Determination of Unnecessary Blood Transfusion by Comprehensive 15-Hospital Record Review.

BACKGROUND: Although unnecessary blood component transfusions are costly and pose substantial patient risks, the extent of unnecessary blood use in a community hospital setting has not been systematically measured. METHODS: A 15-hospital observational analysis was performed using comprehensive retrospective review. Approximately 100 encounters (x¯â€¯= 103.9, standard deviation [SD] ± 7.6) per hospital (6,696 total component transfusion events) were reviewed between 2012 and 2018. Review was performed by two medical directors. Findings were supported by blind intra- and inter-reviewer double review and blind external review by 10 independent reviewers. RESULTS: Patients received an average of 4.3 (± 1.3) units. Only 8.2% (± 6.7) of patient encounters did not receive unnecessary units. Fifty-five percent (54.6% ± 13.5) could have been managed without at least one component type, while 44.6% (± 14.9) could have been managed completely without transfusion. Forty-five percent (45.4% ± 17.0) of red blood cell, 54.9% (± 19.3) of plasma-cryoprecipitate, and 38.0% (± 15.6) of plateletpheresis encounters could likely have been managed without transfusion. Between 2,713 units (40.5%) and 3,306 units (49.4%) were likely unnecessary. In patients who could have been managed without transfusion of at least one component type, unnecessary blood use was associated with a 0.38 (± 0.11)-day increase in length of hospital stay for each additional unnecessary unit received (p < 0.001). CONCLUSION: Substantial unnecessary blood use was identified, all of which was unrecognized by hospitals prior to review. Unnecessary blood use was attributed to overreliance on laboratory transfusion criteria and failure to follow common blood management principles, which resulted in potential harm to patients and avoidable cost.

Optimizing utilization of beta-lactam surgical prophylaxis through implementation of a structured allergy assessment tool in a presurgical clinic.

In patients with ß-lactam allergies, administration of non-ß-lactam surgical prophylaxis is associated with increased risk of infection. Although many patients self-report ß-lactam allergies, most are unconfirmed or mislabeled. A quality improvement process, utilizing a structured ß-lactam allergy tool, was implemented to improve the utilization of preferred ß-lactam surgical prophylaxis.

Multi-institutional survey on imaging practice patterns in pancreatic ductal adenocarcinoma.

PURPOSE: To study the practice patterns for performance and interpretation of CT/MRI imaging studies in patients with pancreatic ductal adenocarcinoma (PDAC) at multiple institutions using a survey-based assessment. METHODS: In this study, abdominal radiologists/body imagers on the Society of Abdominal Radiology disease-focused panel for PDAC and from multiple institutions participated in an online survey. The survey was designed to investigate the imaging and reporting practice patterns for PDAC. The survey questionnaire addressed the experience of referring providers, choice of imaging modality for diagnosis and follow-up of PDAC, structured imaging templates utilization for PDAC, and experiences with the use of structured reports. RESULTS: The response rate was 89.6% (43/48), with majority of the respondents working in a teaching hospital or academic research center (95.4%). While 86% of radiologists reported use of structured reporting templates in their practice, only 60.5% used standardized templates specific to PDAC. This lower percentage was despite most of them (77%) being aware of existence of PDAC-specific templates and recognizing their benefits, such as preference by referring providers (83%), improved uniformity (100%), and higher accuracy of reports (76.2%). The common impediments to the use of PDAC-specific templates were interference with efficient workflow (67.5%), lack of interest (52.5%), and complexity of existing templates (47.5%). With regards to imaging practice, 92.7% (n = 40/43) of respondents reported performing dynamic multiphasic pancreatic protocol CT for evaluation of patients with initial suspicion or staging of PDAC. CONCLUSION: Structured reporting templates for PDAC are not universally utilized in subspecialty abdominal/body imaging practices due to concerns of interference with efficient workflow and complexity of templates. Multiphasic pancreatic protocol CT is most frequently performed for evaluation of PDAC.

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Iron deficiency anemia in women: a practical guide to detection, diagnosis, and treatment.

INTRODUCTION: Iron deficiency anemia (IDA) remains a widely underdiagnosed and unappreciated women's health issue, affecting women of all ages. Despite the fact that IDA is easily diagnosed and treated, it continues to be a major public health issue. The World Health Organization estimates that 30% of nonpregnant and more than 42% of pregnant women have anemia. METHODS: A multidisciplinary Group for the Research and Education on Anemia Therapy in Women (GREAT Women II) was formed, sponsored by the Society for the Advancement of Blood Management. The goal was to focus attention on the impact of IDA on women at various stages of life and evaluate and use published literature to provide a simple, evidence-based approach to diagnose and treat IDA. RESULTS: The group developed specific recommendations for evaluating and treating IDA in women. Initial diagnosis is defined as hemoglobin less than 12 g/dL in nonpregnant women. A trial of iron therapy (4 weeks) can be considered a first-line diagnostic tool. Alternatively, a low or normal mean corpuscular volume (<100 fL), low serum ferritin (<30 µg/L), and/or low transferrin saturation (transferrin saturation <20%) is sufficient to confirm IDA. If the patient does not fit the diagnosis of IDA or fails to respond to a trial of oral iron, or mean corpuscular volume is elevated, further diagnostic evaluation is needed, including iron studies, B12, folate levels, and renal function tests. If results are not definitive, and IDA persists, a hematology referral is recommended. CONCLUSION: Clinicians should routinely identify and treat IDA, thereby decreasing its negative impact on health and quality of life of women.

Improved obstetric safety through programmatic collaboration.

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.

Iron deficiency anemia in women across the life span.

Anemia is a global health issue with disproportionately high prevalence in women. In addition to being an independent risk factor for decreased quality of life and increased morbidity and mortality, anemia in women has been linked to unfavorable outcomes of pregnancy and other issues for children born to anemic women. Iron deficiency is the leading cause of anemia in many populations. Guidelines recommend proactive screening for anemia, particularly in the preoperative setting. Once anemia is diagnosed, treatment should be based on etiology (most commonly, iron deficiency followed, in order of prevalence, by inflammation or chronic disease). Iron supplementation (oral and intravenous) offers safe and effective treatment for anemia associated with iron deficiency. Anemia of chronic disease may be more challenging to treat, and attention must be given to the underlying disease, along with use of hematinic agents. Given its enormous impact on the health and well-being of women and the availability of simple and effective treatment options, anemia should never be left unmanaged.

Feasibility of remote CT colonography at two rural Native American medical centers.

OBJECTIVE: Fort Defiance Indian Hospital and Tuba City Regional Health Care Center are two rural hospitals with limited availability of optical colonoscopy (OC) and other methods of colorectal cancer screening. Our goals were to determine whether adequate examinations could be obtained with remote supervision after brief onsite instruction and to share lessons learned in our experience with a remote CT colonography (CTC) screening program. MATERIALS AND METHODS: After brief onsite instruction, including performing a CTC examination on a volunteer to train the CT technologists, both sites began performing CTC using standard bowel preparation, fecal tagging, automatic insufflation, and low-dose technique. Studies were transferred to the University of Arizona Hospital for image quality assessment of stool, residual fluid, distention, and interpretation, with reports returned via the teleradiology information system. Clinical follow-up was performed on those patients referred for polypectomy or biopsy. RESULTS: Three hundred twenty-one subjects underwent CTC, including 280 individuals referred for screening examinations (87%). Ninety-two percent of subjects (295/321) had acceptable amounts of residual stool, 91% (293/321) had acceptable levels of fluid, and 92% (294/321) had acceptable distention. Fourteen percent (44/321) of CTC patients had polyps 6 mm or larger in size, with a positive predictive value of 41% for those who subsequently underwent colonoscopy-polypectomy (11/27). CONCLUSIONS: CTC can be introduced to rural underserved communities, performed locally, and interpreted remotely with satisfactory performance, thereby increasing colorectal cancer screening capacity. Important aspects of implementation should include technologist training, referring physician education, careful attention to image transmission, and clearly defined methods of communication with patients and referring providers.

Comparison of the accuracy of CT volume calculated by circumscription to prolate ellipsoid volume (bidimensional measurement multiplied by coronal long axis).

RATIONALE AND OBJECTIVES: Tumor volume is one of the most important factors in evaluating the response to treatment of patients with cancer. The objective of this study was to compare computed tomographic (CT) volume calculation using a semiautomated circumscribing tracing tool (manual circumscription [MC]) to prolate ellipsoid volume calculation (PEVC; bidimensional measurement multiplied by coronal long axis) and determine which was more accurate and consistent. MATERIALS AND METHODS: The study included six patients with nine neoplasms, six phantoms, and two radiologists. The neoplasms and phantoms of varying sizes and shapes were imaged using multidetector CT scanners, with slice thicknesses ranging from 0.5 to 3 mm. Measurements were performed using a TeraRecon 3D workstation. Each lesion and phantom was manually circumscribed, and its three dimensions were measured. The measurements were repeated 2 weeks later. RESULTS: MC of the phantoms deviated from their true volumes by an average of 3.0 +/- 1%, whereas PEVC deviated by 10.1 +/- 3.99%. MC interobserver readings varied by 1.2 +/- 0.6% and PEVC by 4.8 +/- 3.3%. MC intraobserver readings varied by 1.95 +/- 1.75% and PEVC by 2.5 +/- 1.55%. Patient tumor volume predicted by MC and PEVC varied greatly; MC interobserver readings differed by 3.3 +/- 2.1% and PEVC by 20.1 +/- 10.6%. MC intraobserver readings varied by 2.5 +/- 1.9% and PEVC by 5.5 +/- 3.2%. Variability was greater for complex shapes than for simple shapes. Bidimensional analysis demonstrated an interobserver difference of 12.1 +/- 8.7% and an intraobserver difference of 5.05 +/- 3.3%. These results demonstrate large interobserver and intraobserver variability. Variability was greater for complex shapes than for simple shapes. CONCLUSION: MC of neoplasms provided more accurate and consistent volume predictions than PEVC. More complicated shapes demonstrated the superiority of MC over PEVC.

Detection, evaluation, and management of anemia in the elective surgical patient.

The prevalence of anemia in elective surgical patients may be as frequent as 75% in certain populations. A national audit demonstrated that 35% of patients scheduled for joint replacement therapy have a hemoglobin <13 g/dL on preadmission testing. Standard practice currently consists of preadmission testing 3 to 7 days before an elective operative procedure, precluding the opportunity to effectively evaluate and manage a patient with unexpected anemia. Therefore, a standardized approach for the detection, evaluation, and management of anemia in the preoperative surgical setting was identified as an unmet medical need. To address this knowledge gap, we convened a panel of physicians to develop a clinical care pathway for anemia management in this setting. Elective surgery patients should receive a hemoglobin (Hgb) determination a minimum of 30 days before the scheduled surgical procedure. Because the identification and evaluation of anemia in this setting will assist in expedited diagnosis and treatment of underlying comorbidities and will improve patient outcomes, unexplained anemia (Hgb <12 g/dL for females and <13 g/dL for males) should cause elective surgery to be deferred until an evaluation can be performed.

Hepatic cavernous hemangioma with atypical peripheral rim activity on hepatic blood pool imaging.

Hemangioma is the most common benign liver tumor. Hepatic blood pool imaging is an effective technique with a specificity approaching 100%. Typically, hemangiomas are completely filled on hepatic blood pool imaging. However, incomplete fill-in can be seen in larger hemangiomas complicated with thrombosis, fibrosis, or bleeding. We report a hepatic cavernous hemangioma with atypical peripheral rim activity.

Pulmonary artery compression by a saphenous vein graft aneurysm and contrast echocardiography using an agitated mixture of ten percent air, ten percent blood, and ten percent saline.

This case illustrates the use of intravenous injection of an agitated mixture of 10% air, 10% blood, and 80% saline during intraoperative transesophageal echocardiography in a patient with a saphenous vein graft aneurysm compressing the main pulmonary artery.