Inpatient Anticoagulation Safety. To provide safe and effective anticoagulation therapy through a collaborative approach.

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1 Inpatient Anticoagulation Safety Purpose: Policy: To provide safe and effective anticoagulation therapy through a collaborative approach. Upon the written order of a physician, Heparin, Low Molecular Weight heparin (LMWH) and/or oral Warfarin therapy will be administered according to the following protocol. Procedure: A. Heparin Therapy 1. Indication for use will be documented on the chart. Indications include: a. Deep Vein Thrombosis (DVT) b. Pulmonary embolism (PE) c. Venous thrombosis d. Atrial fibrillation with embolism e. Prophylaxis of stroke in post MI patient f. Unstable Angina g. Peripheral arterial embolism h. Aortic and/or mitral valve replacement 2. Patients with the following contraindications should not receive heparin therapy. a. Hypersensitivity to Heparin/LMWH b. Active Bleeding c. Severe thrombocytopenia d. Heparin-induced thrombocytopenia 3. The following clinical information should be documented in the chart prior to initiation of therapy a. Patient age, weight, height and gender b. Medical and drug history pertaining to anticoagulation of the patient c. Indication and duration for heparin therapy d. Laboratory baseline values 1. PT/INR, aptt, CBC, platelet count e. Written order for no IM injections while on heparin 4. Dosing recommendations: Loading Dose a. Initial IV push dose will be based upon Actual Body Weight. It will be rounded to the nearest 500 units with a maximum loading dose of 10,000 units. b. Confirmed PE or DVT 1. Loading dose 80 units/kg 2. If the patient has major bleeding risks, use units/kg 3. Major bleeding risks: a. Major surgery within 14 days

2 b. Recent intracranial bleeding c. Bleeding Peptic Ulcer Disease d. Platelet count less than 100,000 e. Biopsy of an internal organ in previous 7 days c. Post CVA prophylaxis, post stent, R/O MI 1. Loading dose of 40 units/kg 5. Maintenance Dose a. Initial maintenance dose will be based on actual body weight. The dose will be rounded to the nearest 50 units. b. Therapy will be initiated with the hospital standard concentration of 25,000 units in 250 ml.45% NaCl (100 units/ml) c. Confirmed PE or DVT: 1. Initial dose is 18 units/kg/hour d. Post CA, Post Stent, R/O MI, major bleeding risk: 1. Initial dose is units/kg/hour 6. Laboratory monitoring and dosing adjustments a. Repeat aptt 6 hours after the start of the heparin infusion, and after each dosage adjustment b. Adjust bolus and infusion according to Table 1. c. After TWO consecutive therapeutic aptt values, order daily am lab. 7. Physician Notification a. The physician must be notified if patient experiences any bleeding. b. The physician must be notified in the event of significant adverse effect to heparin therapy or if aptt is greater than 120. c. The physician should also be notified if the therapy is not consistent with the duration of therapy as documented in the chart. 8. Pharmacy is responsible for reviewing the orders for all heparin therapy. 9. Non-standardized use of heparin, including use as part of procedures, or tubing a written, unit-specific policy which includes patient safety details will be approved by the P&T Committee. 10. Non-standard concentrations of heparin will not be prepared by the pharmacy department unless the protocol, including a pre-printed order form has been approved by the P&T Committee. 11. A prescriber s order is required for the use of all heparin products, including heparin flush solutions.

3 B. Low Molecular Weight (LMW) Heparin 1. Indication for use will be documented on the chart. Indications include: a. Deep Vein Thrombosis (DVT) b. Pulmonary embolism (PE) c. Venous thrombosis d. Atrial fibrillation with embolism e. Prophylaxis of stroke in post MI patient f. Unstable Angina g. Peripheral arterial embolism h. Aortic and/or mitral valve replacement 2. Patients with the following contraindications should not receive heparin therapy. a. Hypersensitivity to Heparin/LMWH b. Active Bleeding c. Severe thrombocytopenia d. Heparin-induced thrombocytopenia 3. The following clinical information should be documented in the chart prior to initiation of therapy a. Patient age, weight, height and gender b. Medical and drug history pertaining to anticoagulation of the patient c. Indication and duration for heparin therapy d. Laboratory baseline values 1. PT/INR, aptt, CBC, platelet count e. Written order for no IM injections while on heparin 4. Dosing a. A Low Molecular Weight Heparin Equivalency Card will be printed and available on the pharmacy website 5. Laboratory monitoring and dosing adjustments: a. No routine monitoring is necessary for standard LMWH therapy (Prophylactic or treatment doses). b. For specialized populations, (i.e., renal failure patients, pregnant patients morbidly obese patients and patients less than 90% of their Ideal Body Weight), a single 3-4 hour post-dose antixa level should be done after a LMWH dose. 6. Physician Notification a. The physician must be notified if patient experiences any bleeding. b. The physician should also be notified if the therapy is not 7. Pharmacy is responsible for reviewing the orders for all LMWH therapy. 8. Non-standardized use of LMWH, including use as part of procedures, or tubing a written, unit-specific policy which includes patient safety details will be approved by the P&T Committee. 9. A prescriber s order is required for the use of all LMWH products.

4 C. Warfarin Therapy 1. General Indications. Indications include: a. Deep Vein Thrombosis (DVT) b. Pulmonary embolism (PE) c. Venous thrombosis d. Atrial fibrillation with and without embolism e. Unstable Angina f. Artificial cardiac valve replacement g. Selected cancer patients h. Other warranted indications 2. Clinical information which must be documented in the chart prior to initiation of therapy: a. Indication for warfarin therapy b. Duration of warfarin therapy c. Therapeutic range d. Patient age e. Medication history including previous anticoagulation therapy f. Nutritional status g. Concurrent disease states 3. Dosing a. May initiate dosing with an average of 5 mg daily. 10mg is the maximum initial dose. b. May initiate therapy with dose less than 5 mg for the following patients: 1. Patients greater than 60 years of age 2. Patients with impaired nutritional status 3. Patients with hepatic impairment 4. Patients with high risk for bleeding 4 Monitoring a. International Normalized Ratio (INR) is used to monitor and modify doses of warfarin therapy. b. Baseline PT/INR must be obtained for all patients before initial dose or dosing change is ordered. c. For new patients, INR should be monitoring daily until it is therapeutic for 2 days, then order 2-3 times weekly for two weeks, then weekly if stable. 5. General Information: a. Warfarin may be started on the first day of heparin/lwm heparin therapy

5 b. When converting from heparin/lmw heparin therapy, the two may be overlapped. c. Warfarin will be dispensed from the pharmacy one dose at a time, labeled with the patient s name and dosage. d. Warfarin will be kept as floor stock in any area of the hospital e. Warfarin will be administered at 4pm daily unless specifically written for another time. 6. Patient education: a. A pharmacist will provide patient education on the safe and effective use of warfarin therapy. Each patient will be educated based upon the patient s level of comprehension. Documentation of the education session and comprehension will be documented in the chart. Compliance aids, schedule cards and reminders, and drug information will be provided to patients as necessary. Patient education will include: 1. Drug names, strength, and description of tablet 2. Daily dosage and administration times 3. How to handle missed doses 4. Purpose of the drug and how it works 5. Dietary and medication interactions 6. Recognition of signs of bleeding and appropriate procedures to follow 7. Importance of compliance with drug regimen and clinic appointments 8. Keeping I.D. indicating warfarin use 9. Importance of avoiding becoming pregnant, if appropriate 10. Importance of medical alert identification b. Nutritional Services may be consulted for additional education. 7. Nutritional Services a. An order for a Warfarin diet will be written for all patients receiving warfarin. b. A list of the patients receiving warfarin will be provided to Nutritional Services by the pharmacy department on a daily basis. c. Nutritional services will use the list to identify patients who are not currently receiving a warfarin diet and notify the patient s nurse. The patient s nurse will contact the prescriber to obtain a written order for a diet modification.

6 D. Outpatient Anticoagulation Therapy Management 1. An anticoagulation service will be provided within the Louisiana State University Shreveport Medicine Clinic. Patients may be referred to this service through completion of the appropriate referral form. Policies and protocols for this anticoagulation service will be reviewed by the P&T Committee/Clinical Board on an annual basis. 2. Physicians who choose to manage their own patient s anticoagulation therapy will also be required to submit a clinic-specific policy to the P&T Committee/Clinical board for approval on an annual basis. E. Anticoagulation Therapy Outcome Measures 1. The following criteria will be evaluated for at least 12 randomly selected patients per quarter. A summary will be presented to the Pharmacy & Therapeutics Committee at least every 6 months. a. 1. INR is in therapeutic range for patient s illness 2. There are no bleeding episodes 3. There are no thrombotic complications 4. Interventions with physicians regarding patient s therapy (e.g., drug interaction avoidance) 2. The summary report will also include the following information. Number of INRs greater than 6.0 Number of INRs less than 1.5

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