Abstract 1251: Anticoagulation Management: Optimizing INR Levels in a Large Cardiology Practice
Background: When monitoring anticoagulation using international normalized ratio (INR) values, an electronic medical record (EMR) may be beneficial in evaluating patient management accuracy and efficacy by providing data regarding factors which promote optimal therapeutic outcomes.
Methods: We recorded 20,799 INR values from 1552 EMR records during a one year period from our 30 physician cardiovascular practice. This anticoagulation data includes the INR levels along with the corresponding changes to the warfarin dosage and identifies the registered nurse (RN) managing each value. Thirty-eight RNs were surveyed to determine the method and comfort level used to manage prescribed INR levels. Copies of the various algorithms and protocols were obtained. The RNs’ individual levels of comfort were scored on a 1 to 5 scale (1-not comfortable at all, 3-somewhat comfortable, 5-very comfortable). Each INR was scored to reflect its proximity to the prescribed INR range. (0=therapeutic, 1=sub-therapeutic, 2=supratherapeutic.
Results: Over a one year period, 38 RNs managed a total of 19,919 INR values of which 11,889 (59.7%) were therapeutic, 5,090 (25.5%) were sub-therapeutic, and 2,940 (14.8%) were supra-therapeutic. Each RN managed an average of 524 +/− 404 INRs (range 25–1,565). The comfort level scores suggested a high level of comfort with an average score of 4.8 +/− 0.5. Management methods used were personal experience (46%), standard protocols (44%), and physician directed algorithms (10%). By univariate analysis, maintenance of therapeutic anticoagulation correlated with the individual RN managing the INRs (p<.0001), the volume of INRs the RN managed (p=.0009), the INR management method (p=.04), and the algorithm type (p=.0014). By multivariate analysis, the only predictors of a therapeutic INR were the individual RN providing INR management and volume of INRs the RN managed.
Conclusions: This large database analysis supports the role of an RN-managed INR clinic based on experience and defined algorithms for the effective management of anticoagulation in a large cardiovascular practice.