Coumadin Management Standards

[Johnny Stephens]

There are a few threads running around the board right now that got me to thinking about this. I read about huge variations in advice given to people with regards to managing their anticoagulation, and it seems something is missing.

My wife averted a "problem" while I was still in the hospital, using information she learned here. An attempt was made to discontinue heparin only hours after I took my very first Coumadin pill. What would my INR have been at that point, 1.X? (My wife, a force not to be trifled with, literally backed the resident out of the room ).

Anyway, my point is, if a layperson knows more about it than a "senior" resident, isn't there some required standard of training that is missing?
Luckily, I have competent caregivers, but I read so much about wild variations in INR (immediately post op discounted) and the knee-jerk reactions to them, that it seems there needs to be some "certification" or validation process that says "I have a clue about anticoagulation."

Al, I know this is part of the awareness you are always trying to raise. Bless you for that. It seems to me that this group has a pretty good body of knowledge in this area, and maybe we could help bring some attention to this area.

Just rambling away during lunch...disregard if I'm only restating the obvious and oft-repeated.

 

[Nancy]

OK-

I'll bite--

If there are any doctors monitoring this site, how about giving a lecture on Coumadin to your local medical society or to your hospital staff. And if there is anyone monitoring who is in the medical education field, how about planning a course on Coumadin. I believe Al Lodwick's site has much information with which to develop a curriculum available all ready to go.

http://www.warfarinfo.com/

You will do a great service to the people in your community and will help to get awareness going in an area of medical knowledge which is not well comprehended by many of your colleagues.

If you monitor this site regularly, you can see the terrible troubles patients get into when their doctor does not thoroughly understand Coumadin.

 

[RCB]

Report!

Report!

Protocol for changing the heparin drip states you do nothing without a confirming INR from the lab. You do NOT stop heprin when you give the first pill- you gradually wean the pt. off as the warfarin begin to have an affect. Three days in my case. You should have done
the other pts. in that hospital and report the incident to his
attending and if that didn't get the senior resident a swift kick in the ass- you report the attending and senior resident
to the chief of staff! This is a clear case of malpractice!

 

[Guest]

I wouldn't say that I have a curriculum but there is a lot of information there.

 

[Johnny Stephens]

Protocol for changing the heparin drip states you do nothing with a confirming INR from the lab. You do NOT stop heprin when you give the first pill- you gradually wean the pt. off as the warfarin begin to have an affect. Three days in my case. You should have done
the other pts. in that hospital and report the incident to his
attending and if that didn't get the senior resident a swift kick in the ass- you report the attending and senior resident
to the chief of staff! This is a clear case of malpractice!

I mentioned the incident only as an example..it has been resolved correctly. My hope was to get people to think about what can be done to help get the word out on what patients go through.

 

[bvdr]

I know what you are getting at, Johnny. I agree that it would be great if health care providers, at least those that were making decisions about coumadin, sounded as if they were reading from the same book. It is truly amazing, or more accurately, deplorable, what is being presented to patients whose lives may well hinge on proper management.

I sometimes think about patients I had who were on coumadin. I remember many many years ago when I was a student nurse and had a blind retired surgeon as a patient. He talked me into letting him shave with a blade instead of an electric razor. Well,.............he didn't do so well. My nursing instructor came in to see a patient will blood all over his face but my patient came to my defense and gave a really good speech about a patient's self-esteem. I always had what I considered a working knowlege of warfarin and target ranges but now, from a patient's point of view, I know that I knew very little. I never dealt with low INR's. I only dealt with bleeding issues.

More and more patients are on anti-coagulation therapy and some type of standard for care should be recognized and adhered to.

 

[Marty]

Lack of interest?

Lack of interest?

I asked my surgeon why he and his staff had so little interest in warfarin mangement.( I did get to give a talk to his staff) He said when they started doing a lot of heart valve surgery 20 years ago the patients were in the hospital at least 2 weeks and they had to manage the anticoagulation. Now the patients are out of there in 3 to 5 days.( I was discharged the A. M. the 4th day). The patients are turned over to a wide variety of practitioners located all over the place. My cardiology group left the management to a group of hard pressed nurses who would sometimes call you after your central lab test and sometimes not.If they did call they seemed to rapidly read from an algorithm they did not really understand. I told my cardiologist after 2 weeks ,their instructions made no sense. At least he knew about Coaguchek and prescribed one for me. He said he had prescribed them for foreign service and military people who did not have access to labs and they seemed to do well..I have not bothered him in almost 5 years. I am impressed with Kaiser where I now work. The program is run by pharmacists like Al and the patients are carefully regulated.

 

[catwoman]

Since my MVR and joining the Coumadin ranks, I've talked to quite a few people who have taken/are taking Coumadin.
One friend, who takes Coumadin because of 2 strokes, has a CoaguCheck. Other than those of you here, I know no one else who has their own testing machine.
One friend had AVR (St. Jude's) in late October and tests monthly at a doctor's office. Another had MVR (St. Jude's) and declines to talk about her health; a mutual friend told me she tests every 2-3MO.
Other people took Coumadin for only a year-couple of years and insist they were not told anything about Coumadin, other than to take their Rx and have periodic tests. And that they were not given any precautions about foods, Rxes, etc.

Those of us here (vr.com) on Coumadin are perhaps "smarter than the average bear." We are doing everything we can to stay as healthy as possible given our particular health condition and being on Coumadin. So it stands to reason that we do expect more from our health care providers when it comes to Coumadin information.

Even though we may not get it!

 

[Blanche]

Catwoman:
You hit the nail on the head!!! I was one of those people. Al was on Coumadin for more than 10 years and all we knew is what we read in a brochure and a few articles from the pharmacist. Then he had a stroke. I learned 98% of what we know from this board.

Patients that I speak with in doctors offices are in the same place we were in, and frankly, most are just as happy knowing little. A guy in the doctors office told me that his Coumadin was off the charts and couldn't even be measured. He didn't know what INR was and had no idea about those factors that affect "his results." I suggested VR.com to him and offered to get him some articles. He works in a nearby optical store. His response was, "Naw, I don't have time for that kind of stuff. I just leave it to KK." KK is the phlebotomist at the doctors office. Most people are not proactive when it comes to their medical care.

This causes problems for people who are proactive and informed.
Nurses and doctors I encounter can't believe that I could possibly know anything about anticoagulation. And when I discuss it with them, they don't believe that I could possibly be informed or understand the information to begin with. One nurse told me recently that Al couldn't test his own anticoagulation at home. When I spoke of the ProTime monitor, she was sure that only authorized medical personnel could use it because the results are too complicated for patients to understand. Seems to me a that a whole lot of education is needed.


Kind regards,

Blanche