title: Elevated international normalized ratio in the ED: clinical course and physician adherence to the published recommendations.
abstract: 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.
authors.affiliation: Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
authors.forename: Ashish
authors.initials: A
authors.lastname: Atreja
authors.forename: Yaser Abu
authors.initials: YA
authors.lastname: El-Sameed
authors.forename: Hani
authors.initials: H
authors.lastname: Jneid
authors.forename: Byron J
authors.initials: BJ
authors.lastname: Hoogwerf
authors.forename: William Frank
authors.initials: WF
authors.lastname: Peacock
mesh_terms: 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
chemical_list: D014812:Vitamin K; D014859:Warfarin