Optimizing emergency department care for people with bleeding disorders: A scoping review of barriers and interventions for improvement

Abstract

Abstract BACKGROUND People with bleeding disorders often require emergency department (ED) care due to increased risk of life-threatening spontaneous or traumatic bleeding events. Timely administration of hemostatic therapy is critical to reduce morbidity and mortality. Current international guidelines are guided by the “Factor First” principle, wherein treatment is initiated based on clinical suspicion prior to investigations—however, delays and underuse of hemostatic therapies persist in ED care. In response to discrepancies from established guidelines, we aimed to evaluate the existing literature on ED care for people with bleeding disorders. AIMS This scoping review describes the identified barriers to ED care, interventions used to optimize care, and impacts on clinical outcomes. METHODS Following the Arksey and O'Malley framework, Joanna Briggs Institute recommendations, and Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines, a comprehensive literature search of the MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases was conducted from inception to March 2025. The review protocol was preregistered with Open Science Framework (https://doi.org/10.17605/OSF.IO/43EHP). Two reviewers independently performed title and abstract screening, full text screening, and data extraction, with discrepancies resolved through consensus or adjudication by a third reviewer. Quality and bias were assessed using both general and bleeding disorder-specific criteria. Data were analyzed with descriptive statistics and thematic analysis. RESULTS After duplicate removal, 3541 articles were screened, with 17 meeting criteria for inclusion. Of these, 10 observational studies were focused exclusively on identifying barriers to optimal ED care, while seven studies also implemented and evaluated intervention(s). All studies were conducted by institutions from urban centres. Patient/caregiver perspectives were infrequently incorporated (2/17). Most interventional studies focused exclusively on hemophilia, while some also included von Willebrand disease, rare factor deficiencies, or unspecified bleeding disorders. Frequently identified barriers included process gaps (10/17; triaged as lower priority, delays or failure to administer hemostatic therapy despite suspected or confirmed bleeding episode, hesitancy to initiate treatment without full assessment or investigations), lack of communication and coordination with hematology or hemophilia treatment centers (HTCs; 10/17), hospital system gaps (9/17; lack of established guidelines or ED care pathways, delayed identification of bleeding disorder patients due to electronic medical record [EMR] limitations), education and awareness gaps (6/17; limited training, high staff turnover), or resource limitations (4/17; lack of or restricted access to hemostatic agents). These barriers were commonly associated with missed or delayed hemostatic therapy. Interventions involved single or combined strategies, including new ED care pathways, simulations, education sessions for ED providers and/or patients, prepopulated EMR order sets for hemostatic therapy replacement, EMR-based triage flags, and development of websites with guidelines. All interventions were associated with improved outcomes. Four studies reported reductions in time to factor administration (range: 25–149 minutes; mean reduction: 69 minutes). Additional outcomes were reported in a single study each and included 11% increase in optimal factor dosing, 15% improvement in triage priority, 39% reduction in non-indicated diagnostic testing, decreased hospitalization rates (no quantitative statistics reported), and 16% increase in hematology involvement. CONCLUSIONS Current studies evaluating ED care for people with bleeding disorders identified persistent barriers to timely and guideline-directed ED care. Barriers to care were multifactorial and often required multimodal interventions by interdisciplinary teams. The findings of this scoping review may assist bleeding disorder care teams to identify potential barriers in their own institutions and inform future knowledge translation efforts and research to improve care. This review provides a comprehensive foundation to inform our ownmulti-institutional evaluation of Canadian emergency care processes and will directly support ongoing quality improvement efforts to enhance guideline-directed care across EDs.