Impact of Pharmacy Response to Hemorrhagic Emergencies on Time to Antithrombotic Reversal

Introduction: American Heart Association recommends a goal of < 90 minutes from stroke presentation to reversal of anticoagulation in intracerebral hemorrhage (ICH). Our study assessed the impact of pharmacy response in reducing time from order entry to administration of appropriate antithrombotic reversal agents.


Methods: A single-center, retrospective chart review was performed in patients diagnosed with ICH, subarachnoid hemorrhage, or subdural hematoma between January 2023-April 2025. Patients above 18 years of age who required a reversal agent for recent antithrombotic use were included. Available reversal agents were four-factor prothrombin complex concentrate, phytonadione, protamine, idarucizumab, and desmopressin. Date of reversal administration separated patients to pre-pharmacy response (January 2023- July 2024) or post-pharmacy response (August 2024- April 2025). The primary outcome was time from order entry to administration of reversal agent. Hemostatic efficacy was assessed in ICH patients.


Results: Of 183 patients diagnosed with an intracranial bleeding event, 20 were identified as subjects (ICH=12) and assigned to pre-pharmacy (n=9) or post-pharmacy groups (n=11). Patients included had similar recent antithrombotic use with receipt of last dose 24-48 hours prior to presentation. Patients in the pre-pharmacy group more commonly experienced Glasgow coma scale scores < 8 (44% vs 9%, p = 0.13) and systolic blood pressure > 150 mmHg (55% vs 36%, p = 0.65). A significant mean reduction of 73 minutes [ p= 0.048] was found from order entry to reversal administration in the post-pharmacy group. The post-pharmacy group demonstrated decreased antithrombotic reversal door-to-needle time from presentation [mean difference of 23 minutes, p = 0.50] and from CT read [mean difference of 62 minutes, p = 0.84]. Hemostatic efficacy within 24 hours of reversal administration was achieved in 42% of patients in the pre-pharmacy and 80% of patients in the post-pharmacy groups [p = 0.29].


Conclusions: Pharmacy response to ICH emergencies significantly reduced time from order entry to antithrombotic reversal agent administration.