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Warfarin and Anticoagulant Therapy in Care Homes (England) Policy

Policy Statement

This care service recognises that every person who uses services has the right to the highest possible quality of safe, personalised care in the management of their health needs.

This document sets out the values, principles and policies underpinning {{org_field_name}}’s approach to the care of those requiring anticoagulant therapy.

Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital. They must be administered and managed with extreme caution and with appropriate safeguards in place.

The most common side effects of all anticoagulants are bleeding and bruising. They are considered critical medicines and must be given at the prescribed times to ensure they are effective.

The policy is in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 12: Safe Care and Treatment, which includes a requirement for the “proper and safe” management of medicines and for sufficient medicines to be made available to meet the needs of those receiving care and ensure their safety.

Guidance

This policy is designed to be compliant with best practice guidance including:

The policy is informed by the now archived National Patient Safety Agency NPSA alert 18: Actions That Can Make Anticoagulant Therapy Safer.

The policy is also informed by updated online guidance from the Care Quality Commission, High Risk Medicines: Anticoagulants (updated May 2022).

Background

{{org_field_name}} understands that certain people are prescribed anticoagulant therapy where they are at risk of their blood clotting within their blood vessels and disrupting the flow of blood around the body (thrombosis). Such an event may lead to other serious medical conditions such as:

  1. strokes
  2. transient ischaemic attacks (TIAs)
  3. heart attacks
  4. deep vein thrombosis (DVT)
  5. pulmonary embolism (PE).

Anticoagulants may be recommended if the person who uses services is at increased risk of developing any of the above conditions, previously had blood clots, has atrial fibrillation or a replacement or mechanical heart valve.

Blood clots are more likely to form if the person is overweight, pregnant or has certain blood disorders. People may be prescribed an anticoagulant following surgery, as prolonged post-operative rest and inactivity can increase risks of developing a blood clot.

Additional consideration should be given to people who use services by clinicians when initiating oral anticoagulants for those with cognitive impairment, previous history of risk of falls or excessive bleeding, excess alcohol intake or liver disease and impaired visual acuity.

Thrombophilia

Thrombophilia refers to the blood having an increased tendency to form clots. People with thrombophilia are particularly at risk of developing a DVT or a pulmonary embolism.

Warning signs of a DVT include:

  1. pain, swelling and tenderness in one leg (usually the calf or thigh and rarely both legs)
  2. a heavy ache, throbbing or cramping pain in one leg in the affected area
  3. warm skin around the painful area of the clot
  4. red or darkened skin around the painful area
  5. swollen veins that are hard or sore when you touch them.

These symptoms may also happen in the person’s arm or abdomen if that is where the blood clot is.

The symptoms of a pulmonary embolism are:

  1. chest or upper back pain
  2. shortness of breath
  3. coughing, usually dry but may include coughed-up blood or mucus containing blood
  4. feeling lightheaded or dizzy
  5. fainting.

People experiencing any of these symptoms should be encouraged to see their GP immediately.

There are different types of thrombophilia. It is diagnosed by having blood tests which look for anticoagulant deficiencies. Those diagnosed with thrombophilia may be referred to a haematologist, a specialist in diagnosing and treating blood disorders.

In mild thrombophilia treatment may not be needed.

Those who develop a blood clot will need treatment to disperse the blood clot and to prevent further clots. This will usually take the form of warfarin tablets or an injection of heparin. Other anticoagulants may be prescribed. In some cases people may be prescribed a low dose of aspirin which also works to reduce the risk of blood clots.

Warfarin and Other Anticoagulants

Anticoagulants are medicines that help prevent blood clots and prescribed to people at high risk of getting clots, to reduce risk of developing serious conditions such as strokes and heart attacks.

Although sometimes known as “blood-thinning” medicines, they do not actually make the blood thinner. They alter certain chemicals in the blood to stop blood clots forming so easily, slowing down the clotting process.

Examples of anticoagulants include:

The most commonly prescribed anticoagulant has historically been warfarin. Prescribers are increasingly making decisions to change people from warfarin to a DOACs to reduce the need for blood tests.

DOACs must be given at the prescribed dose and frequency. Their duration of action is shorter than that of warfarin. The anticoagulant effect of DOACs fades 12–24 hours after taking the last dose. Omitting or delaying doses could lead to a reduction in anticoagulant effect, increasing risk of blood clots.

Warfarin and the newer alternatives may be administered as tablets or capsules or in liquid medicine form.

To maintain safety, the dose of warfarin will need to be adjusted for each person so it prevents the blood from clotting too easily but does not raise the risk of bleeding problems, the main risk with such medication. Under-treatment can result in thrombosis (clot formation), which can be life threatening. Equally, over-anticoagulation can result in haemorrhage (bleeding), which can be fatal and outweigh the benefits of preventing the thrombosis.

The adjustment or warfarin doses will usually be made by the person’s GP or anticoagulant clinic on the basis of a regular blood test, usually every 12 weeks, called the International Normalised Ratio (INR), which measures blood clotting ability while taking warfarin. Blood tests are usually monthly and an INR of two to three is usually the aim.

It is recommended warfarin or other anticoagulants are taken at regular times each day. Warfarin is taken once a day, usually in the evening, to allow for the dose to change if there is an alteration following a blood test result.

Other anticoagulants vary in dosage and frequency of administration which will be prescribed and documented in the person’s MAR chart.

The person’s GP should be contacted immediately if any of these side effects appear:

  1. prolonged nosebleeds (longer than 10 minutes)
  2. blood in vomit or sputum
  3. blood in the urine or faeces
  4. passing black faeces
  5. severe or spontaneous bruising
  6. bleeding gums
  7. unusual headaches.

Other side effects include:

  1. sudden severe back pain
  2. difficulty breathing or chest pain
  3. rashes
  4. diarrhoea
  5. nausea and vomiting
  6. jaundice (yellowing of the eyes or skin).

For people prescribed newer anticoagulants, such as apixaban, dabigatran, edoxaban or rivaroxaban, they will not have the same requirements as those on warfarin to have regular blood tests to monitor their INR.

It is good practice for people to be reassessed every few months to check that the anticoagulant medication is being taken correctly and to monitor for any side effects.

People should not be taking both warfarin and a DOAC. If this is noted this care setting will check with the prescriber before giving.

Anticoagulant or an antiplatelet treatment may be prescribed for people who have recently undergone some kinds of surgery or who have suffered a reduced flow of blood in the veins of the leg caused by long periods of not being able to move.

Injectable Heparin

Injectable heparin works by disrupting the formation of blood clots in the veins. It can prevent blood clots from forming or stop clots that have already formed from getting larger.

Heparin is given by injection and prevents clotting, allowing normal blood flow through the arteries and veins. This is often prescribed for prevention of blood clots in people after surgery and to:

Injectable heparins are normally prescribed as pre-filled syringes. The person may be able to administer these independently via subcutaneous injections, which this care service will support, and ensure the manufacturer’s recommended site rotation administration followed. All used syringes and sharps will be safely disposed of in a sharps bin.

If the person is unable to self-administer the injection, following CQC High Risk Medicines: Anticoagulants, in this care service a healthcare professional may administer or this may be delegated to a care worker. This care service will ensure relevant training and assessment is provided to ensure the competency of care workers who accept this responsibility. The person who uses services’ care plan will clearly document this to support this delegated task and as evidence for CQC inspection.

Prevention

Those with thrombophilia should be made aware of the symptoms of a blood clot. To lower their risk of blood clots they should be advised to:

  1. lose weight if overweight
  2. stop smoking if they smoke
  3. eat a healthy, balanced diet and exercise regularly
  4. avoid being immobile for long periods (this can cause a DVT).

Self-care for People on Warfarin Who Use Services

{{org_field_name}} understands that a key component of the care of the person with health needs is the empowerment of people to look after themselves as far as is possible or as much as they wish to do. This service will strive to meet CQC fundamental standards and a key element in CQC compliance and in enabling people to live with dignity, self-determination and independence.

The National Reporting and Learning Service issued an alert to highlight the importance of warfarin compliance and monitoring. They produced the yellow book and this and supporting information should be given to all people taking warfarin so they understand about the medicine, how it should be taken, side effects and ongoing blood monitoring.

This should be used to flag up anticoagulant medication prior to medical or dental procedures, including any vaccinations or routine appointments with the dental hygienist.

This policy therefore encourages people to retain control over their medication wherever it is safe for them to do so and where they wish to.

Taking Other Medicines or Remedies

For those on anticoagulants, they are advised to gain advice from the GP, anticoagulant clinic or pharmacist prior to taking other medicines, remedies or supplements.

This includes prescription medicines, medicines bought over the counter without a prescription, such as aspirin, and any herbal remedies, such as St John’s Wort.

Some treatments can prevent anticoagulants working or may increase the effect they have, which can be dangerous.

Some of medicines which may affect anticoagulants include certain:

Food and Drink for People Who Use Services Who Take Warfarin

For people who use services taking anticoagulants it is essential they have a healthy, balanced diet, incorporating fruit and vegetables.

This care service follows NHS advice supporting people to maintain a healthy balanced diet but to avoid making frequent changes in their diet with regard to the amount of green vegetables consumed, if taking warfarin.

Foods with a lot of vitamin K, such as leafy green vegetables, chickpeas and liver, can interfere with how warfarin works and may be included in the diet, but should be consumed in consistent amounts.

People should not drink cranberry juice, grapefruit juice or pomegranate juice whist taking warfarin, as these may increase effects of warfarin.

This care service will refer to the yellow book for further information on how certain foods can affect INR levels.

Advice will also be sought prior to people taking supplements containing vitamin K.

Warfarin is also affected by alcohol and people are advised not to drink more than one or two alcoholic drinks a day and advised never to binge drink.

Such food and drink restrictions do not generally apply if the person has been prescribed apixaban, dabigatran, edoxaban or rivaroxaban, but advice should be sought if there is any cause for concern.

Assessment and Screening

All people using the service will be assessed on admission for their capability in being able to self-care, self-medicate and determine what support they require.

Where a person develops anticoagulant medication needs during their residency an assessment will be conducted in partnership with their GP and with any specialist healthcare services involved.

The initial assessment should be designed to elicit exactly how much support the person will need in coping with their condition and to identify who should do what in providing care. The results of the assessment should be entered into the agreed plan of care. It should be compliant with all CQC fundamental standards and with all evidence based best practice in the prevention of blood clot complication and the administration of anticoagulant therapy.

The assessment should identify one or more of the following typical patterns of care:

  1. people who safely maintain control of their condition and medication but who might require monitoring
  2. people who can take partial control over some aspects of their anticoagulant care and who will need support and monitoring by care staff
  3. people who need support on a temporary basis but will be able to resume control as soon as this is possible
  4. people who are unable to take full control of their medication.

Care Protocol for People Taking Warfarin Who Use Services

Each person who requires anticoagulant therapy and is prescribed warfarin can expect:

  1. to be encouraged to play an active role in their own care relative to their own wishes and overall level of independence
  2. to have an individualised care plan which they themselves have played a key part in developing along with any members of their family and/or advocates that they wish to be involved
  3. to have an annual review involving their GP and other essential members of the community health team and care home staff
  4. to have support and assistance from a named and suitably trained care staff who will act as a key worker for their care management, assisting them in monitoring their healthcare needs and in managing their medication as required in the plan of care and in compliance with the policy on medication administration
  5. adequate information about warfarin therapy
  6. care staff to work closely with local healthcare teams and provide access to local specialists for advice, support and educational material, including relevant community health professionals
  7. access to consultant specialist care by direct referral from the general practitioner or by an agreed community health professional
  8. assistance, if required, in attending specialist hospital outpatients or clinics for INR blood monitoring tests and other treatment.

Care staff administering medication should always double check the most recent INR report when giving a dose of warfarin. It is essential that dosages are not given from old INR reports. This would raise the risk that an improper dose of warfarin is given. To mitigate this risk there must be an established process for ensuring blood tests are taken at the correct time, that INR results are received by the individual concerned and that the correct dose is transcribed on to their Medication Administration Record (MAR chart).

The organisation should ensure that the warfarin dose is correctly recorded as milligrams (mg) of dose rather than numbers of tablets. The organisation should work closely with the pharmacy and GP involved to ensure that all doses are correct of any anticoagulant therapy and that any changes are actioned immediately and accurately recorded.

Warfarin should be administered from original packs and should not be included in Monitored Dosage Systems (eg nomad or dosette boxes). It should be taken at the same time each day with a full glass of water.

The following procedures are in place to ensure that high-quality care is provided safely for people who require support with their anticoagulant therapy.

  1. Appropriate facilities, resources and support will be provided for people requiring anticoagulant therapy.
  2. Care staff will comply with the medication management policy and with current NICE (National Institute of Health and Care Excellence) guidelines (SC1) regarding the administration of medication, such as warfarin and the recording of medicines taken
  3. Care staff will have received appropriate training and education in the management of warfarin within care settings, including training in:
    a. recognition of the symptoms of DVTs and pulmonary embolism
    b. risk assessment of thrombophilia
    c. management of warfarin and anticolagulant therapy.
  4. An agreed protocol of anticoagulant care and warfarin management will be in place, having been agreed in partnership with local community nursing staff, with local specialists, and with local GPs.
  5. Suitable information on warfarin therapy will be provided for both the person receiving care and their family in a format that can be understood.
  6. All new people will be fully assessed for healthcare needs on admission, conducted in partnership with their GP, and providing the basis of their care plan.
  7. People requiring anticoagulant therapy will be enabled and supported to attend their regular INR blood tests.
  8. The date when the next INR blood test is required will be clearly recorded in the relevant plan of care to ensure that people are enabled to have their blood tests on the specified date.
  9. All warfarin dose changes necessary after an INR test result will be confirmed by the prescriber in writing. This may be in the person’s handheld yellow INR record book, or via direct written communication from the prescriber.
  10. Warfarin doses will not routinely be changed on a verbal request only.
  11. INR results sheets and any confirmation records will be stored with the person’s MAR chart for cross-referencing.
  12. Where an INR result is not provided automatically by the GP practice or clinic, the organisation will follow up the appointment and ask for the result.
  13. It is safe practice to attach the written oral anticoagulant dosage supplied by the GP practice/clinic to the MAR chart.
  14. Care staff responsible for administering warfarin must accurately record how much is administered each time on the MAR chart.
  15. If there are any concerns that the INR result for an individual is out of date, staff will contact the relevant GP/anticoagulation service for advice.
  16. People who are transferred to another care setting will be accompanied by all relevant records about their anticoagulant treatment, including their MAR chart containing their warfarin administration record.
  17. Before using over-the-counter medicines, people will be advised to get advice from their pharmacist or GP. Oral anticoagulants interact with a variety of other medicines, such as commonly prescribed antibiotics and painkillers.
  18. If a dose is missed, a note will be made on the MAR chart. An extra dose will never be given to “catch up”. If a person accidentally takes an extra dose or takes the wrong dose of warfarin, care staff will contact the individual’s GP immediately for advice.
  19. {{org_field_name}} recognises that careful monitoring is required while people are taking warfarin. Any person experiencing excessive or spontaneous, severe or prolonged bruising, blood in the urine or faeces or any other side effects should be seen by their GP.
  20. If the person has a fall, this must be reported to the person in charge as they are at a higher risk of internal bleeding and may require management or assessment in secondary care.

People Who Use Services Taking Other Anticoagulants

{{org_field_name}} follows NHS advice for people taking other forms of anticoagulants, to ensure correct administration. They will be monitored for side effects and any contraindications recorded and reported.

Further advice and guidance will be sought from the GP or anticoagulant service if there are areas of concern. With regards to specific newer forms of anticoagulants the following applies.

  1. If the person is taking apixaban or dabigatran twice a day and they miss a dose, they should take it as soon as possible, but only if there is more than six hours until the next scheduled dose. If less than six hours until the next dose, this should be omitted, documented as such and the next scheduled dose taken as normal. Dabigatran must be stored in its original container to protect from moisture.
  2. If the person is prescribed rivaroxaban once a day and they miss one dose, they should take it as soon as possible if it is still more than 12 hours until the next scheduled dose. If less than 12 hours until the next dose, omit the dose missed and take the next scheduled dose as normal, ensuring this is recorded.
  3. If the person is taking edoxaban once a day and the dose is missed it should be taken as soon possible. If this is only remembered the following day, the person should omit the missed dose, taking the next dose at the usual time. It is important that only one dose of edoxaban is given in a single day.
  4. If a person is accidentally given more than their prescribed dose of apixaban, dabigatran, rivaroxaban or edoxaban, the GP or anticoagulant clinic should be contacted for advice and the person observed for possible side effects, such as bleeding.

Care Planning

Each person with a healthcare need related to anticoagulant therapy will have an individual personalised care plan agreed between the individual (or relative), their GP and care staff. It will include input from specialist agencies involved in the care of the person where necessary.

The plan will include:

  1. the identification of a designated and appropriately trained member of care staff to function as a key worker
  2. the identification of a designated doctor (usually the GP) to take overall medical responsibility for the anticoagulant care
  3. a full list of medications and anticoagulant treatment, including dosage and frequency information, and arrangements for the administration of the medication (ie whether self-administered or administered by care staff)
  4. arrangements for regular monitoring and an annual review
  5. measures to minimise the risk of both long-term and short-term complications, including DVT and stroke, and arrangements to screen regularly, eg signs and symptoms of DVT, blood tests, etc.
  6. falls prevention and management, with swift reporting of any falls and observation for bleeding or deterioration in the person’s condition.

Staff Training

{{org_field_name}} believes that the education and training of care staff in modern anticoagulant care and in the administration of warfarin is fundamental for the provision of high-quality care services, for the prevention of complications and for the early identification of problems.

Training in warfarin and other forms of anticoagulant therapy administration will include side-effects and contraindications of warfarin therapy. Staff administering medication should be made aware of the different colours and strengths of warfarin tablets.

Training in heparin administration via subcutaneous injection will be undertaken as necessary, and only be administered by staff trained and competent in the procedure. This service will ensure records are maintained of training and assessment of competence.

All new staff are encouraged to read this policy as part of their induction process as well as any associated policies and care protocols. Existing staff will be offered additional training covering anticoagulant care and blood clot prevention.

Audit

A regular audit of all anticoagulant therapy cases will be arranged to ensure that this policy and best practice guidelines are being followed.


Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

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