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Khandelwal A, Minuk L, Liu Y, Arnold DM, Heddle NM, Barty R, Hsia C, Solh Z, Shehata N, Thompson T, Tinmouth A, Perelman I, Skeate R, Kron AT, Callum J. Plasma transfusion practices: A multicentre electronic audit. Vox Sang 2022; 117:1211-1219. [PMID: 36102150 DOI: 10.1111/vox.13355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/02/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Plasma is often transfused to patients with bleeding or requiring invasive procedures and with abnormal tests of coagulation. Chart audits find half of plasma transfusions unnecessary, resulting in avoidable complications and costs. This multicentre electronic audit was conducted to determine the proportion of plasma transfused without an indication and/or at a sub-therapeutic dose. METHODS Data were extracted on adult inpatients in 2017 at five academic sites from the hospital electronic chart, laboratory information systems and the Canadian Institute for Health Information Discharge Abstract Database. Electronic criteria for plasma transfusion outside recommended indications were: (1) international normalized ratio (INR) < 1.5 with no to moderate bleeding; (2) INR ≥ 1.5, with no to mild bleeding and no planned procedures; and (3) no INR before or after plasma infusion. Sub-therapeutic dose was defined as ≤2 units transfused. RESULTS In 1 year, 2590 patients received 6088 plasma transfusions encompassing 11,490 units of plasma occurred at the five sites. 77.7% of events were either outside indications or under-dosed. Of these, 34.8% of plasma orders had no indication identified, and 62% of these occurred in non-bleeding patients and no planned procedure with an isolated elevated INR. 70.7% of transfusions were under-dosed. Most plasma transfusions occurred in the intensive care unit or the operating room. Inter-hospital variability in peri-transfusion testing and dosing was observed. CONCLUSION The majority of plasma transfusions are sub-optimal. Local hospital culture may be an important driver. Electronic audits, with definitions employed in this study, may be a practical alternative to costly chart audits.
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Affiliation(s)
- Aditi Khandelwal
- Canadian Blood Services, Toronto, Ontario, Canada.,The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Leigh Minuk
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yang Liu
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Barty
- McMaster Centre for Transfusion Research (MCTR), McMaster University, Hamilton, Ontario, Canada.,Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Cyrus Hsia
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Transfusion Medicine Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Ziad Solh
- Department of Medicine, Western University, London, Ontario, Canada.,Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.,Transfusion Medicine Laboratories, London Health Sciences Centre, London, Ontario, Canada
| | - Nadine Shehata
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Alan Tinmouth
- Ottawa Hospital Centre for Transfusion Research, Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Iris Perelman
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Robert Skeate
- Canadian Blood Services, Toronto, Ontario, Canada.,The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Amie T Kron
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeannie Callum
- The University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
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Foster M, Presseau J, Podolsky E, McIntyre L, Papoulias M, Brehaut JC. How well do critical care audit and feedback interventions adhere to best practice? Development and application of the REFLECT-52 evaluation tool. Implement Sci 2021; 16:81. [PMID: 34404449 PMCID: PMC8369748 DOI: 10.1186/s13012-021-01145-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/24/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Healthcare Audit and Feedback (A&F) interventions have been shown to be an effective means of changing healthcare professional behavior, but work is required to optimize them, as evidence suggests that A&F interventions are not improving over time. Recent published guidance has suggested an initial set of best practices that may help to increase intervention effectiveness, which focus on the "Nature of the desired action," "Nature of the data available for feedback," "Feedback display," and "Delivering the feedback intervention." We aimed to develop a generalizable evaluation tool that can be used to assess whether A&F interventions conform to these suggestions for best practice and conducted initial testing of the tool through application to a sample of critical care A&F interventions. METHODS We used a consensus-based approach to develop an evaluation tool from published guidance and subsequently applied the tool to conduct a secondary analysis of A&F interventions. To start, the 15 suggestions for improved feedback interventions published by Brehaut et al. were deconstructed into rateable items. Items were developed through iterative consensus meetings among researchers. These items were then piloted on 12 A&F studies (two reviewers met for consensus each time after independently applying the tool to four A&F intervention studies). After each consensus meeting, items were modified to improve clarity and specificity, and to help increase the reliability between coders. We then assessed the conformity to best practices of 17 critical care A&F interventions, sourced from a systematic review of A&F interventions on provider ordering of laboratory tests and transfusions in the critical care setting. Data for each criteria item was extracted by one coder and confirmed by a second; results were then aggregated and presented graphically or in a table and described narratively. RESULTS In total, 52 criteria items were developed (38 ratable items and 14 descriptive items). Eight studies targeted lab test ordering behaviors, and 10 studies targeted blood transfusion ordering. Items focused on specifying the "Nature of the Desired Action" were adhered to most commonly-feedback was often presented in the context of an external priority (13/17), showed or described a discrepancy in performance (14/17), and in all cases it was reasonable for the recipients to be responsible for the change in behavior (17/17). Items focused on the "Nature of the Data Available for Feedback" were adhered to less often-only some interventions provided individual (5/17) or patient-level data (5/17), and few included aspirational comparators (2/17), or justifications for specificity of feedback (4/17), choice of comparator (0/9) or the interval between reports (3/13). Items focused on the "Nature of the Feedback Display" were reported poorly-just under half of interventions reported providing feedback in more than one way (8/17) and interventions rarely included pilot-testing of the feedback (1/17 unclear) or presentation of a visual display and summary message in close proximity of each other (1/13). Items focused on "Delivering the Feedback Intervention" were also poorly reported-feedback rarely reported use of barrier/enabler assessments (0/17), involved target members in the development of the feedback (0/17), or involved explicit design to be received and discussed in a social context (3/17); however, most interventions clearly indicated who was providing the feedback (11/17), involved a facilitator (8/12) or involved engaging in self-assessment around the target behavior prior to receipt of feedback (12/17). CONCLUSIONS Many of the theory-informed best practice items were not consistently applied in critical care and can suggest clear ways to improve interventions. Standardized reporting of detailed intervention descriptions and feedback templates may also help to further advance research in this field. The 52-item tool can serve as a basis for reliably assessing concordance with best practice guidance in existing A&F interventions trialed in other healthcare settings, and could be used to inform future A&F intervention development. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Madison Foster
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.,School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON, K1N 6N5, Canada
| | - Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Maria Papoulias
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada. .,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.
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Foster M, Presseau J, McCleary N, Carroll K, McIntyre L, Hutton B, Brehaut J. Audit and feedback to improve laboratory test and transfusion ordering in critical care: a systematic review. Implement Sci 2020; 15:46. [PMID: 32560666 PMCID: PMC7303577 DOI: 10.1186/s13012-020-00981-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/12/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Laboratory tests and transfusions are sometimes ordered inappropriately, particularly in the critical care setting, which sees frequent use of both. Audit and Feedback (A&F) is a potentially useful intervention for modifying healthcare provider behaviors, but its application to the complex, team-based environment of critical care is not well understood. We conducted a systematic review of the literature on A&F interventions for improving test or transfusion ordering in the critical care setting. METHODS Five databases, two registries, and the bibliographies of relevant articles were searched. We included critical care studies that assessed the use of A&F targeting healthcare provider behaviors, alone or in combination with other interventions to improve test and transfusion ordering, as compared to historical practice, no intervention, or another healthcare behaviour change intervention. Studies were included only if they reported laboratory test or transfusion orders, or the appropriateness of orders, as outcomes. There were no restrictions based on study design, date of publication, or follow-up time. Intervention characteristics and absolute differences in outcomes were summarized. The quality of individual studies was assessed using a modified version of the Effective Practice and Organisation of Care Cochrane Review Group's criteria. RESULTS We identified 16 studies, including 13 uncontrolled before-after studies, one randomized controlled trial, one controlled before-after study, and one controlled clinical trial (quasi-experimental). These studies described 17 interventions, mostly (88%) multifaceted interventions with an A&F component. Feedback was most often provided in a written format only (41%), more than once (53%), and most often only provided data aggregated to the group-level (41%). Most studies saw a change in the hypothesized direction, but not all studies provided statistical analyses to formally test improvement. Overall study quality was low, with studies often lacking a concurrent control group. CONCLUSIONS Our review summarizes characteristics of A&F interventions implemented in the critical care context, points to some mechanisms by which A&F might be made more effective in this setting, and provides an overview of how the appropriateness of orders was reported. Our findings suggest that A&F can be effective in the context of critical care; however, further research is required to characterize approaches that optimize the effectiveness in this setting alongside more rigorous evaluation methods. TRIAL REGISTRATION PROSPERO CRD42016051941.
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Affiliation(s)
- Madison Foster
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON K1N 6N5 Canada
| | - Nicola McCleary
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Kelly Carroll
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- Ottawa Hospital Research Institute, Knowledge Synthesis Unit, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Jamie Brehaut
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
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Efficacy of a strict surveillance policy towards inappropriateness of plasma transfusion. Transfus Apher Sci 2019; 58:423-428. [DOI: 10.1016/j.transci.2019.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 01/14/2023]
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5
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Is Coagulopathy an Appropriate Therapeutic Target During Critical Illness Such as Trauma or Sepsis? Shock 2018; 48:159-167. [PMID: 28234791 DOI: 10.1097/shk.0000000000000854] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Coagulopathy is a common and vexing clinical problem in critically ill patients. Recently, major advances focused on the treatment of coagulopathy in trauma and sepsis have emerged. However, the targeting of coagulopathy with blood product transfusion and drugs directed at attenuating the physiologic response to these conditions has major potential risk to the patient. Therefore, the identification of coagulopathy as a clinical target is an area of uncertainty and controversy. To analyze the state of the science regarding coagulopathy in critical illness, a symposium addressing the problem was organized at the 39th annual meeting of the Shock Society in the summer of 2016. This manuscript synthesizes the viewpoints of the four expert panelists at the debate and presents an overview of the potential positive and negative consequences of targeting coagulopathy in trauma and sepsis.
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Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care. Crit Care Med 2017; 45:271-281. [PMID: 27632673 DOI: 10.1097/ccm.0000000000002077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients. DESIGN Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions. SETTING Fifty-nine U.S. ICUs. PATIENTS A total of 6,027 adult ICU patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia. CONCLUSIONS In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.
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Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Med Care Res Rev 2016; 74:507-550. [PMID: 27402662 DOI: 10.1177/1077558716656970] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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Affiliation(s)
- Carrie H Colla
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Thomas Sequist
- 2 Harvard Medical School, Boston, MA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Partners HealthCare, Boston, MA, USA
| | - Nancy Morden
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,5 Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Tinmouth A. Assessing the Rationale and Effectiveness of Frozen Plasma Transfusions. Hematol Oncol Clin North Am 2016; 30:561-72. [DOI: 10.1016/j.hoc.2016.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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9
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Leão SC, Gomes MAB, Aragão MCDA, Lobo IMF. Practices for rational use of blood components in a universitary hospital. Rev Assoc Med Bras (1992) 2016; 61:355-61. [PMID: 26466218 DOI: 10.1590/1806-9282.61.04.355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 09/16/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to produce improvements in transfusion practices through the implementation of an educational program for health professionals in a university hospital. METHODS this is an interventional and prospective study, with pre- and postanalysis of an educational intervention. The research was developed at the University Hospital of the Universidade Federal de Sergipe, involving participation of health professionals in the stage of training, during the month of February 2011, in addition to the monitoring of blood transfusions performed in the pre- and post-intervention periods. Transfusion practices were investigated upon request for transfusion or devolution of unused blood components. Knowledge of health professionals was assessed based on the responses to a questionnaire about transfusion practices. RESULTS during the educative campaign, 63 professionals were trained, including 33 nurses or nursing technicians and 30 physicians. Among the doctors, there was a statistically significant gain of 20.1% in theoretical knowledge (p=0.037). Gain in the nursing group was even higher: 30.4% (p=0.016). The comparative analysis of transfusion request forms showed a non-significant decrease from 26.7 to 19.5% (p=0.31) in all forms with incomplete information. We also observed a statistically significant improvement in relation to the filling of four items of transfusion request. CONCLUSION there was a significant improvement of the entire process related to blood transfusions after interventional project conducted in February 2011.
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Prophylactic plasma and platelet transfusion in the critically Ill patient: just useless and expensive or even harmful? BMC Anesthesiol 2015; 15:86. [PMID: 26054337 PMCID: PMC4556318 DOI: 10.1186/s12871-015-0074-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/01/2015] [Indexed: 12/14/2022] Open
Abstract
It is still common practice to correct abnormal standard laboratory test results, such as increased INR or low platelet count, prior to invasive interventions, such as tracheostomy, central venous catheter insertion or liver biopsy, in critically ill patients. Data suggest that 30-90 % of plasma transfused for these indications is unnecessary and puts the patient at risk. Plasma transfusion is associated with a high risk of transfusion-associated adverse events such as transfusion-associated circulatory overload (TACO), transfusion-related lung injury (TRALI), transfusion-related immunomodulation (TRIM), and anaphylaxis/allergic reactions. Therefore, the avoidance of inappropriate plasma transfusion bears a high potential of improving patient outcomes. The prospective study by Durila et al., published recently in BMC Anesthesiology, provides evidence that tracheostomies can be performed without prophylactic plasma transfusion and bleeding complications in critically ill patients despite increased INR in case of normal thromboelastometry (ROTEM) results. Thromboelastometry-based restrictive transfusion management helped avoid unnecessary plasma and platelet transfusion, and should reduce the incidence of transfusion-related adverse events and transfusion-associated hospital costs. Therefore, the authors believe that thromboelastometry-based strategies should be implemented to optimize patient blood management in perioperative medicine.
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11
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Zeller MP, Al-Habsi KS, Golder M, Walsh GM, Sheffield WP. Plasma and Plasma Protein Product Transfusion: A Canadian Blood Services Centre for Innovation Symposium. Transfus Med Rev 2015; 29:181-94. [PMID: 25862281 DOI: 10.1016/j.tmrv.2015.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 12/27/2022]
Abstract
Plasma obtained via whole blood donation processing or via apheresis technology can either be transfused directly to patients or pooled and fractionated into plasma protein products that are concentrates of 1 or more purified plasma protein. The evidence base supporting clinical efficacy in most of the indications for which plasma is transfused is weak, whereas high-quality evidence supports the efficacy of plasma protein products in at least some of the clinical settings in which they are used. Transfusable plasma utilization remains composed in part of applications that fall outside of clinical practice guidelines. Plasma contains all of the soluble coagulation factors and is frequently transfused in efforts to restore or reinforce patient hemostasis. The biochemical complexities of coagulation have in recent years been rationalized in newer cell-based models that supplement the cascade hypothesis. Efforts to normalize widely used clinical hemostasis screening test values by plasma transfusion are thought to be misplaced, but superior rapid tests have been slow to emerge. The advent of non-vitamin K-dependent oral anticoagulants has brought new challenges to clinical laboratories in plasma testing and to clinicians needing to reverse non-vitamin K-dependent oral anticoagulants urgently. Current plasma-related controversies include prophylactic plasma transfusion before invasive procedures, plasma vs prothrombin complex concentrates for urgent warfarin reversal, and the utility of increased ratios of plasma to red blood cell units transfused in massive transfusion protocols. The first recombinant plasma protein products to reach the clinic were recombinant hemophilia treatment products, and these donor-free equivalents to factors VIII and IX are now being supplemented with novel products whose circulatory half-lives have been increased by chemical modification or genetic fusion. Achieving optimal plasma utilization is an ongoing challenge in the interconnected worlds of transfusable plasma, plasma protein products, and recombinant and engineered replacements.
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Affiliation(s)
- Michelle P Zeller
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Khalid S Al-Habsi
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Mia Golder
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - Geraldine M Walsh
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada
| | - William P Sheffield
- Centre for Innovation, Medical Services and Innovation, Canadian Blood Services, Hamilton, Ottawa, Vancouver, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.
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12
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Affiliation(s)
- Andrew Shih
- Department of Medicine; McMaster University; Hamilton Ontario Canada
| | - Donald M. Arnold
- Department of Medicine; McMaster University; Hamilton Ontario Canada
- Canadian Blood Services; Hamilton Ontario Canada
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13
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Shih AW, Kolesar E, Ning S, Manning N, Arnold DM, Crowther MA. Evaluation of the appropriateness of frozen plasma usage after introduction of prothrombin complex concentrates: a retrospective study. Vox Sang 2014; 108:274-80. [PMID: 25556889 DOI: 10.1111/vox.12226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/26/2014] [Accepted: 10/30/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prothrombin complex concentrates (PCCs) can be used instead of frozen plasma (FP) transfusion to reverse the effect of warfarin. Audits have demonstrated over usage of FP transfusions even before the introduction of PCC. The objective of this study was to determine the appropriateness of current FP transfusion practice in the current era since the introduction of PCCs. METHODS A retrospective cohort study of consecutive patients receiving FP over 3 months was carried out. Each episode of FP use over a 24-h period was adjudicated independently by two reviewers as appropriate (consistent with Canadian/AABB guidelines), appropriate but inconsistent with guidelines or inappropriate. Discrepancies were resolved by a third reviewer. Use of FP to reverse warfarin was considered inappropriate. FP usage from previous years was assessed as baseline. RESULTS During the study period, 111 FP transfusions were administered. 74.8% of FP usage occurred in the ICU. The proportion of FP transfusions that were deemed appropriate, inconsistent yet appropriate or inappropriate were 33/89 (37.1%), 16/89 (18.0%) and 40/89 (44.9%), respectively, when use of FP for therapeutic plasma exchange was excluded. The most common reasons for inappropriate use were the absence of bleeding with an increased INR or warfarin reversal. CONCLUSION Our study is the first to audit FP transfusions in the post-PCC era in Canada. FP usage remains inappropriately high in INR prolongation without another indication or to reverse warfarin. Targeted interventions to reduce FP usage in the future should focus on the ICU and on education about warfarin reversal.
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Affiliation(s)
- A W Shih
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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14
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Transfusions de plasma en réanimation pédiatrique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0900-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Karam O, Tucci M, Lacroix J, Rimensberger PC. International survey on plasma transfusion practices in critically ill children. Transfusion 2013; 54:1125-32. [PMID: 24032693 DOI: 10.1111/trf.12393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/16/2013] [Accepted: 07/17/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Studies have shown heterogeneity in red blood cell transfusion practices. Although plasma transfusion is common in intensive care, there are no data on plasma transfusion practices in pediatric critical care units. STUDY DESIGN AND METHODS A scenario-based survey was sent to 718 pediatric critical care physicians working in Europe, North America, Australia, and New Zealand. Respondents were asked to report their decisions regarding plasma transfusion practice with respect to four scenarios: pneumonia, septic shock, traumatic brain injury (TBI), and postoperative care after a Tetralogy of Fallot correction. RESULTS The response rate was 187 of 718 (26%); half of the responders worked in North America. The proportion of physicians who transfused plasma to nonbleeding patients, solely based on abnormal international normalized ratio (INR), varied from 66% for pneumonia to 84% for TBI (p < 0.001). In such nonbleeding patients, the median INR threshold that would trigger plasma transfusion was 2.5 for pneumonia and septic shock patients and 2.0 for TBI and the cardiac postoperative patients (p < 0.001). Minor bleeding, minor surgery, insertion of a femoral line, hypotension, abnormal activated partial thromboplastin time, thrombocytopenia, and anemia levels were important determinants of plasma transfusion, whereas none of the respondents' demographic characteristics were important. CONCLUSION More than two-thirds of responding pediatric critical care physicians prescribe plasma transfusions for nonbleeding critically ill children. Additionally, there is a significant variation in transfusion practice patterns with respect to plasma transfusion thresholds.
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Affiliation(s)
- Oliver Karam
- Pediatric Critical Care Unit, Geneva University Hospital, Geneva, Switzerland
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16
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Labarinas S, Arni D, Karam O. Plasma in the PICU: why and when should we transfuse? Ann Intensive Care 2013; 3:16. [PMID: 23725411 PMCID: PMC3698065 DOI: 10.1186/2110-5820-3-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/07/2013] [Indexed: 11/10/2022] Open
Abstract
Whereas red blood cell transfusions have been used since the 19th century, plasma has only been available since 1941. It was originally mainly used as volume replacement, mostly during World War II and the Korean War. Over the years, its indication has shifted to correct coagulation factors deficiencies or to prevent bleeding. Currently, it remains a frequent treatment in the intensive care unit, both for critically ill adults and children. However, observational studies have shown that plasma transfusion fail to correct mildly abnormal coagulation tests. Furthermore, recent epidemiological studies have shown that plasma transfusions are associated with an increased morbidity and mortality in critically ill patients. Therefore, plasma, as any other treatment, has to be used when the benefits outweigh the risks. Based on observational data, most experts suggest limiting its use either to massively bleeding patients or bleeding patients who have documented abnormal coagulation tests, and refraining for transfusing plasma to nonbleeding patients whatever their coagulation tests. In this paper, we will review current evidence on plasma transfusions and discuss its indications.
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Affiliation(s)
- Sonia Labarinas
- Pediatric Critical Care Unit, Geneva University Hospital, 6 rue Willy Donzé, Geneva 1211, Switzerland.
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17
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Tinmouth A, Thompson T, Arnold DM, Callum JL, Gagliardi K, Lauzon D, Owens W, Pinkerton P. Utilization of frozen plasma in Ontario: a provincewide audit reveals a high rate of inappropriate transfusions. Transfusion 2013; 53:2222-9. [PMID: 23672421 DOI: 10.1111/trf.12231] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Frozen plasma (FP) is frequently transfused inappropriately, an intervention that results in risk without benefit for the patient. To better understand current utilization practices in our region, we undertook a provincewide prospective audit to evaluate the clinical indications and appropriateness of FP transfusion. STUDY DESIGN AND METHODS All hospitals in the Canadian province of Ontario with transfusion medicine services were invited to participate in a 5-day audit of FP utilization. FP dose, indication, and clinical patient data were collected for each transfusion request. Indications for FP transfusions were independently adjudicated as appropriate, inappropriate, or indeterminate based on predefined criteria. RESULTS Seventy-six (49%) of 155 invited hospitals participated in the audit, which included 573 requests for 2012 units of FP. A total of 559 transfusions (1909 units) were administered. Of 573 requests, 164 (28.6%) were deemed inappropriate most often because: 1) they were administered to patients with an international normalized ratio below 1.5 or 2) they were administered in absence of bleeding or emergency surgery. The most frequent indications for FP transfusions were before surgery and warfarin reversal. Overall, patients admitted to the clinical areas of surgery, internal medicine, and the emergency department represented the largest users of FP, but this varied by hospital type (community vs. academic). The most frequently requested doses of FP were 2 and 4 units. CONCLUSION This point-prevalence hospital audit revealed that transfusion of FP is frequently inappropriate. Focusing on reducing the two most common reasons for inappropriate FP transfusions could lead to a significant improvement in FP utilization.
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Affiliation(s)
- Alan Tinmouth
- Department of Medicine, Ottawa Hospital and University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Ontario Regional Blood Coordinating Network Office, Toronto, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Laboratory Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Canadian Blood Services, Ottawa and Hamilton, Ontario, Canada
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18
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Arnold DM, Lauzier F, Rabbat C, Zytaruk N, Barlow Cash B, Clarke F, Heels-Ansdell D, Guyatt G, Walter SD, Davies A, Cook DJ. Adjudication of bleeding outcomes in an international thromboprophylaxis trial in critical illness. Thromb Res 2013; 131:204-9. [PMID: 23317632 DOI: 10.1016/j.thromres.2012.12.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 11/26/2012] [Accepted: 12/07/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Measuring bleeding in critical care trials is challenging. We determined the reliability of adjudicated bleeding assessments in a large thromboprophylaxis trial in the intensive care unit (ICU). MATERIALS AND METHODS PROphylaxis for ThromboEmbolism in Critical Care Trial (PROTECT) was an international randomized controlled trial that compared dalteparin to unfractionated heparin for the prevention of deep vein thrombosis in the ICU. Daily bleeding data were collected prospectively using a validated tool. Bleeds were adjudicated in duplicate by 2 of 4 members comprising a central adjudication committee. Bleeds were stratified by severity and study drug, then randomly assigned to adjudicator pairs. Adjudicators were blinded to treatment allocation, study centre and peer-assessments. We calculated agreement on bleeding severity and examined the effect of adjudication on overall trial results. RESULTS In PROTECT, 491 patients had bleeding events including 208 with major bleeding and 283 with minor bleeding only. Of 491 patients, 446 were adjudicated in duplicate: 182 with major, 250 with minor and 14 with no bleeding. After adjudication, 52 of 244 bleeds were downgraded to minor; whereas only 15 of 244 were upgraded to major. Overall agreement among adjudicators was excellent (crude agreement=86.3%; kappa=0.76). Hazard ratios for major or any bleeding with dalteparin or unfractionated heparin were similar when analyzed using non-adjudicated events. CONCLUSIONS Major bleeds were sometimes over-called by research coordinators in a large ICU thromboprohylaxis trial. Adjudicator agreement was excellent. Central adjudication allowed reliable bleeding assessment and enhanced the rigor and validity of this major safety outcome.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Canadian Blood Services, Hamilton, Ontario, Canada
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Eder AF, Dy BA, Perez JM, Rambaud M, Benjamin RJ. The residual risk of transfusion-related acute lung injury at the American Red Cross (2008-2011): limitations of a predominantly male-donor plasma mitigation strategy. Transfusion 2012; 53:1442-9. [DOI: 10.1111/j.1537-2995.2012.03935.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/11/2012] [Accepted: 09/17/2012] [Indexed: 12/01/2022]
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