Introduction: Appropriate monitoring of direct oral anticoagulants (DOACs) is key to ensuring safe prescribing and optimal patient outcomes.
The aims of the project were to:
1. Review communication between secondary and primary care concerning the initiation and transfer of care for DOAC patients.
2. Review the monitoring of DOAC agents to ensure a bodyweight, full blood count (FBC), liver function tests (LFTs) and renal function checks (resulting in an up-to-date creatinine clearance calculation- CrCl) were recorded at appropriate intervals.
3. Ensure that patients requiring a DOAC dose change were highlighted for urgent review by the GP practice- audit results were risk stratified- red colour-coded patients were reviewed as a priority. Practice-based pharmacists were encouraged to take on this role where possible and primary care teams supported with guidance and education sessions.
4.Review patients with contra-indications or cautions to DOACs, co-morbidities and / or concomitant medicines that affect bleeding risk to address any safety issues.
5. Ensure GP surgeries have a process in place for the systematic review of DOAC patients according to local SEL guidance- this was checked in a repeat audit for new DOAC patients.
The outcomes of the project are:
1. An improved transfer process between settings through changes in communication and patient pathway development for DOACs in SEL: Removal of initiation and transfer of care forms for DOAC patients across SEL- the forms were not being completed by all specialities and/or GP systems were not coding them correctly: for the first 883 patients audited- only 38% of GPs had received initiation and transfer of care forms. Changes made: a) to utilise hospital discharge letters and clinic letters with updated IT systems to incorporate required baseline data for DOACs at discharge from hospital and/or at the transfer of prescribing to primary care b) Clearly defined DOAC patient pathways to risk-stratify monitoring and prescribing responsibilities for secondary and primary care.
2. Improved consistency for DOAC monitoring: In the first audit, 795/2115 (38%) of patients required an up-to-date renal function calculation before DOAC recommendations/actions could be made, 163/2115 (8%) of patients required a FBC and 218/2115 (10%) of patients required LFTs. In the repeated audit, 206/221 (93%) of patients had at least annual blood tests – only 5 patients required CrCl, FBC and LFT checks.
3. Improved patient safety: 1024/2115 (48%) of patients had an urgent follow up action (eg. a renal function check and/or a DOAC dose change) - of the patients with an accurate CrCl, 21 patients required an increased DOAC dose to optimise protection from an AF-related stroke or thromboembolism and 47 patients required a reduced DOAC dose in line with SmPC recommendations.
4. Improved management for high-risk medicines: 39 patients were referred to a specialist (eg for a review of APLS indication, antiplatelet therapy, low haemoglobin/platelets) and 36 DOACs, 36 antiplatelets and 5 NSAIDs were stopped/deprescribed.
5. Improved prescribing competence and monitoring processes at practice level: Following these learning points, guidance has been approved across SEL to assist the DOAC prescribing and monitoring process in primary care.
The ICS teams also work collaboratively on the initiation of preferred DOAC agents for NVAF and VTE to encourage familiarity with two DOAC agents and their dosing requirements to reduce the risk of error. Feedback/actions taken from GP practices ensured that processes are in place to safeguard DOAC patients as routine clinical practice through continued monitoring at scheduled time periods. This improvement is evident in the results of the repeated audit.
