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? Restrictive (7 gm)Liberal (10 gm) n=418%n=420%p Mortality 30 day 7818.79823.3.11 60 day 9522.711126.5.23 Hospital 9322.211828.1.05 Length of stay ICU 11.0  10.711.5  11.3.53 Hospital 34.8  19.535.5  19.4.58 “A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal strategy in critically ill patients.” NEJM. 1999.

8. FOCUS results Liberal trigger (n=1007) Restrictive trigger (n=1009) Units transfused 1866 (97% transfused) 652 (41.5% transfused) Median units 2 (IQ 1-2) 0 (IQ 0-1) 1  outcome 35.2%34.7% 60 day mortality 7.6%6.6% In-hosp ACS, death 4.3%5.2% Readmit, fall, fatigue, function No differences Carson et a.l. NEJM. 2011

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 1 st 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)