Analyst Cafe UIHC Strategies To Reduce Blood Utilization 6 17 2014

The Analyst Caf:
Blood, Sweat & Tears Success of

a Patient Blood Management
Program
June 17, 2014
University of Iowa Health Care team
Blood, Sweat & Tears

Success of a Patient Blood Management
Program
Scott Wilson, DO
Director, Hospitalist Care Program
Chair, Transfusion Subcommittee
Michael Miller, MD, FACEP

Chief Safety Officer
Clinical Medical Director, Department of Emergency Medicine
Theresa Brennan, MD
Chief Medical Officer
Aldijana Avdi, BSN, RN, PBMS, CPHQ

Patient Blood Management Specialist
Quality and Operational Improvement Engineer
Deborah Chudzik
Director, Clinical Functions
June 2014 Analyst Caf Blood, Sweat and Tears: Success of a Patient Blood Management Program
Presentation Objectives
Making the PBM program business case

Integrating data analysis into performance
improvement
Data sharing with key stakeholders
Review PBM program outcomes
The University of Iowa Health Care
Academic medical center (711-bed)

190-bed childrens hospital
Patient volume
32,000 annual inpatient admissions

59,000 emergency department visits
27,875 major surgical operations
977,337 outpatient visits
Many employees, students, and volunteers

Making the Business Case
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
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
Patient Blood Management (PBM) Program
Thetimelyapplicationofevidencebased
medicalandsurgicalconceptsdesignedto
maintainhemoglobinconcentration,optimize
hemostasisandminimizebloodlossinaneffort
toimprovepatientoutcome.
SABM
Anevidencebased,multidisciplinaryapproach
tooptimizingthecareofpatientswhomight
needtransfusion.
AABB
Establishing the Program Structure
Nontraditional approach of implementing the

Program under the leadership of our quality office
Experts in achieving clinician buy-in and practice
change
Experienced in leading a wide range of internal
and external quality improvement projects
Familiarity with data mining and analysis
Using UHC CDB reports to identify opportunities
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
Chief Quality Council

Provides leadership and oversight on clinical and medical issues
Program Function
Education & Communication

Competencies, orientation, ongoing training
Reporting and responding to quality and safety concerns
Compliance, Accreditation, and Licensure
Hospital policy
Regulation: AABB 1st edition PBM Standards, JCAHO
Guidelines
Consents
Equipment & Information Systems

Blood scanning
Point of care testing
Program Function
Monitoring of PBM and Utilization Practices

Blood utilization rates
Variation in ordering practice
Lab triggers: hemoglobin, platelet, INR, fibrinogen
triggers compared to others
2-unit orders
Verbal orders
Recognizing and responding to transfusion reactions
Patient outcomes
Anemia and coagulation management
Appropriate use of Massive Transfusion Protocols
10
UHC User Poll Determining a

Head Count for Todays Session
11
UHC User Poll Determining a Head Count for Todays

Session
How many people are in the room with you

today?
Be sure to use numerals and remember to count

yourself! Then make sure to click Submit to send in
your response.
Thanks in advance for participating and helping us

estimate a true head count!
12
Shaping the Culture
Integrating Data Analysis into

Performance Improvement
13
Program Goals and Objectives
Demonstrate transfusion/patient safety

Provide ongoing financial metrics for program
growth, sustainability, and fiscal responsibility
Indicate strategic alignment and stewardship
Strive for excellence in evidence-based
patient care delivery
14
Scope of the Project

Staff and Patient Education, and Program Communication
Blood transfusion safety and conservation techniques
Iatrogenic Blood Loss
Excessive blood loss due to unnecessary testing
Goal: Reduce the amount of blood loss with lab draws
Transfusion Guidelines
Un-informed transfusion practice
Goal: Implement evidence-based approach to ordering of blood
components using a restrictive transfusion strategy
Anemia & Coagulation Management
Presence of correctable anemia
Goal: Detect and treat anemia preoperatively
15
Opportunities Identified Using UHC

Performance Gaps:
Patient outcomes (ICU stay, LOS) among transfused cases or
compared to non-transfused
Blood utilization by diagnosis, by service, by procedure, by
severity of illness, etc.
Mean direct costs with and without use of lab/blood components
% patients with lab tests, type of lab tests, mean days receiving
lab tests, total tests patient received during hospitalization
% patients receiving blood, type of blood component
Pharmaceutical use: erythropoietin, prothrombin complex
concentrates, etc.
Knowledge Gaps:
Assess current level of knowledge
16
Opportunities Identified Using UHC
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)
17
Scope 1: Program Education and Training
Training developed based on knowledge gaps,

prior analysis, and risk assessment findings
Information concise and up-to-date

Specific, actionable opportunities
Consistent theme/message
Flexible and customizable
Training implementation
Patient education pamphlets, staff handouts

Best Practice Alerts
Webinars, presentations, lectures
Department and unit tours
18
Program Communication: Newsletter Examples
Scope 2: Iatrogenic Blood Loss
Eliminate extra tubes or rainbow draws

Eliminate over draws batch labs
Individual nursing/phlebotomy education
Switch to small volume tubes
Increase point of care testing
Reduce unnecessary testing and standing
orders
Selective use of pediatric tubes
Control diagnostic blood loss
20
Scope 3: Transfusion Guidelines

Specific indications for each blood
component as supported by current literature
Age specific: neonate, pediatric, and adult
Minimum effective dose
Usual length of infusion times of blood
components
Type and screen
Suspected transfusion reaction
21
Scope 4: Pre-Operative Anemia Management
Elective high blood loss procedures

Pre-operative anemia is the greatest
predictor of transfusion requirements
Offer screening and treatment of anemia to
elective surgery patients as a clinical
strategy to improve blood management
Reducing LOS by just 1 day for 2000
patients yields > $4.5 million savings
annually
Correcting preoperative anemia has the
potential to reduce RBC utilization and
purchase cost annually
22
Data Reporting
Information sharing with key stakeholders
23
Measuring Process Performance
Senior Leadership Data
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
Small, frequent updates (top of mind)

24
RBC Utilization Rate

RBCTransfusionsperDischarge
0.580
0.530
0.480
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
0.233
0.233
LCL
Rate of Transfused Cases

TransfusedCasesPerDischarge
0.205
0.195
0.185
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
10/1/2013 11/1/2013 12/1/2013
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
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
Laboratory Utilization Metric

MeanLaboratoryUtilizationperCase
91.5
86.5
81.5
76.5
71.5
66.5
LCL
28
Blood Product Opportunity in Units

Orthopaedics,
115
Oncology,88 Neurosciences,
77
Surgical
Specialties,145
CardiacVascular
Thoracic,597
TotalOpportunityOct Dec2013
Womens&
Infants,214
50th percentile$384,596
th percentile$702,632
80
Medical
Specialties,399
Unit Leadership Data

Medical Directors, Nurse Managers
Compare rates by service line to other like-hospitals and
top performers
Calculate nursing time spent on transfusions
Lab utilization rates
Blood utilization rates
30
Transfusion Rate per 1000 Days
31
Patient Blood Draws
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
33
Evidence-Based Practice Metric

2UnitOrdersperTotalRBCOrders
36.50%
34.50%
32.50%
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
10/1/2013 11/1/2013 12/1/2013
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%
19.40%
19.40%
34
Maintaining the Gains
Summary of Outcomes
Quality and Safety
Blood Utilization
Financial
35
Quality and Patient Safety Metrics

March 2011 to December 2013
Complications at 4% per unit:
357 complications avoided
Length of Stay at 1.5 days per unit:
13,390 patient days reduced
Deaths at 0.9% per unit:
80 lives saved
Estimated reduction in nursing
time :
18,891 hours or 9.1 FTEs
Ferrarisetal,ArchSurg2012;147(1)
SurgicalOutcomesandTransfusionofMinimalAmountsofBloodintheOperatingRoom.
June 2014 Analyst Caf
Blood, Sweat and Tears: Success of a Patient Blood Management Program
Blumbergetal.AmJSurg1996;171:32430.
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
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
Baseline: April2010 March2011

Avg#ofRBCUnitsper1000cases:544.4
Avg#ofPlasmaUnitsper1000cases:158.2
YTD: April2011 December2013
Avg#ofRBCUnitsper1000cases:448.7
Avg#ofPlasmaUnitsper1000cases:144.4
TotalSavings
$17,126,935
1000
0
2586
2670
Aug-11
Sep-11
1747
1792
Jan-13
Apr-13
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
Blood Product Utilization Metric
24
15
19
3
7
17
6
5
Tips for a Successful PBM Program
Dedicated leader to develop and drive initiatives

Core patient blood management team
Collaboration among administration, staff, and patients
Clinician leadership and expertise
Identify roadblocks early
Standardization of blood policy, protocols, and practices
Continuing education for physicians and nursing
Its a moving target
41
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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,
2011.
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.
42
Questions?
43
Suggestions / Questions
CDP Member Support Services
Phone: 312-775-4399
Email: cdpinfo@uhc.edu
44
Prize Drawing
And the winner is..
45
Next Analyst Caf
Save the Date:

July 15, 2014
1 2.30 PM CST
Topic TDB stay tuned for additional details!
46

Analyst Cafe UIHC Strategies To Reduce Blood Utilization 6 17 2014

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The Analyst Caf:

Blood, Sweat & Tears Success of

Blood, Sweat & Tears

Michael Miller, MD, FACEP

Aldijana Avdi, BSN, RN, PBMS, CPHQ

Making the PBM program business case

The University of Iowa Health Care

Academic medical center (711-bed)

32,000 annual inpatient admissions

Many employees, students, and volunteers

Making the Business Case

Patient Blood Management (PBM) Program

Establishing the Program Structure

Nontraditional approach of implementing the

Chief Quality Council

Education & Communication

Compliance, Accreditation, and Licensure

Equipment & Information Systems

Monitoring of PBM and Utilization Practices

UHC User Poll Determining a

UHC User Poll Determining a Head Count for Todays

How many people are in the room with you

Be sure to use numerals and remember to count

Thanks in advance for participating and helping us

Shaping the Culture

Integrating Data Analysis into

Program Goals and Objectives

Demonstrate transfusion/patient safety

Scope of the Project

Opportunities Identified Using UHC

Opportunities Identified Using UHC

Scope 1: Program Education and Training

Training developed based on knowledge gaps,

Information concise and up-to-date

Patient education pamphlets, staff handouts

Program Communication: Newsletter Examples

Scope 2: Iatrogenic Blood Loss

Eliminate extra tubes or rainbow draws

Scope 3: Transfusion Guidelines

Scope 4: Pre-Operative Anemia Management

Elective high blood loss procedures

Measuring Process Performance

Senior Leadership Data

Small, frequent updates (top of mind)

RBC Utilization Rate

Rate of Transfused Cases

10/1/2013 11/1/2013 12/1/2013

Laboratory Utilization Metric

Blood Product Opportunity in Units

Measuring Process Performance

Unit Leadership Data

Transfusion Rate per 1000 Days

Patient Blood Draws

Measuring Process Performance

Evidence-Based Practice Metric

10/1/2013 11/1/2013 12/1/2013

Maintaining the Gains

Quality and Patient Safety Metrics

Baseline: April2010 March2011

Blood Product Utilization Metric

Tips for a Successful PBM Program

Dedicated leader to develop and drive initiatives

And the winner is..