Decision Support for Blood TransfusionAppropriate Blood Use

Dr Richard Gregg & Prof. Mike Murphy Oxford University Hospitals and NHS Blood & Transplant

Is blood transfusion an important issue? Is current transfusion practice adequate? How can decision support software help? Do the results support the concept? Future prospects Conclusions, questions and thoughts on

supporting clinical teams during implementation

Introduction

Common◦ 1.8 million red cell units

used in England each year◦ 250,000 platelet units

used in England each year

Risky◦ 10 deaths per year in UK◦ 30-50% of deaths are due

to human error

Do Blood Components Matter?

Expensive◦ Highly refined and

extensively tested ◦ Over £260 million pounds

per year in England

Limited resource◦ Less than 4% of UK

population are donors◦ Shortages remain a real

issue

Do Blood Components Matter?

The consequence....

Transfusion is Politically Sensitive

SANGUIS 1993‘Large variation in prescribing practice’

DOH ‘Better Blood Transfusion’◦ Hospital transfusion teams and committees◦ Blood transfusion policies and procedures◦ Education, training & continuing professional

development◦ Audit

Transfusion Practice Two Decades Ago

National audits consistently show 20-30% inappropriate

Safety of hospital transfusion still an issue

Poor education and training

Limited use of IT for blood safety and informatics

Lack of patient involvement

Where are we now?Proportion of CABG patients receiving RBCs

0 10 20 30 40 50 60 70 80

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HGFEDCBA

%

Integrating available information and guidelines into patient blood

management

How Do We Move Forward..?

Integration – Simple?Lab Results?

Allergies?

Age?

Weight?

Special Requirements?

Guidelines?

Co-Morbidities?

Transfusion Indication?

Transfusion? Appropriate

Integration – Simpler

Lab Results?

Allergies?

Age?

Weight?

SpecialRequirements?

Guidelines?

Co-Morbidities?

TransfusionIndication?

Integration and Decision

Support

Appropriate Transfusion

Prospectively◦ Improved clinician awareness◦ Integrate important data◦ Present data within a guidance framework◦ Alert user about errors

Retrospectively◦ Allow access to usage data

Individual Departmental Procedural

How can electronic decision support help?

‘An elderly man with anaemia attended the outpatient department for monthly blood transfusion. His haemoglobin was eventually found to be dangerously high…..

The consultant had signed a prescription on eight separate occasion without any blood tests’

Improving awareness Inappropriate and Unnecessary Transfusion

Important results clearly displayed at the point of request

Alerts for absent results

Alerts for ‘out-dated’ results

Hb result belongs to another patient

Hb transcription error Substitution of WCC for

Hb

‘14.5% of patients could have been managed differently if advice had been sought from a haematologist’

Unnecessary transfusion

Over transfusion

Guidance

Requesting supported with simple guidance

Hyperlinks ‘Smart

guidance’ with integration

‘A doctor went to the ward to see a new patient. He asked for the patient by name and was taken to the room of a patient with a similar first name. After seeing the patient he prescribed a unit of platelets to be given to the patient because he thought her platelet count was low…..

Later they realised that the patient in the next room was the patient with a low platelet level.’

Non compliance with guidelines

Duplication Dose Specification

Alerts Duplicate

prescription Over transfusion Incorrect patient Incorrect results Human error

Evidence of Effect - RCC

Q1 Q2 Q3 Q40

200

400

600

800

1000

1200

1400

1600

Red cell alert - Order cancelation

Courtesy of Mark Yazer, UPMC Pittsburgh

10% Cancelled

90% Continued

Evidence of Effect - FFP

Q1 Q2 Q30

20

40

60

80

100

120

140

160

FFP alert - Order cancelation

Courtesy of Mark Yazer, UPMC Pittsburgh

20% Cancelled

80% Continued

Informatics - Changing Practice

Specialty A

Specialty B

Specialty C

Specialty D

Specialty E

Specialty F

Specialty G

Specialty H

Specialty I

Accurate data on blood use

Understanding practice Targeted intervention

Optimising safety – Enhanced integration Facilitating data extraction – Uniform coding Ensuring patient involvement Clinician experience End-to-end IT support

Where next?

Robust Patient

Identification

Safe Blood Issue

Enhanced Bedside

Checking

Relevant & Digestible Informatics

Decision Support

True ‘End-to-End’ IT support

Transfusion safety is a key priority

Current practice leaves significant room for improvement

Carefully designed decision support software can help clinicians choose the path of least resistance

Conclusions & Questions

Planning Implementation Testing Development

Hints to help clinicians!