If you handle medical negligence cases, you have probably received calls concerning a death after a doctor failed to provide a spouse or loved one with DVT prophylaxis and the patient died from a PE. Every year, approximately 600,000 people are hospitalized in the United States for deep vein thrombosis (DVT) and its primary complication, pulmonary embolism (PE).1 More people die from DVT complications in the United States than from breast cancer and AIDS combined.2
These rates of DVT-related hospitalization and death can be significantly lowered by following DVT risk stratification guidelines and applying prophylactic treatment in more cases. One test in particular, the Caprini Risk Assessment Model (the “Caprini RAM”), has been an especially valuable tool in the fight against DVT. A patient’s Caprini score can also be a helpful place to start when evaluating a potential DVT prophylaxis case.
Dr. Joseph A Caprini developed his DVT Risk Assessment Model (the “Caprini RAM”) over a decade ago, based on both published data and his own clinical experience working with DVT patients.3 Over the past decade, Dr. Caprini has updated his framework for determining a patient’s potential DVT risk as well as his prophylaxis recommendations.4 In his research, he found that a patient’s likelihood of developing DVT directly correlated with the patient’s total number of risk factors. However, he also noted that certain risk factors had a much stronger correlation with DVT than others. Dr. Caprini gave each risk factor a weighted point scale, depending on the likelihood that a patient with that risk factor would develop DVT.
Today, many medical providers routinely consider a patient’s Caprini RAM score before a surgical procedure to determine the patient’s risk of developing DVT and the best strategy for prophylaxis. Although many medical associations have not formally accepted the Caprini RAM as the standard of care for doctors in their specialty area (the largest example is the American Academy of Orthopedic Surgeons) the model has been validated for determining the DVT risk of general, urologic, vascular, and plastic surgery patients.5 Several national medical associations have even adopted clinical practice guidelines encouraging their members to consult the Caprini RAM before determining a patient’s potential DVT risk.6
The Caprini RAM is easy to use. Each risk factor is weighted on a scale from 1 to 5 points. A doctor or medical negligence attorney simply has to mark each risk factor on the chart and then add up the points. If a patient has a DVT risk factor score of 5 or more points then the patient is at high risk for potentially developing DVT and a doctor should consider different strategies for DVT prophylaxis.7 There are many risk factors, but a few of them are age, pre-existing medical issues, family and personal history of DVT/PE, and the type and duration of the planned surgical procedure. An example of the use of the Caprini RAM in a university-based hospital can be found at www.med.umich.edu/clinical/images/VTE-Risk-Assessment.
If a patient is at high risk for developing DVT, a doctor’s plan should usually include prophylactic anticoagulation therapy unless the patient has specific “increased bleeding” risk factors that outweigh the benefits of anticoagulation therapy. In those cases, the doctor should consider other strategies, such as mechanical prophylaxis, for lowering the risk of DVT.
When evaluating a potential DVT case, use the Caprini RAM to determine the patient’s risk for developing DVT at the time of a procedure. Next, review the medical records to determine whether the patient’s provider acknowledged the patient’s DVT risk and/or considered the potential risks and benefits of anticoagulation and mechanical prophylaxis. It may be a viable case if the doctor failed to properly assess the patient’s DVT risk, or acknowledged the patient’s risk but failed to consider prophylactic treatment options.
Hopefully, the wide distribution and simplicity of the Caprini RAM will lower the number of patients who suffer from DVT complications every year. For an attorney involved in a DVT/PE case, it is also a very useful tool in evaluating whether a health care provider acted negligently in not assessing the need for DVT prophylaxis.
Endnotes:
1. Murin et al. Thromb Haemost. Comparison of the Outcomes after Hospitalization for Deep Venous Thrombosis or Pulmonary Embolism. 2002; 88:407-14.
2. Gerotziafas GT, Samama MM. Prophylaxis of venous thromboembolism medical patients. CurrOpin PulmMed. 2004; 10:356-365.
3. Motykie GD, et al. A Guide to Venous Thromboembolism Risk Factor Assessment, J. Thromb Thrombolysis 2000; 9: 253-262.
4. Caprini JA, et al, Effective Risk Stratification of Surgical and Nonsurgical Patients for Venous Thromboembolic Disease. Semin Hematol 2001; 38:12-9; Caprini JA, Thrombosis Risk Assessment as a guide to Quality Patient Care, Dis Mon 2005; 51: 70-78; Caprini JA, Risk Assessment as a Guide for the Prevention of the Many Faces of Venous Thromboembolism, American Journal of Surgery 2010, Vol. 199, No. 1S.
5. Pannucci CJ et al, Validation of the Caprini Risk Assessment Model in Plastic and Reconstructive Surgery Patients, J Am Coll Surg. 2011 January; 212(1): 105–112; Zakai NA, et al. Risk Factors for Venous Thrombosis in Medical Inpatients: Validation of a Thrombosis Risk Score, J. Thromb Haemost 2004; 2: 2156-2161; Bahl V. Hu HM, et al., A Validation Study of a Retrospective Thromboembolism Risk Scoring Method, Ann. Surg. 2009; 241: 344-50.
6. See e.g. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, J. Chest, February 2012 Supplement, 141/2: 7S-47S;
Evidence-based Practices for Thromboembolism Prevention: A Report from the ASPS Venous Thromboembolism Task Force Approved by ASPS Executive Committee: July 2011; American Society of Plastic Surgeons, July 2011 at http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/key-issues/ASPS_VTE_Report.pdf
7. Bahl V. Hu HM, et al., A Validation Study of a Retrospective Thromboembolism Risk Scoring Method, Ann. Surg. 2009; 241: 344-50 (A recent publication at the University of Michigan suggests that a Caprini score higher than 8 places a patient at “super high risk” of developing DVT without prophylaxis).
Gene Moen, WSAJ EAGLE member, is a partner in the firm of Chemnick Moen Greenstreet, which limits its practice to medical negligence claims. Bill Chemnick, an associate in the firm, assisted in research for this article.
This article originally appeared in the January 2014 Trial News, found here:
https://www.washingtonjustice.org/index.cfm?pg=trialNewsDB&tnType=view&indexID=10465
Publication Date: January 2014
Volume: 49-5
Author: Eugene M. Moen
Categories: Medical Negligence, Medical Issues, Medical Records
