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OUMC Anticoagulation Team
Clinical Guidelines – Unfractionated Heparin
Updated: 1/08/2009
As a means of reducing the likelihood of patient harm associated with the use of anticoagulation therapy within OUMC, the OUMC Anticoagulation Team
has developed the following Clinical Guidelines for use of unfractionated heparin within OU Medical Center.
Responsible
Party
Clinical Guidelines – Unfractionated Heparin
Pharmacy and
Therapeutics
Committee
1. Reviews all adverse drug reactions associated with unfractionated heparin therapy and initiates appropriate follow-up
actions.
2. Ensures that the unfractionated heparin antidote, protamine sulfate, remains on the formulary and is available for use.
3. Develops MUE criteria for subsequent review/reporting through the Joint Quality Review and Medical Executive
Committees.
Medical Staff
1. Initiates either written or electronic (ePOM) orders for unfractionated heparin using the OUMC Adult Heparin
Anticoagulation Protocol. Exceptions are only allowed if there is documentation that the patient requires fluid
restriction.
2. Specifies the indication requiring anticoagulation therapy in the orders or medical record.
3. Orders a CBC and aPTT within 24 hours before initiation of therapy.
4. Monitors platelet count x 1 within first four days of therapy, then daily on days 4-10, then twice weekly thereafter while
hospitalized.
Pharmacy
1. Ensures that only manufacturer’s pre-mixed infusion bags are procured whenever available; otherwise, bar-coded
packaging is provided before unfractionated heparin is dispensed.
2. Dispenses unfractionated heparin drips as a standard concentration (25,000 units/ 500 mL) per OUMC Hospital Policy
12-01: Medication Management.
3. Reviews CBC and aPTT prior to order entry/validation.
4. Dispenses initial unfractionated heparin dose and dose modifications only if related lab results are appropriate.
5. Evaluates the potential for drug-drug interactions involving heparin.
6. Initiates clinical interventions with the prescriber for any deviations from these guidelines.
7. Maintains the unfractionated heparin antidote, protamine sulfate, in the pharmacy at all times.
Nursing
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1. Administers IV unfractionated heparin drips via a programmable infusion pump.
Responsible
Party
Clinical Guidelines – Unfractionated Heparin
2. Monitors patients receiving continuous IV unfractionated heparin therapy according to guidelines in the OUMC Adult
Heparin Anticoagulation Protocol.
3. Draws laboratory tests as ordered via the OUMC Adult Heparin Anticoagulation Protocol.
4. Adjusts heparin dose as ordered via the OUMC Adult Heparin Anticoagulation Protocol.
5. Completes the Heparin Monitoring Flow Sheet in the patient’s paper or electronic medical record.
6. Alerts the physician for signs/symptoms of bleeding or thrombosis, or falls.
7. Limits the use of intramuscular injections of concomitant medications to the upper extremities for patients receiving
unfractionated heparin therapy.
8. Provides education to the patient and family using OUMC Patient Education Committee-approved material.
9. May initiate a pharmacy consult if additional education is needed.
10. At discharge, reviews with patient/family members the follow-up instructions from the physician relative to
anticoagulation medications, e.g. follow-up appointment information.
Laboratory/Blood
Bank Services
1. Maintains Fresh Frozen Plasma (FFP) at all times for the emergent management of bleeding and excessive
anticoagulation.
Approvals:
OU Medical Center Anticoagulation Team:
OU Medical Center Medication Management Team:
OU Medical Center Pharmacy and Therapeutics Committee:
OU Medical Center Joint Quality Review Committee:
OU Medical Center Medical Executive Committee:
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