Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system

Abstract

Intracerebral haemorrhage (ICH) has the worst outcomes of all stroke subtypes, with a case fatality at 1 month of 30%–40% and only 20% regaining independence.1 Improving the implementation of existing evidence-based and guideline-recommended interventions may lead to improved outcomes.2 10%–20% of acute ICH occurs in patients taking oral anticoagulants and this is associated with a high risk of early haematoma expansion.3 4 Rapid treatment to normalise coagulation reduces this risk and may improve outcomes.4 5 The first critical step in achieving this is for suspected stroke patients on anticoagulants to undergo immediate brain imaging, allowing ICH to be identified quickly and anticoagulant reversal therapy initiated. Our regional centralised acute stroke system within Greater Manchester and Eastern Cheshire serves a population of 2.85 million and although suspected stroke patients collected by ambulance <48 hours post onset are transported to a hyperacute stroke unit (HASU), only those within 4 hours of onset are prealerted. We conducted a service evaluation to determine whether an additional prealert and emergency transport for suspected stroke on anticoagulants 4–48 hours post onset facilitated rapid imaging and hence reversal of anticoagulation after ICH on HASU arrival. A proposed prealert for anticoagulant-associated suspected strokes was agreed by the Greater Manchester Stroke Operational Delivery Network and introduced on 13 March 2018. The change in practice was disseminated by the North West Ambulance Service (NWAS) to all prehospital clinicians. https://bmjopenquality.bmj.com/content/9/2/e000883. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/bmjoq-2019-000883