Use of prothrombin complex concentrate in warfarin anticoagulation reversal in the emergency department: a quality improvement study of administration delays

Abstract

Background: Quick reversal of warfarin anticoagulation is important in life threatening bleeding. The aim of this study is to improve the administration delay when using Prothrombin Complex Concentrate (PCC) for the emergent reversal of warfarin anticoagulation in the emergency department.

Methods: An audit and feedback quality improvement project was conducted in three phases: a retrospective audit phase, an analysis and feedback phase and prospective evaluation phase. The charts of all eligible patients in a single Emergency Department (ED) in Québec, Canada, who received PCC since the introduction of this product in 2009 until October 31, 2011, were retrospectively audited. The administration delay of PCC was calculated from the time of prescription to the time of administration. With the data, we determined where improvements could be attained, and jointly with all stakeholders in the ED and the blood bank, we created an action plan to ensure the timely administration of PCC. The action plan was then implemented and a six-month prospective evaluation study was conducted to determine any improvement.

Results: Seventy-seven charts were reviewed in the retrospective chart audit. The mean administration delay was 73.6 minutes (STD [34.1]) with a median of 70.0 minutes (25-75% IQR [45.0-95.0]). We found that this delay was principally due to the following barriers: communication problems between the ED and the blood bank as well as delivery inefficiencies. An action plan that involved a flowchart to remind all clinicians how to order PCC and a new delivery method from the blood bank to the ED were developed. During the 6 months following the implementation of our action plan, 39 patients received PCC and the mean administration time decreased to 33.2 minutes (STD [14.2])(p < .0001) with a median of 30.0 minutes (25-75% IQR [24.3-38.8]).

Conclusion: By implementing an action plan comprising of a flowchart and a new delivery process, this audit and feedback quality improvement project reduced the administration time of PCC by more than half. Future studies to measure the impact of a similar audit and feedback process involving an action plan in other centers should be conducted before this type of quality improvement process is implemented on wider scale.

Figure 1

OMRU applied to our quality improvement project. OMRU: Ottawa Model of Research Use, ED: Emergency Department, PCC: Prothrombine Complex Concentrate. Adapted from Logan and Graham: Toward a Comprehensive Interdisciplinary Model of Health Care Research Use. Science Communication, December 1998 20:229 (with permission).

Figure 2

Patients flowchart.

Figure 3

Delay between prescription and administration of PCC – Phase 1.

Figure 4

Flowchart for the emergent administration of prothrombin complex concentrate (PCC) in the emergency department. The goal of this chart is to reduce the delay to a minimum between the prescription and the administration of PCCs. We hope to achieve an optimal reversal of warfarin anticoagulation in patients with major bleeding.

Figure 5

Delay between prescription and administration of PCC - Phase 3.