You can improve care of elderly patients on blood thinners by doing the following:

• Be sure waiting patients are reassessed.

Patients on anticoagulants need to have more than just "one-shot" triage, where only one evaluation takes place, says Kathleen Emde, RN, MN, CEN, clinical services manager at Swedish Medical Center in Issaquah, WA. "This is a common method of triage, and patients often are not repeatedly evaluated in any sort of a systematic way while they are waiting," she says. "Triage needs to be seen as an ongoing process rather than a one-time event to categorize the patient."

• Consider giving patients a higher acuity.

Change your triage protocols to categorize any injured patient on anticoagulants as emergent, recommends Emde. "The purpose of this is to ensure that the patient is seen rapidly in case there is bleeding due to the drug and to help get it controlled as rapidly as possible if it is present," she says. "Careful history-taking is a must."

• Modify procedures for patients taking anticoagulants.

If an arterial puncture is performed to draw a sample for arterial blood gas analysis, be aware that the puncture site is more likely to bleed and take longer to form a clot, says Emde. "Be aware of the presence of the drug and its effects, and hold pressure over the site for a longer period of time than would be required in other patients," she advises.

The same is true for patients who undergo cardiac catheterizations or other procedures that involve access through a large artery or vein, says Emde. These large vessels can bleed heavily into the surrounding tissues, which creates problems such as hematomas, compromised circulation to a limb, and retroperitoneal hemorrhage, she explains.

• Try not to phlebotomize the hand if possible.

The elderly have less subcutaneous fat and elasticity in the veins, says Linda Whitt, RN, BSN, CEN, ED nurse at Bon Secours DePaul Medical Center in Norfolk, VA. "Therefore, if a punctured vein keeps bleeding after a stick because the puncture doesn't readily seal up, and the blood is thinned, then the hand will get a huge black ecchymosis as the leaky blood spreads under the skin," she says. "Not only is this painful, but it looks barbaric!

• Be ready to reverse the effects of warfarin.

Patients may need to be given fresh-frozen plasma or other coagulation factors such as vitamin K injections to help restore clotting ability, says Emde. However, injections of vitamin K will not have an immediate effect, and you probably will need to use fresh-frozen plasma or other factors to restore a more normal clotting ability before the patient goes to surgery or has an invasive procedure such as lumbar puncture, she explains.

This story was adapted from one originally published by Thomson American Health Consultants (800-688-2421).

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