Interhospital Transfer Delays Anticoagulation Reversal in Warfarin-Associated Intracranial Hemorrhage

Abstract

IntroductionIntracranial hemorrhage (ICH) is a complication of warfarin-associated anticoagulation resulting in significant morbidity and mortality. The purpose of this study was to assess whether interhospital transfer delays the administration of 4-factor prothrombin complex concentrate to patients with warfarin-associated ICH. Materials and MethodsThis was a retrospective cohort study of all patients presenting to a 60,000 visit academic ED between August 2013 and July 2017 requiring emergent anticoagulation reversal for warfarin-associated ICH. Patients were divided into 2 cohorts: (1) transfer patients who arrived at the academic center after receiving care in a local community hospital and (2) control patients who presented directly to the academic center ED. The primary outcome was time to administration of 4-factor prothrombin complex concentrate. Secondary outcomes included hematoma expansion, guideline-adherent vitamin K administration (10mg IV), intensive care unit and hospital length of stay, disposition at discharge, and in-hospital mortality. ResultsThis study included 203 patients (177 transfer patients, 26 control). The median time to arrival in transfer patients was 186 minutes (IQR 145-242). The median time to administration of guideline-adherent therapy in transfer patients was 296 minutes, compared to 119 minutes in patients who were not transferred (median difference= −176, 95% confidence interval −143 to −208, P ≤ .001). Delay in anticoagulation reversal did not result in hematoma expansion, intensive care unit and hospital length of stay, discharge disposition, or in-hospital mortality. ConclusionsPatients requiring interhospital transfer experienced significant delays in guideline-adherent anticoagulation reversal for warfarin-associated ICH, but this delay was not associated with worse outcomes.