HNY Policy and Pathway Repository - Humber

Patients who are registered with a General Practitioner within the postcodes HU1-HU9 and HU11 who are prescribed a Vitamin K Antagonist (VKA) are suitable for referral into the Nurse Led Anticoagulation Service.  All patients will have a Patient Specific Direction (PSD) which will be signed by the referrer (medical or independent non-medical prescriber). The service will titrate Warfarin/VKA for all patients on the caseload utilising Clinical Decision Support Software (CDSS), to facilitate their optimum INR, using a working INR range of 0.8 – 4.9. Patients with INRs outside this range will be managed within the Anticoagulation Service CHCP CIC protocols with input from the GP with special interest (GPwSI) (or the patients GP as required).

The patients registered GP will be responsible for the generation of prescriptions of Warfarin/VKA.

Referrals can be made by secondary care or the patients GP via an electronic referral form.  Inclusion and exclusion criteria for referral is detailed below. Referrals will be made electronically via the Care Coordination Hub (CCH) and will undergo clinical triage before care is accepted by CHCP CIC.

The Anticoagulation Service is not a diagnostic service, a diagnosis, management plan, duration of treatment and INR range will be determined by the referring clinician. The Anticoagulation will undertake an initiation appointment for all new patients referred into the service, Warfarin will not be commenced and advice will be sought from GP/referring clinician if:

• baseline INR is below 0.8 or above 1.3,
• Systolic blood pressure (bp) is greater than 160mmHg
• Diastolic blood pressure greater than 90mmHg
• Haemoglobin (hb) <100, White Blood Count  >12,  Platelets < 140.  

Exclude Red Flags

As below – referrals will not be excepted for patients that fall within the exclusion criteria.

DO NOT REFER

• Alcohol or substance misuse who are unstable.
• Severe Hypertension
• Memory Impairment (unless measures to supervise medication are in place)
• Bacterial Endocarditis
• Gastrointestinal Disease with a high risk of bleeding (e.g., Peptic Ulcer, Oesophageal Varices)
• Severe liver or renal disease (unless under specialist care).
• Patients “unwilling to co-operate” with the service.

Please review if an alternative Anticoagulant such as a Direct Oral Anticoagulant (DOAC) is a suitable pharmacological option prior to referral.

National Institute for Health and Care Excellence (2021) Atrial Fibrillation: diagnosis and management [NG196]. Overview | Atrial fibrillation: diagnosis and management | Guidance | NICE

National Institute for Health and Care Excellence (2023) Venous thromboembolic diseases: diagnosis, management and thrombophilia testing [NG158]. Overview | Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance | NICE

• Patients 18 years of age and over.
• Selected children/adolescents under the care of the Paediatric Cardiologist at Leeds General Infirmary who require lifelong monitoring and dosing under the self-testing guidelines and who have been discussed with the team’s GP with special interest.
• Stable Medical condition.
• Alcohol or substance misuse who are stable and under the care of another primary health care professional/service.
• Patient concordance with treatment
• All patients must have a Patient Specific Direction agreed and signed by the referrer/GP

Referrals

Referrals will be made electronically via secondary care/diagnosing clinician. Referrals will be clinically triaged prior to accepting care, the referring clinician will be expected to complete the referral form in full to enable care to be transferred/accepted.  Referrals will be accepted from Hull based GPs, Acute Trusts and the CHCP Community DVT Service for any patient with a Hull based GP (HU1-HU9 and HU11).

For all new referrals a completed and signed referral form must be completed by a physician or non-medical prescriber.

Incomplete or illegible forms will not be accepted, and the referring Health Care Professional will be contacted to request the form is completed correctly.

All referrals should be emailed to CHCP.247111@nhs.net.

Information to Include

• Electronic referrals emailed to Care Coordination Hub (CCH) chcp.247111@nhs.net

• Incomplete referrals will not be excepted.
• Blood results:  Full Blood count (FBC), Liver Function Tests (LFT’s) Urea and Creatinine (U&E’) if available (within previous 4 weeks)
• Yellow anticoagulation book and Immediate Discharge Summary (IDS) (if secondary care referral).
• Medication history
• New referrals received after 16.45 Monday-Friday and 12.30 Bank Holidays and weekends will not be actioned until the following day.