Tuesday, May 17, 2016

When to obtain “coags”

emDocs - May 16, 2016 - Authors: Iftekhar U, Subasic M, Wallach E, Scoccimarro A and Waseem M - Edited by: Koyfman A and Long B
"In the Emergency Department, routine use of coagulation order sets or “coags’ include PTT and PT/INR. Unnecessary use of these tests adds to overall healthcare costs. Preoperative evaluation utilizing these laboratory tests is not driven by evidence-based guidelines and not determined by disease characteristics.
When to obtain “coags”?
  • PT/INR
    • Warfarin therapy
    • Liver failure
    • Vitamin K deficiency
  • PTT
    • Heparin treatment
    • Hemophilia
    • von Willebrand disease
  • Both (PT/INR and PTT)
    • Bleeding of unknown etiology
    • Bleeding by history or presence of bleeding
    • Known or suspected coagulopathy (e.g. disseminated intravascular coagulation)
    • History cannot be obtained or unreliable history
  • Ask yourself these questions before ordering PT/PTT:
    • Does this patient have a history of bleeding or, on examination, is the patient bleeding?
    • Is this patient taking warfarin?
    • Does this patient have a history of liver disease, von Willebrand disease, or lupus anticoagulant antibodies?
What you can do to reduce “coags” tests?
  • Develop Clear Guidelines: It is important to institute clear guidelines to promote the appropriate use of PT and PTT tests in the emergency department.
  • Develop a Consensus: Discuss the subject in a combined EM, surgical, and anesthesia services meeting. This may be helpful in order to achieve a consensus; otherwise other services may demand “coags” as routine testing.
  • Before ordering “coags,” consider whether the result will alter or change the management plan.
  • Consider ordering PT/INR and PTT separately, as each has a different indication.
  • Use PTT for monitoring heparin, not for determining the initial dosing."