A story in Pro-Publica (7/12/15) and reproduced in the Washington Post highlights the problems with anticoagulants when given in nursing homes. The graphic at the left shows the magnitude of the problem — lots of patients in nursing homes get these drugs. The next graphic shows data from North Carolina pinpointing the main culprit: WARFARIN.
What is going on? Well, warfarin is a tricky drug because it changes the body’s system to make the blood clot. Some people tend to clot too much (and get clots in the brain, a stroke, and some people get clots in the lungs, a pulmonary embolus). Those people are at risk of death from too much blood clotting. So, health care providers prescribe an anticoagulant to make the blood clot less easily. Unfortunately, this creates a state where people bleed easily. It is indeed a situation “between a rock and a hard place“.
Warfarin is one of the most common of the drugs for this purpose. It has the advantage of an existing antidote and it is inexpensive. But, it requires frequent blood testing to keep the anticoagulant effects in a reasonably safe range. Providers must order the tests and must change the dose according to the results.
Thrombin inhibitors are a new class of anticoagulants which have the same bleeding risks and are expensive. Their claim to fame is that blood testing is not needed. They also have the disturbing quality of not having an antidote if bleeding starts. Taking all this into consideration, most providers choose the older drug warfarin.
The reasons for excessive bleeding in nursing homes are:
- Prescribers (not the nursing home staff) fail to order blood testing when they should and fail to adjust the medication as they should.
- Prescribers fail to stop anticoagulants when the risk of falling exceeds the risk of blood clotting.
- Pharmacists for nursing home patients are not as connected to their patients as they should be — usually the pharmacist is the safety net for bad prescribing — sadly, they are out of the loop.
- RNs in nursing homes have the training to catch medication errors but function as administrators and are not on the front line of care. Thus, like pharmacists they are not performing the safety net function they might in hospitals or doctor’s offices.
- Elderly patients are the most prone to adverse drug events — for them, if a side effect is possible they will likely experience it. It there is a risk of bleeding they probably will.
What should be done:
- State certification organizations should develop guidelines that require nursing homes and their prescribers to have a protocol for anticoagulation management — not every prescriber can be allowed to invent their own method — that’s the mess we have already!
- Nursing homes should use electronic means to track anticoagulants and the adherence to prescribing protocols. This is not rocket science, those protocols (evidence based guidelines) and computer programs already exist! So, USE THEM.
- Proactive patients and families should ask about the protocol that will be followed for warfarin in the nursing home — if there is no protocol SPEAK UP — show them a copy of this blog.