Abstract
Background
Reversal of anticoagulation with four-factor prothrombin complex concentrate (4F-PCC)
is critical, yet the optimal timing to 4F-PCC administration and whether quicker administration
improves hemostasis remains unknown.
Objective
The objective of this study was to determine if pharmacist presence is predictive
of faster time to 4F-PCC.
Methods
This retrospective cohort study included patients receiving 4F-PCC for life-threatening
bleeding or urgent procedure in the emergency department (ED) from 2014 to 2018. Patients
with pharmacists at bedside (PharmD group) were compared with physician teams alone
(control group). The primary outcome was time from ED presentation to 4F-PCC administration.
Results
Of 252 patients evaluated, 116 patients (46%) were included (n = 50 PharmD group;
n = 66 control group). Most patients presented on warfarin (68.1%), and of the life-threatening
bleeds (94%), intracranial hemorrhage was most common (67.2%). The median time to
4F-PCC administration was significantly shorter in the PharmD group (66.5 vs. 206.5 min,
p < 0.001). Pharmacist at bedside was the only factor independently associated with
reduction in time to 4F-PCC (β coefficient −163.5 min, 95% confidence interval −249.4
to −77.7). Although there was no difference in hemostasis or mortality, patients in
the PharmD group had a shorter intensive care unit length of stay (LOS) (2 vs. 5 days,
p < 0.01) and hospital LOS (5.5 vs. 8 days, p = 0.02).
Conclusion
A pharmacist at the bedside of patients who present to the ED with life-threatening
bleeding or need for emergent procedure decreased time to 4F-PCC administration by
140 min, even after accounting for confounders. Faster time to 4F-PCC was associated
with significantly shorter intensive care unit and hospital LOS.
Keywords
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References
- Four-factor prothrombin complex concentrate for urgent reversal of vitamin K antagonists in patients with major bleeding.Circulation. 2013; 128: 1179-1181
- Safety of 4-factor prothrombin complex concentrate (4F-PCC) for emergent reversal of factor Xa inhibitors.J Intensive Care. 2018; 6: 34
- Evidence-based management of anticoagulant therapy: American College of Chest Physicians Evidence Based Clinical Practice Guidelines (9th ed.).Chest. 2012; 141: e152S-e184S
- Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine.Neurocrit Care. 2016; 24: 6-46
- Hematoma growth and outcome in treated neurocritical care patients with intracerebral hemorrhage related to oral anticoagulant therapy: comparison of acute treatment strategies using vitamin K, fresh frozen plasma, and prothrombin complex concentrates.Stroke. 2006; 37: 1465-1470
Mehta C, Jones M, Cuero MR, et al. Intracranial hemorrhage on warfarin: time to reversal is of the essence. Poster presented at the 68th Annual Meeting of the American Academy of Neurology. Vancouver, BC, Canada; 2016 Apr 17.
- Use of prothrombin complex concentrate in warfarin anticoagulation reversal in the emergency department: a quality improvement study of administration delays.BMC Health Serv Res. 2015; 15: 106
- ASHP guidelines on emergency medicine pharmacist services.Am J Health Syst Pharm. 2011; 68: e81-e95
- Effect of pharmacists on medication errors in an emergency department.Am J Health Syst Pharm. 2008; 65: 330-333
- Assessment of effectiveness of major bleeding management: proposed definitions for effective hemostasis: communication from the SSC of the ISTH.J Thromb Haemost. 2016; 14: 211-214
- Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381
- Influence of weekend hospital admission on short-term mortality after intracerebral hemorrhage.Stroke. 2009; 40: 2387-2392
- Effect of pharmacy management on turnaround time of 4-factor prothrombin complex concentrate.Am J Health Syst Pharm. 2017; 74: S61-S66
- Impact of a pharmacist-driven prothrombin complex concentrate protocol on time to administration in patients with warfarin-associated intracranial hemorrhage.West J Emerg Med. 2018; 19: 849-854
- Anticoagulant-associated intracranial hemorrhage in the era of reversal agents.Stroke. 2017; 48: 1432-1437
- Predictors of 30-day mortality in patients with spontaneous primary intracerebral hemorrhage.Surg Neurol Int. 2016; 7: S510-S517
- Comparison of prothrombin complex concentrate and vitamin K1 in oral anticoagulant reversal.Br Med J. 1976; 2: 83-85
- 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.Stroke. 2018; 49: e46-e110
- Pharmacist participation in acute ischemic stroke decreases door-to-needle time to recombinant tissue plasminogen activator.Ann Pharmacother. 2017; 51: 1084-1089
- Emergency medicine pharmacist impact on door-to-needle time in patients with acute ischemic stroke.Neurohospitalist. 2018; 8: 60-65
- Impact of an emergency medicine pharmacist on time to thrombolysis in acute ischemic stroke.Am J Emerg Med. 2016; 34: 1997-1999
- Decreasing hospital length of stay: effects on daily functioning in older adults.J Am Geriatr Soc. 2017; 65: 1214-1221
- Relationship between ICU length of stay and long-term mortality for elderly ICU survivors.Crit Care Med. 2016; 44: 655-662
- Effect of length of stay in intensive care unit on hospital and long-term mortality of critically ill adult patients.Br J Anaesth. 2010; 104: 459-464
- Intracerebral hemorrhage and delirium symptoms – length of stay, function, and quality of life in a 114-patient cohort.Am J Respir Crit Care Med. 2013; 188: 1331-1337
Article info
Publication history
Published online: August 22, 2019
Accepted:
June 15,
2019
Received in revised form:
June 14,
2019
Received:
April 9,
2019
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
