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

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