-vascular morbidity in the UK. The publication of the NICE Clinical Guidance for Atrial Fibrillation (2014) and subsequent Quality Standard (2015) prompted the Anticoagulation Service within City Health Care Partnership to undertake a clinical audit to capture the prevalence and compliance with the NICE key recommendations.
A retrospective review of secondary data, held within clinical care records was accessed to determine which patients fitted the guidance-eligibility criteria and to extract the relevant data.
Key findings indicated that;
- 2224 patients receiving Anticoagulation Service care had a diagnosis of Atrial Fibrillation
- 510 patients exhibited poor anticoagulation control
- 214 of these patients had 1 or more contributory factor most commonly interacting drugs
- 296 patients had no contributory factors documented
- Atrial fibrillation (QS93)
Aims and objectives
The overall aim of this project was to capture the prevalence of patients with AF on warfarin for stroke control exhibiting poor anticoagulation control and to introduce measures to address this as identified within the NICE guidance.
- To identify patients with a diagnosis of AF who fit the criteria for poor anticoagulation control
- To identify factors with the potential to contribute to poor anticoagulation control that have been addressed by the Anticoagulation Service CHCP in line with NICE guidance.
- To inform patients GP:
- Of patients poor anticoagulation control mapped against explicit NICE criteria
- Of possible factors contributing to the patients poor anticoagulation (care management strategies have been attempted by the Anticoagulation Service to no avail).
- To request an anticoagulation review from patients GP with consideration to be given to switching the patient from warfarin to a DOAC if the patient fits the criteria.
- To request GP informs the Anticoagulation Service CHCP of decision regarding future anticoagulation management.
Reasons for implementing your project
Prior to this project the Anticoagulation Service CHCP nurses reviewed all patients’ anticoagulation control at every patient consultation identifying factors contributing to poor control and if identified working with patients to address these factors.
Despite this input from the anticoagulation nurses for a variety of reasons poor anticoagulation control persists for a number of patients. The issue of on-going poor anticoagulation control for some patients with AF on warfarin, despite intensive monitoring and education from nurses within the Anticoagulation Service CHCP and the risks associated with this were highlighted to the Clinical Commissioning Group (CCG) who agreed this cohort of patients must be highlighted to their own GP for anticoagulation review with consideration given to stopping or changing anticoagulation therapy dependent on individual patient need.
Following identification of patients that fit the NICE (2015) criteria for poor anticoagulation control, letters were forwarded to patients GP and the patients was informed of this at the next consultation with the Anticoagulation Service.
At the time of completing this project 57% of patients managed by the Anticoagulation Service CHCP were patients on warfarin for AF, this equate to over 2200 patients. Following retrieval and analysis of the data 23% of patients with AF fit the NICE (2015) criteria for poor anticoagulation control, this equates to 510 patients who were subsequently included in this project as they required review of anticoagulation management with consideration of a switch to a DOAC where appropriate.
Six months data (August-November 2015) was abstracted through a retrospective review of patient electronic case notes which identified patients fitting the criteria for poor anticoagulation and also identified any potential contributory factors. The benefits for patient included a medication review by GP and switching to DOAC if appropriate. Resulting in better Anticoagulation control, less clinic attendances, less medication interactions, less restrictions on diet.
How did you implement the project
In order to fully comply with Quality Statement 4: Anticoagulation control (NICE Atrial Fibrillation Quality Standard, 2015) a retrospective audit using secondary data recorded within electronic care records was utilised to capture quantifiable data for analysis.
Using the anticoagulation software utilised within the Anticoagulation Service CHCP a report was constructed to identify patients suitable for this project by applying the inclusion criteria of:
- Aged 18 or over
- Diagnosis of AF
- Patient has completed the initiation period
- Patient fits one or more of the criteria for poor anticoagulation control:
- 2 INR values higher than 5 or 1 INR value higher than 8 within the past 6 months
- 2 INR values less than 1.5 within the last 6 months
- TTR less than 65%
Six months data (June-November 2015) was abstracted through a retrospective review of patient electronic case notes which identified patients fitting the criteria for poor anticoagulation and also identified any potential contributory factors. One person completed the majority of this project including the review of all relevant patient case notes and the completion of relevant documentation to the patients GP.
This inevitably meant there was, on occasions, a time lapse between the pulling of the original report and the reviewing of the case notes. This could potentially affect the accuracy of the TTR on the report as TTR’s fluctuate in response to each INR recorded. Steps were taken to address this by reviewing the current TTR in the patient’s case notes rather than relying solely on the TTR in the report. Also, as anticoagulation control including TTR is reviewed on a regular basis for all patients during routine anticoagulation appointments this was not viewed as a significant risk. This approach did have the advantage of maintaining consistency.
No services were discontinued as a result of the project. Minimal cost incurred to the Anticoagulation Service as the in-house practice development nurse undertook the project, the only costs were printing and stationary costs.
This project demonstrates that there are a significant number of patients with AF on warfarin for stroke prevention who have poor anticoagulation control. Because of the increased risk of thromboembolic events for these patients it is essential processes are in place to identify and manage this patient group.
This project offers one model to achieve this based on the AF Nice guidance (2015) and CCG advice. All relevant data was included on a spread sheet to allow for monitoring and audit of results. Relevant details were also added to the patient’s electronic case notes.
All GP responses regarding the outcome of the anticoagulation review were added to a spread sheet and results used to inform patient management and audit to allow for further analysis of the data produced.
The findings for patients whose GP returned the response letter to the Anticoagulation Service CHCP are that 53% or 97 patients continued on warfarin for varying reasons but the main reason being patient choice (57 patients). The decision to discontinue all anticoagulants was the outcome in 4% of reviews which equates to 7 patients. The remaining 43% or 80 patients were commenced on a direct oral anticoagulant (DOAC).
Key learning points
- For the full project to be carried out on an annual basis in line with NICE guidance and CCG advice.
- For Anticoagulation Service CHCP nurses to continue to monitor individual patient anticoagulation control at every consultation and to highlight identified issues to patients GP for review.
- To increase education for GP’s particularly around the risks associated with poor anticoagulation control for patients on warfarin and management of patients on DOACs.
- In future a team working on this project rather than an individual would ensure no time lapse occurs between generating the report and review individual patient notes.