Would you like to begin by introducing yourself? What's your role within the service and how long have you been there?
My name is Dr Susie Shapiro and I am a Consultant Haematologist at Oxford University Hospitals NHS Foundation Trust. I subspecialise in haemostasis and thrombosis, so all the work that I do is related to venous thromboembolism (VTE) prevention and treatment, anticoagulation, inherited and acquired bleeding disorders.
We are a relatively small team of three consultants within my subspecialty. In addition to our direct clinical work, we take responsibility for medical leadership for various clinical services, including anticoagulation (inpatient and outpatient), venous thrombosis prevention, a deep vein thrombosis (DVT) ‘one-stop’ diagnostic clinic, haemophilia and inherited bleeding disorders, our specialist haemostasis diagnostic laboratory and the regional haemostasis genetics service.
Our haemophilia specialist multidisciplinary team (MDT) aims to support individuals to live the life they want to lead and I really enjoy building up relationships with these patients over time.
Currently, I am the Director of the Oxford Haemophilia Service. The Oxford Haemophilia Centre was the first haemophilia centre to open in the UK and remains one of the largest. Inherited bleeding disorders are relatively rare and affect individuals in different ways at different stages of their lives. Our haemophilia specialist multidisciplinary team (MDT) aims to support individuals to live the life they want to lead and I really enjoy building up relationships with these patients over time. However, when I first arrived in Oxford my leadership roles were anticoagulation and VTE prevention. Within these roles, I received an RCPath Excellence Award in 2019 for leading an anticoagulation improvement project, and so I’ll focus more on this aspect of our service for your questions.
Could you introduce us to your Anticoagulation MDT team – how many people are in the team and what are their job roles?
Within the anticoagulation team, Dr Dalia Khan is the current Consultant Lead for anticoagulation. We have two specialist anticoagulation pharmacists – Vicki Price and Mary Collins – and two senior anticoagulation nurses to support inpatient safety and our warfarin and DVT diagnostic services – Lucy Wood and Claire Harris.
At the heart of the service are 12 specialist thrombosis nurses, one assistant practitioner, administration and clerical support teams led by Sharon Osborne and Michael Meyers, two trainee doctors (an FY2 and haematology ST), a specialist haemostasis diagnostic lab led by Peter Baker, and clinical research nurse team led by Jamie Burbage. Every individual is crucial to the day-to-day running of our services and to advancing clinical treatment option. I am enormously grateful to them for their care and dedication.
Is there anything that you think is particularly unique to your Anticoagulation team at Oxford University Hospitals?
When I asked our Anticoagulation MDT, they come up with lots of things that are pretty special about the services we offer. This includes:
- a 7 day a week specialist DVT diagnostic service (most other areas are open Monday to Friday maximum)
- a pathway for rapid and safe diagnosis of DVT in COVID-19-positive out-patients
- a dedicated anticoagulation service that cares for one of the largest cohorts of patients on vitamin-K antagonists that we’ve come across (approximately 4,000). We maintain a mean service time in therapeutic range of 74% (which is very good) with an advice telephone and email hotline available Monday to Friday for patients and clinicians.
- an assistant practitioner-led point-of-care (POC) testing clinic on two sites for patients who are needle phobic or difficult to bleed. This supports self-testing for warfarin international normalised ratio (INR) dosing and trains patients to use their own POC testing machines at home, or when travelling or working.
- a home visit POC INR testing service provided by specialist nurses. This has been vital during the COVID-19 pandemic for the safe management of clinically extremely vulnerable shielding patients.
- a POC INR testing pathway for patients with active and symptomatic COVID-19.
The team is really good at working together, supporting each other, listening to new ideas, and using individual expertise and strengths to help us go forward. It’s a fun team to be part of! But, ultimately, anything we’ve achieved within anticoagulation and thrombosis could be replicated, or ideas taken and tweaked to work within local service structures. We’re always happy to chat to other teams and hospitals.
In your experience, what has been the impact of digital pathology on your Anticoagulation service and how do you see this developing in the near future?
Our hospital fully switched to Electronic Patient Records (EPR) a few years ago – so the days of writing paper records and request forms and faxing results generally feel long gone!
There are many advantages – electronic prescribing increases safety through the use of ‘power-plans’ and ‘alerts’ if more than one anticoagulant has been prescribed. However, it does take time to adapt all systems and processes, so they work well in the electronic world.
We’ve recently received funding for a pilot project with the Oxford Big Data Institute for trauma-related bleeding and VTE, which has the potential to be expanded to better understand VTE and bleeding risk of all of our inpatients.
We worked with IT at our hospital, GPs and our haemostasis lab to create an electronic system for our anticoagulation warfarin service that should improve patient safety. Rather than relying on paper forms and first-class post to advise patients on the correct dose of warfarin and remind them of their next INR test, this is now done electronically.
On a larger scale, big data sets and their analysis have the power to help understand conditions and improve clinical practice long term. We’ve recently received funding for a pilot project with the Oxford Big Data Institute for trauma-related bleeding and VTE, which has the potential to be expanded to better understand VTE and bleeding risk of all of our inpatients. We’re also using neural networks and machine learning to potentially improve the diagnosis of DVT; and we are about to open a multicentre randomised controlled trial to look at the use of artificial intelligence-guided diagnosis of proximal DVT (AutoDVT).
Throughout your career, you’ve shown a particular interest in improving patient safety. Could you name and briefly describe to us one of the most relevant projects in this sense?
Absolutely, I’ll explain a bit about the project that was recognised with an RCPath award.
Anticoagulants are a commonly prescribed medicine – 1.5–2% of the population takes an anticoagulant. Warfarin was really the only anticoagulant for many years and direct oral anticoagulants (DOACs) have recently expanded the choice of anticoagulant for many patients. This choice is fantastic, but has brought additional safety challenges. Anticoagulants were already associated with high levels of medicine safety incidents nationally. It is therefore absolutely vital that knowledge to ensure safe and optimal anticoagulation is not limited to specialists.
In 2017, I initiated and led a collaboration between local GPs, Oxford Clinical Commissioning Group and Oxford Academic Health Science Network to improve anticoagulant knowledge and safe prescribing in primary care. We obtained a Medical Education Grant to fund an anticoagulation pharmacist for one year to provide, with support from myself, a new email and telephone advice service for DOACs. Additional educational sessions in GP practices were provided in which individual records were reviewed alongside GPs to help support optimal anticoagulant prescribing and patient choice.
The service had really positive feedback and improved the confidence of GPs in prescribing DOACs and assessing how well-controlled an individual is on warfarin. There has been a gradual and sustained decrease in the number of patients poorly controlled on warfarin, and it was predicted that 15 strokes were averted during the first year of the project due to better anticoagulation control.
Following the success of this initiative, we wrote a business case for a new commissioned service, enabling this transformation in care to be continued.
This service continues to evolve to the changing needs of our GPs and local communities. For example, following recent discussions, we will be starting MDT meetings for GPs for complex queries and pharmacy-led reviews for some of the patients with poor warfarin control. It will also focus more on supporting follow-up for patients on DOACs, and analysing outcomes.
I think it’s really important that patient voices and local communities are heard – otherwise you can spend time and effort changing something the wrong way, or focusing on something that shouldn’t have been a priority.
What has been one of the most relevant achievements in working with communities and patient groups??
I think it’s really important that patient voices and local communities are heard – otherwise you can spend time and effort changing something the wrong way, or focusing on something that shouldn’t have been a priority.
Surveying and listening to our local GPs in 2016/2017 was critical in finding out that many wanted additional support with anticoagulation. Listening to patients has been crucial in the re-design of our warfarin service and converting to an electronic system. For example, many of our patients on warfarin are elderly and they wanted a non-electronic option in addition to email/texting of blood results and warfarin dosing advice.
How does your NHS work fit together with your research work?
I’ve always been interested in research as a way to increase our understanding of conditions and, ultimately, to improve patient outcomes. I undertook a basic science translational PhD at Imperial College during my specialist training, on the structure and function of von Willebrand factor (a protein that plays a central role in haemostasis). I really enjoyed my research, but when I completed my PhD, I was part time with a young family and I wasn’t sure that I would be able to be a successful part-time clinical academic. So, I came back to a fully clinical role to finish my specialist training and to take up a consultant position.
As a clinical consultant I’ve always remained involved in research activities. More recently, I wanted a chance to dedicate more time to research again and I was awarded an MRC clinical academic research partnership 3-year fellowship in 2019 . I currently dedicate two days a week to research.
My research interests complement my clinical practice. My main research project is investigating the mechanisms of thrombosis in myeloproliferative disorders (a chronic blood cancer) in collaboration with Prof Adam Mead. The aim is to reduce morbidity and mortality from thrombosis. Trying to ring-fence time to concentrate on research is definitely a challenge, as I suspect every clinical academic would say. But, I’m very much enjoying the diversity of the role and trying to get it to work!
How has COVID-19 affected your work and the Anticoagulation Service? What steps have you taken to overcome the challenges?
COVID-19 has been shattering. Like everywhere, we have struggled with staff shortages due to self-isolation/shielding and, within this, the work of our department has significantly increased.
There was initially concern about how GPs would see patients for blood INR tests for monitoring warfarin. We worked closely with GPs and reduced blood test frequency where possible while maintaining patient safety. We developed a pathway for INR testing in COVID-19-positive patients, utilising POC testing outside. We also adapted our existing POC pathway to incorporate increased demands for POC training, as patients purchased their own POC testing meters, and the number of home visits to shielding patients increased.
We already had guidelines on how to switch from warfarin to DOACs when suitable and these were highlighted. DOACs do not require regular blood monitoring and so were easier to maintain during the pandemic. Our warfarin service nurses, with support from our pharmacists, provided a DOAC counselling service for the increased number of patients switching to DOACs for whom GPs did not have sufficient time to provide full counselling or written patient information.
It became apparent early in the pandemic that COVID-19 increases the risk of VTE. The DVT service saw an extraordinary increase in referrals due to increased awareness of and concern about DVT. We had to work hard to accommodate these referrals and to develop a pathway for patients who are COVID-19 positive or who have recently travelled, to be seen safely, quickly, and with as little risk to other patients and staff as possible.
To better understand the risk of VTE associated with COVID-19 and how best to reduce this, we undertook local audits of our inpatients and have been involved in national and international clinical research studies on anticoagulation and COVID-19. In collaboration with specialty colleagues across the hospital, we revised the local VTE prevention guidelines several times based on emerging evidence. As with anticoagulation, increasing everyone’s awareness of this issue and keeping them updated in a changing field is crucial, so we have been involved in education both locally and nationally.
I believe patient safety is key to everything we should be doing clinically. On the wards it comes up in many forms: whether it’s a ‘safety check list’ for the daily ward round, or dual safety checks when prescribing chemotherapy, or education and increasing awareness of conditions for the MDT team and patients.
As with everywhere, face-to-face clinics were initially minimised, and almost all our clinic appointments were converted to virtual appointments (telephone or video). This was a massive change in how we practice, and, although it was introduced in an emergency as a necessity, it has shown us what is possible. For many patients it does not offer the same quality of appointment, but for others it is reasonable and saves a significant time in coming to hospital. Going forwards, the option for virtual appointments for some clinic visits is definitely something that we will incorporate into our services in the future.
What advice would you give to someone wanting to get more involved in haematology and patient safety?
I’m clearly biased, but I think haematology is a great specialty! It’s a wonderful mix of intensive inpatient work, often requiring close links with critical care, and outpatient work, linking with other specialties across the hospital and in the community. Job options are pretty varied with the ability of practicing across all of haematology or becoming subspecialised (e.g. in haemostasis, malignant haematology, blood transfusion, etc.).
Within my own subspecialty of haemostasis and thrombosis, I really enjoy the mix of clinical work between our lifelong patients with inherited bleeding disorders and the specialised knowledge that is required to look after these patients and helping to support good practice across the relatively common disorders of thrombosis and anticoagulation, which gets us out and about across the hospital and community. If it appeals, then I’d suggest chatting to your local haematology team and consider getting in touch with the British Society for Haematology.
I believe patient safety is key to everything we should be doing clinically. On the wards it comes up in many forms: whether it’s a ‘safety check list’ for the daily ward round, or dual safety checks when prescribing chemotherapy, or education and increasing awareness of conditions for the MDT team and patients. I don’t think there’s one way to get into it; it’s just being aware of potential safety issues, ideally before an event happens, and otherwise acting effectively after an incident. It doesn’t matter what your role is within the team – some things you do may be unique to you and others might not be aware of them – so everyone’s voice is important and should be heard.
What are you focusing on now as the next step in your career?
Clinical work, quality improvement and patient safety will always be at the heart of what I do. Alongside this, I would like to help provide more definitive answers for those ‘grey areas’ where patients ask for advice and there is currently no known right or wrong answer. In 10–15 years I would like to have played a small role in changing some of those conversations and be able to advise on the best course of action based on new evidence.
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