Increased hospital costs associated with red blood cell transfusion.

BACKGROUND: Red blood cell (RBC) transfusion is independently associated in a dose-dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital-acquired complications. Since little is known of the cost of these transfusion-associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose-dependent relationship. STUDY DESIGN AND METHODS: A retrospective cohort study of all multiday acute care inpatients discharged from a five hospital health service in Western Australia between July 2011 and June 2012 was conducted. Main outcome measures were incidence of RBC transfusion and mean inpatient hospital costs. RESULTS: Of 89,996 multiday, acute care inpatient discharges, 4805 (5.3%) were transfused at least 1 unit of RBCs. After potential confounders were adjusted for, the mean inpatient cost was 1.83 times higher in the transfused group compared with the nontransfused group (95% confidence interval, 1.78-1.89; p < 0.001). The estimated total hospital-associated cost of RBC transfusion in this study was AUD $77 million (US $72 million), representing 7.8% of total hospital expenditure on acute care inpatients. There was a significant dose-dependent association between the number of RBC units transfused and increased costs after adjusting for confounders. CONCLUSION: RBC transfusions were independently associated with significantly higher hospital costs. The financial implication to hospital budgets will assist in prioritizing areas to reduce the rate of RBC transfusions and in implementing patient blood management programs.

Measuring the incidence of hospital-acquired complications and their effect on length of stay using CHADx.

OBJECTIVES: To use an automated Classification of Hospital Acquired Diagnoses (CHADx) reporting system to report the incidence of hospital-acquired complications in inpatients and investigate the association between hospital-acquired complications and hospital length of stay (LOS) in multiday-stay patients. DESIGN: Retrospective cross-sectional study for calendar years 2010 and 2011. SETTING: South Metropolitan Health Service in Western Australia, which consists of two teaching and three non-teaching hospitals. MAIN OUTCOME MEASURES: Incidence of hospital-acquired complications and mean LOS for multiday-stay patients. RESULTS: Of 436 841 inpatient separations, 29 172 (6.68%) had at least one hospital-acquired complication code assigned in the administrative data, and there were a total of 56 326 complication codes. The three most common complications were postprocedural complications; cardiovascular complications; and labour, delivery and postpartum complications. In the subset of data on multiday-stay patients, crude mean LOS was longer in separations for patients with hospital-acquired complications than in separations for those without such complications (17.4 days v 5.4 days). After adjusting for potential confounders, separations for patients with hospital-acquired complications had almost four times the mean LOS of separations for those without such complications (incident rate ratio, 3.84; 95% CI, 3.73-3.96; P < 0.001). CONCLUSIONS: An automated CHADx reporting system can be used to collect data on patients with hospital-acquired complications. Such data can be used to increase emphasis on patient safety and quality of care and identify potential opportunities to reduce LOS.

Guidelines for the management of paracetamol poisoning in Australia and New Zealand--explanation and elaboration. A consensus statement from clinical toxicologists consulting to the Australasian poisons information centres.

Paracetamol is involved in a large proportion of accidental paediatric exposures and deliberate self-poisoning cases, although subsequent hepatic failure and death are both uncommon outcomes. The optimal management of most patients with paracetamol overdose is usually straightforward. However, several differing nomograms and varying recommendations regarding potential risk factors for hepatic injury introduce complexity. In order to reconcile management advice with current Australasian clinical toxicology practice, revised guidelines have been developed by a panel of clinical toxicologists consulting to the poisons information centres in Australia and New Zealand using a workshop and consultative process. This article summarises the rationale for the recommendations made in these new guidelines.

Deliberate self-poisoning with tiagabine: an unusual toxidrome.

Tiagabine is an anticonvulsant acting by selective inhibition of neuronal and glial gamma-aminobutyric acid uptake, resulting in increased gamma-aminobutyric acid-mediated inhibition in the brain. Few reports in the literature describe the clinical course of severe tiagabine intoxication. A 44-year-old woman presented after deliberate self-poisoning with 100 tiagabine 15 mg tablets (1,500 mg; 25 mg/kg). Serum tiagabine level was 4,600 microg/L (1,725 mmol/L) at presentation, 20 times levels associated with therapeutic dosing. Intoxication was manifested by profuse vomiting, coma, myoclonus, generalized rigidity, bradycardia, hypertension, hypersalivation and generalized piloerection within 2 h of ingestion. The patient was intubated and management was supportive. Coma lasted until 10 h post-ingestion, but recovery was complicated by severe agitated delirium lasting 12 h. The patient recovered fully within 26 h of ingestion. Tiagabine deliberate self-poisoning was associated with the rapid onset of coma and an unusual toxidrome. Recovery, although complicated by agitated delirium, was complete within 26 h.

Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years.

OBJECTIVE: To investigate the doses of antivenom administered to adult patients with severe brown snake envenoming. DESIGN AND SETTING: Review of charts from Western Australian adult teaching hospitals, December 1991 to December 2001. PATIENTS: 35 patients with severe brown snake envenoming, defined prospectively as afibrinogenaemia (< 0.3 g/L) after a bite by a brown snake (genus Pseudonaja). MAIN OUTCOME MEASURE: The dose of antivenom required to neutralise venom, defined prospectively as the dose of antivenom given before the return of detectable fibrinogen levels. RESULTS: Of 88 patients with brown snake envenoming admitted over the 10 years, at least 35 had severe envenoming. Afibrinogenaemia persisted for 10 hours (range, 1.4-68 hours) after the first dose of antivenom; in four patients afibrinogenaemia lasted more than 24 hours. The dose of antivenom given before venom neutralisation ranged from one to 23 ampoules. In two-thirds of cases, venom was neutralised with five ampoules, and 89% had venom neutralised with 10 ampoules. Two patients died, and another had serious bleeding complications. Another patient died during the study period from intracerebral haemorrhage, but did not have fibrinogen levels measured. CONCLUSIONS: Patients received initial doses of antivenom too small to neutralise circulating venom, and remained afibrinogenaemic for prolonged periods, with serious consequences. The authors now use 10 ampoules as an initial dose in severe brown snake envenoming.

Prospective evaluation of repeated supratherapeutic acetaminophen (paracetamol) ingestion.

STUDY OBJECTIVE: Repeated supratherapeutic ingestion of acetaminophen is potentially lethal but poorly described. We provide the first prospective description of the characteristics, course, and outcome of patients with repeated supratherapeutic ingestion of acetaminophen. METHODS: This was a prospective case series of consecutive patients aged 12 years and older with acetaminophen dosage greater than 4 g per 24 hours referred to our poison center. Acetylcysteine was recommended if serum acetaminophen level exceeded 10 mg/L or aspartate aminotransferase exceeded 50 IU/L. Acetaminophen dosage, demographic factors, treatment, and outcome were recorded using standardized methods. Minimum follow-up was 72 hours. RESULTS: Of 277 patients eligible, 249 patients were enrolled. At presentation, serum aspartate aminotransferase levels less than 50 IU/L were found in 126 patients, aspartate aminotransferase levels of 50 to 1,000 IU/L were present in 47 patients, and aspartate aminotransferase levels were above 1,000 IU/L in 37 patients. No aspartate aminotransferase data were available for 39 patients. No patient with an aspartate aminotransferase level below 50 IU/L at presentation developed hepatotoxicity (aminotransferase >1,000 IU/L). Seven (15%) patients with aspartate aminotransferase levels of 50 to 1,000 IU/L at presentation subsequently developed hepatotoxicity; 1 patient died. Six (16%) patients with aspartate aminotransferase levels above 1,000 IU/L at presentation died or received liver transplants. Study limitations included recall bias, incomplete patient follow-up, and the assumption that absence of clinical signs indicated insignificant liver injury. CONCLUSION: Our results suggest that the injury caused by acetaminophen repeated supratherapeutic ingestion is apparent at presentation and related to dose magnitude and duration. All patients who developed hepatotoxicity presented with aspartate aminotransferase above 50 IU/L. Determination of serum aspartate aminotransferase and acetaminophen concentrations may allow early discharge from the emergency department.

Successful resuscitation after cardiac arrest following massive brown snake envenomation.

We report a 44-year-old Western Australian man who suffered a cardiac arrest several hours after a bite by a brown snake. He was successfully resuscitated after bolus administration of undiluted brown snake antivenom. We suggest that an initial bolus dose of at least five ampoules (5000 units) of undiluted brown snake antivenom should be given as primary therapy for cardiac arrest following brown snake envenomation in Western Australia.