Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.
N.B. If a patient has been on warfarin pre-admission, see guideline on Appropriate and Safe Conversion from Warfarin to a DOAC during the COVID-19 Pandemic.
Patients being discharged from hospital on vitamin K antagonists (warfarin or acenocoumarol) will usually be in an unstable phase of anticoagulation. It is therefore essential that the transition of anticoagulant monitoring from hospital care to the community or outpatient clinic is well organised and clearly documented for the patient and clinical staff involved.
All NHSGGC adult patients taking, or to be commenced on a vitamin K antagonist (VKA) must be referred to Glasgow and Clyde Anticoagulation Service (GCAS, see Appendix 6 for contact details) before discharge from hospital for their ongoing dosing and monitoring. GPs should not be asked to undertake routine INR monitoring. A referral should be made for all vitamin K antagonist-treated patients regardless of whether their anticoagulation is considered stable or not.
For patients resident outwith NHSGGC, please contact the patient's GP to identify the most appropriate anticoagulant provider for their Health Board. Information may also be available from GCAS (see Appendix 6 contact details).
Referrals should be made electronically via TrakCare for all VKA patients, whether they are started on treatment prior to or during hospital admission, or if they are still to commence on it as an outpatient.
GCAS aim to process referrals within 1 hour of referral during the working week (Mon– Fri 9am-4pm). Weekend / out-of-hours referrals will be processed on the next working day. GCAS staff will phone the ward with an appointment for the patient but if the patient has already been discharged then GCAS staff will require telephone contact details for the patient in order to appoint them.
Key recommendations are as follows:
These patients can often be discharged in a less stable anticoagulant state and sometimes on a different dose. They may be on new medicines which could interact with warfarin or acenocoumarol. As they will already have an existing anticoagulant clinic appointment ensure that their appointment is within 3-7 days of discharge with their usual anticoagulant clinic, or nearest hospital clinic to patient's home if this facilitates a quicker appointment. Make referral to GCAS using the TrakCare form in order to obtain an updated appointment. Update the yellow booklet with appointment details and include 3-5 of the most recent INR results and corresponding warfarin / acenocoumarol doses from their inpatient stay.
Patients requiring elective initiation of warfarin (e.g. asymptomatic atrial fibrillation) can be referred to their local hospital anticoagulant clinic for this to be commenced as an outpatient. Use the electronic referral form on TrakCare (see details above) to make the referral. On the referral form where it says 'when was the anticoagulation started', click on the spy glass and select option 'to be commenced at the anticoagulation clinic'. Include the same referral information as for inpatient referrals (see above). It is recommended that such patients do not start anticoagulant therapy in advance of their first anticoagulant clinic appointment. GCAS will contact the patient directly with their anticoagulant clinic appointment and endeavour to appoint these patients within 2 weeks of referral.
Content last updated: April 2020
Page last updated: September 2022