Presentation Transcript

1. Better Blood UseExternal Review as a Service (ERaaS)

   David F Jadwin, DO FCAP Columbia Healthcare Analytics, Inc.
2. Goals Help physicians use blood better Abandon laboratory approach to transfusions medicine Understand extent of unnecessary blood use Describe new model of external review Discuss 7 case studies to understand transfusion pitfalls Discuss principle-approach to transfusion medicine There is not enough time to cover material adequately Most questions will be answered by the presentation
3. Principle-based approach Can’t be mastered in an hour Do not focus on laboratory values Conservative principles of medical practice Am College Physicians Ann Internal Med 116(5): 403-06 (1992) Treat what you know Evaluate the patient, not laboratory results Control bleeding Employ non-transfusion alternatives Adequately monitor and document Indications for Blood Transfusion: Too Complex to Base on a Single Number? Ann Internal Med 2012; 157: 71-72 The only proven indication for blood is hemorrhage

4. External vs Internal Review

5. Blood Use Data (2009 – 2012)
6. Hospital Blood Use Transfusion Requirements in Critical Care N Engl J Med 1999; 340:409-17 Restrictive v Liberal transfusion No difference in outcomes Shorter LOS (0.9 day) STS data Jehovah Witness Bloodless Medicine & Surgery Total cost: blood cost x 6
7. Hazards and Pitfalls of Transfusion Bloodborne Disease Numerous Transfusion-Associated Conditions Transfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI) Transfusion-related immune modulation (TRIM) Subclinical graft-vs-host disease (tissue transplant) Myocardial infarct & death Complexity & Uncertainty
8. Tissue Ischemia Storage Lesion: Old vs fresh blood Reduced viscoelasticity 25 trillion RBCs – 300 miles of capillaries Relative diameters: 7-8 uM (RBC) v 3-5 uM (Capillary) RBCs have to squeeze through capillaries to deliver oxygen Reduced 2, 3-DPG (delivery oxygen) Reduced PRBC nitric oxide Free hemoglobin (nitric oxide scavenger) Inflammatoryproducts and microparticles

9. Videomicroscopy: Normal

10. Videomicroscopy: Transfused Blood

11. Transfusion Medicine Protocols should not be based on laboratory values Cannot apply simple rules Age Clinical condition & goal of therapy Prognosis & palliative care Clinical and laboratory trends Non-transfusion management Requires principle-based approach
12. External Review Educational Confidential Noncontroversial (not a “black box”) Not pass/fail
13. External Review Educational Confidential Noncontroversial (not a “black box”) Not pass/fail Avoid Incomplete Appropriate Defer opinion
14. Patient Case Study #1
15. Patient Case Study #1
16. Patient Case Study #1
17. Non-beneficial Blood Use These cases are common to every hospital 60% of charts have one or more unnecessary units $2000 to $3000 unnecessary cost per patient These problems generally go unrecognized Untold impact on patient safety
18. Patient Case Study #2
19. Patient Case Study #2
20. Patient Case Study #2
21. Patient Case Study #2
22. Patient Case Study #2
23. General Laboratory Principles Avoid H&H or platelet-only orders Pay attention to the platelet count Watch out for spurious laboratory results Assess trends carefully Perform frequent laboratory tests Order reticulocyte count and iron studies early Know what laboratory tests measure INR is not necessarily a predictor of bleeding risk Don’t make assumptions Work up coagulation abnormalities
24. Acute GI Bleed
25. Acute GI Bleed
26. Acute GI Bleed
27. Total Knee Arthroplasty
28. General Principles (Surgery) Correct elective pre-operative anemia (13 gm/dL) “Bloodless” elective surgeries Bypass patients - 80 percent bloodless procedures Use laboratory tests to guide therapy Record start and stop transfusion times
29. Pneumonia/ESLD/Lung Ca
30. Pneumonia/ESLD/Lung Ca
31. Pneumonia/ESLD/Lung Ca
32. Aspiration Pneumonia/ARF
33. Aspiration Pneumonia/ARF
34. General Transfusion Principles Patients should receive full informed consent Treat most patients as if they are Jehovah Witness Anemia or microcytic indicies - order iron studies Establish anemia treatment protocols - Use IV iron Liability involves relative risk: … Risk of over-transfusion is greater than under-transfusion
35. General Transfusion Principles Perform post-transfusion laboratory monitoring Components generally should not be given back-to-back Document adequately Use O negative only when minutes count Use un-crossmatched blood sparingly It may be unethical to aggressive treat certain patients
36. Epistaxis
37. Epistaxis
38. Epistaxis
39. Epistaxis
40. Epistaxis
41. Epistaxis
42. Principle-based approach Can’t be mastered in an hour Treat many patients as if Jehovah Witness Control bleeding Evaluate anemia (iron) and treat appropriately Do not transfuse blood components back-to-back Employ adequate laboratory testing Use laboratory results only as a guide Avoid aggressive therapy if patients don’t benefit Use uncrossmatched and O negative blood wisely The only proven indication for blood use is hemorrhage
43. Further Information Society for the Advancement of Blood Management (SABM)

44. Electronic handouts available by request

    Dave Jadwin 210-598-9256 djadwin@columbia-analytics.com