New DTI Order Form for the Treatment of HIT and Pharmacy to Dose Protocol

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New DTI Order Form for the Treatment of HIT and
Pharmacy to Dose Protocol

• Tanna Cooper, PharmD
• Joseph Mazur, PharmD
• Dave Taber, PharmD

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Direct Thrombin Inhibitor (DTI) Order Set

• The preprinted order form entitled ARGATROBAN
  BIVALIRUDIN (DTIs) for HIT MUST be used to order
  DTIs (excluding the cardiac cath lab)
  
• The form is set up in a similar fashion to the
  heparin order forms
  
• The preprinted order form will direct the RN on
  how to adjust the infusion and when to call the
  physician or pharmacist

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Form View 1st Page
How to Diagnose HIT Clinical Pearls for
Prescribers
Which DTI to order and how to initiate medication
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Order Form 1st Page

• Choosing the DTI and initial dose
• DISCONTINUE ALL HEPARIN PRODUCTS (Including
  flushes and LMWH products)
  
• 2. INDICATION for DTI use
• Anticoagulation for prophylaxis / treatment of
  thrombosis in patients with suspected HIT
  
• Anticoagulation for prophylaxis / treatment of
  thrombosis in patients refractory or allergic to
  heparin
  
• Clinical Practice Point Bivalirudin is the
  preferred DTI in patients with hepatic
  insufficiency AND Argatroban is preferred in
  patients with renal insufficiency
• 3. ORDER STAT OR Begin at (time and date)
  
  
• PHARMACY TO DOSE (RN call pharmacy with
  questions)
  
• ARGATROBAN 250 mg/250 mL at
  micrograms/kg/min (usual dose is 2
  
• micrograms/kg/min). Hourly dose mg/hr
  mL/hr
  
• BIVALIRUDIN 250 mg/250 mL at mg/kg/hour
  (usual dose for patient with normal renal
  function is
  

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Form View Page 2
How to Monitor the DTI
How to transition to warfarin
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Order Form 2nd Page

• MONITORING
• Check aPTT prior to initiation of infusion
• Check aPTT 2 hours after start of infusion, then
  
  
• Check APTT every 4 hours
• If aPTT within range for 2 consecutive aPTTs, go
  to step 4
  
• If aPTT is not within therapeutic range (50 80
  seconds), use the chart below for dose
  adjustments
  
• Check aPTT 2 hours after any dosage change and
  then if within range return to checking aPTT
  every 4 hours
  
• 4. Check aPTT daily when aPTT falls within
  therapeutic range for 2 consecutive aPTTs
  (EXCEPTION check aPTT q12hrs with renal
  impairment or renal or liver function declines)
• (EXCEPTION Check aPTT q12 hrs with renal
  impairment or if renal or liver function
  declines.)
  
• 5. All aPTTs should be drawn from the arm not
  used for the argatroban or bivalirudin infusion
  
• 6. Maintain anticoagulation monitoring flowsheet
• 7. Adjust argatroban or bivalirudin infusion rate
  by the following scale
  

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Order Form 2nd Page
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Form View Page 3
Clinical scoring system to determine the
likelihood of a patient having HIT (not necessary
to complete this section, just a clinical pearl)
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Pharmacy to Dose

• The DTI form introduces a new Pharmacy to Dose
  program
  
• If the physician wants the pharmacist to manage
  the DTI, the physician will check the box
  Pharmacy to Dose on the form
  
• The Pharmacy to Dose program allows
  credentialed pharmacists to not only write
  orders, but also to give a verbal or telephone
  order to a nurse (see MUSC Policy C-56). C-56 has
  been changed
• How to Write A Verbal Order?
• The nurse should write a verbal order as
  (example T.O. Mary Brown, RN/John Smith, PharmD,
  pager ID, Pharmacy to Dose). This should be
  cosigned within 48 hours per C-56.
• The list of credentialed pharmacists can be found
  on the Clinician Order Forms website under the
  Pharmacy section.
  

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Credentialed Pharmacists

• Requirements
• Graduate from an ACPE-accredited pharmacy
  program
  
• Current active license in SC

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Requirements cont.

• Must meet one of the following 2 requirements
• 1. Bachelor of Science in Pharmacy degree (or
  equivalent) plus a, b, or c below
  
• a. Five (5) years of practice with substantial
  component (50 of time) performing direct
  patient care activities OR
  
• b. Completion of a Pharmacy Practice (PGY-1) or
  Specialty Residency (PGY-2) plus three (3)
  additional years of practice with a substantial
  component (50 of time) performing direct
  patient care activities OR
• c. Completion of BOTH a Pharmacy Practice
  (PGY-1) or Specialty Residency (PGY-2) with a
  substantial component (50) performing direct
  patient care activities
• 2. Doctor of Pharmacy degree plus a or b below
  
  
• a. Three (3) years of experience with a
  substantial component (50 of time) performing
  direct patient care activities OR
  
• b. Completion of a Pharmacy Practice (PGY-1) or
  Specialty Residency (PGY-2) with a substantial
  component (50) performing direct patient care
  activities

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Competencies

• Multiple Choice Exam
• To pass, must achieve an 89
• Oral Exam
• Patient cases

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Pharmacist Responsibilites

• Verify pharmacy to dose
• Determine the pharmacist who will be managing the
  DTI infusion
  
• Determine if the pharmacist is credentialed to
  manage DTI infusions
  
• Touch base with clinical pharmacy specialist or
  DTI pharmacist on call
  

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Management of DTI Infusion

• Pharmacy to dose
• DTI pharmacist on call
• On call list provided on pharmacy services
  website and on W3
  
• Credentialed pharmacists
• Listed under clinician order forms (pharmacy or
  anticoagulation) or on pharmacy services website
  

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Summary

• DTI Protocol and Pharmacy to Dose go into effect
  on January 21
  
• Orders found under clinician order forms
• Credentialed DTI pharmacists listed under
  pharmacy under clinician order forms