Features

Keeping anticoagulant services flowing during the COVID-19 pandemic

From blood tests via letterboxes to managing drug switches, nurses have been adapting care

From blood tests via letterboxes to managing drug switches, nurses have had a central role in adapting care

  • In response to lockdown, nurses set up testing in public settings for patients on anticoagulants, including drive-through tests in car parks
  • Where possible patients were switched from warfarin to direct oral anticoagulants that require less frequent monitoring of blood levels
  • Anticoagulation clinics plan to continue some of the service innovations developed during the outbreak as standard best practice
Picture: iStock

Pricking the index finger of a hand extended through a letterbox is not how warfarin blood tests are usually conducted, but the many challenges of the COVID-19 pandemic have demanded innovative responses from nurses in all settings.

...

From blood tests via letterboxes to managing drug switches, nurses have had a central role in adapting care

  • In response to lockdown, nurses set up testing in public settings for patients on anticoagulants, including drive-through tests in car parks
  • Where possible patients were switched from warfarin to direct oral anticoagulants that require less frequent monitoring of blood levels
  • Anticoagulation clinics plan to continue some of the service innovations developed during the outbreak as standard best practice
Picture: iStock

Pricking the index finger of a hand extended through a letterbox is not how warfarin blood tests are usually conducted, but the many challenges of the COVID-19 pandemic have demanded innovative responses from nurses in all settings.

Sandwell and West Birmingham Hospitals NHS Trust lead anticoagulation nurse specialist Kelly Barnickle says one of those challenges has been monitoring the anticoagulant levels of patients too fearful of contracting COVID-19 to allow a nurse – even one practising appropriate infection control – into their homes.

Anticoagulation nurse specialist
Kelly Barnickle

Adapting quickly to meet patients’ needs during the pandemic

Hence, the hand through the letterbox – which, Ms Barnickle says, was duly finger-pricked once the patient on the end of it had been properly identified.

The pandemic has certainly tested nurses’ ingenuity, she says.

‘All haematology services have found the same,’ she says.

‘We had to be quite quick to think how we were going to meet patients’ needs.’

View our COVID-19 resource centre

Dealing with service users’ distress during lockdown

Anticoagulants are prescribed for patients at risk of developing clots, which can prevent the flow of blood and may in turn cause stroke, heart attack, deep vein thrombosis or pulmonary embolism. Patients fitted with artificial heart valves are also treated with anticoagulants.

Use of these drugs is widespread. Warfarin is still a mainstay of anticoagulation therapy, but newer drugs known as direct oral anticoagulants (DOACs) are now widely used.

In 2014 DOACs represented just 9% of all anticoagulant prescriptions. Five years later, that figure had risen to 74%, while use of warfarin fell, although in that period total anticoagulation prescriptions almost doubled.

An advantage of DOACs is that, in comparison with warfarin, they require less frequent monitoring of blood levels.

For some patients taking anticoagulants, the pandemic and ensuing lockdown caused understandable alarm, Ms Barnickle says.

‘Almost as soon as the news about coronavirus started coming in and case numbers started building, we began fielding lots of phone calls from patients, even ones we wouldn’t necessarily say fitted the shielding criteria.

‘There was a lot of misunderstanding and some panic among patients, and I understand that completely. But it massively increased the amount of contact we were having with them. We had to firefight and change our service provision quickly.’

Anticoagulation clinics in primary care settings

Self-testing kits were issued to patients able to monitor their own blood levels Picture: iStock

Ms Barnickle’s clinic at Sandwell General Hospital remained open, with patients screened for COVID-19 symptoms before they attended, while more patients than usual requested home visits. Extra self-testing machines were made available for those able to monitor their own blood levels but patients first had to be trained to use them.

Meanwhile, nurses in primary care settings have also had to respond quickly to changing circumstances.

Jane Patrickson is clinical nurse lead for Affinity Care, a partnership of medical practices in Bradford, West Yorkshire.

She says her warfarin caseload mostly comprises older people, many with co-morbidities, and asking them to continue attending their GP practice for blood tests during the pandemic would not have been appropriate.

‘We were scared to bring them in – not for ourselves but for them,’ she says.

‘But we were in a good position because we have a lot of self-testers whose results come directly to us, and dialogue with them can be done over the phone or by email.’

Self-testing, ‘drive-bys’ and ‘drive-throughs’

Jane Patrickson: ‘I might have been the
only person that patient has seen all week’

Some patients were switched to DOACs but others either could not be switched or could not self-test.

That left two options: ‘drive-bys’ and ‘drive-throughs’. Either the nurse would drive to the patient’s house and – wearing appropriate personal protective equipment (PPE) – conduct the finger-prick test on the patient’s doorstep or over the garden gate, or the patient would drive to the surgery car park where the nurse, again in PPE, would perform the blood test through the car window.

Any home visits involve PPE and social
distancing Picture: Alamy

Ms Patrickson continues to see some vulnerable patients in their homes, although the visits, undertaken in full PPE, are brief, with no time for socialising.

‘It’s nice to be able to sit and have a cup of tea with my patients but I’ve not been able to do that,’ she says.

‘And that’s been hard, saying “I’m so sorry, I’ve got to be in and out as quick as I can. I’m not worrying about you passing anything to me – you’ve been shielding for three months – but I’m more worried about anything I might be bringing in”.’

She adds: ‘I might have been the only person that patient has seen all week.’

Persuading appropriate patients to switch to DOACs

Shain Collins: ‘Patients were receptive
to the switch to a DOAC’

In Perivale, west London, Hillview Surgery’s lead practice nurse Shain Collins has also been making use of the car park to monitor those on anticoagulants (see box). She too has taken the opportunity to talk to patients about switching from warfarin to a DOAC.

‘The patients were receptive,’ she says. ‘We got them at the right time. We’d attempted to switch them previously but then things got too hectic.

‘But at the beginning of the pandemic, we thought, right, this is the ideal opportunity. This is when we should be switching them, to keep them away from the surgery.’

Some patients who had been on warfarin for many years took a little persuading, Ms Collins says. But the less frequent monitoring required with DOACs was often an important factor in their decision to switch.

Warfarin remains a valuable treatment option for some, says Ms Collins. But for most patients who are on long-term anticoagulation therapy, changing to a DOAC makes sense. As well as bringing benefits for patients, DOACs free up time for nurses as the number of attendees at regular ‘warfarin clinics’ falls.

Caring for warfarin patients at the height of the COVID-19 pandemic

Vasu Siva, GP partner at Hillview Surgery in Perivale, west London, writes:

Use of warfarin in anticoagulation therapy
has fallen in recent years Picture: iStock

When the pandemic led to lockdown in March, our nursing team at Hillview Surgery looked at the management of patients on long-term warfarin therapy who were at minimal risk from a thromboembolic event. How could levels be maintained in the therapeutic range while reducing patients’ and clinicians’ risk of exposure to infections?

We have a dedicated clinical team responsible for monitoring international normalised ratio (INR), the finger-prick test that determines warfarin dosage. The plan was to check each patient’s INR in our car park at a specified appointment time, minimising risk for the patients and nurse involved.

Patients, wearing face masks, stay in their cars while the finger-prick check is carried out through the open car window. Once the blood sample has been taken, the patient waits in the car, usually for about five minutes, until the nurse informs them of the readings, with written dosing instructions.

The nursing team also came up with the initiative to switch patients on warfarin to direct oral anticoagulants (DOACs). The lead nurse and a healthcare assistant ran a search for all patients on warfarin therapy. The idea was to see whether they could be switched to a DOAC if clinically appropriate. This would reduce footfall in the practice, limiting the spread of COVID-19 infection.

‘Our nursing team came up with this initiative and implemented it well before NHS England produced guidance recommending switching patients’

The team excluded those who could not be switched – for example, patients with prosthetic/mechanical heart valves – and a template for switching was created.

Those who consented to the switch were invited to attend our car park, where they had initial blood tests, a weight check and a finger-prick. They were advised to stop warfarin for two days and reviewed after a further INR check. Provided the blood tests were satisfactory, the clinical pharmacist counselled the patient again and confirmed the patient was clinically appropriate for the switch.

‘Drive-through’ tests enabled warfarin
patients to be switched and monitored safely

Follow-up and switching more patients

The community pharmacy dispensing the DOAC script contacted each patient after two weeks to check for any side effects or issues related to the new medication. The time frame for blood monitoring after switching to a DOAC is based on the patient’s renal function and other factors such as age and frailty, and is usually either at three or six months. Patients were asked to contact the nurse if any issues arose in the meantime.

The nurses then decided to review all other patients opportunistically as they came for their INR check. A total of 14 patients have switched from warfarin to a DOAC in the last two months. Only two have thus far declined as they felt they did not want a change.

Our nursing team came up with this initiative and implemented it well before NHS England produced guidance recommending switching patients on warfarin.

Innovations that lead to long-lasting change

Some solutions to the problems of delivering an effective anticoagulation service during a pandemic have been quick fixes, intended to plug a gap temporarily, but others are beginning to seem more long-lasting.

Eve Knight: ‘Nurses have been at the
forefront of innovations during lockdown’

‘We’re getting to the point now where we’re starting to feel some of this is normal,’ says Ms Patrickson.

‘It’s made us all think differently about how a job can be done. With some ways of working, we’ve said, “This is good. We wouldn’t have thought of doing this before COVID but, if it works, why would we change back?”. For whichever patient, we’ve managed to find a solution that works for them.’

Nurses vital to maintaining anticoagulation services during the crisis

Anticoagulation UK chief executive Eve Knight says that although no national information is yet available, she thinks nursing staff have played an essential part in maintaining anticoagulation services in challenging circumstances.

‘Anecdotally, we know that nurses have been at the forefront of creating some innovative ways in which patients have continued to access clinics and been supported by their anticoagulation nurses during lockdown.’

Coronavirus escalated the switch from warfarin to DOACs for many patients, but adherence will be vital in the future, she says. ‘We need to ensure patients are offered the support they need.’

Meanwhile, clinics originally established to monitor patients on warfarin could be repurposed for more general prevention and management of cardiovascular disease, she suggests.

Shaking up the way healthcare is provided

Conducting blood tests under a gazebo in a car park, or indeed through a letterbox, are not permanent solutions to difficult situations.

But for all the anguish and tragedy of coronavirus, the pandemic has shaken things up so profoundly that in some corners of healthcare new ways of delivering nursing services have emerged and taken root.

And in the long term they may prove more beneficial to patients than those services and treatments they replaced.

Why warfarin?

Picture: iStock

Warfarin takes its name from the Wisconsin Alumni Research Foundation (WARF), which funded early studies into the compound that later became the anticoagulant taken today by millions of people worldwide.

But warfarin’s history stems back to the 1920s, when farmers in Canada and the northern United States found their previously healthy cattle were dying of internal bleeding. Sweet clover hay was identified as the source of the problem, specifically a mould that developed when the hay was damp.

It was several years before coumarin, the active compound that caused the cows to haemorrhage, was isolated and the first drug developed from it was patented to the WARF in 1941.

WARF-funded research into variants of coumarin led to warfarin, first used as a rat poison but approved for medical use in humans in 1954. The following year, the drug was used to treat US president Dwight Eisenhower after he experienced a myocardial infarction.

Source: British Journal of Haematology


Further information

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to nursing standard.com and the Nursing Standard app
  • Monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs