Aldijana Avdić, BSN, RN, PBMS, CPHQ Assistant Director, Patient Safety and Privacy 1

Aldijana Avdić, BSN, RN, PBMS, CPHQ Assistant Director, Patient Safety and Privacy 1

Program Definition 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. An evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. - SABM - AABB 2

Program Design & Infrastructure 3

University of Iowa Hospitals and Clinics Academic medical center (730-bed) 190-bed children s hospital Patient volume 32,000 annual in-patient admissions 56,000 emergency department visits 29,180 major surgical operations 914,300 outpatient visits 20,700 blood transfusions > 9,000 employees, students, and volunteers 4

DeGowin Blood Center Donation Collects blood for UI Hospitals and Clinics and UI Children s Hospital Therapeutic Procedures Plasma and RBC exchange Stem cell collection LDL apheresis Therapeutic phlebotomy Tissue and cellular therapies Store and distribute human tissues 5

Program Design Nontraditional approach of implementing under quality office leadership in collaboration with the DeGowin Blood Bank Reasons: Experts in achieving clinician buy-in, practice and culture change Experienced in project management Familiarity with data mining and analysis to identify opportunities Identify key stakeholders and leadership who supported program implementation Data Patient Blood Management Information Improve quality of care Reduce costs Foster collaboration Integrating Performance Improvement & Patient Blood Management 6

People 7

Knowledgeable Personnel Transfusion Safety Officer, Chief Quality Officer, Blood Bank Medical Director TSO: Provides operational leadership CQO: Provides leadership and oversight on clinical and medical issues Develops and oversees quality and operational improvement components Implements evidence-based transfusion related strategies Transform data into information for effective decision-making Integrate analytics and performance improvement Provides feedback to clinicians and administration Engages with champions Ortho Review PBM program outcomes PBM Anesthesia 8

Engaging the Clinical Champions PBM 9

Process Design & Implementation 10

Prepare a Business Case Frequency Blood transfusion is a common procedures performed in US² >30,000 blood components transfused in 2010 Risks May be associated with an increased risk of complications, length of stay, infection rates, TRALI, TACO, reactions, and mortality¹ in certain patient populations Cost Blood component purchase cost: ~$6,000,000 per year in 2010 Transfusion cost for 1 unit RBCs: up to 6x the purchase cost Basha, J Dewitt, R, Cable, D et. al. Transfusions And Their Costs: Managing Patients Needs And Hospitals Economics. The Internet Journal of Emergency and Intensive Care Medicine. 2005 Volume 9 Number 2." 11

Program Objectives Demonstrate safety in the transfused patient population Provide ongoing financial metrics for program growth, sustainability, and fiscal responsibility Indicate strategic alignment and stewardship Strive for excellence in evidence-based patient care delivery Improve quality, reduce cost, and foster collaboration 12

Engage the Leadership Champions Leadership PBM 13

Value-Added Processes Deliverables to Reduce Modifiable Risks 1. Educate Staff and Patients Goal: Transfusion safety and conservation techniques 2. Minimize Blood Loss Goal: Amount of blood lost due to unnecessary testing 3. Increase Awareness Goal: Evidence-based approach to ordering of blood components using a restrictive transfusion strategy 4. Manage Anemia Goal: Detect presence of correctable anemia and reduce likelihood of transfusion 14

Deliverable 1: Education & Communication Training developed based on knowledge gaps and risk assessment findings Information concise and up-to-date Specific, actionable opportunities Consistent theme/message Flexible and customizable Department presentations, webinars, lectures, posters Newsletters, patient education pamphlets, staff handouts, best practice alerts Example: Department of Anesthesia In 2009, 21 presentations on transfusion medicine to all levels of providers (faculty, residents, CRNAs, SRNAs) Through the end of 2014, a total of 133 didactic presentations were given And, this DID NOT include individual case-presentations at M&M or blood-use feedback-related presentations 15

Engage the Leadership Champions Leadership PBM 16

Examples of Program Communication

Deliverable 2: Minimize Blood Loss Eliminate too many tubes: extra tubes or rainbow draws Eliminate too many draws: batch labs Reduce unnecessary testing and standing orders Reduce amount of blood drawn Switch to small volume tubes Increase point of care testing Selective use of pediatric tubes Control diagnostic blood loss Example: Department of Orthopedics Intra-operatively Control blood loss Tranexamic acid Postoperatively Reduce standing orders Eliminate extra tubes or rainbow draws Batch labs 18

Deliverable 3: Transfusion Guidelines RBC Adult Indications: Hemoglobin 7 g/dl or hematocrit 21% Complete list of indications: Blood Transfusion Guidelines RBC Pediatric Indications: Hemoglobin 7 g/dl or hematocrit 21% Complete list of indications: Blood Transfusion Guidelines RBC Neonate/Infant Indications: Hemoglobin < 7 g/dl without supplemental O2 and clinically well Complete list of indications: Blood Transfusion Guidelines Dosage: Minimum effective dose of all blood components should be used SINGLE UNIT red blood cell (RBC) transfusions for adults are often effective A dose of 1 unit of RBCs will increase hemoglobin level in an average sized adult who is not bleeding or hemolyzing by about 1 g/dl or HCT by 3% In neonates, dose of 10-15 ml/kg is generally given Duration: RBCs is usually infused over 2 to 4 hours Example: In 2013, Anesthesia began looking at pre and post op hemoglobin values to determine questionable transfusions 19

Restrictive Transfusion Liberal Transfusion Strategy Restrictive Transfusion Strategy Similar or even improved outcomes Rohde JAMA 2014; Hébert et al NEJM 1999; Cooper et al Am J Card 2011; Villanueva et al NEJM 2013 20

Deliverable 3: Transfusion Guidelines PLT Adult Indications: Platelet count <10K/MM3 prophylactically in a patient with failure of platelet production Platelet count <50K/MM3 in a patient with active hemorrhage or invasive procedure Complete list of indications: Blood Transfusion Guidelines PLT Pediatric Indications: Platelet count < 10 K/MM3 prophylactically in a patient with failure of platelet production Platelet count < 50 K/MM3 in a patient with active hemorrhage or invasive procedure Complete list of indications: Blood Transfusion Guidelines PLT Neonate/Infant Indications: Complete list of indications: Blood Transfusion Guidelines Dosage: Minimum effective dose of all blood components should be used One unit of Platelets would be expected to increase the platelet count of a 70-kg adult by 5,000 to 10,000/µL and increase the count of an 18-kg child by 20,000/µL Therapeutic adult dose is a SINGLE UNIT Duration: Platelets are usually infused over 30 to 60 minutes 21

Deliverable 3: Transfusion Guidelines Plasma Adult Indications: Emergent reversal of warfarin (consider prothrombin complex concentrate) INR >1.8 and significant hemorrhage Complete list of indications: Blood Transfusion Guidelines Plasma Pediatric Indications: Emergent reversal of warfarin (consider prothrombin complex concentrate) PT/PTT > 1.5 times the mean of the reference range with active bleeding Complete list of indications: Blood Transfusion Guidelines Plasma Neonate/Infant Indications: Bleeding or invasive procedure with abnormal coagulation studies or documented significant deficiency of a clotting factor PTT > 150 seconds Complete list of indications: Blood Transfusion Guidelines Dosage: Minimum effective dose of all blood components should be used The volume transfused depends on the clinical situation and patient size, and may be guided by laboratory assays of coagulation function Duration: Plasma is usually infused over 30 to 60 minutes 22

Deliverable 3: Transfusion Guidelines Cryo Adult Indications: Fibrinogen <100 mg/dl Complete list of indications: Blood Transfusion Guidelines Cryo Pediatric Indications: Fibrinogen < 100 mg/dl before invasive procedures or if bleeding Complete list of indications: Blood Transfusion Guidelines Dosage Minimum effective dose of all blood components should be used Volume transfused depends on the clinical situation and patient size, and may be guided by laboratory studies Duration: Cryoprecipitate is usually infused over 30 minutes Cryo Neonate/Infant Indications: Fibrinogen < 100 mg/dl Complete list of indications: Blood Transfusion Guidelines 23

Engage the Pharmacy Champions Leadership PBM Pharmacy 24

Deliverable 4: Anemia Management Pre-operative anemia is the greatest predictor of transfusion requirements, >3x as likely be transfused (2) Pre-operative anemia is associated with an increased risk of morbidity and mortality in patients undergoing major surgery (1,2) Offer screening and treatment of anemia as a clinical strategy to optimize surgical patients Correcting preoperative anemia has the potential to reduce RBC utilization and purchase cost annually 1. Dunne. J Surg Res. 2002 2. Shander. Am J Med. 2003 25

Tools & Change Management 26

Engage the Pharmacy Champions Leadership IT PBM Pharmacy 27

Transforming Data Into Information Analyze opportunities, needs, resources, and limitations Performance Gaps: Among transfused and non-transfused patient Blood utilization: by diagnosis, by service, by procedure Lab utilization: # of tests, type of tests, tubes per day, total tests per hospitalization Pharmaceutical utilization: erythropoietin, prothrombin complex concentrates, etc. Outcomes Direct cost Knowledge Gaps: Assess current level of knowledge 28

Analytics Data Analysis and Reporting Monthly quality meeting Information sharing with key stakeholders Summary of key performance indicators Comparison with Best Performers cohort Balance of cost-effectiveness and good practices Celebration of success as positive reinforcement for dedicating time and effort Display opportunities for improvement and consult with the team on solutions Small, frequent updates (top of mind) Example: In late 2010, periodic case-by-case (and provider-by-provider) reports (volume transfused not consistent with EBL) Periodically reported by the CHAIR to the Department as a whole at M&M 29

The Value of Information Transforming data into valuable information has the ability to result in achievement of organization s goals and significant organizational success First, Identify types of information available, who uses it, and how Understand relationships among data Make the information useful to aid in decision-making Provide a feedback mechanism Data Information Second, identify value-added processes and strategies that lower cost and improve service (patient outcomes) Third, knowledgeable personnel is key to unlocking the potential Result: organization with a competitive advantage 30

Evaluate 31

Total Joint Arthroplasty Outcomes % Patients Transfused Total Blood Transfused % Transfused 20 15 10 5 0 11% 9% 6% 2012 2013 2014 % Patients Transfused Linear (% Patients Transfused) Total Blood Units Transfused 300 250 200 150 100 50 0 261 214 165 2012 2013 2014 # of Units Linear (# of Units) 46% Reduction 37% Reduction

Main Operating Room Outcomes 14000 Blood Units Transfused per Year 12000 10000 8000 11,411 10,209 9,340 6000 4000 7,538 6,100 5,170 2000 0 2009 2010 2011 2012 2013 2014 MOR Units Transfused (All Components) Linear (MOR Units Transfused (All Components)) 33

Net Result Between 2009 and 2014 Blood product use in the MOR has dropped by 55% - and by 62% when adjusted for increasing case volumes. This represents a CUMMULATIVE saving (vs. 2009 levels) of over 18,000 units of blood product. Blood Product Use in Non-OR locations throughout UIHC dropped by 27% - meaning that the MOR is now transfusing only 33% of the blood products used in the hospital (down from 54%) 34

Audit 35

Audit 36

OVERALL RESULTS

Total Blood Transfusions 3500 Total Blood Tranfusions 3000 # of Blood Transfusions 2500 2000 1500 1000 500 0 9/1/2009 11/1/2009 1/1/2010 3/1/2010 5/1/2010 7/1/2010 9/1/2010 11/1/2010 1/1/2011 3/1/2011 5/1/2011 7/1/2011 9/1/2011 11/1/2011 1/1/2012 3/1/2012 5/1/2012 7/1/2012 9/1/2012 11/1/2012 1/1/2013 3/1/2013 5/1/2013 7/1/2013 9/1/2013 11/1/2013 1/1/2014 3/1/2014 5/1/2014 7/1/2014 9/1/2014 11/1/2014 1/1/2015 38

Transfusion Rate per 1,000 Discharges 1200 Blood Transfusion Rate per 1,000 Discharges p<0.01 1100 1000 UCL 995 900 Rate 800 CL 779 700 600 LCL 562 500 400 Severity of Illness Pre PBM 2.241 Post PBM 2.296 Jul-10 - Mar-15

RBC Utilization Rate RBC Transfusions per 1,000 Patients 750.0 Transfusion Safety Officer hired p<0.01 650.0 Transfusion Guidelines Developed & Order Sets Implemented Run Chart 550.0 Education Started Best Practice Alert for 2-Unit Orders Anemia Clinic Started 450.0 350.0 250.0 Sep-09 - Apr-15 Data 1 Median Linear (Data 1)

Patients Without Any Blood Transfusion 0.89 Patients Without Transfusion p<0.01 0.88 0.87 UCL 0.8736 Rate of 0 Units per Patient 0.86 0.85 0.84 0.83 0.82 0.81 CL 0.8410 LCL 0.8084 0.80 0.79 Baseline Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Baseline - Apr-15

Units per Transfused Patient 6.70 Units per Transfused Patient p<0.01 6.20 UCL 6.270 Units per Transfused Patient 5.70 5.20 4.70 4.20 CL 4.747 3.70 3.20 LCL 3.224 2.70 Baseline Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 Baseline - Apr-15

Percent of Transfusions per Hospital Stay Transfusions per Hospital Stay Percent Change 1 unit 55.2% 2 units 38.3% 3 to 5 units 30.7% 6 to 10 units 32.4% >11 units 30.0% Any blood 19.3% 43

2-Unit RBC Transfusion Orders 2-Unit RBC Orders 54.50% Best Practice Alert for 2-Unit Orders Pilot Best Practice Alert for 2-Unit Orders Hospital- Wide 49.50% UCL 0.4862 % 44.50% 39.50% 34.50% 29.50% CL 0.4255 LCL 0.3649 24.50% 19.50% 14.50% 9.50% Baseline - 3/1/2015

Single v. Double RBC Unit Transfusions 60.00% Single vs Double Unit Transfusions 50.00% 40.00% % 30.00% 20.00% 10.00% 0.00% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 2-Unit Orders 31.87% 30.84% 31.38% 31.55% 26.84% 23.58% 26.32% 22.52% 22.36% 27.98% 21.53% 18.84% 23.46% 21.99% 22.54% 20.10% 21.88% 22.12% 20.25% 21.82% 21.33% 1-Unit Orders 41.90% 38.83% 39.89% 41.52% 41.34% 41.76% 39.82% 46.38% 49.09% 45.30% 42.78% 41.67% 46.21% 46.64% 44.72% 43.50% 47.17% 46.21% 47.76% 42.77% 48.94%

Blood Loss 31% 23%

Financial Metrics Total Savings: 20,351 blood component units % Saved # of Units Saved Purchase Cost Saving Transfusion Cost Saving Adverse Event Cost Saving Total Savings Total 23% 20,351 $3,347,197 $8,131,063 $20,381,110 $31,859,370 Baseline: Avg # of RBC Units per 1000 cases: 554 Avg # of Plasma Units per 1000 cases: 190 YTD: Avg # of RBC Units per 1000 cases: 362 Avg # of Plasma Units per 1000 cases: 81

Tips for a Successful PBM Program Dedicated leader to develop and drive initiatives Core patient blood management team Focus on a relatively homogenous group of providers working in a well defined geographic area and in a single department Collaboration among administration, staff, and patients Clinician leadership and expertise Recurrent educational efforts focused at all levels of providers Identify roadblocks early Standardization of blood policy, protocols, and practices Data gathering and repeated feedback It s a moving target Persistence! 48

aldijana-avdic@uiowa.edu Thank you! Aldijana Avdić, BSN, RN, PBMS, CPHQ Assistant Director, Patient Safety and Privacy aldijana-avdic@uiowa.edu 49