Why Give 2 When 1 Will Do?”- Reducing Unnecessary Blood

“Why Give 2 When 1 Will Do?”- Reducing Unnecessary Blood Transfusions Through Implementation of a Patient Blood Management Program

Authors: Stephanie Hall, MD MHA, Chief Medical Officer; Gregory A. Magee, MD, PBM Program Director and Attending, Vascular Surgery; Thomas Bates, RN BSN MBA CPHQ CPHRM LNCC, Associate Administrator, Quality and Outcomes; Mansi Baxi, MHA, Program Manager, Quality and Outcomes; Liliana Jimenez, Project Manager, Quality & Outcomes

Methods

Problem Statement

Background Results

Lessons Learned & Next Steps

Keck Hospital is a tertiary/quaternary academic medical center, focused on treating critically ill, surgical patients.

At Keck Hospital, 22.2% of inpatients receive blood – this is ~3 standard deviations away from mean blood utilization.8

There is no standardized provider approach to the use of transfusion guidelines and hemoglobin triggers.

Providers order multiple units of blood at a transfusion trigger higher than 8g/dL for stable patients.

Blood transfusion is one of the most common procedures performed in US hospitals1 with approx. 14M units of packed RBC used each year.2 Transfusions are often associated with increased mortality, complications, infection and LOS.3 There is a large variability in the practice of transfusion – studies show that 40%-60% of transfusions are not necessary.4

Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical concepts aimed at achieving better patient outcomes by relying on patient’s own blood.5 PBM programs have been implemented in hospital systems nationwide to reduce the number of unnecessary transfusions, therefore resulting in better patient outcomes, while also decreasing cost.

A restrictive transfusion threshold of Hgb 7-8g/dL can be used for a majority of hospitalized, stable patients. Single-unit red cell transfusions should be the standard for non-bleeding, hospitalized patients.6

Reducing unnecessary transfusions decreases overall hospital costs. One unit of RBCs at USC have an acquisition cost of $208.25 and a total cost of $1476.25 per unit.7

In late 2018, Keck Hospital embarked on a PBM journey, rallying clinical and administrative champions to form a PBM Collaborative focused on reducing Keck’s unnecessary blood utilization.

The PBM Collaborative utilizes evidence-based data to fuel improvement projects at a monthly Steering Committee. The group is led by a surgeon champion and if composed of surgeons, anesthesiologists, hospitalists, and nursing staff.

Built Patient Blood Management app to show service-line specific and physician-specific blood utilization data. This data is now built into a scorecard and presented on a quarterly basis. Tracks single unit

transfusions Pre-transfusion Hgb

trigger Total unit volume

transfused per patient

“Why Give 2 When 1 Will Do?”9 – In April2019, we invited Dr. Steven Frank of JohnsHopkins to present his success of restrictivetransfusion protocols and a PBM program atJHU. Keck Hospital subsequently developedour own “Why Give 2 When 1 Will Do?”campaign –with pens and mousepads topromote single-unit blood transfusions.

12

64

13

38

12

06

11

17

11

25

12

10

12

52

11

55 13

01

12

48

11

28 1

02

1

57

6907822 805 797 751 789 848 788

910822 806 822

488

Jul'18 Aug'18 Sep'18 Oct'18 Nov'18 Dec'18 Jan'19 Feb'19 Mar'19 Apr'19 May'19 Jun'19 Jul'19

Total Transfused Units by Transfusion Events Total Transfused Units Volume

1.39

1.631.50

1.401.50 1.53 1.48 1.47 1.43

1.521.40

1.24 1.18


Average Units per Event

80% 75% 79% 81% 77% 75% 79% 81% 80% 81% 83%92% 93%

20% 25% 21% 19% 23% 25% 21% 19% 20% 19% 17%8% 7%


Percentage of RBC Single Unit Transfusion Events Single Unit Multiple Unit

$1,865,980

$850,320

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000


Total Cost (Direct & Indirect)

In one calendar, the total number of units has decreased by 54.43% with a majority of the decrease after April 2019. Dr. Frank came to speak in April with educational material handed out in June 2019.

The average units transfused per transfusion event also decreased by 22% since April 2019, indicating less units ordered and transfused on patients during each transfusion.

Keck Hospital had a dramatic decrease in June and July 2019 of multiple unit transfusions, reinforcing our “Why Give 2 When 1 Will Do?” Campaign that launched in June 2019. This result indicates that providers are now transfusing 1 unit vs. 2 which was the previous standard.

Each unit costs $1,476.25 in direct and indirect costs. Using the total units transfused, we see a 54% cost savings (~$1M). The savings from the PBM program justify our investment greatly.

Citations:

1.Agency for Healthcare Research and Quality. Healthcare Cost Utilization Project Statistical Brief #165, Most Frequent Procedures Performed in Hospitals 2011; 2. Department of Health and Human Services, National Blood Utilization and Collection Survey; 3. Petrides, M et. al, To transfuse or not to transfuse: An assessment of risks and benefits; 4. Shander et. al, Appropriateness of allogeneic red blood cell transfusion; 5. Unpublished Work © 2015. Society for the Advancement of Blood Management, Inc.; 6. "Five Things Physicians and Patients Should Question." American Association of Blood Banks, Choosing Wisely, 24 Apr. 2014, www.choosingwisely.org/societies/american-association-of-blood-banks/; 7. Keck Hospital Blood Bank Acquisition and Internal Cost Budget; 8. Vizient Data – November 2018 to June 2019; 9. Frank, MD, Steven M. "Evidence-based Transfusion Practice and ." University of Southern California, 5 Apr. 2019, Los Angeles. Lecture.

Initially, the PBM Collaborative split up the group into 5 working groups reporting to one steering committee. This slowed down progress, so it was streamlined to 1 all-inclusive steering committee.

After presenting first iterations of data, we learned the need to separate Non-OR and Intra-Op transfusions when presenting data to provide a clearer picture. This will become easier when Anesthesia switches from paper records to EMR.

Next Steps: Pre-Op Anemia Optimization pathways are being constructed within Cardiac Surgery to understand the billing and insurance nuances behind giving pre-op iron.

Next Steps: Clinical Decision Support Tool – creating and launching an alert within the medical record to fire RBCs are ordered and the last Hgb on file for the patient is greater than 7g/dL.

In Sept. 2018, 11 members of Keck clinical and administrative staff attended the Society for the Advancement of Blood Management Annual Meeting to learn the nuances and critical success factors behind running a PBM program. These members also became certified in Blood Management.

Patient Blood Management Committee

Data Collection & Reporting

http://www.choosingwisely.org/societies/american-association-of-blood-banks/

Documents

Why Give 2 When 1 Will Do?”- Reducing Unnecessary Blood