Suggested national enhancement scheme for anti-coagulation monitoring

National enhanced service
Anti-coagulation monitoring
1. All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification for the provision of anti-coagulant monitoringoutlines the more specialised services to be provided. The specification of this service is designed to coverthe enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services.
No part of the specification by commission, omission or implication defines or redefines essential oradditional services.
2. Warfarin is being used in the management of increasing numbers of patients and conditions including patients post-myodcardial infarction, atrial fibrillation, DVTs and other disorders. While it is a very effectivedrug in these conditions, it can also have serious side effects, eg severe haemorrhage. These side effectsare related to the International Normalised Ratio (INR) level, which measures the delay in the clotting of theblood caused by the warfarin. While the “normal” INR is 1, the specific range of INR values depends onthe disease and the clinical conditions. Warfarin monitoring aims to stabilise the INR within set limits tohelp prevent serious side-effects while maximising effective treatment.
3. An anti-coagulation monitoring service is designed to be one in which: therapy should normally initiated in secondary care, for recognised indications for specifiedlengths of time maintenance of patients should be properly controlled the need for continuation of therapy is reviewed regularly the therapy is discontinued when appropriate.
4. ‘Doser’ means any person who is suitably trained and qualified who, upon receipt of relevant information from laboratories or near-patient testing equipment or otherwise, with or without computer-assisteddecision-making equipment, determines as the relevant service may require, the anti-coagulant dosage forpatients of practitioners in a practice.
Service outline
5. This national enhanced service will fund: the development and maintenance of a register. Practices should be able to produce an up-
to-date register of all anti-coagulation monitoring service patients, indicating patient name, date
of birth, the indication for, and length of, treatment, including the target INR
call and recall. To ensure that systematic call and recall of patients on this register is taking
place either in a hospital or general practice setting
professional links. To work together with other professionals when appropriate. Any health
professionals involved in the care of patients in the programme should be appropriately trained
referral policies. When appropriate to refer patients promptly to other necessary services and to
the relevant support agencies using locally agreed guidelines where these exist
education and newly diagnosed patients. To ensure that all newly diagnosed patients
(and/or their carers and support staff when appropriate) receive appropriate management of, and
prevention of, secondary complications of their condition including the provision of a patient-held
individual management plan. To prepare with the patient an individual management plan,
which gives the diagnosis, planned duration and therapeutic range to be obtained
clinical procedures. To ensure that at initial diagnosis and at least annually an appropriate
review of the patient’s health is carried out including checks for potential complications and, as
necessary, a review of the patient’s own monitoring records. To ensure that all clinical
information related to the NES is recorded in the patient’s own GP held lifelong record, including
the completion of the “significant event” record that the patient is on warfarin
record-keeping. To maintain adequate records of the performance and result of the service
provided, incorporating appropriate known information, as appropriate. This may include the
number of bleeding episodes requiring hospital admission and deaths caused by anti-coagulants
audit. To carry out clinical audit of the care of patients against the above criteria, including
untoward incidents. This should also review the success of the practice in maintaining its patients
within the designated INR range as part of quality assurance
training. Each practice must ensure that all staff involved in providing any aspect of care under
this scheme have the necessary training and skills to do so
review. All practices involved in the scheme should perform an annual review which could
(a) information on the number of patients being monitored, the indications of anticoagulation, ie DVT etc, and the duration of treatment (b) brief details as to arrangements for each of the aspects highlighted above (c) details of any computer-assisted decision-making equipment used and arrangements for (d) details of any near-patient testing equipment used and arrangements for internal and (e) details of training and education relevant to the anti-coagulation monitoring service received (f) details of the standards used for the control of anti-coagulation.
Untoward events
6. It is a condition of participation in this NES that practitioners will give notification to the PCO clinical governance lead of all emergency admissions or deaths of any patient covered under this service, wheresuch admission or death is or may be due to usage of the drug(s) in question or attributable to the relevantunderlying medical condition. This must be reported within 72 hours of the information becoming knownto the practitioner. This is in addition to a practitioner’s statutory obligations.
7. Those doctors who have previously provided services similar to this enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence asis necessary to enable them to contract for the enhanced service shall be deemed professionally qualifiedto do so.
8. In 2003/04 each practice contracted to provide this service will receive: Level 1 – laboratory outreach sampling, test and dose Level 2 – HA, Trust or other externally funded phlebotomist or pharmacist etc., practice sample, laboratory test, practice dosing Level 3 – Practice-funded phlebotomist or pharmacist etc, practice sample, laboratory Level 4 – Practice-funded phlebotomist or pharmacist etc, practice sample, practice In addition to the above fees, where the sampling requires a domiciliary visit to a housebound patient on or behalf of the practice, and not by a member of staffemployed by an NHS body to provide community health services, an additional feewould be paid for each separate address visited on that day These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06. Warfarin prescribing guidelines
General guidance
1. This protocol sets out details for the care of patients taking warfarin. The patient should also have received advice and written information on anticoagulant therapy, normally in the form of an anticoagulantbooklet.
2. Warfarin use is increasing as new indications for its efficacy have been recently identified. Nevertheless, its use is associated with adverse effects, particularly bleeding, and optimum management can be achieved byshared care between hospital and general practitioner. The present indications for warfarin, together withthe presently agreed degree of anticoagulation for that indication are shown in the attached Tables 1 and2.
Table 1
Therapeutic recommended uses and International Normalised Ratios (INRs) for those uses
(British Society of Haematology)

Prophylaxis of postoperative deep vein thrombosis Prophylaxis of postoperative deep vein thrombosis in hip surgery and fractures Myocardial infarction: prevention of venous thromboembolism Recurrent deep vein thrombosis and pulmonary embolism Arterial disease including myocardial infarction Mechanical prosthetic valves (see table 2) Recommended INR for prosthetic valves
Sinus rhythm
Atrial fibrillation
normal left atrial size
enlarged left atrium
(i.e. most aortic valve
(i.e. most mitral valve
replacement patients)
replacement patients)
Dosage regimens
3. The average dose of warfarin required daily is around 5 mg (range 1-9 mg) but may vary markedly because of several factors. Warfarin should be given once daily (5-6 pm is an ideal time) and is given as a tablet fororal administration. [Tablet strengths are 1 mg (brown), 3 mg (blue), 5 mg (pink).] Duration of therapy
4. After a single episode of venous thromboembolism, it is likely that three months’ therapy is necessary. The duration of therapy needed after a second episode of DVT or PE is uncertain but 6-12 months’ therapy isnormally advocated. Patients with repeated episodes or in whom risk factors persist may require long-term(even life-long) therapy. In other indications long-term therapy may be necessary.
5. For patients in whom no new factor has arisen, the frequency of monitoring can be determined by the Warfarin therapy: maximum recall periods during maintenance therapy*
*(not initiation)
recall in 7-14 days (stop treatment for 1-3 days) (maximum 1 week in prostheticvalve patients) recall in 6 weeks (maximum for prosthetic valve patients) recall in 8 weeks, apart from prosthetic valve patients recall in 10 weeks, apart from prosthetic valve patients recall in 12 weeks, apart from prosthetic valve patients NB Patients seen after discharge from hospital with prosthetic valves may need more frequent INRs in thefirst few weeks.
(Based on data from Ryan et al (1989) British Medical Journal 299, 1207-1209) 6. When a condition known to cause alteration in the dose requirement of warfarin occurs (eg a potentially interacting drug), or the patient has an acute intercurrent illness, frequency of monitoring should beincreased.
7. The following conditions cause warfarin sensitivity (ie need for reduced dose): 8. Some conditions cause warfarin requirements to be increased (ie need for greater than normal dose): vitamin K containing remedies, eg some herbal remedies and enteral feeds


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