First of all, I am getting some really good information from the Medicare 101 quiz posted Sunday evening. When the responses stop coming in, I will share some of the more interesting results with you. It will certainly give us some useful information to use when writing posts in the future.
As I suspected, Coumadin should be a schedule II medication controlled to the same degree as Oxycontin and other medications that shouldn’t be distributed freely due to the risk of untoward side effects up to and including death. Now, I have proof. Medscape has a new, very short CE activity that offers evidence to support my position.
After reading the CE article, I am sure you will agree with me that the best way to prevent unavoidable hospitalizations is to discontinue Coumadin on all of your patients. Seriously, if I was an ambulance chasing lawyer, I wouldn’t spend money on TV commercials for my law practice. I would advertise Coumadin. If your stodgy MD’s don’t agree with my assessment, at least consider upgrading your communication processes related to Coumadin.
(By the way, in case you think Pradaxa is the answer, you may want to rethink your position. Four days ago, the FDA issued this warning about Pradaxa. I only skimmed through it but I believe it said something about post marketing reports of bleeding putting the patient at risk for hospitalization or even death. That is never good and almost always messy.)
So I guess that leaves us with good old fashioned nursing care as a solution. Consider using SBAR-C communication when communicating with others about Coumadin.
- S – Situation
- B – Background
- A – Assessment
- R – Recommendation
- C- Communication
Situation: I just drew lab on Ms Smith as ordered a week past her last dosage change of Coumadin. She is currently on 7.5 mg daily and her INR is now 4.2.
Background: She had a mechanical valve replacement two years ago and did fine on her Coumadin until recently. Her INR’s decreased to sub-therapeutic in recent months. Her two most recent INR’s and corresponding dosage changes are: (give example).
Assessment: She has no signs of external or internal bleeding. (give vital signs)
Recommendation: Do you want me to hold Coumadin for a couple of days and then restart? If so, what do you want her dosage to be?
Communication: Gave above orders to JUDY, patient’s daughter who stated she was removing the Coumadin from the patient’s med planner box now and putting the bottle of Medicine on top of the refrigerator so it wouldn’t be mixed up with normal meds.
All of these steps are important but detailed communication of orders is the most frequently missed step. It is also the step that could get you into serious trouble if the patient ends up in the hospital with a bleed to the brain. Documenting that you told the patient’s daughter is all well and good if she only has one. It is always best to document the name of the person you told and the time and date of the phone call. Details lend credibility. (And details are always easier to provide if you document contemporaneously with your work but that is a subject for another post.)
Sometimes, there is nobody reliable to instruct on changes. In that case, an additional skilled nurse visit should be ordered so the nurse can go to the house and remove the Coumadin herself. Since we know that unstable Coumadin patients are going to have a lot of unanticipated lab and orders, conservative scheduling with PRN orders for medication updates should accommodate the needs of the patient without breaking your budget.
Or, you can go back to my original advice and discontinue Coumadin on all of your patients but before you do that, let me explore some of the regulatory issues that may arise if you don’t follow physician orders. I seem to remember reading something about that somewhere.