Blood product transfusion in emergency department patients: a case-control study of practice patterns and impact on outcome

Unplanned blood use within 24 hours of emergency department presentation: A cohort study in an ageing population

OBJECTIVE

This research aims to elucidate drivers of blood use in an older population, with a focus on unplanned transfusions following ED presentation.

METHODS

In a retrospective cohort study we examined 2015 data for ED presentations and blood use in two hospitals serving a population containing a high proportion (21%) of adults aged ≥65 years. Unplanned blood use was defined as any transfusion ≤24 h of presentation. Data were analysed by age, sex, Major Diagnostic Category, triage category and time to transfusion.

RESULTS

A total of 5294 blood components were transfused, comprising red cells (n = 3784), fresh frozen plasma (n = 657), platelets (n = 563) and cryoprecipitate (n = 290). Men aged ≥65 years were the highest users (40%, 2107 components). Unplanned transfusions accounted for 28% (n = 1057) of annual red cell use. Of 85 014 ED presentations, 494 (0.6%) were associated with unplanned red cell transfusion. Four Major Diagnostic Categories accounted for 81% (n = 853) of unplanned red cell use: gastrointestinal (n = 375), haematology (n = 267), trauma (n = 144) and cardiovascular (n = 67). Over one-fifth of unplanned transfusions (21%, n = 222 of 1057) were associated with ICD-10 codes for anaemia as a reason for presentation within the Haematology Major Diagnostic Category. Adults aged ≥65 years accounted for 62% of overall red cell use and 61% of transfusions ≤24 h of presentation. Odds of unplanned red cell transfusion increased with age, peaking at odds ratio 28.5 (95% confidence interval 14.2-57.4) in those aged 85 years and above.

CONCLUSIONS

Unplanned blood use accounted for 28% of annual hospital blood consumption. Blood component use increased with age and was greatest in older men. A significant burden of anaemia treatment was identified by the ED.

Red Blood Cell Transfusion in the Emergency Department: An Observational Cross-Sectional Multicenter Study

Background: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. Methods: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. Results: During the study period, 529 patients received RBC transfusion. The median age was 74 (59–85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0–7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29–3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53–3.94), and older age (OR: 1.02/year; 95% CI: 1.01–1.04). Conclusion: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

Assessing the appropriateness of blood transfusion among injured patients at a Ghanaian tertiary hospital: Time for clarity on the use of a scarce resource

INTRODUCTION

Hemorrhage is an important cause of preventable injury-related death. Many low- and middle-income country (LMIC) patients do not have timely access to safe blood. We sought to determine the degree of appropriateness of blood transfusion among patients with injuries requiring surgical intervention at presentation to a tertiary hospital in Ghana.

METHODS

We performed a retrospective review of such patients presenting to Komfo Anokye Teaching Hospital (KATH), from January 2015 to December 2016. Patients' hemoglobin levels at presentation were determined as the first record of hemoglobin after presentation and their receipt of blood transfusion was determined by explicit documentation in the chart. We defined appropriate blood transfusion practice as patients receiving transfusion when hemoglobin was equal or below a threshold, or patients not being transfused when hemoglobin was above the threshold. We considered both restrictive (hemoglobin ≤7 g/dL) and liberal (hemoglobin ≤10 g/dL) transfusion thresholds.

RESULTS

There were 1,408 patients who presented to KATH with injuries that met inclusion criteria. Two hundred and ninety two (292) patients were excluded because of missing hemoglobin information. Four hundred and fifty eight (458;41%) patients received blood transfusion. Transfused patients had a higher mean age (38 vs 35 years) and were less likely to be male (62% vs 71%). Transfused patients underwent more external fixation procedures (28% vs 19%), trauma amputations (5% vs 1%) and trauma laparotomies (3% vs 1%). At a restrictive transfusion threshold (hemoglobin ≤7 g/dL), 20% of patients who needed a transfusion did not receive one and 39% of patients who did not need a transfusion received one. At a liberal threshold (hemoglobin ≤10 g/dL), 33% of patients who needed a transfusion did not receive one and 30% of patients who did not need a transfusion received one. Blood transfusion practice was inappropriate in 31%-39% of all patients.

CONCLUSION

Our data suggest that clearer guidelines for blood transfusion among emergency surgery patients are needed in Ghana and similar LMICs to avoid inappropriate use of blood as a scarce resource.

Red blood cell transfusions for emergency department patients with gastrointestinal bleeding within an integrated health system

STUDY OBJECTIVE

To assess trends over time in red blood cell (RBC) transfusion practice among emergency department (ED) patients with gastrointestinal (GI) bleeding within an integrated healthcare system, inclusive of 21 EDs.

METHODS

Retrospective cohort of ED patients diagnosed with GI bleeding between July 1st, 2012 and September 30th, 2016. The primary outcome was receipt of an RBC transfusion in the ED. Secondary outcomes included 90-day rates of RBC transfusion, repeat ED visits, rehospitalization, and all-cause mortality. Logistic regression was used to obtain confounder-adjusted outcome rates.

RESULTS

A total of 24,868 unique patient encounters were used for the primary analysis. The median hemoglobin level in the ED prior to RBC transfusion decreased from 7.5 g/dl to 6.9 g/dl in the first versus last twelve months of the study period (p < 0.0001). A small trend was observed in the overall adjusted rate of ED RBC transfusion (absolute quarterly change of -0.1%, R2 = 0.18, p = 0.0001) largely attributable to the subgroup of patients with hemoglobin nadirs between 7.0 and 9.9 g/dl (absolute quarterly change of -0.4%, R2 = 0.38, p < 0.0001). Rates of RBC transfusions through 90 days likewise decreased (absolute quarterly change of -0.4%, R2 = 0.85, p < 0.0001) with stable to decreased corresponding rates of repeat ED visits, rehospitalizations and mortality.

CONCLUSION

Rates of ED RBC transfusion decreased over time among patients with GI bleeding, particularly in those with hemoglobin nadirs between 7.0 and 9.9 g/dl. These findings suggest that ED providers are willing to adopt evidence-based restrictive RBC transfusion recommendations for patients with GI bleeding.

Thirty-day hospital readmissions among mechanically ventilated emergency department patients

BACKGROUND

Unplanned 30-day readmissions have a negative impact on patients and healthcare systems. Mechanically ventilated ED patients are at high risk for complications, but factors associated with readmission are unknown.

OBJECTIVE

(1) Determine the rate of 30-day hospital readmission for ED patients receiving mechanical ventilation. (2) Identify associations between ED-based risk factors and readmission.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care, academic medical centre.

PATIENTS

Adult ED patients receiving mechanical ventilation.

MEASUREMENTS

Baseline demographics, comorbid conditions, illness severity and treatment variables were collected, as were clinical outcomes occurring during the index hospitalisation. The primary outcome was 30-day hospital readmission rate. Multivariable logistic regression was used to evaluate factors associated with the primary outcome.

RESULTS

A total of 1262 patients were studied. The primary outcome occurred in 287 (22.7%) patients. There was no association between care in the ED and readmission. During the index hospitalisation, readmitted patients had shorter ventilator, hospital and intensive care unit duration (P<0.05 for all). The primary outcome was associated with African-American race (adjusted OR 1.34 (95% CI 1.02 to 1.78)), chronic obstructive pulmonary disease (adjusted OR 1.52 (95% CI 1.12 to 2.06)), diabetes mellitus (adjusted OR 1.34 (95% CI 1.02 to 1.78)) and higher illness severity (adjusted OR 1.03 (95% CI 1.01 to 1.05)).

CONCLUSIONS

Almost one in four mechanically ventilated ED patients are readmitted within 30 days, and readmission is associated with patient-level and institutional-level factors. Strategies must be developed to identify, treat and coordinate care for the most at-risk patients.

Comments on: blood product transfusion in emergency department patients: a case control study of practice patterns and impact on outcome

Clinical decision makings according studies result require the valid and correct data collection, andanalysis. However, there are some common methodological and statistical issues which may ignore by authors. In individual matched case- control design bias arising from the unconditional analysis instead of conditional analysis. Using an unconditional logistic for matched data causes the imposition of a large number of nuisance parameters which may result in seriously biased estimates.