Anticoagulation-NPSG3E

1. Anticoagulation-NPSG3E Keeping our anticoagulated patients safe: How to navigate the new process

2. Course Objectives After completion, nurse should be able to: • Initiate Heparin, Warfarin, and Low Molecular Weight Heparin (LMWH) Orders using new order forms • Obtain appropriate baseline and monitoring lab values • Navigate new Pharmacy Heparin Nomogram • Document therapy using new Heparin and Wafarin Flow sheets • Monitor Patients receiving anticoagulation and know appropriate times to notify physician • Discharge patients receiving Warfarin and LMWH using approved discharge form and education materials

3. Provider Initiates Heparin infusion order using appropriate new form (MV 593).  Heparin Overview  Per pharmacy=nurse receives new nomogram from pharmacist  Per provider=no nomogram  Obtain baseline tabs (aPTT, PT/INR, CBC) PRIOR to giving heparin bolus or infusion. Document results on new Heparin flow sheet (MV589).  Give heparin bolus and/or infusion per orders. Use pump to program infusion rate.  Obtain aPTT 6 hours after infusion initiation and 6 hours after any change to infusion rate. After two values within 48-73 seconds range, order aPTT ever AM. Document results and changes on new heparin flow sheet (MV 589).  Monitor Hgb/Hct and Platelets every 48 hours and document on new Heparin Flow sheet. Always monitor for signs of bleeding!!!  • Call Provider If: • Platelets drop greater than 50% from baseline or less than 100,000 • Signs/symptoms of bleeding develop • Two Consecutive aPTTs are greater than 150  Discontinue only with provider order. Discontinue aPTT, Hgb/Hct, and Platelet lab orders when Heparin is discontinued. Tube Carbon copy of heparin flow sheet (MV 589) to pharmacy.

4. Heparin Special Considerations • Draw all lab values away from infusion site • Pre-operative: Obtain MD order to Discontinue IV Heparin 6 hours prior to surgery and Discontinue SQ heparin 12 hours prior to surgery • Post-Operative: Obtain MD order to restart IV Heparin 12 hours post op. If bleeding noted from surgical site, hold Heparin until bleeding has subdued.

5. LMWH: Special Considerations • Education should be performed with every patient discharged home on Lovenox. • Education should be performed using the “At home with Lovenox” patient education kits • Kits are available on the Medical Surgical Floor and the Telemetry floor Kits contain this logo.

6. Provider Initiates LMWH order using appropriate new form (MV 592)  Low Molecular Weight Heparin (LMWH)-Enoxaparin (Lovenox) Therapy Overview Obtain baseline labs (CBC, PT/INR, aPTT) and (Serum Creatinine within the last 5 days) PRIOR to giving first dose of LMWH.   Give first done of LMWH as prescribed.  Obtain CBC count every 48 hours. Obtain Serum Creatinine every 5 days.  Always monitor for signs of bleeding!!!! Discontinue only with provider order. Discontinue CBC and Serum Creatinine lab orders when LMWH is discontinued.   • Call Provider If: • Platelets drop greater than 50% from baseline or less than 100,000 • Signs/symptoms of bleeding develop OR  If patient discharged home on LWMH, perform education using appropriate materials

7. Warfarin (Coumadin) Overview Provider Initiates Warfarin order using appropriate new form (MV 594)  Obtain baseline tabs (aPTT, PT/INR, CBC, HCG for women of childbearing age-unless documented hysterectomy) PRIOR to giving first does of Warfarin. Document INR on new Warfarin flow sheet (MV 590)   Negative HCG-Give first dose of Warfarin per order form. Doses given daily of 1600. Positive HCG-call to provider-do not give first dose of Warfarin!  Monitor PT/INR daily in AM and document on new Warfarin flow sheet (MV 590). Always monitor for signs of bleeding!!!  • Call Provider If: • INR is greater than 3.5. • Signs/symptoms of bleeding develop  If patient discharged home on Warfarin, perform education using “Understanding my Warfarin therapy” form. Obtain discharge instructions using appropriate Warfarin discharge form. Tube Carbon copy of Warfarin flow sheet (MV 590) to Pharmacy.

8. Warfarin: Special Considerations • An INR equal to or greater than 5 is an alert value. Nurse should call result to provider. Hold Warfarin dose • Dietary should be notified at Warfarin initiation and consulted to provide dietary education. • Initial education regarding Warfarin therapy should be performed within 24 hours of order initiation. • Education regarding Warfarin should be provided again prior to discharge. • Discharge instructions should be written on new Warfarin discharge form.

9. Where do I find the forms? • All heparin, LMWH, and Warfarin order forms, flow sheets, and education materials will be kept in red folders on each unit. • Education and Discharge forms are also on the P drive under clinical forms

10. Additional Information • Providers are required the by policy to use the new forms for ordering anticoagulant therapy. • The Carbon Copy of the Heparin Flow sheet (MV 589) and the Warfarin flow sheet (MV 590) needs to be tubed to pharmacy upon discontinuation or discharge. • For more, information, please see the following policies on the P drive: “Anticoagulation Management Program” and “Heparin Infusion Therapy Policy and Procedure”