Change in Heparin Infusion

Managment: the New Anti-Xa

Protocols

Objectives

• Describe use of Anti-Xa levels (rather than PTT) for monitoring

and dose adjustments of nurse managed heparin infusions

• Review steps for RN management of a heparin infusion with

Anti-Xa level > 1 unit/mL

• Describe changes to Provider Managed Heparin Powerplans

• Describe changes to Mechanical Circulatory Support (MCS)

Heparin Protocols

Heparin Infusion Update

Beginning October 29th, nurse managed heparin infusion dose adjustments will be based on Anti-Xa levels rather than PTT

Why Anti-Xa?

• Increased accuracy –Anti-Xa not affected by liver disease, consumptive

coagulopathy, or lupus anticoagulant that may influence PTT results

–Anti-Xa is more reflective of heparin activity.

• Shorter time to reach therapeutic range

Heparin infusion ordering

• Nurse managed heparin infusion protocols • Nurse adjusts heparin dose using standardized algorithms to maintain

Anti-Xa levels within a goal range

• Majority of heparin infusions

• Provider managed heparin infusions • Provider must ORDER all doses and dose changes

• Nurse will call the ordering team with each lab result

• No algorithms for nurse managed adjustments

Heparin infusion ordering – Available Powerplans

Rx Heparin Infusion Protocol • Nurse adjusts heparin dose using standardized algorithms to maintain Anti-Xa levels within a

goal range

o REGULAR Intensity Goal: Anti-Xa 0.3 – 0.7 units/mL

o LOW Intensity Goal: Anti-Xa 0.3 – 0.5 units/mL

• Majority of heparin infusions

Rx ULTRA LOW Heparin Infusion Protocol • Nurse adjusts heparin dose using a standardized algorithm to maintain Anti-Xa between 0.1 –

0.3 units/mL

• Anti-Xa checks remain at every 6 hours for the duration of the infusion

Rx Heparin Infusion, Provider Managed • Provider must ORDER all doses and dose changes

• There are no algorithms for nurse-managed adjustments

Rx Mechanical Circulatory Support (MCS) Heparin Infusion Protocol • For patients with current/recent implanted mechanical circulatory support (MCS) device ONLY

• Nurse adjusts heparin dose using standardized algorithms to maintain Anti-Xa levels within a prescribed goal range

• Anti-Xa levels are checked every 6 hours while on heparin infusion

• PTT is NOT checked concurrently with Anti-Xa

Heparin infusion ordering

1.Provider selects indication for heparin infusion

2.Provider selects heparin loading bolus, if warranted

3. Provider selects Anti-Xa Goal (Algorithm Intensity)

4. Provider selects PRN re-bolus for low Anti-Xa level, if

warranted

Step 1. Has a loading bolus been ordered? Initial loading bolus:

• Ordered in units

• NOT ALWAYS ORDERED

• Given from bag, via Alaris® pump, using the “bolus” button

Loading bolus found in orders and eMAR:

Nurse Managed Protocols - starting the heparin

infusion

Nurse Managed Protocols - starting the

heparin infusion Step 2. What is the starting dose for the continuous infusion?

Continuous infusion is:

• Dosed based on indication

• Ordered in units/kg/hr

• Programmed into Alaris® pump in units/kg/hr (NOTE: Weight for Calculations must also be programmed into pump)

Continuous infusion starting dose found in orders and eMAR:

Nurse Managed Protocols - starting the

heparin infusion Step 3. Which algorithm will be used for dose adjustments?

REGULAR Intensity Anti-Xa Goal 0.3 -0.7 units/mL or

«LOW» Intensity Anti-Xa Goal 0.3 -0.5 units/mL or

ULTRA LOW intensity Anti-Xa Goal 0.1 -0.3 units/mL

(separate Powerplan “Rx ULTRA LOW Heparin Infusion Protocol” with separate algorithm—see next slide)

Nurse Managed Protocols - starting the

heparin infusion

Step 3a. Determine which algorithm (Anti-Xa goal) has been ordered

You can see this in the continuous infusion order in the Powerplan:

or on eMAR under Continuous Infusions:

Step 3b. Find and print the protocol with algorithms from Reference Text

• In the “Orders” tab, right click on the Heparin Infusion Powerplan

• Click on the Evidence link to access the algorithms

REGULAR Intensity and LOW Intensity algorithms will print on the same page.

Draw an “X” through the algorithm that does not apply.

Nurse Managed Protocols - starting the

heparin infusion

BEST PRACTICE—PRINT PROTOCOL, DRAW “X” THROUGH THE ALGORITHM THAT WILL NOT BE

USED AND POST NEXT TO ALARIS® PUMP

Step 4. When will I check the Anti-Xa level?

Order Anti-Xa for Unfract Heparin 6 hours after the

infusion is started (Written – No Cosign)

Nurse Managed Protocols - starting the heparin infusion

2.7mL to fill

Nurse Managed Protocols - responding to Anti-Xa levels

1) Make sure you are

using the correct

algorithm

2) Find the current Anti-Xa

level in the left column

(example, Anti-Xa level

0.19 units/mL)

3) Follow the row

systematically across,

checking the

instructions in each

column

4) Read the fine print

#1

Nurse Managed Protocols - responding to Anti-Xa levels

Anti-Xa result is low. Now what? (example: REGULAR Intensity algorithm ordered, Anti-Xa result 0.19 units/mL)

a. Make sure you are using the

prescribed algorithm

b. Find the Anti-Xa result in the first

column. NOTE any instructions about

NOTIFYING PROVIDER

c. Check PRN orders/eMAR for re-boluses

d. Adjust heparin DOSE

e. Order next Anti-Xa level

6 hours after adjusting the dose

e

a

c d b

RE-BOLUS for Anti-Xa below goal range—check PRN orders and PRN section of eMAR

Anti-Xa result is high. Now what? (example: REGULAR Intensity algorithm ordered, Anti-Xa result 0.91 units/mL)

Nurse Managed Protocols - responding to Anti-Xa levels

a. Make sure you are using

the right algorithm

b. Hold the infusion for the

designated time, per the

algorithm NOTE: Document dose of “0” in

IVIEW while infusion is on HOLD

c. Adjust the heparin DOSE

d. Order the next Anti-Xa level 6 hours after restarting at the

lower dose

a

Nurse Managed Protocols - responding to Anti-Xa levels

Anti-Xa is > 1 unit/mL. Now what?

See the instructions near the bottom of the protocol:

First, determine quality and timing of the blood sample that

resulted with an Anti-Xa level > 1 unit/mL

Then, follow the detailed INSTRUCTIONS

Nurse Managed Protocols – heparin infusion

after a procedure or surgery

See the instructions at the bottom of the protocol:

• Know the previous dose, algorithm and stability of Anti-Xa

levels at the time the heparin was stopped before discussing

with the provider.

• If there are no orders to resume heparin, check with the

provider, don’t assume that the infusion should not be

restarted.

Nurse Managed Protocols - Pearls for Alaris®

pump programming • At initial set-up, program the

WEIGHT FOR CALCULATIONS into

the pump (not daily weight)

• Program the infusion using the

“DOSE” field (not “RATE”)

• When adjusting the heparin dose in

response to an Anti-Xa level,

program the new infusion DOSE

(units/kg/hr) before programming any

BOLUS dose or a delay period

required by the protocol.

Nurse Managed Protocols -

Pearls for Documentation

• Select the correct units of measure

(e. g. units/kg/hr) from the drop down

menu in the eMAR when beginning

the bag of heparin

• Always document the DOSE, not the

rate

• Verify DOSE and rate documented in

eMAR & IVIEW match the DOSE

and rate displayed on the Alaris®

pump

• Whenever delaying or stopping the

infusion, document the DOSE as “0”

Nurse Managed Protocols - Pearls for Communication

• The RN who initiates the heparin infusion, or makes the DOSE

change, orders the next Anti-Xa level (even if it occurs on the

next shift)

• At any handoff:

– Confirm current DOSE

– Confirm current algorithm

– Review Anti-Xa trends

– Review timing of next Anti-Xa level

NOTE: In some protocols, Anti-Xa checks will reduce to an every

morning check after 2 consecutive Anti-Xa levels in the prescribed

range

• Notify provider as ordered

Nurse Managed Protocols – Pearls for ULTRA

LOW Heparin Infusion Protocol • For use in rare situations with very high concern for bleeding

• Does NOT provide therapeutic anticoagulation and NOT

recommended for treatment of acute thromboembolism

• Anti-Xa level checks remain at every 6 hours for the duration of

the infusion

• If Anti-Xa level > 1 unit/mL (on a properly timed and non-

contaminated sample)

– STOP Heparin infusion

– NOTIFY provider

– REPEAT STAT Anti-Xa hourly until Anti-Xa level < 0.5 units/mL

– RESUME infusion at DECREASED DOSE that is

5 units/kg/hr lower than previous dose (see next slide)

• Includes:

– FIXED RATE— only heparin infusion dosed as units/hr, monitored with Anti-Xa

– PTT monitored—dosed as units/kg/hr

– PROVIDER-SPECIFIED Anti-Xa Goal—dosed as units/kg/hr

• NO dose adjustments per algorithm by nurse

• Provider orders starting dose and EVERY subsequent dose adjustment

• Nurse may order lab draws (Written – No Cosign) and notifies

providers when results are available

Provider Managed Infusions: Pearls for Nurses

Nurse Managed Protocols - Mechanical Circulatory Support (MCS) Heparin Infusion Pearls

• 3 heparin titration algorithms

– ULTRA LOW Intensity (Anti-Xa Goal 0.1 – 0.3 units/mL)

– LOW Intensity (Anti-Xa Goal 0.3 – 0.5 units/mL)

– REGULAR Intensity (Anti-Xa Goal 0.3 – 0.7 units/mL)

• RNs who have been working with the MCS Heparin Protocol—note that the dose titrations and guidance on when to call the provider have changed

• Anti-Xa level checks remain at every 6 hours for the

duration of the infusion

• No more paired PTT and Anti-Xa levels

(See next slide)