CWC: TRANSFUSION MEDICINE FROM RECOMMENDATION TO PRACTICE IN PERIOPERATIVE MEDICINE SYLVAIN GAGNÉ, MD, (ANESTHESIA) FRCPC APRIL 13TH, 2016 www.ottawahospital.on.ca
CFPC CoI Templates: Slide 1 FACULTY/ PRESENTER DISCLOSURE Faculty: Dr. Sylvain Gagné Relationships with commercial interests: None
CFPC CoI Templates: Slide 2 DISCLOSURE OF COMMERCIAL SUPPORT This program has received financial support from [organization name] in the form of [describe support here e.g. an educational grant]. This program has received in-kind support from [organization name] in the form of [describe support here e.g. logistical support]. Potential for conflict(s) of interest: none
Examine the barriers to implementing CWC- Transfusion Medicine in the perioperative setting OBJECTIVES Describe approaches used at The Ottawa Hospital to implement recommendations from CWC- Transfusion Medicine List remaining challenges Encourage discussion exploring other solutions
FAILURE TO IMPLEMENT EBM Failure to implement evidence based medicine 30-40% of patients do not receive care according to present scientific evidence and 20-25% of care provided is not needed or is potentially harmful.
CHANGE TAKES TIME 1996 ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: Executive Summary. - Recommendation for ASA, b-blocker and ACEi at discharge, Statin if LDL elevated 1997-2004: b-blocker 56-71%, ACEi/ARB 37-70%, Statin 22-66% (Canada) 2007: ASA 97.8%, beta-blockers 87%, ACEi/ARB 72%, Statins 87%
WHEN CHANGE COMES FROM OUTSIDE A SPECIAL CHALLENGE FOR CWC TM
WHEN CHANGE COMES FROM OUTSIDE A SPECIAL CHALLENGE FOR CWC TM Cross specialty working group/collaboration Champions within Transfusion Medicine, Hematology and Perioperative Medicine Donna Touchie, RN ONTraC program Elianna Saidenberg, MD, Hematopathology, TOH Marc Carrier, MD, Thrombosis
CHANGE!!!!!!
It s not easy HOW TO AFFECT CHANGE? Reminders: Median improvement across interventions - 14.1% Dissemination of educational materials -8.1% Audit and Feedback - 7.0% Educational outreach - 6.0% Grimshaw J, 2006
PROTOCOLS AND CHECKLISTS? The Checklist Manifesto Atul Gawande Potentially very effective WHO Surgical Safety Checklist 1 Central line insertion checklist 2 Simple, cheap Not effective as stand alone technique Slow adoption of checklists in medicine 1. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010; 251: 976 80. 2. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU Peter Pronovost, M.D., et al. N Engl J Med 2006; 355:2725-2732
FORCED FUNCTION Definition: This is how we operate from now on so suck it up buttercup!!
FORCED FUNCTION Any management device or tool used to limit user errors by prohibiting specific actions without p rior use of necessary safety procedures A forcing function is an aspect of a design that prevents the user from taking an action without consciously considering information relevant to that action. It forces conscious attention upon something ("bringing to conciousness") and thus deliberately disrupts the efficient or automatised performance of a task.
BEYOND FORCED FUNCTION Quasi automation
RECOMMENDATION #8 AUTOLOGOUS TRANSFUSIONS Barrier: Perceived safety benefit Solution: You are the Gatekeepers TOH abandoned this routine practice in ~2011 due to mounting evidence of cost-ineffectiveness Preoperative autologous donation decreases allogeneic transfusion but increases exposure to all red blood cell transfusion: results of a meta-analysis. International Study of Perioperative Transfusion (ISPOT) Investigators. Forgie MA, Wells PS, Laupacis A, Fergusson D. Arch Intern Med. 1998;158(6):610.
RECOMMENDATION #5 NO PLASMA OR PCCS FOR NON-URGENT COUMADIN REVERSAL Barriers: Need system that ensures proof of normalization of INR preop Cancelling is not an option Who s responsibility? Where? Timing Vitamin K administration?
Solutions: Partnerships: (TOH) Thrombosis unit, GP, medical day care clinic, ER Make it easy Standard process (consult/instructions/testing) POCT for INR 24hrs preop Communication
COMMUNICATION
COMMUNICATION
RECOMMENDATION #5 URGENT COUMADIN REVERSAL PCCS Barriers: Knowledge, timing, process (recent INR) Solution: Education Cross specialty buy-in and relationships Pre-printed order set/protocol
RECOMMENDATION #7 UNNECESSARY TYPE & SCREEN Barrier: Habit/individual decision CBC, lytes, BUN/Cr, PTT/INR, CXR, ECG, T&S. No perceived downside of continuing Perceived risk of not testing
RECOMMENDATION #7 UNNECESSARY TYPE & SCREEN Solutions: Medical directives or MBOS (preop clinic) Statistics Education Partnerships Administration (cost-savings) Surgeons Anesthesia CBC, lytes, BUN, Cr, PTT/INR,, CXR, ECG, Type and Screen
LOOK AT YOUR NUMBERS Red Cell Utilization January 1-June 30, 2015 Procedures Primary total knee replacement Revision total knee replacement Primary total hip replacement Revision total hip replacement Biannual TOH Red Cell Rates 2015-2016 Provincial Benchmark 1.5% 3% 8% 6% 3% 3% 33% 27% Those patients who were transfused received their PRBCs on POD#3 not urgent
WHAT IS THE COST? Type & Screen ~ 50$ Crossmatch add 25$ Depending on your surgical volumes Tens of THOUSANDS OF $$$ /year
MEDICAL DIRECTIVES/MBOS Numbers allowed us to convince the surgeons, anesthesiologists and administration But what about those high risk patients?
For selected procedures (i.e. knees) WHAT ABOUT HIGH RISK PATIENTS? T&S if: - Hgb < 120 - Angina - < 50Kg - Coagulopathy/bleeding disorder - High risk of antibodies POCT for Hgb
ONGOING CHALLENGES But I still want a T&S! The non-compliant physician Urgent/non-elective surgery Any suggestions welcome
RECOMMENDATION #2 SINGLE UNIT TRANSFUSION If you need to give a unit of PRBC, give 2 if you drink one beer, you should drink 2 Solutions: Education Transfusion Guideline form (feedback/reminder)
RECOMMENDATION #2 TRANSFUSION TRIGGERS No formal triggers from CWC But decision should be influenced by symptoms and Hgb concentration Solution: If CPOE hard limits based on Hgb when not bleeding 1,2 Transfusion Guideline form 1. Murphy, M.F., et. al, Transfusing blood safely and appropriately. BMJ, 2013 2. Hibs, S.P., The impact of electronic decision support on transfusion practice: a systematic review. Transfusion Medicine Reviews, 2015
RECOMMENDATION #9-10 LIMIT USE OF O -- PRBC AND AB PLASMA EXCEPT FOR EMERGENCIES WITH UNKNOWN TYPE Prospective monitoring of blood orders Risk of delay during emergencies Individual feedback post-emergency Opportunity to intervene is lost CPOE + decision support Murphy, M.F., et. al, Transfusing blood safely and appropriately. BMJ, 2013 Hibs, S.P., The impact of electronic decision support on transfusion practice: a systematic review. Transfusion Medicine Reviews, 2015
RECOMMENDATION #1 ANEMIA CORRECTION Barriers: Complicated Timing Lack of perceived risk Lack of perceived solution
RECOMMENDATION #1 ANEMIA CORRECTION Solutions: Early identification screen at risk populations Rapid access Cancellation of surgery with iron deficiency anemia? Partnerships / support from administration
TOH BLOOD MANAGEMENT PROGRAM Identified high risk cases Established criteria Flagging system Early identification
RECOMMENDATION #3 ACCEPT AN INR OF <1.8 FOR INVASIVE PROCEDURES Barriers Knowledge Conflicting guidelines Perceived risk (hemorrhage, neuraxial hematoma) Lack of perceived benefit for change Abdel-Wahab OI, Healy B, Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion (Paris). Aug 2006;46(8):1279-1285. Estcourt L, Stanworth S, Doree C, et al. Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation. Cochrane Database Syst Rev. 2012;5:Cd004269. Szczepiorkowski ZM, Dunbar NM. Transfusion guidelines: when to transfuse. Hematology Am. Soc. Hematol. Educ. Program. 2013;2013:638-644.
OTHER GUIDELINES When INR < 1.5
The current ASRA guidelines recommends an INR value of 1.4 as acceptable for the performance of neuraxial blocks.(4) The value was based on studies that showed excellent perioperative hemostasis when the INR value was 1.5. The concurrent use of other medications, such as aspirin, NSAIDs, and heparins that affect the clotting mechanism, increases the risk of bleeding complications without affecting the INR.
RECOMMENDATION #3 ACCEPT AN INR OF <1.8 Solutions?
CONCLUSION Champions Cross-specialty collaboration Education + intervention based on identified barriers Local solutions to local barriers Patience and perseverance Thank you.
QUESTIONS?