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Guidelines for restrictive transfusion triggers

May 2012

Published in the May 2012 issue of Today’s Hospitalist

Guidelines: Use restrictive transfusion triggers

NEW GUIDELINES set more restrictive thresholds for red blood cell transfusions, although the authors urge physicians to consider patient symptoms as well as hemoglobin concentrations.

Published online in March by the Annals of Internal Medicine, the guidelines were issued by the AABB, formerly the American Association of Blood Banks. They were based on a systematic review of more than 50 years of literature on randomized controlled trials that looked at many endpoints including overall mortality, cardiac events, pulmonary edema, stroke, function recovery and length of stay.

According to the guidelines, strong evidence supports not transfusing hospitalized patients who are stable above a hemoglobin concentration of 7-8 g/dL. The guidelines also state that physicians should use a trigger of 8 g/dL for hospitalized patients with preexisting cardiovascular disease.

The guideline authors were not able, however, to provide any recommendations for transfusion thresholds for patients with acute coronary syndromes. Symptoms that should guide when to transfuse include chest pain and heart failure.

No mortality benefits from PFP demo

A LOOK AT OUTCOMES FROM MORE THAN 250 HOSPITALS engaged in the pay-for-performance demonstration project maintained by the Centers for Medicare and Medicaid Services (CMS) finds that those hospitals had the same 30-day mortality rates as hospitals that haven’t been participating in the project.

The study compared mortality rates for hospitals in CMS’ six-year Premier project to outcomes of more than 3,300 other hospitals. Authors found that the hospitals in the demonstration project didn’t post better 30-day mortality outcomes for the conditions being followed: heart attack, heart failure, pneumonia and CABG. The study was posted online in March by the New England Journal of Medicine.

Commentary on the study in Kaiser Health News pointed out that hospitals in the demonstration project did achieve better rates on process measures, such as giving beta-blockers to heart attack patients, than nonparticipating hospitals. However, the study authors pointed out that programs being modeled after the Premier demonstration project should keep their expectations “modest.”

A better night’s sleep

WHILE FEW STUDIES HAVE LOOKED AT HOW to improve patients’ sleep in hospitals, a new study found that a series of interventions boosted patients’ perception of how well they slept and improved patient satisfaction scores.

Researchers tested two types of “sleep rounds.” In the basic rounds, nurses made sure that patients’ lights were out at 11 p.m., that TVs were turned off, that room temperature was adjusted and that patients had been helped to the bathroom. The deluxe intervention included those basic steps and offered patients amenities such as a warm blanket, warm milk and a white-noise machine.

Neither set of interventions led patients to actually get more sleep. However, the interventions did improve patients’ perception of having a more restful night. Researchers found that the largest impediments to sleep in the hospital came from poor pain control, interruptions from staff and the presence of a roommate.

The study was posted online by the Journal of Hospital Medicine.

Program delivers cost savings, cautionary tale

IN THE “IF IT’S NOT BROKEN, DON’T FIX IT” DEPARTMENT, a tertiary center reaped major savings from an antimicrobial monitoring program, only to see costs jump again when the program was scrapped in favor of automatic infectious disease consults.

A study published by Infection Control and Hospital Epidemiology notes that an antibiotic stewardship program staffed by a part-time infectious diseases specialist and a pharmacist saved the University of Maryland Medical Center about $3 million a year. After being in place seven years, the program had helped cut antibiotic spending at the center almost in half.

However, when the program was discontinued and replaced with an alternative stewardship program of automatic infectious disease consults, the hospital’s spending on antibiotics increased more than 30% over the next two years. There was no improvement in mortality or readmission rates.

To capture previous cost savings, the hospital has once again implemented a modified stewardship program.

Report: Don’t order these tests, procedures

A GROUP OF NINE SPECIALTY SOCIETIES HAS RELEASED a report urging physicians to perform 45 common tests and procedures less frequently. The group is also recommending that patients educate themselves about those tests and procedures and ask their physicians for a rationale when one is being ordered.

The “Choosing Wisely” campaign is operating under the auspices of the American Board of Internal Medicine Foundation. In the campaign, the medical societies have each identified five interventions that don’t provide much relief or diagnostic value. The questionable tests and interventions include screening exercise ECGs in asymptomatic patients; brain imaging studies for patients with simple syncope and a normal neurological exam; imaging for VTE in patients with low-test probability (patients’ D-dimer should be measured instead); and preop chest X-rays when doctors don’t suspect intrathoracic pathology.

Commentators have noted that some items on the list are overused because of doctors’ malpractice concerns. At the same time, critics of the campaign worry that the list will be used to restrict patient care.

Time to offer elderly their own ED?

A NEW YORK TIMES ARTICLE DESCRIBES A new trend designed to boost patient satisfaction scores and improve care: geriatric emergency departments, or “geri-eds.” Patients sent to one of the new ED units have first been triaged in that hospital’s regular emergency department and have met several requirements, including being over age 65 and having a condition of only low or moderate severity.

The new units are designed to offer a calmer environment than regular EDs. There are no blinking lights or beeping monitors, and some units have painted “skylights” featuring blue skies and trees to mitigate sun-downing among geriatric patients.

The article pointed out that many doctors and nurses in hospitals with geri-ed units were first skeptical about developing them. However, clinicians in such units have seen patient satisfaction scores rise and deep reductions in the number of patient falls and of unscheduled repeat ED visits among patients.