Anticoagulation Therapy Updated March 2015

OBJECTIVES

Review common indications for therapeutic anticoagulation Review heparin infusion calculations and systems available to ensure accuracy Review the Anticoagulation National Patient Safety Goal (NPSG), as it relates to nursing services 3

Rationale for NPSG.03.05.01 The Joint Commission has identified therapeutic anticoagulation as a high-risk therapy that “often leads to adverse drug events due to complex dosing [and] requisite follow-up monitoring”. For this NPSG, “therapeutic anticoagulation” refers to the following therapies: Unfractionated heparin infusions Therapeutically dosed low molecular weight heparins Warfarin

HEPARIN

Standard Concentration The standardized concentration for pre- mixed Heparin bags is 12,500 units/D5W 250 ml The bag MUST come from pharmacy and MUST have a patient label. Standard Concentration

Indications for Adult Intravenous Heparin Infusions High-Intensity Anticoagulation Nomogram Deep vein thrombosis, Pulmonary embolism Aquapheresis therapy Low-Intensity Anticoagulation Nomogram Acute Coronary Syndrome Atrial Fibrillation/Flutter Heart Valve Ultra-Low-Intensity Anticoagulation Nomogram Blunt Cerebrovascular Injury Acute Ischemic Stroke Aquapheresis – removes excess fluid and salt from patients with fluid overload

It is a medical term for a step by step instructions to be followed exactly without skipping steps Review; Do not skips steps like you do you do when you follow a recipe What is a NOMOGRAM?

COMPARISON OF NOMOGRAMS Bolus and Initial infusion Rate High-Intensity Anticoagulation Nomogram Low-Intensity Anticoagulation Nomogram Ultra-Low-Intensity Anticoagulation Nomogram Bolus: 80 units/Kg Maximum Bolus: 10,000 units Bolus: 60 units/Kg Maximum Bolus: 5,000 units NO Bolus Begin Infusion: 18units/Kg/hr Maximum infusion Rate: 1,800units/hr Begin Infusion: 12units/Kg/hr Maximum Infusion Rate: 1,000units/hr Blunt Cerebrovascular Injury (BCI): Begin Infusion: 15units/Kg/hr Maximum:1,500units/hr Acute Ischemic Stroke (AIS): Begin Infusion: 10units/Kg/hr Maximum: 1000 units/hr Goal PTT Range: 65-90 seconds Goal PTT Range: 50-75 seconds Goal PTT Range: 41-50 units Review and emphasize no bolus on ultra low; Emphasize the Maximum bolus for High intensity is 10,000 Emphasize the maximum bolus for low intesity is 5,000 Note the goal ranges for the PTT vary; review rationale for ultra low intensity

Contraindications for Heparin Risk/Benefit Analysis Heparin induced thrombocytopenia (HIT) Recent surgery Active gastrointestinal bleed Epidural anesthesia High fall risk (Discuss) Review … pay attention to the fact that this is critical thinking and a risk benefit analysis. If you have doubts call the doctor. Contraindicated means requires further clarification with MD. Contraindications for Heparin Risk/Benefit Analysis

Baseline CBC & PTT must have been done within the past 24 hours Baseline Labs

Place Poster at Head of Bed Caution Patient on Anticoagulation Therapy e.g. Heparin, lovenox, warfarin Has to be posted at the end of bed; Remember to remove when patient is discharged; Circle w/ dry erase marker which one they are one Place Poster at Head of Bed

Weight Based Intravenous Medication Dosing Practice Alert If the physician chooses to change the dosing weight, a new heparin order must be entered. Pharmacy must verify the order and insert the correct nomograms based on the new weight. A new label will be printed and sent; the process of setting up the Alaris and the independent double checks would start again with the new order. If the physician does not change the order, document in the medical record that you informed the physican of weight discrepancy. Modify the medication order administration instructions, including the date and time of the notification. You may also add this order clarification under ”physician notification“ in doc flow sheets. You may also add a MAR note for communication purposes, so that the treatment team will know that the weight discrepancy was addressed. For questions contact your educator, supervisor, pharmacist, or manager.

Independent Double Check   Definition A check of factors performed independently by a second qualified health care practitioner.  This check should be performed alone and apart (independent) from the other provider Pump settings may be validated together at the time of programming Review; Emphasize make sure we are doing this separately

Independent Double Check For medications, the factors to be verified during the independent double check should include, but are not limited to:  Right patient identification using two identifiers per Patient Identification policy Right drug Right dose of drug Right route of administration Right time of administration Right IV pump setting Right rate of infusion Review; Emphasize make sure we are doing this separately

Heparin drips must be co-signed by a supervisor or farm team supervisor If the supervisors are unavailable, you can ask Kevin, Rodgie, or Royan to co-sign This includes rate verifications when ptt is within range, new bags, rate changes, boluses You DO NOT need a supervisor to co-sign a rate verification at hand off report UNLESS you are completing one of the above actions. The 9W way of co-signing

Hand-Off Whenever patient care is handed off from one provider to another, the infusion needs to be double checked and verified. Required elements to review include: the order, the pump settings, the schedule of lab draws and latest results Tracing the infusion from patient to pump to port connection or vice-versa. Clear and concise handoff prevents potential medication errors and is required by policy.

Scanning for EPIC 1 Barcode 4 actions: Note: default is “new bag”; this action charges the patient for the medication. Be sure to mark the correct action

Double check calculations - Drip Order and calculator comparison: ORDER CALCULATOR (LOCATED ON FORUM) Remember it all has to match… if it doesn’t. Stop and recheck.

Heparin Library in Alaris Pump Enter patients CSN number Select correct library (i.e. Med surg) Choose Guardrail Drugs Choose Heparin and match intensity to order ** Note that there are 2 screens of choices for heparin** YOU MUST LOCK YOUR PUMPS AFTER PROGRAMMING THE SETTINGS Key to remember that there are two weight choices, use of wrong weight will cause an override to occur.

Initial Bolus Requires physician order Must bolus on the Alaris pump If not ordered: Omit initial bolus dose per policy Must give the bolus via the Alaris pump Initial Bolus

After initial 6 hours of continuous infusion draw, first PTT Adjust the infusion rate based on the nomogram and the PTT results Recheck PTT every 6 hours from the time you program the pump May reduce PTT checks to every 12 hours if patient has achieved goal range for 3 consecutive labs values Emphasize Recheck the PTT from the time you programmed the pump PTT Monitoring

PTT Monitoring – high PTT When you have a critically high ptt… Follow the nomogram instructions Hold the heparin drip for 2 hours After 2 hours, restart the drip at a lower rate(per nomogram instruction) Document in critical test result area in flowsheets Your next PTT should be drawn 6 hours from the time you restarted the drip Emphasize Recheck the PTT from the time you programmed the pump PTT Monitoring – high PTT

Lab Draws Phlebotomists are to be used for routine lab draws All timed/stat draws are the RNs responsibility Lab Draws

Infusion Rate Adjustments using the Nomogram -The latest 3 PTT results can be found at the bottom of the MAR order screen (click the name of the medication and scroll down) -Results review “PTT” -Patient summary, “anticoag report” Where to find current PTT results.

Ordering PRN ptts

Intake and Output How often are you supposed to document I&O? How often do you clear your pumps? What are the appropriate times to clear your pumps? You are supposed to clear your pumps for patient safety You are supposed to clear pumps Q8 for NMS, Q4 for NPCU

Documentation Document patient/family education Document any evidence of bleeding and/or ecchymosis and your notification of the physician Documentation

Therapeutic Enoxaparin

Dispensing of Enoxaparin Syringes Pre-filled enoxaparin syringes (doses rounded to the nearest 10 mg) will be dispensed whenever possible. If an appropriate enoxaparin dose is not commercially available as a pre-filled syringe, pharmacy will compound the dose for the patient, so to eliminate the need for nursing to administer a partial syringe. Dispensing of Enoxaparin Syringes

Enoxaparin Monitoring At baseline (within 24 hours prior to therapy initiation): Complete blood count To document baseline hemoglobin, hematocrit and platelet count Blood urea nitrogen (BUN) and serum creatinine To document baseline renal function Enoxaparin Monitoring 31

Enoxaparin Monitoring During therapy: Complete blood count every 1 – 3 days To monitor for possible bleeding complications and/or heparin-induced thrombocytopenia BUN and serum creatinine every 1 – 3 days To monitor for changes in renal function that may alter enoxaparin clearance Enoxaparin Monitoring 32

Heparin & Therapeutic Enoxaparin Special precautions Concurrent use of aspirin and other antiplatelet agents (NSAIDs) may increase risk of bleeding Avoid IM injections as they may cause hematomas Attempt to consolidate blood draws to the time of the planned ptt checks in an effort to minimize needle sticks Heparin & Therapeutic Enoxaparin Special precautions

Heparin & Therapeutic Enoxaparin Notify physician for: Any evidence of major oozing/bleeding or internal bleeding Allergic reactions If the platelet count falls to less than 100 K/microliter Any changes in neurologic status Heparin & Therapeutic Enoxaparin Notify physician for:

Therapeutic Warfarin

Warfarin will not be dispensed from automated medication stations except in patient care areas that are “cartless” and rely on Pyxis Profiling for nursing access to the medication. Exact warfarin doses are to be dispensed for patient administration. The nursing staff is not to be expected to split any warfarin tablets to obtain the prescribed dose. Warfarin Dispensing

At baseline (within 24 hours prior to therapy initiation): Complete blood count To document baseline hemoglobin, hematocrit and platelet count Prothrombin Time (PT) and International Normalized Ratio (INR) MUST be documented before pharmacy dispenses first dose of warfarin Warfarin Monitoring 37

Warfarin Monitoring During therapy: Complete blood count every 1 – 3 days To monitor for possible bleeding complications PT and INR every morning MUST be reviewed by pharmacy services before daily dose of warfarin is dispensed May be reduced to once weekly monitoring once 7 consecutive therapeutic INRs (without warfarin dose changes) have been documented Warfarin Monitoring 38

Warfarin Documentation Patient/Family education regarding Warfarin and dietary changes Document your teaching of the importance of follow up INR monitoring while on Warfarin Can request order for pharmacy and dietician consult as needed to assist in education Warfarin Documentation

Questions about administration of Anticoagulation therapies? Please refer to your clinical leadership with any questions or concerns. Contact the pharmacy department for assistance with individual patient cases. If you don’t receive the assistance you need, follow the chain of command. Know your chain of command.

LET’S REVIEW

What diagnoses receive ultra low intensity?

What diagnoses receive ultra low intensity What diagnoses receive ultra low intensity? Blunt cerebrovascular injury Acute ischemic stroke ULTRA LOW INTENSITY

What is the standard concentration for a bag of heparin?

What is the standard concentration for a bag of heparin? 12,500 units/D5W 250ml What is the standard concentration for a bag of heparin?

When do you need to call the supervisors to co-sign your heparin drip? To rate verify when the ptt is therapeutic and there is no change to your rate When you hang a new bag of heparin At handoff When you need to bolus and increase the rate of the drip A, B, D When do you need to call the supervisors to co-sign your heparin drip?

When do you need to call the supervisors to co-sign your heparin drip? To rate verify when the ptt is therapeutic and there is no change to your rate When you hang a new bag of heparin At handoff When you need to bolus and increase the rate of the drip A, B, D When do you need to call the supervisors to co-sign your heparin drip?

Your patient is on a low intensity heparin drip for atrial fibrillation. He is reported to be a GCS 15, but upon assessment, he is a GCS 14. What should you do?. Critical Thinking

What diagnoses receive low intensity?

What diagnoses receive low intensity What diagnoses receive low intensity? A fib/flutter Acute coronary syndrome Heart Valve LOW INTENSITY

What diagnoses receive high intensity?

What diagnoses receive high intensity? DVT PE Aquapheresis therapy

Critical thinking Your stroke patient is on an ultra low intensity heparin drip. In report, you were told that his urine is clear and yellow. When you empty his foley bag, the urine looks pink. What should you do?

NEED MORE INFORMATION? Refer to these policies for more information: Medications – High Alert & High Risk (CRMC) Medications – Orders, Administration, Storage, Documentation Medications with Special Considerations – IV Medications Therapeutic Anticoagulation with Heparin Products Catheter Directed Fibrinolytic Therapy NEED MORE INFORMATION?

PRACTICE PATIENTS