Implementation of a patient blood management program in hematopoietic stem cell transplantation (Editorial, p. 2763).

BACKGROUND: Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood. STUDY DESIGN AND METHODS: This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015. RESULTS: We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 109 /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events. CONCLUSION: Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.

Improvements in red blood cell transfusion utilization following implementation of a single-unit default for electronic ordering.

BACKGROUND: The prevention of excessive allogeneic red blood cell (RBC) transfusion is an important component of patient blood management initiatives. In this investigation, changes in transfusion behaviors following modification of computerized physician order entry (CPOE) procedures for RBC transfusions to a single-unit default quantity were assessed. STUDY DESIGN AND METHODS: This is an observational cohort study of adults for whom nonemergency allogeneic RBC transfusions were ordered in the 2 years before and 2 years after the date of modification of the CPOE system to a single-unit default (June 18, 2015). Changes in the frequency of single- versus multiunit RBC transfusion orders and other transfusion metrics were compared between preintervention and postintervention cohorts. RESULTS: A total of 52,773 unique transfusion orders for 61,989 RBC units were included, of which 60,045 (96.9%) were transfused. Single-unit orders increased annually, from 10,404 (74.1%) in the first year to 11,645 (88.6%) in the last year, while multiunit orders decreased by more than half (p < 0.0001). The number of RBC units transfused decreased by 13.9% from 32,528 in the preintervention cohort to 27,497 in the post intervention cohort (p < 0.0001) with an estimated reduction in transfusion-related expenditures of nearly $4 million. The percentage of transfusions associated with a posttransfusion hemoglobin of10 g/dL or greater decreased by 34.5% (p < 0.0001). CONCLUSION: Modification of the CPOE process such that nonemergency RBC transfusion orders were defaulted to a single unit was associated with decreased rates of multiunit RBC transfusion orders, lower transfusion volumes, and substantial cost savings.

Assessing the Safety of Overlapping Surgery at a Children's Hospital.

IMPORTANCE: Media reports have questioned the safety of overlapping surgical procedures, and national scrutiny has underscored the necessity of single-center evaluations of its safety; however, sample sizes are likely small. We compared the safety profiles of overlapping and nonoverlapping pediatric procedures at a single children's hospital and discussed methodological considerations of the evaluation. DATA AND DESIGN: Retrospective analysis of inpatient pediatric surgical procedures (January 2013 to September 2015) at a single pediatric referral center. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure. Mixed models adjusting for Vizient-predicted risk, case-mix, and surgeon compared inpatient mortality and length of stay (LOS). RESULTS: Among 315 overlapping procedures, 256 (81.3%) were matched to 645 nonoverlapping procedures. There were 6 deaths in all. The adjusted odds ratio for mortality did not differ significantly between nonoverlapping and overlapping procedures (adjusted odds ratio = 0.94 vs overlapping; 95% CI, 0.02-48.5; P = 0.98). Wide confidence intervals were minimally improved with Bayesian methods (95% CI, 0.07-12.5). Adjusted LOS estimates were not clinically different by overlapping status (0.6% longer for nonoverlapping; 95% CI, 9.7% shorter to 12.2% longer; P = 0.91). Among the 87 overlapping procedures with the greatest overlap (≥60 min or ≥50% of operative duration), there were no deaths. CONCLUSIONS: The safety of overlapping and nonoverlapping surgical procedures did not differ at this children's center. These findings may not extrapolate to other centers. LOS or intraoperative measures may be more appropriate than mortality for safety evaluations due to low event rates for mortality.

Safety of Overlapping Surgery at a High-volume Referral Center.

OBJECTIVE: To compare safety profiles of overlapping and nonoverlapping surgical procedures at a large tertiary-referral center where overlapping surgery is performed. BACKGROUND: Surgical procedures are frequently performed as overlapping, wherein one surgeon is responsible for 2 procedures occurring at the same time, but critical portions are not coincident. The safety of this practice has not been characterized. METHODS: Primary analyses included elective, adult, inpatient surgical procedures from January 2013 to September 2015 available through University HealthSystem Consortium. Overlapping and nonoverlapping procedures were matched in an unbalanced manner (m:n) by procedure type. Confirmatory analyses from the American College of Surgeons-National Surgical Quality Improvement Program investigated elective surgical procedures from January 2011 to December 2014. We compared outcomes mortality and length of stay after adjustment for registry-predicted risk, case-mix, and surgeon using mixed models. RESULTS: The University HealthSystem Consortium sample included 10,765 overlapping cases, of which 10,614 (98.6%) were matched to 16,111 nonoverlapping procedures. Adjusted odds ratio for inpatient mortality was greater for nonoverlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures; 95% confidence interval, CI 1.23-3.73; P = 0.007) and length of stay was no different (+1% for nonoverlapping cases; 95% CI, -1% to +2%; P = 0.50). In confirmatory analyses, 93.7% (3712/3961) of overlapping procedures matched to 5,637 nonoverlapping procedures. The 30-day mortality (adjusted OR = 0.69 nonoverlapping vs overlapping procedures; 95% CI, 0.13-3.57; P = 0.65), morbidity (adjusted OR = 1.11; 95% CI, 0.92-1.35; P = 0.27) and length of stay (-4% for nonoverlapping; 95% CI, -4% to -3%; P < 0.001) were not clinically different. CONCLUSIONS: These findings from administrative and clinical registries support the safety of overlapping surgical procedures at this center but may not extrapolate to other centers.

Understanding the Impact of Obesity on Short-term Outcomes and In-hospital Costs After Instrumented Spinal Fusion.

BACKGROUND: Obesity rates continue to rise along with the number of obese patients undergoing elective spinal fusion. OBJECTIVE: To evaluate the impact of obesity on resource utilization and early complications in patients undergoing surgery for degenerative spine disease. METHODS: A single-institution retrospective analysis was conducted on patients with degenerative spine disease requiring instrumentation between 2008 and 2012. The 801 identified patients were grouped based on a body mass index (BMI) of <30 (nonobese, n = 478), ≥30 and <40 (obese, n = 283), and alternatively BMIs of ≥40 (morbidly obese, n = 40). Baseline characteristics, surgical outcomes and requirements, complications, and cost were compared. Logistic and linear regression analyses were used to determine the strength of association between obesity and outcomes for categorical and continuous data, respectively. RESULTS: Significant differences were found in comorbidities between cohorts. Multivariate analysis revealed significant associations between obesity and longer anesthesia times (30 minutes, P = .008), and surgical times (24 minutes, P = .02). Additionally, there was a 2.8 times higher rate of wound complications in obese patients (4.2% vs 1.5, P = .03), and 2.5 times higher rate of major medical complications (7.8% vs 3.1, P = .01). Morbid obesity resulted in a 10 times higher rate of wound complications (P < .001). Morbid obesity resulted in a $9078 (P = .005) increase in overall cost of care. CONCLUSION: Increased BMI is associated with longer operative times, increased complication rates, and increased cost independent of comorbidities. These effects are more pronounced with morbidly obese patients, further supporting a role for preoperative weight loss.

Improving the Accuracy of Cardiovascular Component of the Sequential Organ Failure Assessment Score.

OBJECTIVES: The Sequential Organ Failure Assessment score is an attractive risk prediction model because of its simplicity and graded assessment of morbidity and mortality. Due to changes in clinical practice over time, the cardiovascular component of the Sequential Organ Failure Assessment score no longer accurately reflects current clinical practice. To address this limitation, we developed and validated a modified cardiovascular component of the Sequential Organ Failure Assessment score that takes into account all vasoactive agents used in current clinical practice, uses shock index as a substitute for mean arterial pressure, and incorporates serum lactate as a biomarker for shock states. DESIGN: Retrospective cohort. SETTING: Mayo Clinic, Rochester, MN. PATIENTS: Adult patients admitted to one of six ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Score performance was assessed via area under the receiver operator characteristic curve. A total of 16,386 ICU admissions were included: 9,204 in the derivation cohort and 7,182 in the validation cohort. area under the receiver operator characteristic curve was significantly higher for modified cardiovascular component of the Sequential Organ Failure Assessment score than for cardiovascular component of the Sequential Organ Failure Assessment for in-ICU mortality (0.801 vs 0.718; difference = 0.083; p < 0.001), in-hospital mortality (0.783 vs 0.651; difference = 0.132; p < 0.001), and 28-day mortality (0.737 vs 0.655; difference = 0.082; p < 0.001). When modified cardiovascular component of the Sequential Organ Failure Assessment score was added to the remaining Sequential Organ Failure Assessment components, the modified Sequential Organ Failure Assessment score again outperformed the existing Sequential Organ Failure Assessment score: in-ICU mortality (0.836 vs 0.822; difference = 0.014; p < 0.001), in-hospital mortality (0.799 vs 0.784; difference = 0.015; p < 0.001), and 28-day mortality (0.798 vs 0.783; difference = 0.015; p < 0.001). Similar results were seen in the validation cohort. CONCLUSIONS: The modified cardiovascular component of the Sequential Organ Failure Assessment score outperforms the existing cardiovascular component of the Sequential Organ Failure Assessment score in predicting patient outcomes and improves the overall performance of the Sequential Organ Failure Assessment model. This score is easily calculated, includes serum lactate as a biomarker for shock states, and incorporates all vasopressors used in current clinical practice.

A multicenter study of plasma use in the United States.

BACKGROUND: Detailed information regarding plasma use in the United States is needed to identify opportunities for practice improvement and design of clinical trials of plasma therapy. STUDY DESIGN AND METHODS: Ten US hospitals collected detailed medical information from the electronic health records for 1 year (2010-2011) for all adult patients transfused with plasma. RESULTS: A total of 72,167 units of plasma were transfused in 19,596 doses to 9269 patients. The median dose of plasma was 2 units (interquartile range, 2-4; range 1-72); 15% of doses were 1 unit, and 45% were 2 units. When adjusted by patient body weight (kg), the median dose was 7.3 mL/kg (interquartile range, 5.5-12.0). The median pretransfusion international normalized ratio (INR) was 1.9 (25%-75% interquartile range, 1.6-2.6). A total of 22.5% of plasma transfusions were given to patients with an INR of less than 1.6 and 48.5% for an INR of 2.0 or more. The median posttransfusion INR was 1.6 (interquartile range, 1.4-2.0). Only 42% of plasma transfusions resulted in a posttransfusion INR of less than 1.6. Correction of INR increased as the plasma dose increased from 1 to 4 units (p < 0.001). There was no difference in the INR response to different types of plasma. The most common issue locations were general ward (38%) and intensive care unit (ICU; 42%). CONCLUSION: This large database describing plasma utilization in the United States provides evidence for both inadequate dosing and unnecessary transfusion. Measures to improve plasma transfusion practice and clinical trials should be directed at patients on medical and surgical wards and in the ICU where plasma is most commonly used.

SpO2/FiO2 ratio on hospital admission is an indicator of early acute respiratory distress syndrome development among patients at risk.

PURPOSE: Oxygen saturation to fraction of inspired oxygen ratio (SpO(2)/FiO(2)) has been validated as a surrogate marker for partial pressure of oxygen to fraction of inspired oxygen ratio among mechanically ventilated patients with acute respiratory distress syndrome (ARDS). The validity of SpO(2)/FiO(2) measurements in predicting ARDS has not been studied. Recently, a Lung Injury Prediction Score (LIPS) has been developed to help identify patients at risk of developing ARDS. METHODS: This was a secondary analysis of the LIPS-1 cohort. A multivariate logistic regression included all established variables for LIPS, Acute Physiology and Chronic Health Evaluation 2, age, and comorbid conditions that could affect SpO(2)/FiO(2). The primary outcome was development of ARDS in the hospital. The secondary outcomes included hospital mortality, hospital day of ARDS development, and hospital day of death. RESULTS: Of the 5584 patients, we evaluated all 4646 with recorded SpO(2)/FiO(2) values. Median SpO(2)/FiO(2) in those who did and did not develop ARDS was 254 (100, 438) and 452 (329, 467), respectively. There was a significant association between SpO(2)/FiO(2) and ARDS (P ≤ .001). The SpO(2)/FiO(2) was found to be an independent predictor of ARDS in a "dose-dependent" manner; for SpO(2)/FiO(2) < 100--odds ratios (OR) 2.49 (1.69-3.64, P < .001), for SpO(2)/FiO(2) 100 < 200--OR 1.75 (1.16-2.58, P = .007), and for SpO(2)/FiO(2) 200 < 300--OR 1.62 (1.06-2.42, P = .025). The discriminatory characteristics of the multivariable model and SpO2/FiO2 as a single variable demonstrated area under the curve (AUC) of 0.81 and AUC of 0.74, respectively. CONCLUSIONS: The SpO2/FiO2, measured within the first 6 hours after hospital admission, is an independent indicator of ARDS development among patients at risk.

Brachial artery catheterization: an assessment of use patterns and associated complications.

BACKGROUND: Although studies have compared safety and outcomes of radial artery cannulation with other arterial catheterization locations, there is insufficient information describing brachial artery catheterization. In this study, we characterized the perioperative use patterns and the complication rates associated with brachial arterial catheterization and compared these outcomes with radial artery catheterization. METHODS: We performed a retrospective analysis of adult patients (age ≥18 years) undergoing surgical procedures at an academic medical center from January 1, 2008, to December 31, 2011. An institutional database containing information on anesthetic care was queried to identify all brachial artery catheterizations. Baseline characteristics, details relating to the surgical and catheterization procedures, and catheter-related complications were collected and compared with a random sample of patients receiving radial artery catheterization. RESULTS: We identified 858 patients receiving brachial catheterization perioperatively. An additional 3432 patients receiving radial catheterization were identified. Patients receiving brachial catheterization were more often women, had a lower body mass index, had more comorbidities, and had longer anesthetic and catheterization durations. Three vascular complications were identified in the cohort receiving brachial artery catheterization compared with 1 patient with a peripheral neuropathy in the radial artery catheterization cohort (unadjusted complication incidence [95% confidence intervals] brachial artery catheterization, 0.35% [0.12%-1.02%] vs radial artery catheterization, 0.03% [0.005%-0.16%], respectively; P = 0.030; relative risk [95% confidence interval] = 12.0 [1.7-83.4]). There were no catheter-related bloodstream infections. CONCLUSIONS: We found that brachial artery catheterization is used in more medically complex patients and for longer duration than radial artery catheterizations. Although the limited number of adverse outcomes precluded statistical adjustments in this investigation, the observed differences in complication rates between cannulation methods suggest that brachial artery catheterization may be a suitable alternative to radial artery catheterization in patients with complex medical comorbidities.

Anesthesiology critical care medicine: a fellowship and faculty recruitment program.

STUDY OBJECTIVE: To review national data on anesthesiology critical care medicine (ACCM) fellowship program enrollment and to describe a program that successfully recruited ACCM fellows and faculty at a single academic medical center. DESIGN: An incentive program known as the Mayo Clinic Scholar program, designed to recruit ACCM fellows and faculty, was reviewed. Interviews were conducted to assess the impact of the Mayo Clinic Scholar program. SETTING: Academic health center. MEASUREMENTS: ACCM fellowship program enrollment data were compared with similar data for critical care medicine fellowship programs in internal medicine, pulmonary medicine, pediatrics, and surgery.The results of a program to recruit ACCM fellows and faculty were reviewed. MAIN RESULTS: Only 89 of 147 (60.5%) ACCM fellowship positions available nationally were filled during the 2010-2011 academic year, and only 89 of the 896 (9.9%) critical care medicine fellows anticipated to graduate in 2011 were in ACCM programs. The Mayo Clinic ACCM fellowship enrolled 28 fellows from January 1, 2000 through July 1, 2010 (range 0-6 per yr). Ten of the 28 (35.7%) were United States medical graduates (USMGs) and 6 of the 10 (60.0%) USMGs who were graduates of the Mayo Clinic residency were appointed as Mayo Clinic Scholars. All 6 Mayo Clinic Scholars were retained as ACCM faculty. Only two of the 6 (33.3%) Mayo Clinic Scholars would have completed ACCM training without a Mayo Clinic Scholar appointment. All recommend ACCM training to others and plan to continue to practice ACCM. CONCLUSIONS: The Mayo Clinic Scholar program effectively recruited ACCM fellows and faculty in a single institution. Incentive-based programs should be considered to support the involvement of anesthesiologists in perioperative medicine.

Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost.

STUDY DESIGN: Single-institution retrospective study. OBJECTIVE: To assess the effect surgical staging (i.e., sequencing) has on clinical and economic outcomes for patients undergoing sacropelvic tumor resection requiring lumbopelvic stabilization. SUMMARY OF BACKGROUND DATA: Sacral corpectomy with lumbopelvic stabilization is an extensive surgical procedure that can be performed in either a single episode or multiple episodes of care on different days. The impact of varied sequencing of surgical episodes of care on patient, resource, and financial outcomes is unknown. METHODS: This single-center retrospective case series identified all cases of sacropelvic tumor resection requiring lumbopelvic stabilization over an 8-year period. We assessed and compared clinical and economic outcomes for patients whose anterior exposure and posterior resection were separated into two distinct surgical episodes of care (staged) versus patients whose anterior exposure and posterior resection occurred in a single encounter (nonstaged procedures). Primary endpoints included procedural outcomes (operative and after-hours surgical time), resuscitative requirements, adverse perioperative events, mortality, and direct medical costs (hospital and physician) associated with the surgical episodes of interest. RESULTS: From January 1, 2000, to July 15, 2008, a total of 25 patients were identified. Eight patients had their procedure staged. Surgical staging was associated with a significant increase in intensive care unit free days (P = 0.03), ventilator free days (P < 0.01), and reduced morbidity (P < 0.01). Surgical staging significantly reduced postoperative red blood cell (P = 0.03), and after-hours red blood cell (P < 0.01) and component requirements (P = 0.04). Mean total inpatient costs were $89,132 lower for patients undergoing the staged procedure (95% confidence interval of mean cost difference = -$178,899 to -$4661). CONCLUSION: Separating the anterior exposure and posterior resection phases of complex sacral tumor resection into two separate surgical episodes of care is associated with improved clinical outcomes and reduced inpatient cost.