Blood Utilization at VUMC: Developing Systems Which Shape

High Quality Care

Gina Whitney, M.D.Departments of Anesthesiology and

Pediatrics

Beginnings

• Philosophical – o Developing a model by which postoperative outcomes

inform intraoperative practice

• Practicalo Giving a large quantity of blood products intra-operativelyo “Empiric” transfusion practiceo Epidemic of “capillary leak” and prolonged ventilator

dependence post-operatively

Perioperative Blood Product Utilization in Pediatric Cardiac Surgery

5 units

6+ units

Koch, CG Ann Thorac Surg 2006; 81:1650-7.

• Two ventricle repairs without arch reconstruction – April 1996 – July 2004– 270 patients– Looked at intraoperative

blood products• 4-34 ml/kg LOW• 35-67 ml/kg MEDIUM• 68-364 ml/kg HIGH

– Measured DMV

The Quality Case:

PRBC transfusion is associated with dose-dependent increases in– surgical site infection– ventilator associated pneumonia– duration of mechanical ventilation– length of stay– mortality

Why (else) should we care about PRBC transfusion?

FINANCIAL

ALL BLOOD PRODUCTS>12, 700 TRANSFUSIONS in 2010 - VCH, ALL PRODUCTS

ANNUAL FACTOR 7 UTILIZATION ~1 MILLION DOLLARS

Blood Product Utilization

Some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them.

-Laurence J. Peter

Standardization of Intraoperative Practice

Statistical Process Control

Total PRBC per case - Anesthesia

Red Cell Transfusion

Implementation Period

P=0.001

Total Cryo per Case - Anes

Implementation Period

Cryoprecipitate Transfusion

P<0.001

Total Blood Products per case - Anesthesia

Total Blood Products per Case – 12h ICU

Total Blood Products per Case Anes + 12h ICU

Balancing Measure – Chest Tube Output

Age < 180 days

Age > 180 days

Factor 7 Utilization

Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q 1 2012 Q2 20120

5

10

15

20

25

30

Vial

s Adm

inist

ered

OR Transfusion ProtocolInitiated TEG Adoption

OOR Exit Criteria

Touchpoint: OR Exit Criteria

• ABG within 30 min of leaving room– pH >7.3– Lactate <10

• CT Output < 3 cc/kg/15min• Inotrope requirement

– Epi <0.05 mcg/kg/min– Dopamine <10 mcg/kg/min

• Debriefing performed

Lessons Learned

• Creating standard practice establishes expectations about evidence based management and clinical course.

• Perfect is the enemy of the good.• Move towards problems and not away from

them.• Replicate successes.• Lynda.com

Moving Beyond the OR

Identifying Challenges

• Need for evidence-based algorithm to determine appropriateness of PRBC transfusion

• Metrics unclear• Attribution of PRBC transfusion to the

incorrect attending physicians• “Drive by” transfusions • Need for education regarding transfusion risk

Systems Support Good Practice

How important are systems?

• Ann Thorac Surg 2012 Oct 3• 12 regional hospitals• Transfusion practice following CAB from Jan

2008 – June 2011– Surgeon identity accounted for 30% of practice

variation – Institution identity accounted for 70% of variation

in practice

Next steps

• Identified pilot ICU’s at both MCJCHV and VUH• Literature Search• Development of evidence based PRBC transfusion

protocol (adult CVICU, trauma ICU)• Modification of existing CPOE system

– “Transfuse and reassess” practice– Warn provider of off protocol transfusion– Attribution of transfusion decision to the correct

attending physician

Define Best Practice

Implemented August 2011

CPOE Decision Support

2010-01

2010-02

2010-03

2010-04

2010-05

2010-06

2010-07

2010-08

2010-09

2010-10

2010-11

2010-12

2011-01

2011-02

2011-03

2011-04

2011-05

2011-06

2011-07

2011-08

2011-09

2011-10

2011-11

2011-12

2012-01

2012-02

2012-03

2012-04

2012-05

2012-06

2012-07

2012-08

2012-090%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

RBC Utilization - Percentage of RBC Units Ordered Within Protocol for PICU

CPOE Implemen-tation

Best Practice Standard

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC300

400

500

600

700

800

900PRBC Transfusion 2010-2012 - VUMC

PRBC

Tra

nsfu

sion

Per 1

000

Disc

harg

es

2010

2012

2011

CPOE Implementation - All MCJCHV, VUH ICU’s and ED

Is our PRBC transfusion practice safer today than it was twelve

months ago?

Future Directions

• Establish “True North” Metrics• Mutual accountability

– Blood utilization metrics are relevant, up to date – Ongoing collaboration with providers (feedback, data and

refinement of existing practices)• Establish partnerships with locations with high

utilization and low adherence to established EB practices– Target resources to areas of greatest opportunity

• Transparency

Ordering Practice by Location - MCJCHV

How to Engage and Communicate?

Questions/discussion