Discharge Planning Checklist:

Key patient education components

Explain all of the following to the patient

· Reason for treatment

· Mechanism of action of warfarin

· Time of day to take warfarin (same time of day)

· The INR, target range and need for regular testing

· Signs and symptoms of bleeding

· Effect of illness, injury or other changes in physical status

· Potential effect of invasive procedures, surgery or dental work

· The effects of common over-the-counter (OTC) medication interactions

· Need for consistent intake of vitamin K rich foods

· Effects of alcohol intake

· Appropriate action if diarrhoea or vomiting occurs

This is covered by the Warfarin Flipchart available at CMDHB.

Text Box: WARFARIN EDUCATION RECORD
(Filled out by pharmacist, nurse or doctor)
Patient educated by…………..............................role………….
Tick if translator required
Language………………………………

Given warfarin book and take-home card

Signed……………………………Date……………

Discharge planning is essential for patients who will be discharged on warfarin. Check that the following has occurred before the patient is discharged:

1. Verbal or written information on the risks and benefits of anticoagulation has been discussed with the patient and is documented in the clinical notes. To organise this, the staff nurse or team doctor should refer patient for education:

· DVT/PE patients to the Anticoagulant nurse 93-8545

· All other patients to the ward pharmacist (See SouthNET phone list)

· Staff nurse can take patient through Warfarin Flipchart

· The Warfarin Education Record on the prescribing sheet MUST be filled out prior to discharge

2. Arrange outpatient laboratory (INR) monitoring for patient and provide blood test forms

3. Specify on the Electronic Discharge Summary :

· Whether patient is discharged on Bridging Anticoagulation, eg with Clexane® /Enoxaparin. If so, the expected duration of therapy and when the Bridging should stop.

· Prescription specifies brand of warfarin (Marevan® or Coumadin®). Marevan® is the preferred brand in New Zealand

· Most new patients on warfarin should just receive 1mg tablets. If 3 or 5mg tablets prescribed, ensure that patient is educated about the colour and strength of the tablets.

· Doses of warfarin given in hospital. This helps the community prescriber work out the maintenance dose

· Dose of warfarin at discharge

· Date of next INR

· Target INR range. For example:

INR 2-3	Atrial Fibrillation stroke prophylaxis Cardioversion Mural thrombus DVT/PE
INR 2.5-3.5	Mechanical heart valves post 1990
INR 3-4	Mechanical heart valve pre-1990 Recurrent DVT-PE whilst on warfarin
Other target range	This is usually on specialist advice. For example, a patient requires anticoagulation but at a slightly lower target INR due to bleeding risk eg 1.5-2.0

· Duration of warfarin therapy. This varies from patient to patient and should be discussed with the team, patient and G.P. For example:

o 3 to 6 months for uncomplicated DVT/P.E

o Life-long for mechanical heart valves, or stroke prophylaxis for atrial fibrillation, recurrent DVT/P.E.

o Procedure dependent e.g. one month before and one month after cardioversion for a heart arrhythmia

· Individual responsible for INR monitoring-make sure the patient knows who to call to follow up the results.

· Date and place for INR blood tests

4. Follow up-again, this varies immensely depending on the reason for anticoagulation. For example:

· DVT/P.E.-Refer to anticoagulation service while an inpatient. Patient will then be seen by a haematologist as an outpatient

· Atrial Fibrillation-followed as usual, by G.P. or specialist in the community

· Mechanical Valve-Initial post-op follow up by Cardiologist. Long term, stable patients are often discharged back to their G.P

· Cardioversion-Will need Cardioversion Clinic follow up by cardiology

Important: It is important to advise GPs of the dose of warfarin at discharge, date of next INR, recommended INR, length of warfarin treatment, and who is responsible for monitoring the INR