Pharmacist Presence Decreases Time to Prothrombin Complex Concentrate in Emergency Department Patients with Life-Threatening Bleeding and Urgent Procedures

Masic, Dalila; Hidalgo, Daniel Colon; Kuhrau, Shannon; Chaney, Whitney; Rech, Megan A.

doi:10.1016/j.jemermed.2019.06.027

Cited by 19 publications

(23 citation statements)

References 23 publications

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“…However, it should be noted that patients on various forms of oral anticoagulation were included in this study. 61 In support of these findings, another retrospective study of patients with bleeding (the majority of whom received warfarin) found that the time from order to start of administration of PCC (3F-or 4F-PCC) was significantly reduced when an ED pharmacist was involved (median 24 min [IQR 15-35] vs 42 min [IQR ; p < 0.001). 3 Furthermore, the implementation of an electronic order set for 4F-PCC for reversing VKA-related ICH demonstrated a significant reduction in the door-to-needle time from 83 to 45 minutes (p ¼ 0.02) and a significant improvement in patients receiving the target dose (pre-order set, 29.4% vs post-order set, 92.9% [p ¼ 0.001]).…”

Section: Removing Institutional Barriers To Urgent 4f-pcc Administrationmentioning

confidence: 84%

Optimal Dosage and Administration Practices for Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate

Rhoney

Chester

Darsey

2020

Clin Appl Thromb Hemost

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Expert consensus and international guidelines recommend urgent co-administration of vitamin K and 4-factor prothrombin complex concentrates (4F-PCCs) to rapidly reverse VKA-related bleeding. This narrative review examined real-world evidence and strategies to optimize international normalized ratio (INR) reversal, hemostasis, and outcomes in patients receiving 4F-PCC in this setting. Key determinants for success include the appropriate use of alternative dosing and administration strategies, such as fixed dosing and increased infusion speed, adherence to institutional guidelines, and removing significant institutional barriers to reduce time to treatment. In the opinion of authors, minimizing the time to treatment with 4F-PCCs is of paramount importance when treating patients with VKA-related bleeding. Practices that safely and feasibly shorten the time to administration should be included in guidelines for institutions responsible for anticoagulant care, and adhered to in centers that perform invasive procedures on patients receiving VKA therapy. Further studies are required to optimize use of 4F-PCC, particularly in relation to the ideal dosing strategy and the role of INR.

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Section: Removing Institutional Barriers To Urgent 4f-pcc Administrationmentioning

confidence: 84%

Optimal Dosage and Administration Practices for Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate

Rhoney

Chester

Darsey

2020

Clin Appl Thromb Hemost

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“…Pharmacists were present for pre‐defined hours each day where they assisted in facilitation between the ED and central pharmacy (where 4F‐PCC was prepared) for bedside delivery of 4F‐PCC. They determined that pharmacist involvement resulted in a decrease in median time from arrival to 4F‐PCC administration from 206.5 to 66.5 minutes 4 …”

Section: Discussionmentioning

confidence: 99%

“…They determined that a pharmacist present in the ED decreased time to administration of 4F‐PCC from 206 to 66 minutes. All doses of 4F‐PCC were prepared in the pharmacy and delivered to the ED 4 …”

Section: Introductionmentioning

confidence: 99%

Time to four‐factor prothrombin complex concentrate administration decreased by presence of a 24/7 pharmacist in the emergency department

Kozlow

Livings

2020

J Am Coll Clin Pharm

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Study objectiveThe objective of this study was to determine the impact of a 24/7 pharmacist (RPh) on time from order to the administration of four‐factor prothrombin concentrate complex (4F‐PCC) in the emergency department (ED).MethodsThis is a retrospective study that included patients who received 4F‐PCC in the ED for acute reversal of oral anticoagulation before and after the implementation of a 24/7 RPh. Patients for whom 4F‐PCC was ordered between May 1, 2014 and June 30, 2015 were in the pre‐RPh group and those between November 1, 2018 and December 31, 2019 were in the post‐RPh group. The primary end point was time from order to administration of 4F‐PCC. Time from arrival to administration of 4F‐PCC was also evaluated.ResultsOf 168 patients evaluated, 100 were included in the study (n = 33 pre‐RPh; n = 67 post‐RPh). The majority of patients were on warfarin (97.0% pre‐RPh and 73.1% post‐RPh) for atrial fibrillation. Both groups included trauma and intracranial hemorrhage patients. The mean time from order to 4F‐PCC administration was significantly shorter in the post‐RPh group (71.2 vs 35.2 minutes, P < .001, 95% confidence interval [CI] [27.013‐44.987]). In addition, the median time from arrival to 4F‐PCC administration was also shorter in the post‐RPh group (153 vs 106 minutes, P = .033).ConclusionsAt our institution, time from order, and from arrival, to administration of 4F‐PCC for reversal of oral anticoagulation in the setting of acute bleeding events in the ED was reduced by 36 minutes after the presence of a 24/7 pharmacist.

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“…EICU, emergency intensive care unit; 4F-PCC, four factor prothrombin complex concentrate groups, although it took longer in the intervention group than in the nonintervention group and (2) because all patients received 4F-PCC after warfarin administration, it took a long time to determine PT-INR and body weight required for designing the prescription. However, Dalila et al reported that a clinical pharmacist's intervention decreased the time taken from patient presentation to the EICU to 4F-PCC administration by 140 min and shorter ICU length of stay [6]. Further, Jessica et al determined that PT-INR ≥ 2 and intracranial hemorrhage was confirmed on imaging but not on patient presentation [7].…”

Section: Discussionmentioning

confidence: 99%

“…4F-PCC must be administered as soon as possible because an early reduction in the prothrombin time-international normalized ratio (PT-INR) has been reported to reduce mortality due to major bleeding [2]. In recent years, there have been reports on the reduction of time to 4F-PCC administration [3][4][5][6][7]. However, in the emergency intensive care unit (EICU), during the time period between patient presentation to 4F-PCC administration, it is necessary to confirm medication histories, design the complicated prescription, and combine intravenous vitamin K but the optimal procedure for this remains unknown.…”

Section: Introductionmentioning

confidence: 99%

Emergency intensive care unit pharmacist’s intervention may reduce time to four-factor prothrombin complex concentrate administration: a retrospective study

Imanaka

Kuwabara

Ikeda

et al. 2020

J Pharm Health Care Sci

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Background: Four-factor prothrombin complex concentrate (4F-PCC) must be administered as soon as possible, and in our emergency intensive care unit (EICU), pharmacists are available on weekdays for consultation on expediting 4F-PCC administration. Although recent reports have described a reduction in time to 4F-PCC administration, few studies have addressed if this is because of EICU pharmacist's intervention, and there are no such studies in Japan. Therefore, we aimed to examine whether EICU pharmacist's intervention reduced time to 4F-PCC administration. Methods: This single-center retrospective cohort study was conducted from December 2017 to May 2019. We enrolled patients who received 4F-PCC due to major bleeding or requirement of urgent surgical/invasive procedures (n = 10). Patients were divided into two groups, namely, the intervention group (n = 5), in which EICU pharmacists consulted on weekdays, and the nonintervention group (n = 5), in which an intervention was not possible because of the absence of the EICU pharmacist. Results: The median time from patient presentation to the EICU to 4F-PCC administration (103 min vs. 111 min, p = 0.4) was similar between the two groups; however, the median time from 4F-PCC prescription ordering to administration was significantly shorter in the intervention group than in the nonintervention group (21 min vs. 60 min, p = 0.02). Conclusions: EICU pharmacist's intervention improves the process from 4F-PCC prescription to administration and can reduce time to 4F-PCC administration.

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Pharmacist Presence Decreases Time to Prothrombin Complex Concentrate in Emergency Department Patients with Life-Threatening Bleeding and Urgent Procedures

Cited by 19 publications

References 23 publications

Optimal Dosage and Administration Practices for Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate

Optimal Dosage and Administration Practices for Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate

Time to four‐factor prothrombin complex concentrate administration decreased by presence of a 24/7 pharmacist in the emergency department

Emergency intensive care unit pharmacist’s intervention may reduce time to four-factor prothrombin complex concentrate administration: a retrospective study

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