Hamad General Hospital (HGH) anticoagulation clinic (ACC) replaced the traditional warfarin clinic and embraced the physician-pharmacist collaborative practice starting in 2016. The ACC clinic functions under the umbrella of the internal medicine ambulatory care service. Its team consists of clinical pharmacists working collaboratively with a team of physicians, and it is supported by nursing and patient care assistants.
When a new patient is referred to the clinic, the first assessment is done and documented by one of the clinic physicians. Subsequent follow up visits are led by the clinical pharmacist running the clinic. After the clinic nurse checks the INR using the CoaguChek® XS Plus point-of-care (POC) device, the patient is interviewed by the clinical pharmacist. Decisions on dose modification, follow up visits, and further investigations (such as complete blood count, renal function test and in-lab INR, etc.) are decided upon and ordered by the clinical pharmacist. All necessary documentation is done by the clinical pharmacist for these follow up visits. In certain scenarios, such as a high INR (>5) or patient complaints that require physical examination, the patient is referred to the clinic physicians who are available at all times for support. (please refer to Appendix 1 for HGH-ACC collaborative agreement). Patients who are being managed using DOACs are also referred to this clinic for follow up and monitoring of their therapy effectiveness, safety, compliance, and regular laboratory parameter checks.
HGH-ACC is a high-volume service. In 2019, around 450 clinics were run in which over 5000 patients visit took place: in an average of 20 patients per day. The average INR recall interval was 23 (±14) days and the mean percentage of days in the target therapeutic range (TTR) was 62.6%; with half of the patients being in the therapeutic range ≥ 65% of the time.
During the COVID-19 pandemic, physical distancing measures were required and the number of patients visiting the clinic had to be reduced to avoid crowding of patients and minimize the risk of acquiring SARS-CoV2 infection. The HGH-ACC team put together a multi-faceted program to limit the number of patients physically attending the clinic by building upon the two main approaches endorsed by the Anticoagulation Forum and incorporating other novel and innovative strategies. The components of this program are described here.
Advanced Chart Review
The HGH-ACC team reviewed the daily list of clinic appointments 2-3 days prior to the given date. The patients’ electronic files on Cerner® (Cerner Corporation, Kansas City, Missouri, U.S.A) were meticulously examined to determine whether a given patient was eligible for extending the INR recall period, switching to DOACs, or needed to attend their clinic visit as planned. The patients were contacted accordingly. All calls and plans were documented in the patients’ files.
Extension of INR Recall Period
The recall period for INR follow up depends on the INR stability. Recall visits are initially at short intervals, but they are then extended based on the achievement of consecutive therapeutic range INR readings. The American College of Chest Physicians (ACCP) Antithrombotic Guidelines (2012) recommend that the follow up interval can be as long as 12 weeks for stable patients with multiple INR readings within the therapeutic range and a low risk of bleeding (8). This recommendation was endorsed by the Anticoagulation Forum in response to the COVID-19 situation.6 As per the Michigan Anticoagulation Quality Improvement Initiative (MAQI), the follow up period depends on the number of therapeutic INR readings. For example, if the patient has one in-range INR, the follow up visit should take place within a week, two-weeks follow up in case of two therapeutic INR readings, and so on, up to a maximum of 12 weeks follow up interval (6,9).
To help us stratify our patients (those who needed to attend the clinic as scheduled versus those who could have their appointments rescheduled), we reviewed the recommendations from multiple respected anticoagulation institutes; which we summarized into a decision-making support algorithm to guide and facilitate the process (Fig.1).
Using Telehealth Consultations
Using this evidence-based approach, we were able to significantly reduce the number of patients physically attending the clinic. However, telehealth was provided for all patients whose INR recall visits were extended to ensure that the safety of patients was not compromised. Telehealth was used to ensure that each patient was taking the correct dose, maintaining a consistent diet, and to assess the commencement or cessation of medications that might affect the INR.
Switch from Warfarin to DOACs
As patients who take DOACs do not need repeated measurement of the INR, they are particularly suited to follow up using telehealth. Each patient was therefore reviewed for their suitability to switch from using warfarin to using a DOAC for anticoagulation.
We designed a decision-support tool (Fig.2 and Fig.3) to comprehensively cover contraindications and supporting factors for the switch. Our main aim was to switch patients who had a labile INR and no contra-indications to DOACs after patient counselling.
Home INR Testing for Elderly and Immunocompromised Patients
A large-scale collaborative project between the anticoagulation clinical pharmacists, physicians, and Home Health Care Service (HHCS) was initiated. The aim of this project was to facilitate the INR monitoring for the fragile, high-risk, and immunocompromised patients who were not eligible for extending the INR recall period nor switching to DOACs. These patients were first identified by our team of clinicians. The inclusion criteria were adapted from the Centers for Disease Control and Prevention (CDC) classified high risk patients and summarized into Table 1(10). The list of patients was provided to the HHCS coordinator. The coordinator reviewed the list to ensure that patients met the project inclusion criteria, and then contacted eligible patients to arrange for the visits. The patients were visited at the comfort of their homes by the HHCS team of nurses for INR testing. The INR value was then recorded into the patient electronic medical record on Cerner® by the HHCS nurse. A clinical pharmacist then provided comprehensive telehealth, inquiring about the current dose of warfarin, ensuring that no signs or symptoms of bleeding or thrombosis were present, providing education, and attending to any patient concerns.
This project significantly reduced the number of elderly or immunocompromised patients physically attending the clinic, and hence reduced their chances of exposure to SARS-CoV-2.
Table 1. High risk patient groups
High-risk patients
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People older than 65 years old
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People of all ages with any of the following conditions:
· Cancer
· Bone marrow transplant
· Solid organ transplant
· Stem cells for cancer treatment
· Genetic immune deficiencies
· Human Immunodeficiency Virus (HIV) infection/ acquired immunodeficiency syndrome (AIDS)
· Use of oral or intravenous corticosteroids or other immunosuppressants infections (e.g., mycophenolate, sirolimus, cyclosporine, tacrolimus, etanercept, rituximab)
· Known respiratory illnesses, e.g. asthma, chronic obstructive pulmonary disease (COPD)
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Establishing an Anticoagulation Hotline
The Qatar System Wide Incident Command Committee (SWICC) has established a national Coronavirus Disease Call Center, which received patients’ calls and had designated healthcare providers available around the clock to attend to all healthcare inquiries, including anticoagulation.
In addition, the HGH-ACC team took a further measure to ensure that patients had easy and quick access to anticoagulation services in case of concerns or anticoagulation emergencies. A corporate mobile phone number was designated to the clinic as an anticoagulation hotline, and the patients were provided with this number to call or text at any time. Examples of issues managed by this line include responding to INR results released after the clinic hours, emphasizing plans by sending text messages, and dose clarification. This reduced the patients’ need to walk-in to clinic for simple inquiries and hence reduced unnecessary patient and healthcare worker exposure.
Relocation of Warfarin Dispensing to the Anticoagulation Clinic
A nation-wide project was led by the Pharmacy Department across Hamad Medical Corporation to verify and dispense medications utilizing telehealth and the national post courier in Qatar, Qatar Post (QPost). Once prescribed, the pharmacy dispense and post the medications directly to the patient doorstep.
To avoid any unexpected delay, and to minimize additional waiting time and person-to-person exposure of our patients, warfarin was dispensed at the clinic at the end of each encounter instead of the usual dispensing process at the hospital pharmacy. This project was coordinated and supported by Hamad General Hospital Pharmacy Department to contribute to patient safety and reduce the exposure during the pandemic.
Multidisciplinary Team (MDT) Meetings
Prior to COVID-19, the clinic team met on a monthly basis in an MDT meeting that included the ACC clinical pharmacists and physicians, internal medicine consultants, and hematology consultants. The aim of the MDT meetings was to discuss and reach consensus regarding the management of complicated patient issues. Examples of issues classically discussed in the MDT meetings were the eligibility of certain complex patients for switching from warfarin to DOACs and duration of anticoagulation therapy when a straightforward answer was not available in the medical literature.
COVID-19 caused an interruption in these meetings. However, as the clinic workflow became clear and smooth, the team resumed virtual MDT meetings through Microsoft Teams® (Microsoft Corporation, Redmond, Washington, United States).