Date of Award
Spring 5-21-2025
Document Type
Doctor of Nursing Practice Final Manuscript
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Joseph Burkard DNSc, CRNA, EBP-C, Professor, USD DNP / PhD Program
Abstract
Background: Maintaining a therapeutic International Normalized Ratio (INR) is essential to reduce bleeding and thromboembolic risks in patients on warfarin therapy. In a rural outpatient cardiac clinic serving a predominantly underserved population, many patients face financial and access barriers that preclude the use of newer non-vitamin K antagonist oral anticoagulants (NOACs). Patients with atrial fibrillation (AF) or mechanical valve replacements who rely on warfarin require consistent monitoring and management, which can be challenging in settings with limited resources and staffing.
Purpose: The purpose of this evidence-based pilot project was to improve therapeutic INR outcomes through the implementation of a standardized warfarin management protocol. The protocol included provider education, an EHR-based warfarin flowsheet, a physical binder for reference, and standardized follow-up intervals. The intervention was designed to promote safety and consistency in anticoagulation management for patients with atrial fibrillation or mechanical valve replacement.
Methods: Two nurse practitioners, one physician, and one medical assistant were educated on warfarin dosing protocols, INR thresholds (2–3 for AF, 2.5–3.5 for mechanical valves), and best practices for monitoring. INR data were tracked over six months using EHR queries and binder logs. The medical assistant assisted with patient follow-up, documented bleeding complications, and coordinated INR monitoring using the standardized protocol.
Evaluation of Outcomes/Results: Post-intervention chart reviews suggested an overall improvement in INR management. The frequency of in-range INR values appeared to increase over time. No adverse events such as major bleeding or thromboembolic complications were documented during the implementation period. These findings may reflect improved consistency in monitoring, enhanced provider awareness, and better patient follow-up, particularly in a rural setting with limited resources.
Conclusion: The implementation of a standardized warfarin management protocol appeared to improve INR control and patient safety within a rural cardiology clinic. This model is sustainable, clinically relevant, and adaptable for other resource-limited settings. Emphasizing workflow structure, provider education, and support staff involvement may enhance anticoagulation outcomes across underserved populations.
Digital USD Citation
Martinez, Tessa A., "Optimizing Warfarin Management in Cardiovascular Care" (2025). Doctor of Nursing Practice Final Manuscripts. 303.
https://digital.sandiego.edu/dnp/303
Copyright
Copyright held by the author
