SJOG Subiaco Hospital: Anti Coagulation Chart

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St John of God Subiaco Hospital - Aim of the Anticoagulation Medical Chart

St John of God Subiaco Hospital - Aim of the Anticoagulation Medical Chart

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  • 1.  
  • 2. Aim of the Anticoagulation Medical Chart
    • Enable the effective achievement of therapeutic levels
    • Minimise the risk of a thromboembolic event due to sub- therapeutic levels
    • Minimise the risk of bleeding events due to supra-therapeutic levels
    • To achieve this the chart includes:
    • recommended dosing and monitoring regime
    • important information required for dosing including test results, weight and renal function
  • 3. Caution Warfarin The regular medication chart HR810 MUST be annotated to identify when an anticoagulation chart is in use Place sticker in a “Regular” medication section of the Medication Chart HR810
  • 4. Patient details – Page 1 Record all Alerts, including those related to anticoagulants on the Regular Medication Chart (see also prescription screen). If any Alerts recorded affix a RED ALERT sticker here.
  • 5. Patient details: pre-prescription screen
    • Check for co-existing conditions, past history of anticoagulant related adverse events and concomitant therapy before prescribing any anticoagulant medication.
    • These may influence the decision to prescribe a particular anticoagulant or indicate a need for closer monitoring and/or dose adjustment.
    At least one box SHOULD be ticked. If there are no coexisting conditions, no history of anticoagulant related adverse events and no antiplatelet or antithrombotic therapy tick the “ Nil Known ” box. First prescriber should complete this section then sign and print and name.
  • 6. Once only and telephone
    • Low molecular weight heparin (enoxaparin)
      • - Initial subcutaneous dose
      • - Intravenous starting bolus
    • Unfractionated heparin
      • - Initial subcutaneous dose
    • - Initiating oral anticoagulant therapy
    Check the route
  • 7. Regular dose orders
    • Subcutaneous heparin
    • Subcutaneous enoxaparin dosing needs
    • adjustment based on creatinine clearance
    • Oral anticoagulation (rivaroxaban)
    Check the route Calculate and record GFR (Clinical Pharmacist Can Assist) BD Dose time 6.00am and 6.00pm as per chart Record baseline creatinine (and platelets)
  • 8. Variable dose orders Note Warfarin dose time 1600 NOT 1800. Now agreed time in Western Australia - pre printed Check the route Dr to complete prior to discharge 3 mg 2-3 3 months Complete prior to discharge Don ’ t forget
  • 9. Best practice when initiating warfarin
    • Measure baseline INR prior to starting therapy
    • Warfarin should be dose modified based on the INR result
    • In the case of acute VTE treatment, heparin (unfractionated or low molecular weight) should be given for at least 5 days and until the INR is greater than 2 for two consecutive days
    • St John of God Pathology will ring the ward if INRs are greater than 4.
  • 10. Ongoing warfarin therapy
    • Brand substitution not allowed
    • In acutely ill patients daily monitoring of INR may be appropriate.
    • Monitor INR more frequently when any change in treatment involves drugs known to interact with warfarin.
  • 11. Intravenous infusions 1 2 3 4 5
  • 12. The SJOGHS therapeutic target ranges Maintenance regimen Maintenance regimen Initiation regimen Initiation regimen Venous Thromboembolism Acute Coronary Syndromes
  • 13. Weight based guides –valid for standard solution 50 units/mL Weight based guides Venous Thromboembolism Initiation regimen Maintenance regimen Acute Coronary Syndromes Initiation regimen Maintenance regimen
  • 14.
    • When should chart NOMOGRAMS not be used?
    Nomograms only apply for STANDARD aPTT TARGETS ie 60 – 90 (VTE) 60 – 79 (ACS)
  • 15. Prescription order  Standard solution – is pre-printed If not applicable Doctor to cross out and document as appropriate eg Glucose 5%. Weight based nomogram guides are only applicable when the standard concentration of volume is used Document target aPTT Weight based nomograms only applicable with STANDARD aPTT therapeutic ranges 60 -90 Document indication Document actual patient weight 74 kg
  • 16. Initial bolus dose and infusion rate Page 2 14/5 14/5 0200 The aPTT must be checked within 6 hours of initial dose Page 3 45 Document as soon as available 6000 27
  • 17. Maintenance regimen continuous infusion – should only be stopped when indicated by nomogram
    • aPTT should be checked
      • within 6 hours of every rate change or
      • within 24 hours (next morning) – when aPTT within target range
    • There should be a timely dose adjustment to each aPTT measurement
    • The infusion should be continuous – only stop when indicated by aPTT
    • The prescriber should always be contacted for EXTREME aPTT ( > 105)levels
    • SJOG Pathology will ring the Ward with results that are greater than 105
    • In all cases the prescriber should check the aPTT result and subsequent infusion rate changes in a timely manner
  • 18. Maintaining the infusion regimen using the weight based nomogram and weight based guide 0830 30 27 + 3 MV GH 1430 25 30 - 5 KJ MN 14/5 0800 55 3000 0830 MV/ GH 14/5 1400 110 14/5 2000 85 2030 25 PO MG
  • 19. CAUTIONS
    • Appropriate monitoring of the aPTT with timely dose adjustments (ideal 30 minutes).
    • Contact prescriber when aPTT is greater than the highest rate specified ( >105) or if indicated by the doctor after each aPTT
    • The infusion should be continuous unless indicated by the aPTT to hold for a period of time due to aPTT. That means NOT
    • allowing the infusion bag to run out
    • stopping the infusion for the patient to
    • shower or go to Xray etc.
  • 20. Infusion bag changes This extra information will assist monitoring actual doses delivered 1800 Document the time the bag was changed/stopped. 480 ml Document volume infused. (Total volume minus volume remaining) 14/5 1800 0200 14/5
  • 21. Summary
    • Anticoagulants are high risk drugs
      • Complex dosing regimen
      • Monitoring required
    • The SJOGS version of the WAAMC designed to enable appropriate dose selection and monitoring- standardised approach across all hospitals and community
    • BUT it is only a piece of paper – practice has to change