Teaching Cases

David F Jadwin, DO FCAPColumbia Healthcare Analytics, Inc.

Better Blood UseExternal Review as a Service (ERaaS)

1GoalsHelp physicians use blood betterAbandon laboratory approach to transfusions medicineUnderstand extent of unnecessary blood useDescribe new model of external reviewDiscuss 7 case studies to understand transfusion pitfallsDiscuss principle-approach to transfusion medicine

There is not enough time to cover material adequatelyMost questions will be answered by the presentation

Principle-based approachCant be mastered in an hourDo not focus on laboratory valuesConservative principles of medical practiceAm College Physicians Ann Internal Med 116(5): 403-06 (1992)Treat what you knowEvaluate the patient, not laboratory resultsControl bleedingEmploy non-transfusion alternativesAdequately monitor and documentIndications for Blood Transfusion: Too Complex to Base on a Single Number? Ann Internal Med 2012; 157: 71-72The only proven indication for blood is hemorrhage

External vs Internal Review

Peer ReviewShouldDont (Often)Do not want to perform peer reviewDo not perform any peer reviewDo not perform critical peer reviewCant (Most, if not all)Cannot identify many errorsCannot be unbiasedCannot perform standardize review

Do you agree or disagree?5Blood Use Data (2009 2012)

Data Capture8

8Hospital Blood UseTransfusion Requirements in Critical Care N Engl J Med 1999; 340:409-17Restrictive v Liberal transfusionNo difference in outcomesShorter LOS (0.9 day)STS dataJehovah WitnessBloodless Medicine & Surgery

Total cost: blood cost x 6

9Hazards and Pitfalls of TransfusionBloodborne DiseaseNumerous Transfusion-Associated ConditionsTransfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI)Transfusion-related immune modulation (TRIM)Subclinical graft-vs-host disease (tissue transplant)Myocardial infarct & deathComplexity & Uncertainty

10While the direct cost of blood may range from $1M a year for a smaller hospital to $1M a month for a larger hospital to tens of millions of dollars for a healthcare system, the true cost of blood is perhaps five times or more larger than just the cost of blood. These include inefficient use of resources such as nurses, needless extension of hospital length of stay and treatment of adverse events associated with unnecessary blood transfusion.10Tissue IschemiaStorage Lesion: Old vs fresh bloodReduced viscoelasticity25 trillion RBCs 300 miles of capillariesRelative diameters: 7-8 uM (RBC) v 3-5 uM (Capillary)RBCs have to squeeze through capillaries to deliver oxygenReduced 2, 3-DPG (delivery oxygen)Reduced PRBC nitric oxideFree hemoglobin (nitric oxide scavenger)Inflammatory products and microparticles

Videomicroscopy: Normal

Videomicroscopy: Transfused Blood

Transfusion MedicineProtocols should not be based on laboratory valuesCannot apply simple rulesAgeClinical condition & goal of therapyPrognosis & palliative careClinical and laboratory trendsNon-transfusion managementRequires principle-based approach

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The first response we typically receive to an announcement about external UR program is: What are the algorithms you use to assess appropriate blood use?

This reaction belies the persons lack of knowledge about the complexity of transfusion medicine and simplistic beliefs that blood can be assigned to appropriate status based upon meeting trigger points.

In many clinical situations there are no simple rules that tell when to give blood. There are however principles to follow that will help avoid giving blood unnecessarily.14External ReviewEducationalConfidentialNoncontroversial (not a black box)Not pass/fail

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Incomplete critiques indicate a need for immediate correction of procedural deficiencies.

Defer critiques offer a novel opportunity for the physician to reflect upon past management and develop new patterns of practice for the future.15External ReviewEducationalConfidentialNoncontroversial (not a black box)Not pass/failAvoidIncompleteAppropriateDefer opinion

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Incomplete critiques indicate a need for immediate correction of procedural deficiencies.

Defer critiques offer a novel opportunity for the physician to reflect upon past management and develop new patterns of practice for the future.16Patient Case Study #117DateTimeEvent04/23/0814:47Admitted 65 F Thoracic Burst Fracture04/23/0816:05Pre-operative Hg: 11.604/24/0819:15Laminectomy EBL: 50 mL04/25/0815:30Post-operative Hg: 8.0Case number one is that of a 65 year old female patient with a burst fracture of the thoracic spine.

Should this patient be transfused? Yes or No.17Patient Case Study #118DateTimeEvent04/23/0814:47Admitted 65 F Thoracic Burst Fracture04/23/0816:05Pre-operative Hg: 11.604/24/0819:15Laminectomy EBL: 50 mL04/25/0815:30Post-operative Hg: 8.004/25/0817:45PRBC04/25/0822:05Hg: 9.504/25/0823:00PRBC04/26/0802:21Hg: The hemoglobin level should rise approximately 1 gram for each PRBC transfusion.

Transfusion of 2 units PRBC would be expected to raise the patients hemoglobin level to approximately 10 grams.18Patient Case Study #119DateTimeEvent04/23/0814:47Admitted 65 F Thoracic Burst Fracture04/23/0816:05Pre-operative Hg: 11.604/24/0819:15Laminectomy EBL: 50 mL04/25/0815:30Post-operative Hg: 8.004/25/0817:45PRBC04/25/0822:05Hg: 9.504/25/0823:00PRBC04/26/0802:21Hg: 11.604/27/0802:55Hg: 13.604/28/0815:35DischargedAnd subsequently to 13.6, up + 5.6 gm or 5.6 units of blood.

How can this inconsistency be explained?

The inconsistency is explained if some of the laboratory data are misleading and in this case it is likely to be the post-operative Hg of 8.0 grams and post-transfusion Hg of 9.5.

19Non-beneficial Blood UseThese cases are common to every hospital60% of charts have one or more unnecessary units$2000 to $3000 unnecessary cost per patientThese problems generally go unrecognizedUntold impact on patient safety

Patient Case Study #221DateTimeTime Event01/23/0900:0100:00Admitted 87F: AF, end-stage dementia01/24/0905:1229:01INR: 1.101/25/0917:0040:49warfarin 3 mg01/26/0907:1555:04INR: 1.401/26/0917:0088:49warfarin 3 mg01/27/0911:10106:5900:00INR: 4.001/27/0914:40110:2900:30INR: 3.401/28/0906:10125:5919:00INR: 3.0The patient was observed for 19 additional hours and the INR decreased from 4.0 to 3.4 to 3.0.21Patient Case Study #222DateTimeTime Event01/23/0900:0100:00Admitted 87F: AF, end-stage dementia01/24/0905:1229:01INR: 1.101/25/0917:0040:49warfarin 3 mg01/26/0907:1555:04INR: 1.401/26/0917:0088:49warfarin 3 mg01/27/0911:10106:5900:00INR: 4.001/27/0914:40110:2900:30INR: 3.401/28/0906:10125:5919:00INR: 3.001/28/0919:00138:4931:50warfarin 2 mg01/29/0907:25151:1444:15INR: 4.0The patient received a non-beneficial third dose of warfarin and the INR has now been supratherapeutic for 44 hours.22Patient Case Study #223DateTimeTime Event01/23/0900:0100:00Admitted 87F: AF, end-stage dementia01/24/0905:1229:01INR: 1.101/25/0917:0040:49warfarin 3 mg01/26/0907:1555:04INR: 1.401/26/0917:0088:49warfarin 3 mg01/27/0911:10106:5900:00INR: 4.001/27/0914:40110:2900:30INR: 3.401/28/0906:10125:5919:00INR: 3.001/28/0919:00138:4931:50warfarin 2 mg01/29/0907:25151:1444:15INR: 4.001/29/0918:45162:3455:35Vitamin KEleven hours later (after office hours) and now 55 hours with supratherapeutic INR the patient finally receives vitamin k.23Patient Case Study #224DateTimeTime Event01/23/0900:0100:00Admitted 87F: AF, end-stage dementia01/24/0905:1229:01INR: 1.101/25/0917:0040:49warfarin 3 mg01/26/0907:1555:04INR: 1.401/26/0917:0088:49warfarin 3 mg01/27/0911:10106:5900:00INR: 4.001/27/0914:40110:2900:30INR: 3.401/28/0906:10125:5919:00INR: 3.001/28/0919:00138:4931:50warfarin 2 mg01/29/0907:25151:1444:15INR: 4.001/29/0918:45162:3455:35Vitamin K01/30/0905:10172:5965:00Thawed Plasma (09:25 post vitamin k)9 hours 25 minutes after receiving vitamin k and without interval INR monitoring to see if vitamin k reversed the INR, the patient receives a potentially avoidable plasma transfusion.24Patient Case Study #225DateTimeTime Event01/23/0900:0100:00Admitted 87F: AF, end-stage dementia01/24/0905:1229:01INR: 1.101/25/0917:0040:49warfarin 3 mg01/26/0907:1555:04INR: 1.401/26/0917:0088:49warfarin 3 mg01/27/0911:10106:5900:00INR: 4.001/27/0914:40110:2900:30INR: 3.401/28/0906:10125:5919:00INR: 3.001/28/0919:00138:4931:50warfarin 2 mg01/29/0907:25151:1444:15INR: 4.001/29/0918:45162:3455:35Vitamin K01/30/0905:10172:5965:00Thawed Plasma (09:25 post vitamin k)01/30/0906:00173:49INR: 1.401/30/0917:00184:49warfarin 1.5 mg01/30/0918:00185:49Discharged (7.75 days)This patient was finally discharged 13 hours later after 7.75 days of treatment, perhaps one, two or more days longer than otherwise would have been necessary.

Unlike traditional UR, Interactive External UR permits complex analysis of hospital treatment, allowing rapid identification of ineffective care in 100% of patient charts and provides the physician and the hospital with awareness to avoid similar episodes in the future.

90% of medicine is practiced by rote memory and the last bad mistake. 25General Laboratory PrinciplesAvoid H&H or platelet-only ordersPay attention to the platelet countWatch out for spurious laboratory resultsAssess trends carefullyPerform frequent laboratory testsOrder reticulocyte count and iron studies earlyKnow what laboratory tests measureINR is not necessarily a predictor of bleeding riskDont make assumptionsWork up coagulation abnormalities

Acute GI BleedDateTimeEvent01/1820:50-0:27Hgb 14.101/1821:170Admitted 79 M01/1904:257:08Hgb 10.601/1911:0013:43PRBC01/1914:0316:46PRBC01/1918:3021:13Hgb 11.001/2003:5530:38Hgb 9.801/2008:4035:22PRBC01/2012:3539:17PRBCAcute GI BleedDateTimeEvent01/1820:50-0:27Hgb 14.101/1821:170Admitted 79 M01/1904:257:08Hgb 10.601/1911:0013:43PRBC01/1914:0316:46PRBC01/1918:3021:13Hgb 11.001/2003:5530:38Hgb 9.801/2008:4035:22PRBC01/2012:3539:17PRBC01/2018:3045:13Hgb 12.401/2106:1056:53Hgb 11.101/2113:5064:33Discharged LOS 2.7 daysAcute GI BleedDateTimeEvent01/1820:50-0:27Hgb 14.101/1821:170Admitted 79 M01/1904:257:08Hgb 10.601/1911:0013:43PRBC01/1914:0316:46PRBC01/1918:3021:13Hgb 11.001/2003:5530:38Hgb 9.801/2008:4035:22PRBC01/2012:3539:17PRBC01/2018:3045:13Hgb 12.401/2106:1056:53Hgb 11.101/2113:5064:33Discharged LOS 2.7 days01/2211:5586:38Hgb 12.101/2404:30127:13Hgb 13.001/2421:05143:47Hgb 14.4Total Knee ArthroplastyDateTimeEvent01/2507:02Admitted 68 F01/2510:47OR In01/2512:04OR Out: EBL 25 mL01/2605:15Hgb 8.301/2704:34Hgb 7.901/2710:10PRBC01/2711:30PRBC01/2714:20PRBC01/2718:10Hgb 11.001/2805:15Hgb 12.101/2815:30DischargedGeneral Principles (Surgery)Correct elective pre-operative anemia (13 gm/dL)Bloodless elective surgeriesBypass patients - 80 percent bloodless proceduresUse laboratory tests to guide therapyRecord start and stop transfusion times

Pneumonia/ESLD/Lung Ca32DateTimeEvent01/30/1108:1081 F Admitted: Respiratory Distress Plt: 27701/31/1104:20Plt: 250, 254, 216, 151, 100, 70, 55, 4602/08/1112:40Plt: 2602/08/1115:53ASA 81 mg Sepsis v Heparin02/09/1103:05Platelets 2 unitsGAMC 12796238932Pneumonia/ESLD/Lung Ca33DateTimeEvent01/30/1108:1081 F Admitted: Respiratory Distress Plt: 27701/31/1104:20Plt: 250, 254, 216, 151, 100, 70, 55, 4602/08/1112:40Plt: 2602/08/1115:53ASA 81 mg Sepsis v Heparin02/09/1103:05Platelets 2 units02/09/1112:40Plt: 151 02/09/1120:15Unresponsive; not a candidate for PEG, patient is terminal02/10/1107:30Plt: 11202/11/1111:00Plt: 99GAMC 12796238933Pneumonia/ESLD/Lung Ca34DateTimeEvent01/30/1108:1081 F Admitted: Respiratory Distress Plt: 27701/31/1104:20Plt: 250, 254, 216, 151, 100, 70, 55, 4602/08/1112:40Plt: 2602/08/1115:53ASA 81 mg Sepsis v Heparin02/09/1103:05Platelets 2 units02/09/1112:40Plt: 151 02/09/1120:15Unresponsive; not a candidate for PEG, patient is terminal02/10/1107:30Plt: 11202/11/1111:00Plt: 9902/11/1116:15Platelets 1 unit02/11/1118:25DNR02/12/1106:15Plt: 86, 3502/13/1120:40Expired LOS: 14.6 daysGAMC 12796238934Aspiration Pneumonia/ARF35DateTimeEvent01/30/1112:2690 F Admitted: SOB, fever Plt: 22001/31/1106:55Plt: 201, 197, 178, 177, 153, 129, 120, 126, 104, 112, 126, 128, 118, 135, 96, 135, 98, 82, 84, 60, 61, 49, 42, 3102/26/1100:00H&H02/26/1108:15Plt: 1802/26/1115:50Platelets 1 unit02/26/1117:10Platelets 1 unitGAMC 12796254635Aspiration Pneumonia/ARF36DateTimeEvent01/30/1112:2690 F Admitted: SOB, fever Plt: 22001/31/1106:55Plt: 201, 197, 178, 177, 153, 129, 120, 126, 104, 112, 126, 128, 118, 135, 96, 135, 98, 82, 84, 60, 61, 49, 42, 3102/26/1100:00H&H02/26/1108:15Plt: 1802/26/1115:50Platelets 1 unit02/26/1117:10Platelets 1 unit02/26/1118:10Platelet transfusion stop02/26/1118:34Code blue02/26/1118:48Code Blue End02/26/1119:07Code Blue02/26/1119:13Code Blue End02/27/1104:00Plt: 13602/27/1123:50Discharged LOS: 28.5 daysGAMC 12796254636General Transfusion PrinciplesPatients should receive full informed consentTreat most patients as if they are Jehovah WitnessAnemia or microcytic indicies - order iron studiesEstablish anemia treatment protocols - Use IV ironLiability involves relative risk: Risk of over-transfusion is greater than under-transfusion

General Transfusion PrinciplesPerform post-transfusion laboratory monitoringComponents generally should not be given back-to-backDocument adequatelyUse O negative only when minutes countUse un-crossmatched blood sparinglyIt may be unethical to aggressive treat certain patients

Epistaxis39DateTimeEvent02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 12402/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFPGAMC 12796254639Epistaxis40DateTimeEvent02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 12402/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP02/02/1117:25FFP 1 unitGAMC 12796254640Epistaxis41DateTimeEvent02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 12402/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP02/02/1117:25FFP 1 unit02/02/1118:20Progress Note: Currently not bleeding02/03/1100:55FFP 2 unitsGAMC 12796254641Epistaxis42DateTimeEvent02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 12402/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP02/02/1117:25FFP 1 unit02/02/1118:20Progress Note: Currently not bleeding02/02/1120:05Hgb: 8.8, 7.902/03/1100:55FFP 2 units02/03/1114:50Hgb: 6.4GAMC 12796254642Epistaxis43DateTimeEvent02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 12402/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP02/02/1117:25FFP 1 unit02/02/1118:20Progress Note: Currently not bleeding02/02/1120:05Hgb: 8.8, 7.902/03/1100:55FFP 2 units02/03/1114:50Hgb: 6.402/03/1115:20Consent to blood transfusion NOS (First consent form in chart)02/03/1116:30PRBC 3 unitsGAMC 12796254643Epistaxis44DateTimeEvent02/02/1113:35ER In: Epistaxis PMHx: DVT, PE, IVC filter, Pradaxa02/02/1114:50INR: 1.3, aPTT: 44, Hgb: 10.1 BP: 163/87 P: 12402/02/1115:1693 F Admitted: Jehovah Witness, but consents to FFP02/02/1117:25FFP 1 unit02/02/1118:20Progress Note: Currently not bleeding02/02/1120:05Hgb: 8.8, 7.902/03/1100:55FFP 2 units02/03/1114:50Hgb: 6.402/03/1115:20Consent to blood transfusion NOS (First consent form in chart)02/03/1116:30PRBC 3 units02/04/1106:25Hgb: 13.5, 12.202/05/1107:00Hgb: 13.202/05/1117:46Discharged LOS 3.1 days No coag study since first setGAMC 12796254644ERaaS: Hemophilia CaseLOS 17 days39 blood components (56 donors)90,000 units Factor VIII + 30 units cryoprecipitate5 minute chart reviewUnnecessary expense: $100,000Education

Principle-based approachCant be mastered in an hour Treat many patients as if Jehovah WitnessControl bleedingEvaluate anemia (iron) and treat appropriatelyDo not transfuse blood components back-to-backEmploy adequate laboratory testingUse laboratory results only as a guideAvoid aggressive therapy if patients dont benefitUse uncrossmatched and O negative blood wiselyThe only proven indication for blood use is hemorrhage

Further InformationSociety for the Advancement of Blood Management (SABM)

Electronic handouts available by requestDave Jadwin

210-598-9256

djadwin@columbia-analytics.com49DateTimeEvent04/09/1013:1032 M Hemophilia, intracerebral hemorrhage04/09/1019:41 06:31OR: Evacuation04/09/1020:55 07:45Cryoprecipitate, pooled04/09/1021:05 07:55Plasma 2 units04/09/1022:22 09:17OR Out (EBL 150 mL)04/10/1006:00 16:55Factor VIII 3,000 IU4950DateTimeEvent04/09/1013:1032 M Hemophilia, intracerebral hemorrhage04/09/1019:41 06:31OR: Evacuation04/09/1020:55 07:45Cryoprecipitate, pooled04/09/1021:05 07:55Plasma 2 units04/09/1022:22 09:17OR Out (EBL 150 mL)04/10/1006:00 16:55Factor VIII 3,000 IU4/10/1011:00 21:55Von Willebrand/Ristocetin Cofactor: 1994/11/1011:50 22:45Platelets (Platelet Count: 81,000)4/10/1018:00 28:55Factor VIII 3,000 IU4/11/1006:00 40:55Factor VIII 3,000 IU4/11/1018:00 52:55Factor VIII 3,000 IU4/12/1004:45 63:40Factor VIII Activity: 157%5051DateTimeEvent04/09/1013:1032 M Hemophilia, intracerebral hemorrhage04/09/1019:41 06:31OR: Evacuation04/09/1020:55 07:45Cryoprecipitate, pooled04/09/1021:05 07:55Plasma 2 units04/09/1022:22 09:17OR Out (EBL 150 mL)04/10/1006:00 16:55Factor VIII 3,000 IU4/10/1011:00 21:55Von Willebrand/Ristocetin Cofactor: 1994/11/1011:50 22:45Platelets (Platelet Count: 81,000)4/10/1018:00 28:55Factor VIII 3,000 IU4/11/1006:00 40:55Factor VIII 3,000 IU4/11/1018:00 52:55Factor VIII 3,000 IU4/12/1004:45 63:40Factor VIII Activity: 157%4/12/1006:00 64:55Factor VIII 3,000 IU4/12/1012:35 77:30Cryoprecipitate, pooled4/12/1018:00 82:55Factor VIII 3,000 IU4/13/1003:35 92:30Cryoprecipitate, pooled04/13/1005:00 93:55Factor VIII Activity: 224%04/13/1006:00 94:55Factor VIII 3,000 IU5152DateTimeEvent04/13/1014:10103:05Packed Red Blood Cells Hemoglobin: 10.004/13/1017:00Plasma 1 unit04/13/1020:00Factor VIII 3,000 IU04/13/1021:50Packed Red Blood Cells04/14/1003:15Factor VIII Activity: 163% Hemoglobin: 10.404/14/1006:00Factor VIII 3,000 IU04/14/1019:00Factor VIII 3,000 IU04/15/1004:20Factor VIII Activity: 130% Hemoglobin: 13.104/15/1006:00Factor VIII 3,000 IU x 204/16/1006:00Factor VIII 3,000 IU x 204/17/1006:00Factor VIII 3,000 IU x 204/18/1006:00Factor VIII 3,000 IU04/18/1006:07Factor VIII Activity: 77%04/19/1006:00Factor VIII 3,000 IU04/19/1007:20Factor VIII Activity: 211%04/20/1003:40Factor VIII Activity: 44%04/20/1006:00Factor VIII 3,000 IU x 204/20/1010:35269Platelets Platelet Count: 75k Post-transfusion: 83, 78, 76, 85, 74, 83k04/20/1012:20Plasma 2 units 5253DateTimeEvent04/21/1004:16Factor VIII Activity: 88%04/21/1006:00Factor VIII 3,000 IU x 204/22/1005:40Factor VIII Activity: 117%04/22/1006:00Factor VIII 3,000 IU x 204/23/1005:48Factor VIII Activity: 80%04/23/1006:00Factor VIII 3,000 IU x 204/24/1006:00Factor VIII 3,000 IU x 204/24/1006:40Factor VIII Activity: 155%04/25/1004:36Factor VIII Activity: 88%04/25/1006:00Factor VIII 3,000 IU x 204/26/1005:46Factor VIII Activity: 87%04/26/1012:31Discharged53