title: Warfarin-associated intracerebral hemorrhage is inadequately treated at community emergency departments.
abstract: OBJECTIVE
  The purpose of this study was to investigate time delays, adherence to guidelines, and their impact on outcomes in patients with warfarin-associated intracerebral hemorrhage transferred from community emergency departments to a comprehensive stroke center.
  
  
  METHODS
  We collected demographic, clinical, transfer time, treatment, and outcome data for patients transferred to our institution with warfarin-associated intracerebral hemorrhage from community emergency departments.
  
  
  RESULTS
  Among 928 patients with intracerebral hemorrhage, 56 (6%) with warfarin-associated intracerebral hemorrhage (median international normalized ratio, 2.55) were transferred to the comprehensive stroke center. Twenty patients received no acute reversal therapy before transfer, only 4 of whom had international normalized ratios ≤1.4 in the community emergency department. Median time of emergency department stay was 3.66 hours and median time to initiation of acute reversal therapy was 4.48 hours. Those who received ≥3 U of fresh-frozen plasma or recombinant activated Factor VIIa (11 patients) before transfer had lower repeat international normalized ratios and better discharge dispositions than those treated less aggressively.
  
  
  CONCLUSIONS
  Treatment of warfarin-associated intracerebral hemorrhage in community emergency departments is often suboptimal and does not adhere to published guidelines. Treating coagulopathy aggressively before interhospital transfer may improve outcomes and warrants further investigation.
authors: Cerebrovascular Disease and Neurocritical Care, Northwestern, University-Feinberg School of Medicine, Chicago, IL, USA.
authors: Eric M
authors: EM
authors: Liotta
authors: Rajeev K
authors: RK
authors: Garg
authors: Richard E
authors: RE
authors: Temes
authors: Sayona
authors: S
authors: John
authors: Vivien H
authors: VH
authors: Lee
authors: Thomas P
authors: TP
authors: Bleck
authors: Shyam
authors: S
authors: Prabhakaran
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects* / Q000037:antagonists & inhibitors; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000401:mortality / Q000628:therapy*; D003151:Community Health Centers; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D015942:Factor VIIa / Q000627:therapeutic use; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D010949:Plasma; D012042:Registries; D013997:Time Factors; D014859:Warfarin / Q000009:adverse effects* / Q000037:antagonists & inhibitors
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D015942:Factor VIIa