Long-Term Care Survey Alert

Develop systems to keep residents' coagulation status in the safety zone.

A great safety slogan for nurses giving patients Coumadin might be: Have you checked your residents' INRs lately?

Nurses can make a potentially lethal error when they don't stay on top of residents' International Normalized Ratio (INR) results--or fail to connect signs of bleeding to the patient's coagulation status.

Case in point: A physician ordered 10 mg. of Coumadin a day for an elderly nursing home resident. The physician had also ordered prothrombin times to check the resident's INRs, but the nurse never took the order off for the lab work, relates nurse attorney Janet Feldkamp in Columbus, OH. And no one noticed that the patient taking the high dose of Coumadin began to develop petechiae (pinpoint hemorrhages) under the skin.

"Once tested, the patient was found to have a very high INR, which means he's lucky he didn't suffer a major bleed," says Feldkamp. While the facility initially blamed the nurse for not transcribing the physician's order for lab testing, it really had a systemic issue on its hands, Feldkamp says. How so? "Not one nurse questioned the high dosage of Coumadin or connected the patient's pinpoint hemorrhage to the Coumadin dosage," she says. In addition, "no one looked for the patient's INR results."

Solution: Develop best-practice policies and protocols for checking nursing home residents' INR levels as part of managing Coumadin therapy, advises Cheryl Phillips, MD, medical director for Sutter Medical Group in Sacramento, CA. The policies and protocols might include:

• A default procedure that ensures all residents on Coumadin receive testing to stay on top of their anticoagulation status. For example, if the attending physician fails to order testing, the nurse notifies the medical director who orders INRs at designated intervals based on the resident's risk profile--or talks to the attending about ordering it, Phillips says.

• Identify ranges of lab values for coagulation status that trigger action, e.g., where the nurse contacts the physician or medical director, if the physician doesn't respond.

• Ensure nurses understand and follow protocols for assessing residents for clinical signs of increased bleeding, such as pinpoint hemorrhages on the skin or mucous membranes, bleeding gums, increased bruising, blood in the urine or tarry stools, etc. Nurses should also receive continuing education on how Coumadin interacts with other common drugs, such as antibiotics, which can increase bleeding.

Develop best practices for anticoagulation therapy: Be on the lookout for the American Medical Director Association's Anticoagulation Toolkit this fall or early winter (www.amda.com/info/ltc/). The toolkit provides long-term care clinicians with an education resource that contains model policies and instruments to implement best practices, William Smucker, MD, CMS, chair of the multidisciplinary medication management committee that developed the toolkit, tells Eli.