Tips for Clinical Review of IV Heparin Infusions How to clinically check an intravenous heparin infusion order

When reviewing an IV heparin infusion, it is important to ask yourself the following:

1. Is IV Heparin the right anticoagulant for my patient?

2. What is the indication/target APTT range for my patient? Is the correct PowerPlan selected?

3. What are the relevant laboratory results for my patient (APTT, PLT and others e.g. Creatinine, Hb, INR)?

4. Has IV heparin been prescribed correctly?

5. Has IV heparin been administered correctly?

6. Is there a plan for further APTT tests and is this appropriate?

1. Is IV Heparin the right anticoagulant for my patient?

▪ Check for contraindications to therapy – previous HIT, other allergy/intolerance tounfractionated/low- molecular weight heparin, active bleeding.

▪ Does the patient need full anticoagulation – check for prescribed VTE prophylaxis. Check for VTE withholdorder (if applicable) on the MAR.

▪ Is the patient already receiving full anticoagulation – check for current NOAC/Warfarintherapy/Enoxaparin (LMWH) (refer to State-wide Guidelines for how to transition from otheranticoagulants to IV heparin)

https://www.health.qld.gov.au/ data/assets/pdf_file/0029/443666/dabigatran-info.pdf (Dabigatran)

https://www.health.qld.gov.au/ data/assets/pdf_file/0023/147533/qh-gdl-951.pdf (LMWH)

https://www.health.qld.gov.au/ data/assets/pdf_file/0026/147662/qh-gdl-950.pdf (Factor Xa Inhibitors)

▪ Is IV heparin the most appropriate parenteral anticoagulant for my patient?

a. Intravenous Heparin is the preferred agent compared to enoxaparin/LMWH in: extremes of body weight(<50kg or >100kg), poor renal function patients (eGFR<30mL/min), bridging pre-procedure for high riskpatients (mechanical heart valves).

b. Consider alternative therapeutic anticoagulants in other patient populations (e.g. LMWH, NOAC)

2. What is the Indication and Target APTT for my patient? Is the correct PowerPlan selected?

There are different PowerPlans for each of the indications for IV Heparin. Each has a specific nomogram that has been tailored to

meet the clinical need for each indication (e.g. rapidity of achieving target APTT). Refer to nomograms on the State-wide IV

Unfractionated Heparin Chart/Guidelines. Nomograms do change from time to time, so it is always best to check the most

current infusion chart.

▪ The available PowerPlans for IV Heparin and their circumstances for use is described in Table 1.

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PowerPlan main heading which has been bolded – demonstrates that this plan is active and being used

Adult PowerPlans

Heparin IV Infusion ACS – Adult For use in Acute Coronary Syndromes

Heparin IV Infusion DVT or PE – Adult For use in new-onset DVT/PE

Heparin IV Infusion Warfarin – Adult For use when temporarily substituting warfarin therapy with IV Heparin (e.g. bridging peri-procedurally)

Heparin IV Infusion Low Target Range – Adult NOT for routine use, ONLY on advice of Specialist.

Paediatric PowerPlans

Heparin IV Infusion Therapeutic Anticoagulation – Paediatric

For therapeutic anticoagulation of paediatric patients

Table 1: The available PowerPlans for IV Heparin.

To check which IV Heparin infusion PowerPlan has been prescribed:

a. Navigate to the ‘Orders’ section of the patient’s PowerChart and check the View section for PowerPlans.

b. PowerPlans which have their main heading bolded have been commenced.

c. Sub-phases of the PowerPlan which are currently signed (and active/available for potential medication

administration) are also bolded.

d. There should be a maximum of two sub-phases bolded at any one time (the Heparin IV Infusion Order and a phase

specific to the last APTT result). If more than two sub-phases are bolded at one time it’s an indication there’s an

incomplete order in the old APTT phase.

e. It is not uncommon to see on the orders screen multiple copies of the same PowerPlan – this often occurs because

the prescriber has

- Forgotten to hit ‘initiate now’ or

- Made a mistake, has tried to start again with a fresh PowerPlan and forgotten to discontinue the old

one.

Fig 1: How to check which IV Heparin PowerPlan is prescribed.

PowerPlan sub-phase which has been initiated and signed. Depending on the content of this phase, there may be medication orders available for administration in the MAR

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3. What are the relevant lab/observations results for my patient?

Consider and collect the important laboratory and observational markers for you to undertake your review of the patient.

Things to consider are:

Lab / Observation When to review Where to find this information

Platelets Baseline, then daily Results tab, Anticoagulation band in iView

APTT Baseline, then per nomogram Results tab, Anticoagulation band in iView

INR Daily as clinically relevant Results tab, Anticoagulation band in iView

Haemoglobin Daily or as clinically relevant Results tab, Anticoagulation band in iView

Weight* Baseline then as per clinically relevant Results tab, Adult Quick View band in iView

Antifibrinolytic

administration

Baseline, prior to infusion commencement Medication Administration Record (MAR)

Table 2: Lab and Observation results and where to find these.

* Actual measured weight should be used wherever possible to base initial dose decisions for IV Heparin Infusions.

Tips and Tricks

Looking for results

The results tab has a number of different views. The following will be useful for your review of Heparin:

Fig 2: Results tab

- Lab – Recent – Lab tests results from the last 4 days will display here

- Lab – Extended – Lab tests for the past 2 years will display here as a default, but you can modify the search criteria by

right clicking on the date range to the time period you are interested in (useful for longstanding IV Heparin infusions or if you are looking for results from a previous encounter where IV Heparin was used)

- Obs – Recent – Observations e.g. weight/height from the last 4 days will display here.

- Obs – Extended – Observations from the past 2 years, but again, modifiable to any time range you want.

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Tips and Tricks

Do Use the Anticoagulation Monitoring Band in iView to review continuing Heparin infusions o This band displays medication administration side-by-side with laboratory test results and is useful for

performing ongoing review of IV Heparin patients. This band is available under

o This band also takes into account the waste and total infusion volume tasks that nursing staff complete, makingit easier to see exactly how much heparin went into the patient (see below for further info).

Fig 3: The Anticoagulation Monitoring band in iView.

Don’t Use Related Results to review Heparin infusions

Related Results is a feature used to view results related to an individual medicine, on the Orders page. Related Results view for Heparin Infusions is not useful for several reasons:

1) Related Results is only viewable when a heparin bolus is selected. When the infusion is selected, the system does notdisplay the correct information relating to IV heparin.

2) Related Results shows inaccurate information which may be interpreted as the patient receiving inappropriate orduplicate heparin bolus doses.

o This is because nursing staff at TTH administer both bolus and ongoing infusions of heparin via the same infusionpump and 50mL pre-filled infusion syringe, but the ieMR splits the bolus and infusion doses into two separate orders.

i. For the system to accurately track when the infusion is due to end, nursing staff need to record inthe infusion order that they have administered part of the syringe volume to give the bolus dose. Thisis documented as a ‘waste’ task (fig 4).

o In addition, nurses must enter the total amount infused when they finish a syringe for the patient’s fluidbalance chart to update appropriately.

o Unfortunately, the related results tab is unable to interpret either of these situations correctly and it will looklike the patient has received duplicate or inappropriate bolus doses (fig 5).

Fig 4: The waste task nursing staff document on the IV Heparin infusion order to take into account volume administered as the bolus order.

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Fig 5: Why we don’t use Related Results to review IV Heparin. Related Results cannot interpret when nursing staff have documented a waste or 24-hour infusion amount, giving the appearance that the patient received duplicate or incorrect bolus doses.

4. Has IV Heparin been prescribed correctly?

▪ Check the MAR/MAR Summary for prescribed doses. NB: boluses will display in the scheduled section, infusions will display in the continuous infusions section.

▪ Ensure your filter in the MAR and MAR Summary is set to All Medications (System) otherwise you will not see

administered/cancelled or ceased doses. If you are wanting to view a bolus from a few days back, you may also need to

adjust your time period filter on the MAR Summary for it to display.

▪ Check doses prescribed against heparin infusion nomogram. Specific things to check for:

For bolus dose orders – 1. Was the correct order sentence selected? In some Heparin IV Infusion PowerPlans prescribers are given two

options, depending on whether the patient has been given a fibrinolytic prior to initiation of IV heparin.

2. Is the bolus calculation correct for indication? Check by right-clicking the order, navigating to the details

tab and – clicking the calculator icon (fig 6).

3. Is any dose capping necessary (e.g. for large weights) NB: provided the correct indication and order sentence was selected, the ieMR will usually cap bolus doses.

Fig 6: How to check the dose calculation for bolus doses.

For continuous infusion orders – 1. For newly commenced infusions - is the initial rate correct for indication?

a. NB: continuous infusion orders WILL NOT cap initial rates – check initial infusion rate calculator to see advice given and whether this was followed.

b. The initial rate calculator is not available when the continuous infusion order is right clicked on. The best way to view the initial rate calculation is from the ‘Forms’ screen. Double click on the form to open the calculator (fig 7)

Looks like: 25,000 units has been administered at once!

Actual: Nurse documenting the total volume administered over 24 hours.

Looks like: Two 8,000 unit boluses have been given!

Actual: Nurse administering the bolus order then documenting in the infusion order that 8,000 units was taken out of the syringe (as waste) to give the bolus.

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Fig 7: How to check the dose calculation for the initial continuous infusion order rate.

For continuous infusion orders – continued 1. Has rate been titrated appropriately according to APTT using the nomogram for the correct indication?

o If you want to view changes made over time to a heparin infusion order, right-click on order and select order information, and then navigate to the history tab to see history (fig 8).

o If something seems odd – go back to the ‘Orders’ screen and see which phase of the PowerPlan was initiated – it may be that the wrong phase was selected or the right phase was selected and not completely followed (e.g. re-bolus was not ticked when it should have been, continuous infusion order was not modified when it should have been).

Fig 8. Checking prescription of the continuous infusion order

against what was administered on the MAR Summary Page.

In this case, the doctor has prescribed two rate changes

since beginning the infusion (12 14 16 units/kg/hr). All

of these have been actioned by the nursing staff in an

appropriate time period.

A similar check could also be done by loading up the

Anticoagulation Monitoring Band, tearing this off and then

opening the order information screens.

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5. Has IV Heparin been administered correctly?

▪ Check the MAR Summary or the Anticoagulation Monitoring Band in iView and compare what was administered with

what was prescribed. For the continuous infusion order, this is easily done by opening the MAR summary and then right

clicking the infusion order and selecting the order information, then the History tab (fig 8). Repeat this process for

boluses.

▪ If withhold periods have been specified – check withhold period has commenced. If time for withhold has passed,

confirm infusion has been restarted and that the rate has been appropriately decreased.

o Infusion rate should be changed to 0 unit/kg/hr (0 mL/hr) for the duration of the withhold period

▪ Check the patient’s IV infusion pump to confirm:

o What the currently infusing rate is,

o That the infusing rate matches the current Doctor’s order and nurse’s administration documentation,

o That the correct infusion profile is being used (‘Heparin 25000u/50mL’, infusing rate in unit/kg/hr)

▪ Nursing staff will document hourly infused volumes on the MAR. This constitutes their hourly infusion device check (fig

9).

Fig 9. Infused volume documented on MAR.

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6. What is the lab testing follow-up for the patient? Is it appropriate to the current clinical picture?

• Check that the patient’s next APTT and platelets have been ordered as per the nomogram. Generally, an APTT is required

every 4-6 hours during the infusion until 2 APTT are in range then it is due the following morning. The exception to this is

when the patient has had an APTT >200. In this case APTT should be rechecked after 90 minutes.

• Pathology order for platelets is not a part of the Heparin IV Infusion PowerPlan and will need to be ordered separately.

• Make sure that the APTT is taken following the commencement of the rate change not from when the last APTT result

was taken.

• When reviewing when the next APTT is ordered navigate to the orders page and change your filter to ‘All Orders (All

statuses) OR ‘All non-Medications (All statuses)’ and you can see which pathology requests have been made and

collected (dispatched) (fig 10).

• You can also click on the initiated phase in the PowerPlan to see if an APTT has been ticked (fig 11).

• It is recommended that for an unstable patient on a heparin infusion that closer monitoring is implemented (i.e. 4

hourly). Remember to follow up your APTT result.

Fig 10: Viewing APTT orders in the general orders page Fig 11: Viewing APTT orders in individual PowerPlan phases

What to do if you encounter issues

• Make sure your patient is safe. Speak with the prescriber and/or nursing staff about any issues identified. Log an

intervention against the order. Involve your Team Leader in the review of patients prescribed heparin.

• Incorrect IV Heparin orders should not be verified within PharmNet.

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FAQs

Q: Why does my patient’s heparin dose appear with 4 decimal places? A: This can sometimes happen when the nurse documents the infusion rate in mL/hr using only one decimal place. The easiest way to avoid this issue is for nursing staff to document the rate in the *heparin Dose (unit/kg/hr) box first (as this then automatically calculates the right mL/hr rate to set the pump at).

Why? The *Rate (mL/hr) box and the *heparin Dose (unit/kg/hr) box are linked within the system. This means when one value is entered in one box, the other automatically calculates.

When the *Rate (mL/hr) box is entered to only one decimal place, the system automatically calculates the heparin dose and does not round the answer.

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When the *heparin Dose (unit/kg/hr) is entered first, the correct *Rate (mL/hr) is calculated and an appropriate dose appears.

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