TRUDI GALLAGHER RN JURISDICTIONAL PATIENT BLOOD MANAGEMENT COORDINATOR FREMANTLE, WA AUSTRALIA...

TRUDI GALLAGHER RNJURISDICTIONAL PATIENT BLOOD

MANAGEMENT COORDINATORFREMANTLE, WA

AUSTRALIA

[email protected]

Patient Blood ManagementPatient Blood ManagementBuilding your foundationBuilding your foundation

Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical

concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort

to improve patient outcome.

Modified from: Shander and Modified from: Shander and Goodnough. Goodnough. Curr Opin HematolCurr Opin Hematol. . 2006;13(6):462-470.2006;13(6):462-470.

Blood Management All Inclusive(what’s in a name)

Transfusion Free Care / “Bloodless Surgery and Medicine”

Anemia PreventionAnemia TreatmentAppropriate use of Blood ProductsBlood ConservationDischarge Anemia needsPreoperative Assessment Postoperative assessmentTransfusion tracking / blood utilizationIntra operative reduction of blood loss

Why Is Patient Blood Management Proving To Be So

Popular Among Medical Centers In 2011?

Timing Is Everything

Why now?

Medicare “never” events Reform reimbursement unknowns Readmission issues

Other timely issues Length of stay issues Infection prevention $$$$$$$ Mortality and morbidity

Patient Satisfaction

WHAT are regulatory directed WHAT are regulatory directed data pointsdata points

Joint Commission LD.04.04.07 Clinical Practice Guidelines LD.04.01.01 thru LD.04.04.07 Leader example NPSG.01.03.01 Eliminate transfusion errors PI.01.01 The hospital collects data to monitor performance

CAP TRM.41000 Transfusion Protocol: Personnel involved in transfusion are

trained in the identification of transfusion recipients and blood components, and in observation of recipients during and after transfusion, with in-service education at least annually.

TRM.20000 is there a written quality control program TRM.40850 does the medical director of transfusion service, review cases

not meeting transfusion audit criteria AABB

9.1 blood bank has process for deviations, nonconformance related to blood 9.2.1 review of information causes of nonconformance 9.2.3 application of controls to monitor effectiveness 9.3 Quality Monitoring: process to collect and evaluate quality indicator on

scheduled basis 8.2 Monitoring of blood utilization: transfusion facility monitors and

addresses transfusion practices for all categories of blood and components

SOCIETY FOR THE ADVANCEMENT OF BLOOD MANAGEMENT

sabm.org

Patient Blood Management Patient Blood Management StandardsStandards

http://www.sabm.org/public/standards.php

Standards CommitteeStandards Committee

Professional role

President, Association for Blood ConservationPresident, Association for Blood ConservationOrgan Procurement CoordinatorOrgan Procurement Coordinator

Blood Management SpecialistBlood Management Specialist

Blood Utilization CoordinatorBlood Utilization Coordinator

Blood Conservation ManagerBlood Conservation Manager

Medical Director of Transfusion ServicesMedical Director of Transfusion Services

Transfusion Service Medical DirectorTransfusion Service Medical Director

President and CEO of Global Blood ResourcesPresident and CEO of Global Blood Resources

Expert ReviewersExpert ReviewersName Title Location

Dr. James AuBuchon

President and CEO of Puget Sound Blood Center

Seattle, WA

Jeffrey B Riley CCT,CCP

Supervisor and Educational Coordinator CardioVas Perf Work Group Mayo Clinic

Rochester, MN

Dr. George J Despotis

Associate Professor, Pathology, Immunology and Anesthesiology Washington Univ School of Med

Saint Louis, MO

Dr. James Isbister

Clinical Professor of Medicine Royal North Shore Hospital of Sydney

St Leonards, NSW, Australia

Dr. Ira A Shulman

Director of Transfusion Medicine University of Southern Ca.

Los Angeles, CA

Dr. Lena Napolitano

Division Chief Univ Of Michigan School of Medicine

Ann Arbor, MI

Leadership and Program Structure(Preparing for the foundation)

Platform Written mission statement Vision and values statement

Scope of service (what areas are affected) Medical Patients / inpatient and outpatient Surgical Patients / in patient and preoperative

Job descriptions Physician medical director Program manager

Leadership and Program Structure(blueprints)

Policies and procedures (standard of care housewide or service line specific?) Interdepartmental

Guide practice and processProtocols and guidelines

Available to the staff at all timesEducation program

Targets Physicians, mid-level providers, nurses, pharmacists Ancillary health care staff regarding

Blood management program’s goals, structure, and scope.

Leadership and Program Structure(GPS)

Quality and outcome measuresData collection and reporting to the hospital quality improvement committee as scheduled

AdministrationLeadership level representation

Transfusion or blood management committee

Consent Process and Patient Consent Process and Patient DirectivesDirectives

Consent Process and Patient Directives

Hospital-wide policy requiring written informed consent for transfusion Documents a discussion

Risk Benefits Alternatives to transfusion

Hospital-wide policy intent Supports and respects right of patients to

decline blood transfusion Addresses the rights of patients who are minors

Consent Process and Patient Directives

Hospital has a document for adult patients Directive establishing the refusal of transfusion

Defines alternatives/options to allogeneic transfusion

• Autologous transfusion modalities• Human derived growth factors• Essential cofactors (e.g. iron, B12, and folic acid)

for red cell production• Recombinant products• Factor concentrates• Blood derivatives and fractions.

Consent and Patient Directives

All patients have access to information regarding The risks and benefits of blood transfusion The risks and benefits of refusing a

transfusion Alternatives to blood transfusion that are

available and applicable to that patientA process is in place that

Identify adult patients who refuse blood transfusions

Consent and Patient Directives

Patients with a previously executed blood refusal advance directive Confirmation process

Continued desire to refuse transfusion? Obtain document and place in chart If the patient is unconscious or incapacitated, the

advance directive is honored

Education Alternatives to blood transfusions

Medical staff and other health care providers Religious proscriptions against blood transfusion

Is available to all providers

Blood Administration SafetyBlood Administration Safety

Blood Administration Safety

Policies and procedures in compliance with applicable agencies College of American Pathologists

requirements (CAP) AABB standards Applicable state regulations Standards of the JC

Ordering blood Dispensing blood Transfusing blood


Individuals involved in administration of allogeneic blood transfusion will… Satisfy requirements

Education prior to independent administration of blood products

Demonstrate skills with a preceptor before acting independently

Transfusion administration policies and procedures are in compliance with regulatory agencies


Qualified staff may not administer blood products without Receiving annual education, training and competency

annually

The hospital’s transfusion review committee reviews Near miss events Sentinel events Significant errors associated with pre-transfusion blood

specimen acquisition NOTE: the hospital defines what constitutes a significant error or near miss event. Labeling Testing Ordering Release, and transfusion of blood and blood components.

Review and Evaluation of the Patient Review and Evaluation of the Patient Blood Management ProgramBlood Management Program

Review and Evaluation of the Patient Blood Management Program

Provider-specific peer review of transfusion decisions Review information is available to the medical director of

the patient blood management program. Review of transfusion decisions includes

Determination of the clinical appropriateness of the transfusion

Documentation regarding clinical indications for transfusion

Recommendations for management without transfusion if transfusion was not clinically appropriate

Review and Evaluation of the Patient Blood Management Program

Blood use is monitored Individual clinical service as well as hospital-wide

Data are analyzed Identify areas for improvement due to over- or under-utilization.

Blood and blood component transfusion is evaluated Metrics defined by the institution

Comparison of blood utilization Transfusion practices with other institutions and published

literature.

Quality measures defined by the hospital Clinical efficacy and cost effectiveness of other treatment

modalities; transfusion alternatives or managing coagulopathy

Implemented new perfusion strategies &

unblinded surgeon data

Complacency

Began Leukoreduced

PRBC only

Education & Full Team Buy-in

CABG Blood Utilization CABG Blood Utilization RatesRates

Preoperative Anemia ManagementPreoperative Anemia Management

Preoperative Anemia Management

Identify elective surgical procedures for which preoperative anemia management screening is required (eg. cases with potential for measureable blood loss)

Patients who need preop screening are identified Three to four weeks prior to surgery

Time to diagnose and manage anemia** NOTE: unless the surgery is of an urgent nature and must be performed sooner

Screening for detecting anemia and allow diagnosis of the common causes of anemia Iron deficiency etc

A process ensures Laboratory data has been reviewed

Patients with moderate to severe anemia Anemia of unclear etiology Additional clinical evaluation and laboratory testing A referral to a specialist is made as necessary.

Outpatient treatment when clinically indicated Parenteral iron and/or erythropoietic-stimulating

agentsResults of preoperative anemia screening are

shared with Referring surgeon Primary care physician

Preoperative Anemia Management

Preoperative anemia Management

Perioperative period If treated during preoperative time period = also

followed in the postoperative period Ensures continued management of their anemia during

their hospital admission

Elective surgery is deferred and rescheduled in anemic patients when The anemia is reversible unless there is an urgent

need for surgery Decision is the responsibility of the surgeon

In consultation with the medical director of the patient blood management program

Perioperative Autologous Blood Perioperative Autologous Blood Collection For AdministrationCollection For Administration

Perioperative Autologous Blood Collection For Administration

Policies and procedures regarding perioperative autologous blood collection Collection modalities offered Methods for blood collection Indications and contraindications Reinfusion of the collected blood

Policy and procedure for; Modifications of the blood collection and reinfusion

conduits Volume of autologous blood collected

Processed Reinfusion process is documented


If hemofiltration/ultrafiltration is performed Equipment used is consistent with the

manufacturer’s instructions for the given device Modification is documented

Including the rationale for the modification

Labeling and storage requirements of perioperative autologous blood collections Defined/ and consistent with the current AABB

standards Variation from accepted techniques is documented

Including the rationale for such variation


Policies for the reinfusion of processed and/or unprocessed shed blood are established

Quality assurance program Perioperative autologous blood collection is;

Indicated, cost-efficient, effective, and safe Quality indicators are defined and monitored Variances to quality indicators

Adverse effects including potential transfusion reactions Complications Patient safety factors are documented and reviewed,

and appropriate action is taken


Personnel involved in handling of blood product collection Qualified on the basis of education and training Competency is documented and evaluated at least annually

Equipment and supplies Validated before initial use Properly maintained Revalidated after any major service or repair

Outsourced staff for perioperative autologous blood collection Outside provider is in compliance with this standard

Acute Normovolemic Acute Normovolemic HemodilutationHemodilutation

Acute Normovolemic Hemodilutation (ANH)

Policy and procedure exists; the use of ANH Approved by the chair of anesthesiology

Blood collection conduits Type of collection bag Formulation and volume of anticoagulant Site of blood collection Methods and solutions used to maintain normovolemia.

Collection and storage requirements for blood collected through ANH Compliant with all applicable accreditation and FDA

requirements

Acute Normovolemic Hemodilutation

Indications and contraindications for the use of ANH Described and include s

Both patient-related and procedure -related factors

Modifications of the blood collection conduits for specialized patient populations Jehovah’s witnesses

Described, including the rationale for the modification

The hemodynamic monitoring technique during the conduct of ANH is described Including any specialized equipment

The mathematical computation of the volume of AWB blood to be collected is stated


The projected end-points of autologous whole blood (AWB) collection are stated Including target hemoglobin or hematocrit

Where applicable, the impact of hemodilution secondary to an extracorporeal circuit prime volume is calculated

The timing and rationale for AWB reinfusion in relationship to the conduct of surgery and/or anesthesia are defined and followed.


There is a quality assurance program to ensure; ANH is cost-efficient Effective and safe Training and on-going competency assessment for

personnel collecting ANH units is defined Quality indicators are defined and monitored Variances to quality indicators

Adverse-affects Complications Patient safety factors are reviewed and addressed by a

quality improvement process


The handling of the AWB product including Sterile collection Labeling requirements Storage location Storage temperature Duration of storage Need for refrigeration Agitation versus non-agitation techniques is defined

and followed Any variation from accepted techniques that occur

must be documented and must include the rationale for such variation

Phlebotomy Blood LossPhlebotomy Blood Loss

Phlebotomy Blood Loss

Policies and processes that pertain to phlebotomy for diagnostic laboratory samples address Importance of reduced size and frequency of lab draws

There is a mechanism for identifying patients At higher risk for transfusion Those who refuse transfusions

Additional measures considered Use of microtainers Point of care testing Reduction in daily or routine labs ordered

Phlebotomy Blood Loss

There is a system in place for reducing blood loss from line draws

Individuals who re infuse blood that is unsuitable for laboratory testing are trained and deemed competent according to policy and procedure guidelines

Minimizing Blood Loss Associated Minimizing Blood Loss Associated With Surgery, Procedures, With Surgery, Procedures,

Underlying Medical Conditions, Underlying Medical Conditions, Antithrombotic Therapy Or Antithrombotic Therapy Or

CoagulopathyCoagulopathy

Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions,

Antithrombotic Therapy Or Coagulopathy

Policies and procedures are defined that minimize intraoperative blood loss

Guidelines for intraoperative use of pharmacologic agents; Topical sealants Topical hemostatic agents to minimize blood loss

Patient blood management program medical director is actively involved in selection of; Clotting factor concentrates, topical hemostatic agents,

tissue adhesives, and pharmacologic agents, including antifibrinolytic and prohemostatic agents to limit blood loss



Hospital coagulation testing services have the capability Assess and characterize hemorrhagic risk factors Assist in diagnosis of the likely etiology of coagulopathy

in a bleeding patient

Guidelines Encourage early definitive intervention and treatment of

acute hemorrhage Early return to the operating room for source of bleeding Early referral for interventional radiology and embolization Early use of endoscopy/ colonoscopy and cystoscopy for

gastrointestinal hemorrhage or genitourinary hemorrhage



Referral and consultation protocolsAssist in the management of patients

Anticoagulant and antithrombotic medications

Patients with history of significant bleeding or coagulation abnormalities

Massive Transfusion ProtocolMassive Transfusion Protocol

Massive Transfusion Protocol

Criteria are defined Initiating and discontinuing the massive transfusion

protocol

In facilities without the capacity to manage patients with massive transfusion needs Guidelines for initial damage control resuscitation Rapid transport to another facility

Responsibility for management of coagulopathy is defined

The massive transfusion protocol includes Guidelines for transfusion of red blood cells, plasma,

platelets, cryoprecipitate, and factor concentrates

Massive Transfusion Protocol

Laboratory testing, if available, is used to monitor the patient Acidosis Hypocalcemia Qualitative and quantitative abnormalities in coagulation

Where available and clinically appropriate Peri-procedural autologous blood collection and

administration is used to minimize the need for allogeneic red cells

There is a mechanism for quality review of complex cases involving massive transfusion

Transfusion GuidelinesTransfusion Guidelines

Transfusion Guidelines

The transfusion guidelines are approved by; Institution’s medical executive committee (MEC) or

Other appropriate authority of the medical staff

There is an effective transfusion utilization review process Guidelines to determine if

The transfusion under review was or is medically appropriate

That adequate and appropriate documentation is present Review may be prospective, concurrent or retrospective If retrospective, it is timely


The results of transfusion review are communicated Ordering provider Chief of the service or department Medical staff quality improvement or quality

management committee These results are used both for

Education Re-credentialing process

Transfusion guidelines are; Accessible and available to ordering providers at the

time they order transfusions


The transfusion guidelines take into consideration Patient specific factors

Age Diagnosis Laboratory values

HemoglobinHematocritPlatelet countCoagulation testingPresence or absence of critical bleeding


There is periodic review of the guidelines They remain current and relevant Promote a restrictive or conservative

approach to the transfusion of blood components

Are consistent with the literature and evolving standard of care in transfusion medicine and patient blood management

Management Of Anemia In Management Of Anemia In Hospitalized PatientsHospitalized Patients

Blood Management Patient Volume

Management Of Anemia In Hospitalized Patients

Clinical leaders of the blood management program have knowledge and experience in Recognition, diagnosis, and management of anemia

Policy requiring “anemia” be documented as part of the early clinical assessment of all patients

Protocols facilitate appropriate; Diagnosis Evaluation Management of anemia

Management strategies help minimize the likelihood of transfusion


Guidelines for the use of; Intravenous iron Erythropoietic stimulating agents (ESA’s)

Hospital transfusion guidelines recommend Against transfusion in

Asymptomatic Non-bleeding patients when the hemoglobin level is

greater than or equal to 6.0 -8.0 gm/dl.

Clinical strategies to optimize hemodynamics and oxygenation are followed before red cell transfusion is considered


Transfusion of blood and/or components is never used for; Volume repletion Treating anemias that can be treated with

specific medicationsWhen red cell transfusion is clinically

indicated in the non-bleeding patient A single unit of red cells is prescribed at a time Followed by clinical reassessment of the

patient

FINANCIALS

Definitions of price graphic:“DIRECT COST OF PRODUCT”:• includes price PRMCE pays to Puget Sound Blood Center• portion of the type of Cross• portion of Leukoreduction fees parallel to overall % of RBC’s affected

•This does not reflect • time on the staff, documentation, storage or transportation.

(**see citation below) Calculate the direct cost of the product to a center by multiplying a factor of 5 = real cost to a center for transfusing a unit of blood. Thus a unit of blood this year cost us $1915.00 overall cost and a direct cost of $383.00 per unit. Blood product costs go up annually.

**Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010 Apr;50(4):753-65. Epub 2009 Dec 9

“UNITS THAT WOULD HAVE BEEN GIVEN AT THE 2005 RATE”:We have reduced our transfusion rate by 45% in 6 years. We saved the community 17,301 units of blood (if we had continued transfusing at the 2005 rate).

DEFINITIONS CONTINUED:“SAVING INCURRED THAT YEAR”:Overall savings for 6 years reduction is 4.3 million dollars. “PATIENTS”:These are all encounters (inpatient and outpatient) in 2010. I have been assured that patient census, and healthcare facility use, has reduced during 2010 throughout the region.

“UNIT PER PATIENT”:Because the delegation and decision in what amount to transfuse varies so drastically, and we geographically transfuse 20% of our RBC’s on an outpatient basis; the allocation of portions of units of blood is the only way to show the slow reduction of overall transfusion rate. Therefore this is the calculated portion of a unit of blood that is assigned to each patient contact for PEMC patients

YEARYEAR UNITS OF UNITS OF BLOOD BLOOD GIVENGIVEN

UNITS UNITS THAT THAT

WOULD WOULD HAVE HAVE BEEN BEEN

GIVEN AT GIVEN AT 2005 RATE2005 RATE

DIRECT DIRECT COST OF COST OF PRODUCPRODUC

TT

TOTAL TOTAL DIRECT DIRECT COST COST

FOR YEARFOR YEAR

SAVINGS SAVINGS INCURRED INCURRED THAT YEAR THAT YEAR over $4.3 Mil over $4.3 Mil savings in 6 savings in 6

yearsyears

PATIENTPATIENTSS

UNIT UNIT PER PER

PATIENTPATIENT45% 45%

decrease decrease in 6 in 6

yearsyears

2005 8,808 NA $146 $1,285,968

NA 179,347

.049

2006 8,014 9,699 $166 $1,330,324

$279,736 197,942

.040

2007 7,733 10,902 $177 $1,368,741

$561,054 222,506

.034

2008 7,417 11,019 $186 $1,381,416

$668,204 224,887

.032

2009 7,124 11,142 $240 $1,709,760

$964,487 227,402

.031

2010 6,182 11,009 $383 $2,367,706

$1,848,732

224,673

.027

Thank you

Blood Management Perfusion ExpertEdy Zelinka

Director of Perfusion ServicesAPC

425-261-4249

[email protected]

TRUDI GALLAGHER RN JURISDICTIONAL PATIENT BLOOD MANAGEMENT COORDINATOR FREMANTLE, WA AUSTRALIA...

Documents

Transcript of TRUDI GALLAGHER RN JURISDICTIONAL PATIENT BLOOD MANAGEMENT COORDINATOR FREMANTLE, WA AUSTRALIA...