Education & Certifications
M.A, University of California, Berkeley, Biostatistics (2016)
B.S, San Francisco State University, Nursing (2010)
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San Francisco, CA, USA
BACKGROUND: Massive transfusion protocols to treat post-injury hemorrhage are based on pre-defined blood product transfusion ratios followed by goal-directed transfusion based on patient's clinical evolution. However, it remains unclear how these transfusion ratios impact patient outcomes over time from injury.METHODS: The Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) is a phase 3, randomized controlled trial, across 12 level-I trauma centers in North America. From 2012 to 2013, 680 severely injured patients required massive transfusion. We used semi-parametric machine learning techniques and causal inference methods to augment the intent-to-treat analysis of PROPPR, estimating the dynamic relationship between transfusion ratios and outcomes: mortality and hemostasis at different time-points during the first 24 hours after admission.RESULTS: In the intention-to-treat analysis, the 1:1:1 group tended to have decreased mortality, but with no statistical significance. For patients in whom hemostasis took longer than 2 hours, the 1:1:1 ratio was associated with a higher probability of hemostasis, statistically significant from the 4 hour on. In the per-protocol, actual-transfusion-ratios-received analysis, during four successive time intervals, no significant association was found between the actual ratios and mortality. When comparing patient groups who received both high plasma:PRBC and high platelet:PRBC ratios to the group of low ratios in both, the relative risk of achieving hemostasis was 2.49 (95% CI = 1.19-5.22) during the 3 hour after admission, suggesting a significant beneficial impact of higher transfusion ratios of plasma and platelets on hemostasis.CONCLUSIONS: Our results suggest that the impact of transfusion ratios on hemostasis is dynamic. Overall, the transfusion ratios had no significant impact on mortality over time. However, receiving higher ratios of platelets and plasma relative to red blood cells hastens hemostasis in subjects who have yet to achieve hemostasis within 3 hours after hospital admission.LEVEL OF EVIDENCE: Prognostic, level III.
View details for DOI 10.1097/TA.0000000000002819
View details for PubMedID 32520897
High quality patient care through timely, precise and efficacious management depends not only on the clinical presentation of a patient, but the context of the care environment to which they present. Understanding and improving factors that affect streamlined workflow, such as provider or department busyness or experience, are essential to improving these care processes, but have been difficult to measure with traditional approaches and clinical data sources. In this exploratory data analysis, we aim to determine whether such contextual factors can be captured for important clinical processes by taking advantage of non-traditional data sources like EHR audit logs which passively track the electronic behavior of clinical teams. Our results illustrate the potential of defining multiple measures of contextual factors and their correlation with key care processes. We illustrate this using thrombolytic (tPA) treatment for ischemic stroke as an example process, but the measurement approaches can be generalized to multiple scenarios.
View details for PubMedID 33936471