Coumadin/WarfarinMinimizing risk

and

Optimizing Safety

National Patient Safety Goal 3JCAHO

Anticoagulation therapy poses risks to patients and often leads to adverse drug events due to complex dosing, requisite follow-up monitoring, and inconsistent [patient] compliance. The use of standardized practices for anticoagulation therapy that include [patient] involvement can reduce the risk of adverse drug events associated with the use of heparin (unfractionated), low molecular weight heparin, and warfarin.

The incidence of major bleeding for patients on Coumadinis 20%

Elements of Performance

• The hospital uses approved protocols for the initiation and maintenance of anticoagulant therapy appropriate to the medication used, to the condition being treated, and to the potential for medication interactions.

• For patients starting on warfarin, a baseline International Normalized Ratio (INR) is available, and for all patients receiving warfarin therapy, a current INR is available and is used to monitor and adjust this therapy.

• The hospital provides education regarding anticoagulant therapy to prescribers, staff, patients, and families.

Why do we need a protocol?

83 y o F presents to the hospital with new onset atrial fibrillation. Her CHADS2 score is 4, so she is started on warfarin.

First MD orders warfarin 5 mg dailyNext MD orders warfarin 10 mg X 1, unaware of first orderPatient receives 15 mg PO warfarin on Day 1 without a baseline INR

INR on Day 2 is 1.2 and patient receives 5 mg warfarin

INR is not checked on Day 3 but patient continues to receive daily 5 mg dose of warfarin….

You can see where this is going!

Pharmokinetics

• Interferes with synthesis of Vitamin K -dependent clotting factors II, VII, IX and X

• Absorbed through GI tract• Activity: Peaks in 1.5 - 3 days

Duration 2- 5days• Half-life: 1-2.5 days• Metabolized in the liver• Excreted through urine and feces

Coumadin affectsthe intrinsiccoagulation

pathway preventingclotting

Coumadin Indications• Prophylaxis of venous thrombosis

(high risk surgery)• Treatment of venous thrombosis• Treatment of PE• Prevention of systemic embolism • AMI (to prevent systemic embolism) • Tissue heart valves• Atrial Fibrillation

Goal INR for these indications is 2-3 is recommended

Goal INR for these orthopedic patients is 2-2.5 is recommended

INR Values and DVTs

Contraindications

• Pregnancy

• Bleeding tendencies/blood dyscrasias

• Recent/contemplated surgery

• Threatened abortion

• Spinal puncture/Epidural

Lab Monitoring

• Regular monitoring INR• Repeat INR Daily until therapeutic

for 2 consecutive days then Q48hrs until discharge

• Goal INR 2-3 for protocol indications.• Other indications may have goal of

2.5 to 3.5• Standard dose time at MAH is 1800 to

allow lab results

WHERE CAN MY PATIENT GO TO GET THEIR INR DRAWN?

Dietary Considerations• Amount of vitamin K in foods affects therapy• Maintain a consistent amount of vit K in your diet• Avoid drastic changes in your dietary habits• Adding large amounts of these food items

will vitamin K in the body: – margarine, canola oil, olive oil, mayonnaise– broccoli, Brussels sprouts, kale, endives

cucumbers, – kiwi, blueberries– sauerkraut, soybeans, dill pickle– beef and pork liver– cashews

Other things that can affect Anticoagulation

Garlic

Ginkgo Biloba

Green tea

Alcohol: can affect liver function which is the site of warfarin/coumadin metabolism

Anticoagulation affect

Drug/Drug Interactions

Drugs that may INCREASE anticoagulant effect or risk of bleeding:

Amiodarone*** Cimetidine (Tagamet) Levothyroxine (Levoxyl) Stomach remedies (Prilosec) Laxatives (Sennakot) Phenytoin (Dilantin) Quinidine Quinine Pain relievers (Motrin)

**** Requires a 50% reduction in warfarin/coumadin if new to therapy

Anticoagulant effect

Drug/Drug Interactions

Anti-infectives: Fluconazole (Diflucan) Erythromycin Fluoroquinolones Metronidazole (Flagyl) TMP-SMX (Bactrim)

Anticoagulanteffect

Drug Interactions

May DECREASE anticoagulant effect: Barbiturates Carbamazepine (Tegretol) Cholestyramine (Questran) Rifampin Vitamin K

Anticoagulanteffect

Side effects: • Bleeding: Assess any of the following

symptoms as they may indicate internal bleeding or INR > 3:

– minor gums bleeding

– nosebleeds

– headache

– joint pain

– nausea/vomit

– melena

CPOE Order or Order SetIf you try to order Warfarin fora patient who has not had anorder for 30 days, you will geta prompt to ask you to consider discarding this orderand ordering the Warfarininitiating protocol

This is the Warfarin initiation protocol

Warfarin Protocolprovides decisionsupport

This is to be usedfor patients:

* new on Coumadin* for the indications listed * with goal INR of 2-3

Normogram indicates for eachday depending on what theINR is what the dose shouldbe or what the dose should becompared to the previousday’s dose

Prompts for baseline INRand daily INRs

Processing the Protocol Order

10/13/09

Coumadin perprotocol One time med sheet

18

Date Medication Time Date Date Date Date Date

IF CPOE Order: place paper order set in MD Order section of chart so MDs have the nomogram

MD will order subsequent orders as one time meds. Documentdose administration on One Time Medication Sheet and Coumadin Worksheet

To be placed in MedicationBooks and document doseadministered daily

Give to patient at discharge

Date Day of Time PT INR Dose RN signature of therapy

10/13

10/14

10/15

1

2

3

1800

1800

1800

1.2 5mg K Murphy RN

1.4 5mg D Morrison RN

2.3 2mg D Devanna RN

Warfarin Protocol Flowsheet

New Patient Education Brochure

New Brochure from theAgency for HealthcareResearch and Quality

Give to all patients on Coumadin

Anticoagulant Risk and Falls

Anticoagulants place a patient at additional RISK OF HARMTake note if patient is at RISK FOR FALL

FALL RISK + ANTICOAGULANTS =

POTENTIAL FOR LIFE THREATENING BLEEDING

Use Fall Mats if High Risk forfalls and onanticoagulants

Patient Teaching to prevent bleeding

Care when using sharp objects

– Use electric razor

– Use soft toothbrush

– Use waxed dental floss

– No toothpicks– Avoid bare feet

Patient Education

From the Caregroup Portal:Click on MicromedexClick on Carenotes systemType in CoumadinSelect tabletSelect English or SpanishPRINT

Provide patient withthis drug information

sheet as well

Case Study

Mr M is admitted to SDU with uncontrolled Atrial Fibrillation. He is initially started on Heparin drip and Metropolol for rate control. His heart rate is now controlled and is being transferred to South 4 to convert to Coumadin

The Coumadin Protocol is initiated

Baseline INR is 0.8

What is the dose this patient should receive on Day 1?

5 mg

Day 2The INR is 1.2 Your dose for the day should be?

5 mg

Day 3The INR is 1.4 Your dose for the day should be?

7.5mg

Day 4The INR is 2.2 Your dose for the day should be?

7.5mg

Day 5The INR is 3.1 your dose for the day should be?

6mg