From the 2018 HVPAA National Conference
Shelby Anderson (Parkland Health and Hospital System), Julian Mccreary (Parkland Health and Hospital System), Kristin S. Alvarez (Parkland Health and Hospital System), Deepak Agrawal (University Texas Southwestern Medical Center)
Albumin infusion is indicated after Large volume paracentesis (LVP) when >5L is removed, to prevent Paracentesis-Induced Circulatory Dysfunction (PICD).At our hospital there is significant variability in grams and concentration of albumin ordered after LVP, resulting in high costs. In some cases, albumin was ordered for < 5L of paracentesis.
1.Establish hospital guidelines on albumin dosing in order set format after LVP and implement them in the electronic medical record.
2.Determine albumin usage after LVP prior to and after implementation of order set guidelines. Determine safety outcomes (hyponatremia, renal failure, and hypotension) after LVP, prior to and after guideline implementation
– Develop multidisciplinary consensus on albumin use in LVP. Guidelines recommend 6-8gram of albumin /L (excess of 5L) removed. Studies have also shown that 4grams of albumin/L removed have similar clinical outcomes.
– Created guidelines and order sets in EMR Expected/actual fluid removed 5-6 liters give 25 grams (1 vial of 25% albumin) Expected/actual fluid removed 7-10 liters give 50 grams (2 vials of 25% albumin) Expected/actual fluid removed > 10 liters give 75 grams (3 vials of 25% albumin)
– Retrospective review of patients who underwent LVP before and after order set implementation for any adverse events
143 patients were included in final analysis. Mean grams of albumin per liter of fluid removed in LVP decreased significantly after order set implementation (Figure 1). No significant difference in safety outcomes (Table 1). Estimated savings were $32 per tire of fluid removed (~ annual savings of $30,000
– Albumin use after LVP can be optimized by use of order sets
– No change in safety outcomes when mean albumin use decreased from 8.3 to 6.7 grams per liter of fluid removed
– Cost savings of $32 per liter of fluid removed
Implications for the Patient
Albumin is one of the high cost items at any hospital. In the last few months, there has been intermittent shortage of albumin. We have shown that use of order sets can result in more optimal use of albumin and decrease variation leading to significant cost savings.