Friday, February 24, 2017

Reinforcing a parsimonious approach toward blood transfusion

Blood transfusion as a treatment modality became a prominent resource throughout the last century. However, in the late 1980’s an analysis of the high volume of blood transfusions associated with its inherent cost and risks, raised concern and skepticism regarding the arbitrary hemoglobin and hematocrit cut-offs of “10/30” which were followed since the 1940 following the recommendations by Adams and Lundy. 1 The NIH consensus statement on blood transfusions published in 1988 brought into question the previous practice and propose more parsimonious thresholds of transfusion (Hb 7 g/dL).2

The evidence that supports the safety of parsimonious approach to blood utilization was built over the decades of 1990 and 2000 with very robust and compelling results. The hemodilution studies demonstrated that the human body could tolerate lower hemoglobin values, and subsequently, clinical comparison of restrictive versus liberal transfusional approaches demonstrated the safety of restrictive transfusional approach in different clinical scenarios such as critical care, high cardiovascular risk surgical patients, sepsis, etc. 3  

In this decade, the AABB has published 2 guidelines (2012 and 2016) which are robustly supported by evidence with recommendations for consideration (not an immediately actionable item) of blood transfusion when the hemoglobin reaches a value of less than 7 g/dL in non-cardiac patients, or 8 g/dL in cardiac patients.4 More importantly, the guideline also demystified a current practice that has increased the costs of blood management - which was avoiding the use of blood older than 14 days; the evidence that “old” blood is not associated with worse outcomes is extremely compelling. 4

The current practices of Medicine are substantially different from 10 years ago - at least from blood utilization - not only it is a lower transfusional threshold being utilized, but also there is a decrease in the number of units of blood transfused at a given time. In addition, the clinicians are increasingly mindful of addressing the primary etiology of anemia with focus on hematinic replacement. Also, the behavior has gradually shifted toward mitigating the risk of iatrogenic blood loss by means of decreasing the routine ancillary diagnostic blood tests, which may not necessarily change management.

There are multiple venues which have adopted the recommendations of parsimonious approach to blood utilization such as the ABIM Foundation Choosing Wisely. And it is highly likely that newer organizations aimed to pursue high value and low cost medical care, will adopt the recommendations of restrictive transfusional thresholds to mitigate excess blood use with its associated inherent risks. 

Less is more - the increased focus on enhancing patient outcomes and minimizing the risk associated with excessive diagnostic and therapeutic approaches, will yield in a safer, more effective and less costly practice of Medicine, pursuing the most elemental principle of medicine...primum non nocere.

1. Adams RC, Lundy JS. Anesthesia in cases of poor surgical risk: Some suggestions for decreasing the risk. Surg Gynecol Obstet.1942;74:1011-1119.
2. Consensus Conference. Perioperative red blood cell transfusion. JAMA, 1988; 260: 2700-2703.
3. Auron M, Duran-Castillo MY, Kumar A. Parsimonious blood utilization and transfusion triggers. Clev Clin J Med. 2017;84(1):43-51.
4. Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025-35.

Friday, April 15, 2016

Readmissions, quality and medical education

Finding the way through understanding quality improvement, and most importantly to hardwire the concepts and best practices can appear difficult and cumbersome to the novice. 

But it is not. 

Quality improvement is, as a matter of fact, a fascinating field where you can gain insight and perspective on your own performance and opportunities to improve. In addition, this has been the reason behind the expansion and growth of all the industrial and technological movement in the past century. 

From Taylor to Deming to the creation of the IHI, and now with well established quality health research institutions like Intermountain, Dartmouth, Harvard, etc. we now have formal training and education of a whole generation of health care scientist and providers. This has rapidly changed the culture, and all new trainees and students are intensely getting exposed to terminologies and practices that I barely had any during medical school and my first residency.

I had the honor an privilege to write this guest blog post  at the SHM Blog "The Hospital Leader". I had the opportunity of having direct mentorship from Dr. Brad Flansbaum who helped me tremendously to put the ideas together to obtain the final published piece. 

I hope you are able to read the guest post and more importantly that it yields into motivating curiosity to explore the fascinating world of quality improvement and patient safety. Remember, primum non nocere...

Friday, February 26, 2016

Musings of a Medical Educator - Reflections of the Philosophy of Teaching

I love medical education and teaching in general. Now that I've been a father for 2.5 years, I have appreciated the incredible beauty of curiosity, of the genuine motivation to know and learn - witnessing it on my son. This has been very refreshing - and has made me a better person and professional. 

I was appointed as an Associate Professor in July 2014. Yet I submit my application in 2012. I had now a recent conversation with a colleague about applying for academic promotion. He asked me for the statement I wrote. 

Reflecting on this - the request from my friend, and the everyday fascination I feel from seeing my son growing and learning, I decided to delve into my archives and search for the statement I wrote for my academic advancement regarding my philosophy of teaching. I wrote and signed in August, 2012. Here it is and I'm happy to share:


As an adult learner myself, involved in the complex world of medical education, I have a strong awareness of the different ways of learning that people use.  People use the senses in different ways: some individuals require a persistent memorization effort and may appear bright in terms of factual information recall yet may be unable to develop a critical and analytical perspective of things. Others may have a more practical way of learning by solving problems and putting analysis and reflection into practice yet may not have the ability to retain factual data.  Yet others may need to visually appreciate a concept or idea in order to create a visuospatial relationship with previous concepts.  And finally, some individuals achieve better understanding by listening on a repetitive basis.

The most important consideration is that the educator be aware of the different methods of learning people have and is creative enough to be able to deliver the information or ideas in an efficient way to each individual learner. Creating an environment that fosters learning is essential so that the learner feels motivated – this is done by matching the teaching technique with the learner’s own best learning style.

First of all, I’m a clinician – a hospitalist – I work in the inpatient wards, where seeing acute patients is the norm. Patients are very sick, families are distressed, and most health-caregivers are under significant emotional and professional pressure. My teaching scenario is the patient bedside. I need to teach medical students, residents and fellows. Each of them has a different level of training in addition to their own learning style.  Although the most experienced learners have had more exposure, may not necessarily have more plasticity toward different learning methodologies.

My responsibility as an educator is to ensure all my trainees feel motivated, inspired, and committed to provide excellent patient care. They must come every morning with a great desire to be here. This is done by fostering a team spirit – we all together as a team see all the patients, and the patients belong to all of us.  We all know about each patient, we all discuss about and learn from each individual patient, we all enjoy taking care of patients. The second thing I do is to have the learners acknowledge their own knowledge gap – they shall not feel embarrassed about it, but rather feel a compelling need to close the gap – I make them read about it and give the team a concise and brief presentation usually accompanied by a handout and /or a journal article. This allows me to understand: 1) the ability of the learner to review and synthesize the literature, 2) the ability to frame and write his/her ideas in the handout, 3) the ability to orally deliver a presentation (clarity, structure, length, sequence, etc.), 4) the creativity involved in putting ideas together (presenting the information in a test format, in a clinical vignette format, in a slide presentation, etc.), 5) the interaction with the other learners answering their questions and delivering the information.

My particular method is to teach while rounding and seeing patients – make them observe carefully the patient at the bedside, and first of all, understand that the patient is in a delicate situation and maybe be suffering – have them empathize and be compassionate; know to talk to the patient, provide comfort and hope. This is perhaps the single best teaching we can do at the bedside: good bedside manners. Everything else follows naturally.  The next thing while providing comfort is to enhance the awareness of clinical signs and symptoms: have the trainees to use their senses and enhance their observation and auscultatory skills; then we discuss a differential diagnosis. I put in play the Bayesian approach using pre-test probability of disease and we define a diagnostic and therapeutic approach based on the likelihood of a given pathology.  I use the electronic health record as a teaching tool as well.  We review the bloodwork and analyze the abnormalities with immediate “on the fly” teaching, associating given laboratory values with the patient’s clinical diagnosis or physiologic condition.  This allows the visual learner to make a visuospatial relationship; my explanation allows the auditory learner to understand the process; the whole clinical experience (seeing the patient, reviewing the labwork and imaging, discussing the case) allows the analytical learner to understand the process of disease. In addition, we have the fortune of being in a technology rich environment – this allows me to do literature searches in PubMed at the bedside and look at the literature in the point of care to help facilitate the medical decision making. I show them how to download podcasts especially for the auditory learners.

Once my trainees have written their clinical documentation, another opportunity arises to help them further reflect into the process of disease as well as medical decision making by reviewing their “Assessment and Plans” and discussing with them about the reason for adjusting or changing it allows them to obtain further feedback and reinforce previously taught concepts or as well identify new teaching opportunities.

In addition, at the end of the day, it is important for them to realize how much they need to know and how much they have already learned but perhaps not been quite aware of it. I send them links to articles based on our patient’s diagnosis, diagnostic pathway or treatment, then ask them to choose one article each to present later on the week.  I send these emails on a routine basis – almost daily throughout the rotation – to foster the need to read and appraise the literature in order to provide the best patient care; in addition motivates them to search for the literature on their own sharing their readings with the rest of the team. The advantage of this is that at the end of the day, the learners not only get “live” teaching during rounds, and close their knowledge gaps on their own, but they learn to become self sufficient to search the literature and start building their core of knowledge.

My main satisfaction comes at the end of a rotation when I witness an impressive learning curve, as well as an enhanced level of comfort and ease for medical decision making. My patients express satisfaction with the degree of thoroughness my learners put in every morning during rounds for both assessing the patients as well as explaining to them the results of the diagnostic pathways. I enjoy seeing the degree of satisfaction that my learners show when we are able to successfully discharge a patient who came very ill and is able to look into the future with hope, renewed strengths and desire for recovery. Most importantly I enjoy when my learners actively demonstrate that critical directive, primum, non nocere.

Cleveland, OH, August 2012.

Friday, February 27, 2015

Choosing wisely - the saga continues

Today, the ABIM Foundation published a nice blog post on the choosing Wisely campaign - which they launched several years ago. It can be read here
This week, this was the topic of my institution Department of Hospital Medicine Grand Rounds. We reviewed the current state of healthcare in USA - and the disproportionate ratio between healthcare expenditure and outcomes. Then we discussed the 5 SHM recommendations. 1) Don't use routine antacid prophylaxis out of ICU, 2) Don't place routinely urinary catheters, 3) Don't get daily labs in the setting of clinical stability, 4) Don't routinely transfuse unless clinically unstable and Hb < 7 (and we emphasized the word "consider" transfusion instead of "just go ahead and transfuse"), 5) Don't use telemetry routinely.
Interestingly, there was a lot of controversy around each topics - why so far, we still have gaps in performance? - why so far is so difficult to hardwire change?.
Let's just focus on the urine catheter use.
Regarding urinary catheters, we have an overall low DUR (Device Utilization Ratio) - meaning the number of "Foley-days" divided by the total number of patient days. We have a low rate of CA-UTI - still it is not zero. Why? 
In most cases, the CA-UTI was linked to urine cultures obtained by trainees at the middle of the night in patients with fever as part of a pan-culture approach. Yet, these patients were: 1) not neutropenic, 2) didn't have urinary malformations, 3) didn't have a renal transplant, 4) did not have any clinical evidence of cystitis or pyelonephritis, 5) were not hemodynamically stable. Still - it is very difficult for a trainee to simply withhold a urine culture in a patient with a Foley catheter. In addition, these positive cultures had no translation whatsoever into any kind of clinical meaning. They become a statistic without clinical relevance, yet with impact in the overall institutional quality metrics.
The question needs to go further and beyond - does the patient still needs the Foley catheter? 
My question to my trainees is - instead of just performing a urine culture in this patient, which most likely will have no real clinical meaning, why don't we just consider having the urine catheter removed?
We reviewed the other organizations Choosing Wisely recommendations - and the ACEP also recommends against routine placement of urinary catheters - therefore, hopefully, the story of "the patient already came with a Foley when admitted from the ED" will be a goner.
We had implemented in 2013-2014 an enterprise-wide Nursing driven protocol for Foley removal - which has impacted in a 30% decrease in CA-UTI rate. The current utilization of the protocol ranges in the 80%. Interestingly is that in quality improvement, it is not only the implementation of a new protocol or change which creates impact, but also the adherence and compliance with it. 
Nowadays an interesting phenomenon, is the engagement of patients in the decision making process, which by the way is a principle objective of Choosing Wisely. When a catheter is placed - for instance to "monitor diuresis in a patient who is getting IV diuretics" - I have now patients asking if the catheter is strictly necessary, as they can use a urinal for quantification of urinary output. Still, I've witnessed resistance from providers regarding the "need for an accurate output measurement" and accepting not placing the catheter in a "lost battle mood". And this is because we were hardwired to use catheters in an indiscriminate way - and now are swinging the balance to the opposite side.
The times are changing and we all need to ensure there is engagement, especially from our young trainees. We need to hardwire best practices early enough. Teach them the words of Henry Ford "Quality is doing the right thing when nobody is watching".

Tuesday, August 5, 2014

Rescuing my blog from the oblivion. Musings on the transformation of our millennial trainees into patient-centered professionals.

It is interesting to see the excitement with which lots of people (including yours truly) starts blogging, using Twitter, etc. and how the energy and effort into it appears to slowly getting diluted within the incredibly intense day to day activites, responsibilities, anxiety, etc.

In my case, I started blogging for a variety of reasons - it is my own forum to express ideas and thoughts that happens in my everyday busy clinical life. We as hospitalists (in my case, Med-Peds), get exposed to an incredibly wide array of different clinical situations from childbirth until caring for a century age patient; these situations can vary from very complex disease presentations with highly complex comorbid conditions, to witnessing very difficult social situations that impedes treatment compliance.

On top of the daily clinical experience, there is the exposure to academic activity, where we are role models and teachers for medical students and residents to train them to become specialists. It is our role to teach them to become patient-centered, rather than self-centered. With this, I mean to change the importance trainees give to their own "presentation" or the feedback/evaluation they receive into focusing in the aspect that they are part of a team privileged in taking care of patients. We have the compromise to provide optimal and evidence-based patient centered medical care - emphasizing in excellent communication and patient experience.

Nowadays, I try to ensure that my residents appreciate teaching through rounds - not necessarily classic Socratic teaching - but the teaching that emanates from actively discussing medical decision making; the dissertation of the different outcomes that can occur, etc. We may complement with additional reading material, and perhaps some protected time for board teaching. Yet, the most important thing to me, is to ignite in them the spark that will trigger their behavior as adult learners to pursue self study and close their own knowledge gaps.

We are training a new generation of medical students and residents - the millennials - self-driven, hi-tech adults. We need to adjust to a different perspective of doing things and approach knowledge. It is cool to have an app for everything you want to teach - but most importantly, this generation does not learn dogmatic concepts by default. I love when they challenge the concepts and try to reason about the rationale for specific outcomes or medical decisions.

However, even if they are self learners, we need to strive in helping them find their own knowledge gaps - and use toward our own advantage their self-learning behavior to go and close it on their own. In my case, I ask them to give a small 3-5 minutes presentation to the team on a specific concept that they have just read upon and learned.

We must create academic momentum within a strongly humanistic, empathetic and compassionate care. I want to appreciate the enthusiasm, interest, motivation, energy, desire to learn and excel, and overall, the most incredible passion for patient care. They are learning to become good doctors and to broaden their knowledge - but most importantly, because they want to provide safe medical care to our patients. I cannot divorce compassionate medical care from excellent medical decision making. What distinguishes the good physician from a mere human being technical expert is the blend of outstanding medical knowledge with genuine compassion and empathy.

When the medical student or resident is compassionate, and feels the compelling need and desire to excel, and master the knowledge as much as possible, it is because wants to provide the best care for their patients - they know the patient well; they have read about their medications; explored in depth the details discussed during rounds - and all this effort is targeted toward providing outstanding medical care.  Then the rounds are about presenting to the team the most relevant aspects of the patient medical status, current state of the diagnostic and treatment phase, provide focused teaching to the team, etc. But rounds are not anymore about "my presentation". They are now genuinly engaging in the care delivery as very valuable team members and their work is centered around the patient.

This is the transformation we desire. They can accompany it by all the issues of the New England Journal, most recent Up To Date articles, McGee's physical diagnosis evidence based information, etc. But this knowledge is parallel to their genuine desire to help the patient thrive through his/her experience in the hospital and receive the most compassionate and empathetic care as possible.

For the trainees, the situation becomes a very different one - the patient experience has becomes a paramount composite not only of the medical care, but is even embedded in the CMS payment models. No matter how technically beautiful a brain aneurysm surgery went - if the patient experience in the hospital is bad, then the technical aspects become secondary. And the trainees as a part of a medical team have a shared responsibility in ensuring the best experience for the patients.

Being a doctor is a tremendous privilege - we get the confidence and trust of our patients. We became doctors to provide healing, relief, and alleviate suffering. I hope that most people who became doctors did it for this sake, and not just to pursue a necessary pathway to become a specialist in refractive surgery, or joint replacement surgery, or cosmetic surgery, etc.

When a trainee is under our supervision, we can't really change what motivated them to become a medical student or now as a doctor, to pursue a residency training, but we can certainly demonstrate a role model for humanistic and compassionate medical care, and teach how to conduct their bedside manners in the most respectful and excellent way as possible. And then, blend this behavior with their own acknowledgment of necessity of self boost of their medical education in order to safely take care of patients. If this combination is successful (learners acknowledgment of their own knowledge gaps with subsequent gap closure, blended with a genuine compassionate behavior and understanding that all we do is patient-centered), then we can take pride on our modest yet valuable contribution to medical education.

Sunday, February 3, 2013

Our journey toward crossing the quality chasm - musings from the Intermountain ATP course

I spent all last week in Salt Lake City, Utah, at one of the worldwide recognized most prestigious academic activities in quality and patient safety - the Intermountain Advanced Training Program in Healthcare Delivery Improvement, which is taught by a veritable pantheon of healthcare quality improvement colossus leaded by Dr. Brent James.

This course is a 20 days course, taught over 4 weeks (one week each month for 4 months), and the attendees are the quality leaders in different institutions - all really smart and engaged individuals with a substantial amount of experience and knowledge in the field - several with 2 or 3 master degrees (MMM or MMA or MBA plus a MS or MPH). However, despite their knowledge and training, still something is missing. It is a fascinating experience to network with such a phenomenal group of professionals with a common goal - provide the best medical care in the world. 

This course helps to fill the gap - Dr. James has taken all the teachings from the gurus in quality, Dr. Deming and Dr. Shewhart and translated into healthcare. Essentially they teach how to understand that healthcare delivery is as well as in manufacturing, a series of processes which receive different inputs in order to have a final output or outcome, and its quality will depend whether it meets or not required specifications. Quality is defined by our own set of values, expectations, cultural beliefs, etc. and good quality is when the output meet specifications (which are defined expectations). The FOCUS-PDSA strategy allows to identify opportunities and implement quality improvement processes in small scales and translate subsequently toward a larger scale. It is very relevant to understand how the industry has improved and how certain industries achieve incredible safety records - e.g. aviation, car manufacturing, etc. - and how the application of Deming's philosophy has been instrumental in this incredible safety record. 

It is important to understand the history of healthcare delivery in America - how its philosophy has changed - after world war 2, there was an emphasis in ensuring access to healthcare to all the population; however after the costs started to rise and the insurance companies started to take control, the shift focused toward cost control and maximizing hospital reimbursement - this was sub-optimal as opportunities to care may have been missed by patients as insurance companies controlled the medical decision making not emphasizing at all in quality of care but just cost of healthcare delivery. However, quality of care was less than optimal and medical errors were the 6th cause of mortality in the US. This was highlighted in an publication by the Institute of Medicine called "To Err is Human" and subsequently by "Crossing the Quality Chasm". This has shifted equation of healthcare delivery toward "value" of care - which meant increasing the quality of healthcare delivery while minimizing unnecessary costs. This is the current philosophy that allows us to design the healthcare processes. 

It is important to stop practicing a highly variable "craft of Medicine" which allows for increase risk of errors and missed opportunities - it allows for an incredibly selfish and individualized practice of "what works for me". This can make a physician practice differently in a same patient/same scenario in different time periods. Patients are increasingly complex; medical knowledge is increasingly complex too - more than 10,000 different journals, it is impossible to know all the current evidence to support a safe medical practice. This is one of the reasons for having quality improvement systems in place - and to have all doctors get on board the ship of quality and safety and adopt the culture of quality as their main philosophy. 

But in order to ensure adequate quality delivery, we need to know whether we are meeting the specifications! Therefore, it is fundamental to have a clear understanding of our current performance - essentially, know well the data to be able to study and appraise it. Be able to graphically show where our performance gaps are is fundamental - using time series, pareto charts, Ishikawa (fish-bone) diagrams or other cause-effect diagrams, histograms, flow charts, etc. (Now a lot of things make more sense!). Metrics should drive performance when understood within an appropriate knowledge and understanding of our own institution philosophy, vision and mission. The graphs allows to identify outliers and areas of opportunity. Errors or mistakes are horrible words - should not be used; the purpose of quality improvement is not to punish or take action toward an individual - the context of all the theory is geared toward improving the system! Rather than using these words, it should be identified as "opportunities for improvement" or "outcomes outside of specification". All individuals within the system should be accountable, but the purpose of QI is to enhance the system in a consistent form. For example - you don't ask when climbing a regional jet whether your pilot is competent - you trust the system! The same should occur in hospitals - create systems that enhance patient safety and consistent quality delivery.

For quality improvement purposes, the most important aspect that Deming taught was to decrease variation - once variation is decreased, the area under the curve decreases - the population bell shape distribution narrows and its peak is more prominent - then it is easier to identify real outliers - the causes for real "signals" and be able to help improve. In a traditional bell shape, when arbitrary cut-offs are met, these outliers can mix with the rest of the population. So it is important to standardize processes to minimize variation. In healthcare, each patient will be different, so if we standardize our processes, the only variation will come from the patient who can receive an individualized care but the overall standards of care will be met. 

The leverage of all resources - technology: electronic health records, computerized-personal-order-entry systems (or CPOE), and non-technology: discharge processes, nurses/physician huddles, etc. - should be targeted toward minimizing variation and use all opportunities to meet top quality standards. 

Once a process is started - a work-flow diagram that illustrates the process and subsequent steps, can be modified with constant feedback from the end-users about its performance to improve it in a continuous way - what is also called continuous improvement.

A beauty if the QI philosophy is that once specifications are being met rather than "sleeping on the fame", a constant pursuit of further enhancement and refinement in the process should be maintained - this desire for continuous improvement is what creates safer and better environments - this philosophy is what helps the world to keep advancing and be a better place for the next generations. 

My responsibility will be to immediately apply all the currently acquired knowledge at my institution, as well as share this philosophy and knowledge with my peers, medical students and both Medicine and Pediatrics residents. This is important as the new generations must harbor the culture of quality and safety as their main philosophy. I'm excited as this will help to deliver a much better medical care and help to shape the Medicine of the future today. 

A safe medicine with highest quality standards allows us to practice our mantra....primum non nocere

Wednesday, January 2, 2013

Less is more - additional evidence against liberal blood transfusion (or in favor for parsimonious use of blood).

I went last year (yes, the year that just ended 2 days ago) to Mexico City to give a lecture at the International  Course of Internal Medicine sponsored by the Mexican College of Internal Medicine. My lecture was named "Blood is life: to transfuse or not" - and it was targeted toward presenting the evidence for parsimonious blood utilization. This invitation came as a result of my involvement with the preoperative anemia optimization program at the Cleveland Clinic.

At the Cleveland Clinic, a large effort was initiated about 6 years ago in order to decrease the number of transfusions, mainly red blood cells, and mostly in surgical patients. The efforts have yielded in an impressive decrease in blood utilization as well as in a more proactive behavior to optimize the patients' anemia before undergoing surgery. One of my main areas of interest is preoperative anemia optimization to minimize the risks of intra-operative or post-operative blood transfusion. We optimize the iron stores, or in special cases, use erithropoiesis stimulating agents (Jehovah's witnesses, hip and knee arthroplasties mainly).

The culture change has been slow but steady. Nowadays, nobody attempts to transfuse liberally in anybody with hemoglobin more than 7 g/dL; of course, each patients is evaluated individually and certainly you can transfuse at higher numbers in patients with other co-morbidities (for example, patients with severe chronic lung disease and active ischemic cardiomyopathy, or severe acute ischemic renal injury, etc.).

I have undergone a large review of literature which I presented in Mexico (the translated slide presentation can be seen here). The presentation raised controversy - some of my Mexican colleagues still transfuse based on "their experience" and not on the evidence; they are scared of using intravenous iron preparations; they still think an hemoglobin of 10 in a critically ill patient is an indication to transfuse. It was a big cultural shock to find out that it was in critical care patients where the evidence came from, supporting a parsimonious blood utilization. Some people advocate autologous blood donation (which we do not use here), as well as the use of perfluorocarbon blood substitutes (which as well we do not utilize here neither). A long road is to be traveled and a large educational effort is required to change long-standing practices; I was grateful by receiving the opportunity to help in the initiation of these efforts and will continue to share our experience and growing literature available.

In the past 2 weeks, two articles have come out to provide additional support to the parsimonious blood utilization - one published online in Archives of Internal Medicine which demonstrates and increased mortality in patients with acute myocardial infarction who were transfused - and the other published in tomorrow's NEJM - which fills out the missing part of the puzzle: whether pursuing a parsimonious blood utilization in active GI bleeding was a safe initiative.

The article in Archives, is a well designed metaanalysis which review 10 studies out of 729 finding interestingly a mortality risk ratio of 2.91 with a number needed to harm of 8 in patients hospitalized with myocardial infarction who were transfused. In addition, this risk was independent of the baseline hemoglobin level and to muddy the waters more, it was associated with increased risk of subsequent myocardial infarction. This is very interesting, as most guidelines recommend a higher threshold for transfusion (e.g 8 g/dL instead of 7 g/dL) in anemic patients with myocardial ischemia. I don't think clinicians should stop from transfusing patients that need blood; but I would advocate a more conservative approach looking into the causes of anemia - hematinic deficiencies (iron, vitamin B12, folate, etc.); bone marrow suppression or dysfunction; ongoing blood losses; etc. As the authors conclude a larger trial is needed and I concur; however, it is interesting to see the trend toward the worse outcomes, including reinfarction. 

The article in the NEJM, comes to provide very needed information in the actively bleeding population. We tend to transfuse as in an actively bleeding patient it is unclear whether the hemoglobin will stabilize or how low it can go. In my institution, we tend to monitor the hemoglobin every 4 to 6 hours in these patients - and hold for transfusion until the hemoglobin reaches 7 g/dL or less. This behavior is supported by this article, which certainly provides a sigh of relief to all who practice a parsimonious blood management. Of course, that in addition to this, clinicians should always optimize the hematinic deficiencies (iron stores, folate, vitamin B12, etc.), in order to maintain the substrate for an adequate hematopoietic response. I'm glad this article is out in print as certainly will provide a stronger support for all blood management programs, and minimize worse outcomes in our patients. 

Doctors and midlevel providers want the best for their patients. It is a matter of education and reaching a comfort level to pursue evidence based and common-sense based medicine. As always, we all strive for the best....primum non nocere.

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