Transcript Strategies to Decrease Blood Utilization and Improve Safety

Strategies to Decrease Blood
Utilization and Improve Safety
Presented by
Paul 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 transfusion
10-8
10-7
10-6
10-5
HIV
10-4
10-3
10-2
10-1
100
Death from general
anesthesia
Death from medical
error
HBV
Death from hosp. infect.
HCV
Bacteria in platelets
Mistransfusion
Modified from S. Dzik, MD
Blood Transfusion Service
MGH, Boston.
Zilberberg, M. BMC
Health Services Res.
2007.
GVHD
TRALI
TACO (CHF)
TSACs/unit RBC/US ICUs
Global Red Cell Utilization Rates: 2008-09
60
RBCs per 1,000 Population
50
40
30
20
10
0
Source: D Devine et al.: International Forum/Inventory Management, Vox Sanguinis 2009
Costs of surgical RBC transfusion
Austria
Switzerland
Rhode Island
New Jersey
$522
Activity-based cost
$154
RBC acquisition cost
$611
$194
$726
$203
$1,183
$248
$0
$200 $400
Shander et al. Transfusion. 2010.
$600
$800 $1,000 $1,200
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)
Mortality
Length of
stay
n=418
%
n=420
%
p
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
ICU
11.010.7
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)
N=160
Liberal (10 gm)
N=197
23%
23%
0.2±4.2
1.3±4.4
Mean Hgb
8.5 ±0.62
10.3 ±0.67
Mean units
transfused
2.4 ±4.1
5.2 ±5.0
30 day
mortality
MODS change
from baseline
Hebert, P et al. Crit. Care Med. 2001
p<.02
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 )
Liberal trigger
(n=1008)
Restrictive trigger
(n=1005)
1866
652
(97% transf.)
(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%
FOCUS results
Units transfused
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)
Hemoglobin triggers (all) by hospital
18
16
14
Grams
12
10
8
Focus
TRICC
6
4
2
0
1
2
3
4
5
6 7 8 9
HOSPITAL ID
10 11 12 13
Trigger by hospital: operative blood loss
13
12
11
Grams
10
9
8
FOCUS
7
6
5
4
1
2
3
5
6
7
8
HOSPITAL ID
9
10
11
12
Trigger by hospital: nonbleeding
15.0
Grams
12.5
10.0
7.5
TRICC
5.0
1
2
3
4
5 6 7 8
HOSPITAL ID
9
10 11 12
Units in first order
3
6
1st Audit
400
300
200
100
0
3
6
9 12 15 18 21
Units 1st order
9 12 15 18 21
2nd audit
Ordering specialty
1st Audit
2nd audit
Category
CAR
CVS
ER
FP
GI
IM
OBG
ONC
ORT
SUR
Transfusion in total hip arthroplasty
MVRBC blood management program
totals for audited quarter
# THA
%
transfused transfused
Hospital ID
# THA
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
26.4-54.0
2=.67 p=.96
95% CI
Transfusion in total knee arthroplasty
MVRBC blood management program
totals for audited quarter
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 rates in orthopedics
Reference
Population
Percent transfused
Hasley et al. Med
Care. 1995.
Range among hospitals
(THA and TKA)
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
Muller et al. BMJ.
2004.
425 THA & TKA before/after
decision support flow sheet
Martinez et al.
BJAnes. 2007.
475 THA and TKA
before/after algorithm
Pierson et al. JBJS. Single surgeon 500 consec.
2004.
THA/TKA on/off algorithm
THA
TKA
36-95
9-97
Usual care
BCA
26.1
16.5
Before
After
39.9
19.8
Total 55 to 24
Allo 21 to 13
Auto 32 to 12
Allo+Auto
8 to 0
On (433)
Off (67)
2.1
16.4
Audit burden for non-bleeding patients: Trinity
99.99
1st Audit
2nd audit
99
Percent
95
80
50
20
18.084
5.515
5
1
TRICC
0.01
3
4
5
6
7
8
9
Trigger hemoglobin
10
11
12
Conclusions
• Non-bleeding patients still receiving 1st units at well above “TRICCvalidated” 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