Emergency management of patients with supratherapeutic INRs on warfarin: A multidisciplinary education study

Inaam Safatly, Hugh Singleton, Kelly Decker, Cristina Roman, Adam Bystrzycki, Biswadev Mitra

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Objective Supratherapeutic INRs exceeding 4.5 are associated with increased risk of haemorrhage. The aim of this study was to evaluate the efficacy of an educational program focused at improving emergency clinician compliance with the Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) guidelines. Design A pre and post-intervention study was undertaken. Retrospective data from 1 July 2014 to 30 June 2015 and prospective data 1 January 2016 to 31 December 2016 were collected. Setting This study was conducted in a large tertiary care hospital in Melbourne, Victoria, Australia. Subjects Included were all consecutive patients in the study periods that presented to the emergency department with an initial INR result of >4.5 on warfarin only. Interventions Development and delivery of an educational program in accordance with the current THANZ guidelines was implemented. Main outcome measures To improve education regarding the correct management of emergency patients on warfarin with a supratherapeutic INR. Results Data on 158 patients with an INR >4.5 were collected. Data on 46 patients were excluded. Management in 31 patients did not follow recommended guidelines. There was no difference detected between groups with 17 compliant with guidelines pre-intervention and 14 post intervention; p=0.87.Conclusion Emergency department management of patients on warfarin with supratherapeutic INR’s requires continual quality improvement. Frequency of emergency clinician compliance with the current evidence-based guidelines was moderate and did not improve significantly with targeted education. This highlights the complexities of warfarin management and the need for multi-disciplinary engagement of patients presenting with supratherapeutic INRs.

Original languageEnglish
Pages (from-to)6-13
Number of pages8
JournalAustralian Journal of Advanced Nursing
Issue number2
Publication statusPublished - 1 Dec 2018


  • Anticoagulant
  • Emergency management
  • Guidelines
  • INR
  • Reversal
  • Supratherapeutic
  • Vitamin K
  • Warfarin

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