Improving appropriate use of intravenous albumin: results of a single-centre audit and multifaceted intervention

Abstract

Background: Intravenous albumin has limited indications supported by randomised controlled trials, yet it is often prescribed for indications not supported by evidence.

Aim: To reduce unnecessary transfusion of albumin.

Interventions: Under the leadership of a multidisciplinary quality improvement team, evidence-based recommendations were disseminated in tandem with a new electronic order set, an educational strategy, qualitative interviews with prescribers and a return policy change to reduce wastage.

Implementation and evaluation: Interventions were introduced in a staggered fashion. The primary outcome, appropriate use of albumin, was monitored and quantified using pre-intervention and post-intervention audits. Process measures included statistical process run charts of monthly usage of 5% and 25% albumin and wastage. Data on length of stay (hospital and intensive care), new inpatient starts on kidney replacement and mortality were collected as balancing measures.

Results: Appropriate albumin usage based on indication increased from 30% to 50% (p<0.0001). There was significantly less overall albumin usage in the post-intervention period compared with the pre-intervention period (negative coefficient, p<0.0001), driven by a major reduction in the utilisation of the 5% formulation (p<0.0001). Overall albumin usage was significantly lower in the post-intervention period, decreasing from 800 to 450 vials per month. The intervention resulted in significantly less wastage (negative coefficient, p=0.017). Mortality, length of stay and new starts on kidney replacement therapy remained constant throughout the study period.

Conclusion: Improved prescribing of albumin was achieved with a multifaceted approach. Substantial and sustained reductions in usage were achieved without negatively impacting patient-important outcomes. The estimated annual savings for the purchase cost of albumin was CAN $300 000. We provide a structured process for other organisations to optimise their use of albumin.

Keywords: Audit and feedback; Patient safety; Quality improvement.

Figure 1

(A) Total albumin usage. Fitted regression lines and 95% CIs for the predicted values. Blue line denotes the pre-intervention period and the red line represents the post-intervention period. (B) Monthly usage of the 25% formulation. Fitted regression lines and 95% CIs for the predicted values. Blue line denotes the pre-intervention period and the red line represents the post-intervention period. (C) Monthly usage of the 5% formulation. Fitted regression lines and 95% CIs for the predicted values. Blue line denotes the pre-intervention period and the red line represents the post-intervention period. (D) Monthly albumin wastage. Fitted regression lines and 95% CIs for the predicted values. Blue line denotes the pre-intervention period and the red line represents the post-intervention period.

Figure 2

Mortality rate (green), mean intensive care unit (ICU) length of stay (LOS; orange) and mean hospital LOS (blue) during the pre-intervention and post-intervention periods. Shadows indicate SE of length of stay in days.

Figure 3

New dialysis starts that occurred during an inpatient admission in the pre-intervention and post-intervention periods.