Elevated international normalized ratio in the ED: clinical course and physician adherence to the published recommendations.
OBJECTIVE
Describe the course of patients with an elevated international normalized ratio (INR) in the emergency department (ED) and determine physicians' adherence with treatment recommendations.


METHODS
One-year retrospective review of all ED patients with an INR >5.0.


RESULTS
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.


CONCLUSIONS
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.
Atreja
Ashish
A
Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
El-Sameed
Yaser Abu
YA
Jneid
Hani
H
Hoogwerf
Byron J
BJ
Peacock
William Frank
WF
D000293:Adolescent; D000328:Adult; D000368:Aged; D004635:Emergency Medicine / Q000592:standards* / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006470:Hemorrhage / Q000097:blood / Q000188:drug therapy; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D019934:International Normalized Ratio / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009820:Ohio; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D014812:Vitamin K / Q000627:therapeutic use; D014859:Warfarin / Q000627:therapeutic use
D014812:Vitamin K; D014859:Warfarin