PrescQIPP

Quality and Safety Improvement Audit Project for Direct Oral Anticoagulants (DOACs) (2020)

NHS SEL CCG - Southwark

Project Summary

The aims of the project were to:

  1. Review communication between secondary and primary care concerning the initiation and transfer of care for DOAC patients
  2. Review monitoring of DOAC agents- ensuring at least annual full blood counts (FBC), liver function tests (LFTs) and renal function checks with a frequency based on an accurate and up-to-date creatinine clearance (CrCl) calculation
  3. Ensure patients with co-morbidities that contra-indicate DOAC use or co-prescribed medicines that affect bleeding risk are reviewed to safeguard patients
  4. Ensure that patients with potential dose changes due to over/under-coagulation are reviewed urgently by risk stratifying audit results so that red colour coded patients are reviewed as a priority- encouraging practice-based pharmacists to take on this role where possible and support primary care with guidance and education sessions
  5. Ensure GP surgeries have a process in place for the review of DOAC patients according to local South East London (SEL) guidance- this will be checked in a repeat audit for 2020/21 for new DOAC patients

The outcomes of the project are:

  1. Improved transfer between settings through changes in communication and patient pathway development for DOACs: Removal of initiation and transfer of care forms for DOAC patients across SEL- the forms were not being completed by all specialities and/or GP systems were not coding them correctly: for the first 883 patients audited- only 38% of GPs had received initiation and transfer of care forms. Proposed changes: a) to utilise hospital discharge letters and clinic letters with updated IT systems to incorporate required baseline data for DOACs at discharge from hospital and/or at the transfer of prescribing to primary care b) Clearly defined DOAC patient pathways to risk-stratify monitoring and prescribing responsibilities for secondary and primary care
  2. Education sessions (Southwark CCG) and guidance (SEL) concerning required monitoring for DOACs: Ensuring that patients are safely monitored through risk-stratification of audit results for GP practices to action, and local guidance to ensure a consistent approach to this across South East London (this is also undergoing approval in South West London)
  3. Patients with DOAC contra-indications (CIs) and interacting medications were identified through the audit and risk-stratified as red- requiring immediate action for primary care healthcare professionals (HCPs): 38 of these patients were highlighted to HCPs at the time of audit data collection as requiring an immediate action to reduce the risk of serious harm
  4. Prioritising a review of patients requiring a potential dose change (through red risk-stratification in audit data- 51% of patients had a red action). Following these learning points, guidance has been approved and is in consultation across SEL to assist the DOAC prescribing process and there is now a SEL-wide focus on preferred DOAC agents for NVAF and VTE to encourage familiarity with two DOAC agents and their dosing requirements to reduce the risk of error.
  5. Asking for feedback/actions taken from GP practices: To ensure that processes are in place to safeguard DOAC patients through continued monitoring at scheduled time periods and for new DOAC patients not reviewed in the initial audit data collection.