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Forster CM, Halls S, Allarakhia S, Modi D, Chung W, Derry K, Digby G, Flemming J, McGugan J, Mackulin H, Montague S, Sibley S, Silver SA, Sirosky-Yanyk A, Stevens A, de Wit K, Zhang L, Callum J. Improving appropriate use of intravenous albumin: results of a single-centre audit and multifaceted intervention. BMJ Open Qual 2024; 13:e002534. [PMID: 38626937 PMCID: PMC11029189 DOI: 10.1136/bmjoq-2023-002534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Intravenous albumin has limited indications supported by randomised controlled trials, yet it is often prescribed for indications not supported by evidence. AIM To reduce unnecessary transfusion of albumin. INTERVENTIONS Under the leadership of a multidisciplinary quality improvement team, evidence-based recommendations were disseminated in tandem with a new electronic order set, an educational strategy, qualitative interviews with prescribers and a return policy change to reduce wastage. IMPLEMENTATION AND EVALUATION Interventions were introduced in a staggered fashion. The primary outcome, appropriate use of albumin, was monitored and quantified using pre-intervention and post-intervention audits. Process measures included statistical process run charts of monthly usage of 5% and 25% albumin and wastage. Data on length of stay (hospital and intensive care), new inpatient starts on kidney replacement and mortality were collected as balancing measures. RESULTS Appropriate albumin usage based on indication increased from 30% to 50% (p<0.0001). There was significantly less overall albumin usage in the post-intervention period compared with the pre-intervention period (negative coefficient, p<0.0001), driven by a major reduction in the utilisation of the 5% formulation (p<0.0001). Overall albumin usage was significantly lower in the post-intervention period, decreasing from 800 to 450 vials per month. The intervention resulted in significantly less wastage (negative coefficient, p=0.017). Mortality, length of stay and new starts on kidney replacement therapy remained constant throughout the study period. CONCLUSION Improved prescribing of albumin was achieved with a multifaceted approach. Substantial and sustained reductions in usage were achieved without negatively impacting patient-important outcomes. The estimated annual savings for the purchase cost of albumin was CAN $300 000. We provide a structured process for other organisations to optimise their use of albumin.
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Affiliation(s)
- Corey M Forster
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | | | - Dimpy Modi
- Department of Medicine, Hamilton, Stockholm, Ontario, Sweden
| | - Wiley Chung
- Surgery, Queen's University, Kingston, Ontario, Canada
| | - Kendra Derry
- Department of Anesthesiology, Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jennifer Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John McGugan
- Department of Anesthesiology and Perioperative Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Heather Mackulin
- Nursing, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Steven Montague
- Department of Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Stephanie Sibley
- Department of Critical Care, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Samuel A Silver
- Department of Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Angela Sirosky-Yanyk
- Transfusion Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Andrew Stevens
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Liying Zhang
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jeannie Callum
- Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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Jug R, Callum J, Ruijs T, Liu Y, Barty R, Thompson T. Intravenous albumin utilization audit at a large community hospital. Transfusion 2024; 64:39-46. [PMID: 38078484 DOI: 10.1111/trf.17610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/01/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND There is a literature gap in terms of albumin utilization practices. METHODS/MATERIALS We conducted a single-center retrospective observational electronic audit of adult admitted patients who received one or more vials of albumin (5% or 25%) between September 1, 2019 and August 31, 2020 at a large community hospital. The Research Ethics Board approval was obtained. Utilization data identified through the laboratory information system were independently adjudicated by two reviewers and resolved by consensus as appropriate-acceptable, appropriate-may be acceptable, or inappropriate. The primary objective of this audit is to determine the proportion of 5% and 25% intravenous albumin infusions meeting a priori appropriateness criteria for indication. Secondary outcomes include determining the patterns of practice surrounding intravenous albumin use: patient demographics, most responsible diagnosis, location at time of order, clinical outcomes of albumin recipients, and types, volumes, and cost of albumin infused. RESULTS The mean total albumin administered was 569.2 mL across 456 total recipients (58% male) with a 29% appropriateness rate. This cohort had an in-hospital mortality rate of 38%, with an average of 6 days from first dose of albumin to death. The mean length of stay was 14 days, with a mean intensive care length of stay of 8 days. The purchase cost of inappropriately transfused albumin was CAD $65,538. CONCLUSION Based on a lack of or an unacceptable indication provided, 71% of patients were inappropriately transfused. Albumin use deviating from guideline recommendations may be contributing to increased healthcare costs, pressure on limited supply, and potential patient harm.
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Affiliation(s)
- Rachel Jug
- University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | | | - Yang Liu
- Michael DeGroote Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Barty
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
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Bai Z, Méndez-Sánchez N, Romeiro FG, Mancuso A, Philips CA, Tacke F, Basaranoglu M, Primignani M, Ibrahim M, Wong YJ, Nery FG, Teschke R, Ferreira CN, Muñoz AE, Pinyopornpanish K, Thevenot T, Singh SP, Mohanty A, Satapathy SK, Ridola L, Maruyama H, Cholongitas E, Levi Sandri GB, Yang L, Shalimar, Yang Y, Villa E, Krag A, Wong F, Jalan R, O’Brien A, Bernardi M, Qi X. Use of albumin infusion for cirrhosis-related complications: An international position statement. JHEP Rep 2023; 5:100785. [PMID: 37456673 PMCID: PMC10339261 DOI: 10.1016/j.jhepr.2023.100785] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 07/18/2023] Open
Abstract
Background & Aims Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.
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Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
| | | | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Metin Basaranoglu
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Filipe Gaio Nery
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Alberto E. Muñoz
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
| | - Kanokwan Pinyopornpanish
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thierry Thevenot
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
| | | | - Arpan Mohanty
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
| | - Sanjaya K. Satapathy
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Li Yang
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Yongping Yang
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Erica Villa
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Aleksander Krag
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
| | | | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - the Liver Cirrhosis-related Complications (LCC)-International Special Interest Group
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
- Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
- Kalinga Gastroenterology Foundation, Odisha, India
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
- Division of Medicine, Royal Free Campus, London, UK
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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