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Point of Care for INR
Yvonne Koolman, Nicole Keech,
Amy Nelson-Long & Sue Vansteel
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:
o Warfarin sodium or Coumadin
o Lovenox
o Aspirin
o Enoxaparin (administered IV).
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
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 costeffect, increases responsiveness to
management of anticoagulation therapy
and improves patient satisfaction.
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
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.
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.
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
Literature Review
Article 1
• Self-monitoring of oral anticoagulation:
•
•
•
systematic review and meta-analysis of
individual patient data
Authors sought to clarify the value of selfmonitoring 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
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
Managing Anticoagulation Clinic
Article 2
•Clinic
•Provides guidance for establishing
•
anticoagulation clinics using a POC INR
device.
Computerized system to determine dosage
based on results.
Article 2
•Benefits
•Autonomy in patients own treatment.
•Increased self-management.
•Patient self testing
Article 2
•Criteria for selecting POC INR device
•Ease of use.
•Speed at which results are produced.
•Reliability of device in terms of:
o Evidence-based purchasing
o International sensitivity Index (ISI) of close to
1.0 in line with World Health Organization
recommendation
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
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
Comparing Point of Care International
Normalised Ratio testing with laboratory testing
methods in a cardiac inpatient setting
Article 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
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
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.
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.
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)
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 laboratorybased 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 Patientfocused Model. The Nurse Practitioner, 29(8), 46-47.
Reference
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•
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Bradford, K., Tyndel,
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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/S01406736(11)61294-4
Murray RGN, MSc, PhD, E. (2007). Managing Anticoagulation. Practice Nurse
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Retrieved May 30, 2012, from CINAHL (2009569414).