Prof. dr. Robert Slappendel, anesthesiologist Manager Quality and Safety, Amphia Hospital

Prof. dr. Robert Slappendel, anesthesiologistManager Quality and Safety, Amphia HospitalTias Nimbas Business School, Tilburg University

100% compliance of blood transfusion guidelines

Conflicts of interest

• All work is paid by Amphia Hospital • no payments by blood banks or

pharmaceutical industries.

Who wants to be a millionaire?

What’s the price of one unit of blood?

Answer:

1.€ 50,=

2.€ 200,=

3.€ 800,=

Price of blood (2009)

Costs of blood

Direct costs Indirect costs

Donor Blood bank

Collection Storage in hospital

Research Cross matching

Infections

Extra hospital stay

€200 € 800

After this session all hospitals using over 7800 units of blood can save

1 million euro a year

Topics to discuss

•Difference in transfusion rates•Risks of blood•The battle of the blood bank•Transfusion triggers•100% compliance to blood transfusion guidelines

•Results•Final conclusion

Variability of Transfusion Rates (2003)

 1. van der Poel, C.L. and M.P. Janssen, Final Report - The collection, testing and use of blood and blood products in Europe in 2002 . 2005: Strasbourg.2. van der Poel, C.L. and M.P. Janssen, Final Report - The collection, testing and use of blood and blood products in Europe in 2003 . 2005: Strasbourg.

3. *Rouger P., Blood Transfusion in Europe: The White Book 2005, European Network of Transfusion Medicine SocietiesPublic Data from National Blood Authority, Australia

Denmark

Austria

Greece

Finland

Germany

Sweden

Belgium

Luxemburg

United Kingdom

Czechia

Hungary*

Slovenia Ita

ly

Netherlands

Malta*

Cyprus

Slovakia+

Ireland

Spain*

Portugal

France

Poland

Lithuania

EstoniaLatvia

Bulgaria

Romania

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

Donations per 1,000 populationRBC transfusions per 1,000 population

NL

Gombotz H, Rehak P, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007;47:1468-1480

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

15 12 13 16 9 3 1 7 2 11 4 6 5 8 14 10

Center No.

1,401 THR - patients transfused

Variability of Transfusion Rates for Matched Patients - Prospective Austrian Benchmark Study

Potential for Reduction

97.4% of all transfusions could have been predicted by:

1. Level of anemia prior to surgery2. Volume of perioperative blood loss3. Transfusion trigger

Blood loss per surgeon (THP)

surgeon A B C D

min 100 110 400 450

max 1150 1500 2100 2500

mean 400 410 800 1000

Take your surgeons apart!

Conclusion

•There are differences between

•countries•hospitals•doctors

Message:

•Get the data out of your own hospital and show it to your colleagues!

Topics to discuss

•Difference in transfusion rates•Risks of blood•The battle of the blood bank•Transfusion triggers•100% compliance to blood transfusion guidelines

•Results•Final conclusion

• Retrospective cohort study of all hospitalisations in the US in 2004 (n=38.66 million) to assess in-hospital outcomes associated with blood transfusion.

• 5.8% (2.33 million) transfused• After adjustment for age, gender, comorbidities,

admission type or DRG transfusion associated with:• 1.7 increased odds of death (P<0.0001)• 1.9 increased odds of infection (P<0.0001)• 2.5 days longer LOS• $17,194 higher charges (P<0.0001)

$40.1 billion more charges for txed pts!

Agreement Allogenic transfusions?

•Mortality•Morbidity

• Hospital stay• Infection rates• Wound disturbances

Topics to discuss

•Difference in transfusion rates•Risks of blood•The battle of the blood bank•Transfusion triggers•100% compliance to blood transfusion guidelines

•Results•Final conclusion

Source: America‘s Blood Centers, 2004

Blood Safety Measures – Another Cost Driver

Current topic: Age of transfused red blood cells

Reduced levels of 2,3 diphosphoglycerate Increased oxygen affinity Shape change Reduced deformability Decreased viability

Reduced tissue oxygenation

Acknowledgement: Gavin Murphy

Topics to discuss

•Difference in transfusion rates•Risks of blood•The battle of the blood bank•Transfusion triggers•100% compliance to blood transfusion guidelines

•Results•Final conclusion

New national guideline blood transfusions 2011

580 pages

270 medical specialist> 200 residents

100% compliance???Doctors???????

IHI Tool

100% compliance to guideline

IHI Tool

Ordering of blood

Normal ordering of blood(non acute bleeding patient)

Hemoglobin level

Orders the amount of packed cells!

Doctor thinks….

Amphia ordering(non bleeding patient)

Age Hemoglobin level Time after surgery (> of <4 hrs) Cardial or pulmonary problems

Determines the number of packed cells!

Physical barrier:If the doctor wants anything else than this guideline he has to motivate and call the lab

Topics to discuss

•Difference in transfusion rates•Risks of blood•The battle of the blood bank•Transfusion triggers•100% compliance to blood transfusion guidelines

•Results•Final conclusion

33

Results:

Basic Principle Dutch Guideline

• Hb-value is the main trigger for transfusion• No Hemoglobin value, no blood• < 4mmol/l all patients need to be transfused• < 5mmol/l might be better for patients > 60y• < 6mmol/l might be better for patients with a history of cardiac disease

Blood transfusionschecklist approaches 100% compliance

Year 2010 2011 2012 2013

Number of red cells 11453 11836 9928 9003

money €2.473.848 € 2.556.576 €2.144.448 €1.944.648

Difference € €412.128 €611.928

Inclusive Indirect

costs€1.6 million

Difference % 16.1% 23.9%

Blood supply in the Netherlands

0

100000

200000

300000

400000

500000

600000

700000

2000 2002 2004 2006 2008 2010 2012

29%

Number of transfusions /hospital admissions per 1000 inhabitants. (Netherlands)

0

20

40

60

80

100

120

140

2000 2006 2012

Number

year

transfusions

Hospital admissions

Benchmark Europa

010203040506070

Use of red blood cell units per 1,000 inhabitants (survey 2010)

Red Blood Cell Units per1,000 inhabitants

Survey 2010 European Directorate for the Quality of Medicines and Health Care

Nederland 2012Netherlands 2012

Topics to discuss

•Difference in transfusion rates•Risks of blood•The battle of the blood bank•Transfusion triggers•100% compliance to blood transfusion guidelines

•Results•Final conclusion

Blood supplyDonors

Costs

Risks

Side effects

5 drivers to change!

Efficiency, Quality and Patient Safety

Request for checklist: robslappendel@hotmail.com