EAST 2014: The Anticoagulated Patient Problem

Not only is the population getting older, many people end up on oral anticoagulants for one reason or another. This is supposed to be good, preventing stroke, pulmonary emobolism, etc. Until you fall down. Or crash your car. Or need emergency surgery.

All EDs are seeing more and more patients who are taking these drugs. But emergency departments are busy places, and if a patient looks okay, they may have to wait a bit for their evaluation. And for an unfortunate few, that wait time can be deadly. What we need is a way to promptly evaluate those patients while being mindful of resource utilization.

A Pennsylvania hospital addressed this problem by creating a special level of team activation called the AnitCoagulation and Trauma alert (ACT). The idea was to identify a subset of patients who were more likely to have problems from their anticoagulation after trauma. They selected the following critieria to trigger the ACT alert:

  • Age > 65 and
  • Taking an anticoagulant or anti-platelet agent and
  • GCS >= 13 and
  • Suspected loss of consciousness and
  • Fall in the last 24 hours

The ACT alert is called overhead and the patient is immediately ushered into a room. They must be seen by ED physician, nurse and phlebotomist within 15 minutes. A point-of-care INR must be performed within 20 minutes, and a head CT obtained within 30 minutes. Further management is then based on the CT result.

The hospital looked at their experience and reported these factoids:

  • A total of 426 patients had an ACT alert over a 10 month period and were compared to a similar control group from the previous year
  • Significantly fewer ACT alert patients who were admitted stayed more than 5 days compared to admitted control patients (38% vs 52%)
  • More ACT alert patients were discharged from the ED directly (56% vs 30%)
  • Patients discharged from the ED were out more quickly than controls (faster throughput)

Bottom line: The analyses in this abstract make me suspect that there is some slicing and dicing of data. Why not just report hospital length of stay rather than the percentage who were in hospital more than 5 days? And I think their criteria should be tightened up a bit. Nevertheless, their research illustrates an approach that addresses a real need in all trauma centers. Anticoagulated “minor” trauma patients (those that don’t meet trauma activation criteria) can quickly develop life-threatening problems. Every center should have a system for rapidly identifying and evaluating these patients. And not using the full trauma team is a good idea, because the amount of wear and tear on the team if they had to respond to every one of these patients would be counterproductive. 

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