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8/18/2014
1
IHI ExpeditionExpedition: Appropriate Use of Blood Products
Session 1: Update on Transfusion Safety
August 19, 2014
Begins at 3:00 PM EST
Diane Jacobson, MPH, CPHQTimothy Hannon, MD, MBARishi Sikka, M.D
Terina Keller, Project Office Assistant,
Institute for Healthcare Improvement (IHI),
assists in programming activities for
expeditions, maintaining Passport
memberships, as well as other projects and
collaboratives throughout IHI. Terina is
currently in the Co-Operative Education
Program at Northeastern University in
Boston, MA, where she majors in Sociology
with a minor in Health Science. Terina plans
to earn her MPH once finished with
undergrad and work on issues dealing with
social determinants of health around the
country and abroad.
Today’s Host
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8/18/2014
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8/18/2014
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What is your goal for participating in this Expedition?
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8/18/2014
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Join Passport to:
• Get unlimited access to Expeditions, two- to four-month,
interactive, web-based programs designed to help front-
line teams make rapid improvements.
• Train your middle managers to effectively lead quality
improvement initiatives.
. . . and much, much more for $5,000 per year!
Visit www.IHI.org/passport for details.
To enroll, call 617-301-4800 or email [email protected].
IHI Open School Courses
More than 20 online courses developed by world-renowned experts in the following topics
– Improvement Capability
– Patient Safety
– Person- and Family-Centered Care
– Triple Aim for Populations
– Quality, Cost, and Value
– Leadership
More than 26 continuing education contact hours for nurses, physicians, and pharmacists. NAHQ has also approved the courses for CPHQ CE credit.
Basic Certificate of Completion available upon completion of 16 foundational course.
Mobile App for iPhone and iPad
20% Discount on organizational subscription for Passport Members
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8/18/2014
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What is an Expedition?
ex•pe•di•tion (noun)
1. an excursion, journey, or voyage made for some specific
purpose
2. the group of persons engaged in such an activity
3. promptness or speed in accomplishing something
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Expedition Support
All sessions are recorded
Materials are sent one day in advance
Listserv address for session communications:
– To add colleagues, email us at [email protected]
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Where are you joining from?
Expedition Director14
Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms. Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C.difficle Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI’s Spread Initiative. She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master’s degree in Public Health- Epidemiology.
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Today’s Agenda15
Ground Rules & Introductions
Pre-program Survey Results
Update on Transfusion Safety
IHI’s Model for Improvement
Action Period Assignment
Ground Rules16
We learn from one another – “All teach, all learn”
Why reinvent the wheel? – Steal shamelessly
This is a transparent learning environment – Share
openly
All ideas/feedback are welcome and encouraged!
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Expedition Objectives
At the end of this Expedition, participants will be able to:
List the quality, economic, and risk management issues
driving the need for safer blood use.
Discuss the pathway required for successful implementation
of evidence-based transfusion guidelines.
Develop three to five key performance indicators for effective
Transfusion Safety Committee oversight
Identify the essential elements of a sustainable Transfusion
Safety Program.
Describe issues of transfusion safety at the bedside and
strategies to improve transfusion administration safety.
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Schedule of Calls
Session 1 – Update on Transfusion Safety
Date: Tuesday, August 19, 3:00-4:30 PM ET
Session 2 – Transfusion Safety Program Infrastructure: Implementing Transfusion GuidelinesDate: Tuesday, September 2, 3:00-4:00 PM ET
Session 3 – Transfusion Safety Program Infrastructure: Measures of Clinical EffectivenessDate: Tuesday, September 16, 3:00-4:00 PM ET
Session 4 – Transfusion Safety Program Infrastructure: Critical Role of Leadership
Date: Tuesday, September 30, 3:00-4:00 PM ET
Session 5 – Nursing at the Bedside: Transfusion Administration SafetyDate: Tuesday, October 14, 3:00-4:00 PM ET
Session 6 – Best Practices: Communication and Awareness StrategiesDate: Tuesday, October 28, 3:00-4:00 PM ET
Session 7 – Putting it All Together: Building a Sustainable Program
Date: Tuesday, November 11, 3:00-4:00 PM ET
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Pre-work Assignment
Complete the Expedition: Use of Blood Products Pre-
Survey
Complete the IHI Open School Course QI 102: The
Model For Improvement: Your Engine for Change
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Pre-Program Survey Results
Diane Jacobsen, MPH, CPHQ
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Survey Results:What roles will be represented on your team participating in the Expedition?
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Survey Results:Degree to which each intervention related to Blood Product use is currently in
place/practice
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Survey Results: Barriers to ensuring appropriate use of blood products in your organization
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Physician/provider related- Lack of physician involvement in the blood management process- Lack of consensus between physicians about appropriate circumstances for blood product usage- Inappropriate orders/use of blood products
Leadership Support/Commitment - Lack of consensus among Hospital Leadership with respect to goals.- Lack of effective leadership accountability, transparency, education
Education-related- Lack of knowledge of current evidence based practice- Lack of electronic guidelines/guidance and support
Lack of transfusion committee oversight- Lack of a system to monitor/regulate blood product usage. - Lack of consistent, ongoing evaluation methods to determine appropriate use of blood products between providers.
Survey Results: What we’re most proud of to support appropriate use of blood products
Physician initiation of joining the IHI Blood Product
expedition
Created a team to develop a hospital Blood
Management Program and influence a system-wide
effort
Hired a transfusion safety officer
E-learning program for mandatory education for all staff
involved in the administration of blood products
Multidisciplinary approach to problem solving to ensure
safety and quality in the use of blood products
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Survey Results: What we’re hoping to learn about appropriate use of Blood Products
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Current practice guidelines and ways to implement within our system
How to engage the stakeholders in building an effective transfusion safety
New strategies so we can reach far and deep to the clinicians to improve blood product management, quality and safety of patient care.
Key measures and innovative ways to support staff at the bedside to do the right thing.
Tools to improve different aspects of blood transfusion activity in my hospital.
Faculty26
Timothy Hannon, MD, MBA, is a board certified anesthesiologist who serves as medical director of the St. Vincent Indianapolis Blood Management Program, a forward thinking program which he designed and implemented with great success. Since its establishment in 2001, the blood management program has reduced hospital transfusions by over 30%, resulting in annual savings of over 7000 units of blood products and cost savings that exceed $4,000,000 per year. The program has also substantially improved quality of care and increased patient safety, becoming a model for innovative quality improvement. Dr. Hannon is also the Founder and CMO of Strategic Healthcare Group LLC, a health care consulting group that is the national leader in safe, efficient and effective blood management solutions.
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FacultyRishi Sikka, M.D, As Senior Vice President of Clinical Transformation at Advocate Health Care, Dr. Sikka has system level responsibility for pharmacy, critical care, quality, safety, clinical effectiveness and business intelligence/”big data.” He also serves on the board of Advocate Physician Partners, the clinically integrated network with 4,000 physicians serving 550,000 attributable lives. He continues to practice emergency medicine and is a clinical associate professor in the Department of Emergency Medicine at the University of Illinois-Chicago, School of Medicine. Dr. Sikka’s career has spanned a variety of leadership roles in fields including media, technology start-ups, hospital administration, managed care and big data. His time included roles at Advocate Christ Medical Center, Oak Lawn, IL; Boston Medical Center, Boston, MA; Medco Health Solutions, Franklin Lakes, NJ; Health Benchmarks, Woodland Hills, CA (acquired by IMS); Praxeon, Cambridge, MA (a Boston health technology start-up); Prudential Health Care, Atlanta, GA; and KTTC-NBC, Rochester, MN. Dr. Sikka received his medical degree from Mayo Medical School in Rochester, MN. His internship in internal medicine was completed at St. Vincent's Hospital, New York, NY and his residency in emergency medicine at Boston Medical Center, Boston, MA. He received his bachelor of science in economics from the Wharton School at the University of Pennsylvania, Philadelphia, PA. Dr. Sikka is the recipient of the 2013 Chicago Health Executives Community Leadership Award and was recognized in 2011 Crain’s Chicago Business as a Top 40 under 40.
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Tim Hannon, MD, MBA
Rishi Sikka, MD
IHI Appropriate Blood Use
Introduction to
Transfusion
Safety
© 2014 Tim Hannon, MD. All rights reserved.
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Agenda
29
Brief Overview of Blood Management &
Transfusion Safety
A High Reliability Approach to Transfusion
Safety
General Approach to Program
Implementation
Advocate Health Care Transfusion Safety
Program Case Study- Dr. Sikka
Q & A
Session I wrap up
www.BloodManagement.comBloodManagement.com
Why is Blood Use an Issue?
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• Blood is a precious and scarce community resource
• According to the 2010 HCUP survey, blood
transfusions are the most commonly employed
procedure for hospital inpatients1
• Scientific evidence over the last decade has
consistently shown transfusions to be less
beneficial and more harmful• Clinical trials in high risk patients (critical care,
cardiac surgery, orthopedics, gi bleed)2-5 show no
benefit of liberal transfusion therapy and a tendency
towards harm
• A growing list of non-infectious risks of transfusion
have been identified, including lung injury, volume
overload, renal injury, multisystem organ failure and
immunosuppression6
1 Available at: http://www.hcup-us.ahrq.gov2 Hébert et al- NEJM 1999;340(6)
3 Hajjar- JAMA 2010;304(14)4 Carson et al- NEJM 2011;365(26)
5 Villaneuva- NEJM 2013;368(1)6 Gilliss- Anesth 2011;115(3)
© 2014 Tim Hannon, MD. All rights reserved.
8/18/2014
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www.BloodManagement.comBloodManagement.com
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Evidence Based Transfusion Practice
1 Hébert et al, NEJM 1999;340(6)2 Blajchman, Transfusion 2005:45
“A restrictive strategy of red cell transfusions is at least as effective as and possibly superior to a liberal strategy in critically ill patients, with the possible exception of patients with
acute myocardial infarction or unstable angina.”1
Ranked as the #1 landmark study that has changed the practice of
transfusion medicine2 but how many physicians are familiar with it?
A Multicenter, Randomized Controlled Clinical Trial of
Transfusion Requirements in Critical Care (TRICC)1
© 2014 Tim Hannon, MD. All rights reserved.
www.BloodManagement.comBloodManagement.com
1
32
1Kim-Shapiro- Transfusion 2011;51(4)2 Hovav- Transfusion 1999; 39
Physical Properties of Stored Blood
Vasoconstriction
and microvascular
occlusion
Platelet adhesion
and aggregation
2
3
Interleukins,
TNF
Cytokines cause
inflammation &
immunosuppression
© 2014 Tim Hannon, MD. All rights reserved.
3Grimshaw- Transfusion 2011;51(4)
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Transfusion- Related Adverse Effects
1 Goodnough- CritCare Med 2003;31(12S)2 Utter- Transfusion 2006;463 Rana- Transfusion 2006;464 Li- Transfusion 2011;51(2)
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Infectious Complications
– Viral transmission
– bacterial contamination of platelets* (1:3000)
– nvCJD, West Nile, Chagas, Babesiosis, Chikungunya
Noninfectious Hazards of Transfusion
– Febrile and allergic reactions 1- 2%
– Hemolytic transfusion reactions
• Mistransfusion* (clerical error) incidence 1:14:000-16,000
– TA- Microchimerism (50% of trauma pts @ discharge/ 30% @ 1 year)2, TA- graft vs. host disease
– SIRS, TRIO, TRAKI, TRAGI
– TRALI* (1:10,000), TACO*(1:16- 1:350)3,4
– TRIM*
Infectious and Noninfectious Risks of Transfusion
* Leading
causes of
morbidity
and
mortality
© 2014 Tim Hannon, MD. All rights reserved.
34
Evidence of circulatory overload within 6 hours of a transfusion1
Increase in CVP and PCWP
BNP may help distinguish from TRALI
Incidence 1%- 8% (FFP and RBC)1,2,3
Mortality 1- 3%1,2
Increased mortality rate (OR=3.2)
Increased LOS by 4 days (ICU)
Risk Factors1,2,3
Extremes of age
Positive fluid balance (OR=9.4/L)
Renal dysfunction (CRF OR=27)
History of CHF (OR=6.6)
Amount of blood given (OR=1.11/ unit)
Higher rates of transfusion (> 170 mL/hr)
Transfusion- Related Adverse Effects
Transfusion Associated Circulatory Overload (TACO)
1 Alam, TransMedRev 20132 Murphy, AmJMed 2013
© 2014 Tim Hannon, MD. All rights reserved.
3 Li, Trans 2011;51(2)
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www.BloodManagement.comBloodManagement.com
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Transfusion- Related Adverse Effects
Transfusion Related Immunomodulation (TRIM)
• Immune system response to foreign tissue1
• Upregulation of humoral immunity-antibody production/ alloimmunization
• Downregulation of cellular immunity
• Decreases in NK cell and macrophage activity
• Activation of T-suppressor cells (anergy)
• Immune system “overload” leads to adverse effects2
• 3- 10 fold increase in postoperative infections and VAP3 in transfused patients leading to increased LOS and costs
• Increased 5 year mortality in CABG4, increased cancer recurrence in some studies
• Effect has been known and well-documented for years
1 Triulzi, Transfusion 1992;322 Blumberg, Transfusion 2005;45(S)
3 Shorr, CurrOpinCritCare 2005;114 Engoren, AnnThorSurg 2002;74
© 2014 Tim Hannon, MD. All rights reserved.
Transfusion Dose Response for Adverse Effects
1 Bernard et al, JAmCollSurg 2009;2082 Ferraris et al, ATS 20113 Ferraris et al, Arch Surg 2012;147(1)
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Surgical Outcomes and Transfusion of Minimal Amounts
of Blood in the Operating Room3
Each unit of RBC
transfused results in:
• 4% increase in
wound complications
• 1.5 day LOS
• 0.9% increase in
mortality 3
© 2014 Tim Hannon, MD. All rights reserved.
8/18/2014
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www.BloodManagement.comBloodManagement.com
© 2006 - 2014 Strategic Healthcare Group LLC. All rights reserved. 37
Transmittable Disease
IMPROVE OXYGEN DELIVERY
PREVENT ORSTOP BLEEDING
IMPROVED WOUND HEALING
IMPROVED REHABILITATION
Transfusion Benefit vs. Risk 1998
www.BloodManagement.comBloodManagement.com
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Transfusion Benefit vs. Risk 2014
© 2006 - 2014 Strategic Healthcare Group LLC. All rights reserved.
8/18/2014
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www.BloodManagement.comBloodManagement.com
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Focus on Overutilization
www.BloodManagement.comBloodManagement.com
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Focus on Overutilization
“Since physicians want to practice evidence-based medicine and do what’s
right during their interactions with individual patients, the work group
emphasized the importance of having the infrastructure and support tools
that help physicians make the best decisions and to document why they
were made.”
“The work group pointed out that more guidelines are not the answer, since
there are many excellent trials and guidelines available that are not being
followed. To make sustainable progress in the use of blood and blood
components, changing behaviors when supporting data are available is the
best solution.”
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www.BloodManagement.comBloodManagement.com
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Focus on Overutilization
www.BloodManagement.comBloodManagement.com
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Focus on Overutilization
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www.BloodManagement.comBloodManagement.com
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Focus on Overutilization
www.BloodManagement.comBloodManagement.com
44© 2006 - 2014 Strategic Healthcare Group LLC. All rights reserved.
Transfusion and Risk Management
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www.BloodManagement.comBloodManagement.com
45
Transfusion Economics
Hannon, Gjerde.
Economics of
Transfusions. In:
Perioperative Blood
Management ( 2005)
Blood Costs
$ 220
$ 660
$ 1220
$ 2100*
Labor
Overhead
Adverse Effects
Transfusion Costs
*2010$ costs
© 2014 Tim Hannon, MD. All rights reserved.
www.BloodManagement.comBloodManagement.com
46
Quality Outcomes Resources Costs
Qualit
y
Cos
t
Healthcare Quality and Costs
© 2014 Tim Hannon, MD. All rights reserved.
8/18/2014
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www.BloodManagement.comBloodManagement.com
Transfusion Appropriateness
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• In spite of the growing evidence for more thoughtful
& conservative blood use, blood utilization is far
from optimal1
• There is wide variation in transfusion practice
between hospitals and among physicians at the
same hospital2
• Published studies and Strategic Healthcare Group
audits demonstrate that 30-70% of transfusions are
inappropriate or unnecessary3
• Transfusion appropriateness in many hospitals is
essentially a “coin toss” decision
• Physicians typically lack formal training in
transfusion medicine and are often unfamiliar with
the current indications and dosing for blood
component therapy4
1Boucher, Hannon- Pharmacotherapy 2007;27(10)2Bennett-Guerrero- JAMA 2010;304
3Friedman et al- ArchPatholLabMed 2006;1304 Dzik- Transfusion 2003;43
© 2014 Tim Hannon, MD. All rights reserved.
www.BloodManagement.comBloodManagement.com
• Blood transfusions are one of the most
common treatments within our hospitals
• Evidence-based transfusion guidance has
become more conservative because of a
significant shift in transfusion benefits and
risks
• In spite of this evidence, transfusion practice
remains less than optimal
• Unnecessary transfusions waste precious
resources and cause avoidable harm
• As such, the medical decision to transfuse
is a critical component of patient safety
© 2014 Tim Hannon, MD. All rights reserved.
Appropriate Blood Use and Patient Safety
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www.BloodManagement.comBloodManagement.com
Introduction to Transfusion Safety
A High Reliability
Approach to
Transfusion Safety
IHI Appropriate Blood Use
www.BloodManagement.comBloodManagement.com
501 Dzik, Transfusion 2003;43
Shifting the Focus From Blood Center to Hospital: A
Vein-to-Vein Transfusion Safety Chain
Bedside ID/
administration
Medical decision
to transfuse
Monitor &
evaluate
Transfusion Safety
From Blood Safety to Transfusion Safety
Safe transfusion therapy depends upon an interconnected series of
processes that begin with the donor and ends with the patient.1
“Unsafe at Any Speed: Dangerous
Focal Points in the Transfusion Process”1
Recruit
Donor screening
Collect & prepare
Infectious disease
tests
Blood Safety
Pre-transfusion testing Issue/
transport
1
© 2014 Tim Hannon, MD. All rights reserved.
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www.BloodManagement.comBloodManagement.com
51
Primary prevention of transfusions
Transfusion Safety is a
multidisciplinary, multimodality
patient safety initiative designed to improve
blood utilization and reduce avoidable harm.
Roadmap for Transfusion Safety
1 Dzik, Transfusion 2003;432 Reason, 19903 Hannon, AAOS Comp Orth Rev 2009
“Unsafe at Any
Speed:
Dangerous
Focal Points in
the Transfusion
Process”1
2
Blood Management Best Practices
3
© 2014 Tim Hannon, MD. All rights reserved.
www.BloodManagement.comBloodManagement.com
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• Avoiding unnecessary transfusions!
• “Meaningful use” of evidence-based transfusion guidelines
• Single unit transfusions (RBC)
• Should be the standard of care for non-bleeding patients
• Reducing transfusion rates
• Specify transfusion rates as mL/hr, not “transfuse over X hours”
• <120mL/h on an infusion pump for patients at high risk (positive fluid balance, history of CHF, history of CRI)
• Splitting units and/ or preemptive diuretics (high risk patients)
• Lasix should not be used to “squeeze in” questionable transfusions
• “Critical Nurse Supervision”1- vigilant monitoring by nursing is key
• Encouraging/ enforcing transfusion guidelines (“stop the line”)
• Careful monitoring for first 15 minutes
• Intermittent monitoring every 30- 60 minutes for duration of infusion
• Use of continuous pulse oximetry?
1 Alam, TransMedRev 2013
Using a High Reliability Approach to Reduce TACO
© 2014 Tim Hannon, MD. All rights reserved.
8/18/2014
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www.BloodManagement.comBloodManagement.com
Introduction to Transfusion Safety
General Approach
to Program
Implementation
IHI Appropriate Blood Use
www.BloodManagement.comBloodManagement.com
Philosophy
• Physicians and nurses want to do the right thing, but they
“don’t know what they don’t know”
• Initial and ongoing education, training and awareness
are essential program elements
• Competency and credentialing should be a
requirement for both physicians and nurses
• Physicians and nurses don’t willingly harm patients!
• Program must continually be framed as a patient
safety initiative
• Emphasis on patient safety drives a sense of urgency
and helps to prioritize the program efforts
Methodology
• Evidence based, patient centered, data driven & systems
oriented
• E4 Process Improvement Methodology
• Evaluate, Educate, Engage, Empower
© 2014 Tim Hannon, MD. All rights reserved.
General Approach to Healthcare Quality Improvement
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www.BloodManagement.comBloodManagement.com
Ongoing Selection, Prioritization and Implementation of Projects
Clinician Education
Physician, Nursing, Mid-Levels
Education , Training and Awareness in Support of
Evidence-Based Transfusion Guidelines and Program Goals
Transfusion Safety Committee
Review of Structure and Function
Transfusion Guideline Development
Development of Key Performance Metrics
Expansion of Membership
Phase I:Leading
Change,
Mobilizing
Commitment,
Developing
Capabilities
Phase II:Changing
Systems &
Structures,
Monitoring,
Hardwiring
Audit and Feedback of Transfusion Ordering
Practices
Audit and Feedback of Transfusion Administration
Safety
Monitoring and Improvement of Key Performance Metrics
Ongoing Education, Training
& Awareness
Process Improvement in High Blood Use
Specialties
© 2014 Tim Hannon, MD. All rights reserved.
Transfusion Safety Program Implementation
www.BloodManagement.comBloodManagement.com
Introduction to Transfusion Safety
Case Study:
Advocate Health
Care
Transfusion Safety
Program
IHI Appropriate Blood Use
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Questions?57
Raise your hand
Use the Chat
Rishi Sikka, MDSenior VP, Clinical Transformation
Advocate Health Care
Safety First Case Study in Implementing Transfusion Guidelines
August 2014
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Discussion Topics • Who is Advocate?
• Why blood product transfusions?
• Leading to safety – leveraging High Reliability Values in change management
• Results
• Closing thoughts…Lessons Learned
59
A Little about Advocate…• Largest integrated healthcare system in Illinois:
– 3000 + beds (12 acute care facilities)
– 250 sites of care
– Largest integrated children’s network
– Largest emergency and Level I trauma network
• Expenditures for blood in 2011: $26 million dollars– Over 28,000 patients transfused annually
• Physicians on staff: 6300
• Nurses on staff: 10,000
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Emerging Issue • By the end of 2011, leadership at
Advocate had watched our use of blood products increase every year
– Was our transfusion practice evidence based?
– What was the impact of non-evidence based use of blood products on patients?
– What could be done to improve our use of blood products?
61
Our Issues• If we want to improve practice, how do we:
– Change the consensus about what safe blood product use is?
– Do this across an integrated health system?
– How do we measure multiple dimensions of change?
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Our Values: High Reliability • These organizations perform
dangerous, complex tasks every day in unforgiving environments
• Manage to do so safely – almost all the time – without hurting anyone, or failing operationally
• Share five characteristics or organizational values
• We leveraged these values in our rollout plan
63
Sensitivity to operations
Reluctance to simplify
Preoccupation with failure
Deference to expertise
Resilience
Values Count… • Defer to expertise
– It’s all about the evidence
– Decision making and project selection were entrusted to physician, blood bank, and nursing experts in transfusion therapy
• Sensitivity to operations– Communications and support focused on direct care
clinicians
– Messaging and tools were developed to support adoption
Sensitivity to operations
Reluctance to simplify
Preoccupation with failure
Deference to expertise
Resilience
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“Why” before “How”
65
• You can ruin a perfectly good idea with bad implementation
– Do not expect physicians to adopt new practices without a good reason
– Integrate the evidence into clinical work flow
– Select projects that drive that integration
– Measure
Improve Each Process Step
66
Pre-transfusion testing
Medical Decision to Transfuse
Dispense the correct product from the Blood
Bank
Safe Administration at the bedside
• Switched the system to smaller specimen tubes to prevent iatrogenic anemia
• Developed evidence-based transfusion guidelines
– Impact - a shared medical consensus on safe blood product use
– Deployed CPOE order sets that embed guidelines into blood product ordering
– Deployed an aggressive communication campaign with the safety message
• System and site Transfusion Safety Committees to own the transfusion process
• Developed a measurement system to track progress and put it on line for Advocate clinicians to view
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The Benefit of Projects• Forces diverse groups to come together
• Drives discussion and debate about improvement
• Creates a shared goal and understanding of what patients need
• The shared understanding translates into shared consensus between clinicians and across sites of care
67
The Power of Consensus…
As a nurse began her pre-transfusion patient assessment she noted that thepatient’s clinical condition did not ‘look like she was less than 7.0.’ She contactedthe physician; he agreed that a re-check was in order. The new lab values indicatedthat a transfusion was not needed, and the physician canceled the order for thetransfusion.
The nurse – physician teamwork, and the awareness of the evidence-base forsafe transfusion avoided a transfusion for this patient.
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Our Safety Message
69
Distill the safety message into a single idea thatcan be used in patient care
RBC Use/1000 Adj Patient Days
Our Results • Since 2011, RBC usage has
declined by: – 49% at the Level I Trauma
sites,
– 44% at all other Advocate sites
• Component use decreased:– Level I
• Platelets = 11% Decrease
• Plasma = 42% Decrease
– Level II • Platelets = 20% Decrease
• Plasma = 27% Decrease
70
**Ferraris et al, Arch Surg 2012;147(1)Assumes outcomes for a single unit of RBC, an apheresis unit of platelets or a 3 unit dose of plasma
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Blood Product Units Saved• RBC’s = 39,642
• Platelets = 3,036
• Plasma = 6,703
• Cryo = 1,918
• Total Resource conservation = 51,299 units
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Clinical Impact• Health Outcomes for Advocate Patients
– 1,797 complications avoided
– 67,369 inpatient days avoided
– 98,809 Nursing hours repurposed
– 404 Lives saved
Ferraris et al, Arch Surg 2012;147(1)Assumes outcomes for a single unit of RBC, an apheresis unit of platelets or a 3 unit dose of plasma
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Stewardship• In 2011, Advocate spent over $26 million
dollars on blood products
• In 2013, we spent $17.5 million dollars for the same purpose
• The bottom line – we are able to repurpose over $8.5 million dollars into improved patient care
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Final Thoughts…• Start with ‘why’
– Make the link between medical decision making and patient safety
• Communicate the message everywhere
• Improve your whole process, from medical decision-making to administration
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Questions?75
Raise your hand
Use the Chat
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
Act Plan
Study Do
Aim of Improvement
Measurement of
Improvement
Developing a Change
Testing a Change
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,
Norman, C. L., & Provost, L. P. The Improvement Guide:
A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass, 1996.
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Plan• Compose aim
• Pose questions/predictions
• Create action plan to carry
out cycle (who, what, when,
where)
• Plan for data collection
DoStudy
Act
• Carry out the test and
collect data
• Document what occurred
• Begin analysis of data
• Complete data analysis
• Compare to predictions
• Summarize learning
• Decide changes to make
• Arrange next cycle
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Why Test?
Increase the belief that the change will result in
improvement
Predict how much improvement can be
expected from the change
Learn how to adapt the change to conditions in
the local environment
Evaluate costs and side-effects of the change
Minimize resistance upon implementation
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Repeated Use of the PDSA Cycle79
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Very Small
Scale Test
Follow-up
Tests
Wide-Scale Tests
of Change
Implementation of
Change
Sequential building of knowledge under a wide range of conditions Spread
Multiple PDSA Cycle Ramps
Transfusion
Administration
Safety
Communication
and Awareness
Strategies
Engaging with
Leadership
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Implementing
Transfusion
Guidelines
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Action Period Assignment
Read “Blood Management: A Primer for Clinicians”
Construct a three year trend chart for your facility noting
percentage change for:
– Blood utilization by product (RBC, platelets, plasma,
cryoprecipitate) and annual blood purchase costs|
– Randomly ask clinical staff if they are familiar with your hospital
transfusion guidelines and if they can list the three leading risks
of blood products
Come prepared to share what you learned………..
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Questions?82
Raise your hand
Use the Chat
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Expedition Communications
Listserv for session communications:
– To add colleagues, email us at [email protected]
– Pose questions, share resources, discuss barriers or successes
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Next Session
Session 2: Transitions to and from the acute care,
long term care and rehabilitation settings
Tuesday, September 2, 3:00 PM – 4:00 PM ET
Faculty: Timothy Hannon MD
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