Time to oral anticoagulant reversal in intracranial hemorrhage with an emergency medicine pharmacist presence

Abstract

PurposeIntracranial hemorrhage (ICH) is associated with high morbidity and mortality, with mortality rates up to 65%. Oral anticoagulants (OAC) are a major risk factor for ICH. Since these patients are usually diagnosed in the emergency department (ED), emergency medicine (EM) pharmacists can help ensure appropriate selection and delivery of medications in urgent situations including reversal agents for OAC-associated bleeding. The purpose of this study was to determine the impact EM pharmacist presence has on time to OAC reversal in patients presenting with an ICH. ProceduresThis was a retrospective, single-center cohort study evaluating time to reversal of OAC-associated ICH at a level one trauma center between November 2016 and September 2022. Patients 18 years or older who presented to the ED with an OAC-associated ICH and received at least one dose of an emergent reversal agent were included. Patients were excluded if their ICH was diagnosed at an outside facility, if they received emergent reversal agents for other indications, or if they had do not resuscitate orders upon admission. The primary outcome was time to administration of reversal agent with or without an EM pharmacist present, represented as median [interquartile range]. Secondary outcomes included hematoma expansion, hospital length of stay, intensive care unit LOS, and in-hospital mortality. ResultsOf the 157 patients evaluated, 83 met criteria for inclusion. Majority of patients presented with warfarin-associated ICH (55%) and the most common indication for OAC was atrial fibrillation (66%). The most common type of ICH was intracerebral hemorrhage (35%). The median time to emergent reversal agent administration was significantly shorter in the EM pharmacist group (50 min [31–65] vs. 85 min [51–121], p < 0.01). No significant differences in secondary outcomes existed. ConclusionsThe presence of an EM pharmacist at the bedside of patients who present to the ED with ICH was associated with a decrease in the time to OAC reversal by 36 min. Presence of an EM pharmacist was not associated with improved clinical outcomes for ICH in our study. Larger trials are warranted to determine whether the presence of an EM pharmacist is associated with improved functional and clinical outcomes in patients with OAC-associated ICH and whether time to newer reversal agents, other than 4F-PCC, has an effect on outcomes.