Practical considerations when developing guidelines for managing critical bleeding

In the critical care environment, clinicians strive to provide the best treatment possible for patients in desperate need. Such motivation, however, can be a key driver of escalating costs, especially when the use of nonreimbursable therapies goes unchecked or when futile attempts are made to improve outcomes in patients who may not benefit from aggressive management. Proactive intervention in the form of protocols is necessary to guide the use of blood products, coagulation factors, and antifibrinolytic agents. Evidence from clinical trials as well as recommendations from opinion leaders and professional societies should be critically evaluated and used to develop institution-specific protocols. If adopted with multidisciplinary cooperation, such protocols can curb the temptation to rely on anecdotal bedside observations to guide care and treat the patient with critical bleeding. Forming an ad hoc group of an institution's pharmacy and therapeutics committee can be an important step toward this end. The processes that a multidisciplinary group might follow are described, thus providing an idealized example of how pharmacists, working collaboratively with other clinicians and administrators, can be positioned at the center of an institution-wide solution to promote carefully considered, safe, effective, and cost-conscious care.