First Author: Caitlin S. Brown, BCCCP, PharmD, FCCM – Mayo Clinic Co-Author: Brian Gilbert, PharmD, MBA, FCCM, BCCCP – Emergency Medicine Clinical Pharmacy Specialist, Wesley Medical Center Co-Author: Alicia Mattson, PharmD, BCEMP – Assistant Professor of Pharmacy & Emergency Medicine, Mayo Clinic-Rochester Co-Author: Fernanda Bellolio, MD, MS – Associate Professor of Emergency Medicine, Mayo Clinic Co-Author: Kristin C. Cole, MS – Principal Biostatistician, Mayo Clinic Co-Author: Brett Faine, PharmD, MS – Associate Professor, University of Iowa Co-Author: Nicole Acquisto, BCCCP, PharmD, FCCM, FASHP, FCCP – Associate Professor of Emergency Medicine, Strong Memorial Hospital of the University of Rochester Co-Author: Erin Wieuruszewski, PharmD, BCCCP – Clinical Pharmacy Manager, Mayo Clinic-Rochester Co-Author: Kevin Mercer, PharmD, MPH, BCCCP – Assistant Professor, University of Texas at Austin College of Pharmacy Co-Author: Alejandro Rabinstein, MD – Consultant, Mayo Clinic
Introduction: Intracranial and extracranial hemorrhages are a significant cause of morbidity and mortality, particularly for patients on anticoagulation. Emergency medicine pharmacists (EMPs) are critical in identifying patients who are on anticoagulation, providing recommendations on anticoagulation reversal agent selection and dosing, and ensuring prompt reversal agent administration. The goal of this systematic review and meta-analysis was to determine the impact of EMP involvement on time to anticoagulation reversal and patient outcomes during anticoagulation-associated hemorrhage management.
Methods: A medical librarian performed a literature search in PubMed, MEDLINE (Ovid), EMBASE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Library (Wiley) from inception to March 2024 for all types of anticoagulants and all types of life-threatening bleeding that required emergent reversal. Newcastle-Ottawa was used to assess risk of bias and Grading Recommendations, Assessment, Development, and Evaluation (GRADE) to assess level of certainty in the evidence. Random effects models estimating mean differences (MD) and 95% confidence intervals are reported.
Results: There were 2,228 titles and abstracts screened, with 40 undergoing full-text evaluation. Five observational studies including 177 patients who received an anticoagulation reversal agent with EMP involvement and 157 patients who received an anticoagulation reversal agent without EMP involvement were included. Time from emergency department (ED) arrival to anticoagulation reversal agent administration and time from reversal agent medication order to administration were faster with an EMP involvement (MD -75.6 minutes, 95% CI -101.7 to -49.5 and MD -18.7 minutes, 95% CI -23.5 to -14.0, respectively). There was no difference in short-term mortality. The included studies had a high risk of bias and were deemed very low quality of evidence.
Conclusions: EMP involvement in anticoagulation reversal for patients with acute hemorrhage reduces the time to anticoagulation reversal agent administration. Large, high-quality studies are needed to determine the value of EMPs in improving patient-centered outcomes for patients with acute hemorrhage requiring anticoagulation reversal.
