Anticoagulant Therapy: Stem the Bleeding

Abstract

Anticoagulant therapy has increased over the past few years for residents of long-term care facilities as it is put to use in diseases such as atrial fibrillation to prevent strokes. Accompanying the undeniable benefits of anticoagulant drugs are the increased risk of bleeding and fluctuations in clotting. In addition, anticoagulants can interact with other drugs in dangerous ways. Particularly concerning are antibiotics, which may increase an anticoagulant’s effect, resulting in elevated risk of clinically significant patient bleeding. Significant injury and death have occurred among long-term care residents receiving anticoagulants, but whose facilities have not monitored blood clotting times of residents receiving this therapy in a timely fashion. The tests used to do so measure the international normalized ratio (INR) and the prothrombin time (PT). Recent civil and regulatory cases based on these failures demonstrate that facilities must take responsibility for monitoring the patients’ blood clotting times and must question attending physicians who do not order frequent monitoring. In April, the federal Health and Human Services Departmental Appeals Board upheld a finding of immediate jeopardy and the imposition of a civil penalty in excess of $143,000 based on an Arkansas nursing home’s violation of professionally recognized standards in administering warfarin (Coumadin). The board found that the facility had violated the “quality of care” regulation 42 C.F.R. § 483.25. The resident had a history of cerebrovascular accidents and atrial fibrillation, for which the resident’s attending physician had prescribed the warfarin. The government’s evidence in the case indicated that the facility had failed to monitor the patient’s INR and PT monthly, as ordered by the attending physician. In addition, the board found that the facility’s staff had failed to comprehend signs of warfarin toxicity in the resident and to take into account in managing her care that she was also receiving antibiotics. Finally, the board found that the facility’s consultant pharmacist had failed to discharge a responsibility to evaluate the resident’s use of warfarin in conjunction with her antibiotic regimen. As a result of the facility’s errors, the resident developed a hemorrhage so severe that she required hospitalization and multiple transfusions to treat the consequent anemia. Although the nursing staff noted the resident’s bruising and bleeding in her chart, the board held that they should have realized that these were signs of warfarin toxicity and, at the very least, determined whether her blood clotting times were being monitored appropriately. This would have alerted the staff that they were not in conformance with the physician’s orders. In addition, the board held that the facility’s nursing staff should have recognized the potential of the antibiotics to heighten the effects of the warfarin and that they should have taken special precautions such as increased INR and PT testing to guard against the possible adverse effects of the woman receiving warfarin with the antibiotics.