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Management of A.F. patients with the DawnAC induction module. David Hirst MidYorkshire Hospitals NHS Trust. Fennerty v5 software. Glasgow from table. Integrated Glasgow v6 software. Referrals to clinic. Out patient referrals In patients referred direct from wards. Out-patient referrals. - PowerPoint PPT Presentation
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Management of A.F. patients with the DawnAC induction module
David HirstMidYorkshire Hospitals NHS
Trust
Referrals to anticoagulant clinic per month
0
5
10
15
20
25
30
35
40
45
50
year
nu
mb
er
total
AF
all others
1996 1997 1998 1999 2000 2001 2002
12
23
17
23
3540
21729
11646
10083
INRs
Fennerty v5 software
Glasgow from table
Integrated Glasgow v6 software
Referrals to clinic Out patient referrals In patients referred direct from
wards
Out-patient referrals Up to 4 a week Written referral request mandatory Details transferred onto warfarin dosing
chart and new patient manager etc. completed
Warfarin prescription done by consultant haematologist
Out-patient referrals Wed am…details confirmed/updated,
counselled Start warfarin (5mg) on Friday and
attend for INR on days 5 and 8 (following Tuesday and Friday)
Dosed by induction algorithm, results telephoned, yellow book returned
Aspirin stops when INR therapeutic (if have written confirmation)
Day8, transferred to maintenance
Ward referrals Dosing chart acts as referral request New patient manager, treatment plan
completed INR, warfarin dose and date of next INR
written on dosing chart and sent back to ward
Patient counselled before discharge Patient may be discharged during
induction
Ward referrals Day8, transferred to maintenance In-patient, continue with dosing chart
with INR checks on a regular basis If discharged, further INRs at hospital or
in community by dose/post using yellow book
Only 32/175 UK sites (18%) have integrated induction module…why?
Expensive luxury…£1838 special offer
Read algorithm from a table and enter results as treatment history
Induction not done…work volume, staffing levels
Why use integrated induction package ?
User friendly Seamless transition to
maintenance Safety features (best practice) Government guidelines Litigation I’m on 10% commission…I wish
Safety features Human error…misread table Import results…reduce
transcription error Calculation prevention Warnings
Calculation prevention No matching rule for day INR greater than cut-off (5.0) No matching rule for previous dose Dialogue box to enter dose, any miss
days and interval…algorithm shown to aid decision
No matching rule for INR No dialogue box…problem with algorithm
Warnings generated on calculation
Large INR change (>=INR entered in setup)
INR less than previous INR and low Review for transfer
Warnings with confirmation prompt Given on accepting dose and next test
date for both manual and computer calculated values
Dose increased for INR rising to within range or high
Dose decreased for INR falling to within range or low
Miss days greater than 2 Next test interval greater than protocol
maximum
PRODIGY guidelines for warfarin therapy in AFwww.prodigy.nhs.uk
An INR of 2.0 can usually be reached by giving warfarin 5 mg for 4-5 days.
People on warfarin need regular monitoring of INR. Ideally this should take place in the setting of an organized anticoagulant clinic.
If no clinic is available, monitor INR daily until the result has stayed in the therapeutic range for at least 2 consecutive days. Then check INR 2-3 times a week for 1-2 weeks, and then less often, depending on the stability of the results.
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg
4mg
3mg
2mg
1mg
1.7
1.8
2.22.3
2.7
2.8
3.23.3
3.7
3.8
1.71.8
2.4
2.5
3.0
3.1
3.53.6
1 15 8
OMIT
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg
4mg
3mg
2mg
1mg
6.0mg x 7days
5.0mg x 7days
1.7
1.8
2.22.3
2.7
2.8
3.23.3
3.7
3.8
1.71.8
2.4
2.5
3.0
3.1
3.5
4.0mg x 7days
3.0mg x 4days
3.6
1 15 8
OMIT
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg
4mg
3mg
2mg
1mg
5.0mg x 7days6.0mg x 7days
4.0mg x 7days5.0mg x 7days
1.7
1.8
2.22.3
2.7
2.8
3.23.3
3.7
3.8
1.71.8
2.4
2.5
3.0
3.1
3.5
3.5mg x 7days4.0mg x 7days
3.0mg x 4days
2.5mg x 4days3.6
1 15 8
OMIT
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg
4mg
3mg
2mg
1mg
4.0mg x 7days5.0mg x 7days6.0mg x 7days
3.5mg x 7days4.0mg x 7days5.0mg x 7days
1.7
1.8
2.22.3
2.7
2.8
3.23.3
3.7
3.8
1.71.8
2.4
2.5
3.0
3.1
3.5
3.0mg x 7days3.5mg x 7days4.0mg x 7days
2.5mg x 4days3.0mg x 4days
2.0mg x 4days2.5mg x 4days3.6
1 15 8
OMIT
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg
4mg
3mg
2mg
1mg
3.0mg x 7days4.0mg x 7days5.0mg x 7days6.0mg x 7days
2.5mg x 7days3.5mg x 7days4.0mg x 7days5.0mg x 7days
1.7
1.8
2.22.3
2.7
2.8
3.23.3
3.7
3.8
1.71.8
2.4
2.5
3.0
3.1
3.5
2.0mg x 7days3.0mg x 7days3.5mg x 7days4.0mg x 7days
1.5mg x 4days2.5mg x 4days3.0mg x 4days
1.0mg x 4days2.0mg x 4days2.5mg x 4days3.6
1 15 8
OMIT
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg
4mg
3mg
2mg
1mg
2.0mg x 7days3.0mg x 7days4.0mg x 7days5.0mg x 7days6.0mg x 7days
1.5mg x 7days2.5mg x 7days3.5mg x 7days4.0mg x 7days5.0mg x 7days
1.7
1.8
2.22.3
2.7
2.8
3.23.3
3.7
3.8
1.71.8
2.4
2.5
3.0
3.1
3.5
1.0mg x 7days2.0mg x 7days3.0mg x 7days3.5mg x 7days4.0mg x 7days
0.5mg x 4days1.5mg x 4days2.5mg x 4days3.0mg x 4days
OMIT x 4days1.0mg x 4days2.0mg x 4days2.5mg x 4days3.6
1 15 8
OMIT
The Tait Algorithm
1
1.5
2
2.5
3
3.5
4
1 2 3
Induction day
INR
5mg
5mg4mg
3mg
2mg
1mg
1.7
1.8
2.2
2.3
2.7
2.8
3.23.3
3.7
3.8
1.9
2.0
2.9
3.0
3.5
1 15 8
OMIT 0.5mg x 4days
1.0mg x 4days
1.5mg x 4days
Analysis of induction algorithm Foxfire…258 induction records
dosed on days 1,5,8 Time taken to 2 consecutive INRs
2.0-4.0 post induction Was day8 dose accurate or did it
overdose/underdose
Analysis of the Tait Algorithm
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
0.0 7.0 14.0 21.0 28.0 35.0 42.0 49.0 56.0 63.0 70.0 77.0 84.0 91.0 98.0 105.0 112.0 119.0 126.0 133.0 140.0 147.0
Days to acheive INR>2.0<4.0
Day
8 w
arfa
rin
mg
Day 8 Dose mg N % 5 8 15 >15 LOW HIGH OK
6.0 40 16 0 0 35 655.0 54 21 0 63 87 134.0 39 15 26 72 97 33.5 24 9 25 71 96 43.0 32 12.5 50 44 97 32.5 18 7 72 11 89 112.0 11 4 36 0 36 641.5 19 7.5 0 0 16 841.0 10 4 0 0 0 1000.5 8 3 0 0 0 1000.0 3 1 0 0 33 67
Total 258 100% of total 19 55 69 31
% induced by day % Day 8 Dose
Analysis of the Tait Algorithm
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
11.00
12.00
13.00
14.00
15.00
16.00
17.00
18.00
0.0 7.0 14.0 21.0 28.0 35.0 42.0 49.0 56.0 63.0 70.0 77.0 84.0 91.0 98.0 105.0 112.0 119.0 126.0 133.0 140.0 147.0
Days to acheive INR>2.0<4.0
Act
ual
War
fari
n n
eed
ed m
g
Day 8 Dose mg N % 5 8 15 >15 LOW HIGH OK
6.0 40 16 0 0 35 65 55 10 355.0 54 21 0 63 87 13 13 4 834.0 39 15 26 72 97 3 0 3 973.5 24 9 25 71 96 4 0 4 963.0 32 12.5 50 44 97 3 0 3 972.5 18 7 72 11 89 11 6 11 832.0 11 4 36 0 36 64 64 0 361.5 19 7.5 0 0 16 84 95 0 51.0 10 4 0 0 0 100 100 0 00.5 8 3 0 0 0 100 100 0 00.0 3 1 0 0 33 67 100 0 0
Total 258 100% of total 19 55 69 31 30 4 66
% induced by day % Day 8 DoseDay 8 Dose mg N % 5 8 15 >15 LOW HIGH OK
6.0 40 16 0 0 35 65 0 10 905.0 54 21 0 63 87 13 0 4 964.0 39 15 26 72 97 3 0 3 973.5 24 9 25 71 96 4 0 4 963.0 32 12.5 50 44 97 3 0 3 972.5 18 7 72 11 89 11 6 11 832.0 11 4 36 0 36 64 64 0 361.5 19 7.5 0 0 16 84 95 0 51.0 10 4 0 0 0 100 100 0 00.5 8 3 0 0 0 100 100 0 00.0 3 1 0 0 33 67 100 0 0
Total 258 100% of total 19 55 69 31 18 4 78
% induced by day % Day 8 Dose
Analysis summary
Acceptable, covered by Aspirin
Unacceptable, Aspirin stopped. Most sensitive to warfarin taking longer to induct. ?increase by 1mg
No problem
No problem
day8 dose 15days >15days low high OK
6.0mg, 5.0mg 65% 35% 31% 6% 63%
4.0,3.5,3.0,2.5mg 97% 3% 3% 97%
2mg day8 INR>day5 100% 100%
2mg day8 INR<day5 100% 100%
1.5,1.0,0.5,0.0mg 10% 90% 98% 2%% of Total 69% 31% 18% 4% 78%
day 8 doseinduced by
What can be done? Tweak algorithm Warning when day8 INR < day5 Advise to restart aspirin Have higher post induction target
INR Let INR fall to baseline and restart on
a different algorithm ‘Intelligent’ algorithm
