I think this particular question is moot. The only pts. who receive warfarin now have a metallic valve replacement; an intracardiac thrombus; a NOAC failure; or a preference for warfarin (price, etc). The DVT's I treat in the ER get apixaban/ rivaroxaban/ etc. Discount cards that provide the first month of treatment for free are plentiful. Even pts. with a PE (who meet guideline requirements for outpatient management) receive one of the newer medications, over a "bridge" of enoxaparin and warfarin.
I agree with the author’s analysis, I’m mildly surprised that this lawsuit was settled in favor of the plaintiff.
My initial thoughts are that this case is nothing more than an unfortunate series of events, within the realm of the accepted risks of anticoagulation.
My take away: the negligence occurred due to failure to check INR daily during a bridge. Perhaps the primary care doctor should have ordered a blood draw, or referred the patient back to the emergency room due to the INR machine not working. In practice, I imagine most physicians would have decided that waiting a couple days would be reasonable risk to take.
Either way, I do think it’s appropriate to place responsibility on the accepting physician, as opposed to the home health agency or social worker. It was this physician who made the decision to wait for the INR machine to be replaced. Logistical errors happen that create a barrier to the standard of care. At the end of the day, the primary attending of this patient felt it was reasonable to wait a couple days for the INR, whether or not this was a passive or active decision.
Nevertheless, the standard of care was not met. The patient was unable to obtain proper monitoring. The 5 days between the INR checks are not ideal.
The argument was that the patient may have had a couple days in which she was receiving therapeutic doses of both lovenox and warfarin, increasing bleeding risks unnecessarily, resulting in a preventable hematoma.
A dose of warfarin 5 mg is a typical starting dose. On average, it takes about 5 days for INR to reach a goal of 2-3. And standard of care (according to uptodate) calls for 2 consecutive days of therapeutic INR before discontinuing the lovenox. In other words, had she received daily INR’s, the earliest lovenox would have been discontinued was on day 3.
The question is: is 48 hours of supratherapeutic anticoagulation (lovenox + INR 2-3), representing the worst case scenario, enough to say that the patient was put at significantly greater risk resulting in a hematoma that wouldn’t have otherwise happened?
I suppose, but I doubt it.
Other things I’m curious about: how did the DVT get diagnosed? How was the pneumonia diagnosed? In other words, how strongly did the patient need to start anticoagulation in the first place? I’m curious to know what the hospitalist’s suspicion for pulmonary embolism was, or if this DVT was purely an incidental finding. In which case, a learning point would be to refrain from getting a lower extremity duplex on everyone who comes in with shortness of breath, especially when they have findings consistent with pneumonia and no clinical findings that suggest DVT.
I agree that it’s debatable whether or not the patient needed anticoagulation in the first place. Although I imagine most physicians in practice would’ve start anticoagulation, despite guidance stating that distal DVTs have a low risk of embolizing and can be watched instead.
I think this particular question is moot. The only pts. who receive warfarin now have a metallic valve replacement; an intracardiac thrombus; a NOAC failure; or a preference for warfarin (price, etc). The DVT's I treat in the ER get apixaban/ rivaroxaban/ etc. Discount cards that provide the first month of treatment for free are plentiful. Even pts. with a PE (who meet guideline requirements for outpatient management) receive one of the newer medications, over a "bridge" of enoxaparin and warfarin.
This has been my recent experience.
I love how the complaint says the INR reached a "therapeutic range of 2.0."
A range ... of one specific number.
Is this just moronically sloppy writing, or is the attorney trying to distract from the fact that the therapeutic range for INR is 2.0-3.0?
This is the kind of crap that drives me nuts.
Yes, clearly the attorney has no idea what he is talking about or tried to regurgitate something from a crooked expert and sorely misunderstood it.
I agree with the author’s analysis, I’m mildly surprised that this lawsuit was settled in favor of the plaintiff.
My initial thoughts are that this case is nothing more than an unfortunate series of events, within the realm of the accepted risks of anticoagulation.
My take away: the negligence occurred due to failure to check INR daily during a bridge. Perhaps the primary care doctor should have ordered a blood draw, or referred the patient back to the emergency room due to the INR machine not working. In practice, I imagine most physicians would have decided that waiting a couple days would be reasonable risk to take.
Either way, I do think it’s appropriate to place responsibility on the accepting physician, as opposed to the home health agency or social worker. It was this physician who made the decision to wait for the INR machine to be replaced. Logistical errors happen that create a barrier to the standard of care. At the end of the day, the primary attending of this patient felt it was reasonable to wait a couple days for the INR, whether or not this was a passive or active decision.
Nevertheless, the standard of care was not met. The patient was unable to obtain proper monitoring. The 5 days between the INR checks are not ideal.
The argument was that the patient may have had a couple days in which she was receiving therapeutic doses of both lovenox and warfarin, increasing bleeding risks unnecessarily, resulting in a preventable hematoma.
A dose of warfarin 5 mg is a typical starting dose. On average, it takes about 5 days for INR to reach a goal of 2-3. And standard of care (according to uptodate) calls for 2 consecutive days of therapeutic INR before discontinuing the lovenox. In other words, had she received daily INR’s, the earliest lovenox would have been discontinued was on day 3.
The question is: is 48 hours of supratherapeutic anticoagulation (lovenox + INR 2-3), representing the worst case scenario, enough to say that the patient was put at significantly greater risk resulting in a hematoma that wouldn’t have otherwise happened?
I suppose, but I doubt it.
Other things I’m curious about: how did the DVT get diagnosed? How was the pneumonia diagnosed? In other words, how strongly did the patient need to start anticoagulation in the first place? I’m curious to know what the hospitalist’s suspicion for pulmonary embolism was, or if this DVT was purely an incidental finding. In which case, a learning point would be to refrain from getting a lower extremity duplex on everyone who comes in with shortness of breath, especially when they have findings consistent with pneumonia and no clinical findings that suggest DVT.
I agree that it’s debatable whether or not the patient needed anticoagulation in the first place. Although I imagine most physicians in practice would’ve start anticoagulation, despite guidance stating that distal DVTs have a low risk of embolizing and can be watched instead.
No defense expert disclosure on this one!