practice partner
transferred to a long-term care home to live.
The patient was continued on enoxaparin in prophylactic doses following transfer to the long-term care home.
While at the long-term care home, she had several falls,
and struck her head on several occasions. She subsequently developed a large intra-cranial hemorrhage and died.
The patient was on appropriate venous thromboembolism (VTE) prophylaxis during her acute hospital stay
in accordance with the CHEST guidelines. (Using the
PADUA risk prediction model, the patient would have
scored five points (three for reduced mobility, one for age
70 years or older and one for acute infection). This risk
assessment model recommends VTE prophylaxis for any
score of ≥4 in acutely hospitalized patients (www.mdcalc.
com/padua-prediction-score-for-risk-of-vte).
Thromboprophylaxis was not, however, indicated
beyond the acute hospital stay and should have been
discontinued when the patient was transferred to the
long-term care home.
Patient B was an 87-year-old female who was admitted to an acute care hospital from a retirement home
with a sixth month decline in strength, weight and
hemoglobin. She was found to be anemic. She was
given VTE prophylaxis on admission using the acute
care hospital’s protocol which recommended enoxaparin
40 mg subcutaneously daily for patients with a creatinine clearance ≥ 30 ml per minute and a lower dose of
enoxaparin 20 mg daily for those with creatinine clear-
ance less than 30 ml per minute.
The patient was significantly under weight at 33.5
kg. Her creatinine on the day of admission was 77.
Using the Cockcroft-Gault formula, her creatinine
clearance was estimated to be 24 ml per minute. Dosing for enoxaparin for full anticoagulation is 1 mg
per kg and therefore, the patient was placed on even
greater than therapeutic doses of anticoagulation during her hospital stay. Anticoagulation was not discontinued until six days after noting frank rectal bleeding
by nursing staff.
Five days later, a hematology physician note indicated that there were still questions regarding the etiology of the anemia. The note did not acknowledge the
presence of rectal bleeding.
It is unclear if the physician read, or had easy access
to, the nursing documentation. Nursing and physician
documentation was not made in an interdisciplinary
format. Nursing documentation was made in the electronic record and physician documentation was hand
written on a paper progress note.
According to the CHEST guidelines, the VTE prophylaxis was indicated during the initial admission, but
anticoagulation should have been discontinued once
acute rectal bleeding was noted.
It is unlikely however, that the patient died as the
result of a gastrointestinal bleed as her hemoglobin was
relatively stable at 108 at the time of her death.
Recommendations
1 Physicians should familiarize
themselves with the American
College of Chest Physicians’ CHEST
guidelines (February 2012) with
respect to the use of venous
thromboembolic (VTE) prophylaxis
outside of the acute care setting.
2 Physicians should be sure t \