An audit of the use of prothrombin complex concentration

Published Date: 20th February 2019

Publication Authors: Bonney S, Nee PA, Schofield J

Background

Prothrombin complex concentrate (PCC) is licensed for emergency reversal of anticoagulation in severe and life-threatening bleeding, intracranial haemorrhage and prior to emergency surgery. It is an expensive resource costing approximately Eur2000 per adult dose. There is evidence of inappropriate use of PCC leading to delays to treatment, inappropriate dosing and use of adjunctive vitamin K. Much product, delivered to clinical settings, is wasted and we reported previously an annual wastage of approximately Eur 15,000 per annum, amounting to a UK-wide financial loss of nearly Eur3 millions. Guidelines governing the use of PCC exist in order to ensure the rapid and appropriate use of the product.

Aim(s)

The aim of the present audit was to determine the appropriateness of use of PCC in a UK teaching hospital setting against published standards (BCSH 2011) Methods: An audit of the emergency use of PCC was undertaken in a UK teaching hospital in 2014/15. Patients prescribed PCC were identified from the Laboratory Information System. Patients were followed up using the hospital's electronic patient management system and the following parameter were recorded: patient demographics, indications for oral anticoagulation, reason for reversal, coagulation metrics, use of vitamin K, date and time that PCC was prescribed and given and 30-day outcome. The audit was repeated in 2016/17 after an educational programme directed at hospital doctors.

Result(s)

There were 103 prescriptions for PCC in 2014/15 and 113 in 2016/17. The clinical settings are listed in Table 1. The indications for PCC are listed in Table 2 and the delays from issue to administration are presented in Table 3. Table 4 shows the number of prescribed units administered, returned and wasted during the two audit periods. Vitamin K pre-treatment is recommended for bleeding on warfarin. Thirteen patients in the first audit and ten in the second did not receive vitamin K. Pre-treatment with vitamin K is unnecessary in patients on direct-acting oral anticoagulants (DOAC). Eleven patients in the first audit and 24 in the second audit were on DOAC. Of these, seven patients in the first audit and nine in the second audit received vitamin K inappropriately. Two patients in the second audit received PCC inappropriately for bleeding associated with use of dabigatran; a specific antidote, idarucizumab, is available for this agent.

Summary/Conclusion

The audit shows that PCC is being used with increasing frequency in the acute hospital setting in the UK, with the emergency department the major user. Adherence to published standards on the use of this agent is not optimal and there is substantial wastage. An educational programme, directed at clinical doctors, was effective at improving standards and wastage was reduced significantly.

 

Bonney, S; Schofield, J; Nee P. (2018). An audit of the use of prothrombin complex concentration . HemaSphere. 2 (Sup 1), p469

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