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Abstract The result of implementing network of care for post operative valvular heart patients who use wafarin

Dusadee Arayawongchai*, Teerapon Kaothean*, Monchaya Siriangkhawut*, Supaporn Promsupan*

*Sappasitthiprasong Hospital, Ubonratchatani province

Back ground: Valvular heart disease, a chronic illness with high mortality rate, is difficult to treat and prone to complications, especially from warfarin. In 2009, before implementing the network of care in Health region 13, we found that about 50 cases of total 217 cases (23.04%) had been brought back to the hospital due to warfarin using. Because of this problem, the network of care for warfarin use has been set

126

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up in January 2010 to look after these patients for continuity of care and to maintain wafarin level. Objec- tive: To study the result of implementing network of care for post-operative valvular heart disease pa- tients who use warfarin. Setting: Health region 13 Method: The study is divided into 3 phases;1) situation analysis 2) developing network of care guideline and 3) implementing and evaluation. The data were collected during January to March 2009 by questionnaire, depth interview, observation and focus group discussion. A descriptive statistic and content analysis were used to analyze the data.

Result: During January to March 2009, only 9 patients (8.11 % & 0.48% of post operative patients & of 1,881 patients who use warfarin during that time respectively) came back to the hospital due to warfarin using ( 5 due to overdose & 4 due to valve dysfunction ). From 15 committed hospitals, 13 hospitals were ready for implementation, 9 & 4 were community hospitals & general hospitals respectively. Conclusion:

The network of care with guideline, monitoring and supervisioon can improve the quality of life by de- creasing the complication of warfarin use.

Key words: Vavular Heart Disease Patients, Post-operative care

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®—ßÀ«—¥ ºŸâÕ”π«¬°“√‚√ß欓∫“≈·≈–ºŸâ√—∫º‘¥™Õ∫À≈—° (War- farin manager) ·æ∑¬å ‡¿ —™°√ ·≈–欓∫“≈®“°‚√ß æ¬“∫“≈„π‡§√◊Õ¢à“¬ Òı ·Ààß ‡ªìπ‡¿ —™°√ Ò √“¬ 欓∫“≈

ı √“¬

- °≈ÿà¡μ—«Õ¬à“ߪ√–°Õ∫¥â«¬ ºŸâªÉ«¬‚√§À—«„®·≈–

À≈—ߺà“μ—¥À—«„®∑’Ë√—∫ª√–∑“𬓫“√åø“√‘π„π‚√ß欓∫“≈‡§√◊Õ

¢à“¬ Ù ·Ààß ‡ªìπ‚√ß欓∫“≈∑—Ë«‰ª Ú ·Ààß ·≈–‚√ß欓∫“≈

™ÿ¡™π Ú ·Ààß „π à«π¢ÕߺŸâªÉ«¬·μà≈–‚√ß欓∫“≈„™â°“√§—¥

‡≈◊Õ°‚¥¬«‘∏’‡©æ“–‡®“–®ß (Purposive sampling) ‡©æ“–ºŸâ ªÉ«¬‚√§À—«„®·≈–À≈—ߺà“μ—¥À—«„®∑’Ë¡“μ√«®√—∫¬“«“√åø“√‘π

∑ÿ°§π„π«—π∑’Ë·æ∑¬åπ—¥ ·≈–‡°Á∫¢âÕ¡Ÿ≈„πª√–‡¥Á𧫓¡√Ÿâ„π

°“√ªØ‘∫—μ‘μ—«¢ÕߺŸâªÉ«¬ ·≈–«—¥ Target INR ¢ÕߺŸâªÉ«¬‚√ß æ¬“∫“≈≈– Ò §√—Èß

√–¬–∑’Ë Ú

- ∑’¡ ÿ¢¿“æª√–°Õ∫¥â«¬ ·æ∑¬å ‡¿ —™°√ ·≈–

欓∫“≈ ‡ªìπ§≥–°√√¡°“√‡§√◊Õ¢à“¬·≈–√—∫º‘¥™Õ∫À≈—° (War- farin manager) „π‡§√◊Õ¢à“¬ Òı ·Ààß ‡ªìπ‡¿ —™°√ ÒÒ √“¬

欓∫“≈ ˜ √“¬

√–¬–∑’Ë Û

- ∑’¡ ÿ¢¿“æª√–°Õ∫¥â«¬ ·æ∑¬å ‡¿ —™°√ ·≈–

æ ¬ “ ∫ “ ≈ ‡ ªì π § ≥ – ° √ √ ¡ ° “ √ ‡ § √◊ Õ ¢à “ ¬ · ≈ – √— ∫ º‘ ¥ ™ Õ ∫ À≈—° (Warfarin manager) „π‡§√◊Õ¢à“¬ Òı ·Ààß ‡ªìπ‡¿ —™°√

ÒÒ √“¬ 欓∫“≈ ˜ √“¬

- °≈ÿà¡μ—«Õ¬à“ߪ√–°Õ∫¥â«¬ ºŸâªÉ«¬ºà“μ—¥‡ª≈’ˬπ≈‘Èπ À—«„® (√—∫ª√–∑“𬓫“√åø“√‘πμ≈Õ¥™’«‘μ) ∑’Ë àßμàÕ„À⇧√◊Õ¢à“¬

ÚÒ˜ √“¬ ºŸâªÉ«¬∑“ßÕ“¬ÿ√°√√¡∑’Ë àßμàÕ„À⇧√◊Õ¢à“¬ ˜ √“¬

- ºŸâªÉ«¬‚√§À—«„®·≈–À≈—ߺà“μ—¥À—«„®∑’Ë√—∫ª√–∑“π

«“√åø“√‘πÕ¬Ÿà„π‚√ß欓∫“≈‡§√◊Õ¢à“¬(‡¥‘¡)∑—Èß ÒÛ ·Ààß

128

«‘∏’°“√»÷°…“

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√«‘®—¬ª√–°Õ∫¥â«¬

Ò. ‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈

 à«π∑’Ë Ò ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈∑—Ë«‰ª¡’∑—ÈßÀ¡¥ Òˆ ¢âÕ

‰¥â·°à ‡æ» Õ“¬ÿ √–¥—∫°“√»÷°…“ Õ“™’æ √“¬‰¥â ‚√§ °“√

ºà“μ—¥À—«„® ‚√§∑’Ë√—°…“§«∫§Ÿà°—∫¬“«“√åø“√‘π ªí®®ÿ∫—π√—∫

ª√–∑“π¬“Õ–‰√∫â“ß Õ“À“√∑’Ë√—∫ª√–∑“π„πªí®®ÿ∫—π Õ“°“√º‘¥

ª°μ‘∑’Ëæ∫¢≥–√—∫ª√–∑“π¬“∑’˺à“π¡“ °“√‰¥â√—∫§”·π–π”„π

°“√ªØ‘∫—μ‘μ—«À≈—ߺà“μ—¥ §”·π–π”°“√√—∫ª√–∑“𬓫“√åø“√‘π

∫—μ√√—∫ª√–∑“𬓠°“√æ°∫—μ√√—∫ª√–∑“𬓠§à“„™â®à“¬„π°“√

¡“μ√«®μ“¡π—¥

 à«π∑’Ë Ú ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈‡°’ˬ«°—∫‚√§·≈–°“√√—°…“

‡ªìπ¢âÕ¡Ÿ≈∑’ˉ¥â®“°‡«™√–‡∫’¬π ‰¥â·°à °“√«‘π‘®©—¬‚√§ °“√ºà“μ—¥

Target INR ·æ∑¬å‡®â“¢Õ߉¢â ∑’ËÕ¬Ÿà ¢π“¥¬“«“√åø“√‘π ∑’Ë√—∫

ª√–∑“π À¡“¬‡≈¢‚∑√»—æ∑å

 à«π∑’Ë Û ·∫∫øÕ√å¡°“√‡°Á∫¢âÕ¡Ÿ≈μ—«™’È«—¥ ‚¥¬ºŸâ«‘®—¬

„™â‡°≥±å§—¥‡≈◊Õ°μ“¡‡°≥±å¡“μ√∞“π°“√∑”‡§√◊Õ¢à“¬«“√åø“

√‘π¢Õß ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘

Ú. ‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√¥”‡π‘π°“√∑¥≈Õß

Ú.Ò ·∫∫øÕ√å¡ àßμàÕ¢âÕ¡Ÿ≈ºŸâªÉ«¬„Àâ‚√ß欓∫“≈

‡§√◊Õ¢à“¬ ª√–°Õ∫¥â«¬ «—π∑’Ë àߢâÕ¡Ÿ≈ ™◊ËÕ- °ÿ≈ºŸâªÉ«¬ Õ“¬ÿ ‚√§

°“√ºà“μ—¥ Target INR ¢π“¥¬“«“√åø“√‘π ·æ∑¬å «—ππ—¥μ√«®

(æ—≤π“‚¥¬∫ÿ§≈“°√„π‡§√◊Õ¢à“¬∑—Èß Òı ·Ààß)

Ú.Ú ·∫∫ —¡¿“…≥废âªØ‘∫—μ‘ß“π‡°’Ë¬«°—∫ªí≠À“°“√

„Àâ∫√‘°“√ºŸâªÉ«¬ ‡ªìπ·∫∫ Õ∫∂“¡ª≈“¬‡ªî¥„πª√–‡¥Áπ‡√◊ËÕß

¬“ ‡§√◊ËÕß¡◊Õμ√«® PT, INR  ∂“π∑’Ë  ◊ËÕ°“√„À⧫“¡√Ÿâ ·≈–

Õ◊ËπÊ

Û. ‡§√◊ËÕß¡◊Õ°”°—∫°“√∑¥≈Õß

Û.Ò ·∫∫∑¥ Õ∫§«“¡√Ÿâ°“√ªØ‘∫—μ‘μ—«À≈—ߺà“μ—¥

‡ª≈’ˬπ≈‘ÈπÀ—«„® ´÷ËߺŸâ«‘®—¬ √â“ߢ÷Èπ®“°°“√∑∫∑«π«√√≥°√√¡

¢Õß ∂“∫—π‚√§∑√«ßÕ° ª√–°Õ∫¥â«¬¢âÕ§”∂“¡®”π«π ÒÚ ¢âÕ

„À⺟âªÉ«¬‡≈◊Õ°μÕ∫Õ¬à“ß„¥Õ¬à“ßÀπ÷Ë߇ªìπ≈—°…≥–§”μÕ∫ ç„™àé

·≈– ç‰¡à„™àé ¢âÕ∑’ËμÕ∫∂Ÿ°μâÕß„Àâ Ò §–·ππ ¢âÕ∑’ËμÕ∫º‘¥‰¥â 

§–·ππ «‘‡§√“–Àå§à“§«“¡‡∑’ˬ߮“°°“√§”π«≥§à“ KR Ú

·≈–§à“§«“¡¬“°ßà“¬¥â«¬ KR ÚÒ ‰¥â‡∑à“°—∫ .¯Ú˜ ·≈– .¯Ò μ“¡≈”¥—∫^(ˆ)

¢—È𥔇π‘π°“√«‘®—¬

√–¬–∑’Ë Ò §âπÀ“ªí≠À“

Ò.Ò ª√–™ÿ¡∑’¡ ÿ¢¿“æ ª√–°Õ∫¥â«¬π“¬·æ∑¬å  “∏“√≥ ÿ¢®—ßÀ«—¥ ºŸâÕ”π«¬°“√‚√ß欓∫“≈ ·æ∑¬å ‡¿ —™°√

·≈–欓∫“≈®“°‚√ß欓∫“≈‡§√◊Õ¢à“¬∑’Ë ¡—§√„®®–‡¢â“√à«¡

‚§√ß°“√ ‡æ◊ËÕ·®âß«—μ∂ÿª√– ß§å„π°“√«‘®—¬

Ò.Ú √«∫√«¡·≈–«‘‡§√“–Àåªí≠À“°“√„Àâ∫√‘°“√ºŸâªÉ«¬

: ‚√ß欓∫“≈‡§√◊Õ¢à“¬ Ù ·Ààß (√æ.∑—Ë«‰ª Ú ·Ààß ·≈– √æ.™ÿ¡™π Ú · Àà ß ) ‚ ¥ ¬ „ ™â · ∫ ∫   Õ ∫ ∂ “ ¡ ª ≈ “ ¬ ‡ ªî ¥ °÷Ë ß ‚ § √ ß   √â “ ß  —¡¿“…≥凙‘ß≈÷° ·≈–∫—π∑÷°°“√ªØ‘∫—μ‘ß“π®“°°“√ —߇°μ°≈ÿà¡

μ—«Õ¬à“ß ·≈–„™â·∫∫ —¡¿“…≥废âªØ‘∫—μ‘ß“π‡°’Ë¬«°—∫ªí≠À“°“√

„Àâ∫√‘°“√ºŸâªÉ«¬

- ‡¿ —™°√·≈–欓∫“≈ „πª√–‡¥Áπ‡√◊ËÕ߬“ Õÿª°√≥å

∫ÿ§≈“°√ §«“¡√Ÿâ/ ◊ËÕ§«“¡√Ÿâ Õ◊ËπÊ „π°≈ÿà¡μ—«Õ¬à“ß Ù ‚√ß æ¬“∫“≈

- ºŸâªÉ«¬∑’ˉ¥â√—∫¬“«“√åø“√‘π ‡≈◊Õ°°≈ÿà¡μ—«Õ¬à“ß‚¥¬

„™âºŸâªÉ«¬∑ÿ°√“¬∑’Ë¡“μ√«®√—∫¬“«“√åø“√‘π„π«—π∑’ËÕÕ°‡°Á∫

¢âÕ¡Ÿ≈‚√ß欓∫“≈≈– Ò §√—Èß „πª√–‡¥Áπ‡√◊ËÕߧ«“¡√Ÿâ„π°“√

ªØ‘∫—μ‘μ—« ·≈– Target INR ¢ÕߺŸâªÉ«¬ ‚¥¬„™â·∫∫∫—π∑÷°

¢âÕ¡Ÿ≈∑—Ë«‰ª ·≈–·∫∫∫—π∑÷°¢âÕ¡Ÿ≈‡°’ˬ«°—∫‚√§·≈–°“√√—°…“

·∫∫∑¥ Õ∫§«“¡√Ÿâ °“√ªØ‘∫—μ‘μ—«À≈—ߺà“μ—¥‡ª≈’ˬπ≈‘ÈπÀ—«„®

„π°≈ÿà¡μ—«Õ¬à“ß ÒÙ √“¬

√–¬–∑’Ë Ú «“ß·ºπÀ“·π«∑“ß°“√ªØ‘∫—μ‘√à«¡°—π Ò. ª√–™ÿ¡∑’¡ ÿ¢¿“æ„π‚√ß欓∫“≈‡§√◊Õ¢à“¬ ·μàß μ—Èߧ≥–°√√¡°“√‡§√◊Õ¢à“¬ Warfarin ·≈–¡’ Warfarin man- ager „π·μà≈–‚√ß欓∫“≈√—∫º‘¥™Õ∫À≈—° (∫“ß·Ààß¡’∑—Èß æ¬“∫“≈·≈–‡¿ —™°√) ª√–°Õ∫¥â«¬‡¿ —™°√ ÒÒ √“¬ 欓∫“≈

˜ √“¬

Ú. ª√–™ÿ¡√–¥¡ ¡Õß π”‡ πÕ /  √ÿªªí≠À“¢Õß

·μà≈–‚√ß欓∫“≈„π‡§√◊Õ¢à“¬ √à«¡ª√÷°…“À“√◊Õ‡æ◊ËÕÀ“

·π«∑“ß„Àâ Õ¥§≈âÕß°—∫§«“¡μâÕß°“√„π·μà≈–æ◊Èπ∑’Ë

Û. ®—¥∑”§Ÿà¡◊Õ·π«∑“ߪؑ∫—μ‘„π°“√¥Ÿ·≈ºŸâªÉ«¬∑’ˉ¥â

√—∫¬“«“√åø“√‘π, ·π«∑“ß°“√¥Ÿ·≈„π°“√ àßμàÕ°“√ª√– “πß“π

√–À«à“ß·¡à¢à“¬ (‚√ß欓∫“≈»Ÿπ¬å) ·≈–‚√ß欓∫“≈≈Ÿ°¢à“¬

(‚√ß欓∫“≈‡§√◊Õ¢à“¬), °”Àπ¥ Target INR, ·π«∑“ß°“√

„À⬓«“√åø“√‘π„πÀ≠‘ßμ—Èߧ√√¿å·≈–°“√∂Õπøíπ ·≈– VCD

°“√ªØ‘∫—μ‘μ—«¢ÕߺŸâªÉ«¬∑’Ë√—∫ª√–∑“𬓫“√åø“√‘π

Ù. °”Àπ¥μ—«™’È«—¥„π°“√μ‘¥μ“¡º≈ ‰¥â·°à ®”π«π ºŸâªÉ«¬∑’Ë√—∫ª√–∑“𬓫“√åø“√‘π ®”π«πºŸâªÉ«¬¢“¥π—¥, bleed- ing events, INR in Target

√–¬–∑’Ë Û ªØ‘∫—μ‘·≈–ª√–‡¡‘πº≈

- §—¥°√ÕߺŸâªÉ«¬°àÕπ àßμàÕ„Àâ‚√ß欓∫“≈≈Ÿ°¢à“¬

‚¥¬„™â·∫∫øÕ√å¡ àßμàÕ¢âÕ¡Ÿ≈ºŸâªÉ«¬

- ÕÕ°π‘‡∑»μ‘¥μ“¡ : °“√¥”‡π‘πß“π§≈‘π‘°«“√åø“√‘π,

°”Àπ¥§à“ Target INR μ“¡·π«∑“ß∑’Ë°”Àπ¥ °“√„À⧫“¡√Ÿâ

„π°“√√—∫ª√–∑“𬓫“√åø“√‘π·°àºŸâªÉ«¬

- ª√–™ÿ¡μ‘¥μ“¡§«“¡°â“«Àπâ“·≈–√à«¡°—π‡ πÕ

·π–·π«∑“ß·°âªí≠À“√à«¡°—π∑ÿ° Û-Ù ‡¥◊Õπ/§√—Èß

- ‡°Á∫¢âÕ¡Ÿ≈‚¥¬„™â·∫∫øÕ√å¡°“√‡°Á∫¢âÕ¡Ÿ≈μ“¡μ—«™’È

«—¥

°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈

- ‡°Á∫¢âÕ¡Ÿ≈μ—«™’È«—¥∑ÿ°‚√ß欓∫“≈∑ÿ°‡¥◊Õπ‚¥¬ War- farin manager ¢Õß·μà≈–‚√ß欓∫“≈ π” àß·¡à¢à“¬¿“¬„π«—π∑’Ë Ò-ı ¢Õ߇¥◊Õπ∂—¥‰ª

¢âÕ¡Ÿ≈μ—«™’È«—¥‰¥â·°à

Ò. ®”π«πºŸâªÉ«¬∑—ÈßÀ¡¥∑’Ë√—∫ª√–∑“𬓫“√åø“√‘π Ú. ®”π«πºŸâªÉ«¬¢“¥π—¥

Û. ®”π«πºŸâªÉ«¬∑’ˇ°‘¥ Bleeding event Ù. ºŸâªÉ«¬§à“ INR Õ¬Ÿà„π‡°≥±å∑’Ë°”Àπ¥

°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈

‚¥¬„™â§à“‡©≈’ˬ·≈–√âÕ¬≈–‡ª√’¬∫‡∑’¬∫°—∫‡ªÑ“À¡“¬∑’Ë μ—È߉«â ‰¥â·°à

Ò. ®”π«πºŸâªÉ«¬¢“¥π—¥ _≤Ò%

Ú. ®”π«πºŸâªÉ«¬∑’ˇ°‘¥ Bleeding event _≤Ò%

Û. ºŸâªÉ«¬§à“ INR Õ¬Ÿà„π‡°≥±å∑’Ë°”Àπ¥ _≥ı%

º≈°“√»÷°…“

√–¬–∑’Ë Ò: §âπÀ“ªí≠À“

Ò) æ∫«à“ : ®“° Òı ‚√ß欓∫“≈ ¡’ ÒÛ ‚√ß欓∫“≈∑’Ë

¥”‡π‘πß“π‡§√◊Õ¢à“¬ Warfarin ‡ªìπ‚√ß欓∫“≈™ÿ¡™π ˘ ·Ààß

‚√ß欓∫“≈∑—Ë«‰ª Ù ·Ààß ªí≠À“„π°“√¥Ÿ·≈ºŸâªÉ«¬∑’ˉ¥â√—∫

¬“«“√åø“√‘π‡°‘¥®“°

Ò.Ò ‡®â“Àπâ“∑’˺Ÿâ√—∫º‘¥™Õ∫À≈—° (Warfarin man- ager) ¢“¥§«“¡√Ÿâ §«“¡‡¢â“„®„π°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë√—∫ª√–∑“π

¬“«“√åø“√‘π‡ªìπ欓∫“≈ ı √“¬ ·≈–¢“¥·π«∑“ß (Guideline)

„π°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë√—∫ª√–∑“𬓫“√åø“√‘π∑—Èß Òı ·Ààß ‡ªìπ 欓∫“≈ ı √“¬ ‡¿ —™°√ Ò √“¬

Ò.Ú ¢“¥Õÿª°√≥å„π°“√μ√«®«—¥§à“ Prothrombin time International normalized ratio (PT-INR) ‡ªìπ

‚√ß欓∫“≈™ÿ¡™π ı ·Ààß

Ò.Û ‰¡à¡’¬“«“√åø“√‘π„π∫—≠™’‚√ß欓∫“≈ ‡ªìπ‚√ß æ¬“∫“≈™ÿ¡™π ı ·Ààß

Ò.Ù ¢“¥ºŸâ√—∫º‘¥™Õ∫À≈—° ÒÚ ·Ààß ‡π◊ËÕß®“°¬—ß

‰¡à¡’§≈‘π‘°«“√åø“√‘π·≈–¡’ß“πª√–®”¡“° ‡ªìπ‚√ß欓∫“≈∑—Ë«‰ª Û ·Ààß ‚√ß欓∫“≈™ÿ¡™π ˘ ·Ààß  à«π‚√ß欓∫“≈∑’Ë¡’ºŸâ√—∫

º‘¥™Õ∫À≈—°¡’ Û ·Ààß ‡ªìπ‚√ß欓∫“≈∑—Ë«‰ª Ò ·Ààß (欓∫“≈)

·≈–‡ªìπ‚√ß欓∫“≈™ÿ¡™π Ú ·Ààß (‡¿ —™°√ Ò/ 欓∫“≈ Ò)

√–¬–∑’Ë Ú : «“ß·ºπÀ“·π«∑“ߪؑ∫—μ‘√à«¡°—π Ò) ¥â“π√–∫∫ : ·¡à¢à“¬

- ®— ¥ ∑” §Ÿà ¡◊ Õ · ≈ – · π « ∑ “ ß ° “ √ ¥Ÿ · ≈ ºŸâ ªÉ « ¬ ∑’Ë √— ∫ ª√–∑“𬓠Warfarin (Guideline) ‚¥¬»—≈¬·æ∑¬å Õ“¬ÿ√·æ∑¬å 欓∫“≈ ·≈–‡¿ —™°√

- «“ß√Ÿª·∫∫·π«∑“ß·≈–À≈—°°“√°“√¥”‡π‘πß“π

‡§√◊Õ¢à“¬ Warfarin ‰¥â·°à

O ®—¥∑”∑–‡∫’¬π¢âÕ¡Ÿ≈ºŸâªÉ«¬√—∫ª√–∑“𬓫“√åø“

√‘π (Warfarin)

O °”Àπ¥·∫∫øÕ√å¡°“√ àßμàÕ¢âÕ¡Ÿ≈ºŸâªÉ«¬„π‡§√◊Õ

¢à“¬

O §—¥°√ÕߺŸâªÉ«¬∑’ËÕ“°“√¥’ àßμàÕ„Àâ≈Ÿ°¢à“¬

130

O ºŸâªÉ«¬∑’Ë√—∫ª√–∑“𬓫“√åø“√‘π‰¥â√—∫°“√‡ΩÑ“√–«—ß

¬“§«“¡‡ ’ˬߠŸß (Hight Alert Drung) ∑ÿ°√“¬ (μ“¡·∫∫

øÕ√å¡´÷Ëß√à«¡¡◊Õ®—¥∑”°—∫‡¿ —™°√)

O ºŸâªÉ«¬®–‰¥â√—∫§«“¡√Ÿâ„π°“√ªØ‘∫—μ‘μ—«„π°“√√—∫

ª√–∑“𬓫“√åø“√‘π·≈–¡’°“√ª√–‡¡‘𧫓¡√Ÿâ∑ÿ°√“¬ √«¡∑—Èß

‰¥â√—∫ VCD °“√ªØ‘∫—μ‘μ—«  ¡ÿ¥§Ÿà¡◊Õ°“√√—∫ª√–∑“𬓠·≈–

∫—μ√ª√–®”μ—«ºŸâªÉ«¬√—∫ª√–∑“𬓫“√åø“√‘π°àÕπ°≈—∫∫â“π

O  àßμàÕ¢âÕ¡Ÿ≈μ“¡·∫∫øÕ√å¡·≈–‚∑√·®âß≈Ÿ°¢à“¬

∑√“∫

O ¡’√–∫∫‡μ◊Õπ°“√„™â¬“«“√åø“√‘π„π√–∫∫°“√®à“¬

¬“„π§Õ¡æ‘«‡μÕ√å ·≈–„π OPD card, ∫—μ√ª√–®”μ—«ºŸâªÉ«¬

‚¥¬„™â μ‘°‡°Õ√å(μ√“¬“ß) §”«à“ çOn warfariné, Target INR

´÷ËߺŸâªÉ«¬·μà≈–√“¬°àÕπ®”Àπà“¬®–μâÕß≈ß§à“‡ªÑ“À¡“¬ (Target INR) ∑ÿ°√“¬ ‡æ◊ËÕ«“ß·ºπ„π°“√√—°…“/ª√—∫¬“·≈– ◊ËÕ “√‡æ◊ËÕ μ√«®√—°…“‚√§Õ◊ËπÀ√◊Õ‡æ◊ËÕ„Àâ·ºπ°Õ◊Ëπ∑√“∫

O ¡’√–∫∫„À⧔ª√÷°…“μ≈Õ¥ ÚÙ ™—Ë«‚¡ß ∑—Èß·æ∑¬å 欓∫“≈ ·≈–‡¿ —™°√

O ¡’√–∫∫ Fast track √—∫ºŸâªÉ«¬®“°≈Ÿ°¢à“¬°√≥’

©ÿ°‡©‘π ‚¥¬∑’ˉ¡àμâÕߺà“π OPD À√◊Õ ER

O ®—¥∑” ◊ËÕ„À⧫“¡√Ÿâ‡√◊ËÕ߬“«“√åø“√‘π„π√Ÿª·∫∫

VCD, „Àâ≈Ÿ°¢à“¬ Õπ·≈– ∑∫∑«π§«“¡√ŸâºŸâªÉ«¬Õ¬à“ß ¡Ë”‡ ¡Õ

O ®—¥μ—Èß»Ÿπ¬åª√– “πß“π Warfarin ·≈–°”Àπ¥

¢Õ∫‡¢μ§«“¡√—∫º‘¥™Õ∫

O ®—¥μ—Èß Warfarin clinic „π‚√ß欓∫“≈ √√æ ‘∑∏‘

ª√– ß§å ∑—Èß»—≈¬°√√¡(«—π®—π∑√å) ·≈–Õ“¬ÿ√°√√¡(«—π»ÿ°√å)

O ®—¥ª√–™ÿ¡„À⧫“¡√Ÿâ·≈–·π«∑“ß°“√¥”‡π‘πß“π

·°à Warfarin manager

¥â“π√–∫∫ : ≈Ÿ°¢à“¬

- ‚√ß欓∫“≈·μà≈–·Ààß®—¥μ—Èß∑’¡√—∫º‘¥™Õ∫ ‚¥¬

ª√–°Õ∫¥â«¬ ·æ∑¬å ‡¿ —™°√·≈–欓∫“≈

√Ÿª∑’Ë Ò

·¡à¢à“¬

≈Ÿ°¢à“¬

·∫∫øÕ√å¡ àßμàÕ Target INR

μ≈Õ¥ ÚÙ ™¡./ FAST TRACK

‡ΩÑ“√–«—ß„π√–∫∫®à“¬¬“

Hight Alert Drug

Guideline

- ®—¥´◊ÈÕÕÿª°√≥凧√◊ËÕßμ√«® Prothrombin Time In- ternational Normalized Ratio (PT-INR) °√≥’∑’Ë‚√ß æ¬“∫“≈¬—߉¡à¡’

- ®—¥∑” Warfarin clinic ¢÷Èπ ( à«π„À≠à«—π

‡¥’¬«°—π°—∫§≈‘π‘°‚√§À—«„®) ÒÛ ‚√ß欓∫“≈ ‡ªìπ‚√ß æ¬“∫“≈∑—Ë«‰ª Ù ·Ààß ‚√ß欓∫“≈™ÿ¡™π ˘ ·Ààß

Ú) ¥â“π∫ÿ§≈“°√ :

- ·μàßμ—Èߧ≥–°√√¡°“√æ—≤𓇧√◊Õ¢à“¬

- °”Àπ¥ºŸâ√—∫º‘¥™Õ∫À≈—° ‰¥â·°à ‡¿ —™°√·≈–

欓∫“≈ ‚¥¬¡’∫∑∫“∑Àπâ“∑’Ë ¥—ßπ’È

Ò. „À⧫“¡√Ÿâ„π‡√◊ËÕß°“√ªØ‘∫—μ‘μ—«„π°“√√—∫ª√–∑“π

¬“ Warfarin æ√âÕ¡∫—μ√ª√–®”μ—«ºŸâªÉ«¬√—∫ª√–∑“𬓠War- farin

Ú. ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ ‚¥¬°“√ÕÕ°μ‘¥μ“¡

‡¬’ˬ¡,  Õ∫∂“¡∑ÿ°§√—È߇¡◊ËÕ¡“μ√«®≈ß∫—π∑÷°‰«â μ‘¥μ“¡‡¡◊ËÕ

¢“¥π—¥ ‡™àπ °“√¡’®ÿ¥®È”‡≈◊Õ¥μ“¡√à“ß°“¬ ‡≈◊Õ¥ÕÕ°μ“¡‰√øíπ

‡≈◊Õ¥°”‡¥“ÕÕ° ªí  “«–‡ªìπ‡≈◊Õ¥ ∂à“¬‡ªìπ‡≈◊Õ¥ ‡ªìπμâπ Û. √«∫√«¡¢âÕ¡Ÿ≈ / ∑–‡∫’¬πºŸâªÉ«¬∑’Ë√—∫ª√–∑“π¬“

Warfarin

Ù. μ‘¥μ“¡º≈°“√μ√«® PT INR „ÀâÕ¬Ÿà„π‡°≥±å∑’Ë

°”Àπ¥ ·≈–∫—π∑÷°§à“ Target INR „πºŸâªÉ«¬∑ÿ°√“¬

ı. ª√– “πß“π°“√√—∫·≈– àßμàÕºŸâªÉ«¬°√≥’©ÿ°‡©‘π

„Àâ “¡“√∂ àßμàÕ‰ª¬—ß»Ÿπ¬å∫√‘°“√·¡à¢à“¬‰¥âÕ¬à“ߪ≈Õ¥¿—¬

ˆ. μ‘¥μ“¡ √«∫√«¡μ—«™’È«—¥ °“√¥”‡π‘πß“π‡§√◊Õ¢à“¬

«‘‡§√“–Àåªí≠À“ ·≈–À“·π«∑“ß°“√·°â‰¢/æ—≤π“„ÀâÕ¬Ÿà„π

‡°≥±å∑’Ë°”Àπ¥

Û) ¥â“πºŸâªÉ«¬ :

- ‰¥â√—∫§«“¡√Ÿâ‡√◊ËÕ߬“ Warfarin °àÕπºà“μ—¥

- ‰¥â√—∫°“√‡ΩÑ“√–«—ß Hight Alert Drug √–À«à“ß æ—°√—°…“μ—«„π‚√ß欓∫“≈

- ‰¥â√—∫§”·π–𔇰’ˬ«°—∫§«“¡√Ÿâ„π°“√ªØ‘∫—μ‘μ—«

·≈–ª√–‡¡‘𧫓¡√Ÿâ°àÕπ°≈—∫∫â“π‚¥¬æ¬“∫“≈, ‡®â“Àπâ“∑’Ë ÿ¢

»÷°…“ ∑—Èßπ’ȇªìπ·π«∑“߇¥’¬«°—π∑ÿ°‚√ß欓∫“≈

√–¬–∑’Ë Û : ªØ‘∫—μ‘·≈–ª√–‡¡‘πº≈

- À≈—ߥ”‡π‘π°“√‡ªìπ√–¬–‡«≈“ Û ‡¥◊Õπ μ‘¥μ“¡

ª√–‡¡‘πº≈ (¡.§.ıÛ - ¡’.§.ıÛ) æ∫«à“ ºŸâªÉ«¬À≈—ߺà“μ—¥

À—«„®°≈—∫¡“√—°…“‡π◊ËÕß®“°ƒ∑∏‘Ϭ“ Warfarin ≈¥≈ß®“°‡¥‘¡„πªï ÚııÚ ´÷Ëß¡’ ı √“¬ (√âÕ¬≈– ÚÛ.Ù) ‡ªìπ ˘ √“¬ (√âÕ¬≈–

¯.ÒÒ) §‘¥‡ªìπ≈¥≈ß√âÕ¬≈– ˆÙ.¯ ‚¥¬‡°‘¥®“°¢π“¥¬“‰¡à

‡À¡“– ¡ ı √“¬ ·≈– Valve dysfunction Ù √“¬ ´÷Ë߉¡à¡’ºŸâ

‡ ’¬™’«‘μ (μ“√“ß∑’Ë Ò)

- °“√¥”‡π‘πß“π‚√ß欓∫“≈‡§√◊Õ¢à“¬  “¡“√∂

¥”‡π‘πß“π‰¥â ÒÛ ·Ààß (√âÕ¬≈– ¯ˆ.ˆ˜) ‡ªìπ‚√ß欓∫“≈∑—Ë«‰ª Ù ·Ààß ‚√ß欓∫“≈™ÿ¡™π ˘ ·Ààß ®“°∑’ˇ¢â“√à«¡∑—ÈßÀ¡¥ Òı

·Ààß ºŸâªÉ«¬∑’Ë√—∫ª√–∑“𬓠Warfarin ∑—ÈßÀ¡¥„π‡§√◊Õ¢à“¬¡’

®”π«π Ò,¯¯Ò √“¬ ¥—ßπ—Èπ ºŸâªÉ«¬À≈—ߺà“μ—¥À—«„®°≈—∫¡“

√—°…“‡π◊ËÕß®“°ƒ∑∏‘Ϭ“ Warfarin §‘¥‡ªìπ√âÕ¬≈– .Ù¯ ¢ÕߺŸâ ªÉ«¬∑’ˉ¥â√—∫ Warfarin ∑—ÈßÀ¡¥ ·≈–æ∫«à“ Õ—μ√“°“√¢“¥π—¥

μ“√“ß∑’Ë Ò

°àÕ𥔇π‘π°“√‡§√◊Õ¢à“¬ ∂‘μ‘ (√“¬) À≈—ߥ”‡π‘πß“π‡§√◊Õ¢à“¬ ∂‘μ‘ (√“¬)

√“¬≈–‡Õ’¬¥

ªï ÚııÚ ¡.§. - ¡’.§. ıÛ

ºŸâªÉ«¬°≈—∫¡“ Admit ®“°¬“ Warfarin ı (ÚÛ.Ù%) ˘ (¯.ÒÒ%)

Ò. ¢π“¥¬“‰¡à‡À¡“– ¡ ÙÙ ı

Ú. √—∫ª√–∑“𬓉¡à∂Ÿ°μâÕß Ò 

Û. ¢∫«π°“√ Medical Error Ò 

Ù. Valve dysfunction Ù Ù

ı. ‡ ’¬™’«‘μ Ò 

132 (¡.§.ıÛ-¡’.§.ıÛ) ‰¡à‰¥âμ“¡‡°≥±åÕ¬Ÿà Û ·Ààß  “‡Àμÿ

‡π◊ËÕß®“°∑—»π§μ‘μàÕ ∂“π∫√‘°“√„π™ÿ¡™π ·≈–≈◊¡«—ππ—¥

®”π«πºŸâªÉ«¬‡°‘¥ Bleeding event _≤Ò% ∑ÿ°‚√ß欓∫“≈,

§à“ INR ∑’ˉ¡à‰¥âμ“¡‡°≥±å¡’Õ¬Ÿà Ú ·Ààß

«‘®“√≥å·≈– √ÿª

º≈°“√«‘®—¬æ∫«à“°“√„™â√–∫∫‚√ß欓∫“≈‡§√◊Õ¢à“¬„π°“√

¥Ÿ·≈ºŸâªÉ«¬‚√§À—«„®¡’º≈∑”„Àâ≈¥°“√‡°‘¥¿“«–·∑√°´âÕπ„πºŸâ ªÉ«¬À≈—ߺà“μ—¥À—«„®∑’ˉ¥â√—∫¬“Warfarin ≈¥°“√°≈—∫‡¢â“√—∫

°“√√—°…“´È”‰¥â ·≈–≈¥°“√쓬 μ—«™’È«—¥‚¥¬√«¡Õ¬Ÿà„π‡°≥±å¥’

 “¡“√∂¥”‡π‘πß“π‰¥â ÒÛ ·Ààß ∑—Èß„π¥â“πº≈°“√√—°…“∑“ß

§≈‘π‘°·≈–‡°‘¥§«“¡ª≈Õ¥¿—¬μàÕºŸâªÉ«¬‡¡◊ËÕ‡∑’¬∫°—∫‚√ß æ¬“∫“≈·¡à¢à“¬ §à“ INR Õ¬Ÿà„π‡°≥±å∑’Ë°”Àπ¥ ∫“ß‚√ß æ¬“∫“≈Õ“®®–¥’°«à“‚√ß欓∫“≈·¡à¢à“¬ ªí®®—¬·Ààߧ«“¡ ”‡√Á®

§◊Õ °“√¡’ à«π√à«¡¢Õ߇§√◊Õ¢à“¬·≈– À “¢“«‘™“™’æ °“√

μ√–Àπ—°·≈–‡ÀÁ𧫓¡ ”§—≠„π°“√æ—≤π“»—°¬¿“æ¢Õß

∫ÿ§≈“°√ (‚¥¬‡©æ“–ºŸâ√—∫º‘¥™Õ∫À≈—°) ·≈–°“√¥”‡π‘πß“π Õ¬à“߇¢â¡·¢Áß °“√¥”‡π‘πß“π·∫∫ À “¢“«‘™“™’æ¢Õß·¡à¢à“¬

‡ªìπμâπ·∫∫„À⇧√◊Õ¢à“¬‰¥â»÷°…“‡ªìπ·∫∫Õ¬à“ß  —¡æ—π∏¿“æ∑’Ë

¥’„π‡§√◊Õ¢à“¬∑”„À⇧√◊Õ¢à“¬‡°‘¥°“√·≈°‡ª≈’ˬπ‡√’¬π√ŸâÕ¬à“ß

°«â“ߢ«“ß ¡’°“√ª√– “πß“π·≈–¡’√–∫∫„À⧔ª√÷°…“∑’Ë¥’ √«¡

∑—Èß°“√¥”‡π‘πß“π·∫∫¬◊¥À¬ÿàπ °“√»÷°…“ Õ¥§≈âÕß°—∫ß“π

«‘®—¬‡°’ˬ«°—∫°“√®—¥∑”‡§√◊Õ¢à“¬«“√åø“√‘π (Warfarin network)

„π®—ßÀ«—¥π§√√“™ ’¡“ §◊Õæ∫«à“§à“ INR Õ¬Ÿà„π‡°≥±å∑’Ë°”Àπ¥

‰¡à·μ°μà“ß°—π√–À«à“ß°àÕπ·≈–À≈—ß°“√√—∫¬“∑’Ë‚√ß欓∫“≈≈Ÿ°

¢à“¬Ù (√âÕ¬≈– ı VS √âÕ¬≈– ıˆ.ˆ; P=.˜) ·≈–

 Õ¥§≈âÕß°—∫°“√»÷°…“‡√◊ËÕß ç«“√åø“√‘π§≈‘π‘° ”À√—∫ºŸâªÉ«¬

ºà“μ—¥‡ª≈’ˬπ≈‘ÈπÀ—«„®®“°·¡à¢à“¬ Ÿà≈Ÿ°¢à“¬é ´÷Ëßæ∫«à“ °“√ª√—∫

¢π“¥¬“¢ÕߺŸâªÉ«¬‡æ◊ËÕ‡¢â“ Ÿà√–¥—∫ INR ¡’°“√‡ª≈’ˬπ·ª≈ß

®“°√âÕ¬≈– ˆı ‡ªìπ√âÕ¬≈– Û^(ı)

º≈°“√«‘®—¬π’È ‡ªìπ°“√™à«¬¬◊π¬—π«à“ °“√¥Ÿ·≈ºŸâªÉ«¬‚√§

À—«„® ·≈–À≈—ߺà“μ—¥À—«„®∑’ˉ¥â√—∫¬“«“√åø“√‘π ‚¥¬„™â√–∫∫

μ“√“ß∑’Ë Û

®”π«πºŸâªÉ«¬∑—ÈßÀ¡¥∑’Ë ®”π«πºŸâªÉ«¬ ®”π«πºŸâªÉ«¬∑’ˇ°‘¥ ºŸâªÉ«¬§à“ INR Õ¬Ÿà„π μ—«™’È«—¥

√—∫ª√–∑“𬓠Warfarin ¢“¥π—¥ Bleeding event ‡°≥±å∑’Ë°”Àπ¥

‡ªÑ“À¡“¬ _≤ Ò% _≤ Ò% _≥ ı%

·¡à¢à“¬ Ò,ıÙ .Ò% .Ò% ıÒ.˜%

√æ∑.Ò ˜˜˜ Ú.˜˜%  ˆˆ.ˆˆ%

√æ∑.Ú ÛÒ ÒÚ.ÛÛ% .˜% ¯ı.ÚÚ%

√æ∑.Û Ò˜Ù  Ò.¯˜% ÚÒ.Ú˘%

√æ∑.Ù ÒÚ Ù.ÚÚ% Ò.Òˆ% ˆˆ.ıÚ%

√æ™.Ò Úˆ Û.¯Ú% Ú.Ù˜% ıı.¯Û%

√æ™.Ú ˘ .˘% Ú.ˆı% ˆÒ.ˆˆ%

√æ™.Û ÚÚ   Ò%

√æ™.Ù Û   ˜ı%

√æ™.ı Ú   Ò%

√æ™.ˆ ÒÛ   ÛÛ.ÛÛ%

√æ™.˜ Û¯ ÒÛ.Û%  ˜˜%

√æ™.¯ Û¯ ˆ.ÛÙ% Ú.Ù% ˆ˘.¯ı%

√æ™.˘ ÛÙ Ú˜.˜˜%  ¯¯.¯¯%

π—π∑‘¬“ μ—Èß»√’‡ √’, ·≈–§≥–. °“√®—¥μ—È߇§√◊Õ¢à“¬°“√¥Ÿ·≈ºŸâªÉ«¬‚√§

À—«„®∑’ˉ¥â√—∫¬“μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥ (Warfarin network)

‚√ß欓∫“≈™ÿ¡™π·≈–»Ÿπ¬å·æ∑¬å™ÿ¡™π ®—ßÀ«—¥π§√√“™ ’¡“. °“√

ª√–™ÿ¡«‘™“°“√‡§√◊Õ¢à“¬À—«„®‡¢â¡·¢Áߧ√—Èß∑’Ë Ú; «—π∑’Ë ÚÙ-Úˆ

°ÿ¡¿“æ—π∏å ÚııÛ; ≥ ‚√ß·√¡·Õ¡∫“ ‡¥Õ√å ®Õ¡‡∑’¬π æ—∑¬“. ™≈∫ÿ√’;

ÚııÛ.

ı.  ÿ‡∑æ ∑—°…‘≥“‡®π°‘®, ®‘πμ«’ ‰™¬™ÿπ, «‘‰≈«√√≥ πÿ™»√’, ·≈–§≥–.

«“√åø“√‘π§≈‘π‘° ”À√—∫ºŸâªÉ«¬ºà“μ—¥À—«„®æ—≤π“®“°·¡à¢à“¬ Ÿà≈Ÿ°¢à“¬.

°“√ª√–™ÿ¡«‘™“°“√‡§√◊Õ¢à“¬À—«„®‡¢â¡·¢Áߧ√—Èß∑’Ë Ú; «—π∑’Ë ÚÙ-Úˆ

°ÿ¡¿“æ—π∏å ÚııÛ; ≥ ‚√ß·√¡·Õ¡∫“ ‡¥Õ√å ®Õ¡‡∑’¬π æ—∑¬“. ™≈∫ÿ√’;

ÚııÛ.

ˆ. ‡æ™√πâÕ¬  ‘ßÀå™à“ß™—¬, »‘√‘æ√ ¢—¡¿≈‘¢‘μ, ∑—»π’¬å π–· . °√–∫«π°“√

«‘®—¬∑“ß°“√欓∫“≈: À≈—°°“√·≈–°√–∫«π°“√. æ‘¡æå§√—Èß∑’Ë Ú.  ß¢≈“:

‡∑¡°“√æ‘¡æå; ÚıÛ˘. Àπâ“. Ú¯-ÒÚ.

˜. °≈ÿà¡ß“π‡¿ —™°√√¡  ∂“∫—π‚√§∑√«ßÕ°. §Ÿà¡◊Õ¬“°≈ÿࡇ ’Ë¬ß (Hight Alert Drug). ÚıÙ¯.

¯. °≈ÿà¡ß“π»—≈¬°√√¡  ∂“∫—π‚√§∑√«ßÕ°. ·π«∑“ß°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë

‰¥â√—∫¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥„πºŸâªÉ«¬À≈—ߺà“μ—¥≈‘ÈπÀ—«„® (Guideline for War- farin Post Valve Surgery). ÚııÒ.

˘. Õ√ “ ‰æ√√ÿ≥. ¬“μâ“π°“√·¢Áßμ—«¢Õ߇≈◊Õ¥ (Anticoagulant).

 ∂“∫—π‚√§∑√«ßÕ°. Úıı.

Ò. Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Alareti G.

Pharmacology and management of the vitamin K antagonists. Chest 2008;133:160S-198S.

ÒÒ. Hirsh J, Fuster V. Guide to anticoagulant therapy part 2: oral anticoagulants. Circulation 1994;89:1469-80.

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