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

2. 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%

3. 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.

4. 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!

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

6. Coumadin affects
the intrinsic
coagulation
pathway preventing
clotting

7. 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

8. INR Values and DVTs

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

10. 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 to 3.5
Standard dose time at MAH is 1800 to allow lab results

11. WHERE CAN MY PATIENT GO TO GET THEIR INR DRAWN?

12. 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

13. 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

14. 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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

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

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

24. 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

25. 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

26. 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

27. 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

28. 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

30. 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