Reducing the rate of iatrogenic supratherapeutic INR due to warfarin administration

From the 2023 HVPA National Conference

Erwin Wang MD (NYU Langone Health), Joseph Eskandrous PharmD, BCIDP

Introduction:
Warfarin is associated with greater bleeding risk and morbidity than direct oral anticoagulants (DOACs). Warfarin use has decreased with more ubiquitous use of DOACs, though warfarin remains the only anticoagulant in certain scenarios, e.g., clinically due to such conditions as valvular atrial fibrillation or psychosocially due to such reasons as lack of insurance. Less frequent use of warfarin has led to diminished trainee familiarity with dosing, exposing patients to increased risk of morbidity.

Methods:
In the pre-intervention time period (2021 Q2 – 2022 Q1), patients at NYU Langone Hospital – Brooklyn experienced iatrogenic supratherapeutic INRs during warfarin administration at a rate of 8.0%, a rate that exceeded peer institutions. Leveraging existing EMR infrastructure, a clinical pharmacist was tasked with reviewing system lists that displayed any patient receiving warfarin. The pharmacist would complete two key tasks for each patient: 1) determine patient’s eligibility to switch from warfarin to DOAC and, if eligible, would discuss the change with the patient and the primary team; 2) for patients still needing continued warfarin administration, provide education to primary teams about appropriate dosing.

Results:
The clinical pharmacist was able to reduce the rate of patients taking warfarin by 16% in the post-intervention time period (2022 Q2 – 2023 Q1). The most common reasons patients did not switch were clinical contraindication and patient unwillingness; a number of patients were made aware of social programs to defray DOAC out-of-pocket costs. The rate of iatrogenic supratherapeutic INR decreased by 83% with only a single incident out of 75 patients.

Discussion:
Leveraging EMR-based system lists and an already staffed clinical pharmacist, our hospital saw a significant reduction in the rate of iatrogenic supratherapeutic INR in the setting of warfarin administration. Many patients were also converted to DOAC, and trainees were exposed to meaningful education about a less commonly used medication.

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