Ms Inaam Safatly1, Dr Hugh  Singleton1, Ms Kelly  Decker1, Ms Cristina Roman1, Dr Adam Bystrzycki1, Professor Biswadev Mitra1
1Emergency and Trauma Centre, The Alfred, Melbourne, Australia

Introduction:  In clinical practice warfarin is a challenging medication to manage due to its narrow therapeutic index and potential for many significant medication interactions.  Numerous international healthcare systems have developed appropriate guidelines to improve the safe use of warfarin.  However, despite these guidelines adverse events to warfarin are common.
Aim:  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) evidence-based guidelines for management of patients that presented to the Emergency Department (ED) with supratherapeutic INR levels. Supratherapeutic INRs, especially those exceeding 4.5, are associated with increased risk of haemorrhage.
Methods:  A pre and post intervention cohort study was conducted. The intervention involved the development and delivery of an educational program in accordance with the current THANZ guidelines. Retrospective data from 1 July 2014 to 30 June 2015 and prospective data 1 Jan 2016 to 31 Dec 2016 were collected on ED patients currently anticoagulated with warfarin. This study was conducted in a large tertiary care hospital in Melbourne, Australia where subjects included all consecutive patients in the study periods that presented to the ED with an initial INR result of >4.5 on warfarin only. Subjects managed by an admitted team or anticoagulated with direct oral anticoagulants were excluded. Data collection included baseline demographics, medical history, INR results, bleeding risk assessment, the presence of active bleeding, and administration of fresh frozen plasma, prothrombinex and vitamin K.
Results: Data on 158 patients with an INR >4.5 were collected. Of these, data on 46 patients were excluded. Overall management in 31 (27.7%) patients did not follow recommended guidelines. There was no difference detected between pre and post groups with 17 (28.3%) compliant with guidelines pre-intervention and 14(26.9%) 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.

Inaam Safatly is a registered nurse currently working in the Emergency and Trauma Centre of The Alfred Hospital.  As a novice researcher, Inaam saw the opportunity of undertaking a department quality project with numerous senior multidisciplinary staff as a learning opportunity.