In part 4 of this 4-part series, Dr. Baugh discusses bleeding protocols in the ED.
Faculty: Christopher Baugh, MD, MBA
Vice Chair of Clinical Affairs Department of Emergency Medicine | Brigham and Women's Hospital Associate Professor | Harvard Medical School
Dr. Baugh has published on the clinical and administrative aspects of observation care in the New England Journal of Medicine, Health Affairs, Annals of Emergency Medicine, and Academic Emergency Medicine. He previously served as Chair of the Observation Medicine Section of the American College of Emergency Physicians.
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- Emergency physicians frequently encounter bleeding anticoagulated patients, and there are more reversal or replacement agents available today than ever before. When and how to use a specific reversal agent can be a challenging task, as the decision-making window is likely to be narrow. Patients may not be capable of accurately communicating the agent, dose, and timing of their anticoagulant. Institutional policies can be obtuse or obstructive. Availability of agents vary by institution and over time, and unique patient factors such as advanced age, coingestants, new or existing comorbidities must be recognized and considered. In addition, most reversal or replacement agents are costly compared to other medications routinely administered. Institution-specific guidelines often lack standardization of indications, such as the specific definitions of life-threatening bleed, critical site, or hemodynamic parameters. As a result, emergency physicians need to be familiar with definitions for these key components. Protocols are shared documents collaboratively created by key stakeholders. For a bleeding protocol, stakeholders include emergency physicians, pharmacists, hematologists, blood bank staff, critical care specialists, and other consultants. Because time to act is an essential consideration for patients with significant ongoing bleeding, establishing a protocol that details the shared expectations of how, when, and why bleeding patients on anticoagulants will or will not be treated with a reversal agent is key. The protocol should consider all common specific anticoagulants that could be encountered in the ED. It should also outline the specific indications and dosing of each reversal or replacement agent. Authors need to be familiar with the latest available evidence to ensure the protocol is evidence-based. It needs to clarify whether any approvals are required, and if so, how to obtain it without delay at any time of day. Once created, an in-service should be done to make ED staff familiar with the protocol, which should always be easily accessible. Finally, the policy should be reviewed and maintained via ongoing governance with continued stakeholder engagement.
