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Trentino KM, Lloyd A, Swain SG, Trentino L, Gross I. Data and Metrics for Patient Blood Management: A Narrative Review and Practical Guide. Anesth Analg 2023:00000539-990000000-00615. [PMID: 37553085 DOI: 10.1213/ane.0000000000006557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Data collection, analysis, and reporting are fundamental for a successful hospital-based patient blood management program; however, very little has been published on the topic. Our aim was to synthesize evidence from a literature review to provide a detailed, practical list of outcome metrics, and the required data collection(s) to inform implementation. Ovid MEDLINE and PubMed were searched for any full-text original research articles published from inception to the year 2020. We included any studies reporting the implementation of interventions or programs study authors defined as "patient blood management" and extracted information on data collected and metrics reported. We included 45 studies describing the implementation of a patient blood management program and/or strategies. The outcomes reported by these studies were grouped into 1 of 36 metrics. We compiled a list of 65 relevant data elements to collect, and their potential source hospital information systems: patient administration, laboratory, transfusion/blood bank, operating room, pharmacy, emergency department, and intensive care unit. We further categorized patient blood management data systems into basic, intermediate, and advanced based on the combination of different information systems sourced. The results of this review can be used to inform patient blood management programs in planning what data collection(s) are needed, where these data can be sourced from, and how they can be analyzed.
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Affiliation(s)
- Kevin M Trentino
- From the Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Adam Lloyd
- From the Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | | | - Laura Trentino
- Data Analysis and Research, Datum Statista, Perth, Western Australia, Australia
| | - Irwin Gross
- Department of Medicine, Emeritus, Northern Light Eastern Maine Medical Center, Bangor, Maine
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2
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Prochaska M, Salcedo J, Berry G, Meltzer D. Racial differences in red blood cell transfusion in hospitalized patients with anemia. Transfusion 2022; 62:1519-1526. [PMID: 35657149 PMCID: PMC9357128 DOI: 10.1111/trf.16935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Guidelines recommend transfusion of red blood cells (RBC's) when a hospitalized patient's hemoglobin (Hb) drops below a restrictive transfusion threshold, either at 7 or 8 g. Hospitals have implemented transfusion policies to encourage compliance with guidelines and reduce variation in transfusion practice. However, variation in transfusion practice remains. The purpose of this study was to examine whether there is variation in the receipt of transfusion by patient race. METHODS Hospitalized general medicine patients with anemia (Hb < 10 g/dL) were eligible. Chi-squared tests were used to compare the percent of patients receiving a transfusion by race overall and within strata of their nadir Hb. Linear regression was used to test the association between a patient's race, their nadir Hb, receipt of an RBC transfusion, and the number of units transfused. RESULTS Four thousand nine hundred and fifty-one patients consented, including 1363 (28%) who received a transfusion. 71% of patients were African American, 25% were White, and 4% were Other Race. Overall African Americans were less likely to be transfused compared to Whites (25% vs. 30%, p < .01), and within Hb strata below a Nadir Hb of 9 g/dL (Hb 8.0-8.9 g/dL 1% vs. 7%, p < .01; 7.0-7.9 g/dL 15% vs. 28%, p < .01; <7 g/dL 80% vs. 86%, p < .01). African Americans also received fewer units of RBC's (β = -.17, p < .01) overall and at lower Hb levels (β = .14, p < .01) compared to Whites. DISCUSSION The Hb level at which patients are transfused at and the total number of RBC units received during hospitalization differ by patient race.
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Affiliation(s)
- Micah Prochaska
- Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoIllinois
| | - Jorge Salcedo
- UCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - Grace Berry
- Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoIllinois
| | - David Meltzer
- Section of Hospital Medicine, Department of MedicineThe University of ChicagoChicagoIllinois
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3
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O'Malley SM, Sanders JO, Nelson SE, Rubery PT, O'Malley NT, Aquina CT. Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery. Spine (Phila Pa 1976) 2021; 46:1588-1597. [PMID: 33882540 DOI: 10.1097/brs.0000000000004077] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case control study. OBJECTIVE To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort. SUMMARY OF BACKGROUND DATA No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery. METHODS Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications. RESULTS Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83). CONCLUSION Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.
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Affiliation(s)
- Sandra M O'Malley
- Department of Trauma and Orthopaedics, Mater Misericordiae University Hospital, Dublin, Ireland
| | - James O Sanders
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Susan E Nelson
- Department of Orthopedic Surgery, University of Rochester, Rochester, NY
| | - Paul T Rubery
- Department of Orthopedic Surgery, University of Rochester, Rochester, NY
| | - Natasha T O'Malley
- Department of Orthopedic Surgery, University of Rochester, Rochester, NY
| | - Christopher T Aquina
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Rochester, NY
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Aboagye JK, Haut ER, Streiff MB, Hobson DB, Kraus PS, Shaffer DL, Holzmueller CG, Lau BD. Audit and Feedback to Surgery Interns and Residents on Prescribing Risk-Appropriate Venous Thromboembolism Prophylaxis. JOURNAL OF SURGICAL EDUCATION 2021; 78:2011-2019. [PMID: 33879395 DOI: 10.1016/j.jsurg.2021.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of feedback using an emailed scorecard and a web-based dashboard on risk-appropriate VTE prophylaxis prescribing practices among general surgery interns and residents. DESIGN Prospective cohort study. SETTING The Johns Hopkins Hospital, an urban academic medical center. PARTICIPANTS All 45 trainees (19 post-graduate year [PGY] 1 interns and 26 PGY-2 to PGY-5 residents) in our general surgery program. INTERVENTION Feedback implementation encompassed three sequential periods: (1) scorecard (July 1, 2014 through June 30, 2015); (2) no feedback/wash-in (July 1 through October 31, 2015); and (3) web-based dashboard (November 1, 2015 through June 30, 2016). No feedback served as the baseline period for the intern cohort. The scorecard was a static document showing an individual's compliance with risk-appropriate VTE prophylaxis prescription compared to compliance of their de-identified peers. The web-based dashboard included other information (e.g., patient details for suboptimal prophylaxis orders) besides individual compliance compared to their de-identified peers. Trainees could access the dashboard anytime to view current and historic performance. We sent monthly emails to all trainees for both feedback mechanisms. Main outcome was proportion of patients prescribed risk-appropriate VTE prophylaxis, and mean percentages reported. RESULTS During this study, 4088 VTE prophylaxis orders were placed. Among residents, mean prescription of risk-appropriate prophylaxis was higher in the wash-in (98.4% vs 95.6%, p < 0.001) and dashboard (98.4 vs 95.6%, p < 0.001) periods compared to the scorecard period. There was no difference in mean compliance between the wash-in and dashboard periods (98.4% vs 98.4%, p = 0.99). Among interns, mean prescription of risk-appropriate VTE prophylaxis improved between the wash-in and dashboard periods (91.5% vs 96.4%, p < 0.001). CONCLUSIONS AND RELEVANCE Using audit and individualized performance feedback to general surgery trainees through a web-based dashboard improved prescribing of appropriate VTE prophylaxis to a near-perfect performance.
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Affiliation(s)
- Jonathan K Aboagye
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah B Hobson
- Department of Nursing, The Johns Hopkins Hospital; Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peggy S Kraus
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dauryne L Shaffer
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine; Department of Nursing, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christine G Holzmueller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brandyn D Lau
- Russell H. Morgan Department of Radiology and Radiological Science; Division of Health Sciences Informatics; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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5
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Feyisa T, Tesfaye Kiya G, Maleko WA. Assessment of recipients' characteristics, transfusion appropriateness, and utilization pattern of blood and blood products in Jimma Medical Center, Jimma, Ethiopia. PLoS One 2021; 16:e0250623. [PMID: 33901253 PMCID: PMC8075257 DOI: 10.1371/journal.pone.0250623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As blood transfusion remains life-saving and is being frequently prescribed, a greater number of its practice is unnecessary or inappropriate. This important clinical intervention is reported as one of the five overused medical treatments, with gross over-ordering and whole blood transfusions as the sole component being common in developing countries. Study of recipient's demographics, clinical conditions, appropriate blood utilization, and continuous clinical audits for quality assurance and service improvement plan are important factors to this practice. This study was designed to assess the recipient's characteristics, blood type distributions, appropriateness of blood transfusion, and utilization practice of the big medical center. METHODS Institution based cross-sectional study was conducted from February 1 to June 30, 2018. Data were collected using a structured data collection format prepared for this study. All transfusion prescriptions were followed from requisition up to completion. Patient's age, sex, requesting departments, hemodynamics, number and component of units requested and issued, and units transfused were collected. Transfusion appropriateness was assessed by a criterion-based method while blood utilization was calculated. RESULTS A total of 545 units of blood for 425 patients were cross-matched of the 809 units of total blood prescribed. The mean and median age of transfused individuals was found to be 27.47 ±15.28 years and 26 years respectively, and 65.4% females most in reproductive age groups. O and A Rhesus-positive blood types were the two major blood groups observed. Overall 82.1% of transfusions were appropriate; while only 27.8% of patients received appropriate components as 96.5% of individuals received a whole blood transfusion. Significant blood utilization was recorded with a C/T ratio of 1.05, TP% of 100%, and TI of 1.23. CONCLUSION Much of the transfusion recipients were relatively young aged and females, most in the reproductive age group. Although whole blood was used as a sole component, significant blood transfusion utilization and appropriateness were recorded; while appropriate component transfusion was recorded to be significantly low. Local transfusion guidelines and appropriate component preparation and utilization are required to improve the sub-optimal blood component transfusion practice.
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Affiliation(s)
- Tufa Feyisa
- Hematology Laboratory Unit of Jimma Medical Center, Jimma University, Jimma, Ethiopia
| | - Girum Tesfaye Kiya
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Wondimagegn Adissu Maleko
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Clinical Trial Unit, Jimma University, Jimma, Ethiopia
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Kruse RL, Neally M, Cho BC, Bloch EM, Lokhandwala PM, Ness PM, Frank SM, Tobian AAR, Gehrie EA. Cryoprecipitate Utilization Patterns Observed With a Required Prospective Approval Process vs Electronic Dosing Guidance. Am J Clin Pathol 2020; 154:362-368. [PMID: 32445461 DOI: 10.1093/ajcp/aqaa042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We evaluated the impact of electronic medical record (EMR)-guided pooled cryoprecipitate dosing vs our previous practice of requiring transfusion medicine (TM) resident approval for every cryoprecipitate transfusion. METHODS At our hospital, cryoprecipitate pooled from five donors is dosed for adult patients, while single-donor cryoprecipitate is dosed for pediatric patients (defined as patients <50 kg in weight). EMR-based dosing guidance replaced a previously required TM consultation when cryoprecipitate pools were ordered, but a consultation remained required for single-unit orders. Usage was defined as thawed cryoprecipitate; wastage was defined as cryoprecipitate that expired prior to transfusion. RESULTS In the 6 months prior to intervention, 178 ± 13 doses of pooled cryoprecipitate were used per month vs 187 ± 15 doses after the intervention (P = .68). Wastage of pooled cryoprecipitate increased from 7.7% ± 1.5% to 12.7% ± 1.4% (P = .038). There was no change in wastage of pediatric cryoprecipitate doses during the study period. These trends remained unchanged for a full year postimplementation. CONCLUSIONS Electronic dosing guidance resulted in similar cryoprecipitate usage as TM auditing. Increased wastage may result from reduced TM oversight. Product wastage should be balanced against the possibility that real-time audits could delay a lifesaving therapy.
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Affiliation(s)
- Robert L Kruse
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Melissa Neally
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric A Gehrie
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
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Jones JM, Sapiano MRP, Savinkina AA, Haass KA, Baker ML, Henry RA, Berger JJ, Basavaraju SV. Slowing decline in blood collection and transfusion in the United States - 2017. Transfusion 2020; 60 Suppl 2:S1-S9. [PMID: 32086817 DOI: 10.1111/trf.15604] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The National Blood Collection and Utilization Survey (NBCUS) has demonstrated declines in blood collection and transfusion in the United States since 2008, including declines of 11.6% in red blood cell (RBC) collections and 13.9% in RBC transfusions during 2013-2015. This study described the 2017 NBCUS results. METHODS The 2017 NBCUS was distributed to all US blood collection centers, all hospitals performing at least 1000 surgeries annually, and a 40% random sample of hospitals performing 100 to 999 surgeries annually. Weighting and imputation were used to generate national estimates for units of blood and components collected, deferred, distributed, transfused, and outdated. RESULTS Response rates for the 2017 NBCUS were 88% for blood collection centers and 86% for transfusing hospitals. Compared with 2015, the number of RBC units collected during 2017 (12,211,000; 95% confidence interval [CI], 11,680,000-12,742,000) declined by 3.0%, and transfused RBC units (10,654,000, 95% CI, 10,314,000-10,995,000) declined by 6.1%. Distributed platelet (PLT) units (2,560,000; 95% CI, 2,391,000-2,730,000 units) increased by 5.1%, and transfused PLT units (1,937,000, 95% CI, 1,794,000-2,079,000) declined by 2.3%. Distributed plasma units (3,209,000; 95% CI, 2,879,000-3,539,000) declined by 13.6%, and transfused plasma units (2,374,000; 95% CI, 2,262,000-2,487,000) declined by 12.9%. CONCLUSION The 2017 NBCUS suggests a continued but slowing decline in demand for RBCs. The decline in blood collection and use will likely continue. Despite decreasing demand and increasing manufacturing costs of blood products, the US blood industry has met the regular and emergent needs of the country.
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Affiliation(s)
- Jefferson M Jones
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mathew R P Sapiano
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexandra A Savinkina
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Kathryn A Haass
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Richard A Henry
- U.S. Department of Health and Human Services, Office of HIV/AIDS and infectious Disease Policy, Office of the Assistant Secretary for Health, Washington, DC
| | - James J Berger
- U.S. Department of Health and Human Services, Office of HIV/AIDS and infectious Disease Policy, Office of the Assistant Secretary for Health, Washington, DC
| | - Sridhar V Basavaraju
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Meybohm P, Straub N, Füllenbach C, Judd L, Kleinerüschkamp A, Taeuber I, Zacharowski K, Choorapoikayil S. Health economics of Patient Blood Management: a cost-benefit analysis based on a meta-analysis. Vox Sang 2019; 115:182-188. [PMID: 31823382 DOI: 10.1111/vox.12873] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/18/2019] [Accepted: 11/14/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical concepts designed to improve haemoglobin concentration, optimize haemostasis and minimize blood loss in an effort to improve patient outcomes. The focus of this cost-benefit analysis is to analyse the economic benefit of widespread implementation of a multimodal PBM programme. MATERIALS AND METHODS Based on a recent meta-analysis including 17 studies (>235 000 patients) comparing PBM with control care and data from the University Hospital Frankfurt, a cost-benefit analysis was performed. Outcome data were red blood cell (RBC) transfusion rate, number of transfused RBC units, and length of hospital stay (LOS). Costs were considered for the following three PBM interventions as examples: anaemia management including therapy of iron deficiency, use of cell salvage and tranexamic acid. For sensitivity analysis, a Monte Carlo simulation was performed. RESULTS Iron supplementation was applied in 3·1%, cell salvage in 65% and tranexamic acid in 89% of the PBM patients. In total, applying these three PBM interventions costs €129·04 per patient. However, PBM was associated with a reduction in transfusion rate, transfused RBC units per patient, and LOS which yielded to mean savings of €150·64 per patient. Thus, the overall benefit of PBM implementation was €21·60 per patient. In the Monte Carlo simulation, the cost savings on the outcome side exceeded the PBM costs in approximately 2/3 of all repetitions and the total benefit was €1 878 000 in 100·000 simulated patients. CONCLUSION Resources to implement a multimodal PBM concept optimizing patient care and safety can be cost-effectively.
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Affiliation(s)
- Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany.,Department of Anaesthesiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Niels Straub
- Institute of Market Research, Statistics and Prognosis, Munich, Germany
| | - Christoph Füllenbach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Leonie Judd
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Adina Kleinerüschkamp
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Isabel Taeuber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt/Main, Germany
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Visagie M, Qin CX, Cho BC, Merkel KR, Kajstura TJ, Amin RM, Purvis TE, Kebaish KM, Frank SM. The impact of patient blood management on blood utilization and clinical outcomes in complex spine surgery. Transfusion 2019; 59:3639-3645. [PMID: 31625178 DOI: 10.1111/trf.15544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patient blood management (PBM) is especially applicable in major spine surgery, during which bleeding and transfusion are common. What remains unclear in this setting is the overall impact of bundled PBM measures on transfusion requirements and clinical outcomes. We compared these outcomes before and after implementing a PBM program. STUDY DESIGN AND METHODS We conducted a retrospective review of 928 adult complex spine surgery patients performed by a single surgeon between January 2009 and June 2016. Although PBM measures were phased in over time, tranexamic acid (TXA) administration became standard protocol in July 2013, which defined our pre- and post-PBM periods. Transfusion rates for all blood components before and after PBM implementation were compared, as were morbid event rates and mortality. RESULTS Baseline characteristics were similar before and after PBM. Before PBM, the mean number of units/patient decreased for red blood cells (RBCs; by 19.5%; p = 0.0057) and plasma (by 33%; p = 0.0008), but not for platelets (p = 0.15). After risk adjustment by multivariable analyses, the composite outcome of morbidity or mortality showed a nonsignificant trend toward improvement after PBM (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.39-1.01; p = 0.055), and the risk of thrombotic events was unchanged (OR, 1.12; 95% CI, 0.42-2.58; p = 0.80). CONCLUSION In complex spine surgery, a multifaceted PBM program that includes TXA can be advantageous by reducing transfusion requirements without changing clinical outcomes.
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Affiliation(s)
- Mereze Visagie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Caroline X Qin
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kevin R Merkel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tymoteusz J Kajstura
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Raj M Amin
- Department of Orthopaedic Surgery, Baltimore, Maryland
| | - Taylor E Purvis
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Health System Blood Management Program, Department of Anesthesiology/Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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10
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Maratt JK, Kerr EA, Klamerus ML, Lohman SE, Froehlich W, Bhatia RS, Saini SD. Measures Used to Assess the Impact of Interventions to Reduce Low-Value Care: a Systematic Review. J Gen Intern Med 2019; 34:1857-1864. [PMID: 31250366 PMCID: PMC6712188 DOI: 10.1007/s11606-019-05069-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/02/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
IMPORTANCE Studies of interventions to reduce low-value care are increasingly common. However, little is known about how the effects of such interventions are measured. OBJECTIVE To characterize measures used to assess interventions to reduce low-value care. EVIDENCE REVIEW We searched PubMed and Web of Science to identify studies published between 2010 and 2016 that examined the effects of interventions to reduce low-value care. We also searched ClinicalTrials.gov to identify ongoing studies. We extracted data on characteristics of studies, interventions, and measures. We then developed a framework to classify measures into the following categories: utilization (e.g., number of tests ordered), outcome (e.g., mortality), appropriateness (e.g., overuse of antibiotics), patient-reported (e.g., satisfaction), provider-reported (e.g., satisfaction), patient-provider interaction (e.g., informed decision-making elements), value, and cost. We also determined whether each measure was designed to assess unintended consequences. FINDINGS A total of 1805 studies were identified, of which 101 published and 16 ongoing studies were included. Of published studies (N = 101), 68% included at least one measure of utilization, 41% of an outcome, 52% of appropriateness, 36% of cost, 8% patient-reported, and 3% provider-reported. Funded studies were more likely to use patient-reported measures (17% vs 0%). Of ongoing studies (registered trials) (N = 16), 69% included at least one measure of utilization, 75% of an outcome, 50% of appropriateness, 19% of cost, 50% patient-reported, 13% provider-reported, and 6% patient-provider interaction. Of published studies, 34% included at least one measure of an unintended consequence as compared to 63% of ongoing studies. CONCLUSIONS AND RELEVANCE Most published studies focused on reductions in utilization rather than on clinically meaningful measures (e.g., improvements in appropriateness, patient-reported outcomes) or unintended consequences. Investigators should systematically incorporate more clinically meaningful measures into their study designs, and sponsors should develop standardized guidance for the evaluation of interventions to reduce low-value care.
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Affiliation(s)
- Jennifer K Maratt
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Eve A Kerr
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Mandi L Klamerus
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Whit Froehlich
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - R Sacha Bhatia
- Department of Internal Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, USA
| | - Sameer D Saini
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
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11
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Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery. Anesthesiology 2019; 129:1082-1091. [PMID: 30124488 DOI: 10.1097/aln.0000000000002397] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes. METHODS After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index. RESULTS After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016). CONCLUSIONS In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.
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Kaserer A, Rössler J, Braun J, Farokhzad F, Pape H, Dutkowski P, Plass A, Horisberger T, Volbracht J, Manz MG, Spahn DR. Impact of a Patient Blood Management monitoring and feedback programme on allogeneic blood transfusions and related costs. Anaesthesia 2019; 74:1534-1541. [DOI: 10.1111/anae.14816] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 11/27/2022]
Affiliation(s)
- A. Kaserer
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Rössler
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Braun
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute University of Zurich Switzerland
| | - F. Farokhzad
- Medical Directorate University of Zurich and University Hospital Zurich Switzerland
| | - H.‐C. Pape
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - P. Dutkowski
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - A. Plass
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - T. Horisberger
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Volbracht
- Medical Directorate University of Zurich and University Hospital Zurich Switzerland
| | - M. G. Manz
- Department of Medical Oncology and Haematology University of Zurich and University Hospital Zurich Switzerland
| | - D. R. Spahn
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
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13
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Cros J, Dalmay F, Yonnet S, Charpentier M, Tran-Van-Ho J, Renaudeau F, Drouet A, Guilbaut P, Marin B, Nathan N. Continuous hemoglobin and plethysmography variability index monitoring can modify blood transfusion practice and is associated with lower mortality. J Clin Monit Comput 2019; 34:683-691. [PMID: 31376030 DOI: 10.1007/s10877-019-00367-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/17/2019] [Indexed: 01/28/2023]
Abstract
To determine the effect of implementing an algorithm of fluid and blood administration based on continuous monitoring of hemoglobin (SpHb) and PVI (plethysmography variability index) on mortality and transfusion on a whole hospital scale. This single-center quality program compared transfusion at 48 h and mortality at 30 days and 90 days after surgery between two 11-month periods in 2013 and 2014 during which all the operating and recovery rooms and intensive care units were equipped with SpHb/PVI monitors. The entire team was trained to use monitors and the algorithm. Team members were free to decide whether or not to use devices. Each device was connected to an electronic wireless acquired database to anonymously acquire parameters on-line and identify patients who received the monitoring. All data were available from electronic files. Patients were divided in three groups; 2013 (G1, n = 9285), 2014 without (G2, n = 5856) and with (G3, n = 3575) goal-directed therapy. The influence of age, ASA class, severity and urgency of surgery and use of algorithm on mortality and blood use were analyzed with cox-proportional hazard models. Because in 2015, SpHb/PVI monitors were no longer available, we assessed post-study mortality observed in 2015 to measure the impact of team training to adjust vascular filling on a patient to patient basis. During non-cardiac surgery, blood was more often transfused during surgery in G3 patients as compared to G2 (66.6% vs. 50.7%, p < 0.001) but with fewer blood units per patient. After adjustment, survival analysis showed a lower risk of transfusion at 48 h in G3 [OR 0.79 (0.68-0.93), p = 0.004] but not in G2 [OR 0.90 (0.78-1.04) p = 0.17] as compared to G1. When adjusting to the severity of surgery as covariable, there was 0.5 and 0.7% differences of mortality at day 30 and 90 whether patients had goal directed therapy (GDT). After high risk surgery, the mortality at day 30 is reduced by 4% when using GDT, and 1% after intermediate risk surgery. There was no difference for low risk surgery. G3 Patients had a lower risk of death at 30 days post-surgery [OR 0.67 (0.49-0.92) p = 0.01] but not G2 patients [OR 1.01, (0.78-1.29), p = 0.96]. In 2015, mortality at 30 days and 90 days increased again to similar levels as those of 2013, respectively 2.18 and 3.09%. Monitoring SpHb and PVI integrated in a vascular filling algorithm is associated with earlier transfusion and reduced 30 and 90-day mortality on a whole hospital scale.
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Affiliation(s)
- Jérôme Cros
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France. .,Anesthésie Réanimation, Hôpital Mère-Enfant, Ave Docteur Larrey, 87042, Limoges, France. .,Département d'Anesthésie-Réanimation, Hôpital de la Mère et de l'enfant, 8, Avenue Dominique Larrey, 87000, Limoges, France.
| | - François Dalmay
- INSERM, U1094, Neuroépidémiologie Tropicale, 87000, Limoges, France.,Univ. Limoges, UMR_S 1094, Neuroépidémiologie Tropicale, Institut d'Epidémiologie Neurologique et de Neurologie Tropicale, CNRS FR, 3503 GEIST, 87000, Limoges, France.,CEBIMER, CHU Limoges, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Sandra Yonnet
- SIME, CHU Limoges, and Faculté de Médecine, Limoges, France
| | - Matthieu Charpentier
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Jessica Tran-Van-Ho
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - François Renaudeau
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Anais Drouet
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Pierre Guilbaut
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Benoit Marin
- INSERM, U1094, Neuroépidémiologie Tropicale, 87000, Limoges, France.,Univ. Limoges, UMR_S 1094, Neuroépidémiologie Tropicale, Institut d'Epidémiologie Neurologique et de Neurologie Tropicale, CNRS FR, 3503 GEIST, 87000, Limoges, France.,CEBIMER, CHU Limoges, 2 Avenue Martin Luther King, 87042, Limoges, France
| | - Nathalie Nathan
- Département d'Anesthésie Réanimation, CHU Dupuytren, 2 Avenue Martin Luther King, 87042, Limoges, France. .,Anesthésie Réanimation, Hôpital Mère-Enfant, Ave Docteur Larrey, 87042, Limoges, France.
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14
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Patel EU, Bloch EM, Grabowski MK, Goel R, Lokhandwala PM, Brunker PAR, White JL, Shaz B, Ness PM, Tobian AAR. Sociodemographic and behavioral characteristics associated with blood donation in the United States: a population-based study. Transfusion 2019; 59:2899-2907. [PMID: 31222779 DOI: 10.1111/trf.15415] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Contemporary population-based data on characteristics associated with blood donation in the United States (U.S.) are limited. STUDY DESIGN AND METHODS A cross-sectional analysis was performed among 28,739 persons aged 18 years and older who participated in the 2016 National Health Interview Survey, a household survey of the noninstitutionalized U.S. civilian population. Analyses were weighted and accounted for the complex survey design. Adjusted prevalence ratios (aPR) were estimated by multivariable log-binomial regression. RESULTS The percentage of individuals reporting a past-year history of blood donation was 5.7% (95% confidence interval [CI], 5.3%-6.1%) and was highest in the youngest age group (18-24 years, 8.4%). A past-year history of blood donation was more common in males compared to females (6.3% vs. 5.1%; aPR, 1.12 [95% CI, 0.99-1.27]) and those born in the U.S. compared to individuals born outside the U.S. (6.4% vs. 2.4%; aPR, 1.92 [95% CI, 1.49-2.47]). The percentage of individuals with a past-year history of blood donation was significantly lower in blacks (3.9%; aPR, 0.60 [95% CI, 0.47-0.75]) and Hispanics (3.0%; aPR, 0.63 [95% CI, 0.48-0.83]) in comparison to whites (6.9%). Being a college graduate, being employed, being physically active, and never being a cigarette smoker were factors positively associated with blood donation. The percentage of individuals with a past-year history of blood donation varied by geographic census region, with prevalence being higher in the Midwest (7.3%) and South (6.0%) compared to the Northeast (4.7%) and West (4.4%). CONCLUSION Continued differences in the blood donor population with reference to the U.S. population underscore the need to understand barriers or deterrents to blood donation. Evidence-based donor recruitment and related policies remain imperative to ensure that there is a sustainable blood supply.
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Affiliation(s)
- Eshan U Patel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary K Grabowski
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, Springfield, Illinois
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patricia A R Brunker
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Biomedical Services, Greater Chesapeake and Potomac Region, The American Red Cross, Baltimore, Maryland
| | - Jodie L White
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Beth Shaz
- New York Blood Center, New York, New York
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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16
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Carson JL, Liu Y, Ness P, Zaccaro DJ, Wu B, Meng C, Zeng X, Qin L, Huang C, Zhou X, Xiong T, Li J, Xing J, Liao Q, Zheng Q, Zhang X, Wang J, Shan H. Blood utilization in five Chinese hospitals shows low hemoglobin thresholds in medical patients. Transfusion 2019; 59:2820-2826. [PMID: 31150566 DOI: 10.1111/trf.15385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/10/2019] [Accepted: 05/10/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The number of red blood cell units transfused per capita in China is lower than in western countries and the reason(s) for the difference is unknown. STUDY DESIGN AND METHODS We randomly chose 5050 transfused patients from five Chinese hospitals. We compared transfused cases to nontransfused controls matched for the same underlying diagnosis. We assessed the pretransfusion hemoglobin (Hb) trigger and other clinical characteristics associated with transfusion. After stratifying by underlying disease, we compared pretransfusion Hb level in Chinese hospitals to 12 US hospitals. RESULTS In 5050 patients who received transfusion, the pretransfusion Hb levels were lower in medical (6.3 g/dL) compared to surgical patients receiving transfusion postoperatively (8.1 g/dL). In patients with nonsurgical diagnoses, the pretransfusion Hb was much lower than that in the United States; the difference in mean Hb level varied by underlying diagnosis from 0.4 to 1.8 g/dL. In case-control analysis of cases (n = 1356) compared to controls (n = 1201), the pretransfusion Hb showed the strongest association with transfusion. Compared to 10 g/dL, the odds ratio (95% confidence interval) for pretransfusion Hb of 7 to 7.9 g/dL was 37.7 (24.8-57.4). CONCLUSION Transfusion triggers in five Chinese hospitals appear comparable to those in the United States for surgical patients; however, medical patients have lower pretransfusion Hb levels (approx. 6 g/dL). Of the factors assessed, the pretransfusion Hb was most strongly associated with transfusion. The clinical impact of lower transfusion thresholds used in China is unknown.
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Affiliation(s)
- Jeffrey L Carson
- Department of Medicine, Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Yu Liu
- The Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, Chengdu, China
| | - Paul Ness
- Division of Transfusion Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Binting Wu
- The Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, Chengdu, China
| | - Chan Meng
- Internal Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xuejun Zeng
- Internal Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Li Qin
- Transfusion Medicine Department, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chunyan Huang
- Transfusion Medicine Department, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoyu Zhou
- Transfusion Department, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Ting Xiong
- Transfusion Department, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Jie Li
- Transfusion Department, Henan Science & Technology University No. 2 Affiliated Hospital, Luoyang, China
| | - Jianwu Xing
- Transfusion Department, Henan Science & Technology University No. 2 Affiliated Hospital, Luoyang, China
| | - Qun Liao
- Transfusion Department, Chongqing Emergency Medical Center, Chongqing, China
| | - Qian Zheng
- Transfusion Department, Chongqing Emergency Medical Center, Chongqing, China
| | - Xiaoyan Zhang
- Transfusion Department, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Jingxing Wang
- The Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, Chengdu, China
| | - Hua Shan
- Division of Transfusion Medicine, Stanford University School of Medicine, Palo Alto, California
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17
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Cronin JA, Oetgen ME, Gordish-Dressman H, Martin BD, Khan N, Pestieau SR. Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion. Paediatr Anaesth 2019; 29:611-619. [PMID: 30801879 DOI: 10.1111/pan.13617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. OBJECTIVE The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. METHODS Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. RESULTS For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0 mL/kg preperioperative surgical home vs 22.8 mL/kg postperioperative surgical home; mean difference = -0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4 mL/kg ± 20.4 mL/kg preperioperative surgical home vs 28.0 mL/kg ± 13.7 mL/kg postperioperative surgical home; log mean difference = 0.37 [95% CI 0.21-0.53], P < 0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference = -0.47 [95% CI -0.70 to -0.23]; P < 0.001), received a significantly higher total anti-fibrinolytic dose (mean difference = -3939 [95% CI -5364 to -2495]; P < 0.001), and were exposed to shorter surgical times (mean difference = 0.72 [95% CI 0.36-1.09]; P < 0.001). CONCLUSIONS Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.
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Affiliation(s)
- Jessica A Cronin
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, Washington, District of Columbia
| | - Matthew E Oetgen
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Health System, Washington, District of Columbia
| | - Heather Gordish-Dressman
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia
| | - Benjamin D Martin
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Health System, Washington, District of Columbia
| | - Nergis Khan
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Health System, Washington, District of Columbia
| | - Sophie R Pestieau
- Research Center for Genetic Medicine, Children's National Health System, Washington, District of Columbia
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18
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Roubinian NH, Murphy EL, Mark DG, Triulzi DJ, Carson JL, Lee C, Kipnis P, Kleinman S, Liu VX, Escobar GJ. Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia: A Retrospective Cohort Study. Ann Intern Med 2019; 170:81-89. [PMID: 30557414 PMCID: PMC6639156 DOI: 10.7326/m17-3253] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described. OBJECTIVE To describe the prevalence of anemia at and after hospital discharge and associated morbidity and mortality events. DESIGN Retrospective cohort study. SETTING Integrated health care delivery system with 21 hospitals serving 4 million members. PARTICIPANTS 445 371 surviving adults who had 801 261 hospitalizations between January 2010 and December 2014. MEASUREMENTS Hemoglobin levels and RBC transfusion, rehospitalization, and mortality events within 6 months of hospital discharge. Generalized estimating equations were used to examine trends over time, accounting for correlated observations and patient-level covariates. RESULTS From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL) at hospital discharge increased from 20% to 25% (P < 0.001) and RBC transfusion declined by 28% (39.8 to 28.5 RBC units per 1000 patients; P < 0.001). The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34% (P < 0.001), and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively (P < 0.001 for both). During this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6% (P = 0.004) in patients with moderate anemia, in parallel with that of all others. LIMITATION Possible unmeasured confounding. CONCLUSION Anemia after hospitalization increased in parallel with decreased RBC transfusion. This increase was not accompanied by a rise in subsequent RBC use, rehospitalization, or mortality within 6 months of hospital discharge. Longitudinal analyses support the safety of practice recommendations to limit RBC transfusion and tolerate anemia during and after hospitalization. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Nareg H Roubinian
- Kaiser Permanente Northern California, Oakland, and Blood Systems Research Institute and University of California, San Francisco, San Francisco, California (N.H.R.)
| | - Edward L Murphy
- Blood Systems Research Institute and University of California, San Francisco, San Francisco, California (E.L.M.)
| | - Dustin G Mark
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Darrell J Triulzi
- Institute for Transfusion Medicine, Pittsburgh, Pennsylvania (D.J.T.)
| | - Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.L.C.)
| | - Catherine Lee
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Patricia Kipnis
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Steven Kleinman
- University of British Columbia, Victoria, British Columbia, Canada (S.K.)
| | - Vincent X Liu
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Gabriel J Escobar
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
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19
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Abraha I, Montedori A, Di Renzo GC, Angelozzi P, Micheli M, Carloni D, Germani A, Palmieri G, Casali M, Nenz CMG, Gargano E, Pazzaglia M, Berchicci L, Tesoro S, Epicoco G, Giovannini G, Marchesi M. Diagnostic, preventive and therapeutic evidence in obstetrics for the implementation of patient blood management: a systematic review protocol. BMJ Open 2018; 8:e021322. [PMID: 30327399 PMCID: PMC6196839 DOI: 10.1136/bmjopen-2017-021322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Patientblood management (PBM) is defined as the application of evidence-based diagnostic, preventive and therapeutic approaches designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcome. We propose a protocol for the assessment of the evidence of diagnostic, preventive and therapeutic approaches for the management of relevant outcomes in obstetrics with the aim to create a framework for PBM implementation. METHODS AND ANALYSIS Diagnostic, preventive and therapeutic tools will be considered in the gynaecological conditions and obstetrics setting (antenatal care, peripartum care and maternity care). For each condition, (1) clinical questions based on prioritised outcomes will be developed; (2) evidence will be retrieved systematically from electronic medical literature (MEDLINE, EMBASE, the Cochrane Library, Web of Science, and CINAHL); (3) quality of the reviews will be assessed using the AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklist; quality of primary intervention studies will be assessed using the risk of bias tool (Cochrane method); quality of diagnostic primary studies will be assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies); (4) the Grading of Recommendations Assessment, Development and Evaluation method will be applied to rate the quality of the evidence and to develop recommendations. ETHICS AND DISSEMINATION For each diagnostic, preventive or therapeutic intervention evaluated, a manuscript comprising the evidence retrieved and the recommendation produced will be provided and published in peer-reviewed journals. Ethical approval is not required.
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Affiliation(s)
- Iosief Abraha
- Centro Regionale Sangue, Servizio Immunotrasfusionale, Azienda Ospedaliera di Perugia, Perugia, Italy
- Health Planning Service, Regional Health Authority of Umbria, Perugia, Italy
| | | | - Gian Carlo Di Renzo
- Clinica Ostetrica e Ginecologica, Policlinico, Università di Perugia, Perugia, Italy
| | | | - Marta Micheli
- Servizio Immunotrasfusionale, USL Umbria 2, Foligno, Italy
| | | | | | - Gianluca Palmieri
- Servizio Immunotrasfusionale, Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | - Marta Casali
- Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | | | | | | | | | - Simonetta Tesoro
- Anestesia e Rianimazione, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Giorgio Epicoco
- Ginecologia e Ostetricia, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Gianni Giovannini
- Health Planning Service, Regional Health Authority of Umbria, Perugia, Italy
| | - Mauro Marchesi
- Centro Regionale Sangue, Servizio Immunotrasfusionale, Azienda Ospedaliera di Perugia, Perugia, Italy
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20
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DeMario VM, Sikorski RA, Efron DT, Serbanescu MA, Buchanan RM, Wang EJ, Visagie M, Gehrie EA, Manukyan MC, Noll K, Ken Lee KH, Ness PM, Frank SM. Blood utilization and mortality in victims of gun violence. Transfusion 2018; 58:2326-2334. [PMID: 30209804 DOI: 10.1111/trf.14925] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Blood transfusion can be lifesaving for patients with hemorrhage; however, transfusion requirements for victims of gun violence are poorly understood. STUDY DESIGN AND METHODS In an urban, Level 1 trauma center, 23,422 trauma patients were analyzed in a retrospective cohort study. Patients with gunshot wounds (GSWs) (n = 2,672; 11.4% of trauma patients) were compared to those with non-GSW traumatic injuries from 2005 to 2017, to assess blood utilization. RESULTS The GSW cohort was approximately five times more likely to require transfusion (538 of 2672 [20.1%] vs. 798 of 20,750 [3.9%]; p < 0.0001), and the number of blood component units transfused per patient was approximately 10 times greater (3.3 ± 13.5 vs. 0.31 ± 3.8 units/patient; p < 0.0001), compared to the non-GSW cohort. The risk-adjusted likelihood of requiring high-dose transfusion was greater in the GSW cohort (odds ratio, 2.38; 95% confidence interval, 1.14-5.80), and requirements were increased for all four blood components (red blood cells, platelets, plasma, and cryoprecipitate). Patients with GSWs had approximately 14 times greater overall mortality (653 of 2672 [24.4%] vs. 352 of 20,750 [1.7%]; p < 0.0001]. Compared to non-GSW penetrating injuries (e.g., stab wounds), those with GSWs had approximately four times higher transfusion requirements (3.3 ± 13.5 vs. 0.80 ± 3.8 units/patient; p < 0.0001), and approximately eight times greater overall mortality (653 of 2672 [24.4%] vs. 28 of 956 [2.9%]; p < 0.0001). CONCLUSIONS Compared to other traumatic injuries, GSW injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating GSW injuries should have ready access to all blood components and ability to implement massive transfusions.
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Affiliation(s)
- Vincent M DeMario
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Robert A Sikorski
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David T Efron
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mara A Serbanescu
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rica M Buchanan
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eric J Wang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mereze Visagie
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eric A Gehrie
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mariuxi C Manukyan
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kathy Noll
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - K H Ken Lee
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Paul M Ness
- Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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21
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Nixon CP, Sweeney JD. Severe iron deficiency anemia: red blood cell transfusion or intravenous iron? Transfusion 2018; 58:1824-1826. [PMID: 30198610 PMCID: PMC7465692 DOI: 10.1111/trf.14819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Christian P Nixon
- Center for International Health Research Rhode Island Hospital and Alpert Medical School of Brown University Providence, Rhode, Island
- Department of Transfusion Medicine, Rhode Island Hospital and The Miriam Hospitals Alpert Medical School of Brown University, Providence, Rhode, Island
| | - Joseph D Sweeney
- Department of Transfusion Medicine, Rhode Island Hospital and The Miriam Hospitals Alpert Medical School of Brown University, Providence, Rhode, Island
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22
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Bielza R, Mora A, Zambrana F, Sanjurjo J, Sanz-Rosa D, Thuissard IJ, Arias E, Neira M, Gómez Cerezo JF. Impact of a patient blood management program within an Orthogeriatric care service. Transfus Apher Sci 2018; 57:517-523. [PMID: 29871842 DOI: 10.1016/j.transci.2018.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/23/2018] [Accepted: 05/25/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patient blood management (PBM) performs multidisciplinary strategies to optimize red blood cell (RBC) transfusion. Orthogeriatric share care models (surgeon and geriatrician manage the patient together from admission) have the goal of improving outcomes in hip fracture patients. MATERIAL AND METHODS A prospective observational study was conducted. Patients aged ≥70 years undergoing hip fracture (HF) surgery were consecutively included. When admitted on the orthogeriatric service a PBM protocol was applied based on: perioperative antithrombotic management, intravenous iron sucrose administration and restrictive transfusion criteria. Risk factors, clinical and functional effects of transfusion and its requirements were assessed to audit our model. RESULTS A total of 383 patients participated (women, 78.8%; median age, 86 (82-90) years). 210 patients (54.8%) were transfused. Age (OR = 1.055, 95% CI 1.017-1.094; p = 0.004) and Hemoglobin (Hb) level on admission (OR = 0.497, 95% CI 0.413-0.597; p < 0.001) were found to be significant risk factors for transfusion. Transfusion increased length of stay (b = 1.37, 95% CI 0.543-2.196; p = 0.001) but did not have an effect on other variables. DISCUSSION The PBM program established within an orthogeriatric service showed positive outcomes in terms of clinical complications, mortality, delirium or functional recovery in transfused patients, whereas it did not impact on shorter length of stay. The risk of transfusion on admission was predicted with the lower Hb levels on admission, along with the age of the patients. New measurements as homogenous restrictive transfusion criteria, a single-unit RBC transfusion and the assessment of the intravenous iron efficacy are need to be applied as a result of the high transfusion requirements.
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Affiliation(s)
- Rafael Bielza
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain.
| | - Asunción Mora
- Department of Hematology, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain
| | - Francisco Zambrana
- Department of Oncology, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain
| | - Jorge Sanjurjo
- Department of Orthopedics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain
| | - David Sanz-Rosa
- School of Doctoral Studies & Research, Universidad Europea, Madrid, Spain
| | - Israel J Thuissard
- School of Doctoral Studies & Research, Universidad Europea, Madrid, Spain
| | - Estefanía Arias
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain
| | - Marta Neira
- Department of Geriatric Medicine, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain
| | - Jorge Francisco Gómez Cerezo
- Department of Internal Medicine, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Health Sciences, Universidad Europea, Madrid, Spain
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23
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Benites BD, Addas‐Carvalho M. Implementing a patient blood management programme in Brazil: challenges and implications for developing countries. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/voxs.12433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- B. D. Benites
- Hematology and Transfusion Medicine Center University of Campinas Campinas Brazil
| | - M. Addas‐Carvalho
- Hematology and Transfusion Medicine Center University of Campinas Campinas Brazil
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24
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Roubinian NH, Hendrickson JE, Triulzi DJ, Gottschall JL, Michalkiewicz M, Chowdhury D, Kor DJ, Looney MR, Matthay MA, Kleinman SH, Brambilla D, Murphy EL. Contemporary Risk Factors and Outcomes of Transfusion-Associated Circulatory Overload. Crit Care Med 2018; 46:577-585. [PMID: 29300236 PMCID: PMC5851817 DOI: 10.1097/ccm.0000000000002948] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Transfusion-associated circulatory overload is characterized by hydrostatic pulmonary edema following blood transfusion. Restrictive transfusion practice may affect the occurrence and severity of transfusion-associated circulatory overload in critically ill patients. We sought to examine contemporary risk factors and outcomes for transfusion-associated circulatory overload. DESIGN Case-control study. SETTING Four tertiary care hospitals. PATIENTS We prospectively enrolled 200 patients with transfusion-associated circulatory overload identified by active surveillance and 405 controls matched by transfusion intensity. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 20,845 transfused patients who received 128,263 blood components from May 2015 until July 2016, transfusion-associated circulatory overload incidence was one case per 100 transfused patients. In addition to cardiovascular comorbidities, multivariable analysis identified the following independent predictors of transfusion-associated circulatory overload: acute kidney injury, emergency surgery, pretransfusion diuretic use, and plasma transfusion-the latter especially in females. Compared with matched controls, transfusion-associated circulatory overload cases were more likely to require mechanical ventilation (71% vs 49%; p < 0.001), experienced longer intensive care and hospital lengths of stay following transfusion, and had higher mortality (21% vs 11%; p = 0.02) even after adjustment for other potentially confounding variables. CONCLUSIONS Despite restrictive transfusion practice, transfusion-associated circulatory overload remains a frequent complication of transfusion and is an independent risk factor for in-hospital morbidity and mortality. In addition to cardiovascular and renal risk factors, plasma transfusion was associated with transfusion-associated circulatory overload after controlling for other covariates. Additional research is needed to examine the benefit of reduced erythrocyte or plasma exposure in patients at high risk for transfusion-associated circulatory overload.
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Affiliation(s)
- Nareg H Roubinian
- Blood Systems Research Institute, San Francisco, California
- Kaiser Permanente Division of Research and Medical Center, Oakland, California
- University of California, San Francisco, San Francisco, California
| | | | | | | | | | | | | | - Mark R Looney
- University of California, San Francisco, San Francisco, California
| | | | | | | | - Edward L Murphy
- Blood Systems Research Institute, San Francisco, California
- University of California, San Francisco, San Francisco, California
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25
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Frank SM, Thakkar RN, Podlasek SJ, Ken Lee KH, Wintermeyer TL, Yang WW, Liu J, Rotello LC, Fleury TA, Wachter PA, Ishii LE, Demski R, Pronovost PJ, Ness PM. Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach. Anesthesiology 2017; 127:754-764. [PMID: 28885446 DOI: 10.1097/aln.0000000000001851] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. METHODS We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods. RESULTS Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. CONCLUSIONS Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.
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Affiliation(s)
- Steven M Frank
- From the Department of Anesthesiology and Critical Care Medicine (S.M.F., W.W.Y., P.J.P.), Department of Medicine (R.N.T., L.C.R.), Department of Pathology, Transfusion Medicine (S.J.P., J.L., T.A.F., P.M.N.), Armstrong Institute for Patient Safety and Quality (K.H.K.L., T.L.W., P.A.W., R.D., P.J.P.), and Department of Otolaryngology Head and Neck Surgery (L.E.I.), The Johns Hopkins Medical Institutions, Baltimore, Maryland
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26
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Bruun MT, Georgsen J, Titlestad K, Yazer M, Murphy MF. Patient Blood Management - from local initiatives to European collaborations. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- M. T. Bruun
- Department of Clinical Immunology; Odense University Hospital; Odense C Denmark
- Member of PaBloE; Working Group of the European Blood Alliance
| | - J. Georgsen
- Department of Clinical Immunology; Odense University Hospital; Odense C Denmark
- Member of PaBloE; Working Group of the European Blood Alliance
| | - K. Titlestad
- Department of Clinical Immunology; Odense University Hospital; Odense C Denmark
| | - M. Yazer
- Department of Clinical Immunology; Odense University Hospital; Odense C Denmark
- University of Pittsburgh; Pittsburgh PA USA
| | - M. F. Murphy
- Member of PaBloE; Working Group of the European Blood Alliance
- NHS Blood & Transplant; Oxford UK
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
- University of Oxford; Oxford UK
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27
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Blood Product Utilization Among Trauma and Nontrauma Massive Transfusion Protocols at an Urban Academic Medical Center. Anesth Analg 2017; 125:967-974. [DOI: 10.1213/ane.0000000000002253] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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28
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Nixon CP, Tavares MF, Sweeney JD. How do we reduce plasma transfusion in Rhode Island? Transfusion 2017; 57:1863-1873. [PMID: 28681548 DOI: 10.1111/trf.14223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Plasma transfusions are given to patients with coagulopathy, either prophylactically, before an invasive procedure; or therapeutically, in the presence of active bleeding; and as an exchange fluid in therapeutic plasma exchange for disorders such as thrombotic thrombocytopenic purpura. There is consensus that many prophylactic plasma transfusions are non-efficacious, and the misdiagnosis of thrombotic thrombocytopenic purpura results in unnecessary therapeutic plasma exchange. STUDY DESIGN AND METHODS Beginning in 2001, programs to reduce plasma transfusion in the three major teaching hospitals in Rhode Island were initiated. The programs evolved through the establishment of guidelines, education for key prescribers of plasma, screening of plasma prescriptions, and engagement of individual prescribing physicians for out-of-guidelines prescriptions with modification or cancellation. Establishment of an in-house ADAMTS13 (ADAM metallopeptidase with thrombospondin type 1, motif 13) assay in 2013 was used to prevent therapeutic plasma exchange in patients with non-thrombotic thrombocytopenic purpura microangiopathy. Transfusion service data were gathered at the hospital level regarding blood component use, hospital data for discharges, inpatient mortality, and mean case-mix index, and, at the state level, for units of plasma shipped from the community blood center to in-state hospitals. RESULTS Between 2006 and 2016, a reduction in plasma use from 11,805 to 2677 units (a 77% decrease) was observed in the three hospitals and was mirrored in the state as a whole. This decline was not associated with any increase in red blood cell transfusion. Inpatient mortality either declined or was unchanged. CONCLUSION An active program focused on education and interdiction can achieve a large decrease in plasma transfusions without evidence of patient harm.
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Affiliation(s)
- Christian P Nixon
- Transfusion Service, Rhode Island Hospital, Providence, Rhode Island.,Transfusion Service, The Miriam Hospital, Providence, Rhode Island
| | - Maria F Tavares
- Blood Bank, Roger Williams Hospital, Providence, Rhode Island
| | - Joseph D Sweeney
- Transfusion Service, Rhode Island Hospital, Providence, Rhode Island.,Transfusion Service, The Miriam Hospital, Providence, Rhode Island.,Blood Bank, Roger Williams Hospital, Providence, Rhode Island
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29
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Hicks CW, Liu J, Yang WW, DiBrito SR, Johnson DJ, Brito A, Higgins RSD, Frank SM, Wick EC. A comprehensive Choosing Wisely quality improvement initiative reduces unnecessary transfusions in an Academic Department of Surgery. Am J Surg 2017; 214:571-576. [PMID: 28683893 DOI: 10.1016/j.amjsurg.2017.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/30/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND We implemented a comprehensive Choosing Wisely initiative to reduce unnecessary transfusions in an Academic Department of Surgery. METHODS We conducted a survey- and lecture-based educational intervention to increase awareness about published transfusion guidelines. Monthly transfusion reports were subsequently distributed to all faculty, fellows, residents, and mid-level practitioners. Blood utilization measures were compared pre- vs. post-intervention to assess effectiveness. RESULTS 7994 blood product orders (5388 pre-intervention, 2606 post-intervention) were placed (07/2014-06/2016). Red blood cell (RBC) (45% vs. 55%; P < 0.001) and plasma (68% vs. 75%; P = 0.02) compliance improved post-intervention, with a corresponding 15% decrease in RBC utilization (0.47 ± 0.02 vs. 0.40 ± 0.02 units/patient; P = 0.01), and 24% decrease in plasma (0.25 ± 0.02 vs. 0.19 ± 0.02 units/patient; P = 0.06). These reductions translate into $125,558 in blood product acquisition cost avoidance (RBC = $114,386, plasma = $11,172). CONCLUSIONS Implementation of a comprehensive Choosing Wisely campaign targeting individual providers at all levels significantly improved transfusion practices and decreased costs within the Department of Surgery.
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Affiliation(s)
- Caitlin W Hicks
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
| | - Jing Liu
- Johns Hopkins Health System Blood Management Program, Baltimore, MD, USA
| | - William W Yang
- Johns Hopkins Health System Blood Management Program, Baltimore, MD, USA
| | - Sandra R DiBrito
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Daniel J Johnson
- Johns Hopkins Health System Blood Management Program, Baltimore, MD, USA
| | - Alexandra Brito
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | | | - Steven M Frank
- Johns Hopkins Health System Blood Management Program, Baltimore, MD, USA; Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elizabeth C Wick
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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30
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Baigger A, Blasczyk R, Figueiredo C. Towards the Manufacture of Megakaryocytes and Platelets for Clinical Application. Transfus Med Hemother 2017. [PMID: 28626367 DOI: 10.1159/000477261] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Platelet transfusions are used in standard clinical practice to prevent hemorrhage in patients suffering from thrombocytopenia or platelet dysfunctions. Recently, a constant rise on the demand of platelets for transfusion has been registered. This may be associated with several factors including demographic changes, population aging as well as incidence and prevalence of hematological diseases. In addition, platelet-regenerative properties have been started to be exploited in different areas such as tissue remodeling and anti-cancer therapies. These new applications are also expected to increase the future demand on platelets. Thus, in vitro generated platelets may constitute a highly desirable alternative to meet the rising demand on platelets. Several factors have been considered in the road trip of producing in vitro megakaryocytes and platelets for clinical application. From selection of the cell source, differentiation protocols and culture conditions to the design of optimal bioreactors, several strategies have been proposed to maximize production yields while preserving functionality. This review summarizes new advances in megakaryocyte and platelet differentiation and their production upscaling.
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Affiliation(s)
- Anja Baigger
- Institute for Transfusion Medicine, Hanover Medical School, Hanover, Germany
| | - Rainer Blasczyk
- Institute for Transfusion Medicine, Hanover Medical School, Hanover, Germany
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31
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Health Policy, Ethical, Business, and Financial Issues Related to Blood Management in Orthopedics. Tech Orthop 2017. [DOI: 10.1097/bto.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Yang WW, Thakkar RN, Gehrie EA, Chen W, Frank SM. Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization. Transfusion 2017; 57:1163-1170. [DOI: 10.1111/trf.14000] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 12/21/2022]
Affiliation(s)
- William W. Yang
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Rajiv N. Thakkar
- Department of Medicine; The Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Eric A. Gehrie
- Department of Pathology (Transfusion Medicine); The Johns Hopkins Medical Institutions; Baltimore Maryland
| | - Weiyun Chen
- Department of Anesthesiology; Peking Union Medical College Hospital; Beijing China
| | - Steven M. Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program; The Johns Hopkins Medical Institutions; Baltimore Maryland
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