Blood Appropriateness Review

[cindym]

Our Health Information Management Department was performing the blood transfusion appropriateness reviews and sending any outliers to the Transfusion Committee. They no longer want to perform these and the Transfusion Committee wants the Blood Bank to take this task over. I wanted to find out how others handle this task??

[Mary**]

Ours is performedby a "Quality Management"team. Mostly nurses.

[Gkloc]

At my hospital me and the lab director pick out questionable cases for each month, and then every other month we have a meeting with a committee comprised of mostly nurse trainers and head nurses.

[David Saikin]

Some institutions utilize Medical Records for the initial screening . . . in most places that I inspect it is the Blood Bank's responsibility. At my facility, the Medical Director reviews transfusions.

[Brenda K Hutson]

At one place I worked at a number of years ago, I was able to create Reports in the LIS that would "pull out" outliers each day. The Medical Director gave me the parameters, outside of which the transfusion would be questionable (so he gave me H&H parameters for RBC transfusions; Platelet parameters for Platelet Transfusions; and Coag parameters for FFP Transfusions). Each day, part of our daily reports was to print 3 separate reports; RBCs, Platelets and FFP. If I recall correctly (which I may not....), once the program was set up with the parameters, all the Tech. had to do was put in the Date Range. The Reports of outliers would then be given to the Medical Director each day. So inbetween Blood Utilization Review Committee Meetings (Quarterly), either he, or another MD on the committee (he divvied them out) would pull the patient's charts and see if they could see a justifiable reason on the chart for the transfusion (even though it was outside of the normal parameters); if YES, case closed; if NO, a letter was sent to the Physician, asking for a response of justification. These were then discussed at the BUR Committee Meetings. The computer system we were using at that time was Sunquest.

Brenda Hutson, CLS(ASCP)SBB

Our Health Information Management Department was performing the blood transfusion appropriateness reviews and sending any outliers to the Transfusion Committee. They no longer want to perform these and the Transfusion Committee wants the Blood Bank to take this task over. I wanted to find out how others handle this task??

[Liz]

The CP Residents review the transfusions.

[Liz]

Approximately how many outliers did you have Brenda? And it seems like a very good system.

[Brenda K Hutson]

You know, this was at a place I left 7 years ago (and a town far away). It was about a 400 bed Hospital and I would say perhaps they reported on 5-10 patients at the Quarterly BUR Committee Meetings. But that does not then include the outliers for which they felt there was adequate justification once they reviewed the patient's chart. Just one basic example; we may wonder why an MD is ordering RBCs when the patients H&H is 11/33. But the piece we may not know is that the patient is actively bleeding.

Brenda Hutson, CLS(ASCP)SBB

Approximately how many outliers did you have Brenda? And it seems like a very good system.

[tbostock]

It has been suggested that having Blood Bank doing the utilization review could be viewed as a "conflict of interest", you might not be as "impartial" as someone outside the process. Don't really totally agree with this, but...

We require justification up front, so we only get a few "fallouts" per month. We screen these and give the list to Quality Management, and they do the chart review. If they are not able to easily find supporting documentation for the transfusion, it goes to Transfusion Committee.

My point is...just because the HIM Department wants to get rid of it, be careful in taking it all on. Spread the love a little and have other departments get involved.

[Brenda K Hutson]

Perhaps this was understood, but the Transfusion Service I referenced was overseen by the Medical Director I referenced. And the Medical Director I referenced was the Head of the Transfusion Committee. So if that is who you are saying should not be doing it because it may be seen as a conflict of interest, then I can interpret your comments; if otherwise, I am not sure what you are saying (does ANY of what I just said make sense?)!

Anyway, I guess I would be a little confused as to why it would be seen as a conflict of interest if the parameters used for transfusions were Hospital-wide; that had been discussed and accepted "up front." So then the only subjective piece would be the chart review for those that fell outside and I don't really see how that is a conflict of interest either; it just "is what it is." If they send the MD a letter asking for forther justification, it is only a letter; the MD can defend their actions.

Brenda

It has been suggested that having Blood Bank doing the utilization review could be viewed as a "conflict of interest", you might not be as "impartial" as someone outside the process. Don't really totally agree with this, but...

We require justification up front, so we only get a few "fallouts" per month. We screen these and give the list to Quality Management, and they do the chart review. If they are not able to easily find supporting documentation for the transfusion, it goes to Transfusion Committee.

My point is...just because the HIM Department wants to get rid of it, be careful in taking it all on. Spread the love a little and have other departments get involved.

[tbostock]

Sorry if you thought I was responding to your response. It was meant as a suggestion for the original poster of this thread.

When someone at a previous facility heard that the Blood Bank was doing utilization review, they said "isn't that like having the fox watch the hen house?" Meaning, I suppose, that we couldn't be objective because by lowering our blood usage, we would benefit in our budget. As I said, I don't agree with that reasoning, as I think we have a pretty good idea in the Blood Bank about who should and should not receive blood, and would be pretty honest about it.

Perhaps this was understood, but the Transfusion Service I referenced was overseen by the Medical Director I referenced. And the Medical Director I referenced was the Head of the Transfusion Committee. So if that is who you are saying should not be doing it because it may be seen as a conflict of interest, then I can interpret your comments; if otherwise, I am not sure what you are saying (does ANY of what I just said make sense?)!

Anyway, I guess I would be a little confused as to why it would be seen as a conflict of interest if the parameters used for transfusions were Hospital-wide; that had been discussed and accepted "up front." So then the only subjective piece would be the chart review for those that fell outside and I don't really see how that is a conflict of interest either; it just "is what it is." If they send the MD a letter asking for forther justification, it is only a letter; the MD can defend their actions.

Brenda

[Brenda K Hutson]

Ah....would have been ok if it was a response to my post; I just wasn't clear.

I see your point (actually, it wasn't "your" point) except that I guess the impression I have had any where I worked was that it was all about using blood appropriately both for the safety of the patient, and for insurance reimbursement purposes; not to lower ones budget (but perhaps I am naive).

Brenda

Sorry if you thought I was responding to your response. It was meant as a suggestion for the original poster of this thread.

When someone at a previous facility heard that the Blood Bank was doing utilization review, they said "isn't that like having the fox watch the hen house?" Meaning, I suppose, that we couldn't be objective because by lowering our blood usage, we would benefit in our budget. As I said, I don't agree with that reasoning, as I think we have a pretty good idea in the Blood Bank about who should and should not receive blood, and would be pretty honest about it.

[Liz]

Brenda, thank you for your reply. I was wondering about the number as we don’t have large numbers nearly nil. For H/H I allow any value if actively bleeding. This makes it easier.

Thank you for sharing. And no there is no conflict of interest, I have been inspected by many agencies and am legal. Once I was asked for the raw data as the results were unbelievably perfect.... and the BOT said even boringly perfect.. haha

To note: The AABB does advise against the BB Med Dir chairing the committee.

thanks

Liz

[Eoin]

I am the QM, BB. We routinely check surgical requests against MSBOS. We also do individual C/T ratios on a six monthly basis for all docs. They are kept strictly confidentiial. If they are high, they get a letter from the Transfusion Committee Chair (Consultant Haematologist).

The docs know we are routinely auditing Tx requests, so if they are outside MSBOS, we would often get a call (or a note on the request) giving justification. We then investigate outliers to look for reasons.

Like Liz, H/H alone is not regarded if actively bleeding. The ones we are interested in are the post-op with Hb above 9 (Trigger is 8 mind you), without any continued bleeding. We do keep in mind that the Hb / crit trigger is not the only reason for requests (low BP, high PR etc). Mind you, we are a relatively small hospital and consultants would routinely have a coffee or lunch with all other staff, so the rapport is good.

There are always the thorny ones mind you.

Cheers

Eoin

[Brenda K Hutson]

Right, but if you want to pull up reports, you can't sort by "patients actively bleeding." So you put in H/H values under "normal" circumstances (so patient who needs transfusion due to anemia); then for patients that fall outside of that, active bleeding may be something that is discovered during the chart audit. That would then be a circumstance in which the Medical Director would not need to contact the patient's physician. But all of that gets defined.

Brenda

Brenda, thank you for your reply. I was wondering about the number as we don’t have large numbers nearly nil. For H/H I allow any value if actively bleeding. This makes it easier.

Thank you for sharing. And no there is no conflict of interest, I have been inspected by many agencies and am legal. Once I was asked for the raw data as the results were unbelievably perfect.... and the BOT said even boringly perfect.. haha

To note: The AABB does advise against the BB Med Dir chairing the committee.

thanks

Liz

[mjshepherd]

At our facility I perforn the initial appropriatness review by randomly selecting a a percentage of total patients transfused and reviewing the chart. If I see anything that falls outside the transfusion guidelines I forward it to our pathologist for the final say. If the path feels it truely falls outside acceptable practice he drafts a letter to the physician. If a physician receives 3 letters in a 2 year period he is asked to appear before the review board.

[Brenda K Hutson]

Right; I hear what you are saying. But what I am saying is that there is no way to input into your Blood Bank computer system a parameter of "patient is bleeding." That is something you would only be able to get from their chart/records. So you first determine what an acceptable H&H is for the non-bleeding patient; so just being transfused due to anemia. So for example, maybe your Institution says patients with a HgB >9 would not need to be transfused with RBCs. So you input that and ALL patients who were transfused with a HgB >9, come up on the Report. Then you can audit those patient's records to see which, if any, of those patients were actively bleeding at the time of the Order/Transfusion. You then disregard those patients and just focus on the ones for whom no "reasonable" explanation was found for transfusing. For those patients, you contact the patient's MD for an explanation.

Anyway, that is just a process I have used elsewhere.

Brenda Hutson

Right, but if you want to pull up reports, you can't sort by "patients actively bleeding." So you put in H/H values under "normal" circumstances (so patient who needs transfusion due to anemia); then for patients that fall outside of that, active bleeding may be something that is discovered during the chart audit. That would then be a circumstance in which the Medical Director would not need to contact the patient's physician. But all of that gets defined.

Brenda