Nurse-led Anticoagulation Service targeted on suboptimal anticoagulated patients: a pilot experience

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Authors (including presenting author) :
MAK CO (1), CHIU SH (1), TSUI PT (1) & TANG C (1)
Affiliation :
(1) Cardiac Team, Department of Medicine & Geriatrics, Princess Margaret Hospital (PMH), Hong Kong SAR, China
Introduction :
Anticoagulation therapy is commonly used in patients to treat and prevent thrombotic events from various cardiac diseases. However, both hyper-coagulated and hypo-coagulated statuses could result in numerous life-threatening events such as hemorrhagic and ischemic stroke, massive internal bleeding and thrombotic events. The unplanned readmission rate is 19.4% at average. Traditionally, either nurse led or pharmacist led anticoagulation service targets on selected stable anticoagulated patients. The remaining complex cases are consulted by physicians. Although intensive patient education, comprehensive assessment and integrated approach are potentially beneficial to high risk patients, these interventions are restricted by time in physician clinic. Nurse led counselling service targeted on suboptimal anticoagulated patients is therefore proposed to optimize patients’ outcome.
Objectives :
1. To identify reasons for suboptimal anticoagulation therapy by use of protocol driven investigations. 2.To optimize patient’s outcomes to anticoagulation therapy by protocol driven nursing interventions. 3.To improve safety and cost effectiveness of anticoagulation service by reducing unplanned admission and physician consultation time.
Methodology :
A pilot nurse led anticoagulation service, co-joined with cardiologist, was established in July 2018 in Princess Margaret Hospital (PMH). Two trained cardiac Advanced Practice Nurses (APNs) were delegated to screen out all suboptimal anticoagulated patients in anticoagulation outpatient clinic. Patients with suboptimal anticoagulation such as hyper-coagulated, hypo-coagulated and fluctuated anticoagulant statuses were invited to the service. A comprehensive nursing assessment was performed to identify barriers to optimal anticoagulation therapy. Problems such as medication non-adherence, poor diet control, knowledge deficit and symptoms of complication are recognized. An individual treatment plan was then formulated based on the problems identified. A protocol driven nursing interventions such as medication counselling, complication management, intensive education and drug titration were delivered accordingly. All cases were referred back to Cardiologist for further clinical managemen
Result & Outcome :
From July to October 2018, total 60 patients were recruited. Four potential life-threatening cases were screened with extreme anticoagulated status. All of them were treated promptly without any major adverse cardiac events (MACE). From the in-depth nursing assessment, 56% cases were identified with poor diet control and knowledge deficit. 52.6% cases were found potential medication interaction. 35% cases are related to poor drug compliance. The nurse led clinic also identified 12 cases (20%) with minor bleeding complications and 16 cases (26%) with cardiovascular symptoms like heart failure and syncope. Up to 31 December 2018, 95% cases have showed improvement in anticoagulation status. 83.3% cases have achieved their targeted anticoagulated status afterwards. Only four unplanned hospitalized cases (6.6%) were reported with cause of chest infection, hypertension, acute coronary syndrome or congestive heart failure. Conclusion: The nurse-led anticoagulation service targeted on subo

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