Case Presentation Cindy Felty MSN, RN, CNP, FCCWS Assistant Professor of Medicine Mayo Clinic March 27, 2008
Acute DVT Case 1- Day 1 68 year old male admitted overnight to hospital for painful acute DVT and shortness of breath PE confirmed by CT DVT of right lower extremity confirmed by ultrasound Started on IV heparin as per protocol Given warfarin 5 mg by mouth Ace wrap to right leg for 1+ edema up to thigh Admitted to hospital
Acute DVT Case 1 Day 2 Uneventful day Shortness of breath improved Continues on IV Heparin Warfarin 5 mg by mouth Limb swelling better but not completely down Continued with ace wrapping
Acute DVT Case 1- Day 3 Next day INR 1.2 Started LMWH SQ per weight based dose Dismissed on 10, 10, 5 mg of warfarin by mouth Patient teaching completed, dismissal summary Instructed to call primary provider on Monday for repeat INR and dose recommendations Patient called primary provider who was not available until later in the week Patient continued with 5 mg warfarin Took home 3 days of LMWH injections Sister was a nurse she was instructed in injections
Acute DVT Case 1- Day 10 1 week later presents to ER with severe nose bleed required ENT to come down and cauterize INR 13.1 Patient reports that he has not felt well all week Shortness of breath getting better Poor appetite Fatigued Stopped wearing ace wrap - has leg edema Given fresh frozen plasma Admitted to hospital Warfarin held until in range Restarted at lower dose Leg edema down Leg is again wrapped with ace wrap Measured for stocking next day after swelling down
Acute DVT missed opportunities No communication / transition to outpatient Primary care provider Alert to call patient Patient was cognitively oriented but assumption that with new diagnosis he also would be able to do own follow-up phone call Information overload at dismissal frequently occurs Family not available No accountability for patient outcome Remember these patients used to be cared for in hospital for 5-7 days until INR was therapeutic and leg edema was down
Acute DVT missed opportunities Anticoagulation (warfarin) dosing 15,10,5mg no protocol Protocol for dose adjustment based on INR would have recommended 5 mg and check INR in 3 days No provision for edema control Risk of post-thrombotic syndrome can be reduced by 50% use of compression stockings after edema
Acute DVT Case 2 Day 1 37 year female with painful acute DVT of left femoral vein Confirmed by ultrasound in ER Given 15,000 units LMWH SQ Call to outpatient infusion center to arrange for next 2 days dose of LMWH Provided with filled prescription 5 mg warfarin by mouth to take daily Communication sent to Thrombophilia clinic to see patient next day group mail Left leg with 1-2+ edema, wrapped with ace wrap up to thigh to reduce edema
Acute DVT Case 2 Day 2 Next day Thrombophilia Clinic calls patient to arrange for consultation after receiving information from ED Patient receives injection of LMWH at infusion center
Acute DVT Case 2 Day 3 Consultation performed by NP in conjunction with RN History and physical obtained Edema down to near normal size of limb Pain down to near no pain Given prescription for LMWH (after confirming with Patients insurance) for self- injection until INR therapeutic Patient given instruction and gives return demonstration for injection technique Provided with calendar outlining dose, INR, and when too return to see Primary care provider Prescription filled for 30-40 mmhg graduated compression stocking to be worn from morning until night when it is removed
Acute DVT Case 2 Arrange for INR for day 5 Holiday weekend. Primary provider office closed Venipuncture at local ER with results faxed to hospital consultant Telephone call by outside lab to covering provider on weekend, who has been given report on patient. Call patient with INR and when to see primary provider for repeat INR in 2 days and dose of warfarin to take Follow-up with primary provider on Wednesday Fax of continuing care directives to primary care provider Phone call to reception desk to confirm information tranferred
Case 2 - Summary Communication occurred throughout all phases of transition of care Involved several different areas for care Coverage during Holidays Patient set up for best possible outcome with consideration for future sequelae Post-thrombotic syndrome 30% develop venous claudication 10% develop significant decrease in functional capacity 10% go on to develop ulcers (76% recurrence rate of ulcer development)