title: Improving the use and timeliness of anticoagulation reversal for warfarin related intracranial haemorrhage.
abstract: BACKGROUND
  Warfarin-related intracranial haemorrhage (WRICH) is a life-threatening complication of warfarin use. Rapid and complete reversal of the coagulopathy is required. Reversal protocols which include prothrombin complex concentrates (PCC) are now recommended. We report on a quality improvement project to implement and refine such a protocol.
  
  
  METHODS
  Retrospective and then prospective audits of all WRICH patients presenting to a single centre. The protocol development and subsequent refinements are described. Outcomes included times to scanning, treatment and overall door-needle times, as well as use of PCC.
  
  
  RESULTS
  Across the three cohorts, use of PCC increased over time from 15% to 100% of eligible patients (p<0.001). There were significant improvements in median time to scanning (1.9 to 1.5 to 1.3 hours, p=0.03) and median door-needle times (4.5 to 2.9 to 1.9 hours, p=0.018). Key steps in the change process included (1) identifying need for change, (2) utilising senior clinical opinion leaders, (3) using "Plan-do-study-act" cycles, (4) involvement of all relevant stakeholders, (5) having a broad implementation and education plan, (6) a "change friendly" environment and (7) collaborating across departments.
  
  
  CONCLUSIONS
  The introduction (and revisions) of an anticoagulation reversal strategy for WRICH has led to increased PCC use and reduced times to both diagnosis and treatment. Further work is required to improve door-needle times and monitoring.
authors.affiliation: Older Persons Health Specialist Service, Burwood Hospital, Stroke Service, Christchurch Hospital, Department of Medicine, University of Otago, Christchurch.
authors.forename: Carl
authors.initials: C
authors.lastname: Hanger
authors.affiliation: Older Persons Health Specialist Service, Burwood Hospital, Department of Medicine, University of Otago, Christchurch.
authors.forename: John
authors.initials: J
authors.lastname: Geddes
authors.affiliation: Older Persons Health Specialist Service, Burwood Hospital, Department of Medicine, University of Otago, Christchurch.
authors.forename: Tim
authors.initials: T
authors.lastname: Wilkinson
authors.affiliation: Older Persons Health Specialist Service, Burwood Hospital, Department of General Medicine, Christchurch Hospital, Christchurch.
authors.forename: Michele
authors.initials: M
authors.lastname: Lee
authors.affiliation: Emergency Department, Christchurch Hospital, Christchurch.
authors.forename: Scott
authors.initials: S
authors.lastname: Pearson
authors.affiliation: Haematology Department, Christchurch Hospital, Department of Medicine, University of Otago, Christchurch.
authors.forename: Andrew
authors.initials: A
authors.lastname: Butler
authors.affiliation: New Zealand Blood Service, Christchurch.
authors.forename: Krishna
authors.initials: K
authors.lastname: Badami
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects*; D001777:Blood Coagulation / Q000187:drug effects; D001779:Blood Coagulation Factors / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced* / Q000175:diagnosis / Q000188:drug therapy*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates; D014859:Warfarin