Minimizing risk and Optimizing Safety Coumadin/Warfarin Minimizing risk and Optimizing Safety

National Patient Safety Goal 3 JCAHO Anticoagulation therapy poses risks to patients and often leads to adverse drug events due to complex dosing, requisite follow-up monitoring, and inconsistent [patient] compliance. The use of standardized practices for anticoagulation therapy that include [patient] involvement can reduce the risk of adverse drug events associated with the use of heparin (unfractionated), low molecular weight heparin, and warfarin. The incidence of major bleeding for patients on Coumadin is 20%

Elements of Performance The hospital uses approved protocols for the initiation and maintenance of anticoagulant therapy appropriate to the medication used, to the condition being treated, and to the potential for medication interactions. For patients starting on warfarin, a baseline International Normalized Ratio (INR) is available, and for all patients receiving warfarin therapy, a current INR is available and is used to monitor and adjust this therapy. The hospital provides education regarding anticoagulant therapy to prescribers, staff, patients, and families.

Why do we need a protocol? 83 y o F presents to the hospital with new onset atrial fibrillation. Her CHADS2 score is 4, so she is started on warfarin. First MD orders warfarin 5 mg daily Next MD orders warfarin 10 mg X 1, unaware of first order Patient receives 15 mg PO warfarin on Day 1 without a baseline INR INR on Day 2 is 1.2 and patient receives 5 mg warfarin INR is not checked on Day 3 but patient continues to receive daily 5 mg dose of warfarin…. You can see where this is going!

Pharmokinetics Interferes with synthesis of Vitamin K -dependent clotting factors II, VII, IX and X Absorbed through GI tract Activity: Peaks in 1.5 - 3 days Duration 2- 5days Half-life: 1-2.5 days Metabolized in the liver Excreted through urine and feces

Coumadin affects the intrinsic coagulation pathway preventing clotting

Coumadin Indications Prophylaxis of venous thrombosis (high risk surgery) Treatment of venous thrombosis Treatment of PE Prevention of systemic embolism AMI (to prevent systemic embolism) Tissue heart valves Atrial Fibrillation Goal INR for these indications is 2-3 is recommended Goal INR for these orthopedic patients is 2-2.5 is recommended

INR Values and DVTs

Contraindications Pregnancy Bleeding tendencies/ blood dyscrasias Recent/contemplated surgery Threatened abortion Spinal puncture/ Epidural

Lab Monitoring Regular monitoring INR Repeat INR Daily until therapeutic for 2 consecutive days then Q48hrs until discharge Goal INR 2-3 for protocol indications. Other indications may have goal of 2.5 to 3.5 Standard dose time at MAH is 1800 to allow lab results

WHERE CAN MY PATIENT GO TO GET THEIR INR DRAWN?

Dietary Considerations Amount of vitamin K in foods affects therapy Maintain a consistent amount of vit K in your diet Avoid drastic changes in your dietary habits Adding large amounts of these food items will  vitamin K in the body: margarine, canola oil, olive oil, mayonnaise broccoli, Brussels sprouts, kale, endives cucumbers, kiwi, blueberries sauerkraut, soybeans, dill pickle beef and pork liver cashews

Other things that can affect Anticoagulation Garlic Ginkgo Biloba Green tea Alcohol: can affect liver function which is the site of warfarin/coumadin metabolism Anticoagulation affect

Drug/Drug Interactions Drugs that may INCREASE anticoagulant effect or risk of bleeding: Amiodarone*** Cimetidine (Tagamet) Levothyroxine (Levoxyl) Stomach remedies (Prilosec) Laxatives (Sennakot) Phenytoin (Dilantin) Quinidine Quinine Pain relievers (Motrin) Anticoagulant effect **** Requires a 50% reduction in warfarin/coumadin if new to therapy

Drug/Drug Interactions Anti-infectives: Fluconazole (Diflucan) Erythromycin Fluoroquinolones Metronidazole (Flagyl) TMP-SMX (Bactrim) Anticoagulant effect

May DECREASE anticoagulant effect: Drug Interactions May DECREASE anticoagulant effect: Barbiturates Carbamazepine (Tegretol) Cholestyramine (Questran) Rifampin Vitamin K Anticoagulant effect

Side effects: Bleeding: Assess any of the following symptoms as they may indicate internal bleeding or INR > 3: – minor gums bleeding – nosebleeds – headache – joint pain – nausea/vomit – melena

CPOE Order or Order Set If you try to order Warfarin for a patient who has not had an order for 30 days, you will get a prompt to ask you to consider discarding this order and ordering the Warfarin initiating protocol This is the Warfarin initiation protocol

Warfarin Protocol provides decision support This is to be used for patients: * new on Coumadin * for the indications listed * with goal INR of 2-3

Normogram indicates for each day depending on what the INR is what the dose should be or what the dose should be compared to the previous day’s dose Prompts for baseline INR and daily INRs

Processing the Protocol Order Date Medication Time Date Date Date Date Date Coumadin per protocol  One time med sheet 10 /13 /09 18 IF CPOE Order: place paper order set in MD Order section of chart so MDs have the nomogram MD will order subsequent orders as one time meds. Document dose administration on One Time Medication Sheet and Coumadin Worksheet

To be placed in Medication Books and document dose administered daily Give to patient at discharge

Warfarin Protocol Flowsheet Date Day of Time PT INR Dose RN signature of therapy 1.2 5mg K Murphy RN 1.4 5mg D Morrison RN 2.3 2mg D Devanna RN 1 2 3 1800 10/13 10/14 10/15

Give to all patients on Coumadin New Patient Education Brochure New Brochure from the Agency for Healthcare Research and Quality Give to all patients on Coumadin

Anticoagulant Risk and Falls Anticoagulants place a patient at additional RISK OF HARM Take note if patient is at RISK FOR FALL FALL RISK + ANTICOAGULANTS = POTENTIAL FOR LIFE THREATENING BLEEDING Use Fall Mats if High Risk for falls and on anticoagulants

Patient Teaching to prevent bleeding Care when using sharp objects Use electric razor Use soft toothbrush Use waxed dental floss No toothpicks Avoid bare feet

Patient Education From the Caregroup Portal: Click on Micromedex Click on Carenotes system Type in Coumadin Select tablet Select English or Spanish PRINT Provide patient with this drug information sheet as well

Case Study Mr M is admitted to SDU with uncontrolled Atrial Fibrillation. He is initially started on Heparin drip and Metropolol for rate control. His heart rate is now controlled and is being transferred to South 4 to convert to Coumadin The Coumadin Protocol is initiated Baseline INR is 0.8 What is the dose this patient should receive on Day 1? 5 mg

Day 2 The INR is 1.2 Your dose for the day should be? 5 mg Day 3 The INR is 1.4 Your dose for the day should be? 7.5mg Day 4 The INR is 2.2 Your dose for the day should be? 7.5mg Day 5 The INR is 3.1 your dose for the day should be? 6mg