Anticoagulation: hospital and GP-based pharmacists working together
The pharmacist-led direct oral anticoagulation (DOAC) clinic at Northwick Park Hospital in Harrow, north west London, was set up in April 2017 and sees patients from Brent and Harrow clinical commissioning groups.
We run clinics five afternoons per week and typically see between five and eight patients per afternoon. Most of the patients who are seen are taking a vitamin K antagonist but need to switch to a DOAC for several reasons; for example, erratic international normalised ratio (INR) results. The clinic also sees patients who have recently been diagnosed with atrial fibrillation (AF) and need to be anticoagulated to minimise the risk of stroke. Patients are normally seen twice in the DOAC clinic and then discharged to the care of their GP.
When the clinics first started, local GPs were not very familiar with DOACs — shared care was in place, so any patient who required a DOAC was referred to our team in secondary care. However, GPs now have more experience with the use of DOACs and haematologists deliver many training sessions for GPs in primary care.
Now that more GPs are taking over the prescribing of DOACs in primary care, the pharmacists in the DOAC clinic have become responsible for mainly seeing complex patients. These patients require more monitoring once they are discharged from our clinic, so, on several occasions, we have worked closely with clinical pharmacists in general practice to ensure safe discharge to primary care.
Clinical pharmacists work as part of the general practice team to improve outcomes from medicines, and consult with and treat patients. They provide extra help to manage long-term conditions, give advice to those on multiple medicines and provide better access to health checks.
Clinical pharmacists in local general practices have enabled primary care and secondary care to work closely with each other; we communicate details, such as monitoring requirements and frequency of monitoring, tailored to our patients. GP pharmacists are often independent prescribers and there are occasions when they may be expected to prescribe anticoagulant medications or amend the dosage for their patients; support from secondary care enables them to do this safely.
We began working collaboratively with primary care when a clinical pharmacist based in general practice expressed in a local meeting that he often struggled with the anticoagulation queries he received in primary care, particularly those relating to DOACs. We discussed the areas of concern and the pharmacist joined me in the DOAC clinic for a day, which he found very useful. We subsequently arranged an anticoagulation teaching day for the local clinical pharmacists in general practice, which I presented with a colleague and a consultant cardiologist. The session was focused on AF patients; the aim was to enhance pharmacists’ knowledge of DOAC use in AF patients and to answer pharmacists’ questions. The session was successful and we will hold more training sessions that focus on other disease states that require anticoagulation, such as venous thromboembolism. Clinical pharmacists in general practice are now also contacting secondary care for anticoagulation-related advice by email or over the phone.
As an example of working collaboratively, 92-year-old Mrs JS, who had deep vein thrombosis, was seen in the DOAC clinic as she was found to be difficult to bleed. Mrs JS was keen to switch to an alternative agent as she was not happy with the frequent INR tests. Owing to her poor kidney function, her GP referred her to secondary care to determine whether a DOAC is appropriate.
I checked her full blood count, liver function and kidney function. Although stable, her calculated creatinine clearance (CrCl) was 19mL/minute. I rebooked her for a further two visits to the clinic, a month apart, and found her CrCl to be consistently around 19mL/minute. I explained to Mrs JS that with low CrCl I prefer to prescribe warfarin, and that perhaps we can arrange to use the CoaguChek® (Roche) machine in her GP surgery for the INR tests, but Mrs JS refused. We agreed to prescribe apixaban; however, this is contraindicated when CrCl is less than 15mL/minute so I needed to monitor her closely.
I wrote to the GP and the clinical pharmacist in the general practice to explain the situation. I advised on the frequency of monitoring her kidney function, and that they must switch Mrs JS to warfarin as a safer option if her CrCl drops to less than 15mL/minute, where the apixaban would be contraindicated. Having given monitoring information to the pharmacist in general practice, and speaking to the pharmacist directly, I felt reassured that the monitoring will be done on a monthly basis, and that if the CrCl drops to less than 15mL/minute then appropriate action will be taken.
In my experience, clinical pharmacists in local general practices have helped to bridge the gap between primary care and secondary care. Perhaps if other teams at the hospital (such as the respiratory, cardiology and diabetes teams) are made aware of clinical pharmacists in general practice, they will liaise with them directly to help with monitoring and titrating medication; this would free up GP time and allow GPs to focus on diagnosis and treating more complex cases.
Mais Al-Hasani, senior clinical services pharmacist, Northwick Park, St Mark’s and Central Middlesex Hospitals
Citation: Clinical Pharmacist DOI: 10.1211/CP.2018.20205729
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