IMPROVE Time to Anti-Coagulation Reversal for Hemorrhagic Strokes

Abstract Background Oral anticoagulation (OAC) is a risk factor for intracerebral hemorrhage (ICH) which is an important source of disability and mortality. OAC-associated ICH (OAC-ICH) patients have worse outcomes as compared to ICH patients not on OAC, likely because of the associated larger stroke volumes, higher propensity to intraventricular hemorrhage, and a higher risk of rebleeding. Although current guidelines recommend that OAC should be reversed quickly, many health care systems have not developed a process for optimizing that aspect of care. Methods Through the IMPROVE Stroke Care Consortium, a group of nine Hub hospitals and their 57 regional community hospitals, a systems of care improvement project was implemented. Performance reviews identified best practices which were disseminated throughout all centers. We compared the median door-to-reversal (DTR) time before and after an institutional campaign to speed the process with a target time of 60 minutes. Results Over two years of the study, there were 6,699 ischemic strokes, 152 subarachnoid hemorrhages, and 889 intracerebral hemorrhages. During that time, 36 hemorrhagic stroke patients received reversal agents emergently. The overall baseline median DTR time was 123 minutes (IQR 99, 361 minutes). By the end of the program, the median DTR time had trended down to 84 minutes (IQR 58.5, 151 minutes) which is a 31.7% reduction of DTR from baseline, though times remained somewhat variable (p = 0.08). Conclusions Utilizing an integrated stroke systems of care approach, we were able to reduce DTR times for patients presenting with acute ICH and concurrent use of anticoagulants despite lack of definitive guidelines around targets for reversal times or operational guidance on protocols and agents.