established local working groups and hosted Alberta Improvement Way sessions at ... In April, we hosted a transfusion di
S P R I N G / S U M M E R
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GI BLEED
Reassessing the Clinical Management of Gastrointestinal (GI) Bleeds We have completed our second year of working to improve the management of upper GI bleeds and related patient outcomes in the emergency department. A great deal of activity is under way! Working with Quality and Healthcare Improvement we have developed an evidence-based clinical pathway for GI management and disposition, established local working groups and hosted Alberta Improvement Way sessions at the Chinook Regional, Royal Alexandra, and University of Alberta Hospitals. Dr. Shawn Dowling has joined our team and is leading the evaluation of GI bleed order set changes in the Calgary Zone. We have partnered with Mount Royal University Information Design and the Physician Learning Program in the development of patient and physician educational materials to support transfusion appropriateness. Our students continue to impress with their research, as Amanda Wang and Bradley Stebner shared their work at the U of C Emergency Research Day, and will soon be presenting at the Canadian Association of Emergency Physicians conference. In April, we hosted a transfusion dinner in the Calgary Zone with a broad range of stakeholders working to advance transfusion appropriateness. A major issue raised was limited access to outpatient IV iron for the treatment of iron deficiency anemia. Our team is currently investigating demand in the zone, and has begun planning to host an Iron Summit in the Fall with the agenda of developing a plan to increase access and streamline care. Finally, we have secured a one-year extension to our grant to continue our work until March 2019. This additional time will allow us to fully realize our ambitious agenda for both research and for clinical practice change. We have a lot of work ahead of us, but we have the diverse and talented team to make it happen. Dr. Eddy Lang Clinical and Academic Department Head, Emergency Medicine, Calgary Zone
Team Mission To improve the management of patients presenting to the emergency with upper GI bleeding, reduce patient exposure to unnecessary risks, and improve patient outcomes
Emergency Strategic Clinical Network (ESCN) The ESCN is a group of health care professionals and patient and family advisors working together across the province to improve emergency services in Alberta
GI BLEED
SPRING/SUMMER 2017
Choosing Wisely Choosing Wisely Canada (CWC) is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care. Unnecessary tests and treatments do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives and contributing to stress for patients. And of course unnecessary tests and treatments put increased strain on the resources of our health care system. Canadian national specialty societies participating in the campaign, representing a broad spectrum of clinicians, have been asked to develop lists of “Five Things Clinicians and Patients Should Question.” These lists identify tests and treatments commonly used in each specialty, but are not supported by evidence, and/or could expose patients to unnecessary harm. Appropriate use of hemoglobin transfusions has been identified by multiple specialty societies as an area of improvement, including Hematology, Critical Care, and the Canadian Society for Transfusion Medicine. The recommendations include: •
Don’t transfuse if other non-transfusion therapies or observation would be just as effective.
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Don’t transfuse in hemodynamically stable patients with a hemoglobin greater than 70 g/L.
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Don’t transfuse more than one unit at a time in stable, non-bleeding patients.
Risks of red blood cell transfusions include allergy, fever, infections, volume overload and hemolysis. Studies show that a restrictive transfusion strategy results in similar or lower mortality compared with higher thresholds, and other complications, including stroke and infections, may also be reduced.
Researcher Profile The PRIHS GI Bleed group is happy to announce the addition of Dr. Shawn Dowling to our team. Dr. Dowling is an Emergency Medicine Physician, the Clinical Content Lead for the Calgary Zone Emergency Department and the Medical Director of the Physician Learning Program. Shawn earned his MD and a research fellowship at the University of Ottawa, and completed a Royal College Emergency Medicine residency at the University of Calgary. His expertise is in knowledge translation and, in particular, identifying gaps in care, appropriate resource usage and incorporating clinical decision support at the point of care.
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GI BLEED
SPRING/SUMMER 2017
Improving the Management of UGIB Patients in EDs across Alberta The ESCN has identified the opportunity to roll out clinical pathways for transfusion and upper GI bleed treatment, which could improve both outcomes and save money/resources. In September 2016, a cross functional team of ED and GI staff and physicians based at RAH came together for a four hour learning session to develop site specific pathways for using the GBS and transfusion protocols. This session was supported by the ESCN and Process Improvement. The AIW Collaboration Model was used for this process.
The goal of the collaborative is to develop and implement a clinical pathway for the risk stratification, disposition and management of Upper GI Bleed patients presenting to emergency with goal to reduce unnecessary hospital admissions and transfusions by 50% within one year. Once the clinical pathways were drafted, the site developed an urgent outpatient endoscopy workflow and referral process that would allow for patients who qualify to be discharged home from the ED to return within 48 hours for endoscopy. A second work session with an expanded team to include Transfusion Medicine and the IV clinic was held in December 2016 to finalize the transfusion protocol. The transfusion and GBS protocol has now been in pilot phase since March 2017 and is expected to run through August. Shannon O’Blenes Senior Process Improvement Consultant, Alberta Health Services
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GI BLEED
SPRING/SUMMER 2017
Understanding Practice Variation of Red Blood Cell Transfusion in Patients with Non-Variceal Upper GI Bleeding The study, started by Dr. Colins Vasquez and, subsequently, joined by Brad Stebner, was recently accepted as a poster presentation for EM Research Day at the University of Calgary and the 2017 CAEP conference in Whistler. The retrospective chart review aims to determine the proportion of patients presenting with nonvariceal upper GI bleed and hemoglobin levels greater than 70 g/L that are still appropriately transfused based on clinical status. To date 48 charts have been pulled from FMC and PLC sites and adjudicated by two members of the PRIHS team. Adjudicators were given a summary sheet that included triage note, past medical history, presenting clinical features, vitals, treatments given, and a calculated GBS score. Agreement was met on 45/48 charts on initial read-through and after deliberation 100% consensus was achieved in categorizing the patients and their management. This preliminary evaluation of the available data showed that in most instances, emergency physicians are effectively integrating hemoglobin thresholds and clinical status to determine if patients with a NVUGIB and Hgb > 70 g/L require blood products. Only in 22.9% (11/48) of the cases was transfusion deemed to be clearly avoidable while emergency physicians appropriately transfused 45.8% (22/48) of patients based on clinical status and other factors. In 31.3% (15/48) of the cases, transfusion was potentially avoidable in favour of other management options. We calculated the mean GBS for the appropriate, potentially avoidable, and clearly avoidable categories yielding 12.8, 12.7, and 10.2 respectively. Mortality occurred in 2 of the 48 cases (4%). Moving forward an additional 50 charts will be reviewed to get an adequate sample size and be able to compare the 2 sites. A final adjudication panel will be created that consists of three physicians: one hospitalist, one gastroenterologist, and one emergency physician. These physicians will not be members of the PRIHS and will be blinded to the study and previous results. Additional outcomes will also look at the average number of units of blood given, GBS scores in each category, and site-to-site practice variation. We expect this initiative will help develop practice guidelines in the ED setting, thereby leading to improved patient outcome, improved compliance with evidence-based transfusion guidelines, and reduced economic burden on the health care system. Bradley Stebner MD Candidate (2018), Cumming School of Medicine
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SPRING/SUMMER 2017
Are we transfusing wisely? An analysis of transfusion practices among stable patients Packed red blood cell (pRBC) transfusions are a mainstay in modern medicine; over 85 million units are transfused annually worldwide. Choosing Wisely Canada now recommends a restrictive red blood cell transfusion strategy to address the risks of over-transfusion. In addition, it has been recognized that iron therapy can often be used as an alternative treatment for certain patients, and has been shown to have just as good and in some cases better results. Transfusion Medicine recommends using a Hgb threshold of 70 g/L, and ordering a single unit at a time. The purpose of our study was to investigate Emergency Department (ED) transfusion practices with respect to CWC guidance for hemodynamically stable patients with iron deficiency anemia. A retrospective analysis was performed on all emergency visits to 4 adult urban ED sites from July 1 2014 to July 1 2016. We excluded unstable patients (CTAS1, temperature >38°C, HR >100 bpm, RR >20 rpm, systolic BP
