Intravenous albumin utilization audit at a large community hospital.

BACKGROUND: There is a literature gap in terms of albumin utilization practices. METHODS/MATERIALS: We conducted a single-center retrospective observational electronic audit of adult admitted patients who received one or more vials of albumin (5% or 25%) between September 1, 2019 and August 31, 2020 at a large community hospital. The Research Ethics Board approval was obtained. Utilization data identified through the laboratory information system were independently adjudicated by two reviewers and resolved by consensus as appropriate-acceptable, appropriate-may be acceptable, or inappropriate. The primary objective of this audit is to determine the proportion of 5% and 25% intravenous albumin infusions meeting a priori appropriateness criteria for indication. Secondary outcomes include determining the patterns of practice surrounding intravenous albumin use: patient demographics, most responsible diagnosis, location at time of order, clinical outcomes of albumin recipients, and types, volumes, and cost of albumin infused. RESULTS: The mean total albumin administered was 569.2 mL across 456 total recipients (58% male) with a 29% appropriateness rate. This cohort had an in-hospital mortality rate of 38%, with an average of 6 days from first dose of albumin to death. The mean length of stay was 14 days, with a mean intensive care length of stay of 8 days. The purchase cost of inappropriately transfused albumin was CAD $65,538. CONCLUSION: Based on a lack of or an unacceptable indication provided, 71% of patients were inappropriately transfused. Albumin use deviating from guideline recommendations may be contributing to increased healthcare costs, pressure on limited supply, and potential patient harm.

A prospective multi-faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study.

BACKGROUND: Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. STUDY DESIGN AND METHODS: A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. RESULTS: Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P < .0001). Pre- and post-transfusion hemoglobin levels and the total number of RBCs transfused decreased from baseline (P < .05). The median pre-transfusion hemoglobin decreased from a baseline of 72.0 g/L to 69.0 g/L in the post-intervention period (P < .0001). RBC transfusions per acute inpatient days decreased significantly in intervention hospitals, but not in control hospitals (P < .001). The intervention had no impact on patient length of stay, need for intensive care support, or in-hospital mortality. CONCLUSION: This multifaceted intervention demonstrated a marked improvement in RBC transfusion appropriateness and reduced overall RBC utilization without impacts on patient safety.

A regional massive hemorrhage protocol developed through a modified Delphi technique.

BACKGROUND: A massive hemorrhage protocol (MHP) enables rapid delivery of blood components in a patient who is exsanguinating pending definitive hemorrhage control, but there is variability in MHP implementation rates, content and compliance owing to challenges presented by infrequent activation, variable team performance and patient acuity. The goal of this project was to identify the key evidence-based principles and quality indicators required to develop a standardized regional MHP. METHODS: A modified Delphi consensus technique was performed in the spring and summer of 2018. Panellists used survey links to independently review and rate (on a 7-point Likert scale) 43 statements and 8 quality indicators drafted by a steering committee composed of transfusion medicine specialists and technologists, and trauma physicians. External stakeholder input from all hospitals in Ontario was sought. RESULTS: Three rounds were held with 36 experts from diverse clinical backgrounds. Consensus was reached for 42 statements and 8 quality indicators. Additional modifications from external stakeholders were incorporated to form the foundation for the proposed MHP. INTERPRETATION: This MHP template will provide the basis for the design of an MHP toolkit, including specific recommendations for pediatric and obstetrical patients, and for hospitals with limited availability of blood components or means to achieve definitive hemorrhage control. We believe that harmonization of MHPs in our region will simplify training, increase uptake of evidence-based interventions, enhance communication, improve patient comfort and safety, and, ultimately, improve patient outcomes.