Scared...

[magnesv3]

so scared , started heparin gtt without baseline ptt, with doctors order to start, basis was elevated D-dimer,will I get fired?

[Dixielee, BSN, RN]

What department are you in? If a d-dimer was drawn, they probably drew other baseline labs, at least we do in the ED. Had the patient been on any anti-coagulants prior to the heparin? Was the baseline pt/ptt ordered? There are a lot of things to consider.

[Pepper The Cat, BSN, RN]

What did you do when you discovered your error?

What have done to correct your mistake?

Most important, how is the patient?

Have you accepted responsbility for the error?

I don't think that you will be fired for one mistake, but it all depends on the answers to the above quesitons.

[Sun0408, ASN, RN]

Depends on what your protocol states.. Was the pt harmed, was a PTT drawn 6 hours after starting? This all plays into it. I know our policy/order set does not require a baseline PTT, which many of us think is asinine.

[magnesv3]

pt . wasn;t on any anti coagulants, she came in wih chest pain. there was an order for ptt before we start the drip but the results aren,t out yet. since this is change of shift, tne nurse getting the pt., told me she'll follow up onlabs. two days after the incident she told me that we shoud've informed the nsg supervisor accdg to the clinical specialist and another RN told me that heparin gtt must always have a baseline PTT:crying2:

[Creamsoda, ASN, RN]

pt . wasn;t on any anti coagulants, she came in wih chest pain. there was an order for ptt before we start the drip but the results aren,t out yet. since this is change of shift, tne nurse getting the pt., told me she'll follow up onlabs. two days after the incident she told me that we shoud've informed the nsg supervisor accdg to the clinical specialist and another RN told me that heparin gtt must always have a baseline PTT:crying2:

im confused "there was an order for ptt before we start the drip but the results aren,t out yet"....I understand that as yes the PTT was drawn before you started the heparin drip but that the results werent back yet. and then you started the heparin drip before the results were back. Im not really seeing the problem. The baseline was drawn, the patient was having an MI/ ACS so he needed the heparin to be started, recheck in 6 hrs per your policy.

[magnesv3]

i was told that there should always have a baseline ptt before starting the gtt, so I was questioning was the d dimer elevation not basis enough to start the gtt? i'm not really familiar with this test and accdg. to the doctor the pt might be having p.e.. i'm so concerned bcoz i got written up by my nurse manager becoz there's no ind verification on my heparin gtt before. and this being HEPARIN makes me so paranoid

[Dixielee, BSN, RN]

im confused "there was an order for ptt before we start the drip but the results aren,t out yet"....I understand that as yes the PTT was drawn before you started the heparin drip but that the results werent back yet. and then you started the heparin drip before the results were back. Im not really seeing the problem. The baseline was drawn, the patient was having an MI/ ACS so he needed the heparin to be started, recheck in 6 hrs per your policy.

Exactly! Since it was not discovered for 2 days, I presume follow up labs and subsequent adjustments had long been made. There are a number of issues to consider here including unit policy.

[ICU_RN2]

D-dimer can elevate for several other reasons as well...in my experience we never use a d-dimer alone to diagnose...

The rest of your questions are hard to follow, but as long as you drew and send the labs before starting the heparin gtt you should be fine.

[Creamsoda, ASN, RN]

yup, D dimer is often not very concise in diagnosing PE, but is used often to rule out PE. But sometimes when its off the chart, its pretty obvious, but CT angio is the best bet. But like I said, as long as a baseline was drawn prior, there shouldn't be an issue even if you didn't know the result

[Double-Helix, BSN, RN]

OP, you did have a baseline ptt. Whether or not you knew the results at the time of starting the infusion isn't really important unless there was a reason to suspect that the patient was already anticoagulated.

The purpose of the baseline ptt is to see where you started in the heparin therapy. Then when you redraw in 6 hours you know how much of a difference you have made. So if your baseline is 12 and in 6 hours it's 20 you know you probably need to increase the rate. But if your baseline is 12 and 6 hours later it's 40 you know the drip needs to be adjusted. So the important part is that you have drawn a baseline before starting the drip and that value is available to compare future results.

See how it's not especially important to know the baseline value before starting? The half life of IV heparin is short and you can make adjustments pretty quickly. (By the way, even if the result comes back an hour after starting and for some reason it's really high, you can shut off the heparin and the value won't have changed significantly in that hour and most of the heparin will be gone by the next hour.) But without drawing your patient's baseline you have no way to gauge if the therapy is effective. In this patient's case, it's more important that the heparin was started than it is to know the baseline value before starting the drip.