Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System

Overuse of phlebotomy testing offers little to improve patient outcomes but may subject patients to additional morbidity. Low-cost, high-frequency tests are ordered recurrently, unnecessarily, and contribute to the high cost of health care. Reducing unnecessary phlebotomy tests can cut costs without compromising quality. Type and screen tests are active for three days from the date the specimen is collected, yet our blood bank laboratory observed type and screen tests were often unnecessarily ordered in our organization. We set out to determine the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests, estimate the cost saved by the CDSS implementation, and describe the unnecessary ordering practices by provider type. Adoption of CDSSs has been successful in reducing unnecessary radiologic imaging, overutilization of antibiotics, and Clostridium dificile testing. Our value improvement initiative was a separate-sample pretest posttest design at a mid-Atlantic academic health system. A CDSS was embedded in our computerized order entry (COPE) system to promote appropriate test ordering. The CDSS appears when a type and screen is ordered informing the provider of the date and time the current test expires. Our study demonstrated that CDSSs impacted a variety of provider types, reduced unnecessary phlebotomy tests, and achieved yearly cost savings. Unnecessary testing continues in health care and contributes to excessive health spending without adding value. Phlebotomy testing is one example of how providers can reduce waste and control healthcare costs for low-cost, high-frequency tests. To further improve test ordering practices of all provider types, we recommend additional interventions such as organizational support, education, audits, and feedback. In this era of precision medicine, ordering the right test, at the right time, for the right reason can reduce cost, reduce waste, and improve quality, outcomes, and satisfaction for patients. Until the establishment of national quality measures aimed to control the number of low-cost, high-frequency tests, health systems must find a way to reduce unnecessary health services. CPOE is widely used in a variety of health care settings and can incorporate CDSS to guide all provider types to make judicious decisions at the time of care

Brown Recluse spider bite mediated hemolysis: clinical features, a possible role for complement inhibitor therapy, and reduced RBC surface glycophorin A as a potential biomarker of venom exposure.

The venom of Loxosceles reclusa (Brown Recluse spider) can cause a severe, life-threatening hemolysis in humans for which no therapy is currently available in the USA beyond supportive measures. Because this hemolysis is uncommon, relatively little is known about its clinical manifestation, diagnosis, or management. Here, we aimed to clarify the clinical details of envenomation, to determine the efficacy of the complement inhibitor eculizumab to prevent the hemolysis in vitro, and to investigate markers of exposure to Brown Recluse venom.We performed a 10-year chart review of cases of Brown Recluse spider bite-mediated hemolysis at our institution. We also designed an in vitro assay to test the efficacy of eculizumab to inhibit hemolysis of venom exposed red blood cells. Finally, we compared levels of CD55, CD59 and glycophorin A on venom exposed versus venom-naïve cells.Most victims of severe Brown Recluse spider mediated hemolysis at our institution are children and follow an unpredictable clinical course. Brown Recluse spider bite mediated hemolysis is reduced by 79.2% (SD=18.8%) by eculizumab in vitro. Erythrocyte glycophorin A, but not CD55 or CD59, is reduced after red blood cells are incubated with venom in vitro.Taken together, our laboratory data and clinical observations indicate that L. reclusa venom exposure results in non-specific antibody and complement fixation on red blood cells, resulting in complement mediated hemolysis that is curtailed by the complement inhibitor eculizumab in vitro. Glycophorin A measurement by flow cytometry may help to identify victims of L. reclusa envenomation

Using trends and outliers in managing delayed transfusions

OBJECTIVES: To investigate if time to initiate a blood transfusion after an informative laboratory test could feasibly be used by the transfusion medicine service as a metric to monitor for transfusion delays. BACKGROUND: Delayed transfusions may result in patient morbidity and mortality, but no standards for timely transfusion have been developed. Information technology tools could be implemented to identify gaps in provision of blood and to recognise areas of improvement. MATERIALS AND METHODS: Data obtained from a children\u27s hospital\u27s data science platform and time from the release of laboratory results to the initiation of transfusions were calculated and weekly medians were used for trend analyses. Outlier events were obtained using locally estimated scatterplot smoothing and generalised extreme studentized deviate test. RESULTS: Overall, the number of outlier events on the timing of transfusions based on patients\u27 haemoglobin level and platelet count were small (n = 1 and n = 0 for 139 weeks, respectively). Investigation of these events for adverse clinical outcomes was non-significant. CONCLUSIONS: Herein, we propose that the trends and outlier events could be further investigated and used to make decisions and implement protocols to improve patient care

Effect of eculizumab on <i>L</i><i>. reclusa</i> associated hemolysis <i>in vitro</i>.

<p>(A) <i>L</i><i>. reclusa</i> venom sensitized cells are hemolyzed over time when incubated with ABO identical plasma, compared to venom naïve RBCs. (B) This hemolysis is reduced by an average of 79.2% (SD = 18.8%) when eculizumab is added to the assay. (C) Eculizumab was statistically indistinguishable from heat inactivation at all timepoints. Results are averages of 3-4 experiments. Error bar shows results +/- 1 standard deviation. Asterisk indicates statistical significance, p<.001.</p

Top Row: Mean data from 5 experiments show that venom exposure results in a statistically insignificant alteration in the expression of CD 55 (A) and CD 59 (B), but a statistically significant reduction of glycophorin A (C). Error bars indicate +/- 1 standard deviation. Bottom Row: Representative histograms from a single experiment (Red = untreated cells; Blue = PBS treated cells; Orange = venom treated cells; Green = isotype control).

<p>Top Row: Mean data from 5 experiments show that venom exposure results in a statistically insignificant alteration in the expression of CD 55 (A) and CD 59 (B), but a statistically significant reduction of glycophorin A (C). Error bars indicate +/- 1 standard deviation. Bottom Row: Representative histograms from a single experiment (Red = untreated cells; Blue = PBS treated cells; Orange = venom treated cells; Green = isotype control).</p

Blood conservation strategies at United States hospitals during the COVID-19 pandemic: Findings from a multi-institutional analysis - International Society of Blood Transfusion survey.

BackgroundDue to the coronavirus disease 2019 (COVID-19) pandemic, the transfusion medicine community has experienced unprecedented blood supply shortages since March 2020. As such, numerous changes to everyday practice have occurred with a specific emphasis on blood conservation. We sought to determine the strategies used to mitigate blood shortages and promote blood conservation during the pandemic.MethodsAn anonymous, 37-question survey was developed using Research Electronic Data Capture and distributed via e-mail to transfusion medicine specialists across the US obtained via publicly available databases.ResultsAmongst surveyed [41.1% response rate (51/124 institutions)], 98.0% experienced a product shortage, with the greatest number reporting red blood cell (RBC) shortages (92.0%). This led to 35.3% of institutions altering the composition and/or number of blood product suppliers, including a 100% increase in the number of institutions acquiring blood from organizations that connect hospital transfusion services with blood collection centers (e.g., Blood Buy) compared to before March 2020. Prospective triaging of blood products was the most common blood conservation strategy (68.1%), though 35.4% altered their RBC exchange or transfusion program for patients receiving chronic RBC transfusion/exchange. As a result of these changes, 78.6% of institutions reported that these changes resulted in a reduction in blood product usage, and 38.1% reported a decrease in product wastage.ConclusionsMost hospitals experienced the effects of the supply shortage, and many of them implemented blood conserving measures. Conservation strategies were associated with decreased blood utilization and waste, and future studies could evaluate whether these changes persist