1. Impact of a PRUDENT © Red Blood Cell Transfusion Strategy in Pediatric HSCT and Oncology Patients Results from the CHB Experience 2009-11 © 2009 All rights reserved. For permission please contact the Physician’s Organization Quality Department.

2. 2 Background  Blood products are increasingly recognized as a resource to target 1. Transfusions are high risk 2. Unnecessary use creates shortage of scarce and costly resource 3. Increasing evidence that tolerating anemia (e.g. Hct 7-9g/dl) in critically ill, stable patients does not adversely impact their outcomes 4. Reducing blood product use may decrease risks of volume overload, transfusion reactions and immunologic consequences  Blood products have become a focus of many clinicians across Children’s Hospital Boston  Growing body of evidence that optimizing blood product use may be beneficial**  Inappropriate (imprudent) use could place our patient at risk **Kipps, 2010; Salvin 2010; Karam, 2010; Bateman, 2008

3. 3 Calendar Year 2009 Total Number of CHB admissions18, 852 Hospital admissions associated with RBC transfusion -(n)2,404 (13.0) Age at admissions associated with RBC transfusions (Years) -median (IQR) 4 (0,12) Length of stay associated with RBC products (Days) - median (IQR)8 days (5, 22) Number of hospital admissions associated with RBC products and ICU admissions - median (IQR) 686(21.4) Number patients with admissions associated with RBCs and mortality – n(%) 128(6.9) Total CHB billed RBC product charges$6,262,829 CHB Use of RBC Products (PHIS)

4. 4 PRBC Transfusions by Location 8 South Amb Transfusion OR 6N7S 6W 6W – (HSCT Unit) Amb Transfusion OR 7South – MSICU 6 North – (Onc) 6 West 8 South (CICU)

5. 5 Background  PRUDENT ©  QI initiative at Children’s Hospital Boston  Focus on identifying areas of physician decision making that shape effectiveness and value of care  “Pediatric Resource Use: Determination of Effective and Necessary Targets”  Analysis of baseline use of a targeted resource  Used RBCs as model  Wise decision making and medical choices  Use of resources when they should be used (appropriate use)  Avoidance of overuse and/or misuse

6. 6 RBC Transfusion Practices Evaluated by HSCT Unit and Oncology  Preliminary evidence/culture change from “Transfusion Requirements in Critical Care Pilot Study”, JAMA 1995  Multicenter, prospective,randomized(Canada)  69 patients in tertiary ICUs, 16yo or older  Hgb maintained at 7-9 (2.5 U/pt) or 10-12 (4.8 U/pt)  48% reduction in transfusions in “conservative” group  No difference in mortality, organ dysfunction  Meta-analysis by Marik, Crit Care Med 2008  45 observational studies, 272,000 adult ICU patients  Primary endpoint was mortality  42/45 studies: risks of rbc transfusion outweighed the benefit; benefit outweighed risk in 1 study of elderly MI patients

7. 7 Presentation to Division (Dr. Lehmann on 2/5/09)  Transfusion strategies for patients on pediatric ICU”, LaCroix, NEJM 2007  637 patients  “noninferiority” trial  HgB at 7 vs 9.5  44% fewer transfusions in conservative group  No change in outcomes  ** Hence, Reasons to be Concerned with RBC Transfusions at CHB  Efficacy  Toxicity  Cost

8. 8 Impact of a PRUDENT © Red Blood Cell Strategy In Children Undergoing HSCT Baseline Characteristics of Pre-Practice Change and Post-Practice Change CHB Bone Marrow Transplant Patients VariablePre-Practice Change (1/1/08-12/31/08) (N=66) Post-Practice Change (3/1/09-2/28/10) (N=75) P-value Male sex- n (%)29 (43.9%)55 (73.3%)0.004 Age (Years), median (IQR)6 (2, 12.25)6 (3, 13) Diagnosis- n (%): Non-Malignant Hematology Lymphoma and Solid Tumor Neuroblastoma Hematologic Malignancies 6 (9.1%) 22 (33.3%) 4 (6.1%) 34 (51.6%) 12 (16.0%) 28 (37.3%) 7 (9.3%) 28 (37.3%) 0.31 Type of Transplant- n (%): Auto Sibling BM-URD Other Family URCord 22 (33.3%) 13 (19.7%) 31 (47.0%) 0 (0%) 26(34.7%) 15 (20.0%) 30 (40.0%) 2 (2.7%) 0.87  Collaboration with 7S (MSICU)  Written policy change in Feb 2009  “Routine” transfusion for Hgb <7 g/dl (vs. 9 g/dl)

9. 9 Impact of a PRUDENT © Red Blood Cell Strategy In Children Undergoing HSCT

10. 10 Impact of a PRUDENT © Red Blood Cell Strategy In Children Undergoing HSCT CHB Bone Marrow Transplant Transfusion Practice by Pre-Practice Change and Post-Practice Change Groups VariablePre-Practice Change (1/1/08-12/31/08) (N=66) Post-Practice Change (3/1/09-2/28/10) (N=75) P-value Patients Transfused- n(%)65 (98.5%)72 (96%)0.38 Total # RBC Transfusion Units392307 RBC Transfusion Units per Patient, median (IQR) 4 (3,8)3 (2,5)0.002 Transfusion Days*286243 Transfusion Days per Patient, median (IQR) 4 (2,5)3 (2,5)0.01

11. 11 Impact of a PRUDENT © Red Blood Cell Strategy In Children Undergoing HSCT

12. 12 Outcomes of a PRUDENT © Red Blood Cell Strategy In Children Undergoing HSCT Pre-Intervention and Post-Intervention CHB Bone Marrow Transplant Patient Outcomes VariablePre-Practice Change (1/1/08-12/31/08) (N=66) Post-Practice Change (3/1/09-2/28/10) (N=75) P-value Time to Engraftment (Days), median (IQR) 20 (12, 25)18 (12,24)0.71 Length of Stay (Days), median (IQR) 37(30, 46)37 (29, 52)0.69 100-Day Mortality (days)- n (%): Relapse Related Transplant Related 17 (25.8%) 9 (13.6%) 8 (12.1%) 13 (17.3%) 6 (8.0%) 7 (9.3%) 0.22 Blood Product Related Charges$3624 ($2265, $6040)$2185 ($1812, $3997)0.0040

13. 13 Diffusion to 06 North – Inpatient Oncology  Written policy change in Jan 2010  “Routine” transfusion Hgb <7 g/dl

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15. 15 PRBC Transfusions by Location 8 South Amb Transfusion OR 6N7S 6W 6W – (HSCT Unit) Amb Transfusion OR 7South – MSICU 6 North – (Onc) 6 West 8 South (CICU)

16. 16 MSICU- 07 South BMT- 06 WestOncology- 06 North ORCardiac ICU- 08 South Solid Organ Tx- 10 South Safety Evaluation- ICU Transfers Cost Modeling PRUDENT © Activities

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