A Pre-­‐ Post-­‐Evaluation of Implementing an Inpatient Warfarin Monitoring and Education Policy

Abstract

OBJECTIVES: The objective of this study was to evaluate whether implementation of new anticoagulation policy at a community hospital resulted in better monitoring of warfarin, increased warfarin patient education prior to discharge, and less bleeding complications due to warfarin. METHODS: This study was a pre-­‐ post-­‐retrospective chart review quality improvement study. A retrospective chart review was conducted of all patients who were inpatients and received warfarin in the time period of April 1, 2008 to July 31, 2008 (historical control group before implementation of the new anticoagulation program) and the time period of April 1, 2009 to July 31, 2009 (after implementation of the new anticoagulation policies). To compare appropriateness of laboratory monitoring, the frequency of warfarin-­‐related laboratory orders that included a baseline international normalized ratio (INR), daily INR, baseline complete blood count (CBC), and CBC every 3 days were assessed before and after program implementation. The analysis was repeated for the frequency of patient education that included documentation by pharmacy, nursing, and dietary services. Finally, data was collected to determine frequencies of bleeding complications associated with warfarin. RESULTS: There were 112 patients in the pre-­‐policy group and 115 patients in the post-­‐policy group. After implementation of the inpatient warfarin policy, obtaining baseline INRs increased from 74% to 90% (p=0.001). In addition, prescriber orders for baseline CBCs increased from 85% to 94% (p=0.026). Obtaining CBCs every 3 days increased from 54% to 74%, (p<0.001). However, there was not a significant increase in orders for daily INR levels (p=0.055). Education by nursing increased from 54% to 80%, (p<0.001). Education by pharmacy increased from 8% to 76%, (p<0.001). Education by dietary increased from 11% to 79%, (p<0.001). Moreover, documentation by all three disciplines in each patient increased significantly from 3.6% to 59%, (p<0.001). There were significantly fewer patients receiving vitamin K and/ or fresh frozen plasma for supratherapeutic INRs with bleeding complications after the policy was initiated compared to baseline (p=0.009). CONCLUSIONS: The implementation of an inpatient warfarin policy led to better monitoring of patients receiving warfarin, and increased patient education. Studies have demonstrated that increased monitoring of warfarin translates to improved patient outcomes. However, a larger and longer assessment is necessary to determine if these changes are maintained and how these changes affect clinical outcomes.