Elevated international normalized ratio in the ED: clinical course and physician adherence to the published recommendations

• Published in: The American journal of emergency medicine 2005, Vol.23 (1), p.40-44
• Main Authors: Atreja, Ashish, El-Sameed, Yaser Abu, Jneid, Hani, Hoogwerf, Byron J., Peacock, William Frank
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Blood clots; Emergency and intensive cardiocirculatory care. Cardiogenic shock. Coronary intensive care; Emergency medical care; Emergency Medicine - standards; Emergency Medicine - statistics & numerical data; Emergency Service, Hospital - statistics & numerical data; Ethics; Female; Guideline Adherence - statistics & numerical data; Heart attacks; Hemorrhage - blood; Hemorrhage - drug therapy; Hospitalization; Hospitalization - statistics & numerical data; Humans; Hypotheses; Intensive care medicine; International Normalized Ratio - statistics & numerical data; Male; Medical sciences; Medicine; Middle Aged; Multivariate analysis; Ohio; Outcome and Process Assessment (Health Care); Practice Guidelines as Topic; Retrospective Studies; Vitamin K - therapeutic use; Warfarin - therapeutic use
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2004.01.005

Describe the course of patients with an elevated international normalized ratio (INR) in the emergency department (ED) and determine physicians' adherence with treatment recommendations. One-year retrospective review of all ED patients with an INR >5.0. Ninety-four patients met the entry criteria. Bleeding was present in 28.7% patients. Two thirds of the major bleeding episodes were of gastrointestinal origin. Physicians' adherence decreased as bleeding and INR increased. At the lowest risk, adherence was 66.6%, whereas at the highest risk, it was 36.3%. Two thirds of patients were admitted to the hospital, one fourth were discharged, and 7.4% were observed in an observation unit. Average length of stay was 3.8 days. Adherence to the recommendations regarding managing elevated INR was suboptimal. There is a need for formal endorsement of recommendations by emergency medicine organizations and development of disposition criteria based on bleeding status and site of bleeding.