Hepatitis A Exposure Response and Outbreak Prevention in a Large Urban Jail - Los Angeles County, California, May-July 2023.

Correctional settings provide a high-risk environment for hepatitis A transmission because of the high proportion of homelessness and injection drug use among persons who are incarcerated. On May 30, 2023, Los Angeles County Department of Public Health informed the Communicable Disease Surveillance and Control (CDSC) unit of the Los Angeles County Jail system that a symptomatic incarcerated person had received a positive test result for acute hepatitis A. Upon learning the next day that the patient was a food handler, CDSC staff members identified 5,830 potential contacts of the index patient, 1,702 of whom had been released from the jail. During June 1-12, a total of 2,766 contacts who did not have a documented history of hepatitis A serology or vaccination that could be confirmed from the electronic health record or state immunization registry were identified. These persons were offered hepatitis A vaccination as postexposure prophylaxis; 1,510 (54.6%) accepted vaccination. Contacts who were food handlers without confirmed evidence of immunity and who declined vaccination were removed from food-handling duties for the duration of their potential incubation period. No additional cases were identified. Identifying contacts promptly and using immunization and serology records to ensure rapid delivery of postexposure prophylactic vaccine can help prevent hepatitis A transmission during exposures among incarcerated populations.

Characterizing predictors of COVID-19 vaccine refusal in an urban southern California jail population.

BACKGROUND: Correctional populations have been disproportionately affected by COVID-19, and many large outbreaks have occurred in jails and prisons. Vaccination is a key strategy to reduce the SARS-CoV-2 transmission in carceral settings. Although implementation can be challenging due to vaccine hesitancy and medical mistrust, correctional settings provide largely equitable healthcare access and present a unique opportunity to identify potential predictors of vaccine hesitancy independent of access issues. METHODS: We retrospectively analyzed electronic health record data for individuals offered COVID-19 vaccination at the Los Angeles County Jail between January 19, 2021, and January 31, 2023, and used multivariable logistic regression to determine predictors of COVID-19 vaccine refusal. RESULTS: Of the 21,424 individuals offered COVID-19 vaccination, 2,060 (9.6 %) refused. Refusal was associated with male sex ([aOR] = 2.3, 95 % CI (1.9, 2.8)), age 18-34 ([aOR] = 1.2, 95 % CI (1.1, 1.4), referent group: age 45-54), Black race ([aOR] = 1.2, 95 % CI (1.1, 1.4)), reporting ever being houseless ([aOR] = 1.2, 95 % CI (1.1, 1.3)), and having a history of not receiving influenza vaccination while incarcerated ([aOR] = 2.4, 95 % CI (2.0, 2.8)). When analyzing male and female populations separately, male-specific trends reflected those seen in the overall population, whereas the only significant predictor of vaccine refusal in the female population was not receiving influenza vaccination while in custody ([aOR] = 6.5, 95 % CI (2.4, 17.6)). CONCLUSION: Identifying predictors of vaccine refusal in correctional populations is an essential first step in the development and implementation of targeted interventions to mitigate vaccine hesitancy.

Not a Rare Disease Anymore? A Case of Ocular Syphilis at the Correctional Facility.

Los Angeles County has been facing a syphilis crisis since 2018. Cases of ocular syphilis have become increasingly identified and reported in the past few years, predominantly in HIV-positive men. Here we report a case of ocular syphilis in an otherwise healthy 49-year-old male in the Los Angeles County jail. This case study emphasizes the importance of increasing awareness of ocular syphilis so that it can be diagnosed promptly to prevent irreversible vision loss. Health care providers who work in the correctional facility setting need to be aware of this disease entity given that they serve a population with high risk of sexually transmitted diseases (STDs). This case study further stresses the importance of initial screening for sexual history and/or history of STDs within this population.

Risk factors for alcohol withdrawal-related hospital transfer in a correctional setting.

INTRODUCTION: A major health concern among individuals with alcohol use disorder is alcohol withdrawal syndrome (AWS), where individuals with physical dependence on alcohol may experience withdrawal signs and symptoms upon stopping or reducing alcohol use. AWS has a range of severity, with the most severe cases referred to as complicated AWS, presenting as seizure or signs and symptoms indicative of delirium or new onset of hallucinations. In the general community, risk factors or predictors of complicated AWS among hospitalized patients have been described, but there is no literature that examines such risk factors in a correctional population. The Los Angeles County Jail (LACJ) is the nation's largest jail system and manages 10-15 new patients per day for AWS. Here we aim to identify the risk factors associated with alcohol withdrawal-related hospital transfers among incarcerated patients being managed for AWS in the LACJ. METHODS: From January 1, 2019, to December 31, 2020, data were gathered about LACJ patients who required transfer to an acute care facility for alcohol withdrawal-related concerns while on the Clinical Institute Withdrawal Assessment for Alcohol revised (CIWA-Ar) protocol. Log regression analysis was performed to generate an odds ratio for acute care facility transfer for the following variables: race, sex assigned at birth, age, CIWA-Ar scores, highest systolic blood pressure (SBP), and highest heart rate (HR). RESULTS: Out of 15,658 patients on CIWA-Ar protocol during this 2-year time frame, a total of 269 (1.7%) were transferred to an acute care facility for alcohol withdrawal-related concerns. Of those 269 patients, significant risk factors associated with withdrawal-related hospital transfer included: Other race (OR 2.9, 95% CI 1.5-5.5), male sex assigned at birth (OR 1.6, 95% CI 1.0-2.5), age ≥55 years (OR 2.3, 95% 1.1-4.9), CIWA-Ar score 9-14 (OR 4.1, 95% CI 3.1-5.3), CIWA-Ar score ≥15 (OR 21.0, 95% CI 12.0-36.6), highest SBP ≥150 mmHg (OR 2.3, 95% CI 1.8-3.0), highest HR ≥ 110 bpm (OR 2.8, 95% CI 2.2-3.8). CONCLUSION: Among patients studied, the higher CIWA-Ar score was the most significant risk factor associated with alcohol withdrawal-related hospital transfer. Other significant risk factors identified are race other than Hispanic, white, and African American; male sex assigned at birth; age ≥55 years; highest SBP ≥150 mmHg; and highest HR ≥ 110 bpm.

Characterizing and combating the opioid epidemic in the Los Angeles County jail system.

INTRODUCTION: Opioid overdose-related morbidity and mortality is a pressing public health crisis. Successful overdose reversal through bystander administration of naloxone is well documented, but there is an absence of literature on the implementation and impact of widespread naloxone access in a correctional setting during incarceration. The objective of this study was to describe our efforts to combat opioid overdose, prevent deaths, and examine and identify opioid use and predictors of opioid use through factors including age, sex assigned at birth, and ethnicity among the incarcerated population within the Los Angeles County jail system. METHODS: We retrospectively analyzed self-reported substance use information from all newly incarcerated persons from September 2018 to December 2020 to characterize opioid use in the Los Angeles County Jail system and used multivariable logistic regression analysis to determine predictors of substance use. We analyzed data on all cases of naloxone administration by custody personnel (i.e., all correctional officers) during the same period by examining patient demographic information, hospital discharge diagnosis, and patient outcome information. To describe naloxone training and access for incarcerated persons as an overdose prevention strategy, we reviewed electronic health record data on patient health outcomes for all cases of naloxone administration by an incarcerated person. RESULTS: A total of 6.4 % (11,881 of 187,528) of incarcerated persons reported opioid use. In the multivariable analysis, reported substance use was most significantly associated with any ethnicity other than Black (aOR for White =11.2; 95 % CI 10.4, 12.0, aOR for Hispanic/Latinx 3.0; 95 % CI 2.8, 3.2, aOR for All Others; 5.2 95 % CI 4.6, 5.8) and being <65 years old. Naloxone was administered by custody personnel to a total of 129 patients, where 122 (94.6 %) survived and 7 (5.4 %) died. After the deployment of naloxone in jail housing units, there were two instances of bystander naloxone administration by incarcerated persons that led to successful opioid overdose reversal and survival. CONCLUSIONS: The expansion of naloxone availability to both custody personnel and incarcerated persons is an effective and warranted method to ensure timely naloxone administration and successful overdose reversal in a correctional setting.

A Missing Piece of Diabetes Management: A Correctional Health Perspective.

A cross-sectional study was conducted in January 2020 to evaluate type 1 diabetes (T1D) management during and between incarcerations at the Los Angeles County Jail. Inclusion criteria were men with a T1D diagnosis who had been incarcerated twice within 5 years with at least two hemoglobin A1c values during each incarceration and a minimum of 3 months in the community between incarcerations. The primary outcome was the percentage change in A1c after release compared with the A1c during incarcerations. Five patients met inclusion criteria. During the first and second incarcerations, mean A1c was reduced by 13% and 9.6%, respectively. While in the community, mean A1c increased by 14%. These results highlight the importance of comprehensive reentry programs for patients with T1D, including linkage to community resources for diabetes management, so health gains made during incarceration are not lost.

Implementation of a COVID-19 Infection Control Plan in a Large Urban Jail System.

When the COVID-19 pandemic hit the United States, the number of people confined in correctional facilities on a single day numbered 1.8 million. Incarcerated people are at an increased risk of contracting and spreading SARS-CoV-2. Recommendations from the Centers for Disease Control and Prevention on case recognition, management, isolation, and contact tracing are particularly challenging in jails because of the high turnover of incarcerated people. Beginning in late February 2020, the Department of Correctional Health Services in the Los Angeles County Jail system implemented a multipronged COVID-19 mitigation plan that was progressively amended in accordance with local and national recommendations. This plan entailed the creation of housing for people under investigation, SARS-CoV-2 screening upon entry, a mass-testing program, and identification and monitoring of medically vulnerable people. After the identification of the first laboratory-confirmed case on March 29, 2020, predictive models were generated to visualize potential disease spread and gain support for mitigation strategy planning, which forecasted approximately 3300-4600 cumulative cases during a 278-day period. From March 7 through December 31, 2020, the percentage positivity among unique people tested for SARS-CoV-2 was 11.6% (3933 of 33 921 tested). Among those screened at intake, the percentage positivity was 2.0% (502 of 25 702 tested). The ethnic distribution among people with a positive SARS-CoV-2 test result was largely representative of the overall jail population, and most people were asymptomatic. A sustainable, multifaceted mitigation plan that relies on collaboration among medical, custodial, and local public health personnel is essential for limiting the spread of SARS-CoV-2 infection in correctional facilities.

Robotic Vessel Sealer Device for Lymphocele Prevention After Pelvic Lymphadenectomy: Results of a Randomized Trial.

Introduction: Pelvic lymph node dissection (PLND) during robotic prostatectomy is associated with potential complications. The most common complication of PLND is lymphoceles, occurring in up to 50% of patients in studies with screening imaging but usually asymptomatic. We performed a prospective randomized trial to evaluate whether using advanced bipolar energy for PLND via the robotic vessel sealer can prevent lymphoceles. Methods: A total of 120 patients were enrolled in the trial with each patient serving as their own control. Robotic PLND was randomly performed using the vessel sealer on one side and standard PLND using clips on the other side. All patients underwent screening computed tomography scan 3 months postoperatively with radiologists blinded to the assigned technique. Significant lymphoceles were defined as fluid collections ≥3 cm in any plane. Results: Of those enrolled, 114 completed the study. The mean nodal yield was 6.5 nodes, with 3.1 versus 3.4 nodes for vessel sealer side versus standard technique (P = .35), respectively. The mean operative time for PLND was 11.3 versus 11.1 minutes (P = .62), respectively. Twenty-two lymphoceles were identified. Ten occurred on the vessel sealer side versus 12 on the standard side (8.8% versus 10.5%, P = .412). All lymphoceles were asymptomatic. Conclusions: While the robotic advanced bipolar device did not appear to prevent lymphoceles, the vessel sealer also did not increase the rate of lymphoceles compared with a standard technique using clips. Both techniques were equally efficacious, efficient, and safe for PLND such that surgeons who prefer to avoid clips can reasonably use the vessel sealer, although at increased cost. Clinical Trial Registration number: NCT02035475.

Establishing an Epidemiologic Profile of Hepatitis C Virus Infection at the Los Angeles County Jail.

OBJECTIVE: The hepatitis C virus (HCV) is the most common blood-borne infection in the United States. Although 2% to 3% of the global population is estimated to be infected with HCV, an estimated 18% of the US prison population may be infected. The objective of this study was to establish an epidemiologic profile of HCV infection in the largest urban jail system in the United States. METHODS: We retrospectively analyzed 20 years of data on demographic characteristics, risk factors, and HCV positivity among 80 681 individuals incarcerated at the Los Angeles County Jail who were tested for HCV infection from January 1, 2000, through December 31, 2019. We used multivariate logistic regression analysis to determine predictors of HCV positivity. RESULTS: Of the 80 681 individuals tested, 27 881 (34.6%) had positive test results for HCV infection. In the multivariate analysis, HCV positivity was most strongly associated with injection drug use (adjusted odds ratio [aOR] = 34.9; 95% CI, 24.6-49.5) and being born during 1946-1955 (aOR = 13.0; 95% CI, 11.9-14.2). Men were more likely than women to have HCV infection (aOR = 1.4; 95% CI, 1.3-1.5), and Hispanic (aOR = 4.2; 95% CI, 3.9-4.4) and non-Hispanic White (aOR = 3.8; 95% CI, 3.5-4.0) individuals were more likely than non-Hispanic African American individuals to have HCV infection. Noninjection drug use, homelessness, and mental health issues were also significantly associated with HCV positivity. CONCLUSION: Even in the absence of resources for universal screening for HCV infection, the creation of a risk profile and its implementation into a screening program may be a beneficial first step toward improving HCV surveillance and establishing an accurate estimate of HCV infection in the incarcerated population.

Clinical Pharmacist's Role in an Alcohol Detox Unit in a Correctional Setting.

INTRODUCTION: Newly incarcerated inmates with chronic alcohol use are at high risk for alcohol withdrawal. This descriptive study aims to describe the role of a clinical pharmacist within an alcohol detoxification unit (ADU) in the Los Angeles County jail that serves nearly 18 000 inmates facility-wide daily. METHODS: This descriptive analysis was conducted from August 2, 2018 through October 31, 2018 within the jail ADU. The pharmacist attended daily assessments on all alcohol detox patients; identified and assessed patients at high risk of severe withdrawal; and initiated, modified, and discontinued withdrawal medication for selected patients. Patients were determined to be high risk of severe withdrawal if they had history of severe withdrawal, any Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) score ≥15, or polysubstance withdrawal. RESULTS: A total of 1263 patients were admitted to the ADU during the study (average 97 per week). A total of 282 patients were assessed by the pharmacist. Patient assessments included substance use and medication history, CIWA-Ar score, response to pharmacotherapy, and referral to a substance use counselor. Medications were initiated, modified, or discontinued in 148 patients after discussion with a physician. Transfer to an acute care facility occurred in 48 patients. Zero alcohol detox patient deaths occurred during the study. CONCLUSION: This is a novel role of a pharmacist in a correctional setting. A pharmacist can aid in an ADU by identifying and assessing patients at high risk of severe withdrawal and managing pharmacotherapy. Future studies can examine pharmacist withdrawal management of additional substances.

Impact of a Pharmacist-Led Diabetes Clinic in a Correctional Setting.

Incarcerated patients often have a high disease burden and poor access to care in the community. In an effort to ensure glycemic control and appropriate initiation of statin therapy for cardiovascular (CV) risk reduction, a pilot program of pharmacist-led diabetes clinic (PLDC) was implemented in a large inner-city jail. A pre-post study was conducted as a quality improvement initiative. Inclusion criteria were inmate-patients (IPs) diagnosed with type 2 diabetes mellitus, treated with oral antidiabetic medications, managed by PLDC, and with at least 2 glycosylated hemoglobin A1cs (HbA1c). The primary outcome was the change in HbA1c after PLDC. The secondary outcome was the frequency of statin therapy. A total of 240 IPs met the inclusion criteria. Mean HbA1c was 8.2% at baseline and 7.6% at the last follow-up encounter, a change of -0.7% (95% confidence interval [CI]: -0.41% to -0.93%). The most dramatic change was seen in the group with the highest initial HbA1c (HbA1c ≥ 10%), from a mean baseline HbA1c of 11.6% to 8.5%, a change of -3.1% (95% CI: -2.5% to -3.7%). IPs with an initial HbA1c between 7% and 9.9% showed a change in mean HbA1c from 8.4% to 8.0%, a change of -0.4% (95% CI: -0.1% to -0.7%). Of the 240 included IPs, 141 were not on a statin at baseline. The frequency of statin use increased by 50.4% after PLDC. PLDC significantly improved glycemic control and guideline concordance for CV risk reduction. Adding PLDC to multidisciplinary care teams has the potential to improve population health outcomes for this medically complex, yet underserved patient population.

The Impact of Implementing an Advance Practice Pharmacist-Led Anticoagulation Clinic Within a Correctional Facility.

Maintaining warfarin in the therapeutic range is clinically challenging and can be made more complex in the correctional health setting. The care of an inmate population is complicated by its episodic and often brief nature in addition to the frequent lack of consistent care prior to incarceration. As part of a process improvement effort, a descriptive study was conducted on a unique pharmacist-led anticoagulation clinic that was initiated in the Los Angeles County jail. The advanced practice pharmacist (APP) used a Collaborative Practice Agreement and had access to a physician supervisor when necessary. The patients who arrived to the jail on warfarin had their doses adjusted by the APP according to their respective international normalized ratio (INR). The primary endpoints were percentage of INR readings within therapeutic range (RR) and time in therapeutic range (TTR). Secondary endpoints included bleeding and thrombotic events. A total of 141 patients were followed by the anticoagulation clinic over the initial 8-month period from September 2017 to April 2018. Indications for warfarin included deep vein thrombosis or pulmonary embolus (67%), mechanical valve (17%), atrial fibrillation (8%), and other (8%). The average RR was 74.1% in the 8 months following APP management, which met the definition of good control (>65%). The TTR was 67% which met the definition of good control (>65%). No bleeding or thrombotic events that required hospitalization occurred. Implementation of an APP-led anticoagulation clinic in a correctional health setting resulted in good INR control as defined in community standards.

Cook's Hernia: Renal Tumor Parasitic Vessels Herniating into Right Inguinal Canal.

We report the incidental findings and management of a hernia whose contents included renal tumor parasitic vessels in a 52-year-old male who presented with a 22 cm large right renal tumor. His initial complaints were right sided fullness and hematuria. Incidentally on CT scan, the patient's large right renal mass was identified, as well as lower pole parasitic tumor vessels which were herniating into the patient's right inguinal canal. Parasitic tumor vessels are often found on larger obscure tumors. Few side effects or associated problems have been reported from issues with the parasitic vessels other than excessive bleeding. Never before, to our knowledge, has an inguinal hernia with renal mass parasitic vessels herniating into it been documented. We named the hernia after the general surgeon, Dr. Craig Cook, MD, FACS, who assisted during the open radical nephrectomy and who reduced and repaired the right inguinal hernia. We present a case presentation and treatment rationale for this tumor and associated parasitic vessels herniation, along with a brief re view of existing literature.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace.

INTRODUCTION: Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting. METHODS: We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant's (patient's) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center. RESULTS: We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different. CONCLUSION: Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.

Reduction in Jail Emergency Department Visits and Closure After Implementation of On-Site Urgent Care.

This descriptive study evaluates the impact of implementation of full service on-site urgent care services at the Los Angeles County Jail (LACJ) by examining the number of patients seen at the referral hospital, Los Angeles County + University of Southern California Medical Center (LAC+USC), and the number of hours that the referral hospital was closed to transfers in the periods before and after the development of the LACJ Urgent Care. The appropriate utilization of public resources is a critical priority for an overburdened county medical health care system. Implementing on-site urgent care staffed by emergency physicians led to reductions in the average number of patients transferred to LAC+USC, the average number of monthly closure hours, and the average days per month when closure to transfer occurred, and a cost savings of some $2 million, primarily in personnel costs.

Inadequate Sensitivity of Laboratory Risk Indicator to Rule Out Necrotizing Fasciitis in the Emergency Department.

INTRODUCTION: Necrotizing fasciitis (NF) is a life-threatening illness, particularly when surgical debridement is delayed. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed to identify patients at higher risk for NF. Despite limited information in this regard, the LRINEC score is often used to "rule out" NF if negative. We describe the sensitivity of the LRINEC score in emergency department (ED) patients for the diagnosis of NF. METHODS: We conducted a chart review of ED patients in whom coding of hospital discharge diagnoses included NF. We employed standard methods to minimize bias. We used laboratory data to calculate the LRINEC score, and confirmed the diagnosis of NF via explicit chart review. We then calculated the sensitivity of a positive LRINEC score (standardly defined as six or greater) in our cohort. We examined the role of patient characteristics in the performance of the LRINEC score. Finally, we performed sensitivity analyses to estimate whether missing data for c-reactive protein (CRP) results were likely to impact our results. RESULTS: Of 266 ED patients coded as having a discharge diagnosis of NF, we were able to confirm the diagnosis, by chart review, in 167. We were able to calculate a LRINEC score in only 80 patients (due to absence of an initial CRP value); an LRINEC score of 6 or greater had a sensitivity of 77%. Sensitivity analyses of missing data supported our finding of inadequate sensitivity to rule out NF. In sub-analysis, NF patients with concurrent diabetes were more likely to be accurately categorized by the LRINEC score. CONCLUSION: Used in isolation, the LRINEC score is not sufficiently sensitive to rule out NF in a general ED population.

Aminocaproic Acid and Tranexamic Acid Fail to Reverse Dabigatran-Induced Coagulopathy.

In recent years, dabigatran has emerged as a popular alternative to warfarin for treatment of atrial fibrillation. If rapid reversal is required, however, no reversal agent has clearly been established. The primary purpose of this manuscript was to evaluate the efficacy of tranexamic acid and aminocaproic acid as agents to reverse dabigatran-induced coagulopathy. Rats were randomly assigned to 6 groups. Each rat received either dabigatran or oral placebo, followed by saline, tranexamic acid, or aminocaproic acid. An activated clotting test was used to measure the coagulopathy. Neither tranexamic acid nor aminocaproic acid successfully reversed dabigatran-induced coagulopathy. In this rodent model of dabigatran-induced coagulopathy, neither tranexamic acid nor aminocaproic acid were able to reverse the coagulopathy.

False-Positive Cystoscopic Diagnosis of Ureteral Obstruction After Hysterectomy Due to a Nonfunctional Kidney.

BACKGROUND: An estimated 0.2% of the population may have a unilateral nonfunctional kidney. This pre-existing condition may lead to the mistaken presumption that a ureteral injury has occurred when performing cystoscopy after hysterectomy. CASES: Two cases are presented in which cystoscopy to confirm ureteral patency after hysterectomy was performed in patients with pre-existing unknown nonfunctional kidneys. These false-positive findings resulted in additional operative time, additional cost, and unnecessary surgical exploration. CONCLUSION: Cystoscopy to confirm ureteral patency after hysterectomy may lead to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney.

Anticoagulation drug therapy: a review.

Historically, most patients who required parenteral anticoagulation received heparin, whereas those patients requiring oral anticoagulation received warfarin. Due to the narrow therapeutic index and need for frequent laboratory monitoring associated with warfarin, there has been a desire to develop newer, more effective anticoagulants. Consequently, in recent years many novel anticoagulants have been developed. The emergency physician may institute anticoagulation therapy in the short term (e.g. heparin) for a patient being admitted, or may start a novel anticoagulation for a patient being discharged. Similarly, a patient on a novel anticoagulant may present to the emergency department due to a hemorrhagic complication. Consequently, the emergency physician should be familiar with the newer and older anticoagulants. This review emphasizes the indication, mechanism of action, adverse effects, and potential reversal strategies for various anticoagulants that the emergency physician will likely encounter.