Before-After Study of an Electronic Order Set for Reversal of Vitamin K Antagonist

Abstract

Background:

Vitamin K antagonist (VKA)–associated intracerebral hemorrhages (ICHs) are more likely to expand and are associated with higher mortality than primary ICH. Prompt reversal of anticoagulant effect with prothrombin complex concentrate (PCC) may promote hemostasis and decrease hematoma expansion. The aim of this study was to evaluate the impact of an electronic order set designed to standardize and facilitate more timely reversal of coagulopathy in VKA-associated ICH.

Methods:

We identified all adults who received PCC for VKA-associated ICH from June 2012 to June 2015 at University of California San Francisco Medical Center, which included a period before and after an electronic order set became available in 2014. We abstracted baseline demographics and clinical data from electronic health records. The primary outcome was time from radiographic identification of ICH to administration of PCC.

Results:

Thirty-one patients received PCC for VKA-associated ICH, including 17 patients before and 14 patients after the order set became available. Baseline demographics and clinical features were similar. Order set use was associated with a significant decrease in the time from identification of ICH on imaging to the administration of PCC (median 83 vs 45 minutes; P = .02), more accurate dosing (29.4% vs 92.9%; P < .01), and a shorter time from the PCC order to follow-up international normalized ratio (INR) testing (median 164 vs 85 minutes, P = .001).

Conclusion:

An electronic order set for administering PCC for VKA-associated ICH was associated with significantly faster time to PCC administration and increased dosing accuracy.

Keywords

intracerebral hemorrhage anticoagulation reversal agents vitamin K antagonist warfarin prothrombin complex concentrate

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References

Barnes

Lucas

Alexander

Goldberger

. National trends in ambulatory oral anticoagulant use. Am J Med. 2015;128(12):1300–1305.

Fang

Chang

. Death and disability from warfarin-associated intracranial and extracranial hemorrhages. Am J Med. 2007;120(8):700–705.

Flaherty

Kissela

Woo

. The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology. 2007;68(2):116–121.

Liotta

Prabhakaran

. Warfarin-associated intracerebral hemorrhage is increasing in prevalence in the United States. J Stroke Cerebrovasc Dis. 2013;22(7):1151–1155.

Berwaerts

Dijkhuizen

Robb

Webster

. Prediction of functional outcome and in-hospital mortality after admission with oral anticoagulant-related intracerebral hemorrhage. Stroke. 2000;31(11):2558–2562

Cucchiara

Messe

Sansing

Kasner

Lyden

, CHANT Investigators. Hematoma growth in oral anticoagulant related intracerebral hemorrhage. Stroke. 2008;39(11):2993–2996.

Kuramatsu

Gerner

Schellinger

. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA. 2015;313(8):824–836.

Davis

Broderick

Hennerici

. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. 2006;66(8):1175–1181.

Huttner

Schellinger

Hartmann

. Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates. Stroke. 2006;37(6):1465–1470.

10.

Steiner

Poli

Griebe

. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol. 2016;15(6):566–573.

11.

Hemphill

Bonovich

Besmertis

Manley

Johnston

. The ICH score a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–897.

12.

Steele

DeBrow

. Efficiency gains with computerized provider order entry. In: Henriksen

Battles

Keyes

Grady

, eds. Advances in Patient Safety: New Directions and Alternative Approaches (vol. 4: Technology and medication safety). Rockville, MD: AHRQ; 2008.

13.

Estellat

Colombet

Vautier

Huault-Quentel

Durieux

Sabatier

. Impact of pharmacy validation in a computerized physician order entry context. Int J Qual Health Care. 2007;19(5):317–325.

14.

Taylor

Loan

Kamara

Blackburn

Whitney

. Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Pediatrics. 2008;121(1):123–128.

15.

Wietholter

Sitterson

Allison

. Effects of computerized prescriber order entry on pharmacy order-processing time. Am J Health Syst Pharm. 2009;66(15):1394–1398.

16.

Ballesca

LaGuardia

Lee

. An electronic order set for acute myocardial infarction is associated with improved patient outcomes through better adherence to clinical practice guidelines. J Hosp Med. 2014;9(3):155–161.

17.

Thiel

Asghar

Micek

Reichley

Doherty

Kollef

. Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis. Crit Care Med. 2009;37(3):819–824.

18.

Ballard

Kim

Huang

. Implementation of computerized physician order entry is associated with increased thrombolytic administration for emergency department patients with acute ischemic stroke. Ann Emerg Med. 2015;66(6):601–610.

19.

Fonarow

Zhao

Smith

. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632–1640.

Before-After Study of an Electronic Order Set for Reversal of Vitamin K Antagonist–Associated Intracerebral Hemorrhage