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De-implementation of Low-value Albumin Fluid Resuscitation in Critical Care – Customized KT during a Pandemic

Background:

Overuse of low-value care remains a major threat to providing high quality healthcare. Fluid resuscitation using human albumin is an exemplar low-value care practice. Albumin is a blood product used intravenously to treat patients whose intravascular volume is severely reduced. Evidence has identified a small number of patient populations that derive benefit from use of intravenous albumin, however the vast majority of albumin is commonly prescribed for patients where rigorous science indicates no benefit. The objective of the current study was to reduce low-value albumin use among adults admitted to ICUs in Alberta, Canada.

Methods:

The RATIONALE (cRitical cAre opTimIzatiON of ALbumin ordEring in Alberta) study was a registry-based stepped wedge quality improvement intervention trial implemented in all 16 adult ICUs in Alberta. Implementation was facilitated by collaboration with the Alberta Critical Care Strategic Clinical Network as well as the Physician Learning Program. Clusters of two ICUs began using the intervention every two months until all 16 ICUs were using the intervention. The quality improvement intervention targeted established barriers and facilitators and was co-developed by a multi-disciplinary working group and consisted of: 1) identifying clinical champions in each ICU; 2) targeted and tailored education to prescribers and bedside nurses; 3) changes to the way in which albumin was ordered; and 4) bi-monthly unit-level audit and feedback. Data was obtained from eCritical, the provincial electronic medical record and data registry for all ICUs. The primary outcome was the proportion of patients without an evidence-based indication for albumin who received at least one unit of albumin during ICU admission. Secondary outcomes included the number of albumin units prescribed per patient that received any albumin, and the amount of avoided biomedical waste. 

Results:

Intervention implementation began with the first cluster of ICUs in November 2019. The final ICUs were brought onboard January 2021. COVID-19 interrupted implementation by six months between March and August 2020, and delayed audit and feedback by another 6 months in 2021. The proportion of patients without an evidence-based indication for albumin who received at least one unit of albumin during ICU admission decreased from 12.9% at baseline to 9.0% as of October 2021 (relative decrease 30.2%). All but one participating ICU decreased albumin utilization compared to baseline (median relative reduction 24.4%; interquartile range: 4.7% – 39.0%). This resulted in 572 patients avoiding unnecessary exposure to a blood product. The number of albumin prescriptions per patient did not change considerably compared to baseline (4.0 versus 3.9), however owing to a reduction in use of the glass bottles used to store albumin, 1329kg has been prevented from entering biomedical waste. 

Conclusions:

A targeted and tailored, multifaceted quality improvement intervention resulted in considerable reduction in low-value albumin use among patients admitted to adult ICUs in Alberta. Pandemic-related strain significantly hampered timelines associated with planned non-pandemic quality improvement work. Additional work to sustain the observed change in practice is ongoing. 

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