FABB Annual MeetingMay 14, 2015

Richard R. Gammon, M.D.

Medical Director

How A Healthcare System and Its Blood Center Can Co-Develop A Successful Patient Blood Management Program

2

Goals/Objectives

• As a result of participation in this CEU activity, learners will be able to:– Discuss how a hospital, with the support of its

blood center, may construct – from the ground up – a maximally effective PBM program

– Define the most useful, benchmark-worthy indicators for measuring a PBM program’s effectiveness

– Review successes and challenges observed following implementation of a PBM program and identify opportunities for the program’s continuous improvement

SECTION ONE

Background

3

Program Evolution

S. Benitez- Santana. Blood Management Summit 11/10

Cost of Allogeneic Blood

Transfusion 2010; 50: 753-65

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Patient Blood Management Definitions

• AABB– Evidence-based multidisciplinary approach

to optimizing the care of patients who may need transfusion

• SABM– Timely application of evidenced-based

medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcomes

Transfusion Medicine’s Emerging Positions- AABB Press 2013

Introduction

• 13.8 million red blood cell (RBC) units transfused annually in US

• Many potential reasons for the different RBC transfusion practices that exist

• Limited high-quality evidence of the benefits and harms of RBC transfusions

2011 NBCUS

Optimal RBC Use

• Administering enough maximize clinical outcomes

• Avoiding unnecessary transfusions – Expose patients to

potential infectious/ noninfectious risks

– Increase costs

SECTION TWO

How to Construct a PBM Program

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Coming Together

• While both blood centers and hospitals may be knowledgeable about patient blood management, individually each may lack resources to implement

• A joint venture, blood center as consultant and three-hospital (400+ beds) healthcare system over a 12-month period will be described

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Create Proposal

• Offer services separately or as a package

• Determine resources needed from both parties

• Build consensus on project objectives

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Obtain Buy-In from Executive Management

Kumar AJ. AABB Webinar 11/13/14

Obtain Buy-In from Executive Management

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Healthcare System CEO Signs Letter of Agreement

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Establish Working Group

• Blood Center– Medical director– Senior medical technologist – Nurse

• Healthcare System– Blood management coordinator (TSO)– Transfusion service supervisor – Lab manager.

• Met every 2 weeks – 60 minutes

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Project Objectives

• Implement kick-off meetings and engagement programs

• Create transfusion committee• Provide nursing education• Develop and implement auditing processes• Create and send nonconformance letters to

physicians and nurses • Work with IT to enhance the current

physician order entry (CPOE) system

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Create Working Group Agendas

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Establish Project MapEvent Date Format Resources Items Needed Deliverables/Output Status

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Kick-Off Meetings

• Scheduled over a period of 3 days at different times and hospitals

• 60 minute meetings with physicians and nurses of major blood users (ER, OR, Oncology and Orthopedics)

• Provide meals or refreshments• Provide CME/CEUs MT or RNs• PBM Working Group Available for

Questions

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Post links on IntranetGet the Word Out

http://medical.oneblood.org/

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Inform of Resources

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Inform of Resources

How To Determine Which Benchmarks to Use?

• Must be obtained from existing infrastructure

• Need resources to review and interpret– Raw data is of little value

• Auditable• Actions will allow for improvement

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Getting Ready for the Transfusion Committee

• Determine what to audit– Transfusion consents– Transfusion tags– Transfusion threshold– Discharge instructions– Product trends– Transfusion Reactions

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Provide Templates

Develop Charter and Attendance Policy

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Create Nonconformance Letters

• Before you get started– Determine if informational vs. punitive– Determine if first letter is not answered,

will additional letters be sent?

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Use Format That Encourages Compliance – Physician Letter

Fillable fields, email responses

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Use Format That Encourages Compliance- Nursing Letter

Individual Letters, Nursing Supervisor has to sign

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Do SOPs=CPOEs?

≠

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CPOE - Clinical Decision Support

• Provides labs/articles/or institutional guidelines

• Asks clinician - want to continue with order?

Transfusion 2012; 52: 1640-45Transfusion and Apheresis Science 2014; 51: 53-58

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CPOE - Clinical Decision Support

• Plasma orders – 10-month period– 1,808 triggered

alerts and 19.6% (354) were cancelled

• RBC warning screen – 15 month period– 15,352 triggered

alerts and 11.3% (1,649) were cancelled RBC Audits

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Create Transfusion Committee

• Consultant (OneBlood) (Chair) 

• Laboratory/Transfusion Service Pathologist  

• Hematology/Oncology    • Surgery/Cardiothoracic•  Anesthesia• Obstetrics/Gynecology• Hospitalist • Nephrology • Emergency Department• Assistant Vice President• Hematology/Oncology • Acute Care/Nursing • Nursing Education

• Coordinator/Blood Utilization • Supervisor/Transfusion Service • Director/Laboratory Services • Corporate Director/Laboratory

Services • Manager/Laboratory• Supervisor/Physician Quality

Resources • Vice President/Quality• Director/Risk Management • Outpatient

Infusion/Supervisor/Director/ Business Development(OneBlood)

• Acute Care Nursing    • Specialist/Therapeutic

Apheresis(OneBlood)• Assistant/Administrative

(OneBlood)

Rotate Transfusion Committee Chair

• Year 1– Chair from OneBlood

• Year 2– Chair from Healthcare System

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SECTION THREE

Program Challenges

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Results

• All objectives were achieved

• Each had challenges that required a solution

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Challenge 1

Objective Challenge Solution• Kick-Off

Meetings• Engagement

Programs

• Low attendance

• Mandatory for all employed physicians

• Mandatory 1-hour webinar for all new physicians

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Challenge 2

Objective Challenge Solution• Transfusion

Committee• Initial chair

from BC• Hospital

physician to chair

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Challenge 3

Objective Challenge Solution• Nursing

education• Most

possessed basic knowledge

• Blood administration policy did not match current practice

• BMC walked the floors and met during huddles

• Onsite audits of transfusions with feedback

• Novice nurses program for new hires

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Example of Transfusion Audit

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Challenge 3

Objective Challenge Solution• Nursing

education• Most possessed

basic knowledge• Blood

administration policy did not match current practice

• Revised blood administration policy based upon current practice

• How to guides (e.g. document blood administration in EMR)

• Tips and tricks sheet

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Challenge 4

Objective Challenge Solution• Auditing

Process• Located data

in several locations within electronic medical records (EMR)

• IT created Crystal Report – review 2-3 areas vs. 20

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Challenge 5

Objective Challenge Solution• Nonconformance

letters• No one wanted

letters in their files- concerned would affect recredentialing

• Send in format to ensure response

• 1st year- Informational only

• Sent using secure email

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Challenge 6

Objective Challenge Solution• IT • SOPs did not

match CPOE • Labs and SOPs not

easily available to ordering physician

• Low compliance with discharge instructions (DI)

• Update CPOE to match SOPs

• Implement clinical decision support system (last 3 labs and link to SOPs)

• DI automatically printed at time consent generated

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Project Results

SECTION FOUR

Opportunities for Continuous Improvement/AABB’s Choose Wisely Initiative

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Why give 2 when 1 will do?

Complications associated with transfusions are dose-dependent

“Transfusion Trigger” hemoglobin < 7.0 g/dL

1

1.2

1.4

1.6

1.8

1 2 3 4 5+

Adjus

ted

haza

rd ra

tio

serious bacterialinfection

pneumonia

Units Transfused

J.L. Carson, D.G. et al. Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair. Transfusion 1999; 39:694-700

R King TSO Workshop 05/15

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Background

• American Board of Internal Medicine Foundation

• Designed to help physicians and patients engage in conversations

• Reduce overuse tests and procedures • Support physician efforts to help

patients make smart and effective care choices

Transfusion epub 080614 doi: 10.1111/trf.12802

48

#1 Don’t transfuse more units of blood than absolutely necessary

• A restrictive threshold (7.0-8.0g/dL) should be used for the vast majority of hospitalized, stable patients without evidence of inadequate tissue oxygenation

• Evidence supports a threshold of 8.0g/dL in patients with existing cardiovascular disease

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#1 Don’t transfuse more units of blood than absolutely necessary

• Transfusion decisions should be influenced by symptoms and hemoglobin (Hb) concentration

• Single unit red blood cell (RBC) transfusions should be the standard for nonbleeding hospitalized patients

• Additional units should only be prescribed after reassessment of the patient and their Hb value

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#2 Don’t transfuse RBCs for iron deficiency without hemodynamic instability

• Blood transfusion has become a routine medical response despite cheaper and safer alternatives in some settings

• Preoperative patients with iron deficiency and patients with chronic iron deficiency without hemodynamic instability (even with low Hb levels) – Oral and/or intravenous (IV) iron

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Anemia Management

Benitez-Sanchez – Blood Management Workshop 11/11

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#3. Don’t routinely use blood products to reverse warfarin• Patients requiring

reversal of warfarin can often be reversed with vitamin K alone

• Prothrombin complex concentrates or plasma should only be used for patients with serious bleeding or requiring emergency surgery

Overuse of plasma transfusion. ASCP Webinar 05/08/13

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#4 Don’t perform serial blood counts on clinically stable patients

• Blood counts – Reason to believe that

a new clinically significant abnormality will be detected

• Stable patients– Serial blood counts are

unlikely to detect clinically significant abnormalities

– Contribute to iatrogenic anemia

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#5. Don’t transfuse O– blood except to O– patients and in emergencies for women of childbearing potential with unknown blood group

• O– blood units are in chronic short supply

• Overutilization for patients who are not O–

• O– RBCs restricted to– O– patients – Women of childbearing potential

• Unknown blood group • Require emergency transfusion before blood

group testing can be performed

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Conclusions

• The collaboration of a blood center and healthcare system allowed for the optimization of resources and expertise

• At the conclusion of the project, the healthcare system had a self-sustaining PBM program

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First Known Photograph Of A Transfusion

Transfusion 2006; 46: 1855

FABB Annual MeetingMay 14, 2015

The End…QuestionsRichard.Gammon@oneblood.org407-947-7963