Analyst Cafe UIHC Strategies to Reduce Blood Utilization 6 17 2014

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June 17, 2014

The Analyst Café:

Blood, Sweat & Tears – Success of a Patient Blood Management Program

University of Iowa Health Care team

June 2014 Analyst Café – Blood, Sweat and Tears: Success of a Patient Blood Management Program 1

Blood, Sweat & Tears Success of a Patient Blood Management

ProgramScott Wilson, DO

Director, Hospitalist Care ProgramChair, Transfusion Subcommittee

Michael Miller, MD, FACEPChief Safety Officer

Clinical Medical Director, Department of Emergency Medicine

Theresa Brennan, MDChief Medical Officer

Aldijana Avdić, BSN, RN, PBMS, CPHQPatient Blood Management Specialist

Quality and Operational Improvement Engineer

Deborah ChudzikDirector, Clinical Functions


Presentation Objectives

Making the PBM program business case

Integrating data analysis into performance improvement

Data sharing with key stakeholders

Review PBM program outcomes


The University of Iowa Health Care

Academic medical center (711-bed) – 190-bed children’s hospital

Patient volume– 32,000 annual inpatient admissions– 59,000 emergency department visits– 27,875 major surgical operations– 977,337 outpatient visits

Many employees, students, and volunteers


Making the Business Case

Frequency– Blood transfusion is one of the most common

procedures performed in US²

Risks– Increased mortality, morbidity, complications, length of

stay, infection rates, TRALI, TACO, reactions¹

Cost– Acquisition cost for 1 unit RBCs: $200 to $300– Transfusion cost for 1 unit RBCs: $1200


Problem Statement

Variability in transfusion practice– Among individual practitioners– Between hospitals

Perceived benefit– 40% to 60% of transfusions are inappropriate

suggesting no benefit to patients or worse – harm4

Overuse– AMA, AHA, Joint Commission, Choosing Wisely³

Blood utilization data – Not routinely shared outside of Blood Bank


Patient Blood Management (PBM) Program

“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.”

‐ SABM“An evidence‐based, multidisciplinary approach to optimizing the care of patients who might need transfusion.”

‐ AABB


Establishing the Program Structure

Nontraditional approach of implementing the Program under the leadership of our quality office

Experts in achieving clinician buy-in and practice change

Experienced in leading a wide range of internal and external quality improvement projects

Familiarity with data mining and analysis– Using UHC CDB reports to identify opportunities


Program Leadership

Transfusion Safety Officer or Blood Management Coordinator– Provides operational leadership– Develops and oversees the quality and operational improvement

components of the Program– Implements evidence based strategies and transfusion related

activities– Provides clinicians and administration with accurate and timely

information for effective decision making related to blood management

Chief Quality Council – Provides leadership and oversight on clinical and medical issues


Program Function

Education & Communication – Competencies, orientation, ongoing training– Reporting and responding to quality and safety concerns

Compliance, Accreditation, and Licensure– Hospital policy– Regulation: AABB 1st edition PBM Standards, JCAHO– Guidelines– Consents

Equipment & Information Systems– Blood scanning – Point of care testing


Program Function

Monitoring of PBM and Utilization Practices– Blood utilization rates– Variation in ordering practice

• Lab triggers: hemoglobin, platelet, INR, fibrinogen triggers compared to others

• 2-unit orders• Verbal orders

– Recognizing and responding to transfusion reactions – Patient outcomes– Anemia and coagulation management– Appropriate use of Massive Transfusion Protocols

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UHC User Poll – Determining a Head Count for Today’s Session

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June 2014 Analyst Café – Blood, Sweat and Tears: Success of a Patient Blood Management Program12

UHC User Poll – Determining a Head Count for Today’s Session

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Thanks in advance for participating and helping us estimate a true head count!


Integrating Data Analysis into Performance Improvement

Shaping the Culture


Program Goals and Objectives

Demonstrate transfusion/patient safety

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


Scope of the Project

Staff and Patient Education, and Program Communication– Blood transfusion safety and conservation techniques

Iatrogenic Blood Loss– Excessive blood loss due to unnecessary testing– Goal: Reduce the amount of blood loss with lab draws

Transfusion Guidelines– Un-informed transfusion practice– Goal: Implement evidence-based approach to ordering of blood

components using a restrictive transfusion strategy

Anemia & Coagulation Management – Presence of correctable anemia– Goal: Detect and treat anemia preoperatively


Opportunities Identified Using UHC

Performance Gaps: – Patient outcomes (ICU stay, LOS) among transfused cases or

compared to non-transfused– Blood utilization by diagnosis, by service, by procedure, by

severity of illness, etc.– Mean direct costs with and without use of lab/blood components– % patients with lab tests, type of lab tests, mean days receiving

lab tests, total tests patient received during hospitalization– % patients receiving blood, type of blood component– Pharmaceutical use: erythropoietin, prothrombin complex

concentrates, etc.

Knowledge Gaps:– Assess current level of knowledge


Opportunities Identified Using UHC

Analyze opportunities, needs, resources, and limitations• Key stakeholders

and unit-based leadership identified

• Interdisciplinary teams formed

% ClinicalPopulationNumerator

Cases

Mean DaysResourceUsed/Case

MeanResourceUnits

Used/Case

LOS Index MortalityIndex

UIHC 10.75 1.7 3.5 0.96 0.77Comparison 11.33 1.9 4.2 1.23 1.02

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Gastroenterology Service Line

Jan‐Mar 2014Comparison: Top UHC Quality & Accountability (2013)


Scope 1: Program Education and Training

Training developed based on knowledge gaps, prior analysis, and risk assessment findings Information concise and up-to-date Specific, actionable opportunities Consistent theme/message Flexible and customizable

Training implementation Patient education pamphlets, staff handouts Best Practice Alerts Webinars, presentations, lectures Department and unit tours

June 2014 Analyst Café – Blood, Sweat and Tears: Success of a Patient Blood Management Program

Program Communication: Newsletter Examples


Scope 2: Iatrogenic Blood Loss

• Eliminate “extra tubes” or rainbow draws• Eliminate over draws – batch labs• Individual nursing/phlebotomy education• Switch to small volume tubes• Increase point of care testing• Reduce unnecessary testing and standing

orders• Selective use of pediatric tubes• Control diagnostic blood loss


Scope 3: Transfusion Guidelines

Specific indications for each blood component as supported by current literature

Age specific: neonate, pediatric, and adult Minimum effective dose Usual length of infusion times of blood

components Type and screen Suspected transfusion reaction


Scope 4: Pre-Operative Anemia Management

Elective high blood loss procedures– Pre-operative anemia is the greatest

predictor of transfusion requirements

– Offer screening and treatment of anemia to elective surgery patients as a clinical strategy to improve blood management

– Reducing LOS by just 1 day for 2000 patients yields > $4.5 million savings annually

– Correcting preoperative anemia has the potential to reduce RBC utilization and purchase cost annually


Data Reporting

Information sharing with key stakeholders


Measuring Process Performance

Senior Leadership Data– Bottom line – Hospital level aggregate data– Compare with Best Performers cohort– Show balance of cost-effectiveness and good

practices– Provide summary of key performance metrics

• Show success as positive reinforcement for dedicating time and effort into your project

• Display areas with opportunity for improvement and consult with them on solutions

– Small, frequent updates (top of mind)


RBC Utilization Rate

May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13 Oct‐13 Nov‐13 Dec‐13 Jan‐14 Feb‐14 Mar‐14 Apr‐14Data1 0.400 0.398 0.386 0.500 0.364 0.452 0.354 0.375 0.331 0.351 0.311 0.350UCL 0.529 0.529 0.529 0.529 0.529 0.529 0.529 0.529 0.529 0.529 0.529 0.529 +2 Sigma 0.480 0.480 0.480 0.480 0.480 0.480 0.480 0.480 0.480 0.480 0.480 0.480 +1 Sigma 0.430 0.430 0.430 0.430 0.430 0.430 0.430 0.430 0.430 0.430 0.430 0.430Average 0.381 0.381 0.381 0.381 0.381 0.381 0.381 0.381 0.381 0.381 0.381 0.381 ‐1 Sigma 0.332 0.332 0.332 0.332 0.332 0.332 0.332 0.332 0.332 0.332 0.332 0.332 ‐2 Sigma 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282LCL 0.233 0.233 0.233 0.233 0.233 0.233 0.233 0.233 0.233 0.233 0.233 0.233

0.180

0.230

0.280

0.330

0.380

0.430

0.480

0.530

0.580

Rate

RBC Transfusions per Discharge


Rate of Transfused Cases

May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13 Oct‐13 Nov‐13 Dec‐13 Jan‐14 Feb‐14 Mar‐14 Apr‐14Data1 0.175 0.178 0.164 0.179 0.164 0.177 0.165 0.157 0.155 0.161 0.145 0.162UCL 0.195 0.195 0.195 0.195 0.195 0.195 0.195 0.195 0.195 0.195 0.195 0.195 +2 Sigma 0.185 0.185 0.185 0.185 0.185 0.185 0.185 0.185 0.185 0.185 0.185 0.185 +1 Sigma 0.175 0.175 0.175 0.175 0.175 0.175 0.175 0.175 0.175 0.175 0.175 0.175Average 0.165 0.165 0.165 0.165 0.165 0.165 0.165 0.165 0.165 0.165 0.165 0.165 ‐1 Sigma 0.155 0.155 0.155 0.155 0.155 0.155 0.155 0.155 0.155 0.155 0.155 0.155 ‐2 Sigma 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145LCL 0.136 0.136 0.136 0.136 0.136 0.136 0.136 0.136 0.136 0.136 0.136 0.136

0.125

0.135

0.145

0.155

0.165

0.175

0.185

0.195

0.205

Rate

Transfused Cases Per Discharge


Transfusion Rate

7/1/2013 8/1/2013 9/1/2013 10/1/2013 11/1/2013 12/1/2013 1/1/2014 2/1/2014 3/1/2014 4/1/2014 5/1/2014Data1 5.13 5.34 4.26 4.24 4.49 3.90 3.79 3.90 4.83 3.64 4.76UCL 5.88 5.88 5.88 5.88 5.88 5.88 5.88 5.88 5.88 5.88 5.88 +2 Sigma 5.38 5.38 5.38 5.38 5.38 5.38 5.38 5.38 5.38 5.38 5.38 +1 Sigma 4.89 4.89 4.89 4.89 4.89 4.89 4.89 4.89 4.89 4.89 4.89Average 4.39 4.39 4.39 4.39 4.39 4.39 4.39 4.39 4.39 4.39 4.39 ‐1 Sigma 3.89 3.89 3.89 3.89 3.89 3.89 3.89 3.89 3.89 3.89 3.89 ‐2 Sigma 3.39 3.39 3.39 3.39 3.39 3.39 3.39 3.39 3.39 3.39 3.39LCL 2.90 2.90 2.90 2.90 2.90 2.90 2.90 2.90 2.90 2.90 2.90

2.40

2.90

3.40

3.90

4.40

4.90

5.40

5.90

6.40

Rate

# of Transfusions per Transfused Case


Laboratory Utilization Metric

66.5

71.5

76.5

81.5

86.5

91.5

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Mean Laboratory Utilization per Case

Data1 UCL +2 Sigma +1 Sigma Average ‐1 Sigma ‐2 Sigma LCL


Blood Product Opportunity in Units

Cardiac Vascular Thoracic, 597

Medical Specialties, 399

Womens & Infants, 214

Surgical Specialties, 145

Orthopaedics, 115

Oncology, 88 Neurosciences, 77

Total Opportunity Oct – Dec 201350th percentile $384,59680th percentile $702,632



Unit Leadership Data– Medical Directors, Nurse Managers– Compare rates by service line to other like-hospitals and

top performers– Calculate nursing time spent on transfusions– Lab utilization rates– Blood utilization rates


Transfusion Rate per 1000 Days


Patient Blood Draws



Ordering/Administering Clinicians– Individual level reports depending on transparency – Blood utilization rates for the same

procedure/diagnosis/MS-DRG compared to peers – Lab triggers: hemoglobin, platelet, INR, fibrinogen

triggers compared to others, is there a lot of variation in ordering practice

– Are they frequently using 2-unit orders?– Transfusion reactions – Restrict verbal orders to emergencies only


Evidence-Based Practice Metric

7/1/2013 8/1/2013 9/1/2013 10/1/2013 11/1/2013 12/1/2013 1/1/2014 2/1/2014 3/1/2014 4/1/2014 5/1/2014Data1 31.87% 30.84% 31.38% 31.55% 26.84% 23.58% 26.32% 22.52% 22.36% 27.98% 21.53%UCL 34.55% 34.55% 34.55% 34.55% 34.55% 34.55% 34.55% 34.55% 34.55% 34.55% 34.55% +2 Sigma 32.03% 32.03% 32.03% 32.03% 32.03% 32.03% 32.03% 32.03% 32.03% 32.03% 32.03% +1 Sigma 29.50% 29.50% 29.50% 29.50% 29.50% 29.50% 29.50% 29.50% 29.50% 29.50% 29.50%Average 26.98% 26.98% 26.98% 26.98% 26.98% 26.98% 26.98% 26.98% 26.98% 26.98% 26.98% ‐1 Sigma 24.45% 24.45% 24.45% 24.45% 24.45% 24.45% 24.45% 24.45% 24.45% 24.45% 24.45% ‐2 Sigma 21.93% 21.93% 21.93% 21.93% 21.93% 21.93% 21.93% 21.93% 21.93% 21.93% 21.93%LCL 19.40% 19.40% 19.40% 19.40% 19.40% 19.40% 19.40% 19.40% 19.40% 19.40% 19.40%

16.50%

18.50%

20.50%

22.50%

24.50%

26.50%

28.50%

30.50%

32.50%

34.50%

36.50%

Percen

tage

2 Unit Orders per Total RBC Orders


Summary of OutcomesQuality and SafetyBlood Utilization

Financial

Maintaining the Gains


Quality and Patient Safety Metrics

March 2011 to December 2013 Complications at 4% per unit:

– 357 complications avoided

Length of Stay at 1.5 days per unit:– 13,390 patient days reduced

Deaths at 0.9% per unit:– 80 lives saved

Estimated reduction in nursing time :– 18,891 hours or 9.1 FTEs

Ferraris et al, Arch Surg 2012; 147(1) – Surgical Outcomes and Transfusion of Minimal Amounts of Blood in the Operating Room.Blumberg et al. AmJSurg 1996;171:324‐30.


Summary Report

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

2010 2011 2012 2013

Length of Stay Index per Month

Blood Tx LOS Index No Blood LOS Index

Reduction of 6255.6 patient days among transfused patients x $2271 cost of hospitalization per day = $14,206,467


Summary Report

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

2010 2011 2012 2013

Mortality Index per Month

Blood Tx Group Mortality Index No Blood Mortality Index


Financial Metrics

% Saved # of Units Saved

Purchase CostSaving

Transfusion Cost Saving

Adverse Event Cost Saving

Total Savings

Total 27% 10,103 $1,770,767 $4,272,956 $11,083,212 $17,126,935

Baseline: April 2010 – March 2011Avg # of RBC Units per 1000 cases: 544.4Avg # of Plasma Units per 1000 cases: 158.2

YTD: April 2011 – December 2013Avg # of RBC Units per 1000 cases: 448.7Avg # of Plasma Units per 1000 cases: 144.4

Total Savings: 10,103 blood component units


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Blood Product Utilization Metric


Tips for a Successful PBM Program

Dedicated leader to develop and drive initiatives Core patient blood management team Collaboration among administration, staff, and patients Clinician leadership and expertise Identify roadblocks early Standardization of blood policy, protocols, and practices Continuing education for physicians and nursing It’s a moving target


References 1. Bernard A, Davenport DL, Chang PK, et al. Intraoperative Transfusion of 1 U to 2 U Packed Red Blood

Cells Is Associated with Increased 30-Day Mortality, Surgical-Site Infection, Pneumonia, and Sepsis in General Surgery Patients. J Am Coll Surg 2009;208:931-937.

2. Agency for Healthcare Research and Quality. Healthcare Cost Utilization Project Statistical Brief. #149. Most Frequent Procedures Performed in Hospitals 2010. http://www.hcup-us.ahrq.gov/reports/stat-briefs/sb149.pdf.

3. Combes JR, & Arespacochaga E. Appropriate Use of Medical Resources. American Hospital Association’s Physician Leadership Forum, Chicago, IL. November 2013.

4. Blumberg N, Kirkley SA, Heal JM. A cost analysis of autologous and allogeneic transfusions in hip replacement surgery. Am J Surg. 1996; 171(3):324-30.

5. Shander A, Fink A, Javidroozi et al. International Consensus Conference on Transfusion Outcomes Group. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfus Med Rev. 2011;35(3):232-246. e53

6. Shander A, Javidroozi M, Perelman S, et al Mt Sinai J Med. Jan-Feb 2012.7. Goodnough LT, Johnston MF, Toy PT. The variability of transfusion practice in coronary artery bypass

surgery. Transfusion Medicine Academic Award Group. JAMA;1991;365(1):86-90.8. Wilson K, MacDougall L, Fergusson D, et al. The effectiveness of interventions to reduce physician’s

level of inappropriate transfusion: what can be learned from systematic review of literature. Transfusion. 2002;42(9):1224-9.

9. Department of Health and Human Services, National Blood Utilization and Collection Survey, http://www.hhs.gov/ash/bloodsafety/nbcus/index.html

10. Agency for Healthcare Research and Quality. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2007. Available at: http://www.hcupus.ahrq.gov/reports/factsandfigures/2007/pdfs/FF_report_2007.pdf

11. Petrides M, AuBuchon JP. To transfuse or not to transfuse: An assessment of risks and benefits. In: Mintz PD, ed. Transfusion Therapy: Clinical principles and practice. 3rd ed. Bethesda, MD: AABB Press, 2011.

12. 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;50(4):753-65.

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Analyst Cafe UIHC Strategies to Reduce Blood Utilization 6 17 2014