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NHS Borders Enhanced Service Programme for Primary and Community Care
Warfarin Anti-Coagulant Monitoring Enhanced Service 2016/2017
Changes to LES for 2016-17
Removal of patient safety bundle and spreadsheet
Introduction
Warfarin is being used in the management of increasing numbers of patients
and conditions including post-myocardial infarction, atrial fibrillation, DVTs &
other disorders. Details of current guidance re: warfarin use in various clinical
conditions may be found within the British Journal of Haematology, Guidelines
on oral anticoagulation with warfarin - 4th edition.
Warfarin is the number one drug which causes harm to patients in Scotland.
Warfarin is a vitamin K antagonist, interferes with the operation of vitamin K in
blood coagulation. The effect does not kick in immediately, and a single dose
can be active from 2 to 5 days. Moreover, Warfarin interacts with a wide range
of other common medications (such as aspirin or ibuprofen), as well as with
many basic foodstuffs which patients may regard as safe such as kale or
spinach. While it is a very effective drug in a wide variety of clinical conditions,
warfarin can also have serious side effects, e.g. severe haemorrhage. These
side effects relate to the International Normalised Ratio (INR) level, which
measures the delay in the clotting of the blood caused by warfarin. While the
“normal” INR is 1, the specific range of INR values depends on the disease
and the clinical conditions. Monitoring aims to stabilise the INR within set
limits to help prevent serious side-effects while maximising effective
treatment.
Achieving a dosage that is both safe for the patient and sufficient to prevent
thrombotic events therefore requires a disciplined approach to both blood
testing and patient prescribing. This is fundamental to patient care and safety,
and needs to include ongoing one-to-one patient education.
Additional information and resources can be found on the SPSP-Primary
Care Community Knowledge website
Service Specification
An anti-coagulation monitoring service is designed to be one in which:

therapy should normally initiated in Primary or Secondary care, for
recognised indications for specified lengths of time

maintenance of patients should be properly controlled
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
the service to the patient is convenient

the need for continuation of therapy is reviewed regularly

the therapy is discontinued when appropriate
Practice requirements
(i) Development and maintenance of a register: Practices should be able to
produce an up-to-date register of all anti-coagulation monitoring service
patients, indicating patient name, date of birth, the indication for and length of
treatment, including the target INR.
(ii) Call and recall: To ensure that systematic call and recall of patients on
this register is taking place. To ensure that INRs are taken at a frequency set
by local guidelines or approved software, that the dose is set by the same
manner and the patient retested within 7 days of the planned repeat INR.
(iii) Dosage and compliance: The practice will use local guidance or
preferably computer assisted decision making to prescribe the dose or
warfarin and set the interval to the next INR test. They will also check at
testing that the patient has been taking the dose as set at the previous test.
The average dose of warfarin required daily is around 5 mg (range 1-9 mg)
but may vary markedly because of several factors. Warfarin should be given
once daily (5-6 pm is an ideal time) and is given as a tablet for oral
administration. [Tablet strengths are 1 mg (brown), 3 mg (blue), 0.5 mg
(white).] The use of the 5mg (pink) tablets is not recommended within NHS
Borders due to the potential confusion with the 0.5mg tablet.
It is strongly recommended that a suitable, approved computerized program
is utilised for the dosage regime for warfarin as well as the testing intervals.
This has been shown to provide faster achievement of the desired level of
anticoagulation together with more appropriate recall dates than any manual
system. Locally approved systems include Bluebay Warfarin package,
INRstar, RAT and Dawn.
(iv) Professional links: To work together with other professionals when
appropriate. Any health professionals involved in the care of patients in the
programme should be appropriately trained.
(v) Education and newly diagnosed patients: To ensure that all newly
diagnosed patients (and/or their carers and support staff when appropriate)
receive appropriate management and prevention of secondary complications
of their condition including the provision of a patient-held anticoagulant
booklet including written information on anticoagulant therapy. Patient
understanding and compliance should be checked regularly and education
reinforced at least 6 monthly. An example of an approved warfarin information
sheet is provided in the Appendix for your use in conjunction with the yellow
warfarin booklets. Information re: practice ordering of the ‘yellow books’ is
also included.
(vi) Individual management plans: To prepare with the patient an individual
management plan, giving the diagnosis, planned duration and therapeutic
range to be obtained.
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(vii) Record-keeping: To maintain adequate records of the performance and
result of the service provided, incorporating relevant known information, as
appropriate.
(viii) Training: Each practice must ensure that all staff involved in providing
any aspect of care under this scheme have the necessary training and skills
to do so.
(ix) Untoward events: Practitioners will undertake a Significant Event
Analysis (SEA) for any hospitalisation or death occurring as a direct result of
the patient being on warfarin i.e. haemorrhage or extreme INR result.
Practices using commercial INR measuring devices are responsible for
ensuring adequate in house training, quality assurance and governance
arrangements surrounding their use.
Funding
Each practice contracted to provide this service will receive payment
according to the level at which they are working for individual patients:
Level 1 – laboratory outreach sampling, test and dose
Level 2 – Health Board or other externally funded phlebotomist or pharmacist
etc., practice sample, laboratory test, practice dosing

Level 2 service £ 95.90 per patient per year
Level 3 – Practice-funded phlebotomist or pharmacist etc, practice sample,
laboratory test, practice dosing

Level 3 service £ 106.56 per patient per year
Level 4 – Practice-funded phlebotomist or pharmacist etc, practice sample,
practice test, practice dosing

Level 4 Service £ 115.20 per patient per year Most practices are
currently paid at Level 3. We anticipate and encourage
movement towards Level 4 payments with the practices
obtaining commercial INR measuring devices (e.g. Coaguchek
©) and thereby offering a complete “in-house” service of
recalling, testing and dose alteration within primary care. This
has additional benefits of being able to advise the patient of their
new dose and retest date whilst they are at the surgery being
tested.
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APPENDIX
Patient information leaflet and warfarin ‘yellow books’
The following generic Warfarin Patient Information leaflet can be used in
conjunction with the patient-held warfarin yellow book. A link to this leaflet is
also available on the Warfarin Enhanced Service RefHelp information page:
Practices can order copies of the yellow warfarin patient information booklets
for free via the following company:
APS Group
E-mail [email protected] or phone: 0131 629 9938
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Please sign and return this completed form only to confirm your
participation.
NHS Borders Enhanced Service Programme for
Primary & Community Services
NHS Borders Local Enhanced Service 2016/17
For Warfarin Anti-Coagulant Monitoring
Practice Name: _____________________________
Practice No: ______________________________________________
Signed for and on behalf of the Practice _____________________________
Please print name and designation __________________________________
Date _______________________________________________________________
Notice Period
In the event of a practice being unable to maintain the service for the
duration of the contract or wishing to opt out, an appropriate period of
notice will be agreed with NHS Borders (normally 3 months).
The payments will be subject to the normal payment verification
processes.
Forms should be returned to Louise Patterson-Coltman in BGH.
e-mail: [email protected]
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