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Theresa Brennan, MD
Chief Medical Officer
Deborah Chudzik
Director, Clinical Functions
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Presentation Objectives
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Patient volume
Frequency
Blood transfusion is one of the most common
procedures performed in US
Risks
Increased mortality, morbidity, complications, length of
stay, infection rates, TRALI, TACO, reactions
Cost
Acquisition cost for 1 unit RBCs: $200 to $300
Transfusion cost for 1 unit RBCs: $1200
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Problem Statement
Variability in transfusion practice
Among individual practitioners
Between hospitals
Perceived benefit
40% to 60% of transfusions are inappropriate
suggesting no benefit to patients or worse harm4
Overuse
AMA, AHA, Joint Commission, Choosing Wisely
Blood utilization data
Not routinely shared outside of Blood Bank
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Thetimelyapplicationofevidencebased
medicalandsurgicalconceptsdesignedto
maintainhemoglobinconcentration,optimize
hemostasisandminimizebloodlossinaneffort
toimprovepatientoutcome.
SABM
Anevidencebased,multidisciplinaryapproach
tooptimizingthecareofpatientswhomight
needtransfusion.
AABB
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Program Leadership
Transfusion Safety Officer or Blood Management
Coordinator
Provides operational leadership
Develops and oversees the quality and operational improvement
components of the Program
Implements evidence based strategies and transfusion related
activities
Provides clinicians and administration with accurate and timely
information for effective decision making related to blood
management
Program Function
Hospital policy
Regulation: AABB 1st edition PBM Standards, JCAHO
Guidelines
Consents
Program Function
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
10
11
12
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
13
14
15
Knowledge Gaps:
Assess current level of knowledge
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
16
Analyze
opportunities,
needs, resources,
and limitations
GastroenterologyServiceLine
12.00
10.00
8.00
6.00
Key stakeholders
and unit-based
leadership
identified
Interdisciplinary
teams formed
4.00
2.00
0.00
%Clinical
Population
Numerator
Cases
MeanDays
Resource
Used/Case
Mean
Resource
Units
Used/Case
LOSIndex
Mortality
Index
UIHC
10.75
1.7
3.5
0.96
0.77
Comparison
11.33
1.9
4.2
1.23
1.02
JanMar2014
Comparison:TopUHCQuality&Accountability(2013)
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
17
Training implementation
18
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
20
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
21
22
Data Reporting
Information sharing with key stakeholders
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
23
Bottom line
Hospital level aggregate data
Compare with Best Performers cohort
Show balance of cost-effectiveness and good
practices
Provide summary of key performance metrics
Show success as positive reinforcement for dedicating time
and effort into your project
Display areas with opportunity for improvement and consult
with them on solutions
24
Rate
0.430
0.380
0.330
0.280
0.230
0.180
May13
Jun13
Jul13
Aug13
Sep13
Oct13
Nov13
Dec13
Jan14
Feb14
Mar14
Apr14
Data1
0.400
0.398
0.386
0.500
0.364
0.452
0.354
0.375
0.331
0.351
0.311
0.350
UCL
0.529
0.529
0.529
0.529
0.529
0.529
0.529
0.529
0.529
0.529
0.529
0.529
+2Sigma
0.480
0.480
0.480
0.480
0.480
0.480
0.480
0.480
0.480
0.480
0.480
0.480
+1Sigma
0.430
0.430
0.430
0.430
0.430
0.430
0.430
0.430
0.430
0.430
0.430
0.430
Average
0.381
0.381
0.381
0.381
0.381
0.381
0.381
0.381
0.381
0.381
0.381
0.381
1Sigma
0.332
0.332
0.332
0.332
0.332
0.332
0.332
0.332
0.332
0.332
0.332
0.332
2Sigma
0.282
0.282
0.282
0.282
0.282
0.282
0.282
0.282
0.282
0.282
0.282
0.282
0.233
0.233
0.233
0.233
0.233
0.233
0.233
0.233
0.233
0.233
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
0.233
0.233
LCL
Rate
0.175
0.165
0.155
0.145
0.135
0.125
May13
Jun13
Jul13
Aug13
Sep13
Oct13
Nov13
Dec13
Jan14
Feb14
Mar14
Apr14
Data1
0.175
0.178
0.164
0.179
0.164
0.177
0.165
0.157
0.155
0.161
0.145
0.162
UCL
0.195
0.195
0.195
0.195
0.195
0.195
0.195
0.195
0.195
0.195
0.195
0.195
+2Sigma
0.185
0.185
0.185
0.185
0.185
0.185
0.185
0.185
0.185
0.185
0.185
0.185
+1Sigma
0.175
0.175
0.175
0.175
0.175
0.175
0.175
0.175
0.175
0.175
0.175
0.175
Average
0.165
0.165
0.165
0.165
0.165
0.165
0.165
0.165
0.165
0.165
0.165
0.165
1Sigma
0.155
0.155
0.155
0.155
0.155
0.155
0.155
0.155
0.155
0.155
0.155
0.155
2Sigma
0.145
0.145
0.145
0.145
0.145
0.145
0.145
0.145
0.145
0.145
0.145
0.145
0.136Caf 0.136
0.136and Tears:
0.136 Success
0.136of a Patient
0.136 Blood
0.136
0.136Program
0.136
June0.136
2014 Analyst
Blood, Sweat
Management
0.136
0.136
LCL
Transfusion Rate
#ofTransfusionsperTransfusedCase
6.40
5.90
5.40
Rate
4.90
4.40
3.90
3.40
2.90
2.40
7/1/2013
8/1/2013
9/1/2013
1/1/2014
2/1/2014
3/1/2014
4/1/2014
5/1/2014
Data1
5.13
5.34
4.26
4.24
4.49
3.90
3.79
3.90
4.83
3.64
4.76
UCL
5.88
5.88
5.88
5.88
5.88
5.88
5.88
5.88
5.88
5.88
5.88
+2Sigma
5.38
5.38
5.38
5.38
5.38
5.38
5.38
5.38
5.38
5.38
5.38
+1Sigma
4.89
4.89
4.89
4.89
4.89
4.89
4.89
4.89
4.89
4.89
4.89
Average
4.39
4.39
4.39
4.39
4.39
4.39
4.39
4.39
4.39
4.39
4.39
1Sigma
3.89
3.89
3.89
3.89
3.89
3.89
3.89
3.89
3.89
3.89
3.89
2Sigma
3.39
3.39
3.39
3.39
3.39
3.39
3.39
3.39
3.39
3.39
3.39
2.90
2.90
LCL
June
2014 Analyst
Blood, Sweat
and Tears:
Success of
a Patient Blood
Program
2.90
2.90 Caf 2.90
2.90
2.90
2.90
2.90 Management
2.90
2.90
Data1
UCL
+2Sigma
+1Sigma
Average
1Sigma
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
2Sigma
201401
201312
201311
201310
201309
201308
201307
201306
201305
201304
201303
201302
201301
201212
201211
201210
201209
201208
201207
201206
201205
201204
201203
201202
201201
201112
201111
201110
201109
201108
201107
201106
201105
201104
201103
201102
201101
91.5
86.5
81.5
76.5
71.5
66.5
LCL
28
Oncology,88 Neurosciences,
77
Surgical
Specialties,145
CardiacVascular
Thoracic,597
TotalOpportunityOct Dec2013
Womens&
Infants,214
50th percentile$384,596
th percentile$702,632
80
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Medical
Specialties,399
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
30
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
31
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
32
Ordering/Administering Clinicians
Individual level reports depending on transparency
Blood utilization rates for the same
procedure/diagnosis/MS-DRG compared to peers
Lab triggers: hemoglobin, platelet, INR, fibrinogen
triggers compared to others, is there a lot of variation
in ordering practice
Are they frequently using 2-unit orders?
Transfusion reactions
Restrict verbal orders to emergencies only
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
33
Percentage
30.50%
28.50%
26.50%
24.50%
22.50%
20.50%
18.50%
16.50%
7/1/2013
8/1/2013
9/1/2013
Data1
31.87%
30.84%
31.38%
31.55%
26.84%
UCL
34.55%
34.55%
34.55%
34.55%
+2Sigma
32.03%
32.03%
32.03%
+1Sigma
29.50%
29.50%
Average
26.98%
1Sigma
2Sigma
LCL
1/1/2014
2/1/2014
3/1/2014
4/1/2014
5/1/2014
23.58%
26.32%
22.52%
22.36%
27.98%
21.53%
34.55%
34.55%
34.55%
34.55%
34.55%
34.55%
34.55%
32.03%
32.03%
32.03%
32.03%
32.03%
32.03%
32.03%
32.03%
29.50%
29.50%
29.50%
29.50%
29.50%
29.50%
29.50%
29.50%
29.50%
26.98%
26.98%
26.98%
26.98%
26.98%
26.98%
26.98%
26.98%
26.98%
26.98%
24.45%
24.45%
24.45%
24.45%
24.45%
24.45%
24.45%
24.45%
24.45%
24.45%
24.45%
21.93%
21.93%
21.93%
21.93%
21.93%
21.93%
21.93%
21.93%
21.93%
21.93%
21.93%
19.40%
19.40%
19.40%
19.40%
19.40%
19.40%
19.40%
19.40%
19.40%
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
19.40%
19.40%
34
Summary of Outcomes
Quality and Safety
Blood Utilization
Financial
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
35
36
Summary Report
LengthofStayIndexperMonth
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
2010
2011
BloodTxLOSIndex
2012
2013
NoBloodLOSIndex
Reductionof6255.6patientdaysamongtransfusedpatientsx$2271costof
June 2014 Analyst Caf hospitalizationperday=$14,206,467
Blood, Sweat and Tears: Success of a Patient Blood Management Program
37
Summary Report
MortalityIndexperMonth
1.60
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
2010
2011
BloodTxGroupMortalityIndex
2012
2013
NoBloodMortalityIndex
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
38
Financial Metrics
TotalSavings:10,103 bloodcomponentunits
Total
%Saved
#of Units
Saved
Purchase
Cost
Saving
27%
10,103
$1,770,767
Transfusion Adverse
CostSaving Event Cost
Saving
$4,272,956
$11,083,212
TotalSavings
$17,126,935
1000
0
2586
2670
Aug-11
Sep-11
1747
1792
Jan-13
Apr-13
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
1521
Feb-14
7
5
1883
1588
Jan-14
16
Mar-14
1652
Dec-13
2005
2154
13
Nov-13
1933
14 11
Oct-13
Sep-13
2671
2288
18
Aug-13
1810
Jul-13
1934
1711
42 15
Jun-13
May-13
8 5
1709
13
Mar-13
1552
1821
Dec-12
2000
Feb-13
1731
Nov-12
2094
Sep-12
Oct-12
2129
10
Aug-12
2494
2290
2381
17
Jul-12
Jun-12
2107
19
May-12
12 13 12
Apr-12
2356
2102
Feb-12
Mar-12
2106
Jan-12
2553
2060
15
Dec-11
4
13 13
10
Nov-11
2439
2630
Jul-11
11 13
8
Oct-11
2662
2392
Jun-11
2408
May-11
500
Apr-11
2474
2155
2500
Mar-11
2747
1500
Jan-11
3000
Feb-11
Number of Administrations
24
15
19
3
7
17
6
5
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
41
References
1.
2.
3.
4.
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6.
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8.
9.
10.
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Bernard A, Davenport DL, Chang PK, et al. Intraoperative Transfusion of 1 U to 2 U Packed Red Blood
Cells Is Associated with Increased 30-Day Mortality, Surgical-Site Infection, Pneumonia, and Sepsis in
General Surgery Patients. J Am Coll Surg 2009;208:931-937.
Agency for Healthcare Research and Quality. Healthcare Cost Utilization Project Statistical Brief. #149.
Most Frequent Procedures Performed in Hospitals 2010. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb149.pdf.
Combes JR, & Arespacochaga E. Appropriate Use of Medical Resources. American Hospital
Associations Physician Leadership Forum, Chicago, IL. November 2013.
Blumberg N, Kirkley SA, Heal JM. A cost analysis of autologous and allogeneic transfusions in hip
replacement surgery. Am J Surg. 1996; 171(3):324-30.
Shander A, Fink A, Javidroozi et al. International Consensus Conference on Transfusion Outcomes
Group. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference
on transfusion outcomes. Transfus Med Rev. 2011;35(3):232-246. e53
Shander A, Javidroozi M, Perelman S, et al Mt Sinai J Med. Jan-Feb 2012.
Goodnough LT, Johnston MF, Toy PT. The variability of transfusion practice in coronary artery bypass
surgery. Transfusion Medicine Academic Award Group. JAMA;1991;365(1):86-90.
Wilson K, MacDougall L, Fergusson D, et al. The effectiveness of interventions to reduce physicians
level of inappropriate transfusion: what can be learned from systematic review of literature. Transfusion.
2002;42(9):1224-9.
Department of Health and Human Services, National Blood Utilization and Collection Survey,
http://www.hhs.gov/ash/bloodsafety/nbcus/index.html
Agency for Healthcare Research and Quality. HCUP Facts and Figures: Statistics on Hospital-Based
Care in the United States, 2007. Available at:
http://www.hcupus.ahrq.gov/reports/factsandfigures/2007/pdfs/FF_report_2007.pdf
Petrides M, AuBuchon JP. To transfuse or not to transfuse: An assessment of risks and benefits. In:
Mintz PD, ed. Transfusion Therapy: Clinical principles and practice. 3rd ed. Bethesda, MD: AABB Press,
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Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of
blood transfusions in surgical patients at four hospitals. Transfusion. 2010;50(4):753-65.
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
42
Questions?
43
Suggestions / Questions
CDP Member Support Services
Phone: 312-775-4399
Email: cdpinfo@uhc.edu
44
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Prize Drawing
45
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
46
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program