Primary Care practice clinics within the Edmonton Southside Primary Care Network.

Transcription

1 INR Monitoring and Warfarin Dose Adjustment Last Review: November 2016 Intervention(s) and/or Procedure: Registered Nurses (RNs) adjust warfarin dosage according to individual patient International Normalized Ratio (INR) laboratory results based on the algorithm attached. Practice Setting: Authorized Implementers: Competencies and Educational Requirements: Primary Care practice clinics within the Edmonton Southside Primary Care Network. Registered Nurses (RN) in the role of Primary Care Nurse (Edmonton Southside Primary Care Network). 1. The RN must complete the Edmonton Southside Primary Care Network self-study module for INR monitoring and Warfarin dose adjustment and complete review with the Clinical Educator. 2. The nurse must assess his/her individual competence in all aspects of the intervention and decide if it is appropriate for him/her to perform the procedure. 3. The nurse must engage in continuing professional development to achieve and maintain that competence. Indications/Clinical Conditions: 1. Warfarin therapy has already been initiated by the responsible physician. 2. The responsible/authorizing physician has provided an order and documented in the patient chart that this medical directive and protocol can be utilized for management of the patient s INR and warfarin therapy. 3. The RN has established a way to receive INR results and developed a process to ensure INR results are not missed or double-managed with each responsible/authorizing physician. 4. Primary and secondary prevention of venous thromboembolism 5. Prevention of systemic arterial embolism in patients with tissue or mechanical prosthetic

2 heart valves (high risk), valvular heart disease, cardiomyopathy, or atrial fibrillation 6. Prevention of recurrent systemic embolism in patients with atrial fibrillation 7. Prevention of acute myocardial infarction in patients with peripheral arterial disease 8. Prevention of stroke, recurrent infarction, and death in patients with myocardial infarction 9. Treatment of venous thrombosis, pulmonary embolism, antiphospholipid antibody syndrome or thrombophilic conditions (e.g., factor V Leiden) Contraindications and Exclusions: 1. Patients who have not already been initiated on warfarin treatment by the responsible physician or specialist. 2. Patients actively bleeding or at high risk of bleeding (e.g., high-risk surgery) 3. Pregnancy, and within 2 weeks of vaginal delivery 4. History of warfarin-induced skin necrosis 5. History of allergy to warfarin Guidelines for Implementation (all above indications must be met): Assessment, Treatment, and 1. RNs utilize the attached Outpatient Monitoring Parameters: Anticoagulation Flow Sheet/Dose Adjustment Algorithm. 2. When a new INR result is received, RNs interview patients in person or by phone to review factors that may impact INR results to include diet, newly started or stopped medications, potential drug-drug interactions, adherence, alcohol use, and other medical conditions. 3. RNs will determine if any warfarin dose adjustments are required and make according adjustments as per the Outpatient Anticoagulation Flow Sheet/Dose Adjustment Algorithm.

3 4. RNs will consult with the patient s family physician, or the on-call physician if patient s INR > 4.9, for further instructions to manage the patient as per the algorithm instructions. 5. RNs will consult with the patient s family physician, or the on-call physician if patients are experiencing adverse drug events (ADE) to include signs and symptoms of bleeding, thrombosis or embolism, for further instructions to manage the patient 6. Laboratory results, dosing recommendations, and ongoing education will be communicated to the patient by either phone or in person by the RN. Delegation of this communication to Medical Office Assistants (MOA) must be clearly documented by the RN. 7. RNs will discuss the need for a new prescription with the family physician and ensure the prescription is created. Communication and Documentation: 1. All laboratory results and dosing recommendations will be documented in the patient s chart as per individual clinic or physician preference. a. Documentation in the patient s medical record needs to include: name of the directive, name of the implementer (including credential), and name of the physician/authorizer responsible for the directive and patient. b. Information regarding implementation of the procedure and the patient s response should be documented in accordance with standard documentation practice. * c. Standard documentation is recommended for prescriptions, requisitions, and requests for consultation. 2. Communication with patient to include education on warfarin. Implementation of Protocol in Practice Setting:

4 1. The Primary Care Nurse (RN) and the authorizing physician in each clinic must sign the Edmonton Southside Primary Care Network "Medical Directive and Protocol Approval Form" indicating acceptance of this medical directive for implementation in the primary care practice setting. 2. Upon accepting this medical directive, it is in permanent effect (including in the case of revisions to the protocol) until otherwise retracted. 3. The implementing RN within each clinic is responsible to notify the authorizing physician(s) of any updates to the medical directive/protocol. Endorsed by: Clinical Governance Committee Date: November 21, 2016 References: * Potter, P.A. & Perry, A.G. (2006). Fundamentals of Nursing. St. Louis: Mosby.

5 OUTPATIENT ANTICOAGULATION FLOWSHEET Patient s name: Date of birth: / / Medical record #: Indication for anticoagulation (check one): Atrial fibrillation Deep vein thrombosis Pulmonary embolism Mechanical valve Cerebrovascular accident Other Target International Normalized Ratio (INR)*: 2.0 to to 3.5 Other: Start date: / / Therapy duration: 3 months 6 months 1 year Indefinite Other: Date Current dose INR Complications New dose Next INR Initials DOSAGE ADJUSTMENT ALGORITHMS For target INR of 2.0 to 3.0, no bleeding:* INR < to to to to Adjustment Increase dose Increase dose No change Decrease dose Hold for 0 to 1 See reverse side. 10 to 20%; consider extra dose 5 to 10% 5 to 10% day then decrease dose 10% Next INR 4 to 8 days 7 to 14 days No. of consecutive in-range INRs x 1 wk (max: 4 wks) 7 to 14 days 4 to 8 days See reverse side. For target INR of 2.5 to 3.5, no bleeding:* INR < to to to to 6.0 > 6.0 Adjustment Increase dose Increase dose No change Decrease dose 5 Hold for 1 to 2 days See reverse side. 10 to 20%; consider extra dose 5 to 10% to 10%; consider holding one dose then decrease dose 5 to 15% Next INR 4 to 8 days 7 to 14 days No. of consecutive in-range INRs x 1 wk (max: 4 wks) 7 to 14 days 2 to 8 days See reverse side. * See reverse side for further guidance. If INR is 1.8 to 1.9 or 3.1 to 3.2, consider no change with repeat INR in seven to 14 days. For example, if a patient has had three consecutive in-range INR values, recheck in 3 weeks. If INR is 2.3 to 2.4 or 3.6 to 3.7, consider no change with repeat INR in seven to 14 days.

6 OUTPATIENT ANTICOAGULATION FLOWSHEET ANTICOAGULATION DECISION SUPPORT Indication Target INR Duration of therapy SORT DVT or PE 1 First episode, transient risk factor 2.0 to months A First episode, idiopathic DVT 2.0 to to 12 months* A First episode, patient with cancer 2.0 to 3.0 LMWH for 3 to 6 months, then warfarin (Coumadin); treat until cancer is resolved* First episode and single risk factor 2.0 to to 12 months* A First episode, antiphospholipid antibodies or at least two risk factors 2.0 to months* B Recurrent DVT 2.0 to 3.0 Indefinitely B Atrial fibrillation to 3.0 Indefinitely A Valvular disease 3 Rheumatic mitral valve and atrial fibrillation or previous emboli 2.0 to 3.0 Indefinitely B Rheumatic mitral valve disease, normal sinus rhythm, and left atrial 2.0 to 3.0 Indefinitely B diameter > 5.5 cm Aortic St. Jude Medical bileaflet valve 2.0 to 3.0 Indefinitely A Mitral tilting disk valves and bileaflet mechanical valves 2.5 to 3.5 Indefinitely B Aortic CarboMedics bileaflet or Medtronic Hall tilting disk valves, 2.0 to 3.0 Indefinitely B normal sinus rhythm, and no LAE Mechanical valves with risk factors (atrial fibrillation, myocardial 2.5 to 3.5 Indefinitely,* low-dose aspirin B infarction, LAE, endocardial damage, low ejection fraction) Caged ball or disk valve 2.5 to 3.5 Indefinitely,* low-dose aspirin B Mechanical valve with breakthrough embolism despite INR 2.0 to to 3.5 Indefinitely,* low-dose aspirin B Bioprosthetic valve (mitral) 2.0 to months after placement B Bioprosthetic valve (aortic) 2.0 to months of warfarin or aspirin B MANAGEMENT OF SIGNIFICANTLY ELEVATED INR WITH OR WITHOUT BLEEDING 4 INR 5.0 to 8.9, no significant bleeding: Omit 1 to 2 doses; reduce dose 10 to 20 percent; monitor frequently. Alternately consider vitamin K1 1 to 2.5 mg orally. INR 9.0, no significant bleeding: Hold warfarin therapy; give vitamin K1 5 to 10 mg orally; monitor frequently. Resume at lower dose when INR is therapeutic. Serious bleeding, any INR: Hold warfarin; give vitamin K1 10 mg slow intravenous (IV) plus fresh plasma or prothrombin complex concentrate, depending on urgency; repeat vitamin K1 every 12 hours as needed. Life-threatening bleeding, any INR: Hold warfarin; give prothrombin complex concentrate (or recombinant factor VIIa as an alternate) supplemented with vitamin K1 (10 mg slow IV); repeat as needed. INR = International Normalized Ratio; SORT = Strength-of-Recommendation Taxonomy; DVT = deep vein thrombosis; PE = pulmonary embolism; LMWH = low-molecularweight heparin; LAE = left atrial enlargement; A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. * Consider indefinite therapy for selected patients. Deficiency of antithrombin III, protein C, or protein S; prothrombotic gene mutation such as V Leiden or prothrombin 20210; homocystinemia, or factor VIII levels above the 90th percentile of normal; or persistent residual thrombosis on repeated testing with compression ultrasonography. Not indicated in patients younger than 65 years who do not have risk factors (i.e., heart failure, hypertension, previous ischemic stroke or transient ischemic attack, or diabetes mellitus). 1. Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [published correction appears in Chest 2005;127:416]. Chest 2004;126(3 suppl):401s-28s. 2. Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic therapy in atrial fibrillation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 suppl):429s-56s. 3. Salem DN, Stein PD, Al-Ahmad A, Bussey HI, Horstkotte D, Miller N, et al. Antithrombotic therapy in valvular heart disease native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 suppl):457s-82s. 4. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [published correction appears in Chest 2005;127:415-6]. Chest 2004;126(3 suppl):204s-33s. Flowsheet developed by Mark H. Ebell, MD, MS. Copyright 2005 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. A Systematic Approach to Managing Warfarin Doses. Ebell MH. Family Practice Management. May 2005:77-83; A