MVRBC Technical Advisory Committee: Jan. 17, 2012

1. MVRBC Technical Advisory Committee: Jan. 17, 2012 Louis M. Katz MD Mississippi Valley Regional Blood Center Davenport, IA Louis M. Katz MD EVP, Medical Affairs Mississippi Valley Regional Blood Center Adj. clinical professor, IM/ID, UIHC Carver College of Medicine

2. 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

3. 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

5. Residual risk from RBC transfusion Carson et al. Submitted. 2012

6. Global Red Cell Utilization Rates: 2008-09 Source: D Devine et al.: International Forum/Inventory Management Vox Sanguinis 2009

7. TRICC: Primum non nocere?

9. Costs of surgical RBC transfusion Shander et al. Transfusion. 2010.

10. 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

11. 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)

12. 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

13. 16 audits at 14 hospitals (or systems)

18. 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

19. AIM-II software: “concurrent”, automated audits

20. AIM-II software

21. 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

22. 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

23. 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)