Improving appropriateness of blood utilization through prospective review of requests for blood products: the role of pathology residents as consultants.

OBJECTIVE: To evaluate the effectiveness of prospective review of orders for fresh-frozen plasma (FFP) and platelets in reducing blood-product use, and of the effectiveness of preparing pathology residents to serve as clinical consultants. DESIGN: At our 572-bed tertiary-care hospital, we developed guidelines for the use of blood products in collaboration with a variety of departments. For patients whose condition(s) met generally accepted criteria, we identified trigger points to allow for quick release by blood bank staff of blood products. For patients whose condition(s) did not meet the applicable criteria, the on-call pathology resident reviewed the medical record of that patient to determine whether there were any extenuating circumstances; consulted with the ordering physician and attending pathologist, as needed; and advised the house staff on appropriate use of blood products. We evaluated the change in use of blood products between the years 2009 and 2012 to assess the effectiveness of the program. RESULTS: We observed a decrease of 38.8% and 31.4% in the use of FFP and platelets, respectively (29.7% and 21.1%, respectively, when normalized for the number of discharges). If projected to the national level, this improvement would translate to an annual cost reduction of approximately $130 million. CONCLUSIONS: Prospective review of orders for blood products can significantly improve use of these products, thereby reducing risk to patients and avoiding unnecessary healthcare costs. The involvement of pathology residents in the prospective review process provides an excellent opportunity for their training as laboratory consultants.

Feasibility and usefulness of troponin I testing in insurance medicine.

OBJECTIVE: Ascertain the prevalence of elevated Troponin I levels in applicants for insurance to assess the utility of routine measurement of Troponin I in this population. BACKGROUND: Patients presenting with chest pain, who are determined not to be experiencing an acute coronary event, but are noted to have increased levels of Troponin have higher mortality rates than a control population. Elevated levels of Tropoins in the general population are also associated with increase in all cause mortality. Therefore elevated Troponin levels in asymptomatic individuals could be considered a cardiac risk marker. METHODS: Blood samples from Insurance applicants and Health & Wellness participants were analyzed for Troponin I by the Siemens ADVIA Centaur immunoanalyzer. Since such samples are in transit for a day, we determined the rate of degradation of Troponin I on 24-hour storage at room temperature and extrapolated the time-zero values. RESULTS: About 1.5% (10 of 697) of the patients had Troponin levels above 0.04 ng/mL. This rate is higher than would be expected in a healthy general population. Three samples (0.43%) had levels > 0.06 ng/mL, which would be considered elevated and indicative of myocardial injury. CONCLUSIONS: Given the low percentage Troponin I elevations in the general population applying for life insurance, it may not be cost effective to routinely measure Troponin I levels in blood specimens submitted for insurance purposes, except for high value policies. It may be prudent collect data on Troponin I levels in Insurance applicants for better defining the risk models of cardiovascular disease.