WA.

MSG

MEDICATION SAFETY GROUP

Explanatory Notes
WA Anticoagulation Medication Chart (WAAMC)

Prepared by Dr Margherita Veroni

Project Coordinator, WA Medication Safety Group
On behalf of the Anticoagulation Medication Chart Working Group

Last revision: 17 February 2010

Introduction_____________________________________________________________ 3
Preamble_____________________________________________________________ 3
When Should This Chart Be Used? ________________________________________ 3
Important _____________________________________________________________ 3
Recommendations For Use Of Anticoagulants ________________________________ 3
Patient Information _______________________________________________________ 4
Patient Location _______________________________________________________ 4
Patient Identification ____________________________________________________ 4
Patient Weight And Height _______________________________________________ 4
Number Of Charts ______________________________________________________ 4
Adr Alert Sticker _______________________________________________________ 4
Relevant Medical History ________________________________________________ 4
Once Only And Telephone Orders ___________________________________________ 5
Regular Dose Orders _____________________________________________________ 5
Best Practice In The Use Of Lmwh _________________________________________ 5
Completing The Chart ___________________________________________________ 6
Variable Dose Orders_____________________________________________________ 7
Best Practice __________________________________________________________ 7
Completing The Chart ___________________________________________________ 9
Discharge Supply _______________________________________________________ 11
Intravenous Unfractionated Heparin_________________________________________ 12
Best Practice _________________________________________________________ 12
Completing The Chart __________________________________________________ 13

Last revision: 17 February 2010

INTRODUCTION
Preamble
This chart was developed by a multidisciplinary working group convened by the Western
Australian Medication Safety Group. The aim of the chart is to improve dosing and
monitoring of anticoagulants and subsequently reduce the risk of anticoagulant related
patient harm. To achieve this, the chart co-locates recommended dosing and monitoring
regimen with the prescription orders. The chart also co-locates important information
where required for dosing including test results, weight and GFR.
The dosing and monitoring regimen provided represent current best practice in the
majority of patients; however they do not cover all clinical scenarios and do not replace the
need for clinical judgement.
The best practice recommendations included in this book refer to the in hospital
management of anticoagulants and may not be appropriate in ambulatory care.

When should this chart be used?

This chart should be used for every hospital episode where a patient is prescribed an oral,
intravenous or subcutaneous anticoagulant. This includes but is not limited to warfarin,
unfractionated heparin (UFH) and low molecular weight heparin (LMWH).

Important
In principle, the requirements for using the Anticoagulation Medication Chart are the same
as those of the National Inpatient Medication Chart (NIMC). Refer to "Guidelines for the
use of the NIMC" available at
http://www.health.wa.gov.au/nimc/docs/NIMC_WAGuidelines.pdf.
Ensure that use of the anticoagulation chart is documented on the main medication chart
(NIMC) by following the guidelines for additional charts (Section 3.5) and warfarin (Section
4.2) in the NIMC guidelines.

Recommendations for use of anticoagulants

The recommendations for the use of subcutaneous LMWH, warfarin and intravenous UFH
represent current best practice. However these do not cover all clinical scenarios and do
not replace the need to clinical judgement.

PATIENT INFORMATION
The following sections are identical to the NIMC and should be completed following the
Health Department Guidelines.

Patient location
Patient Identification
Patient weight and height
Number of charts
ADR alert sticker
Relevant medical history
Best practice
Prior to initiating any anticoagulant therapy, patients must be screened for:

co-existing diseases or conditions that could affect the decision to prescribe or dose
requirements

past anticoagulant related adverse incidents

concomitant antiplatelet or antithrombotic therapy

This recommendation is based on the Medication Safety Self Assessment for

Antithrombotics Therapy in Australian Hospitals 1 and alerts the prescriber to a possible
need for dose modification or a need to monitor more closely.
Completing the chart

This section should be completed by the first prescriber on the anticoagulant chart. The
prescriber should sign and date this section on completion. The Nil significant box
should be ticked where there are no confounding conditions.
Where any ADRs including allergies are listed on the NIMC an ADR sticker should be
affixed to the anticoagulant chart.

Clinical Excellence Commission, NSW (2007). Medication Safety Self Assessment for Antithrombotic Therapy in
Australian Hospitals (sections 1.17-1.19), http://www.cec.health.nsw.gov.au/pdf/MSSA-AT.pdf

ONCE ONLY AND TELEPHONE ORDERS

This section of the chart should be used for all one-off doses of oral, subcutaneous or
intravenous anticoagulant drugs. This applies to both once only and telephone orders.
Telephone orders should all be signed by the prescriber with 24 hours.
This is identical to the "Telephone Orders" section of the NIMC and should be completed
following the NIMC guidelines.

REGULAR DOSE ORDERS

This section of the chart should be used for all regular dose orders, both subcutaneous
LMWH and UFH and the oral anticoagulant, rivaroxaban.

Best practice in the use of LMWH

Dosing of LMWH is recognised to be a function of the indication, perception of bleeding

risk and modifying factors (eg renal failure). In WA the recommended dosing regimen
for enoxaparin (Clexane) is:
INDICATION

DOSE AND FREQUENCY

Impaired renal function
Normal renal function
(GFR <30 mL/min)

Venous Thromboembolism (VTE) prophylaxis

40 mg once daily

20 mg once daily

DVT treatment

1.5 mg/kg once daily or

1 mg/kg twice daily

1 mg/kg once daily

Acute Coronary Syndromes (ACS)/VTE treatment

1 mg/kg twice daily

1 mg/kg once daily

Dose modification of these drugs is required when the creatinine clearance (CrCl) is
less than 30 ml/min. GFR should be estimated using the Cockroft-Gault equation.
This is especially important in the elderly. The Modification of Diet in Renal Disease
(eGFR) provided with laboratory results should not be used 2 .

Routine monitoring of residual anti-Xa activity as a measure of LMWH therapy is not

required. However, in the case of patients at high risk of bleeding, anti-factor Xa
monitoring may be appropriate.

While the risk of heparin induced thrombocytopaenia (HIT) is lower with LMWH than
unfractionated heparin, screening for HIT with a platelet count at day 5 of therapy is
recommended.

Guidelines for treatment reversal: Seek specialist/senior advice.

As a guide: Give 1mg protamine sulphate per 1mg enoxaparin/100 units of heparin.
Give half the protamine sulphate dose as a slow IV push (10 minutes) and the
remainder as an infusion (in 5% glucose or 0.9% saline) over 6-8 hours.

Roberts, G. W. (2006). "Dosing of key renally cleared drugs in the elderly - Time to be wary of the eGFR." Journal of Pharmacy
Practice and Research. 36(3): 204-209.

Timing of VTE prophylaxis in the peri-operative/invasive procedures setting

Interventional (surgical) procedure: may commence treatment 4-6 hours after
procedure.
Spinal/epidural anaesthesia: do not institute anaesthesia or remove catheter within
12 hours of a dose of LMWH. Treatment may be commenced 2 hours after catheter
removal.
Consider longer exclusion periods in the presence of complications or high risk of
bleeding.

Timing of VTE/ACS treatment in the peri-operative/invasive procedures setting

Interventional (surgical) procedure: withhold treatment 12-24 hours before and after
procedure.
Spinal/epidural anaesthesia: do not institute anaesthesia or remove catheter within
24 hours of a dose of LMWH. Treatment may be commenced 2 hours after catheter
removal.
Consider longer exclusion periods in the presence of complications or high risk of
bleeding.

Completing the chart

This section is similar to the Regular Orders section of the NIMC and should be completed
following the NIMC guidelines.
Date:

Date the medication order was commenced in hospital.

Medication:

Print the generic name of the drug.

CrCl:

Document the baseline GFR used to determine LMWH dose. Ideal body
weight should be used in cases of extreme weight. Calculators for GFR
and IBW are available online (CIAO/Therapeutic Guidelines/Popular
links/Creatinine clearance and ideal body weight calculators). Do not use
eGFR provided with the laboratory results.
Indicate whether subcutaneous (subcut) or oral.
Follow recommended dose and frequency. Seek specialist advice for
obese patients or weight >150 kg.

Route
Dose and
frequency:
Times:

Preferred administration times for twice daily dosing are 0600 and 1800.
Daily thromboprophylaxis should be given in the evening.

Indication:

Tick the appropriate box. If TREATMENT, specify the condition.

Pharmacy:

This section is for use by the ward/clinical pharmacist

Creatinine/
Platelets:

There is provision to record creatinine and platelets to assist monitoring. As

a minimum platelets should be measured on Day 5.

Prescriber

The signature of the prescriber must be written to complete each

Sign,
Print name,
Contact:

medication order. For each signature, the name must be written in print at
least once on the medication chart.

VARIABLE DOSE ORDERS

This section of the chart should be used for all variable dose anticoagulants, usually
warfarin.

Best practice

Warfarin should be prescribed without brand substitution. Individual patients should

remain on one brand of warfarin. Within the WA Public sector Marevan is the
preferred brand.

Before initiating warfarin therapy measure baseline INR. If INR>1.4 do not commence
warfarin - seek senior/specialist advice.

Warfarin should be monitored and dose modified based on the INR result.
Initiating treatment: A dose nomogram should be available to provide decision support
to junior staff so as to provide assistance with the initiation of warfarin therapy. The
warfarin initiation nomogram should be simple and easy to use and balance rapid
anticoagulation with bleeding risk. In WA is the recommended nomogram for an INR 23 is:
Day

INR

Suggested dose

1.0-1.4

5 mg

No INR required

5 mg

<1.8
1.8

5 mg
1 mg

4&5

<1.5
1.5-1.9
2.0-2.5
2.6-3.5
3.6-4.0
4.1-4.5
>4.5

7 mg
5 mg
4 mg
3 mg
2 mg
1 mg
see treatment reversal

6 onwards

Measure on alternate days until stable

(daily if drug interaction or high bleeding risk)

as for days 4&5 or per clinical judgement

This dosing regimen takes about 6 days to achieve therapeutic INR, longer in those
under 60 years. If a shorter time to therapeutic levels is indicated or for younger
patients consider 7 to 10 mg on day 1 and day 2. Consider smaller starting doses
when the patient is elderly, has low body weight or abnormal liver function, or, is at high
bleeding risk. Consider dose modification in the presence of interacting drugs.
Ongoing treatment: In acutely ill patients daily monitoring of INR may be appropriate.
Monitor INR more frequently when any change in treatment involves drugs known to
interact with warfarin.

Recommended time for inpatient dosing is 1600. This allows the medical team caring
for the patient to order the next dose based on INR results, rather than leaving it for
after-hours staff.

INR testing is recommended at morning blood round.

Indication for treatment, appropriate target range and planned duration of treatment
should all be documented.

All patients should receive warfarin education, including written information prior to
discharge. This should be documented. It is recognised that education may be
completed by pharmacy, nursing or medical staff.

The dose modifications made to warfarin therapy should be communicated to the

primary care practitioner to assist further dose modification in the early post-discharge
phase.

In the case of acute VTE treatment, heparin (unfractionated or low molecular weight)
should be given for at least of 5 days and until the INR is greater than 2 for two
consecutive days.

Reversal of overtreatment should be managed in accordance with the Australasian

Society of Thrombosis and Haemostasis 3 . In the case of bleeding, always seek advice
from senior staff or a specialist.
Risk factors for bleeding complications include: recent surgery/trauma/bleed, advanced
age, renal failure, hypertension, alcohol abuse, active GI disease, antiplatelet therapy
and other relevant comorbidity.
Clinical
Action
setting
INR <5;
Lower the dose or omit the next dose. Resume therapy at reduced dose
no bleeding
when INR approaches therapeutic range.

If INR is only minimally above therapeutic range (up to 10%), dose

reduction may not be necessary.

Cease warfarin; consider reasons for elevated INR and patient-specific

factors.

If high bleeding risk, give vitamin K (1-2 mg orally1 or 0.5-1 mg IV2).

Measure INR within 24 hours. Resume warfarin at reduced dose once

INR is in therapeutic range.

If low bleeding risk, cease warfarin, give vitamin K either (2.5-5 mg

orally1 or 1 mg IV2). Measure INR in 6-12 hours. Resume warfarin at
reduced dose once INR<5.

If high bleeding risk, cease warfarin, give vitamin K 1 mg IV2. Consider

Prothrombinex VF (25-50 units factor IX/kg)34 and 300 ml of fresh frozen
plasma. Measure INR in 6-12 hours. Monitor patient, resume warfarin at
reduced dose when INR<5.

Warfarinrelated
clinically
significant
bleeding.

Cease warfarin, give 5.010.0mg vitamin K IV2, as well as

Prothrombinex VF (25-50 units of factor IX/kg)34 and fresh frozen
plasma4 (300mL), assess patient continuously until INR < 5.0, and
bleeding stops.

Seek senior
advice.

INR 5-9;
no bleeding

INR>9;
no bleeding

OR
If fresh frozen plasma is unavailable, cease warfarin, give 5.010.0mg
vitamin K IV2, and Prothrombinex-VF (25-50 units of factor IX/kg)34,

Baker, R. I., P. B. Coughlin, et al. (2004). "Warfarin reversal: consensus guidelines, on behalf of the Australasian
Society of Thrombosis and Haemostasis." Medical Journal of Australia 181(9): 492-7.

assess patient continuously until INR < 5.0, and bleeding stops.
OR

If Prothrombinex-VF is unavailable, cease warfarin therapy, give 5.0

10.0mg vitamin K IV2, and 1015mL/kg of fresh frozen plasma4, assess
patient continuously until INR < 5.0, and bleeding stops.

NOTES:
1
Oral Vitamin K: use undiluted paediatric IV formulation.
2
IV Vitamin K: use undiluted as slow IV bolus over at least 30 seconds.
3
Prothrombinex VF should be dosed to deliver 25-50 units of factor IX/kg at a rate of
3mL/min. 1 vial of Prothrombinex VF contains 500 units of factor IX.
4
Prothrombinex VF and fresh frozen plasma are available from transfusion service.

Completing the chart

Warfarin-Drug Interactions

Completing this section is pharmacy responsibility, and allows the pharmacist to

communicate potential clinically significant interactions to the prescriber. Details of drug
interactions are available online (CIAO/Australian Medicines Handbook/Appendix B Drug
interactions/Warfarin or eMIMS/Essential resources/MIMS DrugAlert Interactions).
AT THE TIME OF ADMISSION

List all concomitant therapy that has a significant warfarin interaction.

DURING THE HOSPITAL EPISODE

Add any new medications that that have a significant interaction, and

Highlight any change made to the medications listed.

Each entry should be signed and dated.

The left hand side of the chart is completed at the time the order is started:
Dose at
admission:

This refers to the use of warfarin prior to hospital presentation. If not

used prior to hospital presentation tick Not Applicable, otherwise
indicate the brand of warfarin and the last pre-hospital dose.

Date:

Date medication order was started in hospital.

Medication:

Warfarin is pre-printed. If not appropriate, print generic drug name.

Warfarin brands are not equivalent and cannot be used
interchangeably. Marevan is the brand of warfarin recommended for
use in WA hospitals. If Coumadin used prior to hospital presentation
use patient's own Coumadin if available. If switching from Coumadin
to Marevan monitor INR daily.

Indication:

Indication for oral anticoagulant therapy.

Route:

In the case of warfarin this will be oral.

Document the target INR.

Target INR:
2.0-3.0

Preventing DVT: high risk patients eg hip or knee surgery

Therapy for DVT or PE

Preventing systemic embolisation: AF, valvular heart disease, post MI,

bioprosthetic heart valves (first 3 months)

2.5-3.5

Bileaflet mechanical heart valve (aortic)

3.0-4.5

Mechanical prosthetic valve (high risk)

Pharmacy:

This section is for use by the ward/clinical pharmacist

Prescriber
Sign
Print name,
Contact:

The signature of the prescriber must be written to complete each

medication order. For each signature, the name must be written in print
at least once on the medication chart.

Dose time:

The recommended time is 1600. This time is pre-printed on the chart. If

this is not suitable, cross out 1600 and enter appropriate time.

The right hand side of the chart must be completed each day:
INR result:
Recommended time for INR testing is 0700 (morning blood round). Document
the INR result for this day. If no test was performed this day, leave blank.
Dose prescribed for this day. If a dose is to be withheld this should be
Dose:
documented following the NIMC guidelines. If initiating warfarin, see
nomogram on page 4.
Prescriber:
Initials of doctor prescribing the daily warfarin dose. If the name is not already
printed on the chart document the medical notes included printed name and
signature.
Phone orders are not appropriate at all institutions - check local policy. Where
Phone
orders:
allowed, two nurses must check the prescription and sign appropriately.
Nursing staff should record full details in Clinical Record and doctor must sign
order within 24 hours.
Given by:
Initials of the nurse administering the daily dose.

10

Discharge Treatment Plan

This should be completed by the prescriber at the time of hospital discharge.
Dose:

Dose to be taken until the next INR test.

Target INR:

as above

Duration:

The expected duration of therapy eg long-term, 3-6 months.

Next INR:

Date the next INR test is due.

To ensure continuity of care, the front page should be copied or preferably faxed to the
GP. This provides information about the treatment plan as well as informing the GP about
the course of treatment during the hospital episode of care.
Discharge Process

This is a checklist and all activities should be completed by the time of hospital discharge.
This is the official warfarin education and discharge record and will usually be completed
by the pharmacist. However in some cases such as after-hours discharge this will need to
be completed by another member of the clinical team. The person completing each of
these mandatory activities must sign that the activity has been completed and print name.

Patient has warfarin booklet: This may include on a previous episode. Living with
warfarin information for patients is available through the pharmacy department or
contact [email protected].

Patient education completed: This may include on a previous episode, provided the
patients knowledge has been checked.

Patient given treatment plan: The patient should be informed about the discharge
dose and date of next INR test. The warfarin book contains a detachable
wallet/purse size warfarin treatment card. Document the treatment plan on this card.

GP communication: Indicate whether the patients GP has been contacted about the
management plan. Fax or copy this page to the GP at discharge.

DISCHARGE SUPPLY

This section is similar to the NIMC and should be completed following the NIMC
guidelines. Note that warfarin tablet strengths are pre-printed. Indicate the number of
tablets of each strength required.

11

INTRAVENOUS UNFRACTIONATED HEPARIN

Best practice

Given the common use of dual antiplatelet therapy in the setting of ACS management,
less intensive initial and maintenance dosing is advisable compared with the treatment
of VTE. Accordingly indication-dependent nomograms are appropriate.

Intravenous heparin should be prescribed using weight based initial bolus and infusion
rates.
Initial bolus dose
80 units/kg
VENOUS THROMBOEMBOLISM
(max 7200 units)
60 units/kg
ACUTE CORONARY SYNDROMES
(max 4000 units)

Initial infusion rate

18 units/kg/h
(max 1600 units/hr)
12 units/kg/h
(max 1000 units/hr)

Intravenous UFH should be monitored using the Activated Partial Thromboplastin Time
(aPTT).

aPTT levels should be measured at baseline, then within 6 hours of each infusion rate
change. When the aPTT is within the therapeutic range it should be remeasured within
24 hours (or the next morning).

Each laboratory should determine its own therapeutic target range for heparin against a
gold standard test (eg residual anti-Xa activity).

Dose modification of intravenous UFH should be based on the aPTT using a weight
based maintenance nomogram. The nomograms can only be used with the standard
therapeutic aPTT range.
VENOUS THROMBOEMBOLISM
aPTT

Action required

Rate change

<55

80 units/kg bolus

Increase 4 units/kg/h

55-<70

40 units/kg bolus

Increase 2 units/kg/h

70-105
(Therapeutic range)

No change

No change

>105-120

No change

Decrease 2 units/kg/h

>120

Contact doctor, hold infusion for 60 minutes

Decrease 3 units/kg/h

ACUTE CORONARY SYNDROMES

aPTT

Action required

Rate change

<55

60 units/kg bolus

Increase 3 units/kg/h

55-<70

No change

Increase 2 units/kg/h

70-90
(Therapeutic range)

No change

No change

>90-105

No change

Decrease 1 units/kg/h

>105-120

Hold infusion for 30 minutes

Decrease 2 units/kg/h

>120

Contact doctor, hold infusion for 60 minutes

Decrease 3 units/kg/h

12

Medical responsibilities include

Prescription of initial bolus dose and infusion rate,
Selection of maintenance nomogram for nurse to use, including indication and
weight,
or
Prescription of dose modification following each aPTT test,
Monitoring for complications of anticoagulation, and
Identification of treatment end points.
NOTE: The weight based guide provided with the WA Anticoagulation Medication Chart is
only valid when using the standard heparin dilution of 50 units/mL of heparin. Where other
dilutions are used or, the target aPTT is not the standard therapeutic range, the prescriber
is responsible for dose modification following each aPTT test.
Nursing responsibilities include
Ensuring that an aPTT has been taken at the indicated time,
Obtaining the aPTT result in a timely manner,
Alerting the prescriber to extreme aPTT results
Implementing dose modification as indicated by prescribed nomogram
or
Contacting the prescriber with the aPTT result for prescription of dose modification.

Nursing staff are to ensure that unfractionated heparin infusions are not stopped to
allow patients to attend investigations; a nurse escort is required in this setting.

In the setting of VTE treatment, where warfarin therapy is being initiated, intravenous
unfractionated heparin should be continued until the INR is greater than 2.0 in two
consecutive days.

Measure platelets at baseline and at least twice weekly.

Contact haematologist in all suspected cases of Heparin Induced Thrombocytopaenia

(HIT).

Protamine reversal should be reserved for cases of major of bleeding or where

required prior to emergency surgery. For high aPTT without bleeding apply relevant
nomogram. Protamine reversal should always be carried out with senior/specialist
advice. As a guide: Estimate heparin dose received in last hour. Administer 1mg
protamine sulphate per 100 units of heparin (max 50 mg) as a slow IV push (over 10
minutes). Monitor aPTT immediately after the bolus then as required.

Completing the chart

NOTE: The management of IV heparin using the WA Anticoagulation Medication Chart
assumes the use of a standard heparin solution of 50 units/mL. Where non-standard
solutions are used management of IV heparin infusions is solely the responsibility of the
individual unit.
Intravenous injection/infusion orders

13

This must be completed by the prescriber. A new prescription is required if the order (total
dose, fluid or volume) is changed. This requires a new anticoagulation chart.
Target aPTT:
See the recommendations on page 3 or as specified by consultant.
Note that standard therapeutic ranges vary between test centres and
are hospital specific. Where the target aPTT is not the hospital
specific standard therapeutic range, the prescriber is responsible for all
dose adjustments.
Indication:
Tick appropriate box.
Weight:
The patient weight used to determine the dose should be documented.
Date:
Date of prescription (total dose, fluid or volume).
Drug:
Heparin is pre-printed. If not appropriate, print generic name.
Total dose:
Number of units to be diluted. 25,000 is pre-printed. Amend if
required.
Fluid:
Type of dilution fluid. 0.9% Saline may be pre-printed.
Volume:
Volume of dilution fluid. 500 mL may be pre-printed.
Prescriber Sign
Print name,
Contact:

The signature of the prescriber must be written to complete each

medication order. For each signature, the name must be written in
print at least once on the medication chart.

Initial dose order and administration

The prescriber should document:

Date:

Date of order.

Baseline aPTT:

aPTT should be measured prior to treatment commencing,

although treatment may commence before the test result is
available. The result should be documented, when available
and, treatment modified if required.

Date/time of dose:

Date/time of initial bolus dose.

Bolus dose (units):

Total number of units to be given by bolus. This should be

based on the patient weight and indication. Recommendations
are provided on page 3.

Infusion rate (mL/hr):

mL of prepared solution to be infused each hour. This should be

based on the patient weight and indication. Recommendations are
provided on page 3.

Prescriber:
Signature, Print
name

The signature of the prescriber must be written to complete each

medication order. For each signature, the name must be written in
print at least once on the medication chart.

The nurse administering the initial dose then documents:

Time:

The time the therapy commenced.

N1/N2:

Two nurses to check/sign initial dose. The volume (of standard

solutions) corresponding to each bolus dose is shown on page 3.

14

Maintenance infusion rate changes and bolus doses

The prescriber has the option to be contacted following each aPTT result for a decision
about dosing, or, allowing nursing staff to make adjustments as indicated by appropriate
nomograms. In the latter case the prescriber must show which nomogram is to be used
(VTE or ACS) and the column (based on patient weight) to be used. This is only valid
when using the standard heparin dilution and the standard aPTT therapeutic ranges.
Date:

Date of the order.

Prescriber:
Signature, Print
name, Contact

The prescriber sign to complete the order. For each signature, the
name must be written in print at least once on the medication chart.

Pharmacy:

This section is for use by the ward/clinical pharmacist

On page 3, the first nurse should strike out the nomogram that is not applicable and
highlight the appropriate weight column.

aPTT test
The nurse records the date and time the blood was taken and the aPTT result. Where the
aPTT is within the highest band the doctor should always be notified.
Infusion change and bolus dose
This will usually be completed by nursing staff following the prescribed nomogram or as
specifically ordered by the prescriber.
Time:

If a bolus dose is indicated, record the time the dose is administered.

IV bolus (units):

If a bolus dose is indicated, record the total number of units given.

Bolus sign:

Two nurses to check/sign the bolus dose.

Hold (mins):

If temporary stop to infusion indicated, record the length of the pause.

Time stopped:

If infusion stopped record the time the infusion was stopped.

Hold sign:

Two nurses to check/sign infusion temporarily stopped.

Time started:

Record the time an infusion rate is changed. This includes following a

pause. If the aPTT is within the target range and no change is required
indicate the time that the aPTT result noted.

Rate (mL/hr):

Record the rate of infusion. Where the aPTT is within the target range
this will be the same as the previous, otherwise document the new rate.

Rate sign:

Two nurses check/sign the rate of infusion.

Dr Sign:

Each aPTT result and subsequent action should be reviewed by the

responsible prescriber.

15

Infusion bag changes

This section must be completed by nurses every time a new infusion bag is hung. An
infusion of unfractionated heparin is a continuous infusion and should not be interrupted
(eg for showering, imaging) unless ordered by the doctor.
Date:

Date the bag was hung.

Time
commenced:

Time infusion commenced.

Checked:

Name/signature of nurse checking infusion.

Given:

Name/signature of nurse putting up infusion.

Time completed:

Time the bag was removed.

Volumed infused: Total volume infused.

16