Converting patients from warfarin to non-vitamin K antagonist oral anticoagulants.

Background: Non-vitamin K antagonist oral anticoagulants (NOACs) are favorable in stroke prevention for geriatric patients with nonvalvular atrial fibrillation versus warfarin. These anticoagulants do not require international normalized ratio (INR) monitoring and have lower food/drug interactions. In addition, NOACs have risk reduction in bleeding and all-cause mortality compared with warfarin.

Local Problem: At a geriatric primary care practice, two registered nurses manage 88 patients on warfarin for INR monitoring. Nurse practitioners (NPs) provide oversight for warfarin titration after abnormal results. The goal of this quality-improvement project was to decrease the time spent monitoring patients on warfarin.

Methods: Primary care providers and cardiologists of patients on warfarin were contacted to gain approval of transition to a NOAC. The NP reviewed patients' renal function and the indication for anticoagulation and then created a list of eligible patients for transition.

Interventions: Patients eligible for transition to NOACs were contacted for their consent. The transition process included stopping warfarin, ordering apixaban, ordering INR level, educating about starting apixaban, and coordinating appropriate follow-up.

Results: Of 88 patients on warfarin, 21 were eligible for conversion from warfarin to apixaban. Of these 21 patients, 66% ( n = 14) consented to the conversion. Of those who were not converted to apixaban, five declined due to cost and two were lost to follow-up.

Conclusion: There was a reduction in nurses' monthly monitoring of patients on warfarin by 22%. Transition to NOAC was not only beneficial for patient safety and efficacy but also reduced nursing clinical time for anticoagulation encounters.