IntroductionMedical emergency response teams optimally involve interdisciplinary expertise, including pharmacists. A pharmacist may make therapy recommendations, prepare medications, and act as a drug information resource, which are important skills for a postgraduate year one pharmacy resident (PGY1) to develop. Limited data exist evaluating current national practices for PGY1 emergency response. ObjectivesThe purpose of this study was to describe national practices for PGY1 emergency response. These data may help PGY1 programs identify potential best practices for self-improvement. MethodsAn anonymous survey was developed to describe PGY1 emergency response within the United States and electronically distributed to PGY1 residency program directors. The questionnaire included general demographic information along with questions involving pharmacist and pharmacy resident emergency response and training within their institution. A univariate analysis was performed to evaluate potential predictors of survey respondent confidence in PGY1 independent emergency response by the end of the residency year. ResultsA total of 178 completed responses were obtained (response rate: 33.0%). The majority of respondents had both pharmacist and PGY1 response at their institution, with response to cardiopulmonary arrest being the most common. Of the 36 programs that did not have pharmacy resident involvement, the most common reason was due to lack of pharmacy response at their institution (61.1%). The majority of programs (68.3%) were confident in the ability for a PGY1 to independently respond by the end of their residency year. Only the number of emergency response by the end of the residency year was a predictor in their confidence of PGY1 independent response (p = 0.002). ConclusionThe majority of PGY1 programs had both pharmacist and pharmacy resident response to medical emergencies. The results of this survey may help PGY1 programs identify potential areas of improvement and help prospective residency candidates identify program characteristics that may best prepare them for emergency response.

Introduction: Hospital medical and trauma emergency response requires an interdisciplinary care team to help improve patient outcomes. Pharmacists provide medication therapy recommendations and have been shown to help with adherence to guideline-recommended therapies and reduce medication errors. Limited data exist evaluating what post-graduate year 2 (PGY2) pharmacy residency program directors (RPDs) value in prospective residents in regards to emergency response training. This information may help post-graduate year 1 (PGY1) pharmacy residents identify residency programs that are a good fit for their training. Methods: A list of PGY2 critical care (CC) and emergency medicine (EM) RPDs were identified from two residency program directories. Survey questions focused on demographics of the residency program’s institution and what aspects of PGY1 education programs value in prospective PGY2 residents. A Fisher’s exact test was used to compare differences between CC and EM programs in regards to the effect of PGY1 emergency response experience on PGY2 identification and ranking of prospective residency candidates, using R (version 4.2.1). Results: A total of 122 complete survey responses were analyzed (response rate: CC = 45.6%; EM = 50.6%). The majority of programs were at an academic medical center (60.7%). The majority of programs do not take into account PGY1 emergency response training when considering candidates for interviewing or in the development of their rank list (56.6% and 64.8%, respectively). In those that do (n=52), both ACLS certification and quantity of emergency response were priorities, accounting for up to 10% of candidate scoring (51.9%). There was no difference between CC and EM programs in importance of emergency response for identifying candidates for interview (36.4% vs. 54.5%; p=0.06), while EM programs were more likely to factor this into ranking candidates (26.0% vs. 50%; p< 0.01). Conclusions: The results of this survey indicate that PGY1 pharmacy residents interested in pursuing PGY2 CC or EM training should consider emergency response training as a factor in identifying PGY1 programs, especially if they are interested in EM. Future research delineating the type of PGY2 training will help further define what type of emergency response training is viewed as most important.

ABSTRACTIntroductionMedical emergency response within the hospital involves an interdisciplinary team, including pharmacists. Pharmacist involvement in these teams has increased over time due to published benefits of their involvement. Development of emergency response skills may start during pharmacy residency, although limited data suggest how this is best implemented.ObjectivesLimited data evaluate post-graduate year 2 (PGY2) pharmacy resident training for emergency response, as well as PGY2 program values for this in screening/ranking candidates. A survey may help PGY2 programs improve their own programs and allow post-graduate year one (PGY1) pharmacy residents to identify residency programs that are a good fit for their career goals.MethodsA list of PGY2 critical care (CC) and emergency medicine (EM) programs were identified. The questionnaire included program demographics, characteristics of PGY2 emergency response training, and PGY2 residency program values of PGY1 emergency response exposure for screening and ranking applicants for their programs. A Fisher’s exact test was used to compare differences between CC and EM programs for these outcomes.ResultsA total of 85 complete responses were analyzed (response rate: CC = 36.4%; EM = 32.1%). Emergency response training was often with both core and longitudinal experiences (72.9%), although differed by type of programs (p<0.001). Both CC and EM programs considered PGY1 pharmacy resident exposure to emergency response in screening candidates (33.9% and 57.7%, respectively), as well as ranking candidates (22% and 38.5%, respectively). For CC programs, both Advanced Cardiovascular Life Support certification and quantity of PGY1 emergency response ranked as the most important characteristics, while EM programs ranked quantity as the most important.ConclusionThe results of this survey indicate heterogeneity in PGY2 CC and EM emergency response training. PGY1 applicants for these programs should consider their experience with emergency response as a factor in identifying an appropriate program for their initial training.

Introduction: Four-Factor PCC (4F-PCC) is labeled for the reversal of vitamin K antagonists and may be considered off label for the reversal of factor Xa inhibitors. A fixed-dose strategy of 4F-PCC for the reversal of factor Xa inhibitors has the potential to minimize delay to reversal, avoid confusion during the ordering process, and lead to cost savings. The purpose of this study is to evaluate the safety and efficacy of fixed-dose 4F-PCC for the management of life-threatening bleeds associated with factor Xa inhibitors. Methods: This was a single center retrospective chart review conducted from May 2019 to January 2022. Patients were included if they were 18 years or older, experienced a life-threatening bleed while on a factor Xa inhibitor, and received 4F-PCC at a fixed dose of 2000 units. Exclusion criteria included: reversal for non-emergent surgery, receipt of 4F-PCC at an outside hospital, and/or receipt of an additional reversal agent. The primary outcome was achievement of hemostasis using a hemostatic effectiveness scale described by Sarode et al. Secondary outcomes included incidence of thrombosis within seven days of 4F-PCC administration and mortality. Results: A total of 39 patients received 4F-PCC for the reversal of a factor Xa inhibitor; 26 patients had central nervous system (CNS) bleeding and 13 had a non-CNS bleed. Overall 49% achieved excellent hemostatic effectiveness, 3% achieved good hemostatic effectiveness, 28% achieved poor, and in 20% we were unable to assess hemostatic effectiveness. In the subset of patients with CNS bleeding, 61% had either excellent or good effectiveness, 8% had poor, and 31% were unable to assess. There was one patient who experienced thromboembolism within seven days of reversal. In-hospital mortality was 18%. Conclusions: The results of this study demonstrate that a fixed-dose 4F-PCC dosing strategy for the reversal of factor Xa inhibitors produces reasonable hemostatic effectiveness and is safe. The rates of effectiveness seen in the subset of patients with CNS bleeding are similar to what has previously been reported for a weight-based dosing strategy. Randomized prospective studies are needed comparing 4F-PCC to andexanet alfa, the FDA labeled reversal agent for factor Xa inhibitors.

DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To manage factor Xa (FXa) inhibitor-associated bleeding, andexanet alfa or 4-factor prothrombin concentrate (4F-PCC) has been used to restore hemostasis. However, literature on the outcomes for patients who received both andexanet alfa and 4F-PCC is limited. SUMMARY We report a case series of 5 patients who received andexanet alfa plus 4F-PCC for reversal of FXa inhibitor-associated bleeding. Patients were included in this case series if they received both andexanet alfa and 4F-PCC for reversal of FXa inhibitor-associated bleeding. They were followed to either discharge or death, and in-hospital complications related to concurrent use of andexanet alfa and 4F-PCC were documented. We report an incidence of thromboembolism of 40% (2 of 5 cases) and an in-hospital mortality rate of 60% (3 of 5 cases). Taking these cases together with those in the existing literature, we found a total of 23 reported cases of safety outcomes with andexanet alfa plus 4F-PCC. The overall incidence of thromboembolism was 35% (8 of 23 cases). CONCLUSION This case series adds to the limited literature describing the outcomes for patients receiving andexanet alfa plus 4F-PCC. We encourage other institutions to report safety data on administering both agents.