Case 5 (8/25/2013): Case Management Commentary
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… You must download the file after opening the link in box.net, or you will not be able to easily see all of the information in the file. This case management commentary follows the initial patient presentation posted August 25, 2013 and includes commentary about blood management in this patient. If you encounter a problem with the box download, notify me at djadwin@columbia-analytics.com. This material is Copyright 2013 © by Columbia Healthcare Analytics, Inc. and may not be used for other purpose without written permission.
Assessment
The patient in Case 5 presented with normochromic, normocytic anemia, yet no reticulocyte count or iron studies were performed. Coagulation studies were not performed until 32 hours post initial laboratory study; even though the patient had liver disease and might require paracentesis. At 28:25 hours post-admission the patient’s INR is 1.7, perhaps not sufficiently increased to warrant reversal with plasma prior to paracentesis. The elevated INR is not related to anticoagulation therapy, therefore coagulation mixing study workup to exclude a coagulation inhibitor may be indicated. Plasma therapy does not correct an elevated INR due to coagulation inhibitor.
Paracentesis was performed on the day following admission (1/03) but the time of the procedure was not recorded in the procedure record. Four units of plasma were administered the day following paracetesis between 04:33 (AM) and 10:35 (AM). The paracentesis fluid was received for cytopathology processing later that day (1/04) at 4:28 (PM). The date of specimen collection is not recorded in the pathology report. No post-transfusion coagulation testing was performed.
At first glance the paracentesis appears to have been performed prior to plasma transfusion, which does not seem logical. The procedure date is not indicated in the pathology report and the date/time of paracentesis is not recorded in the progress notes. On paper it appears that the plasma was given post-paracentesis, and therefore there is no justification for giving plasma. More likely the date recorded in the radiology report is incorrect; the procedure was likely performed 1/04 (not 1/03) and the plasma was given prior to paracentesis (not afterward). Analysis of hospital events in this manner highlights the importance of accurate date and time recording in medical records.
Important transfusion management issues flagged by retrospective review include:
1) failure to perform an adequate anemia workup and potentially provide non-transfusion management of the patient’s anemia.
2) failure to perform a more detailed investigation of an INR abnormality (coagulation mixing study), in a patient not receiving anticoagulation therapy, and failure to perform earlier coagulation testing.
3) missed opportunity to use vitamin k to potentially correct an INR abnormality.
4) failure to perform a post-transfusion INR to measure the degree of INR correction (if any).
5) uncertainty of plasma therapy in relation to paracentesis.
The patient was hospitalized for 4.6 days. Does the patient meet criteria for acute hospitalization? She was admitted for diarrhea and ascites. The discharge summary does not document any acute care management, other than paracentesis. The discharge diagnosis lists “functional diarrhea”. Plasma transfusions, elevated INR, and anemia are not mentioned in the discharge diagnoses.
Display of data in chronological format provides attending physicians with a unique opportunity to quickly study case management in hindsight and permit wider discussion. Comments are not intended to be complete or authoritative, but instead are made to stimulate discussion. Others are encouraged to share their comments and encourage others to join in the discussion.