Abstract

The Impact of Criteria for Use and a Prescriber Order From on Albumin Utilization

Purpose: Fluid management is fundamental to the care of critically ill patients. Albumin solutions are protein colloids that are oncotically equivalent to human plasma. These solutions are commonly administered to increase or maintain intravascular volume. Within the critical care setting, albumin is often used for several reasons including distributive and hemorrhagic shock, cerebral ischemia and maintenance of cerebral perfusion pressure, and management of postoperative hypotension. The choice of whether to use crystalloids or colloids for these indications continues to be debated despite the lack of adequate evidence or guidelines to support its use. Jackson Memorial Hospital (JMH) implemented albumin usage criteria in concordance with the University Health Consortium (UHC) guidelines in 2007 in order to establish evidence based criteria for use and promote a cost-effective approach without compromising patient care. The study was conducted in two phases, a pre-implementation phase and a post-implementation phase. Methods: This retrospective cohort study was conducted from November 2011 to November 2012 to assess adherence with the revised usage guidelines and prescriber order form for albumin. A data collection tool was developed to collect the following: age, sex, physician and specialty/service, length of stay, indication(s), contraindication(s) to non-colloid use (if any), albumin concentration, dose, frequency, dose volume, number of doses, adverse event associated with albumin, and use of other concurrent therapy. Each instance of albumin use will be assessed for its indication then correlated with the current guidelines and literature. Results: The primary indications for albumin use were hypotension/hypovolemia, cerebral ischemia/perfusion, low serum albumin and cirrhosis/paracentesis. There were 953 doses evaluated. Appropriateness of colloid utilization post implementation was 54.4%. When used for hypotension/hypovolemia, the appropriateness was 49% and 67% received crystalloid prior to colloid use. With implementation of the protocol for colloid use, the cost savings for albumin expenditure was approximately $400,000. Conclusion: Implementation of revised guidelines and dedicated order form was deemed necessary to promote more appropriate albumin utilization. Despite complete use of order form only being approximately 50%, its implementation was able to effectively decrease albumin expenditure.