How Do I Assess the Competency of my Warfarin Dosing Team

1.  How Do I Assess the Competency of my Warfarin Dosing Team?  Dr Virginia Clough Consultant Haematologist Countess of Chester Hospital NHS Foundation Trust

4. BCSH and NPSA recommendationsSafety indicators for inpatient and outpatient anticoagulant care (2006)www.bcsh guidelines.org “Failure to implement guidelines and inadequate competencies of health care professionals prescibing,monitoring,and administering anticoagulants are …….identified by the risk assessment process” Identification of required competencies and training for staff responsible for anticoagulant care (see skills for health at www.dh.gov.uk )

5. Key Skills Framework (KSF) KSF assigned to Job Role 6 core dimensions Plus specific dimensions which includes: (Health & Wellbeing) HWB8: Biomedical investigation and intervention. Level 3: Plan, undertake, evaluate and report biomedical investigations and/or interventions One competency - Manage Anticoagulant Therapy

6. Skills for health competence databaseHCS_HM15: manage anticoagulation therapy Assess the effectiveness of current anticoagulant regime using validated laboratory results Investigate further in the event of predetermined abnormal results, in accordance with relevant protocol Obtain clinical details of direct relevance to the review of patient dosage Seek clinical advice according to local protocols Calculate correct dose using the relevant anticoagulant management system Confirm results or adjust dose based on additional clinical details of relevance Validate and authorise dosage Ensure the patient understands all factors affecting their treatment, including key information which should be communicated to the clinician Accurately record results, dosage and other pertinent information for use in further patient management………….

7. Knowledge & Understanding The importance of patient confidentiality and how to ensure that this is fully maintained When to inform the clinician about results requiring urgent attention The principles of various anticoagulant therapies Methods, principles and purpose of laboratory monitoring of oral anticoagulant management Local guidelines, policies and procedures and who is responsible for these Factors affecting dosage and time interval of testing for individual patients The interactions of anticoagulants with other drugs and substances Oral anticoagulant reversal Requirements and indications of non-compliance with management regime Medico-legal issues associated with management regimes Possible complications or side effects of anticoagulant therapy and how to recognise them The use of clinical audit in relation to anticoagulant dosing Specific national/international guidelines.

8. www.skillsforhealth.org.uk/ksfcomps/php

9. Group protocol for Chester Anticoagulant Service Non dosing tasks Dosing tasks BMS, pharmacist, Basic dosing SHO, SpR, consultant Senior dosing (level 2) Advanced dosing (level 3) Clinical opinion needed (level 4)

10. Named personnel and dosing level competency All DAWN team members have a designated dosing competency level. All new members will be assigned a dosing level after appropriate training and authorisation by a named member of staff. All team members will be able to perform the functions of any level up to and including their designated level.

11. Non-dosing tasks The AC clerks are responsible for: Entry of demographics onto DAWN Taking and recording of patient queries and acting appropriately Telephoning dosage and dose changes as directed by a dosing operator AC clerks will not be involved in DAWN dosing nor manual dosing of patients.

12. Dosing, checking and releasing yellow anticoagulant books The dosing and checking process is divided into stages and each stage will be assigned a distinct level of competency. All team members have a designated dosing competency level. New team members will be assigned a dosing level only after training and authorisation by the head of service. Team members will perform all functions up to and including those of their competency level. Any operator who is unsure of a dosage in a clinical situation WILL refer the matter to the level 4 operator of the day.

13. Basic Dosing - The DAWN software with computer dose calculation The pre-set software algorithm based dose will: Dose when INRs match from interface Print dosage and next appointment date directly into yellow book from book printer Operator will verify on individual patient screen that the correct dose has been printed into correct book. Operator will release book to the post.

14. Level 1 personnel Inclusion criteria: No dose changes No change in medication/ no new clinical information Pre-existing clinic appointment Exclusion criteria: New medication Dose change Walked in for clinical reason Not fulfilling inclusion criteria Any book operator feels unable to release

15.  Senior Dosing – Authorizing dose changes Check any dose changes are appropriate Check the next appointment date is appropriate Amend or ask clerk to amend next appointment dates if necessary Phone dose changes if necessary Release book to the post

16. Level 2 personnel Inclusion criteria: Dose changes due to fluctuation in INR with no change in clinical circumstances, where experienced operator feels confident to release book. Exclusion criteria: Check slip with any clinical information Medication changes INR DAWN unable to dose i.e. >5 or <1.3 Patients due for imminent cardioversion Any dose the operator feels unable to authorise should be referred to a higher level operator.

17.  Advanced Dosing -Authorizing complex dose changes where there is new clinical Information or DAWN unable to dose. Manual intervention to dose patients that DAWN is unable to calculate a dose (i.e. >5 or <1.3) or where DAWN is to be over ridden Amend DAWN dose as necessary Understands and takes immediate appropriate action for patients with INR >5

18. Level 3 personnel Inclusion criteria: Any patient with a change in medication Any patient with attached clinical information Any patient listed as requiring manual dosage (e.g. “problem” patients) Any patient the Level 2 operator feels unable to authorise All high INR’s (>5) Newly started and unstable INR patients Exclusion criteria: Any patient the Level 3 operator feels unable to dose or authorise

19.  Refer dosing to Clinician / Senior Anticoagulant Practitioner Manual dosing Induction of anticoagulation INR out of target 2 successive visits INR range 3.5 without adequate reason INR <1.3 on 2 successive visits Known “problem” patients ANY patient who is bleeding ANY patient where date to stop is unclear

20. Level 4 personnel Inclusion criteria: This level requires clinical experience and will normally involve discussion / referral to a Consultant Haematologist ,a Specialist Registrar in Haematology, on call medical team or a senior anticoagulant practitioner.

22. PATHOLOGY DIRECTORATECOMPETENCE SKILLS – DAWN Anticoagulant Management System

25. Anticoagulant Team Members

26. Contact us at Chester Virginia.clough@coch.nhs.uk Lucy.langan@coch.nhs.uk Telephone 01244 365373