Cutting delays in reversing anticoagulation after intracerebral haemorrhage: three key changes at a UK comprehensive stroke centre

Prothrombin complex concentrate (PCC) reduces the risk of early haematoma expansion after intracerebral haemorrhage in patients taking vitamin K antagonists (VKA-ICH), so must be given without delay. We sought to identify and remove key barriers to rapid administration of PCC at our centre. We describe a single UK comprehensive stroke centre cohort study with mixed retrospective (1/1/2008 to 1/12/2010) and prospective (1/12/2010 to 31/7/2014) participant identification and a survey of UK stroke physicians. Seven hundred and thirteen ICH patients were admitted during the study period. Sixty nine of these patients were VKA-ICH. Patients not admitted on the acute stroke pathway (n=8) or who had palliative care commenced immediately on admission (n=6) were excluded, leaving 55 patients in the final analysis. During 2011/12 we identified and implemented service changes to reduce delays in PCC administration. The primary outcome was the time interval between diagnostic brain scan and commencement of PCC treatment (scan-to-needle time). Secondary outcomes were the time interval between admission and commencement of PCC (door-to-needle time) and symptom onset and commencement of PCC (onset-to-needle time). Three key barriers were identified to rapid administration of PCC, including haematology consultation, collection of PCC from the transfusion laboratory, and obtaining the laboratory INR result. Our survey indicated that these barriers existed at most UK centres. We implemented point-of-care INR testing, moved PCC to the emergency department, and agreed a protocol to administer PCC autonomously. Our scan-to-needle time more than halved, from a median of 127 min (interquartile range (IQR), 111 to 208 min) prior to service changes to 58 min (IQR 50 to 91 min; p<0.001) afterwards. We have substantially reduced delays in delivering PCC to VKA-ICH patients at our centre and our simple changes could be easily implemented at centres facing similar barriers.