David F Jadwin, DO FCAP Columbia Healthcare Analytics, Inc. Better Blood Use External Review as a...

David F Jadwin, DO FCAP Columbia Healthcare Analytics, Inc. Better Blood Use External Review as a Service (ERaaS)

Goals Help physicians use blood better Abandon laboratory approach to transfusions medicine Understand extent of unnecessary blood use Describe new model of external review Discuss 7 case studies to understand transfusion pitfalls Discuss principle-approach to transfusion medicine There is not enough time to cover material adequately Most questions will be answered by the presentation

Principle-based approach Cant be mastered in an hour Do not focus on laboratory values Conservative principles of medical practice Am College Physicians Ann Internal Med 116(5): 403-06 (1992) Treat what you know Evaluate the patient, not laboratory results Control bleeding Employ non-transfusion alternatives Adequately monitor and document Indications for Blood Transfusion: Too Complex to Base on a Single Number? Ann Internal Med 2012; 157: 71-72 The only proven indication for blood is hemorrhage

External vs Internal Review

Peer Review Should Dont (Often) Do not want to perform peer review Do not perform any peer review Do not perform critical peer review Cant (Most, if not all) Cannot identify many errors Cannot be unbiased Cannot perform standardize review

Blood Use Data (2009 2012)

Data Capture 8

Hospital Blood Use Transfusion Requirements in Critical Care N Engl J Med 1999; 340:409-17 Restrictive v Liberal transfusion No difference in outcomes Shorter LOS (0.9 day) STS data Jehovah Witness Bloodless Medicine & Surgery Total cost: blood cost x 6 9

Hazards and Pitfalls of Transfusion Bloodborne Disease Numerous Transfusion-Associated Conditions Transfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI) Transfusion-related immune modulation (TRIM) Subclinical graft-vs-host disease (tissue transplant) Myocardial infarct & death Complexity & Uncertainty 10

Tissue Ischemia Storage Lesion: Old vs fresh blood Reduced viscoelasticity 25 trillion RBCs 300 miles of capillaries Relative diameters: 7-8 uM (RBC) v 3-5 uM (Capillary) RBCs have to squeeze through capillaries to deliver oxygen Reduced 2, 3-DPG (delivery oxygen) Reduced PRBC nitric oxide Free hemoglobin (nitric oxide scavenger) Inflammatory products and microparticles

Videomicroscopy: Normal

Videomicroscopy: Transfused Blood

Transfusion Medicine Protocols should not be based on laboratory values Cannot apply simple rules Age Clinical condition & goal of therapy Prognosis & palliative care Clinical and laboratory trends Non-transfusion management Requires principle-based approach 14

External Review Educational Confidential Noncontroversial (not a black box) Not pass/fail 15

External Review Educational Confidential Noncontroversial (not a black box) Not pass/fail Avoid Incomplete Appropriate Defer opinion 16

Patient Case Study #1 17 DateTimeEvent 04/23/0814:47 Admitted 65 F Thoracic Burst Fracture 04/23/0816:05 Pre-operative Hg: 11.6 04/24/0819:15 Laminectomy EBL: 50 mL 04/25/0815:30 Post-operative Hg: 8.0

Patient Case Study #1 18 DateTimeEvent 04/23/0814:47 Admitted 65 F Thoracic Burst Fracture 04/23/0816:05 Pre-operative Hg: 11.6 04/24/0819:15 Laminectomy EBL: 50 mL 04/25/0815:30 Post-operative Hg: 8.0 04/25/0817:45 PRBC 04/25/0822:05 Hg: 9.5 04/25/0823:00 PRBC 04/26/0802:21 Hg:

Patient Case Study #1 19 DateTimeEvent 04/23/0814:47 Admitted 65 F Thoracic Burst Fracture 04/23/0816:05 Pre-operative Hg: 11.6 04/24/0819:15 Laminectomy EBL: 50 mL 04/25/0815:30 Post-operative Hg: 8.0 04/25/0817:45 PRBC 04/25/0822:05 Hg: 9.5 04/25/0823:00 PRBC 04/26/0802:21 Hg: 11.6 04/27/0802:55 Hg: 13.6 04/28/0815:35 Discharged

Non-beneficial Blood Use These cases are common to every hospital 60% of charts have one or more unnecessary units $2000 to $3000 unnecessary cost per patient These problems generally go unrecognized Untold impact on patient safety

Patient Case Study #2 21 DateTimeTime Event 01/23/0900:0100:00Admitted 87F: AF, end-stage dementia 01/24/0905:1229:01INR: 1.1 01/25/0917:0040:49warfarin 3 mg 01/26/0907:1555:04INR: 1.4 01/26/0917:0088:49warfarin 3 mg 01/27/0911:10106:5900:00INR: 4.0 01/27/0914:40110:2900:30INR: 3.4 01/28/0906:10125:5919:00INR: 3.0

Patient Case Study #2 22 DateTimeTime Event 01/23/0900:0100:00Admitted 87F: AF, end-stage dementia 01/24/0905:1229:01INR: 1.1 01/25/0917:0040:49warfarin 3 mg 01/26/0907:1555:04INR: 1.4 01/26/0917:0088:49warfarin 3 mg 01/27/0911:10106:5900:00INR: 4.0 01/27/0914:40110:2900:30INR: 3.4 01/28/0906:10125:5919:00INR: 3.0 01/28/0919:00138:4931:50warfarin 2 mg 01/29/0907:25151:1444:15INR: 4.0

Patient Case Study #2 23 DateTimeTime Event 01/23/0900:0100:00Admitted 87F: AF, end-stage dementia 01/24/0905:1229:01INR: 1.1 01/25/0917:0040:49warfarin 3 mg 01/26/0907:1555:04INR: 1.4 01/26/0917:0088:49warfarin 3 mg 01/27/0911:10106:5900:00INR: 4.0 01/27/0914:40110:2900:30INR: 3.4 01/28/0906:10125:5919:00INR: 3.0 01/28/0919:00138:4931:50warfarin 2 mg 01/29/0907:25151:1444:15INR: 4.0 01/29/0918:45162:3455:35Vitamin K

Patient Case Study #2 24 DateTimeTime Event 01/23/0900:0100:00Admitted 87F: AF, end-stage dementia 01/24/0905:1229:01INR: 1.1 01/25/0917:0040:49warfarin 3 mg 01/26/0907:1555:04INR: 1.4 01/26/0917:0088:49warfarin 3 mg 01/27/0911:10106:5900:00INR: 4.0 01/27/0914:40110:2900:30INR: 3.4 01/28/0906:10125:5919:00INR: 3.0 01/28/0919:00138:4931:50warfarin 2 mg 01/29/0907:25151:1444:15INR: 4.0 01/29/0918:45162:3455:35Vitamin K 01/30/0905:10172:5965:00Thawed Plasma (09:25 post vitamin k)

Patient Case Study #2 25 DateTimeTime Event 01/23/0900:0100:00Admitted 87F: AF, end-stage dementia 01/24/0905:1229:01INR: 1.1 01/25/0917:0040:49warfarin 3 mg 01/26/0907:1555:04INR: 1.4 01/26/0917:0088:49warfarin 3 mg 01/27/0911:10106:5900:00INR: 4.0 01/27/0914:40110:2900:30INR: 3.4 01/28/0906:10125:5919:00INR: 3.0 01/28/0919:00138:4931:50warfarin 2 mg 01/29/0907:25151:1444:15INR: 4.0 01/29/0918:45162:3455:35Vitamin K 01/30/0905:10172:5965:00Thawed Plasma (09:25 post vitamin k) 01/30/0906:00173:49INR: 1.4 01/30/0917:00184:49warfarin 1.5 mg 01/30/0918:00185:49Discharged (7.75 days)

General Laboratory Principles Avoid H&H or platelet-only orders Pay attention to the platelet count Watch out for spurious laboratory results Assess trends carefully Perform frequent laboratory tests Order reticulocyte count and iron studies early Know what laboratory tests measure INR is not necessarily a predictor of bleeding risk Dont make assumptions Work up coagulation abnormalities

Acute GI Bleed DateTimeEvent 01/1820:50-0:27Hgb 14.1 01/1821:170Admitted 79 M 01/1904:257:08Hgb 10.6 01/1911:0013:43PRBC 01/1914:0316:46PRBC 01/1918:3021:13Hgb 11.0 01/2003:5530:38Hgb 9.8 01/2008:4035:22PRBC 01/2012:3539:17PRBC

Acute GI Bleed DateTimeEvent 01/1820:50-0:27Hgb 14.1 01/1821:170Admitted 79 M 01/1904:257:08Hgb 10.6 01/1911:0013:43PRBC 01/1914:0316:46PRBC 01/1918:3021:13Hgb 11.0 01/2003:5530:38Hgb 9.8 01/2008:4035:22PRBC 01/2012:3539:17PRBC 01/2018:3045:13Hgb 12.4 01/2106:1056:53Hgb 11.1 01/2113:5064:33Discharged LOS 2.7 days

Acute GI Bleed DateTimeEvent 01/1820:50-0:27Hgb 14.1 01/1821:170Admitted 79 M 01/1904:257:08Hgb 10.6 01/1911:0013:43PRBC 01/1914:0316:46PRBC 01/1918:3021:13Hgb 11.0 01/2003:5530:38Hgb 9.8 01/2008:4035:22PRBC 01/2012:3539:17PRBC 01/2018:3045:13Hgb 12.4 01/2106:1056:53Hgb 11.1 01/2113:5064:33Discharged LOS 2.7 days 01/2211:5586:38Hgb 12.1 01/2404:30127:13Hgb 13.0 01/2421:05143:47Hgb 14.4

Total Knee Arthroplasty DateTimeEvent 01/2507:02Admitted 68 F 01/2510:47OR In 01/2512:04OR Out: EBL 25 mL 01/2605:15Hgb 8.3 01/2704:34Hgb 7.9 01/2710:10PRBC 01/2711:30PRBC 01/2714:20PRBC 01/2718:10Hgb 11.0 01/2805:15Hgb 12.1 01/2815:30Discharged

General Principles (Surgery) Correct elective pre-operative anemia (13 gm/dL) Bloodless elective surgeries Bypass patients - 80 percent bloodless procedures Use laboratory tests to guide therapy Record start and stop transfusion times

Pneumonia/ESLD/Lung Ca 32 DateTimeEvent 01/30/1108:1081 F Admitted: Respiratory Distress Plt: 277 01/31/1104:20Plt: 250, 254, 216, 151, 100, 70, 55, 46 02/08/1112:40Plt: 26 02/08/1115:53ASA 81 mg Sepsis v Heparin 02/09/1103:05Platelets 2 units

Pneumonia/ESLD/Lung Ca 33 DateTimeEvent 01/30/1108:1081 F Admitted: Respiratory Distress Plt: 277 01/31/1104:20Plt: 250, 254, 216, 151, 100, 70, 55, 46 02/08/1112:40Plt: 26 02/08/1115:53ASA 81 mg Sepsis v Heparin 02/09/1103:05Platelets 2 units 02/09/1112:40Plt: 151 02/09/1120:15Unresponsive; not a candidate for PEG, patient is terminal 02/10/1107:30Plt: 112 02/11/1111:00Plt: 99

Pneumonia/ESLD/Lung Ca 34 DateTimeEvent 01/30/1108:1081 F Admitted: Respiratory Distress Plt: 277 01/31/1104:20Plt: 250, 254, 216, 151, 100, 70, 55, 46 02/08/1112:40Plt: 26 02/08/1115:53ASA 81 mg Sepsis v Heparin 02/09/1103:05Platelets 2 units 02/09/1112:40Plt: 151 02/09/1120:15Unresponsive; not a candidate for PEG, patient is terminal 02/10/1107:30Plt: 112 02/11/1111:00Plt: 99 02/11/1116:15Platelets 1 unit 02/11/1118:25DNR 02/12/1106:15Plt: 86, 35 02/13/1120:40Expired LOS: 14.6 days

Aspiration Pneumonia/ARF 35 DateTimeEvent 01/30/1112:2690 F Admitted: SOB, fever Plt: 220 01/31/1106:55Plt: 201, 197, 178, 177, 153, 129, 120, 126, 104, 112, 126, 128, 118, 135, 96, 135, 98, 82, 84, 60, 61, 49, 42, 31 02/26/1100:00H&H 02/26/1108:15Plt: 18 02/26/1115:50Platelets 1 unit 02/26/1117:10Platelets 1 unit

Aspiration Pneumonia/ARF 36 DateTimeEvent 01/30/1112:2690 F Admitted: SOB, fever Plt: 220 01/31/1106:55Plt: 201, 197, 178, 177, 153, 129, 120, 126, 104, 112, 126, 128, 118, 135, 96, 135, 98, 82, 84, 60, 61, 49, 42, 31 02/26/1100:00H&H 02/26/1108:15Plt: 18 02/26/1115:50Platelets 1 unit 02/26/1117:10Platelets 1 unit 02/26/1118:10Platelet transfusion stop 02/26/1118:34Code blue 02/26/1118:48Code Blue End 02/26/1119:07Code Blue 02/26/1119:13Code Blue End 02/27/1104:00Plt: 136 02/27/1123:50Discharged LOS: 28.5 days

General Transfusion Principles Patients should receive full informed consent Treat most patients as if they are Jehovah Witness Anemia or microcytic indicies - order iron studies Establish anemia treatment protocols - Use IV iron Liability involves relative risk: Risk of over-transfusion is greater than under-transfusion

General Transfusion Principles Perform post-transfusion laboratory monitoring Components generally should not be given back-to- back Document adequately Use O negative only when minutes count Use un-crossmatched blood sparingly It may be unethical to aggressive treat certain patients

Epistaxis 39 DateTimeEvent 02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa 02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 124 02/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP

Epistaxis 40 DateTimeEvent 02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa 02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 124 02/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP 02/02/1117:25FFP 1 unit

Epistaxis 41 DateTimeEvent 02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa 02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 124 02/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP 02/02/1117:25FFP 1 unit 02/02/1118:20Progress Note: Currently not bleeding 02/03/1100:55FFP 2 units

Epistaxis 42 DateTimeEvent 02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa 02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 124 02/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP 02/02/1117:25FFP 1 unit 02/02/1118:20Progress Note: Currently not bleeding 02/02/1120:05Hgb: 8.8, 7.9 02/03/1100:55FFP 2 units 02/03/1114:50Hgb: 6.4

Epistaxis 43 DateTimeEvent 02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa 02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 124 02/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP 02/02/1117:25FFP 1 unit 02/02/1118:20Progress Note: Currently not bleeding 02/02/1120:05Hgb: 8.8, 7.9 02/03/1100:55FFP 2 units 02/03/1114:50Hgb: 6.4 02/03/1115:20Consent to blood transfusion NOS (First consent form in chart) 02/03/1116:30PRBC 3 units

Epistaxis 44 DateTimeEvent 02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa 02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 124 02/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP 02/02/1117:25FFP 1 unit 02/02/1118:20Progress Note: Currently not bleeding 02/02/1120:05Hgb: 8.8, 7.9 02/03/1100:55FFP 2 units 02/03/1114:50Hgb: 6.4 02/03/1115:20Consent to blood transfusion NOS (First consent form in chart) 02/03/1116:30PRBC 3 units 02/04/1106:25Hgb: 13.5, 12.2 02/05/1107:00Hgb: 13.2 02/05/1117:46Discharged LOS 3.1 days No coag study since first set

ERaaS: Hemophilia Case LOS 17 days 39 blood components (56 donors) 90,000 units Factor VIII + 30 units cryoprecipitate 5 minute chart review Unnecessary expense: $100,000 Education

Principle-based approach Cant be mastered in an hour Treat many patients as if Jehovah Witness Control bleeding Evaluate anemia (iron) and treat appropriately Do not transfuse blood components back-to-back Employ adequate laboratory testing Use laboratory results only as a guide Avoid aggressive therapy if patients dont benefit Use uncrossmatched and O negative blood wisely The only proven indication for blood use is hemorrhage

Further Information Society for the Advancement of Blood Management (SABM)

Electronic handouts available by request Dave Jadwin 210-598-9256 [email protected]

49 DateTimeEvent 04/09/1013:10 32 M Hemophilia, intracerebral hemorrhage 04/09/1019:41 06:31OR: Evacuation 04/09/1020:55 07:45Cryoprecipitate, pooled 04/09/1021:05 07:55Plasma 2 units 04/09/1022:22 09:17OR Out (EBL 150 mL) 04/10/1006:00 16:55Factor VIII 3,000 IU

50 DateTimeEvent 04/09/1013:10 32 M Hemophilia, intracerebral hemorrhage 04/09/1019:41 06:31OR: Evacuation 04/09/1020:55 07:45Cryoprecipitate, pooled 04/09/1021:05 07:55Plasma 2 units 04/09/1022:22 09:17OR Out (EBL 150 mL) 04/10/1006:00 16:55Factor VIII 3,000 IU 4/10/1011:00 21:55Von Willebrand/Ristocetin Cofactor: 199 4/11/1011:50 22:45Platelets (Platelet Count: 81,000) 4/10/1018:00 28:55Factor VIII 3,000 IU 4/11/1006:00 40:55Factor VIII 3,000 IU 4/11/1018:00 52:55Factor VIII 3,000 IU 4/12/1004:45 63:40Factor VIII Activity: 157%

51 DateTimeEvent 04/09/1013:10 32 M Hemophilia, intracerebral hemorrhage 04/09/1019:41 06:31OR: Evacuation 04/09/1020:55 07:45Cryoprecipitate, pooled 04/09/1021:05 07:55Plasma 2 units 04/09/1022:22 09:17OR Out (EBL 150 mL) 04/10/1006:00 16:55Factor VIII 3,000 IU 4/10/1011:00 21:55Von Willebrand/Ristocetin Cofactor: 199 4/11/1011:50 22:45Platelets (Platelet Count: 81,000) 4/10/1018:00 28:55Factor VIII 3,000 IU 4/11/1006:00 40:55Factor VIII 3,000 IU 4/11/1018:00 52:55Factor VIII 3,000 IU 4/12/1004:45 63:40Factor VIII Activity: 157% 4/12/1006:00 64:55 Factor VIII 3,000 IU 4/12/1012:35 77:30 Cryoprecipitate, pooled 4/12/1018:00 82:55 Factor VIII 3,000 IU 4/13/1003:35 92:30 Cryoprecipitate, pooled 04/13/1005:00 93:55Factor VIII Activity: 224% 04/13/1006:00 94:55 Factor VIII 3,000 IU

52 DateTimeEvent 04/13/1014:10103:05 Packed Red Blood Cells Hemoglobin: 10.0 04/13/1017:00Plasma 1 unit 04/13/1020:00Factor VIII 3,000 IU 04/13/1021:50 Packed Red Blood Cells 04/14/1003:15Factor VIII Activity: 163% Hemoglobin: 10.4 04/14/1006:00Factor VIII 3,000 IU 04/14/1019:00Factor VIII 3,000 IU 04/15/1004:20Factor VIII Activity: 130% Hemoglobin: 13.1 04/15/1006:00Factor VIII 3,000 IU x 2 04/16/1006:00Factor VIII 3,000 IU x 2 04/17/1006:00Factor VIII 3,000 IU x 2 04/18/1006:00Factor VIII 3,000 IU 04/18/1006:07Factor VIII Activity: 77% 04/19/1006:00Factor VIII 3,000 IU 04/19/1007:20Factor VIII Activity: 211% 04/20/1003:40Factor VIII Activity: 44% 04/20/1006:00Factor VIII 3,000 IU x 2 04/20/1010:35269Platelets Platelet Count: 75k Post-transfusion: 83, 78, 76, 85, 74, 83k 04/20/1012:20Plasma 2 units

53 DateTimeEvent 04/21/1004:16Factor VIII Activity: 88% 04/21/1006:00Factor VIII 3,000 IU x 2 04/22/1005:40Factor VIII Activity: 117% 04/22/1006:00Factor VIII 3,000 IU x 2 04/23/1005:48Factor VIII Activity: 80% 04/23/1006:00Factor VIII 3,000 IU x 2 04/24/1006:00Factor VIII 3,000 IU x 2 04/24/1006:40Factor VIII Activity: 155% 04/25/1004:36Factor VIII Activity: 88% 04/25/1006:00Factor VIII 3,000 IU x 2 04/26/1005:46Factor VIII Activity: 87% 04/26/1012:31Discharged

David F Jadwin, DO FCAP Columbia Healthcare Analytics, Inc. Better Blood Use External Review as a...

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