1. Anticoagulation Therapy
Updated March 2015

2. OBJECTIVES

3. 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

4. Rationale for NPSG
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

5. HEPARIN

6. 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

7. 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

8. 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?

9. 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: seconds
Goal PTT Range: seconds
Goal PTT Range: 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

10. 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

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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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.

20. 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.

21. 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

22. 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

23. 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

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

25. 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.

26. Ordering PRN ptts

27. 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

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

29. Therapeutic Enoxaparin

30. 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

31. 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

32. 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

33. 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

34. 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:

35. Therapeutic Warfarin

36. 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

37. 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

38. 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

39. 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

40. 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.

41. LET’S REVIEW

42. What diagnoses receive ultra low intensity?

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

44. What is the standard concentration for a bag of heparin?

45. 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?

46. 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?

47. 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?

48. 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

49. What diagnoses receive low intensity?

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

51. What diagnoses receive high intensity?

52. What diagnoses receive high intensity? DVT PE Aquapheresis therapy

53. 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?

54. 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?

55. PRACTICE PATIENTS