Audit of start of anticoagulation treatment in inpatients.
OBJECTIVE
To develop a method for evaluating the start of anticoagulation treatment in inpatients.


METHODS
One hundred case notes were audited using a proforma based on local guidelines in accordance with British Society for Haematology recommendations.


RESULTS
Confirmatory investigations were done in 93% and 79% of patients with symptomatic deep venous thrombosis and pulmonary embolism, respectively. Identification of patients' risk factors for anticoagulation by history taking and laboratory tests was often inadequate: baseline coagulation screen, platelet count, liver function and renal function tests were done in 52%, 95%, 70% and 87% of cases, respectively. There was a tendency to undertreat patients: 33% of the activated partial thromboplastin times (APTT) and 58% of the International Normalised Ratios (INR) were subtherapeutic. The heparin-warfarin crossover period was particularly problematic: 37% stopped heparin without an INR that day, or had an INR of less than 2. Microscopic haematuria was monitored occasionally. Of the 62 patients continuing anticoagulation, 72% were discharged with the final INR in the therapeutic range. At discharge, only 74% of patients had documented appointments for the anticoagulant Clinic, the period between discharge and appointment ranging from 0 to 12 days. Of the 25 cases with an appointment exceeding four days after discharge, only six (24%) had arrangements for an interim INR check.


CONCLUSIONS
The experience allowed the proforma to become streamlined to a more practical, reliable, and valid tool for use elsewhere. Findings will be fed back to the hospital staff to promote practice improvements before closing the audit loop by re-evaluating practice. Further studies are in progress to identify barriers experienced by doctors in implementing the guidelines and problems in the process of referral to the anticoagulant clinic.
Tan
G
G
Research Unit, Royal College of Physicians, London.
Cohen
H
H
Taylor
F
F
Gabbay
J
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004334:Drug Administration Schedule; D006493:Heparin / Q000627:therapeutic use*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008485:Medical Audit / Q000379:methods*; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D011655:Pulmonary Embolism / Q000517:prevention & control*; D013927:Thrombosis / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use
D014859:Warfarin; D006493:Heparin