Never Event

Filed under: by: Hey Doc Wait

I once treated a patient who experienced a deep venous thrombosis while in the hospital. This unfortunate person was being treated for acute MI, on heparin drip until they went to the cath lab, so heparin was held that morning prior to cath. That night and the next day, the patient was at risk for bleeding after the cath, so heparin was held, and started at a low dose for DVT prophylaxis that night (just over 24 hours post-cath). Patient received 2 doses of subcutaneous heparin, and on the second morning after the cath began to complain of leg pain and swelling. Ultrasound revealed a DVT. The other kicker? This patient has a below-the-knee amputation of one leg, and the DVT developed on that same side. I'm not sure what the evidence is for using sequential compression devices in patients with only one leg (and terrible peripheral vascular disease) but we had elected not to do so.

Other than the SCD (which we considered, and rejected), there really wasn't anything else we could have done differently. We were stuck between the risk of bleeding (the cath was done from a "high stick" to go above a femoral stent and therefore was at higher risk of bleeding, at least according to my attending) and the risk of DVT. Patient did not bleed, but did have a DVT. If this patient were a Medicare patient, none of the treatment (which includes IV heparin drip with nursing protocols, extended hospitalization, starting warfarin treatment, etc) would be paid for under the "never event" policy. But is this a never event? This patient had terrible peripheral vascular disease, HTN, diabetes, and history of previous DVT--their risk was extremely high to begin with. The patient did not receive anticoagulation for less than 48 hours, but was still taking aspirin and Plavix during this time, which (one would hope) provided at least some small amount of protection against platelet aggregation and clot formation. If we had treated the patient more aggressively with anticoagulation, would they have bled out onto the cath table or developed a large hematoma at the cath site? Would Medicare cover these complications of the anticoagulation?

I think the never event policy is really stupid. Amputating the wrong leg? Fine, don't pay for that, I completely understand. But a hospital acquired UTI? Pneumonia? DVT? Pressure ulcer? Show me the clinical guidelines that tell me how to prevent 100% of these known risks and I'll buy the never event thing. But until we know how to prevent 100% of these complications, they cannot be considered "never" events.

Oh, and I am a resident, paid a salary; my attending is on salary; we do not get paid extra for causing complications in our patients (which was one reason behind the "never event" policy).