Transfusion thresholds, bedside rounding

Summaries from ACP Hospitalist Weekly.

Mortality of patients with cancer and septic shock slightly lower with liberal transfusions

A restrictive transfusion strategy did not reduce mortality among ICU patients with septic shock and cancer, a recent trial found.

The single-center trial randomized adult cancer patients with septic shock to either a liberal red blood cell transfusion strategy (hemoglobin threshold of <9 g/dL) or a restrictive strategy (hemoglobin threshold of <7 g/dL) during their ICU stays. The primary outcome was 28-day mortality. Results were published by Critical Care Medicine on Feb. 24 and appear in the May issue.

Photo by Thinkstock
Photo by Thinkstock.

There were 149 patients in the liberal group, and they received an average of one unit of blood (range, 0 to 3 units), while the 151 patients in the restrictive group received an average of zero units (range, 0 to 2 units) (P<0.001). After 28 days, there was a trend toward lower mortality in the liberal group compared to the restrictive group (45% vs. 56%; hazard ratio, 0.74; 95% CI, 0.53 to 1.04; P=0.08). At 90 days, the mortality difference was even greater (59% vs. 70%; hazard ratio, 0.72; 95% CI, 0.53 to 0.97; P=0.03). The groups had similar lengths of stay in the hospital and the ICU.

The study authors concluded that the survival trend favored the liberal transfusion strategy. “These results went in the opposite direction of our a priori hypothesis, of existing guidelines and of other trials in the field and should be considered of limited external generalizability and only hypothesis generating,” they wrote. The study focused on cancer patients because they make up 15% of ICU admissions due to septic shock, they are at high risk of anemia, and they have not been well represented in previous randomized trials on this question. The researchers had hypothesized that lowering the risk of transfusion-related complications would result in lower mortality.

Although the results should be interpreted with caution, they do “create concern regarding the safety of a restrictive strategy of [red blood cell] transfusion in cancer patients with septic shock,” the authors said. They noted that while current guidelines support restrictive strategies generally, liberal strategies might be found to provide better outcomes for certain subsets of patients, such as oncology and perioperative patients.

Bedside interdisciplinary rounding may not affect clinical outcomes

Bedside interdisciplinary rounds may not be associated with improved clinical outcomes but may affect clinicians' perception of patient safety, and regionalization of care teams may decrease total rounding time, according to two recent studies.

The first study was a controlled trial that examined whether adoption of a bedside system for interdisciplinary rounds improved length of stay and patient outcomes. Researchers developed a bedside model for mobile interdisciplinary care rounds (MICRO) that involved a defined structure, scripting, patient engagement, and a patient safety checklist. A total of 2005 hospitalizations over a 12-month period were included, with primary outcomes of clinical deterioration (a composite of death, transfer to a higher level of care, or occurrence of a hospital-acquired infection) and length of stay. Clinicians' perceptions of the hospital's patient safety culture and the MICRO model were assessed before and after implementation.

Photo by Thinkstock
Photo by Thinkstock.

The model was not associated with a difference in length of stay (6.6 vs. 7.0 days; P=0.17) or clinical deterioration (7.7% vs. 9.3%; P=0.46) between the MICRO group and the control group, respectively. However, patients who transferred to the unit where the study was performed did see a difference in length of stay (10.4 vs. 14.0 days; P=0.02). Both nurses and hospitalists felt that the patient safety climate and the efficiency of rounds improved with the MICRO model.

The authors noted that their trial involved only a single hospital. However, they concluded that the MICRO model used in their study for interdisciplinary bedside rounds did not affect overall length of stay or patients' clinical deterioration. “Future studies should examine whether comprehensive transformation of medical units, including co-leadership, geographic cohorting of teams, and bedside interdisciplinary rounding, improves clinical outcomes compared to units without these features,” the authors wrote.

The second study used time-motion analysis to examine whether regionalization of care teams and encouragement of bedside rounds had an effect on rounding participants and rounding time. Four general medical teams at an academic medical center were studied before the intervention, and five teams were studied afterward in a pre-post analysis. In the intervention, general medical teams were assigned to specific units, the admitting structure was adjusted to accommodate regionalization, and teams were encouraged to round at patients' bedsides. The study's primary outcomes were proportion of rounding time at the bedside and the proportion of time each team member was present on rounds, while secondary outcomes included duration of rounds and nonpatient time spent on rounds.

After the intervention, statistically significant increases were seen in the time that a nurse was present on rounds (24.1% to 67.8%; P<0.001) and in the proportion of total bedside rounding time (39.9% to 55.8%; P<0.001). Although the patient census was higher after the intervention, a decrease was seen in total rounding time from 3.0 hours to 2.4 hours (P=0.01). The authors concluded that these changes were due to the creation of regionalized care teams and encouragement of interdisciplinary bedside rounds.

Both articles were published in the March Journal of Hospital Medicine.