Strategies to Decrease Blood Utilization and Improve Safety
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Transcript of Strategies to Decrease Blood Utilization and Improve Safety
Strategies to Decrease Blood Utilization and Improve Safety
Presented byPaul McLoone, M.D.
April 17, 2012
History of RBC transfusion “triggers”
• To mid-1980s: 10 g/dL hemoglobin
• Conservative trend in 1980s and ff.– TTDs (HIV and NANB hepatitis (HCV))
–Shortages–Evidence that anemia is well tolerated–Non-infectious serious hazards–Threats from emerging infections
How are triggers “set”?• Guidelines and systematic reviews• Few RCTs (garbage in, garbage out)
–Observational cohorts, case series, expert opinion
–Unstudied populations affect generalizability–Key functional outcomes generally not
available
~16 million RBCs transfused annually
Why?– Prevent/reverse tissue ischemia
• Preserve aerobic metabolism
• Decrease cardiac effects of anemia
• Decrease symptoms of anemia
– “Anemia is bad”
– “May help, will not hurt”
~16 million RBCs transfused annually• Why not ????
– TRALI (transfusion-related acute lung injury) – TACO (circulatory overload)– TRIM (immunomodulation)– Vasoregulatory abnormalities– Immunohematological events– TTIs: Known and emerging– TA-GVHD (graft v. host disease)– Dollar costs
“Recognized” risks of transfusion010-110-210-310-4 1010-510-610-710-8
HIV
HCV
HBV
Mistransfusion
GVHD
TACO (CHF)
TSACs/unit RBC/US ICUs
Bacteria in platelets
Modified from S. Dzik, MD Blood Transfusion Service MGH, Boston.
Zilberberg, M. BMC Health Services Res. 2007.
Death from medical error
Death from general anesthesia
TRALI
Death from hosp. infect.
Global Red Cell Utilization Rates: 2008-09
Venez
uela
Brazil
South
Africa
Singap
ore
Saudi-
Arabia
Poland
Hong K
ong
New Zea
land
Canad
a CBS
Canad
a Hem
a-Que
bec
Irelan
dSpa
in
Netherl
ands
²⁾Croa
tia
France
UK NHSBT ¹
⁾
Portug
al
Austra
lia
Hunga
ryIta
ly
Norway
Japa
n
Finlan
dUSA
Sweden
Austria
Belgium
Flande
rs
German
y0
10
20
30
40
50
60
RBCs
per
1,0
00 P
opul
atio
n
Source: D Devine et al.: International Forum/Inventory Management, Vox Sanguinis 2009
Costs of surgical RBC transfusion
New Jersey
Rhode Island
Switzerland
Austria
$0 $200 $400 $600 $800 $1,000 $1,200
$248
$203
$194
$154
$1,183
$726
$611
$522 Activity-based costRBC acquisition cost
Shander et al. Transfusion. 2010.
Paradox: anemic patients may do better without transfusion: TRICC*
• Multicenter, randomized trial in >800 patients with <9 gram Hgb within 72 h. of ICU admit
• Liberal vs. restrictive PRBC triggers
– Restrictive = <7 gm, Liberal = <10 gm
• Mortality endpoints and severity of organ dysfunction
*Transfusion Requirements In Critical Care. Hebert et al. NEJM. 1999.
TRICC: Primum non nocere?Restrictive (7 gm) Liberal (10 gm)
n=418 % n=420 % p
Mortality
30 day 78 18.7 98 23.3 .11
60 day 95 22.7 111 26.5 .23
Hospital 93 22.2 118 28.1 .05
Length of stay
ICU 11.010.7 11.5 11.3 .53
Hospital 34.8 19.5 35.5 19.4 .58
“A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients.” Hebert et al. NEJM. 1999.
TRICC: Post hoc analysis of pts. with cardiovascular disease
Restrictive (7 gm) Liberal (10 gm)N=160 N=197
30 day mortality 23% 23%
MODS change from baseline 0.2±4.2 1.3±4.4 p<.02
Mean Hgb 8.5 ±0.62 10.3 ±0.67Mean units transfused 2.4 ±4.1 5.2 ±5.0
Hebert, P et al. Crit. Care Med. 2001
TRICC: Post hoc analysis of ventilated pts.
Restrictive (7 gm)N=357
Liberal (10 gm)N=356
Mean vent days 8.3 ±8.1 8.8 ±8.7
Mean vent free days 17.9 ±10.9 16.1 ±11.4
Successful weaning 82% 78%
Mean Hgb 8.4 ±0.62 10.4 ±0.71
Mean units transfused 2.7 ±4.0 5.5 ±5.1
Hebert, P et al. Chest. 2001
FOCUS*: Surgery for hip fracture• RCT: 2016 patients: liberal (10 g) vs. conservative
(<8 g or symptoms) RBC trigger• Heart disease or risk for heart disease (CAD, CHF,
PVD, CVA, DM, BP, lipids, or CRF)• 1 outcomes: Death or inability to cross room
unassisted at 60 d.• 2 outcomes: 60 d. mortality, fatigues, falls,
readmission, functional status*Functional Outcomes in Cardiovascular patients Undergoing Surgical hip fracture repair (clinicaltrials.gov NCT00071032 )
FOCUS results Liberal trigger(n=1008)
Restrictive trigger(n=1005)
Units transfused 1866(97% transf.)
652(41.5% transf.)
Median units 2 (IQ 1-2) 0 (IQ 0-1)
1 outcome 35% 35%
60 day mortality 7.6% 6.5%
In-hosp MI, unstab angina, death 4.3% 5.2%
Readmit, fall, fatigue, function No differences
Carson et al. AHA Scientific Session and ASH Late Breaking Abstracts. 2009.
Why are restrictive triggers appropriate?primum non nocere
• SHOTs woefully under-reported
• Description of putative “new” serious hazards
– Pro-inflammatory– Immunosuppressive
• Large prospective trials (TRICC, TRIPICU, PINT, FOCUS, TRACS) demonstrate outcomes at least as good using restrictive triggers
• Positive impact of liberal triggers on functional outcomes not demonstrated in (FOCUS)
• Activity costs of transfusion
Changing Physician Practice• Continue Education Event: Dr. Katz
MVRBC Medical Director• Medical Staff Performance Improvement
Committee ( ownership of process)• Metrics, as close to real time as possible• Order set development• Medical Executive Committee• Ongoing presentations to multiple groups
Caveat emptor• Retrospective nature of project
– Data are as reliable as our ability to find information in the medical record
– Confounders (e.g. cardio-respiratory compromise, severity of illness were not systematically sought)
– Acuity of operative bleeding not readily assessed
– DRG and many ICD-9 numbers too small for meaningful analysis
– Denominators vary from year to year
Trinity RBC audits• Descriptive manual chart audit of RBC units given
during 1st quarter of 2009 and 2011• Recorded ordering physician and specialty• Hemoglobin on admission, at time of 1st order (i.e.
“transfusion trigger”) and after transfusion• Documentation of bleeding in medical record• Initial data presented to various constituencies
after intial audit with recommendations• Trinity ongoing intervention (Marvis et al)
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HOSPITAL ID
Gra
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TRICCFocus
Hemoglobin triggers (all) by hospital
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HOSPITAL ID
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FOCUS
Trigger by hospital: operative blood loss
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HOSPITAL ID
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Trigger by hospital: nonbleeding
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400
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211815129631st Audit
Units 1st order
2nd audit
Units in first order
1st Audit 2nd audit
ORTSUR
CARCVSERFPGIIMOBGONC
Category
Ordering specialty
Transfusion in total hip arthroplastyMVRBC blood management program
totals for audited quarterHospital ID # THA # THA
transfused%
transfused 95% CI
1 26 15 57.7 36.9-76.6
2 52 23 44.2 30.5-58.7
7 52 20 38.5 25.3-53.0
8 26 12 46.2 26.6-66.6
10 53 21 39.6 26.4-54.02=.67 p=.96
Hospital ID # TKA # TKA transfused
% transfused 95% CI
1 77 19 24.7 15.6-35.8
2 124 31 25.0 17.7-33.6
7 105 37 35.2 26.2-45.2
8 55 25 45.5 32.0-59.5
10 139 56 40.3 32.1-48.9
2=13.2 p=0.010
Transfusion in total knee arthroplastyMVRBC blood management program
totals for audited quarter
Transfusion rates in orthopedicsReference Population Percent transfused
Hasley et al. Med Care. 1995.
Range among hospitals (THA and TKA)
THA 36-95 TKA 9-97
Carson et al. JAMA. 1998.
8787 consecutive hip fractures 42.1
Pedersen et al. BMC MS. 2010.
28087 consecutive Danish THA 1999-2007 32.3
Wong et al. Transfusion. 2007.
THA at 30 hospitals randomized UC or BCA
Usual care 26.1 BCA 16.5
Muller et al. BMJ. 2004.
425 THA & TKA before/after decision support flow sheet
Before 39.9 After 19.8
Martinez et al. BJAnes. 2007.
475 THA and TKA before/after algorithm
Total 55 to 24Allo 21 to 13
Auto 32 to 12 Allo+Auto 8 to 0
Pierson et al. JBJS. 2004.
Single surgeon 500 consec. THA/TKA on/off algorithm
On (433) 2.1 Off (67) 16.4
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9995
80
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0.01
Trigger hemoglobin
Per
cent
5.515
18.084
TRICC
1st Audit2nd audit
Audit burden for non-bleeding patients: Trinity
Conclusions• Non-bleeding patients still receiving 1st units at well above “TRICC-
validated” thresholds, but appear to have improved• Operative bleeding is transfused above FOCUS thresholds• Single unit transfusions should be encouraged
– Probably requires “rules”• Concurrent analysis of non-bleeding patients and patients with
operative bleeding may reduce transfusion of RBCs– Establish clinical guidelines for broad clinical groups– Medical staff buy in is an ongoing effort in multiple settings over
time– Enlist clinical champions for that process and for the remedial efforts– Close to real time analysis of outliers– Frequent reports comparing apples to apples