Leading the Evolution of Patient Blood Management in Pediatric Critical Care

Stacey L. Valentine, MD, MPH is a pediatric critical care physician at UMass Memorial Medical Center and an associate professor at University of Massachusetts Medical School. Her clinical interests include anemia, blood transfusions, and pediatric acute lung injury. She spoke with Healthcare Performance Insider about patient blood management initiatives that are moving the needle on transfusions for critically ill children.

Dr. Valentine chose to pursue medicine early on, earning her medical degree from the University of Vermont School of Medicine, after which she pursued residency training at Boston Children’s Hospital for pediatrics. Throughout my residency, I was always drawn to pediatric critical care medicine, and I developed a passion for the physiology that I saw in the pediatric ICU. I pursued a fellowship at Boston Children’s and a subsequent career in pediatric critical care medicine. 

During her residency and fellowship, Dr. Valentine took care of patients who made a significant impact on her. My experiences caring for patients led me to the interest in anemia, blood transfusion, and patient blood management. In particular, I had taken care of patients who I noticed were anemic because of the blood samples that we were taking from phlebotomy, and I couldn’t help but think, is there a way to be able to prevent that blood loss? That question resulted in her first peer-reviewed paper on the topic of minimizing phlebotomy-induced blood loss in critically ill children.

Dr. Valentine began to focus more and more on ways to use patient blood management to not only treat anemia, but also to potentially avoid blood transfusions when possible. Of course, blood transfusions are absolutely necessary when they’re needed, and trying to figure out how to differentiate the necessary blood transfusions from the unnecessary transfusions was a keyway to improve patient blood management.

The Pediatric Critical Care Transfusion and Anemia Expertise Initiative

The Pediatric Critical Care Transfusion and Anemia Expertise (TAXI) was born out of discussions with the Pediatric Critical Care Blood Research Network. I had just finished as an invited expert in the Pediatric Acute Lung Injury and Consensus Conference, where I had developed guidelines for fluid and transfusion management in particular, in respiratory failure. And as my research group sat down, we thought, wouldn’t this be a wonderful thing to be able to do for the field of blood management, creating guidelines for transfusion in critically ill children? And using what I learned from my first Consensus Conference, we proposed using the same methodology for TAXI. Dr. Valentine co-led the initiative, the goal of which was to create international recommendations for transfusion in critically ill children.

In order to do that, the TAXI team was committed to studying the evidence in order to make evidence-based recommendations. However, large, randomized control trials are not available in pediatric populations. The challenge was, how do we leverage having these world experts in the room to be able to create recommendations, really expert recommendations, when the evidence is not there? And then, when the evidence is not there, how can we align our research going forward to be able to answer those questions?

TAXI led to the start of research into blood transfusions in pediatric critical care patients. The team also developed more than 100 recommendations, half research, half clinical. The most exciting part for me was creating the pediatric decision tree. In that decision tree, we were able to incorporate almost all of our recommendations into one place on one piece of paper. Pediatric critical care physicians across the world have that decision tree on the walls of their offices.

The decision tree has impacted transfusion practice by giving the practitioner a way to follow through on their patients and determine where their patients fit. We really want to change the thought process of indications for transfusion, and especially that word “trigger versus threshold.” And what we emphasize quite a bit in TAXI is that, in good practice, you have to think about the entire patient and how your patient fits into the algorithm, and to use good clinical judgment. And for instance, what we wanted to say is that there’s a threshold potentially for transfusion and we don’t want one particular number, for instance, hemoglobin, to trigger that transfusion. Instead, think about that threshold of where you should consider a transfusion and also consider the clinical context as well, so that you’re not ordering blood products based on a number alone.

While the first step of TAXI was to evaluate transfusion practices pertaining to red cell transfusions, the next steps are looking at transfusion practices for platelets and plasma in critically ill children. That initiative is the Pediatric Critical Care Transfusion Anemia Expertise Initiative-Control Avoidance of Bleeding, or TAXI-CAB. And with this, we are creating evidence-based, and when evidence is lacking, expert-based recommendations, particularly for platelets and plasma in critically ill children, and looking at that evidence and making recommendations when we can. And the hope is to be able to create a decision tree for our yellow products, or platelet and plasma, in children.

For hospitals that haven’t created a patient blood management program yet, Dr. Valentine encourages them to think about creating a team that is interested and invested in patient blood management, including physicians, nursing, and executive teams. The team can then study the hospital’s current practice and compare them to national standards. It certainly takes investment, but once you start to break down each standard into individual pieces, it is certainly accomplishable. For guidance, look at resources from other hospitals that have created patient blood management programs, as well as other blood management resources out there to help you do this.

Focusing on implementation leads to results

My passion is to improve healthcare for children across the country and across the world. And the key part in looking at current practice and creating guidelines and recommendations, it’s really to be able to look at our current practices. What I want to do is impact that child at the bedside to improve their care.

How can we leverage everything that we have in our resources to be able to do that? For me, the answer is looking at our current practice and asking, is our current practice what we should be doing? And if not, how can we develop recommendations to change our current practice?

A critically important part of this process is implementation science. Creating recommendations and guidelines that are impractical to implement at the bedside does not actually improve care. Considering implementation also incorporates other questions, such as how can the recommendations that we create be implemented at the bedside? What are the barriers that caregivers face?

And by doing that, according to Dr. Valentine, those recommendations that we create are actually implemented at the bedside and impact care. And I think that’s really, really crucial. Focusing on implementation helps to bridge the gap between what works for a single patient and what might work on a large scale.

What I’ve been very passionate about is that you can create recommendations, but you have to make sure that these are able to be performed at the bedside and that your clinicians can use them and that they are effective. Because once they are, you can impact healthcare across the country and across the world.

Stacey Valentine, MD, MPH

Stacey Valentine, MD, MPH

Pediatric Critical Care Physician at UMass Memorial Medical Center and an associate professor at University of Massachusetts Medical School

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