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Audit of start of anticoagulation treatment in inpatients
Insights
This study evaluated inpatient anticoagulation initiation, finding inadequate risk factor assessment and undertreatment. Streamlined protocols and staff feedback are crucial for improving patient care and ensuring therapeutic anticoagulation.
Area of Science:
- Medical Auditing
- Hematology
- Clinical Practice Improvement
Background:
- Anticoagulation therapy is critical for managing venous thromboembolism.
- Standardized guidelines exist for initiating and monitoring anticoagulation.
- Effective anticoagulation requires careful patient assessment and monitoring.
Purpose of the Study:
- To develop and evaluate a method for assessing the initiation of anticoagulation treatment in hospitalized patients.
- To identify areas for improvement in current anticoagulation practices.
Main Methods:
- A retrospective audit of 100 inpatient case notes was conducted.
- A proforma based on British Society for Haematology guidelines was utilized.
- Data on confirmatory investigations, risk factor assessment, and monitoring were collected.
Main Results:
- Confirmatory investigations were performed in most patients with deep venous thrombosis (93%) and pulmonary embolism (79%).
- Inadequate identification of risk factors and undertreatment were observed, with subtherapeutic activated partial thromboplastin times (APTT) and International Normalised Ratios (INR).
- The transition from heparin to warfarin was problematic, and post-discharge anticoagulant clinic follow-up was often delayed or inadequate.
Conclusions:
- The developed proforma was refined into a practical tool for evaluating anticoagulation practices.
- Findings will inform hospital staff to improve clinical practice and ensure effective anticoagulation management.
- Further research is needed to address barriers to guideline implementation and anticoagulant clinic referrals.
Aims:
To develop a method for evaluating the start of anticoagulation treatment in inpatients.
Methods:
One hundred case notes were audited using a proforma based on local guidelines in accordance with British Society for Haematology recommendations.
Results:
Confirmatory investigations were done in 93% and 79% of patients with symptomatic deep venous thrombosis and pulmonary embolism, respectively. Identification of patients' risk factors for anticoagulation by history taking and laboratory tests was often inadequate: baseline coagulation screen, platelet count, liver function and renal function tests were done in 52%, 95%, 70% and 87% of cases, respectively. There was a tendency to undertreat patients: 33% of the activated partial thromboplastin times (APTT) and 58% of the International Normalised Ratios (INR) were subtherapeutic. The heparin-warfarin crossover period was particularly problematic: 37% stopped heparin without an INR that day, or had an INR of less than 2. Microscopic haematuria was monitored occasionally. Of the 62 patients continuing anticoagulation, 72% were discharged with the final INR in the therapeutic range. At discharge, only 74% of patients had documented appointments for the anticoagulant Clinic, the period between discharge and appointment ranging from 0 to 12 days. Of the 25 cases with an appointment exceeding four days after discharge, only six (24%) had arrangements for an interim INR check.
Conclusions:
The experience allowed the proforma to become streamlined to a more practical, reliable, and valid tool for use elsewhere. Findings will be fed back to the hospital staff to promote practice improvements before closing the audit loop by re-evaluating practice. Further studies are in progress to identify barriers experienced by doctors in implementing the guidelines and problems in the process of referral to the anticoagulant clinic.