At low-volume trauma centers and critical access hospitals, there are a number of measures trauma personnel can take to prepare for patients taking DOACs who present with traumatic injury, says Nei. She recommends these steps:

Know your stock.

Hospital staff members treating trauma patients should be keenly aware of their reversal stock, whether that is prothrombin complex concentrate human injection or fresh frozen plasma.

"The biggest thing is what's available for you at your center for DOAC reversal," says Nei. "Unfortunately, there have been shortages in the last couple of years, so it's important to know what you have on hand."

Determine your reversal plan.

Beyond the initial resuscitation of the patient, starting in July 2019, The Joint Commission is requiring all hospitals, including critical access hospitals, to have anticoagulant therapy safety measures in place, including a number of requirements for reversal management. Bearing in mind what is feasible at your facility and what medications are available, a multidisciplinary team, including pharmacy, needs to create a plan, even if your facility does not frequently see patients requiring such reversals.

Awareness of The Joint Commission consensus guidelines pertaining to anticoagulant reversal in patients undergoing trauma also is important in formulating a plan, says Nei, as the guidelines do not suggest routine reversal in all patients, particularly those who aren't bleeding. Rather, consensus guidelines encourage providers to carefully consider whether reversal is needed on an individual basis.

Additionally, knowing what labs your facility can draw upon — those that would be rapidly available to conduct such as thromboelastogram, anti-Xa level or prothrombin time — is crucial, as prolongation of coagulopathy testing may assist in identifying resuscitative agents.

Establish communication with your receiving hospital.

Ensuring the accepting physician is aware of the injured patient's DOAC prescription and the status of reversal agent administration is critical upon transfer. If the medical center where the patient initially presents does not stock the necessary reversal agent to treat immediately, alert the physician at the receiving hospital. As some of these medications can take time to prepare, such as bringing them to room temperature before administration, advance notice helps give the pharmacy at the receiving facility sufficient time to be ready for the patient's needs.

"These are challenging products to get to the bedside," says Nei. "It's really challenging for institutions trying to come up with a plan. But achievement of hemostasis is critical. I'm hoping as more studies are done, we will have more of an idea of how to manage these patients."