Patient Safety Science & Technology Summit 2014

1. Patient Safety Science & Technology Summit2014

2. AryehShander, MD, FCCM, FCCP • Clinical Professor of Anesthesiology, Medicine & SurgeryMt. Sinai School of Medicine

3. Suboptimal Red Blood Cell Transfusion: A Patient Safety Issue

5. IOM – National Round Table on Health Care Quality 1980 coined the term “overuse” Do harm to patients Excess costs to society Defy patients’preference A patient safety concern JAMA Intern Med. 2013

7. WHY?

8. Blood Transfusion in the USA • USDHSS: In 2011, total of 13,785,000 units of RBC • Total components 20,930,000 • RBC - 2006 - 50/1,000, 2012 ~ 47/1,000 • AHRQ: Blood transfusions occurred in 1/10 of all hospital stays • One of the fastest growing top-five procedures • Consumption of safety?

9. Quality Concern and Rationale • Although blood transfusions might be life-saving… • Carry adverse event risks • - From fever to worse patient outcomes including death • Variability in clinician practice leads to inappropriate use of blood components • Proper use of patient blood management interventions would reduce unnecessary transfusions • Scope of the working group • - Review patient blood management (PBM) strategies by care settings

10. Transfusion is one of the most common procedure in hospitals But in 4 yrs of medical education…1-4 hrs of learning N = 86 American medical schools surveyed (AAMC) 83% reported - didactic lectures 48% of medical schools providing 1 or 2 hours of lectures 6% reported small group sessions on transfusion medicine 92% reported were unfamiliar with the 1989 or the 1995 TMAA curricula Transfusion Medicine Education in Undergraduate Medical Schools Karp JK. et al. Transfusion. 2011 Nov;51(11):2470-9

11. Could this lead to: • 1 – Extreme variability in transfusion practice?2 – Little to no “evidence practice”?3 – Overuse? • Low knowledge – fear - learning behavior from others A Patient Safety Issue

12. None of this would be an issue if RBC transfusion had no: • Risks to recipient • Poor risk to benefit ratio • Adverse poor clinical outcome • Inventory pressure • Cost to healthcare and society A Patient Safety Issue

13. Reported Adverse Outcomes Associated with Transfusion Thromboembolism (arterial, venous) Diminished postop functional recovery Bleeding requiring re-operation Cancer recurrence Increased mortality Increased admission to ICU Prolonged mechanical ventilation Increased ICU length of stay Increased hospital length of stay Increased hospital readmission • Infection • Septicaemia • Delayed wound healing • TRALI • MOF • SIRS • ARDS • Vasospasm • Low-output heart failure • Atrial fibrillation • Cardiac arrest • Renal failure • Stroke • Myocardial infarction Hofmann A et al. Oncologist. 2011;16. (suppl3):3-11. Thomson A et al. ISBT Science Series. 2009;4(n2):423-35

14. Risks of Transfusion: Outcome Focus • “There are few if any articles that support transfusion actually improving patient outcomes.” • “The majority of database papers show associations between transfusion utilization and with immunosuppression, increased infection, increased renal failure, multisystem organ failure, and death.”1 • 88% of RBC transfusions show no benefit while being associated with harm2 1.Spiess B.D. TRANSFUSION 2004;44(supp 4s). 2. Shander et al. TransMed Rev. 2011. 232-246.

15. RBC and Activity-based Costs per Patient Shander A et al. Transfusion. 2010;50(4):753-765.

16. What Needs to Change • Role of physician education • Only area in medicine where the therapy is central and patient secondary – we must change that! • Detection, diagnosis, & proper treatment of anemia • Decision support and continuous hemoglobin monitoring. • Changes in hospital leadership, practice, and technology

17. Patient Blood Management • “Is the timely application of evidence based medical and surgical concepts designed to manage anemia, optimize hemostasis, and minimize blood loss and blood transfusion in order to improve patient outcomes.” A multimodality approach

19. ABIM 2012

20. Moving in the right direction

21. Elora Thorpe, RN, MSN Dr. Keith Ruskin, MD Bradford Ray, RABT, PBMT, BC Dr. Jesse Ehrenfeld, MD, MPH Dr. Michael Henderson, MD Stephen Thames Patient Blood Management & Transfusion Safety Nurse Manager, University of Kansas Hospital Professor of Anestheseology and Neurosurgery Yale University School of Medicine Chief Executive Officer, Citizens Medical Center Director of Patient Blood Management, Del Sol Medical Center Associate Professor of Anesthesiology, Surgery and Biomedical Informatics, Director of Anesthesiology and Perioperative Informatics Research Division, Director of Center for Evidence-based Anesthesia, Medical Director for Perioperative Quality, Vanderbilt University Medical Center Chief Quality Officer, Cleveland Clinic Suboptimal RBC Transfusions Panel

22. Sub-optimal RBC Transfusions

23. Patient Safety Science & Technology Summit2014