Effective Methods of Utilization Review Richard R. Gammon, M.D. Medical Director Florida Society of Pathologists July 14, 2019
SECTION ONE Background 2
Why does use of blood products need to be monitored? • Blood transfusion most common all‐listed procedure performed during hospitalizations in 2010 – 11 percent of stays with procedure • Rate of hospitalization with blood transfusion more than doubled since 1997 http://hcup‐us.ahrq.gov/reports/statbriefs/sb149.pdf 07/19 3
Choosing Wisely Program • Overuse of blood transfusion has also been listed as Choosing Wisely statement – American Society of Hematology – Society of Hospital Medicine – Critical Care Societies Collaborative • AABB developed set of five recommendations with input committees and Board of Directors Transfusion 2014; 54: 2344‐2352
1. Don’t transfuse more units of blood than absolutely necessary
Know the Thresholds AABB Recommendation 1 • Transfusion is not indicated until the hemoglobin level is 7g/dL • Hospitalized adult patients who are hemodynamically stable • Including critically ill patients • Strong recommendation, moderate quality evidence JAMA 2016; 316: 2025‐35
Recommendation 1 • Orthopedic surgery or cardiac surgery and those with preexisting cardiovascular disease • Restrictive RBC transfusion threshold hemoglobin level of 8g/dL • Strong recommendation, moderate quality evidence 7
Recommendation 1 Does Not Apply • Acute coronary syndrome • Severe thrombocytopenia (patients treated for hematological or oncological disorders who at risk of bleeding) • Chronic transfusion–dependent anemia • Evidence is insufficient for any recommendation 8
Reassure that patients are not going to be affected‐ Reduction in mortality using data from RCTs evaluating Hb trigger < 7g/dl Am J Med 2014; 127:124-131 S. Sloan FABB 06/15
3. Don’t routinely use blood products to reverse warfarin 11
When should you consider reversing with a blood product? • Limb or life‐threatening bleeding – Intracranial hemorrhage – Pericardial bleed • Emergency surgical procedure in the next 6 hours – Traumatic rupture of a spleen, perforated viscous, ruptured aneurysm – Not just because the surgeon has operating room time in one hour
Substantial proportion of plasma is used inappropriately to reverse warfarin 1. Tinmouth et al. Transfusion 2013;53:2222‐9.
Warfarin accounts for 20% of plasma use (in the PCC/FFP era in Ontario) 1. Tinmouth et al. Transfusion 2013;53:2222‐9.
Intravenous vitamin K is safe • Some clinicians (and nurses) refuse to administer vitamin K intravenously due to the risk of anaphylaxis • Historically, the product had castor oil… • Risk: – 0.04‐11/10,000 doses Fiore et al. J Thromb Thrombolysis 2001; 11:175‐83
• Widespread misconception that subcutaneous is better than oral despite clear evidence of inferiority – Survey of 52 anticoagulant clinics in the USA – 25% had never used oral vitamin K • No orally available tablet in many countries (and often only 5 mg tablets) – Oral Vitamin K is available in USA in 5 mg tablets Vanier et al. Can J Hosp Pharm 2006;59:125‐35 Libby et al. Arch Intern Med 2002; 162: 1893‐6.
Slow to Reverse Warfarin • Observation of effect of vitamin K on the international normalized ratio (INR) when administered subcutaneously • Fat‐soluble compound, subcutaneous injection slows absorption due to its solubility in subcutaneous fat • Route of administration is least effective • Effectively reverses the INR when given intravenously (IV) or orally Overuse of plasma transfusion. ASCP Webinar 05/08/13 Transfusion 2012;52:45S‐55S Arch Intern Med 1999;159:2721‐4. 17 Ann Intern Med 2002;137:251‐4 Arch Intern Med 2003;163:2469‐73
SECTION TWO Methods of Review 18
Which Best Describes the Blood Use Review Process at Your Hospital Jadwin D, et al. AABB 10/17 19
Challenges With Blood‐Use Review • Time, staffing • Reviewer bias, politics • CPOE, limited clinical context • Expertise, arbitration • Feedback and Ongoing Professional Practice Evaluation (OPPE) Transfusion 2006;46:862‐867 20
Prospective Review • Verification by reviewer that criteria have been met before a blood component is available for transfusion • Most beneficial because occurs in real‐time Rossi’s Principles of Transfusion Medicine. 4 th ed. 2009
Prospective Review • Transfusion order – Reduced • Multiple platelet transfusions with no post‐count – Changed • Mistaken belief that cryoprecipitate is super‐plasma – Increased or additional components suggested • Platelets in the setting of massive transfusion • Undertransfusion of plasma 22
Is Undertransfusion a Problem? Plasma • 10 US hospitals • Medical information from the electronic health records for 1 year (2010‐2011) • All adult patients transfused with plasma Triulzi D. Transfusion 2015; 55: 1313‐1319 23
Study Population • 72,167 units of plasma were transfused in 19,596 doses to 9,269 patients • The median dose of was 2 units (interquartile range, 2‐4; range 1‐ 72) • 15% ‐1 unit • 45% ‐ 2 units 24
Suboptimal Dosing • Previous studies have shown less than 10 mL/kg plasma results in inadequate INR correction • Median weight‐adjusted dose was only 7.3 mL/kg • 15.5% of doses were at least 15 mL/kg 25
Prospective Review • Ideal time to discuss appropriate transfusion practices or to provide effective education may not be during the course of providing emergency care • One issue that arises is that point‐of‐care test results available to clinicians are likely to contribute to real‐ time transfusion decisions • These data are not likely to be readily available to BBTS physician Transfusion Therapy: Clinical Principles and Practice, 3 rd ed. 2011 AABB Technical Manual. 19 th ed. 2017 26
Prospective Review • Perceived it as potentially confrontational • Offer most potential for influencing clinical practices • Emergency circumstances, complete information may not be available before component release – Member of clinical team can provide this information after emergency has been resolved – This may limit application of prospective review 27
Prospective Review • May be most useful before the provision of customized blood components • Gamma irradiation or washing • CMV negative products • Before unusual orders 28
Retrospective Review • Conducted any time after transfusion • No data to substantiate effectiveness alone in improving transfusion practice • Must always consider both information available to physician as well as patient’s clinical condition at the time transfusion was prescribed • Must be familiar with nuances of transfusion practices 29
SECTION THREE What Works and What Does Not? 30
Build Relationships Transfusion Committee • Actively engaging one’s colleagues in decision making can energize their interest and make them feel that decisions made are truly their own, not forced upon them (probably unsuccessfully) by transfusion service • On physician‐to‐physician basis, transfusion service director can impress upon colleagues importance of certain issues and need to address them Transfusion 2006;46:862‐867 . 31
Build Relationships • At same time, he or she can impress them with valuable information that can improve patient care • By using the committee for more than just “blood utilization review,” transfusion service can win many friends and establish new conduits for communication and cooperation 32
Clinical Management From The Laboratory • Many clinical situations develop that require an unusual or nonstandard response • Problems that fit in this category include broad range of complexity, urgency, and frequency 33
Interactions with Physicians in Real‐Time • Huge impact on clinical practice can be made through interactions surrounding clinicians’ decisions whether to transfuse blood component • Prospective audits more effectively shape ordering habits of clinicians 34
Requirements • Availability to be interrupted without notice • Proficiency with literature defining the appropriate indications for transfusion • Willingness to insert oneself into clinical situation where clinician may have expected his or her “order” to be filled without question 35
Interactions with Physicians in Real‐Time • Successful interactions are promoted if expertise of the TM physician is well known and his or her ability to provide assistance in transfusion matters has already been demonstrated • Communications approaches are needed that can diffuse potentially tense situation where defensiveness is unlikely to aid objectivity 36
Interactions with Physicians in Real‐Time • Starting off conversation with, “Yes, we have the plasma thawing, but I wanted to learn a little more about the problem you’re dealing with,” can quickly defuse tension • Offering to thaw but hold plasma until oozing is actually evident may allow reticent surgeon opportunity to (perhaps grudgingly) try it “your way.” 37
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