David F Jadwin, DO FCAP Columbia Healthcare Analytics, Inc.
Better Blood Use External Review as a Service (ERaaS)
Slide 2
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
Slide 3
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
Slide 4
External vs Internal Review
Slide 5
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
Slide 6
Blood Use Data (2009 2012)
Slide 7
Slide 8
Data Capture 8
Slide 9
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
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
Slide 12
Videomicroscopy: Normal
Slide 13
Videomicroscopy: Transfused Blood
Slide 14
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
Slide 15
External Review Educational Confidential Noncontroversial (not
a black box) Not pass/fail 15
Slide 16
External Review Educational Confidential Noncontroversial (not
a black box) Not pass/fail Avoid Incomplete Appropriate Defer
opinion 16
Slide 17
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
Slide 18
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:
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
Slide 21
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 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
Slide 24
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)
Slide 25
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)
Slide 26
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
Slide 27
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
Slide 28
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
Slide 29
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
Slide 30
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
Slide 31
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
Slide 32
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
Slide 33
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
Slide 34
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 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
Slide 37
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
Slide 38
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 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
Slide 41
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
Slide 42
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
Slide 43
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
Slide 44
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
Slide 45
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
Slide 46
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
Slide 47
Further Information Society for the Advancement of Blood
Management (SABM)
Slide 48
Electronic handouts available by request Dave Jadwin
210-598-9256 [email protected]
Slide 49
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
Slide 50
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%
Slide 51
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
Slide 52
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
Slide 53
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