ISG Summer Meeting 2016
Poster Prize - Merit Award
Dr Roisin Stack
AMNCH Tallaght Dublin
Pre-assessment of patients awaiting endoscopic procedures while on anti-coagulation therapy.
R. Stack, F. Lindsay, V. Parihar, N. Breslin, D. Mc Namara, A. Alakkari, B. Ryan.
AMNCH, Tallaght, Dublin 24. Trinity College Dublin, College Green, Dublin 2.
Anti-coagulation therapy is commonly encountered in patients who are referred for endoscopy. Pre-assessment of such patients helps to ensure clear instruction is given to patients with regards to withholding of medications and instigation of bridging therapy where indicated. We believe this contributes to safer patient management and may potentially reduce numbers of cancelled or repeat endoscopy procedures.
In 2013, a nurse-led pre-assessment clinic for endoscopy was established to review patients on anti-coagulation therapy who were waiting endoscopy procedures. Patients were risk-assessed depending on indication of anti-coagulation and likelihood of intervention at time of endoscopy. Patient were counselled by telephone whether to hold or continue anti-coagulation medication. Patients who warranted bridging therapy were reviewed in the nurse-led clinic and educated regarding administration of LMWH.
We undertook a retrospective review of 615 patients who have been assessed in the pre-assessment clinic from 2013 to date. Patients were referred to the clinic by the doctor ordering the endoscopy procedure. Anti-coagulation drug, whether the medication was held and whether the patient required bridging was recorded. Indication for anti-coagulation was documented in 212 out of 612 patients, including atrial fibrillation, valvular disease, thrombotic disease, TIA/stroke, ischaemic heart disease and heart failure.
615 patients were reviewed in the pre-assessment clinic. 472 patient were on warfarin, 80 patient on rivaroxaban, 26 on dabigatran, 25 on apixaban and 12 on LMWH . In total, 317 patients had their anti-coagulation medication held prior to endoscopy and 129 patients were commenced on bridging therapy. 119/129 commenced on bridging therapy were on warfarin, 3 patients each on rivaroxaban and dabigatran and 2 patients each on LMWH and apixaban respectively. The percentage of patients referred on NOACs in 2013 and 2016 were 7% and 28%, respectively.
The number of patients referred on NOACs has increased since 2013. Each NOAC has a different half-life and requires different management. Identification and active management of these patients avoids unnecessary cancellations and ensures safe anti-coagulation peri- endoscopy. The number of patients requiring bridging therapy also supports the need for contact with medical staff for implementation and patient education.