Improving Therapeutic INR Range for Anticoagulant Patients through Care Coordination

Background of the problem: Well-managed oral anticoagulant (OAC) therapy can reduce the risk of adverse events, including excessive bleeding or venous thromboembolism. The percentage of international normalized ratio (INR) values in therapeutic range for active chronic care clinic patients taking OACs, averaged 52.9% in 2018. Routine follow-up for INR checks is crucial and often challenging.

Objectives/purpose: The goal is to increase the percentage of active oral anticoagulant therapy patients in the chronic care clinic having an INR value in their recommended targeted range.

Literature review: Repeatedly missing INR value check has been associated with an increases risk for thromboembolic complications during warfarin therapy. Most patients treated with OACs spend the majority of their time with their INR values out of their recommended target range. Improving INR values within the recommended therapeutic range can reduce major adverse events. A systematic process for tracking patients should be used to minimize the possibility that a patient on warfarin therapy is lost to follow-up. Improving care coordination and the appropriate length of time between follow-up INR testing is critical to achieve the INR therapy goal.

Methods: The chronic care clinic implemented usage of an Epic tool, the INR reminder list, for all active clinic patients on OACs. Patients who are overdue for their INR check will show up in the INR reminder list. This list is reviewed daily by the LPN to make sure the patients have a follow-up appointment. The LPN reports to the RN with any patient having barriers to attending their appointment. The RN will coordinate their care based on the patients need. Coordination of care includes, but not limited to, transportation arrangements, pill box fill, and social worker consult.

Outcomes: Since initiating the project, the percentage of INR values in the targeted range improved from the average 52.9% to 56-57 % most months. Improving the process over time helped to sustain the percentage of INR values in target range. Nurses and support staff must work together to ensure that patients do not get lost in follow-up.

Conclusion: Maintaining INR values within therapeutic range is associated with better outcomes. Patients with multiple comorbidities are particularly challenging. Engaging in a patient-focused quality improvement project, with care coordination as an intervention, helps manage the OAC patient population and reduces their risk for adverse events.

Implications for nursing practice: Ambulatory care RNs provide leadership in coordination of services and collaborative efforts. The INR reminder list is a systematic process for tracking patients to minimize the lost to follow-up appointments. The INR reminder list helps to improve care coordination and the appropriate length of time between follow-up INR testing to help manage the OAC patients and reduce the risk of major adverse events while on anticoagulant therapy. Sustaining the process can be challenging; utilizing the plan/do/adjust/check cycle will assist in the progression of continual improvement.