IVIG Induced Hemolytic Anemia

Intravenous immunoglobulin (IVIG) is derived from donated plasma used to treat immune deficiency, autoimmune, and inflammatory disorders. Adverse effects occur in 5-15% of patients with hemolytic anemia being a delayed reaction. Risk factors for hemolysis are high-dose infusions (1-2g/kg/day or \u3e100g/day), female sex, and non-O blood group. Our case involves a 69-year old male presetting with bilateral lower extremity weakness for 1 year after sustaining a fall, affecting his ability to ambulate with no bowel or urinary incontinence. MRI revealed spondylotic changes of the lumbar spine. EMG showed severe bilateral lumbosacral polyradiculopathy with ongoing denervation and severe sensorimotor peripheral polyneuropathy with axonal loss. He was diagnosed with chronic inflammatory demyelinating polyneuropathy and started on high-dose IVIG (0.4mg/kg; 77.6mg) therapy for 5 days. 48 hours after IVIG completion, patient developed acute drop in hemoglobin (9.1 g/dL to 7.0 g/dL) that continued to down-trend (5.7 g/dL). Type and screen was AB positive. Labs were significant for elevated absolute reticulocyte count (141.5 K/uL), reticulocyte percentage (6.1%), and LDH (321 IU/L) while haptoglobin was low (\u3c30.0 mg/dL), consistent with hemolytic anemia. Direct antiglobulin anti-IgG coombs test was positive and anti-complement negative, consistent with immunohemolytic anemia. He was supported with blood transfusion and continued on high-dose Prednisone (1mg/kg/day) for 3 months. Antibodies present in IVIG product react with RBC antigens predominantly of the ABO blood group, causing intravascular hemolysis. Although IVIG induced hemolysis is typically mild and self-limiting, it can often go undetected and prescribers should be aware.https://scholarlycommons.henryford.com/merf2020caserpt/1138/thumbnail.jp

Putting the shm key principles into practice: Direct objective clinical evaluation of new-hire hospitalists to improve physician communication and engagement while fulfilling fppe

Background: SHM Key Characteristic 9.1 on patient centered care encourages using guidelines/checklists to reinforce effective communication. Focused practice performance evaluations (FPPE) are a required regulatory hospital process for new medical staff members. In cognitive specialties, such as hospital medicine, completing an objective assessment of clinical skills can be difficult, with most initial evaluations based on more subjective performance assessments completed by peers or ancillary staff, which can be inconsistent across environments and personnel. Purpose: We sought to develop and implement an objective clinical assessment tool for initial FPPE of new hires in a multi-site hospital medicine group to reinforce clinical communication guidelines. Description: After developing divisional evidence based clinical communication guidelines for hospitalists in 2015, an assessment tool was designed based on the already validated SEGUE framework, a communication checklist commonly used in medical education, containing the domains of Set the stage, Elicit information, Give information, Understand the patient’s perspective, and End the encounter. The core SEGUE tool was selected for use in the inpatient environment along with a general comment area to evaluate other observed communication/safety behaviors as it aligned with the hospital medicine group’s clinical communication guidelines reinforcing AIDET (Acknowledge, Introduce, Duration, Explain, Thank You). Using an online survey service, the tool was available electronically, so that it could be used remotely by all authorized users on a variety of devices, including smartphones (Figure 1). After a 2 hour training session of observers, assessments were conducted at the bedside primarily in the direct care clinical environment. A majority of the observations were made on all new hires by the division head to create a level of inter-subject reliability for ratings, and so the division head could directly interact with all new staff. Additional observations were made by the section head at each specific clinical campus. A total of at least 5 observations were made for each subject. Formative feedback was given immediately to the subject hospitalist after each encounter and a summative feedback on the experience was provided to the new hire. The results were also reviewed in the new hire’s formal performance evaluation within approximately 6 months with the division head. Informal feedback from new hires on the observation process was positive, and it also helped to identify opportunities for workflow improvement as divisional leadership was able to more closely observe bedside activities. After successful completion of the first cohort in 2015, a second cohort is being evaluated during the latter half of 2016. To date, over 140 assessments have been performed on over 30 new hire hospitalists. Information from these assessments allowed our group to assess opportunities for continued training and improvement. We plan to correlate observation assessment results with patient experience scores, physician engagement, and staff retention.Conclusions: The use of a modified SEGUE framework adapted for the inpatient setting and operationalized on an online survey service, allowed for an objective evaluation of new hire hospitalists across multiple clinical settings, with completion of requirements for FPPE and generation of meaningful feedback to the hospitalists on their communication with patients