Improving Blood Stewardship in a Level 1 Trauma Intensive Care Unit (TICU) Michael Stellmaker, MD* Frances Hite Philp, MS Allan Philp, MD, FACS
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1 Improving Blood Stewardship in a Level 1 Trauma Intensive Care Unit (TICU) Michael Stellmaker, MD* Frances Hite Philp, MS Allan Philp, MD, FACS
2 Disclosure Information This study was presented at the Society for the Advancement of Blood Management, September 19-21, 2013 in Los Angeles, CA. The study team has no conflicts of interest, financial or otherwise, to report for this research
3 The Problem Hemoglobin drops an average of 0.5 grams/ deciliter/ day for each of the first 3 days in ICU Diagnostic blood loss averages 41.5 ml/day in U.S. ICUs One third of ICU admissions receive transfusions 80,000 units of blood components transfused daily in the U.S. Fowler & Berenson. Blood conservation in the intensive care unit. Critical Care Medicine, 2003; 31, S715-S720. Foulke & Harlow. Effective measures for reducing blood loss from diagnostic laboratory tests in intensive care patients. Critical Care Medicine, Smoller & Kruskall. Phlebotomy for Diagnostic Laboratory Tests in Adults. New England Journal of Medicine, 1986; 314,
4 The Problem Reducing transfusions by 1 unit/day in a single ICU could save $328,000/year CMS, AMA, Joint Commission and Choosing Wisely Campaign consider red blood cell transfusions, one of the top five overused procedures in medicine. Boucher & Hannon. Blood Management: A Primer for Clinicians. Pharmacotherapy, The Joint Commission and the American Medical Association- Convened Physician Consortium for Performance Improvement (PCPI). Proceedings from the National Summit on Overuse
5 Proposed Solutions Restrictive diagnostic phlebotomy (small volume tubes) Point-of-care testing Minimization of waste (closed systems) Removal of non-essential catheters Institution of threshold-based transfusion policies Professional education
6 Our Study Hypothesis: Blood stewardship education can reduce ICU blood draw volume Primary outcome: Volume of blood drawn per patient per day Secondary outcomes: Rate/frequency of transfusions, mortality, ICU length of stay (LOS)
7 Methods TICU patients over a 9-week period Pre- and Post- Education cohorts (4 weeks each) Intensive Blood Stewardship Education (1 week) Nursing/provider education performed daily Highlighted add-on labs, less frequent blood draws All blood draw volumes, including waste, recorded prospectively in patient rooms Pre- and post- education groups compared for blood volumes drawn, transfusions required, demographics, mortality, ICU LOS Statistical analysis used Fisher s exact and t-tests to compare categorical and continuous variables
8 Educational Tool Diagnostic Lab Add-On Guide
9 Results: Pre-Education (Group A) and Post-Education (Group B) (LOS= length of stay, DBL= diagnostic blood loss, PRBC= packed red blood cells, FFP= fresh frozen plasma)
10 Results: Pre-Education (Group A) and Post-Education (Group B) Transfusion Requirements
11 Results Summary 17% decrease in daily average blood drawn per patient after education Hospital mortality and ICU LOS not negatively impacted Fewer patients transfused after education Compared to historical data, less blood drawn in the TICU than in Med/Surg ICUs
12 Conclusions Education resulted in a significant decrease in blood loss from ICU patients Drawing less blood did not significantly worsen ICU LOS Decrease in in-hospital mortality noted (did not reach significance) Reinforces recommendations to include education in blood conservation measures
13 Ongoing Areas of Study Determine number of labs drawn pre- and posteducation for additional analysis Examine trauma registry data for a specific substudy Expand to include other institutional ICUs Continue to promote blood stewardship through regular education campaigns Combine educational efforts with other blood conservation practices to increase efficacy
14 Limitations Small sample size Observational Statistically significant difference in the gender comparison of our 2 groups Lack of data regarding illness severity in the general surgery population
15 References Boucher, B. A., & Hannon, T. J. Blood Management: A Primer for Clinicians. Pharmacotherapy, 2007; 27, Foulke, G. E., & Harlow, D. J. Effective measures for reducing blood loss from diagnostic laboratory tests in intensive care patients. Critical Care Medicine, 1989; 17, Fowler, R. A., & Berenson, M. Blood conservation in the intensive care unit. Critical Care Medicine, 2003; 31, S715-S720. Schander, A. Patient Safety Science and Technology Summit. Overuse of Red Blood Cell Transfusions. Laguna Niguel, CA. Jan 14, Smoller, B. R., & Kruskall, M. S. Phlebotomy for Diagnostic Laboratory Tests in Adults. New England Journal of Medicine, 1986; 314,
16 Questions?
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