SJOG Subiaco Hospital: Anti Coagulation Chart


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

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SJOG Subiaco Hospital: Anti Coagulation Chart

  1. 2. Aim of the Anticoagulation Medical Chart <ul><li>Enable the effective achievement of therapeutic levels </li></ul><ul><li>Minimise the risk of a thromboembolic event due to sub- therapeutic levels </li></ul><ul><li>Minimise the risk of bleeding events due to supra-therapeutic levels </li></ul><ul><li>To achieve this the chart includes: </li></ul><ul><li>recommended dosing and monitoring regime </li></ul><ul><li>important information required for dosing including test results, weight and renal function </li></ul>
  2. 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
  3. 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.
  4. 5. Patient details: pre-prescription screen <ul><li>Check for co-existing conditions, past history of anticoagulant related adverse events and concomitant therapy before prescribing any anticoagulant medication. </li></ul><ul><li>These may influence the decision to prescribe a particular anticoagulant or indicate a need for closer monitoring and/or dose adjustment. </li></ul>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.
  5. 6. Once only and telephone <ul><li>Low molecular weight heparin (enoxaparin) </li></ul><ul><ul><li>- Initial subcutaneous dose </li></ul></ul><ul><ul><li>- Intravenous starting bolus </li></ul></ul><ul><li>Unfractionated heparin </li></ul><ul><ul><li>- Initial subcutaneous dose </li></ul></ul><ul><li>- Initiating oral anticoagulant therapy </li></ul>Check the route
  6. 7. Regular dose orders <ul><li>Subcutaneous heparin </li></ul><ul><li>Subcutaneous enoxaparin dosing needs </li></ul><ul><li>adjustment based on creatinine clearance </li></ul><ul><li>Oral anticoagulation (rivaroxaban) </li></ul>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)
  7. 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
  8. 9. Best practice when initiating warfarin <ul><li>Measure baseline INR prior to starting therapy </li></ul><ul><li>Warfarin should be dose modified based on the INR result </li></ul><ul><li>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 </li></ul><ul><li>St John of God Pathology will ring the ward if INRs are greater than 4. </li></ul>
  9. 10. Ongoing warfarin therapy <ul><li>Brand substitution not allowed </li></ul><ul><li>In acutely ill patients daily monitoring of INR may be appropriate. </li></ul><ul><li>Monitor INR more frequently when any change in treatment involves drugs known to interact with warfarin. </li></ul>
  10. 11. Intravenous infusions 1 2 3 4 5
  11. 12. The SJOGHS therapeutic target ranges Maintenance regimen Maintenance regimen Initiation regimen Initiation regimen Venous Thromboembolism Acute Coronary Syndromes
  12. 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
  13. 14. <ul><li>When should chart NOMOGRAMS not be used? </li></ul>Nomograms only apply for STANDARD aPTT TARGETS ie 60 – 90 (VTE) 60 – 79 (ACS)
  14. 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
  15. 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
  16. 17. Maintenance regimen continuous infusion – should only be stopped when indicated by nomogram <ul><li>aPTT should be checked </li></ul><ul><ul><li>within 6 hours of every rate change or </li></ul></ul><ul><ul><li>within 24 hours (next morning) – when aPTT within target range </li></ul></ul><ul><li>There should be a timely dose adjustment to each aPTT measurement </li></ul><ul><li>The infusion should be continuous – only stop when indicated by aPTT </li></ul><ul><li>The prescriber should always be contacted for EXTREME aPTT ( > 105)levels </li></ul><ul><li>SJOG Pathology will ring the Ward with results that are greater than 105 </li></ul><ul><li>In all cases the prescriber should check the aPTT result and subsequent infusion rate changes in a timely manner </li></ul>
  17. 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
  18. 19. CAUTIONS <ul><li>Appropriate monitoring of the aPTT with timely dose adjustments (ideal 30 minutes). </li></ul><ul><li>Contact prescriber when aPTT is greater than the highest rate specified ( >105) or if indicated by the doctor after each aPTT </li></ul><ul><li>The infusion should be continuous unless indicated by the aPTT to hold for a period of time due to aPTT. That means NOT </li></ul><ul><li>allowing the infusion bag to run out </li></ul><ul><li>stopping the infusion for the patient to </li></ul><ul><li>shower or go to Xray etc. </li></ul>
  19. 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
  20. 21. Summary <ul><li>Anticoagulants are high risk drugs </li></ul><ul><ul><li>Complex dosing regimen </li></ul></ul><ul><ul><li>Monitoring required </li></ul></ul><ul><li>The SJOGS version of the WAAMC designed to enable appropriate dose selection and monitoring- standardised approach across all hospitals and community </li></ul><ul><li>BUT it is only a piece of paper – practice has to change </li></ul>