Training activity information
Details
Select appropriate tests for monitoring all types of anticoagulation therapy to include:
- INR
- Anti Xa based test
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Considerations
- Timing of sample collection
- The sample type required and the preanalytical variables affecting results
- Clinical presentations and other investigations
- Electronic dosing packages
- Point of care and self-testing
- National guidelines
- Local SOPs
- Quality assurance
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
What does success look like?
- Identify what is expected of you in relation to selecting appropriate tests for monitoring all types of anticoagulation therapy, including INR and Anti Xa based tests.
- Consider how the learning outcomes apply, specifically what criteria define the ‘appropriateness’ of a test for monitoring specific anticoagulant therapies.
- What does successful selection look like, particularly concerning the expected outcomes of accurate anticoagulation monitoring for patient care?
- Discuss with your training officer to gain clarity on expectations for the range of anticoagulants you should cover and the expected level of detail in your selection criteria.
What is your prior experience of this activity?
- Think about what you already know about different types of anticoagulant drugs (e.g., Warfarin, Heparin, DOACs) and their mechanisms of action.
- What do you already know about INR and Anti-Xa based tests, including their principles and limitations?
- Consider possible challenges you might face in selecting appropriate tests, and think about how you might handle them, for example:
- Understanding drug interactions.
- Non-standard dosing.
- Specific patient conditions.
- Recognise the scope of your own practice for this activity, i.e., know when you would need to seek advice regarding complex anticoagulation monitoring scenarios.
- Acknowledge how you feel about this task, particularly understanding the clinical context behind monitoring requests.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop in selecting and justifying laboratory tests based on clinical context.
- Identify specific insights you hope to gain into the appropriate monitoring strategies for different anticoagulants and patient populations.
What additional considerations do you need to make?
- Consult actions identified following previous experience with coagulation tests or clinical cases involving anticoagulants.
- Identify important information you need to consider before embarking on the activity, such as:
- Current guidelines for monitoring different anticoagulants
- Laboratory standard operating procedures
- Available test methodologies in your department
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst selecting appropriate tests for monitoring anticoagulation therapy?
- Are you encountering situations such as:
- A monitoring request for a rare or novel anticoagulant e.g., a specific Direct Oral Anticoagulant – DOAC for which the standard Anti-Xa assay requires specific calibration or is not locally validated.
- Incomplete or ambiguous patient information e.g., drug name or dose missing, making it unclear whether INR or Anti-Xa is the appropriate initial monitoring test.
- The expected monitoring test being unavailable due to equipment maintenance, necessitating the selection of an alternative, less conventional test.
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to the test selection process?
- Consider the steps you are taking in the moment, such as:
- Immediately consulting the laboratory Standard Operating Procedures (SOPs) or the hospital drug formulary to determine the appropriate monitoring test for a non-standard drug
- Pausing the selection process to contact the requesting department for immediate clarification on the patient’s specific drug regimen or indication
- Seeking immediate guidance from a clinical scientist regarding the limitations or interferences associated with the primary Anti-Xa assay for a specific class of anticoagulant
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your knowledge of testing criteria to encompass new or rare anticoagulants? Is it affecting your confidence in justifying the selected test?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice e.g., successfully selecting the alternative test based on SOPs, or needing support because the required test is outside local capability and requires external referral?
- What are you learning as a result of the unexpected development? For example, are you gaining key insight into the specific assay interferences affecting Anti-Xa tests, or mastering the procedure for rapid consultation on therapeutic monitoring guidelines?
On action
What happened?
- Begin by summarising the key points of the experience of selecting tests for monitoring anticoagulation therapy for a specific patient or scenario. Which anticoagulants and corresponding tests (like INR or Anti Xa) did you consider?
- Describe any specific interactions or moments which felt important, such as having to make a specific decision or feeling uncertain about the best test. How did that feel?
- Include any ‘reflect-in-action’ moments where your immediate considerations about the patient’s drug or other factors led you to adjust your selection criteria.
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding matching monitoring tests to different types of anticoagulants. What new knowledge did you gain about specific tests like INR or Anti Xa assays, and were there knowledge gaps regarding certain drugs or monitoring strategies?
- Compare this experience against previous engagement with similar activities. Has your understanding improved of why specific tests are used?
- Identify any challenges you experienced e.g., incomplete clinical information, novel anticoagulant and how you reacted to these. Were you able to overcome them?
- Identify anything significant about the activity, such as whether you needed to seek advice or clarification from a senior colleague regarding appropriate monitoring tests. Did you ensure your recommendations were within your scope of practice?
- Acknowledge any changes in your own feelings now you are looking back on the experience regarding your confidence in selecting anticoagulation monitoring tests.
What will you take from the experience moving forward?
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt. For example, what specific actions will you take to enhance your knowledge of anticoagulation monitoring, particularly for drugs you were less familiar with?
- What will you do differently next time in your approach to selecting monitoring tests?
- Do you need to practise any aspect of the activity further, such as evaluating patient information to inform test selection, or understanding the nuances of different assays?
Beyond action
Have you revisited the experiences?
- Reviewing your past experiences selecting monitoring tests for various anticoagulation therapies including INR and Anti Xa tests, what specific actions for development did you identify in previous reflections?
- Have you focused on improving your knowledge of specific anticoagulant mechanisms or test interferences? How ready are you to apply this enhanced knowledge in selecting appropriate tests?
- Have you engaged in discussions with colleagues about the selection of monitoring tests for patients on novel anticoagulants or those with complex clinical conditions? Did these conversations provide new insights that have altered your perspective on selecting the most appropriate tests?
How have these experiences impacted upon current practice?
- How does your accumulated experience and reflection on selecting anticoagulation monitoring tests prepare you for assessments such as a DOPS on performing a thrombophilia screen and recommending further testing, or an OCE discussing the implications of anticoagulation therapy including drug choice?
- How has your understanding of different anticoagulants and the appropriate tests for monitoring them deepened over time? Are you more confident in selecting tests for less common therapies or in complex patient scenarios?
- Can you now more readily identify situations where expert advice is needed regarding anticoagulation monitoring tests?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Identify appropriate clinical and laboratory investigations for the investigation of haemostasis. |
| # 2 |
Outcome
Interpret and report results of investigations of haemostasis in the correct clinical context. |
| # 7 |
Outcome
Perform quality assurance and control tasks across the range of investigations. |