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Author Interview: Dr. Salisbury: Diagnostic Phlebotomy & Hospital Acquired Anemia during Acute MI
Author Interview: Dr. Adam Salisbury, MD
Division of Cardiovascular Diseases,
Saint Luke's Mid America Heart and Vascular Institute Kansas City Missouri
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Publication:
Author Interview: Dr. Adam Salisbury, MD
Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial Infarction
Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, Bach RG, Wang TY, Spertus JA, Kosiborod M.
Arch Intern Med. 2011 Aug 8.
Division of Cardiovascular Diseases, Saint Luke's Mid America Heart and Vascular Institute, Kansas City, Missouri (Drs Salisbury, Chan, Spertus, and Kosiborod and Ms Reid); University of Missouri-Kansas City School of Medicine, Kansas City (Drs Salisbury, Chan, Spertus, and Kosiborod); Department of Internal Medicine, Division of Cardiovascular Diseases, Duke Clinical Research Institute, Durham, North Carolina (Drs Alexander and Wang); Department of Internal Medicine, Division of Cardiovascular Diseases, University of Colorado-Denver, Aurora (Dr Masoudi); Department of Preventive Medicine, University of Kansas, Kansas City (Dr Lai); and Department of Internal Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine, St Louis, Missouri (Dr Bach).
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What are the main findings of the study?
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In earlier studies, we found that hospital-acquired anemia (HAA) commonly developed during hospitalization for acute myocardial infarction (AMI), affecting nearly 1 in 2 patients who were not anemic upon hospital arrival and were managed medically or with percutaneous coronary intervention (Circ Cardiovasc Qual Outcomes; 2010; 3(4): 337-346).
Interestingly, we found that HAA was common in the absence of bleeding, even among patients with more severe grades of anemia. Although bleeding is clearly a major risk factor for HAA, these findings prompted us to search for other potentially modifiable risk factors for HAA.
We studied 17,676 patients hospitalized with AMI from 57 hospitals using the Cerner electronic medical record that contributed data to the Health Facts database. This database included the date and time of every phlebotomy event and the laboratory tests obtained with each blood draw, which allowed us to calculate each patient’s cumulative blood loss from laboratory testing – diagnostic blood loss – during the course of their hospitalization.
We have previously shown that moderate-severe HAA (a hemoglobin decline from normal to ≤ 11 g/dl) is strongly associated with increased mortality. Accordingly, we defined moderate-severe HAA as the outcome of interest in the present study and aimed to understand whether diagnostic blood loss from phlebotomy was associated with development of moderate-severe HAA.
We found that 1 in 5 patients developed moderate-severe HAA. Among these patients, average diagnostic blood loss was substantial during the course of patients’ hospitalizations, and was considerably higher than among patients developed moderate-severe HAA than those who did not develop moderate-severe HAA (173.8±139.3 ml in those who had moderate-severe HAA vs. 83.5±52.0 ml in those who did not developed moderate-severe HAA, p<0.001). Adjusting for a broad array of potential confounders, diagnostic blood loss was a strong, independent predictor of moderate-severe HAA.
Each 50 ml of blood drawn for laboratory tests was associated with an adjusted 15% increase in the risk of moderate-severe HAA. We also found substantial variability in average diagnostic blood loss across hospitals participating in the Health Facts database, suggesting that variability in hospital-based processes of care may influence the amount of blood drawn from patients during hospitalization with AMI.
Finally, we conducted exploratory analyses assuming pediatric blood tubes were used for all blood draws in place of standard adult tubes. Under this assumption, we calculated a greater than 60% reduction in diagnostic blood loss over the course of patients’ hospitalizations.
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Were any of the findings unexpected?
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We were particularly surprised by several findings. First, the magnitude of the relationship between diagnostic blood loss and HAA was impressive. Although each tube of blood drawn may require only a few milliliters of blood, cumulative diagnostic blood loss can be substantial for individuals who have long lengths of stay and complicated hospitalizations. The robust relationship between diagnostic blood loss and HAA suggests research is needed to understand whether implementing programs to reduce diagnostic blood loss effectively limits phlebotomy volumes and improves outcomes.
It is likely that development of HAA is multifactorial, and successful programs to prevent it will include multiple interventions such as measures to prevent periprocedural bleeding, limit diagnostic blood loss and to detect and treat underlying risk factors for anemia.
Second, there was significant variability in patient’s average diagnostic blood loss across hospitals. This supports the hypothesis that variability in phlebotomy practices across institutions may influence how much blood is drawn from patients during AMI hospitalization.
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What should clinicians and patients take away from this study?
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This study is one of the first large-scale studies to suggest that phlebotomy is an important risk factor for HAA, which portends a poor short- and long-term prognosis.
Providers should be aware that phlebotomy should be used judiciously, particularly in patients at high risk for HAA, including those experiencing long hospitalizations and with risk factors for HAA such as older age, renal disease, heart failure and bleeding.
It is particularly important that awareness is raised about the potential impact of large diagnostic blood losses during AMI hospitalization since these data likely generalize to other groups of hospitalized patients.
Moreover, the importance of paying greater attention to phlebotomy is underscored by the fact that there are simple, common-sense measures to limit diagnostic blood loss, such as using pediatric tubes in place of standard adult tubes, more frequently using stored serum samples when additional laboratory tests are needed, and grouping appropriate lab draws for a single phlebotomy event rather than drawing blood repeatedly.
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What recommendations do you have for nephrology health care providers as a result of your study?
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Providers should be aware that diagnostic blood loss may be an important risk factor for HAA.
Although further studies are needed to determine whether limiting diagnostic blood loss is feasible in the process of routine care, and whether these efforts reduce diagnostic blood loss and improve patients’ outcomes, measures to limit phlebotomy could dramatically reduce blood loss from phlebotomy. Several common-sense interventions may be useful to limit phlebotomy.
First, pediatric tubes are often compatible with analytic equipment used to analyze samples from standard adult tubes. Using these smaller tubes may considerably reduce diagnostic blood loss when used consistently.
Second, programs could be initiated to use stored serum samples when additional laboratory tests are requested that can be appropriately obtained from a prior serum specimen.
Third, it may be possible to implement programs to routinely batch tests that are not required STAT or on a timed basis for a single blood draw.
Finally, clinicians can consider whether some blood tests can be avoided altogether. It is possible that many routine, daily blood tests provide little additional diagnostic information as patients stabilize later in the course of their hospitalizations and can be avoided.
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Abstract: |
Background: Hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) is associated with higher mortality and worse health status, and often develops in the absence of recognized bleeding. The extent to which diagnostic phlebotomy, a modifiable process of care, contributes to HAA is unknown.
Methods: We studied 17,676 AMI patients from 57 U.S. hospitals included in a contemporary AMI database between January 1, 2000 and December 31, 2008 who were not anemic at admission, but developed moderate-severe HAA (hemoglobin decline to < 11 g/dl), a degree of HAA which has been shown to be prognostically important. Patients’ total diagnostic blood loss was calculated by multiplying the number and types of blood tubes drawn by the standard volume for each tube type. Hierarchical modified Poisson regression was used to test the association between phlebotomy and moderate-severe HAA, after adjusting for site and potential confounders.
Results: Moderate-severe HAA developed in 3,551 patients (20%). Mean phlebotomy volume was higher in patients with (173.8±139.3 ml) vs. without HAA (83.5±52.0 ml, p<0.001). There was significant variation in the mean diagnostic blood loss across hospitals (moderate-severe HAA: range 119.1-246.0 ml; mild HAA or no HAA: 53.0-110.1 ml). For every 50 ml of blood drawn, the risk of moderate-severe HAA increased by 18% (RR 1.18 (1.13-1.22), which was only modestly attenuated after multivariable adjustment (RR=1.15, 95% CI 1.12-1.18).
Conclusions: Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.
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Recovery From Hospital-Acquired Anemia After Acute Myocardial Infarction and Effect on Outcomes.
Salisbury AC, Kosiborod M, Amin AP, Reid KJ, Alexander KP,
Spertus JA, Masoudi FA.
Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
Am J Cardiol. 2011 Jul 22 |
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Featured Angina| Acute Coronary Syndrome and Heart Disease Interviews
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Highlights of Article by Dr. Erik Hess et of Mayo Clinic ;CIRCOUTCOMES 2012
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Chest pain is the 2nd most common reason patients come to EDs across the United States
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Initial testing – including information obtained from the history, physical exam, electrocardiogram, and cardiac troponin – identifies > 98% of heart attacks
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To avoid missing a diagnosis of heart attack or pre-heart attack symptoms, emergency physicians often admit patients to observation units or to the hospital for extensive diagnostic testing, including stress testing
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This results in false positive test results, unnecessary exposure to radiation, and unnecessary downstream procedures such as stent placement in arteries of the heart
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Decision aids are evidence-based tools designed to educate and engage patients in decisions regarding their care
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We hypothesized that patients who were educated regarding their future risk for a heart attack and engaged in the decision of whether to be admitted to the observation unit for stress testing or to follow-up with a Mayo Clinic heart doctor in the next 72 hours would have greater knowledge about their short-term risk for heart attack, be more aware of the management options, and choose less intensive approaches to evaluation
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We randomly assigned 204 patients who came to the ED with chest pain and were being considered for observation unit admission to the decision aid or to usual care
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Decision aid patients:
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Had greater knowledge regarding their short-term risk for a heart attack
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Less frequently decided to be admitted to the observation unit for stress testing
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Had 4 times greater engagement in the decision making process
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Had no adverse events within 30 days of the ED visit
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Take home points
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Patients want to be educated and engaged in decisions regarding their care
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Once properly informed and engaged in treatment decisions, patients often choose less intensive treatment options
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Integrated health systems like the Mayo Clinic in which physicians collaboratively work together to provide ER patients ready access to outpatient follow-up have potential to improve the value of Emergency care
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Glucose, Insulin and Potassium (“GIK”) TO MINIMIZE IMPACT OF HEART ATTACKS BEFORE PATIENTS GET TO THE HOSPITAL
Study puts life-saving drugs in the hands of paramedics, decreasing rate of cardiac arrest and death from heart attacks
CHICAGO (March 27, 2012) — Paramedics can potentially reduce someone’s chances of having a cardiac arrest or dying by 50 percent by immediately administering a mixture of glucose, insulin and potassium (“GIK”) to people having a heart attack, according to research presented today at the American College of Cardiology’s 61st Annual Scientific Session. The Scientific Session, the premier cardiovascular medical meeting, brings cardiovascular professionals together to further advances in the field.
The study showed that patients who received GIK immediately after being diagnosed with acute coronary syndrome — which indicates a possible heart attack is either in progress or on the way — were 50 percent less likely to have cardiac arrest (a condition in which the heart suddenly stops beating) or die than those who received a placebo, although the treatment did not prevent the heart attack from occurring. The reduction in in-hospital cardiac arrest or death was a “secondary endpoint”, so statistically was not definitive, but was consistent with how GIK seems to work in experimental models of heart attack.
The effect was also present for patients with ST-elevation heart attacks, which require immediate treatment. For those patients, immediate GIK was associated with a 60 percent reduction in in-hospital cardiac arrest or death.
“When started immediately in the home or on the way to the hospital — even before the diagnosis is completely established — GIK appears not completely prevent any heart attack from occurring, but appeared in this trial to reduce the size of heart attacks and to reduce by half the risk of having a cardiac arrest or dying,” said Harry P. Selker, MD, MSPH, executive director of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, who led the study with Joni Beshansky, RN, MPH, co-principal investigator and project director. “Acute coronary syndromes represent the largest cause of death in this country. GIK is a very inexpensive treatment that appears to have promise in reducing those deaths and morbidity.”
The cost of the treatment is about $50.
“Because the trial is the first to show GIK could be effective when used by paramedics in real-world community settings, it could have important implications for the treatment of heart attacks,” Dr. Selker said. Previous clinical trials have shown no consistent effect, likely because the GIK was given too late to help. This study, the “IMMEDIATE Trial,” was the first to test the effectiveness of administering GIK at the very first signs of a threatening heart attack, in the community, rather than waiting hours until the diagnosis was well-established at a hospital, as done in previous clinical trials.
“We wanted to do something that is effective and can be used anywhere,” said Dr. Selker. “We’ve done a lot of studies of acute cardiac care in emergency departments and hospitals, but more people die of heart attacks outside the hospital than inside the hospital. Hundreds of thousands of people per year are dying out in the community; we wanted to direct our attention to those patients.”
The researchers trained paramedics in 36 Emergency Medical Services systems in 13 cities across the country to administer GIK after determining that a patient was likely having a threatened or already established heart attack using electrocardiograph-based ACI-TIPI (acute cardiac ischemia time-insensitive predictive instrument) and thrombolytic predictive instrument decision support that prints patient-specific predictions on the top of an electrocardiogram. The paramedics used these predictions to decide if a patient would likely benefit from treatment. There were 911 patients randomized to receive either the GIK treatment or a placebo.
Administering GIK immediately also reduced the severity of the damage to the heart tissue from the heart attack. On average, 2 percent of the heart tissue was destroyed by the heart attack in people receiving GIK, compared with 10 percent in those who received the placebo. Although a significant proportion of suspected heart attacks are later determined to be false alarms (23 percent in this study), administering GIK does not appear to cause any harmful effects in such patients.
The research team will follow up with study participants at six and 12 months to evaluate the longer-term benefit of the GIK treatment.
This study was funded by the NIH’s National Heart, Lung and Blood Institute.
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