Department of Human Services Medical Services Division
UPDATE Vaccine Administration Payment Increase
On May 17 2013 the Medical Services Division released information containing a self-attestation form
relative to the enhanced payments for vaccine administrations rendered by certain primary care
physicians The increased payments are in accordance with Section 1202 of the Affordable Care Act
(ACA)
In order to be eligible for the increased payment physicians must be enrolled as family medicine
general internal medicine pediatric medicine or a sub-specialty thereof and must self-attest as
qualifying either by board certification or show that 60 of all Medicaid services they bill are for the
specified evaluation and management and vaccine administration codes The original letter issued by
the Department along with the North Dakota Medicaid attestation form can be found at
httpwwwndgovdhsservicesmedicalservmedicaidprovider-updateshtml
Qualifying physicians interested in receiving the higher Medicaid payment for vaccination administration
must submit a completed self-attestation form Please note that the original documentation stated that
the attestation is due on or before June 17 2013 in order to receive retrospective payment
consideration back to January 1 2013 THE DUE DATE FOR THE ATTESTATIONS HAS BEEN EXTENDED TO
AUGUST 17 2013 Physicians who submit a self-attestation after August 17 2013 will continue to be
eligible for the enhanced rates on a prospective basis effective the date they are received
If you have any questions please contact Cindy Sheldon by phone at (701) 3284626 or via email at
cmsheldonndgov
possible but no later than June 3 2013
To find out more information about the NDHIN visit wwwndhinorg
INSIDE THIS ISSUE
NDHIN Update 1
Benefits 2
Successes 2
Reminder 2
New Participants 3
Privacy amp Securityhelliphelliphelliphelliphellip3
User Grouphelliphelliphelliphelliphelliphelliphelliphelliphellip4
Integration of Participantshellip4
Did You Know 4
Upcoming Eventshelliphelliphelliphelliphellip4
Contact Information 4
May 2013
NDHIN Update
The North Dakota Health Information Network (NDHIN) is excited to announce our partnership with Orion
Health Orion Health HIE is the most widely deployed Health Information Exchange (HIE) solution in the
world
The contract has been signed by the State Both the NDHIN and Orion Health staff have been working dili-
gently and will be prepared to move forward quickly with Direct Secure Messaging (DSM) and the Query-
based Services (Clinical Portal) DSM will be operational for Participantsrsquo existing user accounts as soon as
Orion Health HIE also has
clients in Europe Asia and
Australia
Newsletter
DOMAIN
WORKGROUPS
Technical Infrastructure
Finance
Legal amp Policy
Clinical
Communication amp
Education
Data Use
If you or someone on your staff
would like to participate in the
Domain Workgroups please
contact one of individuals
listed in the contact section
For more information on the
workgroups go to
wwwhealthitndgov
membersdomainworkgroups
2
Successes
Benefits
There are now 88 participation agreements signed and 360 authorized
users enrolled in NDHIN Direct Secure Messaging (DSM) As soon as
DSM is up and running we will begin to enroll additional users If you
wish to use DSM with another organization (hospital ambulatory care
long term care pharmacy public health etc) that has not yet joined
NDHIN please encourage them to do so The NDHIN Participation
Agreements are available at httpwwwndhinorgservicesndhin-
directdirect-enrollment
The ability to exchange health information electronically is the founda-
tion of efforts to improve health care quality and safety
Provides a vehicle for improving quality and safety of patient care
Provides a basic level of interoperability among EHRs maintained
by individual physicians and organizations
Stimulates consumer education and patients involvement in their
own health care
Helps public health officials meet their commitment to the
community
Creates a potential loop for feedback between health-related
research and actual practice
Facilitates efficient deployment of emerging technology and health
care services
Provides the backbone of technical infrastructure for leverage by
national and State-level initiatives
Reminders
The NDHIN should be notified within 24 hours to inactivate an Au-
thorized Userrsquos account when the Authorized User has been removed
by a Participant for reason of termination of employment or otherwise
2
EDUCATION TOOLS ABOUT HIPAA PRIVACY AND SECURITY
The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has devel-
oped an array of new tools to educate consumers and health care providers about the Health Insur-
ance Portability and Accountability Act (HIPAA) Privacy and Security Rules
Many consumers are unfamiliar with their rights under the HIPAA Privacy Rule With that in mind
OCR has posted a series of factsheets also available in eight languages to inform consumers about
their rights under the HIPAA Privacy Rule These materials are available on OCRrsquos website at http
wwwhhsgovocrprivacyhipaaunderstandingconsumers
The fact sheets compliment a set of seven consumer-facing videos released earlier this year on OCRrsquos
YouTube channel The videos are available on the HHS OCR YouTube Channel at http
wwwyoutubecomuserUSGovHHSOCR
OCR has also launched three modules for health care providers on compliance with various aspects of
the HIPAA Privacy and Security Rules available at Medscapeorg
Patient Privacy A Guide for Providers httpwwwmedscapeorgviewarticle781892src=ocr
HIPAA and You Building a Culture of Compliance httpwwwmedscapeorg
viewarticle762170src=ocr
Examining Compliance with the HIPAA Privacy Rule httpwwwmedscapeorg
viewarticle763251src=ocr
For more information please visit httpwwwhhsgovocrprivacy
Privacy and Security
For a complete list of participants go to wwwndhinorgprovidersparticipating-providers
ND Veterans Home
Thrifty White Drug Patient Care Center
Rosewood on Broadway
Elbowoods Memorial Health Center
New Participants
NDHIN USER GROUP
The next NDHIN User Group
webinar will be June 13th from
1200-100 PM (CDT) Join
this informative session and
register today Go to https
www1gotomeetingcom
register217633521
User Group offers you the
opportunity to network with
your peers to discuss use
cases share successes ask
questions and learn from each
other
CONTACT INFORMATION
ND HIT Director
Sheldon Wolf
ND HIT Director
701-328-1991
shwolfndgov
NDHIN Contacts
Charles Peterson
NDHIN Technology Manager
701-328-1955
chapetersonndgov
Tina Gagner RN
NDHIN Business Analyst
701-328-1126
tgagnerndgov
Robin Hirsch
NDHIN Trainer
701-328-2508
rhirschndgov
Jennifer Kunz
NDHIN Project Manager
701-328-7395
jlkunzndgov
3
Dakota Conference on Rural and Public Health
June 5-7 2013
Seven Seas Hotel amp Waterpark ~ Mandan North Dakota
wwwruralhealthundedudakotaconference
HIMSS Spring Health IT Conference
June 20 2013 ~ 830AM-500PM
Hilton Garden Inn ~ Fargo North Dakota
wwwndhimssorgeventseventshtml
Upcoming Events
Did You Know
There are 3 platforms for Direct Secure Messaging (DSM)
DSM Web
Web-based Direct Messaging
Resides in the HIE Clinical Portal
Able to send structured and unstructured messages securely
DSM Direct
3rd party EHR Direct Connectivity (ex Epic Cerner)
DSM Connect
EHR Connectivity for EHRs without Direct functionality
NDHIN and Orion Health teams have been meeting with initial partici-pants to plan their integration with the core solution (Clinical Portal query-based services) The status is as follows
Jamestown Regional Medical Center ndash VPN configuration Readi-ness Assessment in progress
Sanford (Fargo) - VPN planningReadiness Assessment in progress
St Alexius - VPN planningReadiness Assessment in progress
Dept of Health - VPN planningReadiness Assessment in progress
Contact Chad Peterson at 701-328-1955 or chapetersonndgov if you
are ready to begin planning your connection
Integration of Participants
Portsmouth Regional Hospital
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS ORDERS Instructions CHECK ALL ORDERS THAT APPLY or WRITE IN THE DESIGNATED SPACE Those items preceded by boxes that are not checked
will not be implemented DO NOT ALTERAMEND PRE-PRINTED MEDICATION ORDERS WRITE A NEW MEDICATION ORDER
Identify Risk Factor(s) and complete order section below
Low Risk Ambulatory patient with no VTE risk factors Minor surgery patient
Moderate to High Risk ndash Patient Factors Bed or chair confinement immobilization gt 12 hours Obesity
Age gt 60 years (VTE risk increases with advancing age) Tobacco Use
Previous VTE (DVT or PE) or Family History Varicose Veins
Indwelling Central Venous Catheter ICU Admission
Moderate to High Risk ndash MedicalSurgical Condition Factors Hypercoagulable state inherited or acquired Dehydration Major Surgery (particularly operations involving
the abdomen pelvis and lower extremities)
Ischemic (non-hemorrhagic) Stroke Sepsis or Severe Infection
Trauma (especially fractures of the pelvis hip or leg) Malignancy
Thrombophilia Sickle Cell or other hematological disorders Paralysis
Estrogen or Other Hormonal Therapy Myeloproliferative Disease
Lung Disease ndash Chronic or Acute Respiratory Failure
Cardiac Dysfunction PregnancyPost partum
Inflammatory Bowel Disease Nephrotic Syndrome
No VTE prophylaxis indicated due to Low risk for VTE CMO orders High INR
Pharmacologic Prophylaxis
Enoxaparin (Lovenox) 40 mg subcutaneous daily at bedtime (medical)
Enoxaparin (Lovenox) 30 mg subcutaneous daily at bedtime (Renal dose for creatinine clearance less than 30 mlminute)
Heparin 5000 units subcutaneous every 8 hours
Pharmacological VTE prophylaxis is not indicated secondary to risk of bleeding
on other anticoagulant therapy on continuous heparin other_________________________
Mechanical Prophylaxis
Bilateral calf-length sequential compression boots unless pharmacologic prophylaxis ordered or
compression boots not indicated due to ambulatory low VTE risk severe peripheral vascular disease
Other ____________________________________________________________
Provider Signature Date Time
PRH 917331 Original 32013
POS PATIENT STICKER
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
possible but no later than June 3 2013
To find out more information about the NDHIN visit wwwndhinorg
INSIDE THIS ISSUE
NDHIN Update 1
Benefits 2
Successes 2
Reminder 2
New Participants 3
Privacy amp Securityhelliphelliphelliphelliphellip3
User Grouphelliphelliphelliphelliphelliphelliphelliphelliphellip4
Integration of Participantshellip4
Did You Know 4
Upcoming Eventshelliphelliphelliphelliphellip4
Contact Information 4
May 2013
NDHIN Update
The North Dakota Health Information Network (NDHIN) is excited to announce our partnership with Orion
Health Orion Health HIE is the most widely deployed Health Information Exchange (HIE) solution in the
world
The contract has been signed by the State Both the NDHIN and Orion Health staff have been working dili-
gently and will be prepared to move forward quickly with Direct Secure Messaging (DSM) and the Query-
based Services (Clinical Portal) DSM will be operational for Participantsrsquo existing user accounts as soon as
Orion Health HIE also has
clients in Europe Asia and
Australia
Newsletter
DOMAIN
WORKGROUPS
Technical Infrastructure
Finance
Legal amp Policy
Clinical
Communication amp
Education
Data Use
If you or someone on your staff
would like to participate in the
Domain Workgroups please
contact one of individuals
listed in the contact section
For more information on the
workgroups go to
wwwhealthitndgov
membersdomainworkgroups
2
Successes
Benefits
There are now 88 participation agreements signed and 360 authorized
users enrolled in NDHIN Direct Secure Messaging (DSM) As soon as
DSM is up and running we will begin to enroll additional users If you
wish to use DSM with another organization (hospital ambulatory care
long term care pharmacy public health etc) that has not yet joined
NDHIN please encourage them to do so The NDHIN Participation
Agreements are available at httpwwwndhinorgservicesndhin-
directdirect-enrollment
The ability to exchange health information electronically is the founda-
tion of efforts to improve health care quality and safety
Provides a vehicle for improving quality and safety of patient care
Provides a basic level of interoperability among EHRs maintained
by individual physicians and organizations
Stimulates consumer education and patients involvement in their
own health care
Helps public health officials meet their commitment to the
community
Creates a potential loop for feedback between health-related
research and actual practice
Facilitates efficient deployment of emerging technology and health
care services
Provides the backbone of technical infrastructure for leverage by
national and State-level initiatives
Reminders
The NDHIN should be notified within 24 hours to inactivate an Au-
thorized Userrsquos account when the Authorized User has been removed
by a Participant for reason of termination of employment or otherwise
2
EDUCATION TOOLS ABOUT HIPAA PRIVACY AND SECURITY
The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has devel-
oped an array of new tools to educate consumers and health care providers about the Health Insur-
ance Portability and Accountability Act (HIPAA) Privacy and Security Rules
Many consumers are unfamiliar with their rights under the HIPAA Privacy Rule With that in mind
OCR has posted a series of factsheets also available in eight languages to inform consumers about
their rights under the HIPAA Privacy Rule These materials are available on OCRrsquos website at http
wwwhhsgovocrprivacyhipaaunderstandingconsumers
The fact sheets compliment a set of seven consumer-facing videos released earlier this year on OCRrsquos
YouTube channel The videos are available on the HHS OCR YouTube Channel at http
wwwyoutubecomuserUSGovHHSOCR
OCR has also launched three modules for health care providers on compliance with various aspects of
the HIPAA Privacy and Security Rules available at Medscapeorg
Patient Privacy A Guide for Providers httpwwwmedscapeorgviewarticle781892src=ocr
HIPAA and You Building a Culture of Compliance httpwwwmedscapeorg
viewarticle762170src=ocr
Examining Compliance with the HIPAA Privacy Rule httpwwwmedscapeorg
viewarticle763251src=ocr
For more information please visit httpwwwhhsgovocrprivacy
Privacy and Security
For a complete list of participants go to wwwndhinorgprovidersparticipating-providers
ND Veterans Home
Thrifty White Drug Patient Care Center
Rosewood on Broadway
Elbowoods Memorial Health Center
New Participants
NDHIN USER GROUP
The next NDHIN User Group
webinar will be June 13th from
1200-100 PM (CDT) Join
this informative session and
register today Go to https
www1gotomeetingcom
register217633521
User Group offers you the
opportunity to network with
your peers to discuss use
cases share successes ask
questions and learn from each
other
CONTACT INFORMATION
ND HIT Director
Sheldon Wolf
ND HIT Director
701-328-1991
shwolfndgov
NDHIN Contacts
Charles Peterson
NDHIN Technology Manager
701-328-1955
chapetersonndgov
Tina Gagner RN
NDHIN Business Analyst
701-328-1126
tgagnerndgov
Robin Hirsch
NDHIN Trainer
701-328-2508
rhirschndgov
Jennifer Kunz
NDHIN Project Manager
701-328-7395
jlkunzndgov
3
Dakota Conference on Rural and Public Health
June 5-7 2013
Seven Seas Hotel amp Waterpark ~ Mandan North Dakota
wwwruralhealthundedudakotaconference
HIMSS Spring Health IT Conference
June 20 2013 ~ 830AM-500PM
Hilton Garden Inn ~ Fargo North Dakota
wwwndhimssorgeventseventshtml
Upcoming Events
Did You Know
There are 3 platforms for Direct Secure Messaging (DSM)
DSM Web
Web-based Direct Messaging
Resides in the HIE Clinical Portal
Able to send structured and unstructured messages securely
DSM Direct
3rd party EHR Direct Connectivity (ex Epic Cerner)
DSM Connect
EHR Connectivity for EHRs without Direct functionality
NDHIN and Orion Health teams have been meeting with initial partici-pants to plan their integration with the core solution (Clinical Portal query-based services) The status is as follows
Jamestown Regional Medical Center ndash VPN configuration Readi-ness Assessment in progress
Sanford (Fargo) - VPN planningReadiness Assessment in progress
St Alexius - VPN planningReadiness Assessment in progress
Dept of Health - VPN planningReadiness Assessment in progress
Contact Chad Peterson at 701-328-1955 or chapetersonndgov if you
are ready to begin planning your connection
Integration of Participants
Portsmouth Regional Hospital
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS ORDERS Instructions CHECK ALL ORDERS THAT APPLY or WRITE IN THE DESIGNATED SPACE Those items preceded by boxes that are not checked
will not be implemented DO NOT ALTERAMEND PRE-PRINTED MEDICATION ORDERS WRITE A NEW MEDICATION ORDER
Identify Risk Factor(s) and complete order section below
Low Risk Ambulatory patient with no VTE risk factors Minor surgery patient
Moderate to High Risk ndash Patient Factors Bed or chair confinement immobilization gt 12 hours Obesity
Age gt 60 years (VTE risk increases with advancing age) Tobacco Use
Previous VTE (DVT or PE) or Family History Varicose Veins
Indwelling Central Venous Catheter ICU Admission
Moderate to High Risk ndash MedicalSurgical Condition Factors Hypercoagulable state inherited or acquired Dehydration Major Surgery (particularly operations involving
the abdomen pelvis and lower extremities)
Ischemic (non-hemorrhagic) Stroke Sepsis or Severe Infection
Trauma (especially fractures of the pelvis hip or leg) Malignancy
Thrombophilia Sickle Cell or other hematological disorders Paralysis
Estrogen or Other Hormonal Therapy Myeloproliferative Disease
Lung Disease ndash Chronic or Acute Respiratory Failure
Cardiac Dysfunction PregnancyPost partum
Inflammatory Bowel Disease Nephrotic Syndrome
No VTE prophylaxis indicated due to Low risk for VTE CMO orders High INR
Pharmacologic Prophylaxis
Enoxaparin (Lovenox) 40 mg subcutaneous daily at bedtime (medical)
Enoxaparin (Lovenox) 30 mg subcutaneous daily at bedtime (Renal dose for creatinine clearance less than 30 mlminute)
Heparin 5000 units subcutaneous every 8 hours
Pharmacological VTE prophylaxis is not indicated secondary to risk of bleeding
on other anticoagulant therapy on continuous heparin other_________________________
Mechanical Prophylaxis
Bilateral calf-length sequential compression boots unless pharmacologic prophylaxis ordered or
compression boots not indicated due to ambulatory low VTE risk severe peripheral vascular disease
Other ____________________________________________________________
Provider Signature Date Time
PRH 917331 Original 32013
POS PATIENT STICKER
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
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If you or someone on your staff
would like to participate in the
Domain Workgroups please
contact one of individuals
listed in the contact section
For more information on the
workgroups go to
wwwhealthitndgov
membersdomainworkgroups
2
Successes
Benefits
There are now 88 participation agreements signed and 360 authorized
users enrolled in NDHIN Direct Secure Messaging (DSM) As soon as
DSM is up and running we will begin to enroll additional users If you
wish to use DSM with another organization (hospital ambulatory care
long term care pharmacy public health etc) that has not yet joined
NDHIN please encourage them to do so The NDHIN Participation
Agreements are available at httpwwwndhinorgservicesndhin-
directdirect-enrollment
The ability to exchange health information electronically is the founda-
tion of efforts to improve health care quality and safety
Provides a vehicle for improving quality and safety of patient care
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Stimulates consumer education and patients involvement in their
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Reminders
The NDHIN should be notified within 24 hours to inactivate an Au-
thorized Userrsquos account when the Authorized User has been removed
by a Participant for reason of termination of employment or otherwise
2
EDUCATION TOOLS ABOUT HIPAA PRIVACY AND SECURITY
The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has devel-
oped an array of new tools to educate consumers and health care providers about the Health Insur-
ance Portability and Accountability Act (HIPAA) Privacy and Security Rules
Many consumers are unfamiliar with their rights under the HIPAA Privacy Rule With that in mind
OCR has posted a series of factsheets also available in eight languages to inform consumers about
their rights under the HIPAA Privacy Rule These materials are available on OCRrsquos website at http
wwwhhsgovocrprivacyhipaaunderstandingconsumers
The fact sheets compliment a set of seven consumer-facing videos released earlier this year on OCRrsquos
YouTube channel The videos are available on the HHS OCR YouTube Channel at http
wwwyoutubecomuserUSGovHHSOCR
OCR has also launched three modules for health care providers on compliance with various aspects of
the HIPAA Privacy and Security Rules available at Medscapeorg
Patient Privacy A Guide for Providers httpwwwmedscapeorgviewarticle781892src=ocr
HIPAA and You Building a Culture of Compliance httpwwwmedscapeorg
viewarticle762170src=ocr
Examining Compliance with the HIPAA Privacy Rule httpwwwmedscapeorg
viewarticle763251src=ocr
For more information please visit httpwwwhhsgovocrprivacy
Privacy and Security
For a complete list of participants go to wwwndhinorgprovidersparticipating-providers
ND Veterans Home
Thrifty White Drug Patient Care Center
Rosewood on Broadway
Elbowoods Memorial Health Center
New Participants
NDHIN USER GROUP
The next NDHIN User Group
webinar will be June 13th from
1200-100 PM (CDT) Join
this informative session and
register today Go to https
www1gotomeetingcom
register217633521
User Group offers you the
opportunity to network with
your peers to discuss use
cases share successes ask
questions and learn from each
other
CONTACT INFORMATION
ND HIT Director
Sheldon Wolf
ND HIT Director
701-328-1991
shwolfndgov
NDHIN Contacts
Charles Peterson
NDHIN Technology Manager
701-328-1955
chapetersonndgov
Tina Gagner RN
NDHIN Business Analyst
701-328-1126
tgagnerndgov
Robin Hirsch
NDHIN Trainer
701-328-2508
rhirschndgov
Jennifer Kunz
NDHIN Project Manager
701-328-7395
jlkunzndgov
3
Dakota Conference on Rural and Public Health
June 5-7 2013
Seven Seas Hotel amp Waterpark ~ Mandan North Dakota
wwwruralhealthundedudakotaconference
HIMSS Spring Health IT Conference
June 20 2013 ~ 830AM-500PM
Hilton Garden Inn ~ Fargo North Dakota
wwwndhimssorgeventseventshtml
Upcoming Events
Did You Know
There are 3 platforms for Direct Secure Messaging (DSM)
DSM Web
Web-based Direct Messaging
Resides in the HIE Clinical Portal
Able to send structured and unstructured messages securely
DSM Direct
3rd party EHR Direct Connectivity (ex Epic Cerner)
DSM Connect
EHR Connectivity for EHRs without Direct functionality
NDHIN and Orion Health teams have been meeting with initial partici-pants to plan their integration with the core solution (Clinical Portal query-based services) The status is as follows
Jamestown Regional Medical Center ndash VPN configuration Readi-ness Assessment in progress
Sanford (Fargo) - VPN planningReadiness Assessment in progress
St Alexius - VPN planningReadiness Assessment in progress
Dept of Health - VPN planningReadiness Assessment in progress
Contact Chad Peterson at 701-328-1955 or chapetersonndgov if you
are ready to begin planning your connection
Integration of Participants
Portsmouth Regional Hospital
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS ORDERS Instructions CHECK ALL ORDERS THAT APPLY or WRITE IN THE DESIGNATED SPACE Those items preceded by boxes that are not checked
will not be implemented DO NOT ALTERAMEND PRE-PRINTED MEDICATION ORDERS WRITE A NEW MEDICATION ORDER
Identify Risk Factor(s) and complete order section below
Low Risk Ambulatory patient with no VTE risk factors Minor surgery patient
Moderate to High Risk ndash Patient Factors Bed or chair confinement immobilization gt 12 hours Obesity
Age gt 60 years (VTE risk increases with advancing age) Tobacco Use
Previous VTE (DVT or PE) or Family History Varicose Veins
Indwelling Central Venous Catheter ICU Admission
Moderate to High Risk ndash MedicalSurgical Condition Factors Hypercoagulable state inherited or acquired Dehydration Major Surgery (particularly operations involving
the abdomen pelvis and lower extremities)
Ischemic (non-hemorrhagic) Stroke Sepsis or Severe Infection
Trauma (especially fractures of the pelvis hip or leg) Malignancy
Thrombophilia Sickle Cell or other hematological disorders Paralysis
Estrogen or Other Hormonal Therapy Myeloproliferative Disease
Lung Disease ndash Chronic or Acute Respiratory Failure
Cardiac Dysfunction PregnancyPost partum
Inflammatory Bowel Disease Nephrotic Syndrome
No VTE prophylaxis indicated due to Low risk for VTE CMO orders High INR
Pharmacologic Prophylaxis
Enoxaparin (Lovenox) 40 mg subcutaneous daily at bedtime (medical)
Enoxaparin (Lovenox) 30 mg subcutaneous daily at bedtime (Renal dose for creatinine clearance less than 30 mlminute)
Heparin 5000 units subcutaneous every 8 hours
Pharmacological VTE prophylaxis is not indicated secondary to risk of bleeding
on other anticoagulant therapy on continuous heparin other_________________________
Mechanical Prophylaxis
Bilateral calf-length sequential compression boots unless pharmacologic prophylaxis ordered or
compression boots not indicated due to ambulatory low VTE risk severe peripheral vascular disease
Other ____________________________________________________________
Provider Signature Date Time
PRH 917331 Original 32013
POS PATIENT STICKER
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
2
EDUCATION TOOLS ABOUT HIPAA PRIVACY AND SECURITY
The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has devel-
oped an array of new tools to educate consumers and health care providers about the Health Insur-
ance Portability and Accountability Act (HIPAA) Privacy and Security Rules
Many consumers are unfamiliar with their rights under the HIPAA Privacy Rule With that in mind
OCR has posted a series of factsheets also available in eight languages to inform consumers about
their rights under the HIPAA Privacy Rule These materials are available on OCRrsquos website at http
wwwhhsgovocrprivacyhipaaunderstandingconsumers
The fact sheets compliment a set of seven consumer-facing videos released earlier this year on OCRrsquos
YouTube channel The videos are available on the HHS OCR YouTube Channel at http
wwwyoutubecomuserUSGovHHSOCR
OCR has also launched three modules for health care providers on compliance with various aspects of
the HIPAA Privacy and Security Rules available at Medscapeorg
Patient Privacy A Guide for Providers httpwwwmedscapeorgviewarticle781892src=ocr
HIPAA and You Building a Culture of Compliance httpwwwmedscapeorg
viewarticle762170src=ocr
Examining Compliance with the HIPAA Privacy Rule httpwwwmedscapeorg
viewarticle763251src=ocr
For more information please visit httpwwwhhsgovocrprivacy
Privacy and Security
For a complete list of participants go to wwwndhinorgprovidersparticipating-providers
ND Veterans Home
Thrifty White Drug Patient Care Center
Rosewood on Broadway
Elbowoods Memorial Health Center
New Participants
NDHIN USER GROUP
The next NDHIN User Group
webinar will be June 13th from
1200-100 PM (CDT) Join
this informative session and
register today Go to https
www1gotomeetingcom
register217633521
User Group offers you the
opportunity to network with
your peers to discuss use
cases share successes ask
questions and learn from each
other
CONTACT INFORMATION
ND HIT Director
Sheldon Wolf
ND HIT Director
701-328-1991
shwolfndgov
NDHIN Contacts
Charles Peterson
NDHIN Technology Manager
701-328-1955
chapetersonndgov
Tina Gagner RN
NDHIN Business Analyst
701-328-1126
tgagnerndgov
Robin Hirsch
NDHIN Trainer
701-328-2508
rhirschndgov
Jennifer Kunz
NDHIN Project Manager
701-328-7395
jlkunzndgov
3
Dakota Conference on Rural and Public Health
June 5-7 2013
Seven Seas Hotel amp Waterpark ~ Mandan North Dakota
wwwruralhealthundedudakotaconference
HIMSS Spring Health IT Conference
June 20 2013 ~ 830AM-500PM
Hilton Garden Inn ~ Fargo North Dakota
wwwndhimssorgeventseventshtml
Upcoming Events
Did You Know
There are 3 platforms for Direct Secure Messaging (DSM)
DSM Web
Web-based Direct Messaging
Resides in the HIE Clinical Portal
Able to send structured and unstructured messages securely
DSM Direct
3rd party EHR Direct Connectivity (ex Epic Cerner)
DSM Connect
EHR Connectivity for EHRs without Direct functionality
NDHIN and Orion Health teams have been meeting with initial partici-pants to plan their integration with the core solution (Clinical Portal query-based services) The status is as follows
Jamestown Regional Medical Center ndash VPN configuration Readi-ness Assessment in progress
Sanford (Fargo) - VPN planningReadiness Assessment in progress
St Alexius - VPN planningReadiness Assessment in progress
Dept of Health - VPN planningReadiness Assessment in progress
Contact Chad Peterson at 701-328-1955 or chapetersonndgov if you
are ready to begin planning your connection
Integration of Participants
Portsmouth Regional Hospital
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS ORDERS Instructions CHECK ALL ORDERS THAT APPLY or WRITE IN THE DESIGNATED SPACE Those items preceded by boxes that are not checked
will not be implemented DO NOT ALTERAMEND PRE-PRINTED MEDICATION ORDERS WRITE A NEW MEDICATION ORDER
Identify Risk Factor(s) and complete order section below
Low Risk Ambulatory patient with no VTE risk factors Minor surgery patient
Moderate to High Risk ndash Patient Factors Bed or chair confinement immobilization gt 12 hours Obesity
Age gt 60 years (VTE risk increases with advancing age) Tobacco Use
Previous VTE (DVT or PE) or Family History Varicose Veins
Indwelling Central Venous Catheter ICU Admission
Moderate to High Risk ndash MedicalSurgical Condition Factors Hypercoagulable state inherited or acquired Dehydration Major Surgery (particularly operations involving
the abdomen pelvis and lower extremities)
Ischemic (non-hemorrhagic) Stroke Sepsis or Severe Infection
Trauma (especially fractures of the pelvis hip or leg) Malignancy
Thrombophilia Sickle Cell or other hematological disorders Paralysis
Estrogen or Other Hormonal Therapy Myeloproliferative Disease
Lung Disease ndash Chronic or Acute Respiratory Failure
Cardiac Dysfunction PregnancyPost partum
Inflammatory Bowel Disease Nephrotic Syndrome
No VTE prophylaxis indicated due to Low risk for VTE CMO orders High INR
Pharmacologic Prophylaxis
Enoxaparin (Lovenox) 40 mg subcutaneous daily at bedtime (medical)
Enoxaparin (Lovenox) 30 mg subcutaneous daily at bedtime (Renal dose for creatinine clearance less than 30 mlminute)
Heparin 5000 units subcutaneous every 8 hours
Pharmacological VTE prophylaxis is not indicated secondary to risk of bleeding
on other anticoagulant therapy on continuous heparin other_________________________
Mechanical Prophylaxis
Bilateral calf-length sequential compression boots unless pharmacologic prophylaxis ordered or
compression boots not indicated due to ambulatory low VTE risk severe peripheral vascular disease
Other ____________________________________________________________
Provider Signature Date Time
PRH 917331 Original 32013
POS PATIENT STICKER
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
NDHIN USER GROUP
The next NDHIN User Group
webinar will be June 13th from
1200-100 PM (CDT) Join
this informative session and
register today Go to https
www1gotomeetingcom
register217633521
User Group offers you the
opportunity to network with
your peers to discuss use
cases share successes ask
questions and learn from each
other
CONTACT INFORMATION
ND HIT Director
Sheldon Wolf
ND HIT Director
701-328-1991
shwolfndgov
NDHIN Contacts
Charles Peterson
NDHIN Technology Manager
701-328-1955
chapetersonndgov
Tina Gagner RN
NDHIN Business Analyst
701-328-1126
tgagnerndgov
Robin Hirsch
NDHIN Trainer
701-328-2508
rhirschndgov
Jennifer Kunz
NDHIN Project Manager
701-328-7395
jlkunzndgov
3
Dakota Conference on Rural and Public Health
June 5-7 2013
Seven Seas Hotel amp Waterpark ~ Mandan North Dakota
wwwruralhealthundedudakotaconference
HIMSS Spring Health IT Conference
June 20 2013 ~ 830AM-500PM
Hilton Garden Inn ~ Fargo North Dakota
wwwndhimssorgeventseventshtml
Upcoming Events
Did You Know
There are 3 platforms for Direct Secure Messaging (DSM)
DSM Web
Web-based Direct Messaging
Resides in the HIE Clinical Portal
Able to send structured and unstructured messages securely
DSM Direct
3rd party EHR Direct Connectivity (ex Epic Cerner)
DSM Connect
EHR Connectivity for EHRs without Direct functionality
NDHIN and Orion Health teams have been meeting with initial partici-pants to plan their integration with the core solution (Clinical Portal query-based services) The status is as follows
Jamestown Regional Medical Center ndash VPN configuration Readi-ness Assessment in progress
Sanford (Fargo) - VPN planningReadiness Assessment in progress
St Alexius - VPN planningReadiness Assessment in progress
Dept of Health - VPN planningReadiness Assessment in progress
Contact Chad Peterson at 701-328-1955 or chapetersonndgov if you
are ready to begin planning your connection
Integration of Participants
Portsmouth Regional Hospital
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS ORDERS Instructions CHECK ALL ORDERS THAT APPLY or WRITE IN THE DESIGNATED SPACE Those items preceded by boxes that are not checked
will not be implemented DO NOT ALTERAMEND PRE-PRINTED MEDICATION ORDERS WRITE A NEW MEDICATION ORDER
Identify Risk Factor(s) and complete order section below
Low Risk Ambulatory patient with no VTE risk factors Minor surgery patient
Moderate to High Risk ndash Patient Factors Bed or chair confinement immobilization gt 12 hours Obesity
Age gt 60 years (VTE risk increases with advancing age) Tobacco Use
Previous VTE (DVT or PE) or Family History Varicose Veins
Indwelling Central Venous Catheter ICU Admission
Moderate to High Risk ndash MedicalSurgical Condition Factors Hypercoagulable state inherited or acquired Dehydration Major Surgery (particularly operations involving
the abdomen pelvis and lower extremities)
Ischemic (non-hemorrhagic) Stroke Sepsis or Severe Infection
Trauma (especially fractures of the pelvis hip or leg) Malignancy
Thrombophilia Sickle Cell or other hematological disorders Paralysis
Estrogen or Other Hormonal Therapy Myeloproliferative Disease
Lung Disease ndash Chronic or Acute Respiratory Failure
Cardiac Dysfunction PregnancyPost partum
Inflammatory Bowel Disease Nephrotic Syndrome
No VTE prophylaxis indicated due to Low risk for VTE CMO orders High INR
Pharmacologic Prophylaxis
Enoxaparin (Lovenox) 40 mg subcutaneous daily at bedtime (medical)
Enoxaparin (Lovenox) 30 mg subcutaneous daily at bedtime (Renal dose for creatinine clearance less than 30 mlminute)
Heparin 5000 units subcutaneous every 8 hours
Pharmacological VTE prophylaxis is not indicated secondary to risk of bleeding
on other anticoagulant therapy on continuous heparin other_________________________
Mechanical Prophylaxis
Bilateral calf-length sequential compression boots unless pharmacologic prophylaxis ordered or
compression boots not indicated due to ambulatory low VTE risk severe peripheral vascular disease
Other ____________________________________________________________
Provider Signature Date Time
PRH 917331 Original 32013
POS PATIENT STICKER
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
Portsmouth Regional Hospital
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS ORDERS Instructions CHECK ALL ORDERS THAT APPLY or WRITE IN THE DESIGNATED SPACE Those items preceded by boxes that are not checked
will not be implemented DO NOT ALTERAMEND PRE-PRINTED MEDICATION ORDERS WRITE A NEW MEDICATION ORDER
Identify Risk Factor(s) and complete order section below
Low Risk Ambulatory patient with no VTE risk factors Minor surgery patient
Moderate to High Risk ndash Patient Factors Bed or chair confinement immobilization gt 12 hours Obesity
Age gt 60 years (VTE risk increases with advancing age) Tobacco Use
Previous VTE (DVT or PE) or Family History Varicose Veins
Indwelling Central Venous Catheter ICU Admission
Moderate to High Risk ndash MedicalSurgical Condition Factors Hypercoagulable state inherited or acquired Dehydration Major Surgery (particularly operations involving
the abdomen pelvis and lower extremities)
Ischemic (non-hemorrhagic) Stroke Sepsis or Severe Infection
Trauma (especially fractures of the pelvis hip or leg) Malignancy
Thrombophilia Sickle Cell or other hematological disorders Paralysis
Estrogen or Other Hormonal Therapy Myeloproliferative Disease
Lung Disease ndash Chronic or Acute Respiratory Failure
Cardiac Dysfunction PregnancyPost partum
Inflammatory Bowel Disease Nephrotic Syndrome
No VTE prophylaxis indicated due to Low risk for VTE CMO orders High INR
Pharmacologic Prophylaxis
Enoxaparin (Lovenox) 40 mg subcutaneous daily at bedtime (medical)
Enoxaparin (Lovenox) 30 mg subcutaneous daily at bedtime (Renal dose for creatinine clearance less than 30 mlminute)
Heparin 5000 units subcutaneous every 8 hours
Pharmacological VTE prophylaxis is not indicated secondary to risk of bleeding
on other anticoagulant therapy on continuous heparin other_________________________
Mechanical Prophylaxis
Bilateral calf-length sequential compression boots unless pharmacologic prophylaxis ordered or
compression boots not indicated due to ambulatory low VTE risk severe peripheral vascular disease
Other ____________________________________________________________
Provider Signature Date Time
PRH 917331 Original 32013
POS PATIENT STICKER
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
1 Risk factors for the development of VTE
Active collagen
vascular disorder
Age greater than 40
years
Chronic lung disease
CVLcatheter
Estrogen use
Heart failure
Hiplegpelvic fracture
Immobilityparalysis
Inflammatory
disorders
Ischemic stroke
Malignancy
Multiple traumas
Obesity
Pneumonia
Pregnancy
Prior history of
DVTPE
Respiratory failure
Serious infection
Thrombophilia
Varicose veins
2 Select risk stratification for acquiring VTE (check indication)
HIGH RISK DVT History of Current
Major orthopedic procedures (including lower extremity arthroplastyfracture)
Spinal cord injury multiple trauma
Abdominalpelvic cancer undergoing operative procedure
Other__________________________________________________________________
MODERATE RISK Stable medical patient with at least one risk factor
Moderate surgery without risk factors
Major surgery or moderate surgery with risk factors
Major medical problems (CHF sepsis)
Other__________________________________________________________________
LOW RISK Medical patient ndash fully mobile brief admission (anticipate less than 48 hour admission)
Surgical patient ndash procedure less than 30 minutes mobile no additional risk factors
Other_________________________________________________________________
3 Select VTE prophylaxis (select therapy consistent with risk stratification identified above)
HIGH RISK
Pharmacological regimen recommendations (choose one)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30 mg subcutaneously q12 hours (preferred in trauma)
Enoxaparin (Lovenox) 30 mg subcutaneously q24 hours (CrCl less than 30 mLmin)
Warfarin (Coumadin)__________mg PO daily (main INR 2-3)
Other__________________________________________________________
MODERATE RISK
Pharmacological regimen recommendations (choose one)
ASA 325mg PO BID (NOTE discharge regimen is ASA 325 mg BID x 10 days to 6 weeks based on patient activity) ASA 81 mg PO daily bid Heparin 5000 units subcutaneously q8 hours
Heparin 5000 units subcutaneously q12 hours (age greater than 75 y or weigh less than 50 kg)
Heparin 5000 units subcutaneously q12 hours (CrCl 15 mLmin to 30 mLmin)
Enoxaparin (Lovenox) 40 mg subcutaneously q24 hours
Enoxaparin (Lovenox) 30mg subcutaneously q24 hours
Other_____________________________________________________________
LOW RISK
No Pharmacological Intervention at this time due to (an option below must be selected HUC please order lsquoNo Intervention at this timersquo)
Active BleedHigh Bleeding Risk Comfort Care
Anti-Coagulant Allergy Patient Refused
Anti-Coagulation Not Tolerated Surgical Contraindication
Blood Coagulation Disorder Medical Contraindication ________________________
Mechanical Prevention
TEDs Left Right until fully ambulatory
SCDs Left Right until fully ambulatory
Other_________________________________
3 If evidence of any bleeding hold next dose and notify MD
Physician Signature____________________________________ Date__________ Time_________
RN noted_____________Date_______Time________HUC Initial________Date________Time______
PATIENT LABEL BENEWAH COMMUNITY HOSPITAL REV 021913 PAGE 1 OF 1
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
Page 1 of 1NWorkgrpsCHIOrders amp Protocols-ClinicalVTE Prophylaxis Last Revision 031413
VTE Prophylaxis MED
Patient currently on therapeutic warfarin No additional VTE prophylaxis required
ORLOW RISK Observation patients LOS lt 48 hours MinorAmbulatory surgery or Age lt 50 and NO other risk factors or already on
therapeutic anticoagulationEarly ambulation - no additional VTE prophylaxis required
MODERATE RISK Most medicalsurgical patients CHF pneumonia active inflammation advanced age dehydration varicoseveins less than fully and independently ambulatory many other factors All patients not in the Low or Highest Risk CategoriesIf patient is moderate risk may select mechanical prophylaxis (sequential compression device) OR pharmacologic prophylaxis
[ knee-high bilateral left right ] sequential compression deviceOR
Enoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
HIGH RISK Elective hip or knee arthroplasty acute spinal cord injury with paresis multiple major trauma abdominal or pelvicsurgery for cancer
If patient is high risk must select mechanical prophylaxis AND pharmacological prophylaxisSequential Compression Device [ knee-high bilateral left right ]
AND select one of the followingEnoxaparin sodium 40 mg subcutaneously every 24 hours (Pharmacy to adjust for renal function)Heparin sodium 5000 units subcutaneously every 8 hoursHeparin sodium 5000 units subcutaneously every 12 hours if less than 50 kg or greater than 75 yo
VTE PROPHYLAXIS CONTRAINDICATEDIf prophylaxis is contraindicated for a patient the appropriate mechanical contraindication AND pharmacological contraindicationmust be selected
Mechanical ContraindicationsBilateral AmputeeBilateral lower extremity traumaContinuous IV heparin therapy within 24 hours peri-opPatient or family refusalintolerant
Pharmacological ContraindicationsActive hemorrhage (GI bleeding cerebral hemorrhage retroperitoneal bleeding)Continuous IV heparin therapy within 24 hours peri-opSevere Trauma to head or spinal cord with hemorrhage in last 4 weeksIntracranial hemorrhage within last yearCraniotomy within 2 weeksIntraocular surgery within 2 weeksGI or GU hemorrhage within last monthThrombocytopenia (lt50K) or coagulopathy (prothrombin time gt 18 seconds)End stage liver diseaseActive intracranial lesionsneoplasmsHypertensive urgencyemergencyPost-Op bleeding concerns (see linked reference document for details)Immune mediated heparin-induced thrombocytopeniaEpidural analgesia with spinal catheter (current or planned)Patient or family refusalintolerant
Provider Signature ________________________________EMR_________ Date___________ Time __________
Prog amp
OrdersPatient Label
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
819 Ash Street - Spooner WI 54801Phone 715-635-2111 Fax 715-635-8674
DIAGNOSIS_______________________BMI________________________
ALLERGIES_______________________(CPSI Number Name and Room Number Above)
Venous Thromboembolism (VTE) Prophylaxis ProtocolMark the for desired orders If are blank order is inactive
Criteria Indicating Need for VTE Prophylaxis Acutely ill hospitalized patient with anticipated stay of more than 24 hours
AND ANY ONE OF THE FOLLOWING
Class 3 CHF (marked limits to activity levels although comfortable at rest)OR
Class 4 CHF (severe limitation of activities and discomfort is present even at rest)OR
Severe Respiratory Disease (Decompensated COPD)OR
Confined to bed and have one or more additional risk factors such as age gt40 MCU (monitored care unit) obesityactive cancer previous VTE sepsisserious infection central venous catheter varicose veins collagen vasculardisease hypercoagulable states fracturetrauma recent surgery estrogentamoxifen pregnancy nephrotic syndromeischemic CVA myocardial infarction inflammatory bowel disease
Physician Orders
Place compression stockings (eg Teds)
Place Intermittent Compression Devices (ICDs)
Enoxaparin (Lovenoxreg) 40 mg subcutaneous daily (Pharmacy may increase to 40 mg Q12H for BMI gt 40 Kgm2 ordecrease to 30 mg daily for Est CrCl less than 30 mlmin)
Enoxaparin (Lovenoxreg) 30 mg subcutaneous daily -- for patients with Est CrCl less than 30 mlmin
Heparin 5000 units subcutaneous every 8 hours
No thromboprophylaxis indicated Reason______________________________________________
Contraindications Active bleeding within 48-72 hours Hypertensive crisis Coagulopathysevere liver disease Hemophilia Heparin or porcine protein hypersensitivity Heparin induced thrombocytopenia (HIT) Idiopathic thrombocytopenia purpura (ITP) Platelet count lt20K without coagulopathy LP spinal injection or epidural catheter Recent intraocular spinal intracranial surgery Use of tPA for stroke within 24hrs Head trauma or CNS hemorrhage
Multiple trauma with high bleeding risk Proven or suspected peri-spinal hematoma Other high risk for bleeding or active bleeding
conditions based on judgment Currently therapeutic or supratherapeutic INR due
to warfarin therapy
Prescriber Signature ________________________ Date amp Time ____________________Form 685-335 1111
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
Room
DATE TIME ORDERS - ORDERED BY PROGRESS NOTES
VTE Prophylaxis Order SetLINE OUT INAPPROPRIATE ORDERS
SCIP recommendations bySurgery Type on back side oforder sheet
Patient Risk ________ Low Risk Criteria
1 Mechanical prophylaxis Already on therapeuticanticoagulation
Observation
Expected LOS lt40hrs
Age lt50 with no other risk factors
Minor ambulatory surgery
SCDs
Knee-high Ted stockings
Thigh-high Ted stockings
2 Pharmacological agentsHigh Risk Criteria
Choose ONE Pharmacolgic Option
Arixtra 25 mg subcutaneous daily
(contraindicated in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time Advanced age gt50
Multiple major trauma
Pneumonia
CHF
Major abd or pelvic surgery
Active Inflammation
Dehydration
Varicose veins
Less than fully amp independentlyambulatory
Elective hip or knee arthroplasty
Acute spinal cord injury withparesis
Lovenox 40 mg subcutaneous daily
Initiate on Date Time
Lovenox 30 mg subcutaneous daily(pt with renal failure creatinine clearance lt 30 mlmin)
Initiate on Date Time
Heparin 5000 units subcutaneous every 8 hours
Initiate on Date TimeHeparin 5000 units subcutaneous every 12 hours
Initiate on Date Time
Xarelto (rivaroxaban) 10mg po daily(For hips amp knees ONLY)(avoid use in patient with creatinine clearance lt 30mlmin)
Initiate on Date Time
3 Contraindications
Pharmacological Mechanical
Risk of bleeding or activebleeding
Bilateralamputee
Patient on Coumadin ortreatment dose of Lovenoxor Arixtra
Bilateral lowerextremitytrauma
Patient Refusal Patient refusal
Patient on continuous IVheparin therapy
Patient oncontinuous IVheparin therapy
Thrombocytopenia Other_________
Other __________
PHYSICIANrsquoS ORDER SHEET amp PROGRESS NOTESCMy DocumentsDRORDERSphysicianorder1doc Revised 040313
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-
Surgery Type (not risk based) Recommended Prophylaxis OptionsGeneral surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Splenectomy Repair of stomach Small Bowel Resection LargeBowel Resection Colostomy Ileostomy Exploratory Laparotomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily LDUH or LMWH or Factor Xa combined with SCDs
General surgery with Physician documentedhigh risk for bleeding
Any of the followingTED hose SCDs
Gynecological surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days)Examples Transabdominal Hysterectomy Transvaginal HysterectomyLAVH Oopherectomy Salpingectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs LDUH or LMWH combined with SCDsTED hose
Urologic surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Nephrectomy Cystectomy Repair of Bladder LacerationBladder Fistula Repair Radical Prostatectomy
Any of the followingLDUH 5000 units SubQ BID or TID LMWH (Lovenox) 40mg SubQ Daily (30mg for renal failure) Factor Xa Inhibitor (Arixtra) 25 SubQ Daily SCDs TED HOSE LDUH or LMWH or Factor Xa combined with SCDs or TED hose
Elective total hip replacement(Open surgical procedure gt60 minutes and requiringhospital stay gt 3 days post op)Examples Total partial or revision
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily
Elective total knee replacement(Open surgical procedure gt60 minutes andrequiring hospital stay gt 3 days post op)Examples Knee revision of one or all componenets Total Knee
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) Rivaroxaban 10mg po daily SCDs
Hip fracture surgery(Open surgical procedure gt 60 minutes and requiringhospital stay gt 3 days post op)Examples Repair of Hip
Any of the followingLMWH (Lovenox) 40mg SubQ Daily Factor Xa (Arixtra) 25 mg Adjusted dose Warfarin (INR target 25) LDUH 5000 units SubQ BID or TID
Hip fracture surgery or total hip replacementwith Physician documented high risk forbleeding
Any of the followingTED hose SCDs
Cases receiving neuraxial anesthesia pass with mechanical prophylaxis onlyLDUH Low dose unfractionated heparin LMWH=Low molecular weight heparinCall Anesthesiologist prior to dose if insertionremoval of epiduralspinal plannedRecommended prophylaxis should be instituted 24 hrs preop to 24 hrs postop
CMy DocumentsDRORDERSphysicianorder1doc Revised 040313
- (2013-06-05) Extension due date-vaccine admin paymentpdf
- May Newsletter ND Health Information Networkpdf
- Venous Thromboembolism Risk Assessment and Order Form 3-7-13 (2)pdf
- ADULT VTEpdf
- VTE Prophylaxis MED 2013-03-14pdf
- Venous Thromboembolism (VTE or DVT) Prophylaxis Protocol Final 11-11pdf
- VTE changes2pdf
-