Disclosure. I have no conflict of interest with this event because I have no affiliations, sponsorships, honoraria, monetary support or conflict of

Transcription

1 The RBC Audit: What s in your closet? Yulia Lin, MD, FRCPC Transfusion Medicine & Hematology, Sunnybrook HSC Assistant Professor, Dept of LMP, University of Toronto On behalf of the RBC Audit Working Group ORBCON 6 th Annual Transfusion Committee Forum February 24,

2 Disclosure I have no conflict of interest with this event because I have no affiliations, sponsorships, honoraria, monetary support or conflict of interest from any commercial source

3 Objectives By the end of this session, the attendee will be able to: 1. Identify opportunities to improve RBC ordering practices 2. Determine strategies to assess the effectiveness of education/training

4 Why should we look at our RBC ordering practices?

5 Infectious Risks Decreasing 2012 HBV 1 in 1.7 million HCV 1 in 6.7 million HIV 1 in 8 million Busch et al. JAMA 2003;289:

6 Serious Hazards of Transfusion SHOT 2012 (UK hemovigilance)

7 Serious Hazards of Transfusion SHOT 2012 (UK hemovigilance) 6 of 9 deaths

8 Serious Hazards of Transfusion SHOT 2012 (UK hemovigilance)

9 Airing out our closet. Transfusion Errors as part of the Transfusion Error Surveillance System 15,134 errors 10% were inappropriate request of blood product Top High-Severity error 23 errors resulted in patient harm 21 were clinical due to inappropriate use of blood Maskens et al. Transfusion 2014;54:66-73

10 21 Clinical Errors causing Harm Maskens et al. Transfusion 2014;54:66-73

11 21 Clinical Errors causing Harm Orders that were outsideof hospital guidelines (N=20) TACO Acute Transfusion TRALI Reaction Maskens et al. Transfusion 2014;54:66-73

12 This is in the absence of proven benefit

13 This is in the absence of proven benefit

14 RBC Transfusion Audits Is the transfusion appropriate? Quality Gap: 3-46% inappropriate RBC transfusion Difficult to define appropriate Difficult to extract information (retrospective, missing documentation) French et al. MJA 2002;177: (ICU-3%) Barr et al. Transfusion 2011;51: (Hospital-23%) Parker et al. Int J Obs Anesth 2009;18: (Obs-31%) Joy PJ et al. Ann R Coll Surg Engl 2012;94: (Ortho-46%)

15 RBC Transfusion Audits Non-compliance with recommended triggers UK National Audit: 15-48% (hip replacement, acute GI bleed) John Hopkins RBC utilization: 10-50% Variability also noted Lowest Hbvaried g/l (10 th -90 th percentile) Hbat discharge varied 30 g/l (10 th -90 th percentile) Murphy & Yazer. Transfusion Dec 2013;53: Frank et al. Transfusion Dec 2013;3052-9

16 Variability across ICUs in Canada Wilton K, Callum J et al Chest Meeting Abstract

17 Step 1: Is there a problem? Physician/prescriber RBC transfusion ordering practice is an essential area of focus for ensuring appropriate blood utilization First step to targeting educational needs of physicians perform a baseline audit of RBC transfusion practice at our institution

18 The RBC Audit Working Group Participating Sites Cornwall Community McConnell Site Joseph Brant Hospital Mackenzie Health Peterborough Regional Health Centre Trillium Health Partners Credit Valley RBC Audit WG members Allison Collins, Peterborough Allahna Elahie, Joseph Brant Laura Harrison, Trillium Goretti Lafond, Mackenzie Health Wendy Owens, ORBCON Elianna Saidenberg, Ottawa Hospital & Cornwall Nancy Heddle, MTRP Katerina Pavenski, St. Michael s Hospital, OBAC Alan Tinmouth, Ottawa Hospital Deborah Lauzon, ORBCON Troy Thompson, ORBCON

19 Provincial RBC Audit Tool

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21 Key Questions 1. Which practitioners most often transfuse RBCs? 2. What is the current practice of ordering RBCs?

22 Methods Audit at 5 community hospitals Two 7-day periods (July 2 Aug 31, 2013) Transfusion order Orders with a pre-transfusion Hb 80 g/l mandated further chart review on clinical indications and comorbidities Data entry completed by Sept 30, report forms from each site used to validate data entry

23 Results Community Hospitals Site Number of RBC transfusion orders Number of RBC units ordered Number of RBC units transfused Number of patients Cornwall Community McConnell Site Joseph Brant Hospital Mackenzie Health Peterborough Regional Health Centre Trillium Health Partners Credit Valley Total Transfusion service activity (2012) ranged from 2613 to 6062 RBC units transfused

24 Who were the prescribers? Almost 100% were staff physicians Figure 3: Specialty of ordering physician (based on number of RBC units transfused; N=856) Internal Medicine, 22.1% Emergency, 17.3% Family Medicine, 14.6% Nephrology, 9.3% General Surgery, 8.6% Oncology, 8.2% Hematology, 3.9% Orthopedic Surgery, 3.7% Critical Care Medicine, 3.2% Hospitalist, 2.6% Other Gynecology Surgery Anesthesia Obstetrics Urology Cardiology Gastroenterology Family Medicine Emergency 44% Inpatient 28% Outpatient 24%

25 Where did the transfusions occur? N=856 RBC units 22% Inpatient 3% 13% 43% Emergency dept ICU Operating room Outpatient Clinic 19%

26 What was the transfusion practice?

27 Number of units ordered/transfused orders Number of Median # of RBC ordered = 2-55% of orders for 2 unit transfusions - 64% were even number of units Median # of RBC transfused = 2-49% were for 2 unit transfusions Units Ordered Units Transfused Units per order

28 Pre-transfusion Hemoglobin (N=431) Number of orders Available in 98.6% of orders 32% Hb 80 g/l Avg 75.6 g/l < >99 Pre-transfusion Hemoglobin (g/l)

29 Post-transfusion Hemoglobin (N=349) Number of orders Available in 79.9% Avg 91.9 g/l 58% Hb 90 g/l 29% Hb 100 g/l < >99 Post-transfusion Hemoglobin (g/l)

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34 Who were the patients? 56% female Avgage 68.9 ±17.9 yrs Median age 73.5 years Figure 1: Ptadmitting diagnoses (based on 1 st transfusion episode during audit; N=384) Oncologic, 24.7% Gastrointestinal, 19.8% Renal/Urologic, 12.5% Hematologic non malignant, 10.9% Orthopedic, 8.9% Respiratory, 5.2% Cardiac, 4.9% Obstetric/Gynecologic, 3.9% Trauma, 2.9% Infectious Disease, 2.3% Other, 2.1% Cerebrovascular, 1.3% Not Known, 0.5%

35 Transfusions with Pre-transfusion Hb 80 g/l 140 transfusion orders Median number of units ordered = 2 (50%) 35% single unit transfusions

36 Clinical indication (Pre-txHb 80 g/l) Percentage e of orders 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% All orders N=140 Symptomatic Bleeding Low Hb Not known Other Clinical Indication

37 Existing Co-morbidities (Pre-txHb 80 g/l) 40% 35% 30% 25% 20% 15% 10% 5% 0% N=140 transfusion orders

38 Answers to Key Questions 1. Which practitioners most often transfuse RBCs? For community hospitals, target for education: Internists, Emergency, Family Medicine MDs 2. What is the current practice of ordering RBCs? Still a tendency to order 2 units at a time?gap between evidence and practice with 30% of pre-transfusion Hb 80 g/l and 30% of posttransfusion Hb 100 g/l (not outpatients)

39 Step 2: Identify opportunities for improving practice Two simple key messages 1) Transfuse one unit at a time in non-bleeding patients 2) Reinforce evidence-based transfusion guidelines

40 Step 3: Use the Audit results Present to your transfusion committee and the target prescribers Keep it simple Number of single unit transfusions per order Pre & post-transfusion hemoglobin Rationale for narrowing the gap between practice and the evidence-based guidelines Interventions: audit & feedback, rounds, transfusion guidelines, pre-printed orders Re-audit

41 Challenges with the Audit Process Good Audit tool easy to use, can do it tomorrow Useful exercise Automated report Bad Time consuming To collect clinical information labour intensive 3 days (60 transfusion orders) 5 days (120 transfusion orders) Extracting information variable (electronic systems, paper chart)

42 The Future The Data Strategy Establish IT connections between blood bank system, laboratory system and electronic patient record Pilot at 3 sites in Ontario has been successful Allow us to benchmark with peers

43 Take Home Messages Provincial RBC audit tool available Time to look at your own practice Things you will likely find for improvement Single unit transfusions Pre-transfusion hemoglobin Re-audit after interventions

44 Acknowledgements Participating Sites Cornwall Community McConnell Site Joseph Brant Hospital Mackenzie Health Peterborough Regional Health Centre Trillium Health Partners Credit Valley RBC Audit WG members Allison Collins, Peterborough Allahna Elahie, Joseph Brant Laura Harrison, Trillium Goretti Lafond, Mackenzie Health Wendy Owens, ORBCON Elianna Saidenberg, Ottawa Hospital & Cornwall Nancy Heddle, MTRP Katerina Pavenski, St. Michael s Hospital, OBAC Alan Tinmouth, Ottawa Hospital Deborah Lauzon, ORBCON Troy Thompson, ORBCON