Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit.
adherence
blood transfusion
patient blood management
Journal
Transfusion medicine (Oxford, England)
ISSN: 1365-3148
Titre abrégé: Transfus Med
Pays: England
ID NLM: 9301182
Informations de publication
Date de publication:
Aug 2021
Aug 2021
Historique:
revised:
17
02
2021
received:
04
11
2020
accepted:
05
03
2021
pubmed:
23
3
2021
medline:
18
1
2022
entrez:
22
3
2021
Statut:
ppublish
Résumé
Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.
Sections du résumé
BACKGROUND
BACKGROUND
Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost.
OBJECTIVES
OBJECTIVE
In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions.
METHODS
METHODS
We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015.
RESULTS
RESULTS
In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β
CONCLUSION
CONCLUSIONS
A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.
Substances chimiques
Hemoglobins
0
Types de publication
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
227-235Informations de copyright
© 2021 British Blood Transfusion Society.
Références
Most Frequent Procedures Performed in U.S Hospitals, 2011 Statistical Brief #165. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb165.jsp. Accessed February 17, 2017.
Jones JM, Sapiano MRP, Savinkina AA, et al. Slowing decline in blood collection and transfusion in the United States-2017. Transfusion. 2020;60(S2):S1-S9. https://doi.org/10.1111/trf.15604.
Liberal Versus Restrictive Transfusion Thresholds For Patients With Symptomatic Coronary Artery Disease. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664840/. Accessed February 3, 2021.
Wang JK, Klein HG. Red blood cell transfusion in the treatment and management of anaemia: the search for the elusive transfusion trigger. Vox Sang. 2010;98(1):2-11. https://doi.org/10.1111/j.1423-0410.2009.01223.x.
Semba RD, Ricks MO, Ferrucci L, et al. Types of anemia and mortality among older disabled women living in the community: the Women's Health and Aging Study I. Aging Clin Exp Res. 2007;19(4):259-264. http://www.ncbi.nlm.nih.gov/pubmed/17726354. Accessed August 30, 2019.
Wu W-C, Schifftner TL, Henderson WG, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA. 2007;297(22):2481-2488. https://doi.org/10.1001/jama.297.22.2481.
Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion. 2002;42(7):812-818. https://doi.org/10.1046/j.1537-2995.2002.00123.x.
Shander A, Javidroozi M, Naqvi S, et al. An update on mortality and morbidity in patients with very low postoperative hemoglobin levels who decline blood transfusion (CME). Transfusion. 2014;54(10 Pt 2):2688-2695; quiz 2687. https://doi.org/10.1111/trf.12565.
Caro JJ, Salas M, Ward A, Goss G. Anemia as an independent prognostic factor for survival in patients with cancer: a systemic, quantitative review. Cancer. 2001;91(12):2214-2221. http://www.ncbi.nlm.nih.gov/pubmed/11413508. Accessed August 30, 2019.
McClellan WM, Flanders WD, Langston RD, Jurkovitz C, Presley R. Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study. J Am Soc Nephrol. 2002;13(7):1928-1936. https://doi.org/10.1097/01.asn.0000018409.45834.fa.
Young JB, Abraham WT, Albert NM, et al. Relation of low hemoglobin and anemia to morbidity and mortality in patients hospitalized with heart failure (insight from the OPTIMIZE-HF registry). Am J Cardiol. 2008;101(2):223-230. https://doi.org/10.1016/j.amjcard.2007.07.067.
Sahu S, Hemlata VA. Adverse events related to blood transfusion. Indian J Anaesth. 2014;58(5):543-551. https://doi.org/10.4103/0019-5049.144650.
Hendrickson JE, Roubinian NH, Chowdhury D, et al. Incidence of transfusion reactions: a multicenter study utilizing systematic active surveillance and expert adjudication. AABB Transfus. 2016;56:2587-2596. https://doi.org/10.1111/trf.13730.
Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012;157(1):49. https://doi.org/10.7326/0003-4819-157-1-201206190-00429.
Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB. JAMA. 2016;316(19):2025-2035. https://doi.org/10.1001/jama.2016.9185.
Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340(6):409-417. https://doi.org/10.1056/NEJM199902113400601.
Holst LB, Haase N, Wetterslev J, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014;371(15):1381-1391. https://doi.org/10.1056/NEJMoa1406617.
Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11-21. https://doi.org/10.1056/NEJMoa1211801.
Critical Care Societies Collaborative-Critical Care|Choosing Wisely. http://www.choosingwisely.org/societies/critical-care-societies-collaborative-critical-care/. Accessed August 24, 2019.
Wang AA, Lonergan K, Wang D, Lang E. P126: are we transfusing wisely? An analysis of transfusion practices among hemodynamically stable patients with anemia in four hospitals. CJEM. 2017;19(S1):S120-S121. https://doi.org/10.1017/cem.2017.328.
Blood Observational Study Investigators of ANZICS-Clinical Trials Group, Westbrook A, Pettilä V, et al. Transfusion practice and guidelines in Australian and New Zealand intensive care units. Intensive Care Med. 2010;36(7):1138-1146. https://doi.org/10.1007/s00134-010-1867-8.
Soril LJJ, Noseworthy TW, Stelfox HT, Zygun DA, Clement FM. A retrospective observational analysis of red blood cell transfusion practices in stable, non-bleeding adult patients admitted to nine medical-surgical intensive care units. J Intensive Care. 2019;7(1):19. https://doi.org/10.1186/s40560-019-0375-3.
Chohan SS, McArdle F, McClelland DBL, Mackenzie SJ, Walsh TS. Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UKintensive care unit. Vox Sang. 2003;84(3):211-218. https://doi.org/10.1046/j.1423-0410.2003.00284.x.
Al-Faris L, Al-Fares AR, Abdul Malek K, Omran A, Al-Humood S. Blood transfusion practice in critically ill patients: a single institutional experience. Med Princ Pract. 2012;21(6):560-565. https://doi.org/10.1159/000338887.
Singer M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801-810. https://doi.org/10.1001/jama.2016.0287.
Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H Spahn DR. from the Society for the Advancement of Blood Management (SABM) and the Medical Society for Blood Management (MSBM) Activity-based costs of blood transfusions in surgical patients at four hospitals 753-765. https://doi.org/10.1111/j.1537-2995.2009.02518.x
Sadana D, Pratzer A, Scher LJ, et al. Promoting high-value practice by reducing unnecessary transfusions with a patient blood management program. JAMA Intern Med. 2018;178(1):116-122. https://doi.org/10.1001/jamainternmed.2017.6369.
Frank SM, Thakkar RN, Podlasek SJ, et al. Implementing a health system-wide patient blood management program with a clinical community approach. Anesthesiology. 2017;127(5):754-764. https://doi.org/10.1097/ALN.0000000000001851.
Zuckerberg GS, Scott AV, Wasey JO, et al. Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization. Transfusion. 2015;55(7):1628-1636. https://doi.org/10.1111/trf.13003.
Goodnough LT, Shieh L, Hadhazy E, Cheng N, Khari P, Maggio P. Improved blood utilization using real-time clinical decision support. Transfusion. 2014;54(5):1358-1365. https://doi.org/10.1111/trf.12445.
Mueller MM, Van Remoortel H, Meybohm P, et al. Patient blood management: recommendations from the 2018 Frankfurt consensus conference. JAMA. 2019;321:983-997. https://doi.org/10.1001/jama.2019.0554.
Seitz KP, Sevransky JE, Martin GS, Roback JD, Murphy DJ. Evaluation of RBC transfusion practice in adult ICUs and the effect of restrictive transfusion protocols on routine care. Crit Care Med. 2017;45(2):271-281. https://doi.org/10.1097/CCM.0000000000002077.
Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion. 2014;54(1):2753-2759. https://doi.org/10.1111/trf.12723.
Fine MJ, Pratt HM, Obrosky DS, et al. Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia. Am J Med. 2000;109(5):378-385. https://doi.org/10.1016/S0002-9343(00)00500-3.
Mahesh B, Choong CK, Goldsmith K, Gerrard C, Nashef SAM, Vuylsteke A. Prolonged stay in intensive care unit is a powerful predictor of adverse outcomes after cardiac operations. Ann Thorac Surg. 2012;94(1):109-116. https://doi.org/10.1016/j.athoracsur.2012.02.010.
van Vliet M, Huisman M, Deeg DJH. Decreasing hospital length of stay: effects on daily functioning in older adults. J Am Geriatr Soc. 2017;65(6):1214-1221. https://doi.org/10.1111/jgs.14767.
Baek H, Cho M, Kim S, Hwang H, Song M, Yoo S. Analysis of length of hospital stay using electronic health records: a statistical and data mining approach. PLoS One. 2018;13(4):1-2. https://doi.org/10.1371/journal.pone.0195901.
Coté CJ, Grabowski EF, Stowell CP. Strategies for blood product management and reducing transfusions. A Practice of Anesthesia for Infants and Children. Elsevier Inc; 2009:195-219. https://doi.org/10.1016/B978-141603134-5.50014-7.
Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564-2575. https://doi.org/10.1056/NEJMoa062200.
Bouchard J, Soroko SB, Chertow GM, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int. 2009;76(4):422-427. https://doi.org/10.1038/ki.2009.159.
Cordemans C, De Laet I, Van Regenmortel N, et al. Fluid management in critically ill patients: the role of extravascular lung water, abdominal hypertension, capillary leak, and fluid balance. Ann Intensive Care. 2012;2((Suppl 1)):S1. https://doi.org/10.1186/2110-5820-2-S1-S1.
van Mourik N, Metske HA, Hofstra JJ, et al. Cumulative fluid balance predicts mortality and increases time on mechanical ventilation in ARDS patients: an observational cohort study. PLoS One. 2019;14(10):e0224563. Lazzeri C, Ed. https://doi.org/10.1371/journal.pone.0224563.
Koonrangsesomboon W, Khwannimit B. Impact of positive fluid balance on mortality and length of stay in septic shock patients. Indian J Crit Care Med. 2015;19(12):708-713. https://doi.org/10.4103/0972-5229.171356.
Lee J, de Louw E, Niemi M, et al. Association between fluid balance and survival in critically ill patients. J Intern Med. 2015;277(4):468-477. https://doi.org/10.1111/joim.12274.
Koop AH, Stancampiano FF, Jackson J, et al. Association of total fluid intake and output with duration of hospital stay in patients with acute pancreatitis. Gastroenterol Res Pract. 2018;2018:1-8. https://doi.org/10.1155/2018/7614381.
Fuller BM, Gajera M, Schorr C, et al. The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy. Indian J Crit Care Med. 2010;14(4):165-169. https://doi.org/10.4103/0972-5229.76078.
Leahy MF, Hofmann A, Towler S, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57(6):1347-1358. https://doi.org/10.1111/trf.14006.
Comstedt P, Storgaard M, Lassen AT. The systemic inflammatory response syndrome (SIRS) in acutely hospitalised medical patients: a cohort study. Scand J Trauma Resusc Emerg Med. 2009;17(1):1-6. https://doi.org/10.1186/1757-7241-17-67.