Pediatric critical care transfusion and anemia expertise initiative

Pediatric Critical Care
Transfusion and Anemia eXpertise Initiative
(TAXI)
Stacey Valentine, MD MPH
2018 AABB Meeting
Boston, MA

Funding
 NICHD and NHLBI R13
 Washington University of Children’s
Discovery Grant
 Canadian Institutes of Health Research
 Society for the Advancement of Blood
Management (SABM)-Haemonetics
Research Starter Grant

Support
• Pediatric Acute Lung Injury and Sepsis
Investigators (PALISI) Network
• BloodNet
• Society of Critical Care Medicine (SCCM)
• AABB
• Centre de Recherche, Hema-Quebec and
Univeriste de Montreal
• Our TAXI Experts

5 Pediatric Critical Care Pediatric Hematology/Oncology
Andrew Argent University of Cape Town Leslie Lehmann Harvard University
Scot Bateman University of Massachusetts Robert Parker Stony Brook University
Melania Bembea Johns Hopkins University Marie Steiner University of Minnesota
Ira Cheifetz Duke University Pediatric Anesthesia
Pierre Demaret Clinique de L’Esperance Nina Guzetta Emory University
Allan Doctor Washington University, St. Louis Paul Stricker University of Pennsylvania
Guillaume
Emeriaud
University of Montreal Pediatric Surgery
James Fortenberry James Fortenberry Robert Russell University of Alabama
Mark Hall Nationwide Children’s Adam Vogel Washington University, St. Louis
Nabil Hassan Helen DeVos Children’s Transfusion Medicine
Oliver Karam Geneva University Hospital Meghan Delaney University of Washington
Martin Kneyber University Medical Center Groningen Cassandra Josephson Emory University
Jacques Lacroix University of Montreal Naomi Luban George Washington University
Duncan Macrae Royal Brompton Hospital Simon Stanworth John Radcliffe Hospital, UK
Jennifer Muszynski Nationwide Children’s Leo van de Watering Sanquin Center for Transfusion
Kenneth Remy Washington University, St. Louis Internal Medicine
Phillip Spinella Washington University, St. Louis Jeffrey Carson State University of New Jersey
Robert Tasker Harvard University Alexis Turgeon Hopital de l’Enfant-Jesus
Marisa Tucci University of Montreal Evidenced-Based Medicine
Stacey Valentine University of Massachusetts Nicole Zantek University of Minnesota
Ariane Willems University of Brussels Karen Robinson Johns Hopkins University
Pediatric Cardiology Implementation Science
Jill Cholette University of Rochester Enola Proctor Washington University, St. Louis
Joshua Salvin Harvard University Sara Small Washington University, St. Louis
Steven Schwartz University of Toronto Kate Steffen Washington University, St. Louis

6
Pediatric Critical Care Pediatric Hematology/Oncology
Guillaume
Emeriaud

TAXI Executive Committee
Jacques Lacroix
Melania Bembea
Allan Doctor
Robert Parker
Phillip Spinella
Marie Steiner
Marisa Tucci

Objectives
• Provide a background of red blood cell (RBC) transfusion
practices in critically ill children
• Outline an approach of creating consensus recommendations
for clinical RBC transfusion practice in critically ill children
• Describe the Transfusion and Anemia eXpertise Initiative
(TAXI)

Hebert et al. NEJM. 1999; 340:409-417

• 838 critically ill adults
• Restrictive strategy vs. Liberal strategy
• Restrictive strategy not inferior to the liberal strategy
• Significant reduction in transfusions in the restrictive arm
Hebert et al. NEJM. 1999; 340:409-417

• Prospective observational multicenter study
• 977 critically ill children
• 33% anemic on PICU admission, 41% developed anemia in the PICU
• 49% received a blood transfusion
• Mean pre-transfusion hemoglobin 9.7 g/dl (SD 2.7)
Bateman S, et al. Am J Respir Crit Care Med 2008; 178:26–33

Bateman S, et al. Am J Respir Crit Care Med 2008; 178:26–33

Lacroix J, N Engl J Med. 2007;356:1609-19

TRIPICU Study Design
Eligible: Hb ≤ 9.5 g/dL (95 g/L)
within 7 days post entry into
PICU
Targeted Hb post-
transfusion: 11.0-12.0 g/dL
Targeted Hb post-
transfusion: 8.5-9.5
g/dL
Liberal group:
transfusion if Hb
≤ 9.5 g/dL
Restrictive group:
transfusion if Hb ≤ 7.0
g/dL
Only pre-storage leukocyte-
reduced packed RBC units were
used

Stable/Stabilized patients
• Mean Arterial Pressure Not < 2 SD below normal
mean for age AND
• Cardiovascular (pressors/inotropes and fluids)
support not increased for at least 2 hours

• Restrictive Transfusion Strategy
• Not inferior to a liberal transfusion strategy
• No new or progressive multiple-organ dysfunction syndrome (MODS)
• No increased risk of MODS with illness severity
• 44% fewer transfusions

Transfusion thresholds
decrease over time
– 2006: Hb 8.0 g/dL
– 2009: Hb 7.8 g/dL
– 2010: Hb 7.5 g/dL
Valentine SL, et al. Pediatr Crit Care Med 2014;15:e89–e94

Where do we go from here?
• Emerging literature in pediatric critical care
• Variation in uptake of existing literature
• Knowledge gaps remain
• Adult guidelines for transfusion practice

• Expert consensus a successful means of providing
guidance

• Expert consensus a successful means of providing
guidance
Pediatr Crit Care Med. 2015;16(5):428-39

The Pediatric Critical Care Transfusion
and Anemia eXpertise Initiative (TAXI)
Aims:
To create evidence-based, and when evidence is lacking, expert-
based consensus on blood management strategies for clinicians
caring for critically ill children aimed to maintain a physiologically
relevant hemoglobin concentration, optimize hemostasis and minimize
blood loss.
Valentine S, et al. Pediatr Crit Care Med. 2018;19:884-898

• Staged approach:
• 1st series focused on red blood cell transfusion
– Three part conference series
– International multidisciplinary experts on RBC transfusion
» Pediatric: critical care, cardiology, transfusion medicine,
hematology/oncology, surgery and anesthesia
– Engage experts on guideline development and implementation
science
– Modeled after Pediatric Acute Lung Injury Consensus Conference
(PALICC) Methodology

October 2014
Montreal, Canada
PEDIATRIC CRITICAL CARE
TRANSFUSION and ANEMIA eXPERTISE INITIATIVE (TAXI)
Preparation
1. Create organizing
committee
2. Define Methodology
3. Select Topics
4. Select Experts
Time
First Expert Meeting
Discuss and Finalize:
1. Methodology
2. Specific Subtopics
Second Expert Meeting
Discuss:
1. Short text recommendations
2. Determine agreement
(Delphi method)
Third Expert Meeting
Present
2. Discuss disagreements
3. Finalize recommendations
October 2015
Austin, Texas
June 2016
Toronto, Canada
Spring 2017
Montreal, Canada
Between Meetings
1. Analyze literature
2. Create recommendations
Between Meetings
1. Score recommendations
(RAND UCLA)
2. Reword if necessary
3. Finalize long text
2018
Publication and Dissemination

TAXI Organization
Organizing Committee:
Stacey Valentine
Scot Bateman
Executive Committee:
Jacques Lacroix
Melania Bembea
Allan Doctor
Nabil Hassan
Robert Parker
Phillip Spinella
Marie Steiner
Marisa Tucci

Our Experts
49 experts from 8 countries

Guillaume
Emeriaud

October 2014
Montreal, Canada
PEDIATRIC CRITICAL CARE
TRANSFUSION and ANEMIA eXPERTISE INITIATIVE (TAXI)
Preparation
1. Create organizing
committee
2. Define Methodology
3. Select Topics
4. Select Experts
Time
First Expert Meeting
Discuss and Finalize:
1. Methodology
2. Specific Subtopics
Second Expert Meeting
Discuss:
2. Determine agreement
(Delphi method)
Present
2. Discuss disagreements
3. Finalize recommendations
October 2015
Austin, Texas
June 2016
Toronto, Canada
Spring 2017
Montreal, Canada
Between Meetings
1. Analyze literature
2. Create recommendations
Between Meetings
1. Score recommendations
(RAND UCLA)
2. Reword if necessary
3. Finalize long text
2018
Publication and Dissemination
Valentine S et al, Pediatr Crit Care Med. 2018;19:884-898

“Clinical practice guidelines are
statements that include
recommendations intended to
optimize patient care that are
informed by a systematic review of
the evidence and an assessment of
the benefits and harms of
alternative care options.”
IOM (Institute of Medicine). 2011. Clinical Practice
Guidelines We Can Trust. Washington, DC: The National
Academies Press
Methodology Finalized
Bembea M, et al. Pediatr Crit Care Med. 2018;19:S93-97

Guideline Implementability
Appraisal
• Global
• Executability
• Decidability
• Validity
• Flexibility
• Effect on process
of care
• Measurability
• Novelty/innovation
• Computability
• Presentation
Shiffman 2005

TAXI Subtopics
A. Indications for Red Blood Cell Transfusion
1. Hemoglobin and Physiologic thresholds
B. Population-based Indications for Red Blood Cell Transfusion
1. Acute Brain Injury
2. Congenital cardiac disease
3. Sickle cell/Oncologic disease
4. Respiratory Failure
5. Shock
6. Life threatening and non life threatening bleeding
7. Extracorporeal support, dialysis and ventricular assist devices
8. Alternative Processing of Blood Products

Between 1st and 2nd meetings
• Systematic Review
– PICOS questions used for comprehensive literature
searches
– Abstracts and included manuscripts reviewed by two
experts
• Conflict resolution by 3rd expert reviewer

Between 1st and 2nd meetings
• Evidence Evaluated
– Using GRADE Methodology
• Short text recommendations created
– With guidance from evidence-based medicine
and implementation science experts

2nd Expert Meeting
• Discussed and reviewed short text
recommendations (Delphi)
– Ensured draft recommendations are clearly worded,
unambiguous and easily understood by the experts
– Implementation principles ensured (GLIA)
– Recommendations revised until agreement achieved

Determining Consensus
• Three rounds of on-line scoring by
experts
• All experts encouraged to vote
• Reasons for disagreement sent back to groups to enable
revisions
• A priori agreement 80%
1 2 3 4 5 6 7 8 9
Disagreement Equivocal Agreement

• Short text recommendations discussed and refined if
necessary
– Any changes in recommendations sent for third round of
voting
• Implementation strategies discussed
• Transfusion decision tree proposed
• Knowledge gaps highlighted
• Research priorities discussed

www.aabb.org Pediatr Crit Care Med. 2018;19:884-898 Pediatr Crit Care Med. 2018;19:S93-S176

Pediatric Critical Care
(TAXI)
Scot Bateman, MD
2018 AABB Meeting
Boston, MA

Results
• Recommendations:
• Clinical Recommendations: 56
• Research Recommendations: 45

Recommendation Strength
• Clinical Recommendations
• 7% (4) Strong recommendation, Moderate quality pediatric evidence (1B)
• 9% (5) Strong recommendation, Weak quality pediatric evidence
• 20% (11) Weak Recommendation, Low quality pediatric evidence
• 64% (36) Consensus Panel Expertise
• Research Recommendations
• 100% (45) Consensus Panel Expertise

50

Good Practice Statement
• When deciding to transfuse an individual
critically ill child, it is good practice to consider
not only the hemoglobin concentration, but the
overall clinical context (for example, symptoms,
signs, physiological markers, etc.) and the
risks, benefits and alternatives to transfusion.
Doctor A, et al. Pediatr Crit Care Med. 2018;19:S98-S113

Good Practice Statements
• Causes of anemia should be appropriately
considered, investigated and managed.
• Adoption of patient blood management
principles should be implemented.

Critically Ill Children with
Life-Threatening Bleeding
1Severe bleeding in patients at risk of exsanguination
Karam O, et al. Pediatr Crit Care Med. 2018;19:S127-S132

Critically Ill Children with Life-Threatening
Bleeding
• In critically ill children with life-threatening bleeding,
we suggest that RBCs, plasma and platelets be
transfused empirically in ratios between 2:1:1 to
1:1:1 for RBCs:plasma:platelets until the bleeding is
no longer life-threatening.
– Consensus panel expertise
Karam O, et al. Pediatr Crit Care Med. 2018;19:S127-S132

Critically Ill Child with
Hemoglobin <5 g/dL or 5-7 g/dL

Hemoglobin <5 g/dL
• In critically Ill children or those at risk for critical
illness we recommend a RBC transfusion if the
Hb concentration is <5 g/dL.
– Strong recommendation, Low quality pediatric evidence
(1C)

• There is insufficient evidence to make a
recommendation regarding transfusion thresholds
for critically ill children who have an Hb
concentration between 5 and 7 g/dL.
– However, it is reasonable to consider transfusion based
on clinical judgment in these children.
• Consensus panel expertise
Hemoglobin 5-7 g/dL

Hemodynamic Instability and Hb >7 g/dL

Critically Ill Children with Hemodynamic
Instability
• In critically ill children with hemodynamic
instability, we cannot make a recommendation
regarding optimal RBC transfusion strategy.

Critically Ill Child with Hemodynamic
Stability and Hb ≥7 g/dL

TRIPICU Definition used for TAXI
• Hemodynamic stability=Mean Arterial Pressure not
<2 standard deviations below normal mean for age
AND cardiovascular support (pressors/inotropes and
fluids)not increased for at least 2 hours
61

Hemoglobin ≥7 g/dL
• In critically ill children or those at risk for
critical illness, who are hemodynamically
stable and who have an Hb concentration
≥7 g/dL, we recommend not administering
a RBC transfusion.
– Strong recommendation, Moderate quality
pediatric evidence (1B)

Respiratory Failure
• In critically ill children with respiratory failure
who do not have severe acute hypoxemia, a
chronic cyanotic condition or hemolytic anemia,
and whose hemodynamic status is stable we
recommend not administering a RBC
transfusion if the Hb concentration is ≥7 g/dL.
– Strong recommendation, Moderate quality pediatric
evidence (1B)
Demaret P, et al. Pediatr Crit Care Med. 2018;19:S114-S120

Critically Ill Children with Shock
• In hemodynamically stable critically ill
children with a diagnosis of severe sepsis
or septic shock, we recommend not
administering a RBC transfusion if the Hb
concentration is > 7 g/dL.
– Weak recommendation, Low quality pediatric
evidence (2C)
Musynski JA, et al. Pediatr Crit Care Med. 2018;19:S121-S126

Acute Brain Injury
• In critically ill children with acute brain injury (e.g.,
trauma, stroke) a RBC transfusion could be
considered if the Hb concentration falls between 7 –
10 g/dL.
Tasker RC, et al. Pediatr Crit Care Med. 2018;19:S133-S136

Oncologic Disease
• In children with oncologic diagnoses or undergoing
hematopoietic stem cell transplant are critically ill or
at risk for critical illness, and hemodynamically
stable:
– We suggest an Hb concentration of 7- 8 g/dL be
considered a threshold for RBC transfusion.
• Weak recommendation, Low quality pediatric evidence (2C)
Steiner ME, et al. Pediatr Crit Care Med. 2018;19:S149-S156

Acquired and Congenital Heart Disease
Cholette JM, et al. Pediatr Crit Care Med. 2018;19:S137-S148

Critically Ill Children with Acquired and
Congenital Heart Disease
• In hemodynamically stable critically ill infants
and children with uncorrected CHD, we
recommend RBC transfusion to maintain an
Hb concentration of at least 7.0- 9.0 g/dL
depending on the degree of cardiopulmonary
reserve.
– Weak recommendation, Low quality pediatric
evidence (2C)

• In infants undergoing stage 1 palliation procedures
(Norwood, Damus-Kaye-Stansel, Blalock-Taussig or
central shunt, or pulmonary artery band) for single
ventricle physiology who have stable hemodynamics,
adequate oxygenation and normal end organ function:
– We recommend avoiding reflexive ("solely Hb-based")
RBC transfusions if the Hb concentration is >9.0 g/dL.

• In hemodynamically stable infants and
children with single ventricle physiology
undergoing stage 2 and 3 procedures with
adequate oxygen delivery:
– We recommend not administering a RBC
transfusion if the Hb concentration is >9 g/dL.
• Weak recommendation, Low quality pediatric evidence
(2C)

• In infants and children with CHD undergoing
biventricular repair who are hemodynamically stable
and have adequate oxygenation and normal end
organ function:
– We recommend not administering a RBC transfusion if the
Hb concentration is >7.0 g/dL.
• Strong recommendation, Moderate quality pediatric evidence (1B)

Critically Ill Children on ECMO
In critically ill children on ECMO, we recommend
using physiologic metrics and biomarkers of oxygen
delivery in addition to Hb concentration to guide
RBC transfusion.
– Administration of a RBC transfusion should be based on
evidence of inadequate cardiorespiratory support or
decreased systemic and/or regional oxygen delivery.
Bembea MM, et al. Pediatr Crit Care Med. 2018;19:S157-S162

Critically Ill Children with Sickle Cell
In children with sickle cell disease who are critically
ill or those at risk of critical illness, we recommend
RBC transfusion to achieve a target Hb
concentration of 10 g/dL (rather than a hemoglobin
S (HbS) of <30%) prior to a surgical procedure
requiring general anesthesia.
– Strong recommendation, Moderate quality pediatric
evidence (1B )

In children with sickle cell disease and acute chest
syndrome (ACS) who are critically ill, we
recommend an exchange transfusion over a simple
(non-exchange) transfusion if the child’s condition is
deteriorating (based on clinical judgment); otherwise
a simple (non-exchange) RBC transfusion is recommended.
– Strong recommendation, Low quality pediatric
evidence (1C )
Critically Ill Children with Sickle Cell Disease
with Acute Chest Syndrome

Alternative Processing of Blood Products
We recommend the use of irradiated cellular
blood components for all critically ill children at
risk for transfusion-associated graft versus host
disease (ta-GVHD) due to severe congenital or
acquired causes of immune deficiency.
Zantek ND, et al. Pediatr Crit Care Med. 2018;19:S163-S169

Alternative Processing of Blood Products
We recommend the use of the washed cellular blood
components and avoidance of other plasma
containing products (e.g. plasma, cryoprecipitate,
etc) for critically ill children with history of severe
allergic reactions or anaphylaxis to blood
transfusions, although patient factors appear to be
critically important in the pathogenesis.
Zantek ND, et al. Pediatr Crit Care Med. 2018;19:S163-S169

–Anemia Tolerance
–Risk/benefit ratio of anemia tolerance vs.
risk/benefit ratio of giving a RBC
transfusion in critically ill children
Knowledge Gaps

– Physiologic metrics/biomarkers
• In critically ill children or those at risk for critical
illness, we recommend creating clinical
research programs specifically designed to
determine the efficacy and safety of
transfusion decision-making based upon
physiologic metrics and biomarkers.
Knowledge Gaps

–Hemoglobin threshold
• What is the appropriate Hb concentration to
guide administration of a RBC transfusion
in subpopulations of hemodynamically
stable and unstable critically ill children?
Knowledge Gaps

–Hemoglobin threshold
• What is the appropriate Hb concentration to
guide administration of a RBC transfusion
in critically ill children on ECMO support?
Knowledge Gaps
Bembea MM, et al. Pediatr Crit Care Med. 2018;19:S157-S162

• Proposed studies
– Large pragmatic trial to evaluate lower
thresholds in critically ill children
– Appropriate transfusion thresholds for ECMO
Future Research

Next Steps
• Dissemination and education
• Development of Implementation Tools
– TAXI Decision Tree
– CPOE Clinical Decision Support Tool
• Evaluation of efficacy of guidelines and decision
support tools

Next Steps
• Address knowledge gaps
• Update guidelines periodically
• Initiate next phases of TAXI

Summary
• Evidence based and expert consensus recommendations
– Guidance for transfusion practices in critically ill children
– Defines areas for future research
• Improving transfusion practices in critically ill children
– Goal to reduce unnecessary transfusions and associated
transfusion related complications

Implementation of the TAXI
Recommendations
Kate Steffen, MD, MHS
October 16th, 2018

Balas & Boren, 2000
Publication
Bibliographic databases
Submission
Reviews, guidelines, textbook
Negative
results
variable
0.3 year
6. 0 - 13.0 years
50%
46%
18%
35%
0.6 year
0.5 year
9.3 years
Dickersin, 1987
Koren, 1989
Balas, 1995
Poynard, 1985
Kumar, 1992
Kumar, 1992
Poyer, 1982
Antman, 1992
Negative
results
Lack of
numbers
Expert
opinion
Original research
Acceptance
Inconsistent
indexing Implementation
• Failure to translate:
-30-40% do not get effective treatments
-20-25% get care that is not needed or
potentially harmful
• Implementation: fundamental challenge to
optimize care

TAXI Aims:
1. Ensure dissemination
2. Facilitate implementation
www.aabb.org

www.aabb.org
Implementation Science
The scientific study of methods to promote the systematic
uptake of research findings and other evidence based
practices into routine practice to improve the quality and
effectiveness of health services and care.
Eccles & Mittman, Implement Sci, 2006

www.aabb.org
Integration into each phase
• Implementation advisors: TAXI members
– Advice: recommendation development
– Feedback to workgroups: Guideline modification
• Guideline Implementability Appraisal (GLIA) - identified
barriers
www.aabb.org Shiffman et al, BMC Med Inform Decis Mak, 2005

TAXI Dissemination
• World Federation of Pediatric Intensive and Critical Care
Societies (WFPICCS)
• Society for the Advancement of Blood Management (SABM)
• Pediatric Academic Society (PAS)
• Open Pediatrics World Shared Practice Forum – webcast
• North East Pediatric Intensive Care Collaborative (NEPICC)
www.aabb.org

Publication alone unlikely to ensure adoption
• TAXI recommendations - initial step
• Next: integrate recommendations into practice
• Methods:
– Improve knowledge
– Modify care processes
www.aabb.org Gross et al., Med Care, 2001
Mickan, Burls & Glasziou, Postgrad Med J, 2011

Transfusion Guideline Implementation
• Adult Studies
• Insight into application in Pediatric ICU
• Approaches:
– Adaptation/Adoption
– Education
– Audit and Feedback (prospective/retrospective)
– Clinical Decision Support
www.aabb.org

Adaptation/Adoption: guided by local practice
• Institution specific  guided by evidence
• Peri-operative Transfusion
– Joint replacement – transfusion in 35%  19.8%
– Pediatric cardiac surgery – 0.41 0.14 units/case (66%)
www.aabb.org Muller et al, BMJ (Clinical Research Ed), 2004
Whitney et al, Pediatric Anesthesia, 2013
Key: workflow integration
- Decision flowcharts
- Clinician education, widespread
distribution, ease of use, leader
endorsement, sense of ownership

Education: often used, rarely used alone
• 44-47% of studies
• Types:
– One-on-one, group, workshops
– Single or multi-specialty
– Evidence only, systems-based intervention
www.aabb.org Wilson et al, Transfusion, 2002
Tinmouth et al, Arch Int Med, 2005
Variable impact
Lecture + 1:1:
- surgical services improved
- medical services no change
Training workshops:
- pediatrics improved
- adult medicine worsened
- Sustained improvement:
regular meetings & supervision
Vos et al, AIDS, 1994
Soumeri et al, JAMA, 1993

Audit and Feedback - Retrospective
• Summarize clinical performance
– group or individual
• Use of data to influence provider practice
• Overall: variable impact on RBC utilization
www.aabb.org Gutsche et al, J Cardiothorac Vasc Anesth, 2013
Individual feedback:
- 60% fewer patients transfused
- 75% decrease RBC units transfused
Individual and Group:
- “unnecessary” transfusions: 14.7% 
8.1%
Criticisms: collective feedback ineffective,
not timely
Morrison et al, Am J Gynecol, 1993
Borgert et al, Int J for Qual in Health Care, 2016

Audit and Feedback: Prospective
• Evaluate at time of RBC request
– Ordering provider submits information re: indications for
RBC
• “Gatekeepers” review requests  approval
www.aabb.org Van Gammeren, Haneveer, & Slappendel, Transfus Med, 2016
Rosen, Bates & Herod, Transfusion, 1993
Tuckfield et al, Med J Aust, 1997
Rehm et al, J Surg Res, 1998
Number of RBC units
- 28.8  24.3 units/1000 pt days
- 20.5% fewer units transfused
Overall transfusion rates: 7.7  6.1 pts/1000
hospital days
“Inappropriate” transfusion rates : 16% to 3%
Criticisms:
- Labor intensive, difficult to maintain
- Transfusion delays (bleeding, unstable
exempt)  Limited application in ICU

Clinical Decision Support (CDS)
• Information at point of care to inform decision
making  timely, evidence-based, patient-specific
• Simple to sophisticated; stand-alone or EMR
integrated
• Reduce choice complexity & cost, improve
outcomes
www.aabb.org
Systematic review: 20 studies, variable outcomes
- 7/8: improved guideline compliance
- 6/13: reduction in number of transfusions
- No improvement in ICU, hospital LOS, mortality
Hibbs et al, Transfus Med Rev, 2015

CDS and Transfusion
• Goodnough et al: reminder of pre-transfusion Hb
– Improved LOS (5.8  5.5 days p=0.003)
– Improved mortality (2.8  2.4/100 discharges, p=0.03)
www.aabb.org Goodnough et al, Transfusion, 2014
Adams et al, Pediatrics, 2011
Criticisms:
Design: alert fatigue, workflow disruption
Development: user input, education, and
feedback
Practice Drift without maintenance?

Stanford Experience: Practice Drift
Adams et al, Pediatrics, 2011
Reduced PICU pre-transfusion Hb:
9.83  8.75 (2010)  9.55 (2016)

Limitations: Prior Studies
• Variable results  No optimal approach
• Selected implementation strategy  No rationale
• Single (tertiary, academic) centers, pre- post-design
• Publication bias
www.aabb.org

Practice shaped by clinical experience, local culture
• Little formal training
• Benefits of restrictive strategy understood, but:
– Not a high priority
– Anemic patients at high risk of organ compromise
– Harder to follow guidelines: unstable patient, sub-specialist
pressure
www.aabb.org Francis et al, Br J Health Psychol, 2009
Islam et al, Implement Sci, 2012
Fortin et al, Transfusion, 2016

Potential Barriers: TAXI Focus Group
• Education gaps
• Misperception - risks and benefits
• Historical practice, “transfusion culture”
• Lack of:
- Leadership - blood transfusion practices
- Prioritization - restrictive transfusion
- Reinforcement or consequences
- Resources - data collection or monitoring
www.aabb.org

Approach
www.aabb.org Gagliardi et al, Implement Sci, 2015
Key Actions
1 Assemble an Implementation Planning Team
2 Assemble resources for implementation
3 Audit baseline practice
4 Assess local barriers to implementation
5 Interact with stakeholders to gather contextual information to inform
selection of strategies
6 Develop guideline implementation tools
7 Prepare implementation plan. Specify: strategies, roles, responsibilities,
timelines, process and outcomes measures

Multi-Professional Team
Intensivists
Surgeons
Anesthesiologists
Cardiologists
Gastroenterologists
Hematologists/oncologists
Hospitalists
Transfusion specialists
Information technology
specialists
Patient representatives
Hospital executives
Finance and quality personnel
www.aabb.org
Executive sponsorship, practice leadership

Auditing Implementation
• Pre-transfusion hemoglobin*
• Number of “appropriate” transfusions
• Total Transfusions
• Additional: blood waste, donor exposures, transfusion
reactions, cost analysis
• Provider decision making: transfused and not transfused
www.aabb.org

Implementation Strategy
• Single strategy or combination
• Practical and feasible
• Agreement on guideline content
• Flexible, adjustment over time  allow continuous
improvement
www.aabb.org

Studying Implementation
A tailored implementation strategy with Computerized
Clinical Decision Support tool will:
– enhance use of RBC transfusion
recommendations
– reduce unnecessary transfusion

1. Assess Context: i-PARIHS Framework

integrated Promoting Action on Research Implementation in
Health Services
Implementation = Facilitation (Innovation + Recipient + Context)

– Semi-structured interviews: ICU physicians, APPs,
nurses, sub-specialists
– 4-5 PICU/CVICUs – range of sizes, types

– Semi-structured interviews: ICU physicians, APPs,
nurses, sub-specialists
– 4-5 PICU/CVICUs – range of sizes, types
2. Develop CCDS tool + Implementation Strategy
- provider needs, barriers and facilitators
3. Evaluate feasibility, acceptability, impact on practice

Summary
• Publication of TAXI recommendations alone won’t ensure
adoption  improve knowledge, modify care process
• No optimal strategy for implementation
• Approach:
– Multidisciplinary implementation team
– Assess current practice, local barriers
– Engage stakeholders (strategy selection, support)
– Implementation plan: practical, feasible, flexible
– Assess impact of implementation
www.aabb.org

Thank you!
www.aabb.org
• Pediatric Acute Lung Injury and Sepsis
Investigators (PALISI) Network
• BloodNet
• AABB
• Centre de Recherche, Hema-Quebec and
Univeriste de Montreal
• Our TAXI Experts

CDS Tool + Implementation Strategy
• CDS tool: Ongoing development
• Implementation Strategy
– Additional tools to optimize TAXI recommendation use
– Based on provider needs, barriers and facilitators
Context Content System Implementation*

Evaluation of CDS tool + implementation strategy
– Feasible?
– Acceptable?
– Impact practice?
- Appropriate tool triggering (%)
- Transfusions consistent with recommendations (%)
- Pre-transfusion Hemoglobin (pre- and post-
implementation)

Critically Ill Children with Sickle Cell

Review Process
• TAXI/BloodNet Internal Review
– Organizing and Executive committees review
– All TAXI members review
• PALISI Scientific Committee Review
• Submission to PCCM
– Short text in main journal
– Long text supplement

Consensus Recommendations for Red
Blood Cell Transfusion Practice in Critically
Ill Children: Results from the International
Pediatric Critical Care Transfusion and
Anemia Expertise Initiative (TAXI) and Blood
Research Network (BloodNet)
10/16/2018

Faculty Disclosures
The following faculty have no
relevant financial relationships to
disclose:
– Stacey Valentine MD, MPH
– Scot Bateman MD
– Katherine Steffen MD
The following faculty have a
relevant financial relationship:
– Allan Doctor MD
KaloCyte, Inc.: Stock
Shareholder (self-
managed)
Fresenius KABI:
Honoraria
www.aabb.org 2

Learning Objectives
• Describe the process of developing international consensus
recommendations for red blood cell transfusion in critically ill
children
• Summarize the recommendations developed for red blood cell
transfusion in critically ill children and the existing evidence
behind these recommendations
• Describe how considerations around implementation were
integrated into development of the TAXI recommendations
and the approach for implementing the recommendations
www.aabb.org 3

Pediatric critical care transfusion and anemia expertise initiative

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