Blood Management program in smaller hospital

[Mabel Adams]

Has anyone started a blood management program in a US hospital of less than, say, 400 beds? Did the program work to save money and reduce unnecessary transfusions? What made it work? Did you hire a consultant?

[John C. Staley]

Mabel, I'm curious, what are you referring to as a "blood management program"? Are you thinkning of a computer program to help manage inventory or just a process that would include ordering practice as well?

:pcproblem

[Mabel Adams]

http://www.bloodmanagement.com/the-bloody-truth/the-bloody-truthinfo@bloodmanagement.com

Blood Management is the new plan for a hospital wide-program that makes sure patients get the blood products that they need and not ones that they don't. Joint Commission is starting to take an interest in this and, of course, it saves money on blood products. It takes a lot of integration because it involves things like screening pre-op patients for anemia and treating them with iron or EPO etc. before surgery. I'll try to remember to post the JC info I have at work about it. They didn't make them standards---yet.

[Deny Morlino]

ARC has been slowly making their customers aware of this developing mindset in our area. I have had discussions with our pathologist on this very topic, but we are only in the very earliest stages of considering these practices. Check with your blood supplier(s) as this is in their best interest to promote conservation of blood products. Like many other changes this will be a mountain of a project moved one shovelful at a time.

[Malcolm Needs ☆]

ARC has been slowly making their customers aware of this developing mindset in our area. I have had discussions with our pathologist on this very topic, but we are only in the very earliest stages of considering these practices. Check with your blood supplier(s) as this is in their best interest to promote conservation of blood products. Like many other changes this will be a mountain of a project moved one shovelful at a time.

The UK has been trying to do this kind of thing for some time, under the banner of a government-led intiative called "Better Blood Transfusion".

I fear that moving one shovelful at a time may be wildly optomistic. Here, we are using a teaspoon!!!!!!

:omg::omg:

[Mabel Adams]

http://www.jointcommission.org/assets/1/6/PBM_Implementation_Guide_20110624.pdf

John, here is the JC link I spoke of.

[pbaker]

We have just organized our blood utilization committee. We started by revising the ordering practices and lowering the hemoglobin cutoff for red cell transfusion. It is almost ready to be rolled out to the medical staff, so we will see how it goes over. Our hospital chief medical officer is totally on board and says "just do it." We are trying to utilize products more efficiently and reduce the number of unnecessary transfusions (hgb 9.0 gets a unit of blood because "it will make them feel better."), as well as reduce cost.

[Malcolm Needs ☆]

(hgb 9.0 gets a unit of blood because "it will make them feel better.").

Good luck, and I hope it all goes well for you (but, be prepared for teething troubles).

That having been said, unless there is a clinical reason for giving a single blood at an Hb of 9g/dL (e.g. a dodgy heart), it is an experiment in in vivo antibody production to see which antigen is the most immunogenic.

Edited September 7, 2011 by Malcolm Needs

[Liz]

in vivo...

[Malcolm Needs ☆]

Quite right Liz - sorry!!!!!!!!!!!!

I've changed it to hide my idiocy.

[cthherbal ☆]

pbaker: We are hoping to start something similar as well. Reducing critical Hgb call value from 8 to 7 we think will help the "trigger" physicians use to order blood. Spoke to some other hospitals in our region and we are catching up to what they've already been doing for years. One hospital saved over 1 million in blood costs in 18 months by just making this one change. We are getting some resistance from our docs but we hope to push this through our transfusion committee but also the Medical Quality Council.

[tbostock]

We had quite a successful Blood Conservation Program at my previous hospital (about 250 beds). We were hoping for a 20% decrease, but ended up with 50%. We did it ourselves, and did not go the consultant route. The two most successful parts:

1. Lowering the Hgb threshold to 7, and requiring docs to select a transfusion rationale before transfusing.

2. They also had to attest which non-blood alternatives they had considered prior to ordering the transfusion (iron, epogen, interventional radiology techniques, cell saver, fluid challenge, etc).

These two made them think about why they were transfusing and what other options they could try before transfusing as a last resort instead of it being their first response.

Another piece of advice: for this to "fly" with the medical staff, you need a champion physician (hematologist or anesthesiologist is best) to advocate for it, showing current literature about the need for more conservative blood usage.

[Mabel Adams]

What interventional radiology techniques might they use?

[tbostock]

What interventional radiology techniques might they use?

Mostly for trauma cases: embolization of bleeding vessels, usually in spleen or sometimes in pelvic bleeds. Also used for fibroids.

[cthherbal ☆]

Thanks so much for sharing, Terri.

[BankerGirl]

We are trying to start this at our facility as well. We are still trying to get baseline data so we can identify the potential impact, and are still looking for that physician champion. We actually have an anesthesiologist who asked us about starting this, so I will be contacting him once we have data. It will definitely be an uphill battle here, but we are preparing to fight it.

[tbostock]

We are trying to start this at our facility as well. We are still trying to get baseline data so we can identify the potential impact, and are still looking for that physician champion. We actually have an anesthesiologist who asked us about starting this, so I will be contacting him once we have data. It will definitely be an uphill battle here, but we are preparing to fight it.

Sometimes you have to bring people kicking and screaming into the 21st century. Most of our docs were still transfusing like it was the 80's and had not been educated about conservative blood usage. Wishing you the best...it is definitely worth the fight, not just financially, but better patient care in my opinion.

[DPruden]

The physician champion is key! And I think it should be a transfusing physician, as opposed to a pathologist, preferably a doc that is well respected and listened to by other medical staff members. We were much more successful after adding standard indications into the EMR, so that something had to be chosen by the ordering MD.

[AMcCord]

We are just starting work on this. Our cheer leader is a fairly recent addition to the medical staff -Internal Medicine - and is one of our heavier blood product users (very appropriate user, I might add). He is on the Quality Committee and the Transfusion Committee, so he is well placed to move this product. He has asked me to gather information about suggested protocols, so he is going to be willing to work with Blood Bank - fabulous! I'll let you all know how it goes.

[bbville]

We started a transfusion committee about 18 months ago and although few of the doctors we invited to participate show up we do have nurses from several areas, a risk management representative, infection control, perfusion and the chief medical officer represented (along with Blood Bank of course). Over a period of about 7 months we developed an 'Order Form' and require it for pick up of blood products. Although the nurses fill it out about 80% of the time we require a MD name on the order. Our biggest success so far has resulted from requiring 'reflex' hemoglobins on non-bleeding patients before a 2nd unit is dispensed. The physician must re-justify the subsequent unit(s) one at a time. Our hospital is only about 250 beds, but we increased our single unit transfusions from about 25 per month to consistantly about 75 per month every month since the order form was placed into use saving about 50 units per month. Now....this wasn't as easy as it sounds. It takes great resolve and baby steps are celebrated and you need a pathologist who is involved and supportive, but I truly believe we are providing better patient care and saving money to boot!

[Mabel Adams]

Has anyone had their hospital make an administrative decision to not use pre-deposit autologous blood? Or has your decrease in its use been driven solely by changes in the practice of the surgeons?

[Deny Morlino]

Ours has been by practice of the surgeons. Just listened to an AABB webinar yesterday covering Orthopedic blood use reduction strategies. The speaker seemed strongly against autologous blood use due to the reduction in hemoglobin of the patient prior to surgery, and higher frequency of transfusion of the autologous donors with not only auto units but allo units as well. He stressed better preparation of the patient approaching surgery as one part of the strategy to reduce use.

[AMcCord]

Surgeons - also much less patient interest in autologous and directed donation.

[BankerGirl]

For autologous donations, I think ours is two-fold: surgeons stopped asking patients if they wanted to pre-donate and we stopped drawing them. This means that if they want to do autologous donations, they have to drive 90 miles to the blood center, and most of them are not that motivated.

[dlizama]

The link above about blood management was not working correctly. Here is the correct link: http://www.bloodmanagement.com/the-bloody-truth/the-bloody-truth