Journal of Pharmacy Management - Jan 2022

Journal of Pharmacy Management • Volume 38 • Issue 1 • January 2022 only) and Thursday, with telephone and email reviews running Monday to Fridays. The venous blood test service in hospital was a flexible drop-in clinic with bloods taken by the phlebotomist in outpatients and no set clinic appointments for the patients. Patients could optionally have a face-to-face consultation if required with the pharmacist or nurse in the designated clinic room, which was primarily used for new patients, teaching and support with VKA dosing or self-testing devices, or bi-annual reviews. Implementation of new initiatives: A shared database was developed for patients that required venous blood monitoring which included details of indication of VKA therapy, patients shielding due to age or medical background, patients reluctant to attend INR appointments in hospital and those not consenting to a DOAC switch. This database was important for staff to rapidly track changes, identify priorities or areas of difficulty for patients, and ensure clarity in our processes during this project. Local INR testing: For patients in the shared database we facilitated venous bloods to be taken locally either by the GP or district nurse as appropriate. However, VKA dosing continued to be managed and led by the RBHH pharmacy anticoagulation team through close communication with the GPs and district nurses via email and telephone. Despite these efforts, patients who still required venous blood tests in hospital were allocated specific time slots for blood tests by the pharmacy team to maintain social distancing. DOAC switches: The patient database was used to identify patients who could safely switch to alternative anticoagulation therapy that did not require INR monitoring. DOACs were identified as a suitable alternative anticoagulation of choice. National guidance was used to support and implement this change with the focus primarily on patients on anticoagulation for the prevention of atrial fibrillation related stroke (in non-valvular AF) and treatment of pulmonary embolism (PE) and deep vein thrombosis (DVT). 5 Since this was a proposal to change long term anticoagulation therapy, it was important that the patient and medical physicians involved in the patient’s care were agreeable to the switch, so they were contacted early in the process. A 3-step consent process was used involving the patient, specialist consultant and GP. All three parties were required to consent for the switch to go ahead. We also incorporated the community pharmacy as a final step (no consent required) due to the importance of keeping records up to date across the primary care interface. In addition, template letters were developed for the community pharmacist and GPs to streamline our communication to inform themof the DOAC switch andmonitoring requirements. Those who could not be switched due to clinical indication were considered for the INR self-testing scheme. Once a patient was ready to commence DOAC therapy, the following baseline tests were arranged: • INR • U&Es, • FBCs • LFTs • Weight These were organised either at the hospital outpatient clinic, or if patients were clinically vulnerable, then arrangements were made with the patient’s GP to facilitate a local blood test. Upon reviewing the blood tests, an appropriate regimen and dose was prescribed by the pharmacists within the pharmacy clinical teams, prompt medication supply was arranged, and a follow up phone call was made to counsel patients on their DOAC therapy and give details on when and how to switch from warfarin. INR self-testers: It was recognised that there were many patients who were not eligible for DOAC 6