Use of prothrombin complex concentrate in warfarin anticoagulation reversal in the emergency department: a quality improvement study of administration delays

Impact of Pharmacist Preparation of Four-Factor Prothrombin Complex Concentrate at the Bedside in Patients with Life-Threatening Hemorrhage in the Emergency Department

Purpose: One option recommended by expert guidelines for prompt reversal of anticoagulation-induced hemorrhage is four-factor prothrombin complex concentrate (4F-PCC). Pharmacist presence has been shown to reduce order entry to administration and door-to-needle (DTN) times. However, how pharmacist preparation of 4F-PCC at the bedside in the Emergency Department (ED) can affect times to administration has not been thoroughly studied. The purpose of this study was to assess if pharmacist presence along with preparation of 4F-PCC at the bedside could improve administration times. Methods: This retrospective cohort study included anticoagulated patients requiring emergent reversal with 4F-PCC in the ED from January 2019 to April 2020 (pre-group) to March 2022 to March 2023 (post-group). Patients in the post-intervention group who had 4F-PCC prepared at the bedside were compared to a historical group without bedside 4F-PCC preparation. The primary outcome was time from 4F-PCC order entry to administration. Results: Of 193 patients evaluated, 99 (51.3%) were included (N = 41 pre-group; N = 58 post-group). There was a significant 11 minute difference in median time from order entry to administration favoring the post-group (31 vs 20 minutes, P < .001). The subset of patients with intracranial hemorrhage (ICH) in the post-group also had a significantly shorter order to administration time of 14 minutes (31 vs 17 minutes, P < .001). There was no difference in overall DTN times, in-hospital mortality, or length of stay (LOS) between groups, including in the subset of patients with ICH. Conclusion: 4F-PCC preparation at the bedside by the ED pharmacist significantly reduced 4F-PCC order entry to administration time. However, this intervention did not reduce overall DTN times.

Prothrombin complex concentrate in cardiac surgery for the treatment of coagulopathic bleeding

BACKGROUND

Coagulopathy following cardiac surgery is associated with considerable blood product transfusion and high morbidity and mortality. The treatment of coagulopathy following cardiac surgery is challenging, with the replacement of clotting factors being based on transfusion of fresh frozen plasma (FFP). Prothrombin complex concentrate (PCCs) is an alternative method to replace clotting factors and warrants evaluation. PCCs are also an alternative method to treat refractory ongoing bleeding post-cardiac surgery compared to recombinant factor VIIa (rFVIIa) and also warrants evaluation.   OBJECTIVES: Assess the benefits and harms of PCCs in people undergoing cardiac surgery who have coagulopathic non-surgical bleeding.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science on 20 April 2021. We searched Clinicaltrials.gov (www.

CLINICALTRIALS

gov), and the World Health Organisation (WHO) International Clinical Trials Registry Platform (ICTRP; apps.who.int/trialsearch/), for ongoing or unpublished trials. We checked the reference lists for additional references. We did not limit the searches by language or publication status.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised trials (NRSs).  DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane.   MAIN RESULTS: Eighteen studies were included  (4993 participants). Two were RCTs (151 participants) and 16 were NRSs. Both RCTs had low risk of bias (RoB) in almost all domains. Of the 16 NRSs, 14 were retrospective cohort analyses with one prospective study and one case report. The nine studies used in quantitative analysis were judged to have critical RoB, three serious and three moderate.   1. PCC versus standard treatment Evidence from RCTs showed PCCs are likely to reduce the number of units transfused compared to standard care (MD -0.89, 95% CI -1.78 to 0.00; participants = 151; studies = 2; moderate-quality evidence). Evidence from NRSs agreed with this, showing that PCCs may reduce the mean number of units transfused compared to standard care but the evidence is uncertain (MD -1.87 units, 95% CI -2.53 to -1.20; participants = 551; studies = 2; very low-quality evidence). There was no evidence from RCTs showing a difference in the incidence of red blood cell (RBC) transfusion compared to standard care (OR 0.53, 95% CI 0.20 to 1.40; participants = 101; studies = 1; low-quality evidence). Evidence from NRSs disagreed with this, showing that PCCs may reduce the mean number of units transfused compared to standard care but the evidence is uncertain (OR 0.54, 95% CI 0.30 to 0.98; participants = 1046; studies = 4; low-quality evidence). There was no evidence from RCTs showing a difference in the number of thrombotic events with PCC compared to standard care (OR 0.68 95% CI 0.20 to 2.31; participants = 152; studies = 2; moderate-quality evidence). This is supported by NRSs, showing that PCCs may have no effect on the number of thrombotic events compared to standard care but the evidence is very uncertain (OR 1.32, 95% CI 0.87 to 1.99; participants = 1359; studies = 7; very low-quality evidence). There was no evidence from RCTs showing a difference in mortality with PCC compared to standard care  (OR 0.53, 95% CI 0.12 to 2.35; participants = 149; studies = 2; moderate-quality evidence). This is supported by evidence from NRSs, showing that PCCs may have little to no effect on mortality compared to standard care but the evidence is very uncertain (OR 1.02, 95% CI 0.69 to 1.51; participants = 1334; studies = 6; very low-quality evidence). Evidence from RCTs indicated that there was little to no difference in postoperative bleeding (MD -107.05 mLs, 95% CI -278.92 to 64.83; participants = 151, studies = 2; low-quality evidence).  PCCs may have little to no effect on intensive care length of stay (RCT evidence: MD -0.35 hours, 95% CI -19.26 to 18.57; participants = 151; studies = 2; moderate-quality evidence) (NRS evidence: MD -18.00, 95% CI -43.14 to 7.14; participants = 225; studies = 1; very low-quality evidence) or incidence of renal replacement therapy (RCT evidence: OR 0.72, 95% CI 0.14 to 3.59; participants = 50; studies = 1; low-quality evidence) (NRS evidence: OR 1.46, 95% CI 0.71 to 2.98; participants = 684; studies = 2; very low-quality evidence). No studies reported on additional adverse outcomes.   2. PCC versus rFVIIa For this comparison, all evidence was provided from NRSs.  PCC likely results in a large reduction of RBCs transfused intra-operatively in comparison to rFVIIa (MD-4.98 units, 95% CI -6.37 to -3.59; participants = 256; studies = 2; moderate-quality evidence).  PCC may have little to no effect on the incidence of RBC units transfused comparative to rFVIIa; evidence is very uncertain (OR 0.16, 95% CI 0.02 to 1.56; participants = 150; studies = 1; very low-quality evidence). PCC may have little to no effect on the number of thrombotic events comparative to rFVIIa; evidence is very uncertain (OR 0.51, 95% CI 0.23 to 1.16; participants = 407; studies = 4; very low-quality evidence). PCC may have little to no effect on the incidence of mortality (OR 1.07, 95% CI 0.38 to 3.03; participants = 278; studies = 3; very low-quality evidence) or intensive care length of stay comparative to rFVIIa (MD -40 hours, 95% CI -110.41 to 30.41; participants = 106; studies = 1; very low-quality evidence); evidence is very uncertain . PCC may reduce bleeding (MD -674.34 mLs, 95% CI -906.04 to -442.64; participants = 150; studies = 1; very low-quality evidence) and incidence of renal replacement therapy (OR 0.29, 95% CI 0.12 to 0.71; participants = 106; studies = 1; very low-quality evidence) comparative to rFVIIa; evidence is very uncertain. No studies reported on other adverse events.  AUTHORS' CONCLUSIONS: PCCs could potentially be used as an alternative to standard therapy for coagulopathic bleeding post-cardiac surgery compared to FFP as shown by moderate-quality evidence and it may be an alternative to rFVIIa in refractory non-surgical bleeding but this is based on moderate to very low quality of evidence.

Audit and Feedback in emergency: a systematic review and an Italian project to investigate and improve quality of care

The Audit and Feedback process (AandF) is commonly accepted as a good way to improve quality in health care, also in Emergency Departments (ED), where health aspects and pathologies are very different, usually acute and highly complex. Within an Italian Ministry of Health research project called EASY-NET, we conducted a systematic review of literature on AandF in EDs from 2014 to December 2019 to evaluate the impact of this approach in a particular setting where time-dependent indicators are fundamental. We selected 24 articles: 9 about infective pathologies (i.e. antibiotic stewardship), 6 about cardiovascular acute emergencies (i.e. cardiac arrest), 2 about stroke, 3 about laboratory tests, and 4 about other fields (i.e. diabetic ketoacidosis or use of prothrombin complex). Most of articles proposed a multimodal approach: only 7 concerned AandF alone. Despite the wide range on interventions modality and the poor comparability of the considered studies, the results are encouraging and confirm the importance to implement AandF both in emergency and in other clinical settings.

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

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.

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

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.

Impact of a Pharmacist-Driven Prothrombin Complex Concentrate Protocol on Time to Administration in Patients with Warfarin-associated Intracranial Hemorrhage

Introduction

Advancements in the treatment of warfarin-associated intracranial hemorrhage (ICH) include the use of four-factor prothrombin complex concentrate (4F-PCC), which has demonstrated more rapid reversal of the international normalized ratio (INR) when compared with fresh frozen plasma. A pharmacist-driven protocol for 4F-PCC was implemented within our institution, which allows for pharmacist approval of 4F-PCC in patients diagnosed with warfarin-associated ICH and an INR ≥2. The pharmacist is responsible for determining the appropriate dose of 4F-PCC, preparation, bedside delivery, and order entry into the electronic medical record. Prior to implementation of the new protocol, the blood bank was responsible for 4F-PCC approval, dosing, product preparation, and arranging delivery with emergency department (ED) staff. The purpose of this study was to evaluate the impact of a pharmacist-driven protocol on time to 4F-PCC administration in warfarin-associated ICH.

Methods

We performed a retrospective review of consecutive patients who received 4F-PCC in a single ED from September 2015 through February 2017. Patients ≥18 years old were eligible for inclusion based on three criteria: confirmed diagnosis of ICH; confirmed warfarin use; and INR ≥2. Secondary outcomes included dose of 4F-PCC in concordance with INR and weight-based dosing recommendations and hospital protocol, as well as concomitant intravenous vitamin K administration.

Results

A total of 48 patients met inclusion criteria for the study with 24 patients in each protocol group. The median time to administration of 4F-PCC in the pharmacist-driven protocol group was 35 minutes (interquartile range [IQR] [25–62]; range, 11–133) compared with 70 minutes (IQR [34–89]; range, 14–244) in the pre-protocol group (p=0.034). We saw no differences for appropriate 4F-PCC dosing based on INR and patient weight between the two groups.

Conclusion

Implementation of a pharmacist-driven protocol for 4F-PCC in the ED at our institution significantly reduced time to administration in patients presenting with warfarin-associated ICH.