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1 Presentation Handouts (9233-LMT-PBM) A Case Study in Patient Blood Management at a Private Community Hospital October 7, :00 PM - 5:30 PM

2 Event Faculty List 9233-LMT-PBM: A Case Study in Patient Blood Management at a Private Community Event Title: Hospital Event Date: Sunday, October 7, 2012 Event Time: 4:00 PM to 5:30 PM Director/Moderator Rosemary Steuber MT, SBB(ASCP)CM Catskill Regional Medical Center Blood Bank Supervisor steuberr@crmcny.org Disclosures: No Speaker Regina Castor BS, MT(ASCP)SBB Immucor Blood Bank Technical Specialist rcastor@immucor.com Disclosures: Yes

3 Autologous Blood: Revisited Catskill Regional Medical Center Transfusion Services Rosemary Steuber, MT, SBB(ASCP) CM Blood Bank Supervisor Reasons for Preoperative Autologous Blood Donations (PABD) Rare antibodies in patients Mistrust of Allogeneic blood supply Special needs Increased Risk for blood transfusion during or post-surgical procedure For example: vascular or thoracic surgery Background CRMC, 2006: increased PABD practices led to a discussion of the benefits and disadvantages of this program Increased wastage of units = loss of $$ Retrospective in-house study performed to analyze potential savings 1

4 Clinical Triggers Analyze: What are the chances for a transfusion? Develop criteria for who is a candidate Target the high risk group for PABD Point Score System (PSS) Developed by Canadian group in 1997 Laroque, Brien & Gilbert (Transfusion, 1998) Validation Studies Accuracy in determining High Risk patients using Point Score System Question proposed: Who would benefit the most from PABD?? 2

5 Laroque study: Over 400 patients studied in 2 Canadian hospitals Four Risk Groups were constructed by grouping the scores into relevant categories Point Score System Hemoglobin (g/dl) Weight (kg) Type of Surgery Primary vs. Revision Hemoglobin (g/l) Good predictor for perioperative blood txn Preop Hgb low = likely to be tx d post-op Transfusion threshold Range: > points points points 3

6 Weight (kg) Blood volume directly proportional to weight Heavier Volume Range: > points points < 80 3 points Type of Surgery Statistically blood loss greater with hip surgery Hip vs. Knee Range: Knee 0 points Hip 2 points Bilateral knee Bilateral hip 3 points 6 points Primary vs. Revision 0 points vs. 2 points 4

7 Predictors calculated and categorized into Risk Groups Group Points Frequency of Tx % % % % Who should donate PABD?? Only high risk patients: Group 4! Example: 80 year old female weighing 82kg needs a revision of a unilateral hip replacement. Her hgb is 12.8 How many points under the PPS system? 5

8 Answer: 8 POINTS! She falls into category 4 High risk patient Qualifies for PABD PABD Advantages: Patient has antibodies Patient does receive his/her own blood (but it is mixed w/anticoagulants and preservatives) Does not impact allogeneic blood supply Disadvantages Patient still subject to adverse reactions Potential clerical errors/mistransfusions Unnecessarily induce patient into semianemic state PABD collections are not covered by insurance carriers Possible delay of surgery 6

9 Currently: Only ~ 40% AWB actually transfused Possibly Tx d due to preop induced anemia Tx s because they were there and available (not clinically justified) Significant blood loss during surgery Reality of AWB Program Not all patients qualify Units only available to that patient NOT for general inventory Costs of units NOT reimbursable Significant loss $$$$ Wastage of units BLOOD Costs $$$ BLOOD Costs $$$ Labor Overhead Supplies Storage & monitoring Adverse effects Possibly longer stay in hospital 7

10 Average Direct Cost of AWB = ~ $280/unit CRMC Direct loss for 2005 = ~ $25,000 Can NOT bill the patient for autologous units collected!! Alternatives to General AWB prescribing Cell saver EPO Restrict AWB to Risk Group 4 Allogeneic units Tx can actually hurt, not help Adverse reactions Febrile reactions TRALI, ARDS, TACO, bacterial, etc. Potential allergic reactions Increased post-op infection rates 8

11 Determination for Transfusion Realization: Hospital has established basic triggers but overall final decision to transfuse rests with physician (other reality: repeated examples show that a patient can recover successfully even if Hgb goes to 6 or 7 g) CRMC Results CRMC Results 9

12 CRMC Results Summary Introduction to Canadian PABD PSS made a positive effect on physician ordering practices Doctors became more discretionary & selective= fewer units collected= maximized benefits of autologous program Summary Wastage of PABD units reduced by 48% Allogeneic units transfused reduced by 44% High risk patients had AWB units available Reduced hospital s cost of unused units 10

13 Conclusion Utilization of Point Score System Beneficial to Patients, Doctors & Hospitals Thank you for your time Reference: Laroque, BJ, Gilbert, K, and Brien, WF. Prospective validation of a point score system for predicting blood transfusion following hip or knee replacement. Transfusion 1998; 38:

14 Blood Management at Baptist Hospital Objectives Describe the history of the Blood Management Program at Baptist Hospital Discuss successes/outcomes of the program to date Financial Quality Inspection-Readiness A little about Baptist Hospital Private, communitybased hospital in Pensacola, Florida Licensed for 492 beds Active Orthopedic, Oncology, Cardiac service lines, some OB Trauma Center Network of 4 hospitals and Behavioral Medicine facilities 1

15 A little more about Baptist Hospital Very competitive healthcare market (HCA, Ascension Health and Military Hospitals all in the same town of about 300,000) 2005 Malcolm Baldridge Quality Award Winner Focus on empowering employees History Blood Management began around 2004 loose program that lacked structure Began as a grass-roots campaign by passionate and engaged individuals Perfusion Blood Bank Efforts focused primarily on anecdotal stories which indicated a need for change Drawer full of articles and publications relating to transfusion best practices History Blood Utilization reviews began with Blood Bank technologists performing audits Outliers referred to Pathologist for follow-up with medical staff Follow-up rarely occurred C/T ratios Transfusion audits 2 per floor per month conducted by Blood Bank staff Scores went to Nurse Managers 2

16 History Autologous blood use perceived to be high Wastage Non-reimbursed costs Cell Savers and TEG used primarily in Open Heart cases History History 2005 Blood Management Team formed Part of Grand Slam initiatives to track cost savings Membership included: Lab including Core Lab, Stat Lab, Blood Bank Nursing Perfusion Pharmacy Administration for cost keeping 3

17 History Grand Slam period included: Focus on lowering use of autologous blood Increasing use of cell savers Pharmaceutical cost savings Bringing Platelet Factor IV antibody testing inhouse to reduce turn around times Increasing the use of TEG to guide component therapy Cardiopats purchased low hanging fruit period Point of Care History 2007 Baptist switches to Red Cross as Blood Supplier Strategic Healthcare Group pilot slot negotiated into contract 3-year contract negotiated Blood cost reduced 2008 Dr. Hannon/SHG site visits occur Blood Management Website goes live on intranet 4

18 SHG Significance of SHG Outside experts Regulatory vulnerabilities exposed Mass blitz of education/awareness Blood Bank Quality/Risk Management Nursing Physicians Administration Significance of SHG Administration lends full support to Blood Management initiatives Savings were real Quality was real Regulatory concerns were real Validation that we were on a good path 5

19 Education Initiatives A Blood Management Website was created for clinicians and staff. In addition to transfusion statistics, the website contains published articles and learning modules on transfusion best practices Blood Bank participates in each Nursing Orientation class to go over best practices Topics such as TRALI, preventing TA- GvHD, and consents are covered. History 2008 Transfusion Committee forms Membership includes: Pathology Open Heart Surgeon (team lead) Oncology Anesthesia Orthopedics ER/Surgery Lab Pharmacy Perfusion Nursing Affiliates Administration The Transfusion Committee reports to the Performance Review Committee which reports to the Medical Executive Committee Transfusion Triggers 2008 Reduced critical value for Hgb/Hct from 8/24 to 7/21. Reducing calls to physicians for critical values reduced ordering practices Values based on current best practices, literature Transfusion Policy written 6

20 History Oct 2009 Blood Component Order Form Implemented Baptist participates in Alpha Site Visit for Joint Commission Blood Management Standards Blood Auditing Process revised Sep 2010 Return Visit by SHG Gulf Breeze Hospital included Oct 2010 Scoring process for Blood Audits made more stringent Implementation of a blood order form was noted as a best practice by Blood management experts and the AABB. Use of the form provides the following: 1) Encourages physicians to review lab values before transfusing 2) Improves the safety of the transfusion by addressing the infusion rate 3) Gives a standard way to communicate special transfusion needs to improve safety 4) Requires Physicians to provide a justification for the transfusion to improve decision making and aids in performing utilization review 5) Improvesdocumentation from a regulatory perspective Transfusion Review/Utilization In FY2010, the auditing process was changed so that not only were more transfusions reviewed, but that they were also reviewed for more criteria. AABB recommends 5% of all transfusions be audited; our stretch goal is to audit 25% of all transfusions. Changing the process also allowed more auditing to be done on transfusions that took place on evening and night shifts 7

21 Avoiding Autologous blood is good: Keeps blood in the patient, Units cannot be released to others if they aren t used leading to increased waste and expense, storage lesion effects seen in autologous units too, focus is to use better techniques during surgery so that patients don t need to get blood Pharmaceutical Changes Pharmaceutical changes included: NovoSeven Protocol Change from HESPAN to HEXTEND as a volume expander Switched from Procrit to Darbopoetin for reduced costs Switched from using Bovine Thrombin to Recombinant Thrombin for better patient outcomes Began using platelet glues to reduce bleeding 8

22 Nursing In-line waste devices implemented to reduce iatrogenic blood loss Use of the Cardiopat at the bedside following Open Heart surgery reduces the amount of banked blood use Updated Blood Consent Form (engagement) Required Annual Training Module for Nurses Improved reporting/response to Txn Rxns Blood Bank Electronic Crossmatch implemented Automation installed in the Blood Bank Consents reviewed at time of issue New Unit Tags implemented Better capture of information for review Improved process of reporting transfusion rxns Reduced paperwork Revised Transfusion Record 9

23 Blood Bank All dedicated Blood Bankers (Day-shift) share in QA responsibilities Transfusion audits Chart reviews Blood Collection Audits Successfully leveraged blood management cost savings, regulatory compliance against staff cuts Transfusion Audits Included Environment of Care audits Included Hand Hygiene Audits = Blood Bank is a team player = Regulatory Compliance improved = Staffing discussions not as painful Successes 10

24 Successes Successes Blood Costs per Admission 11

25 Successes Where are we going next Pre-operative anemia management Drive accountability through reporting Blood use by DRG Blood use by physician New Utilization review process that is related to OPPE OPPE = Ongoing Professional Practice Evaluation 12

26 OPPE = Ongoing Professional Practice Evaluation Transfusion reviews moved to Microsoft Access Key Take Aways Don t just focus one department, look at what is driving the blood usage pre-op?, post-op? anemia management? Pharmaceuticals? Nursing? Get all the players to the table, spirit of cooperation Don t under-estimate education Measure what is important 13

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