A gap analysis on warfarin dosing management of time in the therapeutic range among adult patients with left ventricular assist device (LVAD) in the outpatient LVAD clinic

Purpose of ProjectDetermine if a gap analysis on warfarin dosing management of time in the therapeutic range (TTR) among patients with left ventricular assist device (LVAD) supports the adoption of a warfarin dosing algorithm in managing international normalized ratio (INR) levels in the LVAD ambulatory clinic.MethodThis was a retrospective gap analysis quality improvement project conducted at an outpatient LVAD clinic where four cardiologists and four nurse practitioners manage warfarin dose based on INR levels. ResultsA total of thirty-one charts were reviewed and identified as patients receiving LVAD support, and five charts were excluded from the gap analysis. The remaining charts consisted of twenty-two male and four female patients. The mean age was 57.8 years old. There were varying INR goals: 2 to 3, 2 to 2.5, and 1.4 to 2.2. Time in the therapeutic range was calculated using the Rosendaal Method, and poor anticoagulation control was defined as TTR less than 65%. Nine out of sixteen patients with an INR goal of 2 to 3 had TTR of 65% or better. Two patients with an INR goal of 2 to 2.5 were noted to have a TTR above 65%. All four patients with an INR goal of 1.4 to 2.2 had TTR less than 65%. Data revealed that 58% of the twenty-six patients had poor anticoagulation control. Implications for PracticeBased on these findings, the recommendation would be to share the results with key stakeholders and recommend adopting an evidence-based warfarin dosing algorithm. Following an algorithm would decrease practice discrepancies among the healthcare providers, leading to improved TTR goals. Future education is warranted among the providers and team members once the algorithm has been developed and approved.