1. REDUCE THE LIKELIHOOD OF PATIENT HARM ASSOCIATED WITH THE USE OF ANTICOAGULANT THERAPY

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

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

11. 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

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