708 - Reducing Red Blood Cell Transfusions (RBCTs) Following Pediatric Heart Catheterization.
Friday, April 28, 2023
5:15 PM – 7:15 PM ET
Poster Number: 708 Publication Number: 708.153
Connor Cook, American Family Children's Hospital, Madison, WI, United States; Michael Wilhelm, University of Wisconsin School of Medicine and Public Health, Middleton, WI, United States; Jenna N. Torgeson, University of Wisconsin School of Medicine and Public Health, Monona, WI, United States; Juan Boriosi, University of Wisconsin Madison, Madison, WI, United States; Luke Lamers, American Family Children's Hospital, Madison, WI, United States
Resident Physician American Family Children's Hospital Madison, Wisconsin, United States
Background: Cardiac catheterization (cath) is essential for managing congenital heart disease. Complications following cath, including the need for red blood cell transfusion (RBCT), are relatively common. The IMPACT Registry, a collaborative of > 120 cath programs, classifies RBCT within 72 hours of cath as a major adverse event. During the first three years participating, our complication rate exceeded the Registry mean, with RBCT being most common. Objective: We undertook a quality improvement project to reduce RBCT within 72 hours of cath. Design/Methods: We used an iterative improvement strategy based on the Model for Improvement, testing multiple interventions using PDSA methodology. Our Specific Aim was to reduce the incidence of RBCT to < 3% (IMPACT Registry mean) by 12/31/22. We created a local copy of all IMPACT data to allow real-time analysis using process control charts. We used a G-chart (rare event) of cases between transfusions (CBT) as our primary outcome. Initial interventions targeted reducing procedural hemodilution, blood loss, and excessive anticoagulation. We then amended our theory of improvement using additional Pareto analysis. Subsequent interventions standardized transfusion practices. We followed post-cath length of stay (LOS) using an I-chart as a countermeasure of avoiding RBCT. Results: Pareto analysis determined RBCT within 72 hours of catheterization as our most common major adverse event, averaging 6%. We created a local database and developed a G-chart of CBT. Pre-intervention CBT baseline was 11 cases with an upper control limit (UCL) of 64.7. Initial procedure related interventions did not increase the CBT. A second Pareto analysis revealed a majority of RBCTs were for cyanosis in single ventricle patients. Saturations were not different before and after transfusion, however. Additional PDSA cycles standardized RBCT practices and eliminated isolated cyanosis as an indication. By October 1, 2022, we exceeded the UCL of CBT, without increasing LOS; IMPACT data had not yet shown an improvement.
Conclusion(s): Comparative registry data can identify key improvement opportunities but has limited utility in active improvement efforts. Using an iterative improvement strategy, combined with real-time analysis of local data, we reduced RBCT following catheterization. We also hypothesize RBCT for isolated post-cath cyanosis might be safely avoided in many patients.
