THannonMD

It sounds like our policy is similar to others that have posted here. The anesthesiologist must sign the transfusion administration form as the transfusionist, and there must be a start and stop time included, the serial number of any blood warmers used, and an indication of whether any transfusion reactions were suspected. Regarding vital signs documentation before, during and after the transfusion, our policy allows a notation that states "see anesthesia record."

I think everyone agrees that tools are necessary but not sufficient- you also have to find physician and nursing champions to own the process. Blood utilization improvement is not a lab issue- it is a clinical issue. Just remember- the only way to get a surgeon to do something is to make him think he came up with the idea! -Tim

Cat and group- I am an anesthesiologist that has been involved in implementing blood management programs for 20 years, I am past president of the Indiana State Association of Blood Banks, I am on the MAC for the Indiana Blood Center, and I am on the AABB Perioperative Standards Committee. I try as I can to post info on discussion boards like this and on LinkedIn. In full disclosure, I established a consulting group 7 years ago that develops and helps continuously improve comprehensive blood management programs (Strategic Healthcare Group). I didn't go to medical school to be a consultant, but I was continually asked by hospitals to help them with the difficult task of changing embedded behaviors and cultures among doctors and nurses, then making the change stick. My team is front line doctors and nurses with significant blood management experience, and our approach is evidence based, patient centered, data driven and systems oriented. As an MD, I am extremely proud that what we do rapidly and sustainably improves patient safety and quality of care; as a business owner, I am also very proud that what we do rapidly and measurably returns value with a substantial ROI. For those hospitals who prefer to build their own program, we have a world class set of online tools as well as training and support program for TSOs and program leaders. The tool set include access to our proprietary Analytics to benchmark and track blood use compared to centers of excellence (a true benchmark, not just an average), a knowledge management system with a repository of articles, policies, guidelines and best practices, and a learning management system that includes 24 hours of live CME Webinars a year, 60 hours of online training, and a train the trainer program at our HQ in Indianapolis. With regards to client references, we strive to make every hospital fully satisfied and we garner superlative recommendations. We have worked with over 100 hospitals and hospital systems across the US, both academic and community, from 150 beds to 1000 beds. I apologize for the commercial message, but I take great pride in what we do and would be very pleased to work with any of your hospitals to improve transfusion safety and blood management. If you would like more information, you can reach out to me directly at thannonmd@gmail.com, or check out our web site www. BloodManagement.com, which has quite a bit of information as well as case studies. Best regards, Tim Hannon, MD

You can download a flyer we made called "The Bloody Truth" which lists ten facts about blood transfusion every clinician, administrator and patient should know. It is available at http://www.bloodmanagement.com/the-bloody-truth/the-bloody-truth

Change comes slowly if at all, particularly when things are left to their own. I am happy to talk to your Ortho MD directly- he can email me at thannonmd@bloodmanagement.com . Good luck!

Two recently published studies show that a conservative approach to transfusions in elderly hip fracture patients does not negatively effect either complication rates or rehab potential (Carson et al,NEJM 2011;365(24)) and a study showed there was no correlation between anemia as low as 7 gm/ dL and rehab potential (Vuille-Lessard et al, Transfusion 2012;52(2).

I think transfusion audits present a tremendous opportunity for "teachable moments" and to build relationships with the clinical staff. I would aspire to do a certain number of audits a month rather than just set aside time, because when things go to hell in a hand basket in the blood bank the audits go away. With regards to involving nursing staff, I feel very strongly that this should be a shared responsibility, ideally with a med tech and a nurse educator working shoulder to shoulder. In order to be effective and sustainable, nurses need to feel a sense of ownership.

I agree with the 0 pos for females > 50. Any thoughts on plasma and/ or platelet requirements? Most hospitals are adapting high ratio RBC/FFP/Plt into their massive transfusion protocols, so you might consider walking through that requirement for at least some of the patients who would meet the massive transfusion criteria.

It's great to be here! I have always tried my best to improve communication across departments, and the lab and clinical units definitely don't speak the same language. You are spot on regarding the need for MD buy in, particularly those MDs who order lots of blood. In hospitals we are working with, I am beginning to see some alignment incentives from administrators to encourage appropriate blood use, and that's a trend I'd like to see continue.

Another good question- the short answer is that predonation is no longer a recommended strategy for blood conservation, so it should be abandoned. I recently wrote a blog on this topic that has some key references: http://www.thebloodytruth.com/appropriate-blood-utilization/to-predonate-or-not-to-predonate-that-is-the-question/ .

Mabel- I am an anesthesiologist that has set up two blood management programs (Navy, St. Vincent Indianapolis) and now work 80+ outside hospitals to establish comprehensive blood management programs. We have worked with some very large organizations such as the University of Alabama Birmingham and the University of Iowa, but the bulk of these hospitals have been community hospitals less than 400 beds; in fact, some have been as small as 150 beds (Boulder Community Hospital). All have seen substantial reductions in blood use (20- 30% being typical) while improving quality and safety. We are now working with critical access hospitals within these health system, where there is also a need for safer, smarter. However, it would be a challenge to cost-justify extensive efforts in these very small hospitals if they were stand alone projects. If you are interested in talking with any of these hospitals regarding their programs, please contact me and I can put you in touch. Best regards, Tim