Blood Management program in smaller hospital

[THannonMD]

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

[THannonMD]

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/ .

[tbostock]

We still allow autologous pre-donation if a patient and physician insist, but we strongly discourage it because we are just making the patient anemic pre-surgically.

[Liz]

I thought the point was to have the patient bleed anemic blood during surgery and give back the PAD post op.

[Barbarakym]

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

John, here is the JC link I spoke of.

Has anyone really looked at this guide? It is huge, I just printed it, have not read it but did look for table of contents. Am I blind or are there are no final guideline suggestions? This is just a how to book? Nothing that they determined from their 4 year collaboration was the right thing to do. It is very technical....but practicle help? Not sure I'm seeing the picture.

[Mabel Adams]

The JC link is definitely a manual for how to collect the data, but the implication is that hospitals are expected to get good scores on that data so their guidelines for gathering data on pre-admission anemia screening and completion of BB testing before start of anesthesia etc. seems to me to set a standard.

I will try to attach an excerpt from it that lists just the standards they want us to measure.

[LCoronado]

I think the "Holy Grail" everyone is looking for is not just about how to encourage blood conservation in a general way, but what standard transfusion triggers to use for various products. Unfortunately as far as I know those do not exist as published standards but rather as recommendations, subject to many clinical variables. We audit transfusions retrospectively every month and have many that fail the first tier, laboratory criteria. However, all of those seem to pass the second tier, which is done as an in depth chart audit by the PI department. However, I think in looking at these JC measures, there is some work we can do - particularly with regard to laboratory testing before each unit as opposed to the standard order for two at a time. So thanks Mabel!

[Likewine99]

It's great to see a post by a physician here, thank you Dr. Hannon.

Having been on a Bld Conservation Team as a Blood Bank Supervisor, the best way to get a bld conservation program off the ground is physician buy in; starting with the Med Dir of the the BB, CMO of the organization, CEO of the hospitals. Once the clinicians are in agreement the next logical step is to start collecting data on patient outcomes, lenght of stay, start quantifying thing in terms of what a bld transfusion really costs your organization.

Once you start tying some $$$ to this I bet it will get everyone's attention. Good luck, this is a tough (but fun) project and it's not insurmountable. IMHO it's also a great service to the patients we care for.

[Liz]

After reading the article in Bloody Truth what I said no longer applies, in Orthopedic surgery at least.

[THannonMD]

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.

[Mabel Adams]

What sort of "incentives" are you seeing?

[goodchild]

Thank you very much to everyone for posting all of the information in this thread. Does anyone involved in their hospital's blood management program have any sort of template letter for requesting additional information regarding the prescription of blood products outside of indication that they would be willing to share with the community?

[tbostock]

Thank you very much to everyone for posting all of the information in this thread. Does anyone involved in their hospital's blood management program have any sort of template letter for requesting additional information regarding the prescription of blood products outside of indication that they would be willing to share with the community?

I review all transfusions each day to make sure that the criteria that the doctor selected is accurate (Hgb <7, acute blood loss, etc). Any that look suspicious, I will bring to our Medical Director. He looks in the EMR for more info and calls the physician to discuss. If he is satisfied, he approves it. If not, it goes to Transfusion Committee for more peer review discussion. If Tx Committee does not approve it, we send a form to the ordering physician. I am trying to attach the form but am having trouble. I will send it in a private message.

[goodchild]

Thank you very much Terri ! We are planning on implementing a very similar program for auditing. One concern is that the transfusion committee only meets every other month (sometimes further apart than that).

[Barbarakym]

I would like to discuss something mentioned in the March posts. Why is it desirable to check HGB between each unit. Why is having 1 unit transfusions such a good thing? I have always believed that if you only need 1 transfusion you don't need blood (rare exceptions). Wouldn't it be better to have a trigger that is low enough where 2 units is given? And then watch?

[tbostock]

I would like to discuss something mentioned in the March posts. Why is it desirable to check HGB between each unit. Why is having 1 unit transfusions such a good thing? I have always believed that if you only need 1 transfusion you don't need blood (rare exceptions). Wouldn't it be better to have a trigger that is low enough where 2 units is given? And then watch?

Yes, it's true that is what physicians used to be taught. If a patient needs blood, they need more than one. I believe the present day opinion is...why double a patient's risk? If they are at a 6 Hgb and short of breath, and one unit relieves their symptoms, why expose them to a second.

By requiring a post-transfusion Hgb after the 1st unit (in the absence of active bleeding), the physician has to re-evaluate the patient and see if more blood is still necessary. This is where you should make your greatest strides in a blood management program, because usually they do NOT order a second. And over time, the docs get used to lower Hgb thresholds.

[Malcolm Needs ☆]

Yes, it's true that is what physicians used to be taught. If a patient needs blood, they need more than one. I believe the present day opinion is...why double a patient's risk? If they are at a 6 Hgb and short of breath, and one unit relieves their symptoms, why expose them to a second.

By requiring a post-transfusion Hgb after the 1st unit (in the absence of active bleeding), the physician has to re-evaluate the patient and see if more blood is still necessary. This is where you should make your greatest strides in a blood management program, because usually they do NOT order a second. And over time, the docs get used to lower Hgb thresholds.

This is very much the vogue in the UK now Terri.

[carolyn swickard]

Try not having a Transfusion Comm at all because they gave up on getting the Drs to come. We are trying to get started on a Blood Management program (200 bed hospital) here, we know the expected parameters, but have no "champion". Our Pathologist is behind the program, but has no time to administer it or chase the Drs down who don't meet indications. Med Exec Comm approved (x2) a Physician's order form that was really good and would have made the Drs consider their "indications" for transfusion - you guessed it - they wouldn't use it. We are trying again with indications in the new Electronic Ordering platform - see if that helps. Our best advocate at this time is actually our blood supplier - they are trying to get things moving in this region. United Blood Services has a good monitoring software program that can get data from your MIS and make useful reports - if you are in their regions, you might ask them about it. They are also running Transfusion Safety Officer training seminars - look on their web site for information - some of them are free, you just have to pay to get there (AZ) and stay 2-3 days. Nice to know that the Blood Centers have more interest in Blood conservation than we can get anyone in this hospital to get behind. Our Utilization Management folks know we need the program, but they have no time either to administer it or chase Drs down.

[tbostock]

Try not having a Transfusion Comm at all because they gave up on getting the Drs to come. We are trying to get started on a Blood Management program (200 bed hospital) here, we know the expected parameters, but have no "champion". Our Pathologist is behind the program, but has no time to administer it or chase the Drs down who don't meet indications. Med Exec Comm approved (x2) a Physician's order form that was really good and would have made the Drs consider their "indications" for transfusion - you guessed it - they wouldn't use it. We are trying again with indications in the new Electronic Ordering platform - see if that helps. Our best advocate at this time is actually our blood supplier - they are trying to get things moving in this region. United Blood Services has a good monitoring software program that can get data from your MIS and make useful reports - if you are in their regions, you might ask them about it. They are also running Transfusion Safety Officer training seminars - look on their web site for information - some of them are free, you just have to pay to get there (AZ) and stay 2-3 days. Nice to know that the Blood Centers have more interest in Blood conservation than we can get anyone in this hospital to get behind. Our Utilization Management folks know we need the program, but they have no time either to administer it or chase Drs down.

When we set up our transfusion indications in the EMR blood order, we made it a mandatory field (hard stop), and we put all of our approved indications in there. We did not put an "other" category...the docs balked at this, but it has worked beautifully. If they want to give blood for another indication, they are told to attend the next Transfusion Committee with supporting literature (must be after the year 2000 or so) and make their case. Only one doc has ever done this, and we added an indication for him.

[BankerGirl]

Terri,

Would you share your transfusion indications? We are trying to make the indications mandatory as well, and I would like to know how you did this without an "other" category.

[EDibble]

Yes, I second the request Terri!

[jerriemc]

One problem we have had with trying to reduce ortho patient blood transfusions is new guidelines for sending patients to rehab facilities. Often our patients were anemic pre surgery and did not lose much blood during surgery. They are tolerating the anemia and the orthopedic surgeon does not want to transfusion, but the Rehab facility will not accept them with a lower than normal H and H and the patients need rehab, so they end up getting transfused.

[THannonMD]

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).

[jerriemc]

Dr. Hannon thanks for the reply. One of our othro surgeons is having a hard time with the Rehab hospital. If a patient is anemic they either won't accept them or they accept them and then send them to the hospital the next day for a transfusion. He hates for the patients to be put thru the ordeal of getting put in an ambulance, brought to the hospital, given a transfusion and then put back in an ambulance to go back to the rehab hospital. I am going to forward these studies to him, maybe he can convince the Rehab hospital to lower their standards.

[THannonMD]

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!