Planned Implementation Date: June 18, 2013 NEW Heparin Protocol Planned Implementation Date: June 18, 2013

Situation: Several serious errors involving heparin infusions have occurred across UW Medicine. Background: Challenges: Different units of measure used at UWMC and HMC No fixed-rate option on current powerplans Inconsistencies in weight used for dose calculations and Alaris pump programming Why Change?

Why Change? Assessment: Recommendation: Different powerplans between HMC and UWMC: Dosing units: HMC – units/kg/hr UWMC – units/hr Heparin dosing algorithms Recommendation: Standardize across UW Medicine and utilize the best practices from each institution to improve patient outcomes and minimize medication errors related to heparin. Practice Changes: Provider ordering Nurse management Why Change?

New Heparin Powerplans Providers will choose from two Powerplans: “Standard Protocols” RN adjusts rate based on algorithms linked to powerplan Almost ALL heparin infusions will be ordered this way. “Provider Managed” Practitioner completes an order for EVERY rate change RN adjusts rate based on practitioner order. New Heparin Powerplans

Standard Protocols: Provider Ordering Provider selects “Standard Protocols” Powerplan: Provider chooses a sub-phase based on the indication for use of heparin

Indication-based Ordering Indication-based heparin ordering with standardized dosing. Indication-based Ordering

Standard Protocols: Provider Ordering Selects loading bolus, if warranted Selects infusion by goal PTT REGULAR intensity (goal PTT: 60-100) LOW intensity (goal PTT: 60-80) Selects PRN re-bolus for low PTT, if warranted If PRN Re-Bolus ordered, BOTH must be checked. Page provider to clarify if only 1 is ordered

Algorithm Changes Name: Regular vs. Low Intensity PRN re-bolus: RN must review PRN medication section to see if ordered and what dose to give Dose adjustment Monitoring frequency Algorithm Changes

*NEW* Protocol for PTT>200 For management of PTT>200: See reference text PTT CHECK TIMING OF SAMPLE INSTRUCTIONS > 200 (potentially contaminated or improperly timed sample) If < 6 hours since most recent bolus or rate change Continue infusion at current rate, and repeat PTT at the appropriate time. If > 6 hours since most recent bolus or rate change   TURN OFF HEPARIN INFUSION. Repeat STAT PTT immediately using peripheral blood draw. If repeat PTT < 200, resume heparin according to heparin algorithm. If repeat PTT > 200, follow steps below. > 200 (properly timed, non-contaminated sample) TURN OFF HEPARIN INFUSION, and NOTIFY PROVIDER. Repeat STAT PTT hourly using peripheral blood draw until PTT < 100. Then, resume infusion at DECREASED dose that is 4 units/kg/hr lower than previous dose and repeat PTT in 6 hours. *NEW* Protocol for PTT>200

Provider-Managed: Ordering Selection of Provider Managed powerplan Selection of desired subphase Provider may order in either weight-based or non-weight based units (i.e. units/kg/hr vs units/hr)

Provider-Managed: Practitioner orders every dose adjustment. Practitioner may order: Weight-based dosing in units/kg/hr NON-weight-based dosing in units/hr NOTE: Provider can document desired algorithm to follow for rest of the team in a Clinical note if necessary - but NOT under Infusions Instructions of the heparin infusion order or a nurse communication order

Provider Managed Treatment: For RN Review: Notice where ordered dose will appear for nursing.