A coumadin clinic helps me sleep at night

July 7, 2006

This physician found out the hard way what can happen when a patient on an anticoagulant isn't monitored.

This morning, as I re-evaluated P.G., a patient who had had subtherapeutic coagulation levels and had thrown an embolus to her right brachial artery a few days ago, I thought about the malpractice suit.

Several years ago, one of my younger patients had come to the hospital in acute cardiovascular distress and died. It was later determined that she'd had extensive fibrosis of her prosthetic aortic valve, and that this obstruction had killed her. The attorney for her widower also discovered that she'd failed to show up for her monthly blood work to monitor the effectiveness of the coumadin she was taking. The patient's coumadin happened to be at a therapeutic level on the day of her death, but nobody knew what her levels had been during the several months since I'd seen her.

The plaintiff's attorney assumed that subtherapeutic levels had caused the fibrosis and her death. He further assumed that this could have been prevented if I'd checked on her condition. Although he couldn't prove cause and effect, he could show that the patient hadn't been adequately monitored. It was that "failure to monitor" that led to the action against me.

Now available in my hospital, a coumadin clinic consists of one or more nurses working under the supervision of a cardiologist. A patient comes to the clinic, has her blood drawn and tested, and has her medication dose adjusted, if necessary, according to a standard protocol. The advantage of this approach-which includes education and follow-up to make sure that the patient returns-is that a dedicated clinician is keeping tabs on the patient, while freeing up busy physicians and their staffs.

My hospital's coumadin clinic is available to every doctor on the hospital staff. (There are an increasing number of freestanding coumadin clinics, too.) While my 45-physician group doesn't require any of us to send patients to the clinic, I encourage all of my patients on anticoagulants to use it. From painful experience, I know that patients can fall through the cracks and that, without a good tracking program, patients like the young woman with the prosthetic valve can have disastrous consequences.

The clinic also gives me peace of mind. There is never a question about who will adjust the anticoagulant dose if I'm out of town or simply out of the office. And the clinic has a callback program to help ensure that patients actually get in to be monitored. The nurses not only phone them but also send out letters and copy me on them. That way, I know whether my patients are coming in to be tested. If there's a problem, I can follow up with them myself.

Although most insurance plans cover visits to the coumadin clinic, a few patients don't want to go there because of the modest copay. (If they don't have insurance and can't afford it, the hospital will absorb the cost.) But after I tell them this could be a matter of life and death, most patients go.

P.G. is one of those who didn't. She's on coumadin for atrial fibrillation, but has not been getting her PT/INR levels checked regularly. She had a successful embolectomy and I sincerely believe she'll be much more compliant in the future. We can't enforce compliance, but the coumadin clinic not only improves patient safety, but also ensures that patient education and efforts to follow up with patients are documented. Although it's still possible that something could go wrong, and that I could be sued again, at least the attorney won't be able to allege that I failed to monitor the patient. For all these reasons, I now sleep better at night.

I am a believer.