MVRBC

Technical Advisory

Committee: Jan. 17, 2012

Louis M. Katz MD

Mississippi Valley Regional Blood Center

Davenport, IA

Louis M. Katz MDEVP, Medical Affairs

Mississippi Valley Regional Blood CenterAdj. clinical professor, IM/ID, UIHC Carver

College of Medicine

Premise(s) of blood management

“Blood still kills” Blood still costs money, and transfusion costs much more

Growing evidence supports much more restrictive transfusion strategies than used in most venues

Why are restrictive triggers appropriate?

primum non nocere SHOTs woefully under-reported Description of putative “new” serious hazards

Pro-inflammatory Immunosuppressive

Large prospective trials (TRICC, TRIPICU, PINT, FOCUS, TRACS) demonstrate outcomes at least as good using restrictive triggers

Positive impact of liberal triggers on functional outcomes not demonstrated in (FOCUS)

Activity costs of transfusion

Residual risk from RBC transfusion

Carson et al. Submitted. 2012

Global Red Cell Utilization Rates: 2008-09

Venez

uela

Brazil

Sout

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ca

Sing

apor

e

Saud

i-Ara

bia

Pola

nd

Hong

Kong

New Z

eala

nd

Canad

a CBS

Canad

a Hem

a-Que

bec

Irela

nd

Spai

n

Nethe

rland

s ²⁾

Croat

ia

Fran

ce

UK NHSB

T ¹⁾

Portu

gal

Austra

lia

Hunga

ryIta

ly

Norway

Japa

n

Finla

nd USA

Swed

en

Austri

a

Belgi

um Fl

ande

rs

Germ

any

0

10

20

30

40

50

60

RBCs

per

1,0

00 P

opul

ation

Source: D Devine et al.: International Forum/Inventory ManagementVox Sanguinis 2009

TRICC: Primum non nocere?Restrictive (7 gm) Liberal (10 gm)

n=418 % n=420 % p

Mortality

30 day 78 18.7 98 23.3 .11

60 day 95 22.7 111 26.5 .23

Hospital 93 22.2 118 28.1 .05

Length of stay

ICU 11.010.7 11.5 11.3 .53

Hospital 34.8 19.5 35.5 19.4 .58

“A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal strategy in critically ill patients.” NEJM. 1999.

FOCUS results Liberal trigger(n=1007)

Restrictive trigger(n=1009)

Units transfused 1866(97% transfused)

652(41.5%

transfused)

Median units 2 (IQ 1-2) 0 (IQ 0-1)

1 outcome 35.2% 34.7%

60 day mortality 7.6% 6.6%

In-hosp ACS, death 4.3% 5.2%

Readmit, fall, fatigue, function No differences

Carson et a.l. NEJM. 2011

Costs of surgical RBC transfusion

New Jersey

Rhode Island

Switzerland

Austria

$0 $200 $400 $600 $800 $1,000 $1,200

$248

$203

$194

$154

$1,183

$726

$611

$522Activity-based cost

RBC acquisition cost

Shander et al. Transfusion. 2010.

Getting the ground ready

Admin and doc buy-in (oh, and trust)

Center Hospital

Clinical people who know their way around medical documentation at the facilities

Access and IT resources Simple (reproducible) data

requirements

What we have done

Initial pitch(es) to admin and medical in support of conservative transfusion

Confidentiality in writing IT preparation to find the records we

need Record review Data analysis and reporting Multiple presentations of the data Process development to the level

they allow Reaudit (just starting)

MVRBC RBC trigger audits

• Descriptive manual chart audit of RBC units given. Generally during a single quarter

• Record ordering physician and specialty• Hemoglobin on admission, at time of 1st order

(i.e. “transfusion trigger”) and after transfusion• Documentation of bleeding in medical record• DRG, ICD-9• Hypothesis generating

108643210

3000

2500

2000

1500

1000

500

0

Units

Number of units ordered for 1st transfusion

16 audits at 14 hospitals(or systems)

DCPost-1st1st transfusionAdmission

16

14

12

10

8

6

4

Grams

TRICC

9.18.3

10.5 10.6

Hgb in nonbleeding patients during episode of care

DCAfter 1st1st transfusionAdmission

20

18

16

14

12

10

8

6

4

Grams

FOCUS

12.1

8.4

10.4 10.6

Hemoglobins associated with perioperative transfusions

9A1413121110A10987654321

14

12

10

8

6

4

2

Grams

TRICC

7.98.4

7.6

8.88.6

7.98.5

8.18.48.5

8.17.77.7

8.18.38.2

Hbg trigger with no bleeding: by hospital

9A14121110A1098765321

14

12

10

8

6

4

2

Grams FOCUS8.08.0

8.78.5

8.18.4

8.18.68.7

9.1

7.6

8.38.48.8

Hbg trigger for perioperative transfusion: by hospital

Caveat emptor

Reliable as our ability to find info in the record Confounders (e.g. cardio-respiratory

compromise, severity of illness) not sought (TRICC says don’t matter)

Acuity of intra-operative bleeding hard to assess DRG/ICD-9 numbers too small for real analysis Denominators can be hard to get, especially for

inter-hospital comparisons Retrospective, manual audits

AIM-II software: “concurrent”, automated audits

AIM-II software

Conclusions

Transfusion in acute hemorrhage best left to judgment at the bedside consensus guidelines

91% of non-bleeders transfused above TRICC

76% with operative bleeding transfused above FOCUS

Attention to non-bleeding & periop patients with an emphasis on EBM will reduce RBC use

Discharge hemoglobin levels suggest that an emphasis on single unit transfusions will be useful

Reduction = direct $$ and clinical savings

Barriers

Lack of basic training in transfusion medicine at all levels

“This is how Dr. Osler taught me to do it…”

“My patients are sicker…” “I’ve never seen TRALI…”

Resources for real-time decision support and intervention

Process IT support (including AIM-II?) Clinical (“real docs”) champions

Barriers

Hospital-acquired infections Falls Med errors Readmissions etc., etc.… ad

nauseum. This is about getting on the

priority menu for resources (people and time)

(TJC was supposed to fix this)