Point of Care for INR

1. Point of Care for INR • Yvonne Koolman, Nicole Keech, Amy Nelson-Long & Sue Vansteel

2. Point of Care for INR • Introduction • Large proportion of patients, from long term care, acute care and home care settings require anticoagulant (blood thinning) medications. • These medications include: • Warfarin sodium or Coumadin • Lovenox • Aspirin • Enoxaparin (administered IV).

3. Why INR • The"Gold Standard" monitoring patients on anticoagulants is laboratory based venipuncture for INR and PT • Sub-therapeutic anticoagulation: can increase the risk of clot formation, thereby increasing the risk of stroke or venous thromboembolism • Supra-therapeutic anticoagulation: increases the risk for bleeding • Donaldson, 2010

4. Purpose • Critically analyze available literature to determine the relevance of Point of Care INR testing for inpatient and outpatient settings. • To demonstrate POC INR testing is cost-effect, increases responsiveness to management of anticoagulation therapy and improves patient satisfaction.

5. Problem • Lengthy turnaround time for the lab results has been demonstrated to cause delays in management of anticoagulation therapy. • Decreased compliance with getting labs drawn and medication changes • Patients unable to obtain transportation to the lab • Decreased patient satisfaction related to lab wait time. • Affects the patient's quality of life

6. Hypothesis • A review of literature will demonstrate POC INR testing is relevant in outpatient and inpatient setting. • Use of POC INR testing is cost-effective and decreases the time from results to management of anticoagulation therapy.

7. POC for INR • POC testing requires reduced amount of blood to perform test thus the ability to use a finger prick instead of a venipuncture • Point of Care (POC) testing- blood specimen is obtained from the patient with a handheld device. • Results are reported within minutes.

8. Point of Care for INR • Point of Care (POC) INR testing devices has been utilized in outpatient settings • Benefits • Instant results • Reduce delays in management of anticoagulation therapy • Prevent adverse reaction • Cost-effective • Improved patient satisfaction

9. Literature ReviewArticle 1 • Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data • Authors sought to clarify the value of self-monitoring of oral anticoagulation • Of 1357 abstracts, 11 trials were included in the study for a total of 6416 participants. • Study indicated a significant reduction in thromboembolic events in the self-monitoring groups

10. Article 1 cont • Study did not show significant reductions in major hemorrhage or death • Participants younger than 55 years and participants with mechanical heart valves showed a striking reduction in thrombotic events • Analysis of the very elderly (age > 85 years) showed no significant adverse effects of the intervention for all outcomes

11. Managing Anticoagulation ClinicArticle 2 • Clinic • Provides guidance for establishing anticoagulation clinics using a POC INR device. • Computerized system to determine dosage based on results.

12. Article 2 • Benefits • Autonomy in patients own treatment. • Increased self-management. • Patient self testing

13. Article 2 • Criteria for selecting POC INR device • Ease of use. • Speed at which results are produced. • Reliability of device in terms of: • Evidence-based purchasing • International sensitivity Index (ISI) of close to 1.0 in line with World Health Organization recommendation

14. Disease focused model compared to nurse managed model study • 90% of study participants remained within target range after 6 months of going to the clinic • All PT/INR done with POC testing in a nurse clinic during the study • Patients are able to get test results and new orders within their 15 minutes visits • No patients were admitted to the hospital related to their INR being out of therapeutic range

15. Article 3 cont. • 74 patients INR results were followed in the nurse clinic for 6 months • The use of POC testing assists with immediate results and the ability to educate related to the new dose thus improving overall medication management and health

16. Comparing Point of Care International Normalised Ratio testing with laboratory testing methods in a cardiac inpatient settingArticle 4 • POC testing was demonstrated to a viable method for INR testing in an outpatient setting. • Lack of research related to POC INR in inpatient setting • A prospective comparison study to analyze the efficacy of POC for INR in an inpatient setting was conducted

17. Article 4 cont. • 117 paired results of laboratory and POC INR results were compared • POC INR were blinded and not used for management of Warfarin dosing • Outcome of the study revealed there was close agreement in the results with significant correlation • With established guideline laboratory INR testing can be safely substituted using POC INR in an inpatient setting

18. Recommendations • Patients in an acute care, home care, long term care, and outpatient settings can benefit from the use of POC testing for PT/INR results to improve medication management and health. • Further research into the the possible scenarios where POC INR use would be beneficial to patient satisfaction and outcomes is necessary.

19. Conclusion • There is a potential to create change in acute care, long term care and outpatient setting with management of anticoagulation therapy. • Lab INR testing can be safely replaced with POC INR testing utilizing guidelines and protocols.

20. Conclusion • Comparison of INR from a lab and POC were significantly correlated. • Enhanced responsiveness for managing anticoagulation therapy is an outcome of POC INR in an inpatient and outpatient setting. • Additional benefits include “cost saving, increased patient comfort, and reduce handling errors” (Giles et al., 2009 pg. 3085)

21. References • Giles, Michelle T., Vicki Parker, Heather Bevan, and Ian MR Wright. Comparing point of care International Normalized Ratio testing with laboratory testing methods in a cardiac inpatient population. Journal of Clinical Nursing 19: 3085-91. CINAHL. • Burns, N. & Groves S. K. (2011) Understanding nursing research: Building an evidence-based. Maryland Heights, MO: Elsevier • Donaldson, M., Sullivan, J., Norbeck, A. 2010. Comparison of International Normalized Ratios provided by two point-of-care devices and laboratory-based venipuncture in a pharmacist-managed anticoagulation clinic. American Journal of Health-System Pharmacists- Vol. 67. DOI 10.2146/ahp100096 • j • Gesechwinger, R.F. (2004). Anticoagulation Therapy a Success with Patient-focused Model. The Nurse Practitioner, 29(8), 46-47.

22. Reference • Heneghan, C., Ward, A., Perera, R., Bankhead, C., Fuller, A., Stevens, R., Bradford, K., Tyndel, S., Alonso- Coelo, P., Ansell, J., Beyeth, R., Brenardo, A., Cristensen, T., Cromheecke, M., Edson, E., Fitzmaurice, D., Gadisseur, A., Garcia-Alamino, J., Gardiner, C., Hasenkam, M., Jacobson, A., Kaatz, S., Kamali, F., Khan, T., Knight, E., Kortke, H., Levi, M., Matchar, D., Menendez- Jandula, B., Rakovac, I., Schaefer, C., Siebenhofer, A., Souto, J., Sunderji, R., Gin, K., Shalansky, K., Voller, H., Wagner, O., Zittermann, A., The Self- Monitoring Trialist Collaboration (2012). Self- monitoring of oral anticoagulation: systematic review and meta- analysis of individual patient data. The Lancet. (379). DOI: 10.1016/S0140-6736(11)61294-4 • Murray RGN, MSc, PhD, E. (2007). Managing Anticoagulation. Practice Nurse Arp 6; 33(7) Retrieved May 30, 2012, from CINAHL (2009569414).