SOMETIMES LESS IS MORE CHOOSING WISELY CANADA CANADIAN SOCIETY OF TRANSFUSION MEDICINE. Irene Sadek

Transcription

1 SOMETIMES LESS IS MORE CHOOSING WISELY CANADA CANADIAN SOCIETY OF TRANSFUSION MEDICINE Irene Sadek

2 OBJECTIVES Introduce Choosing Wisely Canada Explain CSTM process to develop CWC recommendations Review the CSTM recommendations Discuss examples and results of implementation of some CWC recommendations Future directions How to disseminate recommendations Assess effect of implementing recommendations

3 CHOOSING WISELY Choosing Wisely Canada is a campaign to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures. Choosing Wisely Canada is modelled after the Choosing Wisely campaign in the United States, which was launched by the ABIM Foundation in April

4 CHOOSING WISELY CANADA Initially in Ontario and has quickly been adopted by all provincial and territorial medical associations. It is now a truly national campaign in Canada Has spread to Australia, Germany, Italy, Japan, Netherlands, Switzerland and elsewhere. Choosing Wisely Canada leads the international effort.

5 CHOOSING WISELY CANADA Choosing Wisely is now spreading worldwide. With the funding support of the Commonwealth Fund and Canadian Institutes of Health Research Two annual international round tables in Europe. Bringing 18 different countries together to discuss their Choosing Wisely campaigns and experience

6 G/

7 WHAT DO THEY DO? Approach Professional Canadian National Societies representing a broad spectrum of physicians Professional societies: Develop lists of Five Things Physicians and Patients Should Question.

8 PROFESSIONAL SOCIETY The development process is thoroughly documented and publicly available Each recommendation is within the specialty s scope of practice Tests, treatments or procedures that (a) are frequently used, and, (b) may expose patients to harm or stress. (c) not only about saving resources or money. Each recommendation is supported by evidence

9 WHAT DO THEY DO? Chossing Wisely Canada Launch Media release with the recommendation from different societies Develop patient and physicians resources Establish mechanisms to support the adoption of the Choosing Wisely Canada lists.

10 CHOOSING WISELY CANADA Choosing Wisely Canada is working with various stakeholder groups to disseminate the patient materials widely. Choosing Wisely Canada is also working with medical schools to introduce new content into the undergraduate, postgraduate and continuing medical education curricula.

12 CSTM PROCESS

13 CSTM PROCESS a call to all membership for suggested list items. Membership : Submitted suggestions /lists Some groups worked together and submitted a long list Recommendation and scientific evidence for it

14 CSTM PROCESS CSTM board voted on the accumulated list ranked the items according to their assessment of what was most important. worked together to refine the wording found additional references as required.

15 MEDIA RELEASE ON OCTOBER 29, 2014

16 CHOOSING WISELY CANADA 49 NEW RECOMMENDATIONS TO RELEASE JUNE 2, 2015 On June 2 at 10:00am EDT, 49 new Choosing Wisely Canada recommendations will be released by 10 specialty societies including: Emergency Medicine Canadian Association of Emergency Physicians Hospital Medicine Canadian Society of Hospital Medicine Nuclear Medicine Canadian Association of Nuclear Medicine Paediatric Surgery Canadian Association of Paediatric Surgeons Psychiatry Canadian Academy of Child and Adolescent Psychiatry Canadian Academy of Geriatric Psychiatry Canadian Psychiatric Association Spine Canadian Spine Society Transfusion Medicine (releasing 5 additional items) Canadian Society for Transfusion Medicine Vascular Surgery Canadian Society for Vascular Surgery

18 CSTM'S CHOOSING WISELY CANADA LIST OF TEN THINGS PHYSICIANS AND PATIENTS SHOULD QUESTION Read More

19 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 1-Don t transfuse blood if other non-transfusion therapies or observation would be just as effective. Blood transfusion should not be given if other safer nontransfusion alternatives are available. For example, patients with iron deficiency without hemodynamic instability should be given iron therapy.

20 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 2- Don t transfuse more than one Red cell unit at a time when transfusion is required in stable, nonbleeding patients. Why?

21 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS Indications for red blood transfusion depend on clinical assessment and the cause of the anemia. In a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients.

22 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS Transfusion decisions should be influenced by symptoms and hemoglobin concentration. Single unit red cell transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be prescribed after reassessment of the patient and their hemoglobin value.

23 IF ONE UNIT WILL DO WHY TRANSFUSE TWO?

24 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 3-Don t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aptt) before a procedure. A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

25 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMENDATIONS 4- Don t routinely transfuse platelets for patients with chemotherapy-induced thrombocytopenia if the platelet count is greater than 10 X 109/L in the absence of bleeding.

26 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS A platelet count of 10 X 10 9 /L or greater usually provides adequate haemostasis. Platelet transfusions are associated with adverse events and risks. Considerations in the decision to transfuse platelets include the cause of the thrombocytopenia, comorbid conditions, symptoms of bleeding, risk factors for bleeding, and the need to perform an invasive procedure.

27 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 5- Don t routinely use plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists. Patients requiring non-emergent reversal of warfarin can often be treated with vitamin K or by discontinuing the warfarin therapy. Prothrombin complex concentrates should only be used for patients with serious bleeding or for those who need urgent surgery. Plasma should only be used in this setting if prothrombin complex concentrates are not available or are contraindicated.

28 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 6- Don t use immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated. Immunoglobulin (gammaglobulin) replacement does not improve outcomes unless there is impairment of antigen-specific IgG antibody responses to vaccine immunizations or natural infections. Isolated decreases in immunoglobulins (isotypes or subclasses), alone, do not indicate a need for immunoglobulin replacement therapy. Exceptions include genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin. American Academy of Allergy, Asthma & Immunology Ten Things Physicians and Patients Should Question

29 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 7- Don t order unnecessary pre-transfusion testing (type and screen) for all pre-operative patients. Pre-operative transfusion testing is not necessary for the vast majority of surgical patients (e.g., appendectomy, cholecystectomy, hysterectomy and hernia repair) as those patients usually do not require transfusion. Ordering pre-transfusion testing for patients who will likely not require transfusion will lead to unnecessary blood drawn from a patient and unnecessary testing performed. It may also lead to unnecessary delay in the surgical procedure waiting for the results. To guide you whether pre-transfusion testing is required for a certain surgical procedure, your hospital may have a maximum surgical blood ordering schedule or specific testing guidelines based on current surgical practices.

30 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 8- Don t routinely order perioperative autologous and directed blood collection. There is no role for routine perioperative autologous donation or directed donation except for selected patients (for example, patients with rare red blood cell antigen types). Medical evidence does not support the concept that autologous (blood donated by one s self) or directed blood (blood donated by a friend/family member) is safer than allogeneic blood. In fact, there is concern that the risks of directed donation may be greater (higher rates of positive test results for infectious diseases). Autologous transfusion has risks of bacterial contamination and clerical errors (wrong unit/patient transfused). As well, autologous blood donation before surgery can contribute to perioperative anemia and a greater need for transfusion.

31 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 9- Don t transfuse O negative blood except to O negative patients and in emergencies for female patients of child-bearing potential of unknown blood group. Males and females without childbearing potential can receive O Rhpositive red cells. O-negative red cell units are in chronic short supply, in some part due to over utilization for patients who are not O-negative. To ensure O-negative red cells are available for patients who truly need them, their use should be restricted to: (1) patients who are O-Rh-negative; (2) patients with unknown blood group requiring emergent transfusion who are female and of child-bearing age. Type specific red cells should be administered as soon as possible in all emergency situations..

32 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 10- Don t transfuse group AB plasma to non-group AB patients unless in emergency situations where the ABO group is unknown. The demand for AB plasma has increased. Group AB individuals comprise only 3% of Canadian blood donors. Those donors who are group AB are universal donors for plasma, thus are the most in-demand type for plasma transfusion. Type-specific plasma should be issued as soon as possible in emergency situations to preserve the AB plasma inventory for those patients where the blood group is unknown.

33 CHOOSING WISELY CANADA Other societies?

34 CHOOSING WISELY CANADA APRIL, 2014 Canadian Society of Internal Medicine Third recommendation: Don t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke.

35 CHOOSING WISELY CANADA OCTOBER 29, 2014 Canadian Hematology Society Fifth recommendation: Don t transfuse patients based solely on an arbitrary hemoglobin threshold.

36 CHOOSING WISELY CANADA OCTOBER 29, 2014 Canadian Society of Palliative Care Physicians Fifth recommendation: Don t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, or if no benefit was perceived from previous transfusions.

38 MEASURE OUTCOMES OF IMPLEMENTING THE RECOMMENDATIONS

39 CHOOSING WISELY CANADA OCTOBER 29, 2014 Canadian Society for Transfusion Medicine Second recommendation: Don t transfuse more than one Red cell unit at a time when transfusion is required in stable, non-bleeding patients.

40 CDHA RETROSPECTIVE REVIEW E. KAHWASH ET AL 2012 Results Average pre-transfusion Hgb was 73 ± 10 g/l, post-transfusion the average Hgb level was 94 ± 11 g/l. Asymptomatic patients with Hgb >70 # 77 patients, received 2 RBCs with no indications at all. So, 144 RBCs not indicated. Asymptomatic patients with Hgb<69 # 38 patients, received 2 RBCs, while one could have been enough. So, around 38 units not indicated.

41 CDHA RETROSPECTIVE REVIEW Results Based on two months study 256 units transfused for stable patients. >180 units (70%) could have been avoided. = units unnecessary transfusions per year, 5% of total RBCs issued from blood bank at QEII.

42 RED CELL UTILIZATIONS INITIATIVES

43 RED CELL UTILIZATIONS INITIATIVES 9 months discussion with the medical Staff

44 POLICY ENFORCEMENT Transfuse one red cell unit and then reassess based on the indication: hemoglobin level/ clinical symptoms. Policy approved By DMAC Fall Policy was enforced by blood transfusion services starting January 2013

45 POLICY ENFORCEMENT Transfuse one red cell unit and then reassess based on the indication: hemoglobin level/ clinical symptoms. Did not include out patient clinic or Emergency room Did not include Hematology in-patients due to nursing workload concern. Did not indicate a hemoglobin cut off as there are no agreed upon National or Provincial guidelines

46 POLICY ALGORITHM

47 NUMBER AND PERCENTAGE OF PATIENTS RECEIVING ONE VERSUS 2 UNITS OF RED CELLS 47

48 RED CELL UNIT AT A TIME POLICY Increased awareness

49 EFFECT OF EDUCATION ON ER TRANSFUSIONS 49

50 RE- ASSESSMENT OF NEED FOR RED CELL TRANSFUSION BEFORE ISSUING A SECOND UNIT Jan Feb March April May June July August Total Overall 20% Decrease in Red Cell Transfusions Fifty to One hundred patients receiving one less red cell transfusion every month The decrease in 8 months is 2112 units resulting in an approximate >$1,000,000 saving in the blood budget for the province.

51 Conclusions The policy was implemented in Jan 2013: -from Jan to Aug 2012 : RBCs were transfused -from Jan to Aug 2013 : RBCs were transfused -From Jan to Aug 2013: -20% decrease in red cell transfusions -10% increase in one unit transfusions -10% Decrease in number of patients transfused (335 patients). RBCs 2012 # of patients 2013# of patients 2012 % of patients One vs two units in 2012 vs % of patients One % 75.76% Two % 21% Total patients

52 HEMATOLOGY AND STEM CELL TRANSPLANT PATIENTS Significant reduction of red blood cell transfusion requirements by changing from a double-unit to a singleunit transfusion policy in patients receiving intensive chemotherapy or stem cell transplantation Martin David Berger, Bernhard Gerber, Kornelius Arn, Oliver Senn, Urs Schanz, Georg Stussi Haematologica January : Conclusions Implementing a single-unit transfusion policy saves 25% of red blood cell units and, thereby, reduces the risks associated with allogeneic blood transfusions.

53 TRANSFUSION OF ONE RED CELL UNIT AT A TIME Hematology inpatients Concerns Large number of red cell transfusion Increase nursing workload Delay second unit transfusion Transfuse into the late evening.

54 TRANSFUSION OF ONE RED CELL UNIT AT A TIME Hematology inpatients In November 2013 and in collaboration with the Clinical hematologists BTS implemented a modified Red Cell Guidelines for elective non-bleeding General Hematology and Bone Marrow Transplant patients. If a non-bleeding patient has a hemoglobin 70-80g/L will receive ONE unit of red cells and have a repeat CBC on the following morning. If a non-bleeding patient has hemoglobin of< 70g/L will receive TWO units of red cells and have a repeat CBC on the following morning.

55 TRANSFUSION OF ONE RED CELL UNIT AT A TIME 3 Month Audit of Hematology & Bone Marrow Transplant Pre & Post Red Cell Guidelines 16% Decrease # of red cell units transfused 87% Decrease # of post transfusion hemoglobin >100 g/l 81% Decrease # of patients receiving two red cell units in one setting 13% Decrease # of red cell units transfused per patient

56 TRANSFUSION OF ONE RED CELL UNIT AT A TIME Red Cells Received from CBS 16,236 15,082 13,487 Decrease from 2011/2012 n/a % change in Receipts n/a 7% 17% Transfused 15,495 14,457 12,951 Decrease from 2011/2012 n/a % Change in Transfusions n/a 6.7% 16.4%

57 TRANSFUSION OF ONE RED CELL UNIT AT A TIME Decrease number of patients transfused By around 300 patients per year. 10% of patients Decrease red cell transfusions by 1038 units in 2012/2013 By 2544 units in 2013/2014. For the year , the cost savings to the Nova Scotia blood budget was $519,000 and in the year of , the savings increased to $1,272,000.

58 RED CELL TRANSFUSIONS IF ONE UNIT WILL DO WHY TRANSFUSE TWO?

59 TRANSFUSION HEMOGLOBIN THRESHOLDS

60

61 CHOOSING WISELY CANADA OCTOBER 29, 2014 Canadian Hematology Society Fifth recommendation: Don t transfuse patients based solely on an arbitrary hemoglobin threshold. Canadian Society of Internal Medicine Third recommendation: Don t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke.

62 NAC COMPANION DOCUMENT Red Blood Cell Transfusion: A Clinical Practice Guideline from the AABB l Transfusion decisions should be influenced by symptoms as well as hemoglobin concentration

63 MEASURE OUTCOMES OF IMPLEMENTING THE RECOMMENDATIONS

64 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC RECOMMENDATIONS 3-Don t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aptt) before a procedure. A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

65 FRESH-FROZEN PLASMA TRANSFUSION IN PATIENTS WITH MILD COAGULATION ABNORMALITIES AT A LARGE CANADIAN TRANSFUSION CENTER. CHENG ET AL 2007

66 FRESH-FROZEN PLASMA TRANSFUSION IN PATIENTS WITH MILD COAGULATION ABNORMALITIES AT A LARGE CANADIAN TRANSFUSION CENTER. CHENG ET AL 2007

67 INTERNATIONAL NORMALIZED RATIO VERSUS PLASMA LEVELS OF COAGULATION FACTORS IN PATIENTS ON VITAMIN K ANTAGONIST THERAPY GENE GULATI, PHD; MEGAN HEVELOW, MS; MELISSA GEORGE, DO; ERIC BEHLING, MD; JAMIE SIEGEL, MD. ARCH PATHOL LAB MED VOL 135, APRIL 2011

68 TOWARD RATIONAL FRESH FROZEN PLASMA TRANSFUSION THE EFFECT OF PLASMA TRANSFUSION ON COAGULATION TEST RESULTS LORNE L. HOLLAND, AM J CLIN PATHOL 2006;126:

69 INAPPROPRIATE USE OF PLASMA Crit Care Med Jul;35(7): Fresh frozen plasma transfusion in critically ill patients. Lauzier F et al 73 (32.4%) were consistent with guidelines, 45 (20.0%) were inconsistent but appropriate, 107 (47.6%) were inappropriate

70 Transfusion 2011; 51:62-70 Of patients receiving FFP for non-bleeding indications: % received FFP with an INR of 1.3 or less % received FFP with an INR of 1.5 or less

71 APPROPRIATENESS OF FROZEN PLASMA AND PCC TRANSFUSION IN CANADA. TINMOUTH ET AL Jan-March Preliminary data at CSTM 2012 CDHA Plasma transfusions; 160 episodes of Plasma transfusions 85 episodes for surgical patients. 27 episodes for bleeding patients 27 episodes for plasma exchange. 46% of plasma transfusions were considered inappropriate for INR<1.7.

72 APPROPRIATENESS OF FROZEN PLASMA AND PCC TRANSFUSION IN CANADA. TINMOUTH ET AL # of FP transfusion breakdown by transfusion Queen Elizabeth II HSC Pre-INR <= 1.7 Prophylaxis Surgery Bleeding Plasma E Other

73 The inappropriate use of frozen plasma places patients at risk of serious adverse transfusion reactions such Transfusion-related acute lung injury (TRALI) Transfusion-associated circulatory overload (TACO), Anaphylaxis Others.

74 Transfusion 2011; 51: Physician education Enforcement of plasma guidelines

75 OBJECTIVES Introduce choosing wisely Canada Explain CSTM process to develop CWC recommendations Review the CSTM recommendations Discuss examples and results of implementation of some CWC recommendations Future directions How to disseminate recommendations Assess effect of implementing recommendations

76 CHOOSING WISELY CANADA Opportunities are currently being identified, through partnerships with various health care organizations and associations, to support implementation of the physician recommendations in practice settings. Choosing Wisely Canada has recently introduced an Early Adopter Collaborative to bring such groups together. Each Society is also identifying opportunities to disseminate the recommendations

77 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC Educational opportunities about the CSTM recommendations to health professionals and patients Establish mechanisms to support the adoption of the Choosing Wisely Canada lists. Measure outcomes of implementing the recommendations

78 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC Educational opportunities For example: Blood Matters Nova Scotia November 2014 Newfoundland Transfusion Medicine symposium November 2014 CSTM Education Day, Prince George March 2015 The Canadian Blood Coordinating Programs Collaborative (CBCPC) meeting May 2015 University of Toronto Transfusion Medicine rounds September 2015 Saskatchewan Transfusion Medicine Symposium October 2015 Manitoba blood management rounds November 2015 CSTM Annual conference Vancouver 2016 Education to non TM audiences Any suggestions

79 CHOOSING WISELY CANADA 10 MILLION CHALLENGE CAMPAIGN Help prevent 10,000,000 tests and treatments by 2020

80 RED CELL TRANSFUSIONS IF ONE UNIT WILL DO WHY TRANSFUSE TWO?

81 CANADIAN SOCIETY FOR TRANSFUSION MEDICINE CWC Mechanisms to support the adoption of the Choosing Wisely Canada lists Current processes New ideas?? Measure outcomes Suggestions and ideas??

83 G/ CSTM'S CHOOSING WISELY CANADA LIST OF TEN THINGS PHYSICIANS AND PATIENTS SHOULD QUESTION Read More

84 Questions or Suggestions