Review communication between secondary and primary care concerning the initiation and transfer of care for DOAC patients
Review monitoring of DOAC agents- ensuring at least annual full blood counts (FBC), liver function tests (LFTs) and renal function checks with a frequency based on an accurate and up-to-date creatinine clearance (CrCl) calculation
Ensure patients with co-morbidities that contra-indicate DOAC use or co-prescribed medicines that affect bleeding risk are reviewed to safeguard patients
Ensure that patients with potential dose changes due to over/under-coagulation are reviewed urgently by risk stratifying audit results so that red colour coded patients are reviewed as a priority- encouraging practice-based pharmacists to take on this role where possible and support primary care with guidance and education sessions
Ensure GP surgeries have a process in place for the review of DOAC patients according to local South East London (SEL) guidance- this will be checked in a repeat audit for 2020/21 for new DOAC patients
The outcomes of the project are:
Improved transfer between settings through changes in communication and patient pathway development for DOACs: 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. Proposed changes: 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
Education sessions (Southwark CCG) and guidance (SEL) concerning required monitoring for DOACs: Ensuring that patients are safely monitored through risk-stratification of audit results for GP practices to action, and local guidance to ensure a consistent approach to this across South East London (this is also undergoing approval in South West London)
Patients with DOAC contra-indications (CIs) and interacting medications were identified through the audit and risk-stratified as red- requiring immediate action for primary care healthcare professionals (HCPs): 38 of these patients were highlighted to HCPs at the time of audit data collection as requiring an immediate action to reduce the risk of serious harm
Prioritising a review of patients requiring a potential dose change (through red risk-stratification in audit data- 51% of patients had a red action). Following these learning points, guidance has been approved and is in consultation across SEL to assist the DOAC prescribing process and there is now a SEL-wide focus on preferred DOAC agents for NVAF and VTE to encourage familiarity with two DOAC agents and their dosing requirements to reduce the risk of error.
Asking for feedback/actions taken from GP practices: To ensure that processes are in place to safeguard DOAC patients through continued monitoring at scheduled time periods and for new DOAC patients not reviewed in the initial audit data collection.
