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Table 2 Educational needs and responsibilities for healthcare professionals responsible for patients receiving non-vitamin K antagonist oral anticoagulant therapy

From: Implementation of non-vitamin K antagonist oral anticoagulants in daily practice: the need for comprehensive education for professionals and patients

The initial prescriber The anticoagulation clinic nurse The general practitioner The pharmacist The patient
Needs Needs Educational needs Educational needs Educational needs
• Access to the latest data and expert opinion via colleagues, academic literature, and internal and external meetings and congresses • To receive regular updates on current best practice from the cardiology/haematology department (as detailed above); nurse coordinators also need access to academic literature and the chance to attend national coagulation nursing meetings • Ongoing updates (6-monthly in the first 1.5 years and annual thereafter) from specialists on evolving treatment options for VTE/AF; these could be provided online or by email, or via an in-hospital training day, and tied to professional development • Ongoing (annual or ad hoc) updates from anticoagulation clinic nurses and/or GPs regarding the loco-regional organisation of structured anticoagulant care (who is responsible for what, which lines of communication are available, etc.) and questions to ask the patient when filling a prescription (adherence – check blister pack) • Basic knowledge of their condition, treatment and the importance of adherence
• Simple flowcharts outlining recommended indications, dose adjustment and follow-up • Clear and concise guides on how to perform follow-up actions (SOPs), including clear instructions on how and when to contact their supervising physician, GPs, other HCPs and patients themselves throughout follow-up       – GPs are likely to be familiar with VKAs but less so with NOACs, and they will need to receive education on the differences between NOACs and other agents, and important aspects of ongoing care of patients receiving NOACs, including patient education Educational responsibilities • Awareness of what to do if an adverse event occurs, and ability to differentiate between minor and major events
Responsibilities • Software to assist in these tasks       – What to do in different scenarios; what constitutes an emergency/which issues should be referred via a routine appointment to the coagulation clinic/specialist department • To patients: • Regular contact with an HCP responsible for follow-up at a frequency dependent on individual risk assessment
• Provide education to other hospital departments and community GPs on treatment options for VTE/AF (regular updates) • To the patient (at each visit)       – Support with posters/checklists/desk note reminder cards, references to online sources of information       – Ensure that appropriate questions are asked of the patient when they collect their medication, based on the indication for use and the type of patient (elderly, with renal impairment, etc.) and medication (NOAC, VKA, etc.) • Materials and tools to assist with ongoing education and therapeutic adherence
      – Hospital meetings, including specific training days for GPs if practicable (could link to professional development) Responsibilities       – Provide patient leaflets and checklists to GP offices       – Ensure that patients are not prescribed contraindicated co-medications Educational responsibilities
      – Support with posters, checklists, desk note reminder cards that HCPs can take away and use; provide links to online sources of information       – Continual reinforcement of key educational messages about the anticoagulant they are taking (NOAC or VKA) at each visit (frequency of visits different for each patient based on health and risk factors for thrombosis/bleeding as discussed above) Educational responsibilities       – Add follow-up information to the patient’s NOAC card • To take a proactive role in their own treatment
• Provide education and training to anticoagulation clinic nurses (at least 6-monthly updates)       – Informal assessment of patient understanding (e.g. can they name their condition and explain why they have to take an anticoagulant, what the dose is, what signs of bleeding they should be looking out for, etc.?) • To the patient • Notify the coagulation clinic and/or GP of any concerns about the patient  
      – This could take the format of a session co-chaired by a senior nurse from the clinic or a GP experienced in NOAC use plus the specialist to give two different perspectives (practical and scientific)       – Support with printed leaflets and checklists, educational posters in the office, etc.       – In the absence of an anticoagulation clinic: follow-up with patients receiving anticoagulants (NOACs or other) at regular intervals (frequency dependent on risk) to remind them of the important aspects of their medication and what to do if they are concerned about an aspect of their health relating to their treatment   
      – Topics • To GPs       – As an adjunct to an anticoagulation clinic: take the opportunity at any patient visit for any reason other than anticoagulation to remind them of the important points regarding their anticoagulant treatment (adherence – check blister pack to make sure all doses taken)   
• Which patients are suitable for NOACs (e.g. stable condition, good renal function, knowledgeable about treatment, having a carer in charge of medication) vs which are not (or less) suitable (e.g. confused, elderly, likely to be non-compliant, with contraindications) – support with case studies       – Periodical (3- to 6-monthly?) contact to check on individual patients • To pharmacists (ad hoc communication):   
• Fundamental aspects of each NOAC vs heparin/VKAs (e.g. predictable pharmacology, drug interactions, etc.) • Those requiring only infrequent visits to the anticoagulation clinic       – Pass on educational information on questions to ask the patient before issuing a repeat prescription (this interaction could be mediated by the patient NOAC card)   
• Practical guides (e.g. based on EHRA advice) on topics such as taking a full bleeding history, calculating risk score (CHA2DS2-VASc, HAS-BLED, etc.), switching, appropriate laboratory tests and how to interpret them • Follow-up on patients who have missed scheduled clinic visits       – Remind about important aspects of pharmacology, drug interactions, etc.   
• ‘What to do if…’ guidance, including identification of potential emergency scenarios (serious bleeding event, e.g. head injury, major surgery required) vs minor problems (e.g. nose bleed, minor surgical procedure) and whom to contact in each case • Receive information on changes of patient status that may lead to an intensification of follow-up (e.g. anaemia, thrombocytopenia, new concomitant medication that may increase the risk of bleeding, exclusion of hypertension)       – Send posters/checklists; encourage pharmacist to get in contact if they have concerns   
• Latest information on patient adherence and how it can be improved; which practical tools they can use and offer to patients       – Reminders about key aspects of anticoagulants (NOAC and VKA), e.g. pharmacology, drug interactions, etc., and warning signs to look out for in patients receiving them (e.g. bleeding, vomiting, bruising)    
      – Smartphone/tablet apps and other online tools could be used in case physical meetings cannot be held       – Support with posters/checklists/desk note reminder cards, references to online sources of information    
• Education of the patient about their condition and how it will be managed • To the pharmacist    
      – First discussion at point of initial prescription       – Periodical (annual?) contact to remind pharmacists about questions they should ask the patient when filling a repeat prescription for any anticoagulant (e.g. ask the patient to present his/her NOAC card; the pharmacist could also complete a line on the follow-up page of the NOAC card, indicating how many drug doses have been delivered or any other important information), and, specifically for NOAC vs LMWH/VKA, whom to contact in case of concerns    
• Emphasise patient understanding of their condition and the drug they are taking (NOAC or VKA), and the importance of correct adherence to the prescribed regimen – use language that the patient can understand       – Key information on pharmacology and drug interactions    
• Support with printed leaflets and checklists that the patient can take home – these can include QR codes/online links, but should be physical copies so that patients can keep them in a convenient place and have constant access to them       – Support with posters/checklists/desk note reminder cards, references to online sources of information    
      – Second discussion to reinforce messages before discharge     
• Warning signs to look out for (e.g. anaemia, thrombocytopenia, hypertension, bleeding, vomiting, bruising)     
• Importance of keeping follow-up appointments with coagulation clinic/GP     
• Why adherence is important     
      – Support with printed leaflets and checklists as above     
      – Provision of NOAC card to the patient     
  1. AF, atrial fibrillation; EHRA, European Heart Rhythm Association; GP, general practitioner; LMWH, low molecular weight heparin; NOAC, non-vitamin K antagonist oral anticoagulant; QR, quick response; SOP, standard operating procedure; VKA, vitamin K antagonist; VTE, venous thromboembolism.