Module 3 REDUCE THE LIKELIHOOD OF PATIENT HARM ASSOCIATED WITH THE USE OF ANTICOAGULANT THERAPY

ONLY oral unit-dose warfarin, prefilled Fragmin syringes, and premixed heparin drips are used at CHSB.

Use Approved Protocols CHSB Inpatient Anticoagulation Protocol Available on all units in the Pharmacy Protocol/Formulary Book Includes warfarin (Coumadin), heparin and LMWH (Fragmin) Defines roles of RPh, RN, and Dietician

Warfarin Pharmacy-dosed protocol Rx will monitor and dose all patients MUST check/document INR before 1st dose Rx will not dispense doses until INR available RN must document INR on eMAR prior to each dose Care Plan must be initiated & updated Monitor patient for bleeding Check INR Educate patient re: bleeding, safety precautions Education must be documented during admission and at discharge

Vitamin K reverses the effects of warfarin Food-Drug Interactions Vitamin K in foods Green, leafy vegetables spinach, collard greens, brussel sprouts, broccoli Cranberry juice Discharge Instructions Krames On Demand MUST include: Compliance and the importance of follow-up monitoring Potential for adverse drug reactions and interactions

Heparin NPSG includes therapeutic heparin Heparin flushes, prophylactic doses excluded MUST use premade heparin drips Do NOT mix a heparin drip MUST use the drug library on the infusion pumps when administering

Heparin Protocol Bolus Doses – use 1000 units/ml ONLY NEVER bolus from the infusion bag! Weight-based dosing Monitoring aPTT baseline every 6 hours after ANY dosage change 6 hours after first therapeutic aPTT every 24 hours after 2 consecutive aPTTs CBC with platelets Baseline every 3 days

Heparin Protocol Adjusting the rate: Recheck the aPTT in 6 hours aPTT <60: bolus dose and ↑ rate aPTT 60-90: NO ADJUSTMENT aPTT >90: hold drip and/or ↓ rate Recheck the aPTT in 6 hours Document all bolus doses and rate changes on eMAR Each bolus dose is documented on eMAR Any rate changes and each bag change are document on eMAR

Low-Molecular Weight Heparin (Fragmin) NPSG includes therapeutic doses Low-dose for DVT prophylaxis excluded Baseline labs required CBC with platelets

Pradaxa (dabigatran) Baseline laboratory tests: PT/INR SCr Ongoing laboratory tests: SCr every 7 days Pharmacy will adjust dose as needed for renal function

Xarelto (RIVAROXABAN) Baseline laboratory tests: CBC SCr Ongoing laboratory tests: SCr every 7 days Should be avoided in patients on dialysis Medication should not be crushed Give with food for better absorption

Patient Education Only Krames On-Demand will be used Coumadin (warfarin) Heparin Fragmin Pradaxa Xarelto