Albumin Video Presentation- SCM/EPIC

Hi, everyone.

Thank you for taking the time to listen to this

presentation on the critical care albumin Optimization initiative Rational.

I'm Karen Sharif.

I work for the Critical Care Strategic Clinical Network and

I'm the knowledge translation lead for this project.

I'm gonna go over a bit of the background to

this initiative.

Why? It's important what we're actually doing and hope to

achieve through this work.

Unfortunately, we won't be able to visit your site with

our new co vid realities.

So we're trying something new with this video, and we

hope you enjoy it.

The presentation will take about 15 minutes and we'll finish

with my contact information because you have any questions or

feedback. So this project was developed and is led by

Dr Dan Niven, who is an assistant professor and intensive

us with the Department of Critical Care Medicine in conjunction

with the Critical Care Strategic Clinical Network.

The project is spending by a grant received from the

Canadian Institutes of Health Research.

So let's get right into it.

Ah, Through to this initiative is a concept called low

value care, which presents itself is an opportunity in the

case of albumin.

So you may have heard of low value care.

But what does that actually mean?

Low value care is an intervention in which evidence suggests

it confers no or very little benefit for patients.

Or in that the risk for harm exceeds probable benefit.

Where again, in other words, that the added cost of

the intervention do not add proportional benefits.

So we've identified the album and overuse in Alberta.

I see who's offers a prime example of this type

of low value care and therefore presents an opportunity for

improvement. But why is this actually important?

Why should we care?

There's a number of perspectives I'd like to present to

you, the first being the patients.

So this quote was obtained from one of our patient

representatives as a potential recipient, I would only want to

receive blood if there were no other options because their

risk to receiving blood and I would want to ensure

the blood is there for people that really need it.

So how pointing is that?

I think it really shows that we as health care

workers, aren't the only one to think about appropriateness of

care and the implications that might have not just on

them as patients, but to the wider public.

And when it comes right down to it, I think

most people would probably agree that they wouldn't want to

be infused a blood product unless they absolutely needed it.

The next quote speaks to the public perspective and in

particular, a person who has made the generous donation of

their blood.

So people trust doctors to make the right decisions about

using blood.

We expect that they only use blood where it's beneficial.

So this is part of their responsibility to know when

to use the gift of donated blood for patients who

will benefit.

So I think this quote really highlights well, the unique

thing about blood products, including album um so there donated

by actual people.

And that's they're very precious and limited resource, which one

I think could argue, make it even more important for

us, is health care worker sees appropriately so the last

perspective I'll highlight is the health systems perspective, which in

light of the recent straight owing to the Copa 19

pandemic, may be more important than ever.

It makes sense that limiting low value care or care

that doesn't really provide real benefit to patients in relation

to its cost of the system will help to make

our health system sustainable.

So less resource put toe words low value treatments means

more for those that really help or more bang for

your buck.

I'm sure some of you will be aware of the

blue ribbon report from last year or the more recent

Ernst and Young Age s audit.

So both have found room for improvement in terms of

the value we're producing from the money we spent.

The Ernst and Young report actually specifically comments on aligning

the care we provide with the choosing wisely Canada recommendations

and to reduce procedures of limited clinical value or that

low value care keep referring thio.

So now that we've gone through a bit of the

background to why initiatives to reduce low value care are

important and in particular those focusing on blood products, the

question remains okay, well, why I'll be men.

First of all, as I said before so needed by

the public, which improves the responsibility on our behalf to

use it appropriately, as I'm sure you can all attest

you from your practice experience.

It's a fairly commonly use fluid But in fact, there

is strong evidence that there is no benefit in the

majority of patients that it's used for and even harm

in some groups.

So in analysis done by our team, the an inappropriate

use of albumin not only puts patients at unnecessary risk,

it's not a benign treatment, um, but contributes to unnecessary

health care spending, adding up to $2.2 million in 2018

for Alberta.

So it's quite a bit of money.

Another thing that's been a recent relevant is a global

effort to protect the environment.

The health care industry around the world contributes considerably to

global emissions.

And if you think of the extra waste cause from

album and processing, packaging administration and then incineration, this might

also add to make sure motivation for some to use

it. Only when we have reason to believe it will

actually benefit.

So now you might be rendering okay, So when can

we reasonably believe that album and will benefit a patient?

When should we be using it?

So let's take a closer look at the evidence, so

there's actually only three times where Albumin administration has been

scientifically shown to benefit patients.

Those situations air large volume, Paris synthesis and by large

volume, we mean more than five leaders have taken off.

Not that you know, 1.5 or two leaders that we

might more frequently seeing are critically ill.

I see patients.

So in this case, when large volume taken off, it's

actually been demonstrated through men analysis of RTC so really

high quality of evidence that it decreases mortality.

The next is spontaneous bacterial peritonitis, where similarly high quality

of evidence supports that albumin could have a positive effect

on mortality.

Lastly, there's plasmapheresis where the evidence to support its use

isn't quite as high, but it's widely been accepted as

the standard of care to use albumin in this situation.

So to repeat, we have large volume Paris synthesis, spontaneous

bacterial peritonitis, or SPP and plasmapheresis.

So next we have the conditions with evidence of no

benefit. So that means there's actual evidence that albumin does

not benefit patients with these conditions, so that type of

bulimia, sepsis, traumatic brain injury and stroke albumin is actually

been shown to cause harm in patients with TV I

and stroke, so it isn't is commonly used in those

cases anymore.

So in the interest of time, we're just going to

focus on the first two.

The biggest trial done to test the benefit of using

albumin over sailing was the safe trial, which had over

7000 patients in rural totes.

Huge study show of no mortality benefit for using albumin,

which is the primary outcome.

But it also showed no difference in icy length of

stay, duration of positive pressure, ventilation or a renal replacement

therapy days.

That safe study was included in a follow up Cochran,

then analysis that included over 10,000 patients.

So again very large, this again show that there was

no benefit on mortality for using albumin over sailing in

patients with Hypo Valley Mia.

But what about those patients with sepsis?

So the most important trial to look at albumin versus

sailing and patients with sepsis is the Al Bo's trial.

This study had almost 2000 patients so again is pretty

big. It actually use serum albumin levels to guide administration

with the goal to keep serum albumin above 30.

So it's probably not surprising to you that the patients

that receive albumin had better maths heart rate to him,

even flew of balances.

I'm sure you've also seen this effect when even ministered

albumin in your practice.

But the interesting thing is you can see by the

graph on the side Here is that there was no

difference in survival.

And now when you think about it, which outcomes you

think patients tend to care about more?

Yeah, so next we have a number of other conditions.

That album intends to be used for where the evidence

is less clear.

So again, for the interest of time, we're going to

focus on him.

Powdery no syndrome is.

This continues to be a time where albumin is often

prescribed. So what's interesting is that when you search back

through the literature, the practice of administering albumin for patients

with HRs stems back to this article that showed there

was improved renal function with patients who received albumin with

terrible Presson, which is the type of visa presser versus

received Terell oppressing alone.

But I think the devil is really in the details

with this one.

So as you could see, it was very small.

It only had 21 patients, it was non randomized, and

they actually changed the study protocol halfway through so you

can see that there's a high risk for bias in

these results, and thus we should really be interpreting them

with caution.

But unfortunately, from then on, the studies have looked at

various types of vase oppressors.

But albumin has always been administered to both groups is

a sort of baseline standard intervention.

So a question that we also tend to get when

discussing this evidence is, Well, why doesn't it work the

way we intended to?

Because it seems like it should.

The true answer.

This question is unknown, although we do have some evidence

to recently Guider thinking you will all I'm sure, be

familiar with the physiologic responses states of inflammation, which most

I see you patients will be contending with.

So in those states have increased vascular permeability fluid, including

album, um, leaks out of the vascular place into compliant

issues. So how come you know the albumin is leaking

out along with other fluids?

Ah, good clues in this review, looking at Hydra ethel

starches, for example, you might remember giving value pen or

pencil Stan eso.

It was discovered that even at the lowest dose of

these hydro Ethel starches administer.

There was deposition into tissues, which means that even this

really large molecule designed specifically to be able to stay

in the vessels was leaking out and it was causing

renal failure and other sorts of issues.

So what makes this interesting is that value ven molecule,

for example, is twice the size of albumin.

So a reasonable question to ask might be OK if

volume and confined its way out of the intravascular space.

Why couldn't the much smaller albumin molecule we might then

be led to understand why, despite initial appearance of improve

vital signs, we fail to see that longer term positive

effects that we want to see, like reduction in mortality

or length of stay for most patient populations.

So that brings us back to our original question.

So is reducing albumin overuse important?

I would argue Yes.

For one, we have a duty to provide evidence, supported

Karen to not expose patients unnecessary risk.

And second of all, we have a duty to use

the resources we have responsibly.

So how are we actually going to do this?

What is our strategy?

This brings us to our project rational or critical care

optimization of albumin ordering.

So this is a quality improvement project that's being rolled

out to the ice use across Alberta.

We provide education like what you're listening to now.

We introduced a change to the way the albumin is

ordered and will be providing bi monthly audit and feedback

reports to each units.

You can monitor your success.

A resource has been developed on dhe.

It's called the Decision Support Tool.

So this is available on insight.

You could search album mental, and it should be the

first or second item to pop up.

It's a really nice summary of the evidence, as it

really is to albumin ordering, and it's available for anyone

to use.

So let's take a closer look.

This top section here you can see the times where

albumin should be ordered, so that's including a guide for

prescription and dozing as well.

You can then see the times where evidence suggests no

benefit from ordering albumin and the recommendation not to order

for these circumstances.

Then this next section outlines the times where album where

the evidence is less clear and you'll see that references

air provided eso anyone interested can read further should they

choose and lastly, you see that the pricing summary is

provided so you might find it interesting that a bottle

of albumin costs almost $60 compared to a dollar 30

for a leader of sailing, so search for it on

inside. If you want to take a closer look, then

in terms of the process change.

Both ECM and Connect care have been updated to reflect

the recommendations we have discussed so you can see three

only Adult Indication and ECM for 5%.

Albumin is T P E and then large volume Paris,

anti sis and SBP for 25%.

Although there's still the option to select, others should have

prescribed shoes and connect care.

The same logic is applied, although you'll see approved by

transfusion medicine, which would be the equivalent of other in

ECM and can still be selected.

So each unit will be receiving their unit specific data.

Every couple of months, we'll be tracking the number of

patients receive albumin who did not have either SBP large

volume Paris synthesis or plasmapheresis, and this is what we're

going to use to describe this inappropriate use.

The goal will be a 50% reduction in the number

of admissions receiving albumin inappropriately based on each unit's individual

baseline. So we work closely with the Physician Learning Program

to develop these reports and will continue to work with

them in the event.

Should any site like a facilitated session to review their

data in more detail.

So on the reports, we have included a number of

different metrics.

To contextualize the importance of this work, you'll see the

first block box lets you know the total decrease from

baseline, followed by a measure of the number of patients

that avoided receiving album and unnecessarily again based on your

units baseline.

So this middle section contains a graph that depicts the

trend of inappropriate albumin ordering in your unit and the

average number of bottles ordered per patient.

And both used the other ice use in Alberta as

a comparison.

So we've also included a measure of the waste save

from incineration by reducing inappropriate Alfie menus.

So finally we've come to the goal.

So for able to reach that 50% reduction from baseline

by the end of the intervention, it's estimated that we

would save $350,000 annually and as importantly, will develop and

define a process for future appropriateness projects.

So to finish off, this is what we need from

you. We ask that you educate yourself on when album

and should be used in when it shouldn't.

So thank you for taking the time to watch this.

And the next step is to facilitate the use of

that decision support tool with prescribers, So don't be afraid

to pull it out.

It is not.

Everyone will have heard about it.

Watch out for your audit and feedback reports to get

a sense of your unit is moving in the right

direction. And lastly, speak up.

Don't be afraid to start conversations on your unit about

the appropriateness of albumin ordering.

So thank you for listening and don't hesitate to contact

with any question.

Albumin Video Presentation- SCM/EPIC

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