Keeping warfarin patients safe during the COVID-19 pandemic: review of an INR self-testing programme.

BACKGROUND: Anticoagulation clinics faced an unprecedented challenge during the COVID-19 pandemic to safely manage patients on warfarin therapy. METHODS: A London teaching hospital trust received INR point-of-care (POC) testing devices from its clinical commissioning group. The Trust distributed the devices to patients who were cognitively and physically able to self-test and evaluated clinical outcomes and patient experience. FINDINGS: A significant improvement in warfarin control (mean time in therapeutic range (TTR) before POC 52%, standard deviation (SD) 24.8, vs mean after 60.7%, SD 19.7; P>0.009) and a 39% reduction in missed appointments were seen in self-testing patients. Positive patient satisfaction and lifestyle outcomes were identified through a telephone survey. A minority of patients struggled with the technique, leading to frustration. Some patients used many test strips through unsuccessful and additional tests. CONCLUSION: POC testing in a carefully selected group of patients on warfarin therapy resulted in positive clinical and patient satisfaction outcomes. Appropriate governance processes are needed, and clinical expertise is required to support patients. Cost-effectiveness of POC testing needs careful monitoring.

A nurse's guide to direct oral anticoagulants.

Direct oral anticoagulants (DOACs) have provided a practical alternative to warfarin sodium and low molecular weight heparin for people requiring anticoagulation. Their advantages include a more predictable clinical effect than warfarin, with no requirement for routine monitoring, regular fixed doses, no food or drink interactions and few drug interactions. Nurses have an important role in ensuring the safe use and administration of medicines. As the use of anticoagulants advances and they are used in a variety of conditions, nurses need to ensure their knowledge of these medicines is up to date to provide safe and informed care. This article provides an overview of the DOACs currently licensed for use in the UK, including their indications, doses, side effects and other considerations.

Co-Designing a New Yoga-Based Mindfulness Intervention for Survivors of Stroke: A Formative Evaluation.

Movement-based mindfulness interventions (MBI) are complex, multi-component interventions for which the design process is rarely reported. For people with stroke, emerging evidence suggests benefits, but mainstream programs are generally unsuitable. We aimed to describe the processes involved and to conduct a formative evaluation of the development of a novel yoga-based MBI designed for survivors of stroke. We used the Medical Research Council complex interventions framework and principles of co-design. We purposefully approached health professionals and consumers to establish an advisory committee for developing the intervention. Members collaborated and iteratively reviewed the design and content of the program, formatted into a training manual. Four external yoga teachers independently reviewed the program. Formative evaluation included review of multiple data sources and documentation (e.g., formal meeting minutes, focus group discussions, researcher observations). The data were synthesized using inductive thematic analysis. Three broad themes emerged: (a) MBI content and terminology; (b) manual design and readability; and (c) barriers and enablers to deliver the intervention. Various perspectives and feedback on essential components guided finalizing the program. The design phase of a novel yoga-based MBI was strengthened by interdisciplinary, consumer contributions and peer review. The 12-week intervention is ready for testing among survivors of stroke.

British Thoracic Society Quality Standards for outpatient management of pulmonary embolism.

INTRODUCTION: The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for the Initial Outpatient Management of Pulmonary Embolism. METHODS: Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. RESULTS: Six quality statements have been developed, each describing a standard of care for the outpatient management of pulmonary embolism in the UK, together with measurable markers of good practice. DISCUSSION: BTS Quality Standards for Outpatient Management of Pulmonary Embolism form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline's recommendations.

Postdischarge venous thromboembolism following hospital admission with COVID-19.

The association of severe coronavirus disease 2019 (COVID-19) with an increased risk of venous thromboembolism (VTE) has resulted in specific guidelines for its prevention and management. The VTE risk appears highest in those with critical care admission. The need for postdischarge thromboprophylaxis remains controversial, which is reflected in conflicting expert guideline recommendations. Our local protocol provides thromboprophylaxis to COVID-19 patients during admission only. We report postdischarge VTE data from an ongoing quality improvement program incorporating root-cause analysis of hospital-associated VTE (HA-VTE). Following 1877 hospital discharges associated with COVID-19, 9 episodes of HA-VTE were diagnosed within 42 days, giving a postdischarge rate of 4.8 per 1000 discharges. Over 2019, following 18 159 discharges associated with a medical admission; there were 56 episodes of HA-VTE within 42 days (3.1 per 1000 discharges). The odds ratio for postdischarge HA-VTE associated with COVID-19 compared with 2019 was 1.6 (95% confidence interval, 0.77-3.1). COVID-19 hospitalization does not appear to increase the risk of postdischarge HA-VTE compared with hospitalization with other acute medical illness. Given that the risk-benefit ratio of postdischarge thromboprophylaxis remains uncertain, randomized controlled trials to evaluate the role of continuing thromboprophylaxis in COVID-19 patients following hospital discharge are required.

Fixed dose rivaroxaban can be used in extremes of bodyweight: A population pharmacokinetic analysis.

BACKGROUND: Emerging safety and efficacy data for rivaroxaban suggest traditional therapy and rivaroxaban are comparable in the morbidly obese. However, real-world data that indicate pharmacokinetic (PK) parameters are comparable at the extremes of body size are lacking. The International Society of Thrombosis and Haemostasis Scientific and Standardisation Committee (ISTH SSC) suggests avoiding the use of direct oral anticoagulants (DOACs) in patients weighing >120 kg or with a body mass index >40 kg/m2 and gives no recommendation on the use of DOACs in those <50 kg. OBJECTIVES: To generate a population PK model to understand the influence of bodyweight on rivaroxaban exposure from clinical practice data. METHOD: Rivaroxaban plasma concentrations and patient characteristics were collated between 2013 and 2018 at King's College Hospital anticoagulation clinic. A population PK model was developed using a nonlinear mixed effects approach and then used to simulate rivaroxaban concentrations at the extremes of bodyweight. RESULTS: A robust population PK model derived from 913 patients weighing between 39 kg and 172 kg was developed. The model included data from n = 86 >120 kg, n = 74 BMI >40 kg/m2 , and n = 30 <50 kg. A one-compartment model with between-subject variability on clearance and a proportional error model best described the data. Creatinine clearance calculated by Cockcroft-Gault, with lean bodyweight as the weight descriptor in this equation, was the most significant covariate influencing rivaroxaban exposure. CONCLUSIONS: Our work demonstrates rivaroxaban can be used at extremes of bodyweight provided renal function is satisfactory. We recommend that the ISTH SSC revises the current guidance with respect to rivaroxaban at extremes of body size.

Patient experience of pregnancy-related venous thrombosis: A phenomenological study.

This study used a descriptive phenomenological approach to explore the lived experience of women diagnosed with VTE in pregnancy and the perinatal period. The study setting was a London, university affiliated hospital. The sample consisted of nine women with deep vein thrombosis or pulmonary embolism in pregnancy or up to six weeks post-partum, diagnosed in the last two years. Semi-structured interviews were undertaken using an interview guide. Interviews were transcribed and analysed using phenomenological descriptive analysis. Clustered invariant constituents that represented the lived experience of subjects emerged. The study revealed that the experience of pregnancy-related venous thrombosis is an overwhelmingly negative one with the journey through diagnosis and treatment being fraught with challenges, uncertainty and anxiety. Four main themes that contributed to the women's lived experience were identified: 1. Challenges in establishing a diagnosis; 2. Dealing with diagnosis; 3. Coping with treatment; and 4. Fears for the future. This is the first study to explore the experience of pregnancy-related venous thrombosis and offers valuable insight into the phenomenon. There is opportunity for clinicians to enhance the experience of pregnancy-related venous thromboembolism (PRVTE) by improving communication and information given to patients, clarifying diagnostic and treatment pathways and improving awareness of the condition.

Principles and nursing management of anticoagulation.

Anticoagulant drugs are widely used in hospital and community settings. Anticoagulation is the first-line treatment for venous thromboembolism, and anticoagulant drugs have an important role in the treatment and prevention of blood clots. However, maintaining the equilibrium between clotting and bleeding can be challenging and anticoagulants have been identified as a class of drug associated with preventable patient harm. Direct oral anticoagulants (DOACs) have become the first-line treatment for many patients requiring an anticoagulant, removing the burden of frequent tests and the many food and drug interactions associated with vitamin K antagonists such as warfarin sodium. However, DOACs have increased the complexity of decision-making regarding treatment, which also increases the risk of drug errors. This article discusses the uses, modes of action and potential side effects of anticoagulants, to improve nurses' understanding and enable them to have an active role in limiting the risk of harm from these drugs.

Collaborative working to reduce VTE.

The thrombosis team at King's College Hospital used innovative methods to bring about a change in the trust's VTE prevention practice. The team took a structured approach with a focus on positive aspects of practice. The aim was to involve clinical staff by forming partnerships rather than using a dictatorial approach. The creation of a nurse and midwife link network and valuing the individuality of clinical areas were fundamental to successful change.