Blood Conservation Initiative - Craig Rhyne, Covenant Health

Covenant Health

One Hospital’s Approach

to Improving Blood

Management

Patient Blood Management:

The Ongoing Message and Mission

“The rational use of blood involves the elimination of all

unnecessary transfusion, it prevents transfusion from becoming a

thoughtless habit…”

Chapelin H N Engl J Med 1969; 281: 364

Traditional Thinking (Until the Mid 1990s)

BENEFITS OF TRANSFUSION RISKS OF

TRANSFUSIONS

Improved Oxygen Delivery

Prevention or Correction

of Bleeding

Known risk of infection

transmission (AIDS,

Hepatitis)

Accelerated Rehabilitation

(Better, Quicker)

3

Benefit vs. Risk in 2016

BENEFITS OF

TRANSFUSION RISKS OF TRANSFUSIONS

Improved Oxygen

Delivery

Systemic Inflammatory Response Syndrome

(SIRS)

Prevention or Correction

of Bleeding Known risk of infection transmission

Transfusion Associated Lung Injury (TRALI)

Transfusion Associated Circulatory Overload

(TACO)

SEPSIS Risk

Infectious Disease Risk (AIDS, Hepatitis)

Transfusion Related Immunomodulation

4

Transfusion Requirements in Critical Care

5

Transfusion Requirements in Critical Care

NEMJ, Vol 340, No. 6, p409-417

6

Transfusion Literature

7


Journal of Vascular Surg. Vol 51, No. 3, Mar 2010. P 616-621.

8



“To conclude, our study in a large number of patients undergoing lower

extremity revascularization indicates that allogeneic intraoperative transfusion

is associated with higher postoperative morbidity and mortality. This finding is

true after adjusting for propensity for transfusion, thus, the reason that

transfused patients do poorly is not because they have a lower preoperative

hematocrit. When do the risks of anemia outweigh the hazards of transfusion?

In the absence of acute bleeding, hemoglobin levels consistent with the TRICC

trial (7.0-9.0 g/dL) are well tolerated. There is little evidence that RBC

transfusion in the non-bleeding patient with a hemoglobin concentration greater

than 7.0 g/dL leads to improved outcome”

9



“To conclude, our study in a large number of patients undergoing lower

extremity revascularization indicates that allogeneic intraoperative transfusion

is associated with higher postoperative morbidity and mortality. This finding is

true after adjusting for propensity for transfusion, thus, the reason that

transfused patients do poorly is not because they have a lower preoperative

hematocrit. When do the risks of anemia outweigh the hazards of transfusion?

In the absence of acute bleeding, hemoglobin levels consistent with the TRICC

trial (7.0-9.0 g/dL) are well tolerated. There is little evidence that RBC

transfusion in the non-bleeding patient with a hemoglobin concentration greater

than 7.0 g/dL leads to improved outcome”

10

© 2016 Mediware Information Systems, Inc. All rights reserved.

Background/Context: History

Blood Utilization Recommendation

Implement a system wide Blood Utilization program

Partner with Mediware Consulting & Analytics for

tools and program support

Establish goal to save 20% of the Acquisition costs

for ministries included in the program

Provide proactive strategies to reduce transfusions

in high-risk patients

Report results to senior management twice a year

Sep

2011 Originated

Nov

2012

Approved by

Program

Sponsors

Jan

2013

Approved by

Executive

Council

April

2013

Partnered

with

Mediware

11


Background/Context: History

12


Background/Context: Key Roles for Sustainability

CMO/CNO

VP

Blood-Ordering

MD

Pathologist

Quality Blood Bank

Provider Support

Patient Safety

13


Blood Management and Transfusion Safety Initiative

*Expected completion dates based off Mediware standard timeline and adjusted for Meditech rollout

Milestones CMC SJO SJMC MH SRM/PVH SMMC QVH SJE/RMH

Ph

as

e 1

:

Imp

lem

en

tin

g

Ch

an

ge

Audit and Assessment

Core Education (MD/RN)

Transfusion Safety Committee

Development

Ph

as

e 2

:

Ha

rdw

irin

g

Ch

an

ge

Transfusion Guideline

Implementation

Performance Improvement

Project Active

GI Hemorrhage

Ph

as

e 3

:

Pe

rfo

rma

nc

e

Imp

rove

me

nt


Project Pre-op Anemia


Project

Program Milestone Report

Contract Start Date: April 2013 Contract End Date: April 2016

14


Savings Impact

Average %

saved for

RBCs in

Year 1 is 15%

CMC is

already at

29% in 11

months!

15


Inpatient Utilization by Blood Product Group

16

Covenant Confirmation of Reduction in Utilization

0

10

20

30

40

50

60

70

80

CMC RBC Units/100 Discharges

LS RBC Units/100 Discharges

CPH RBC Units/100 Discharges

Month January February March April May June July August Sept October November December January February March April May June

CMC RBC Units/

100 Discharges 46 62 52 54 54 71 54 54 46 55 50 36 46 41 46 33 32 39

LS RBC Units/

100 Discharges 61 67 58 61 58 58 69 61 52 54 73 67 60 74 53 42 71 58

CPH RBC Units/

100 Discharges 65 31 48 74 43 56 34 43 21 12 23 15 17 17 23 31 18 24

17



April 2013 June 2013 July 2013 Oct 2013 Nov 2013

Mediware

Contract

Effective

Program Kickoff • Meeting with TSO (Karin Whitten)

• Meeting: MD education

• Meeting: Nurse Educators

• Also met with Quality Director, MICU nurse

manager, ECMO Coordinator, Inpatient

Oncology

Presentation of Results

• Meetings with: • Leadership

• Project Team

• Dr. Blann

• Transfusion

Committee

• Dr. Thompson

• Dr. Fay

• Dr. Bayouth

Physician Education • 4 CME presentations

• Rounding (surgical

lounge/anesthesia ready

room)

Nursing Education • Offered 26 sessions

– reached roughly

500 nurses

Covenant Medical Center/Children’s Hospital Accomplishments - 2013

18



April 2013 June 2013 July 2013 Oct 2013 Nov 2013

Mediware

Contract

Effective

Program Kickoff • Meeting with TSO (Karin Whitten)

• Meeting: MD education

• Meeting: Nurse Educators

• Also met with Quality Director, MICU nurse

manager, ECMO Coordinator, Inpatient

Oncology

Presentation of Results

• Meetings with: • Leadership

• Project Team

• Dr. Blann

• Transfusion

Committee

• Dr. Thompson

• Dr. Fay

• Dr. Bayouth

Physician Education • 4 CME presentations

• Rounding (surgical

lounge/anesthesia ready

room)

Nursing Education • Offered 26 sessions

– reached roughly

500 nurses


19


20




Feb 2014 April 2014 May 2014 Aug 2014

Physician Education

• Meetings with: • Interventional radiologists

• Dr. Burke

• Rounding (Surgery Lounge, cardiac

anesthesiologist, cardiac PAs)

• Transfusion Committee

• Oncologists

• GI section

• 2 CME presentations

Nursing Education • 16 sessions offered –

reached about 140

nurses

Physician Education/Projects • Meetings with:

• Tumor Board

• Dr. Rhyne/Dr. Ghandour

(GI project)

• Trauma Journal Club

Nursing Education • 48 sessions offered –

reached about 100

nurses

Transfusion

Guidelines

released/

Meditech updated

21


Findings: Savings (Financial Impact)

October 2013 – December 2015*

*Note: Savings for each ministry is calculated from their program implementation date. CMC, SJO (October 2013), SRM/PVH

(December 2013), SJMC, MH (January 2014), SMMC (March 2014), SJE/RMH (August 2014), QVMC (December 2014)

% Saved Unit Savings

Purchase Cost

Savings

Transfusion Cost

Savings1

Adverse Events

Cost Savings2

Total Estimated

Savings

Covenant Medical Center 37% 13,287 $2,872,913 $5,181,818 $13,203,514 $21,258,245

St. Joseph Orange 37% 9,674 $1,949,503 $3,938,363 $10,129,811 $16,017,677

Mission 24% 4,502 $1,031,746 $1,588,328 $3,990,626 $6,610,700

St. Jude 27% 3,635 $857,772 $1,551,755 $4,031,864 $6,441,391

St. Mary 12% 1,341 $317,218 $636,631 $1,688,858 $2,642,707

Santa Rosa 28% 4,273 $704,841 $1,521,196 $3,789,196 $6,015,233

Petaluma Valley 13% 201 $36,076 $85,322 $221,408 $342,806

Queen Of The Valley 27% 779 $146,604 $310,554 $796,010 $1,253,168

St. Joseph Eureka 34% 1,494 $235,970 $469,330 $1,126,623 $1,831,923

Redwood 16% 57 $18,502 $31,387 $85,451 $135,341

TOTAL 29% 39,244 $8,171,145 $15,314,686 $39,063,361 $62,549,192

1Transfusion cost per unit in 2010 $ (source: Cremieux et al, JClinOncol 2000;18:2755-61)

2Adverse events cost per unit, including LOS and infections in 2010 $ (source: Blumberg et al, AmJSurg 1996;171:324-30)

22


Findings: Savings (Patient Impact)

October 2013 – December 2015*

Complications

Avoided1

(4% per unit)

Patient Days Reduced1

(1.5 days per unit)

Nursing Hours

Reduced1

(2.2 hrs per unit)

Lives Saved1

(0.9% per unit)

Covenant Medical Center 448 16,818 24,667 101

St. Joseph Orange 341 12,801 18,775 77

Mission 132 4,957 7,270 30

St. Jude 135 5,045 7,400 30

St. Mary 55 2,071 3,037 12

Santa Rosa 132 4,939 7,243 30

Petaluma Valley 7 277 407 2

Queen Of The Valley 27 1,005 1,474 6

St. Joseph Eureka 41 1,531 2,245 9

Redwood 3 102 149 1

TOTAL 1,321 49,546 72,667 297

1Assumes outcomes for a single unit of RBC, an apheresis unit of platelets, or a 3-unit dose of plasma (source: Ferraris et al, Arch Surg 2012;147)

*Note: Savings for each ministry is calculated from their program implementation date. CMC, SJO (October 2013), SRM/PVH

(December 2013), SJMC, MH (January 2014), SMMC (March 2014), SJE/RMH (August 2014), QVMC (December 2014)

23


Savings Impact

1 Ferraris et al, Arch Surg 2012;147(1). Assumes outcomes for a single unit of RBCs, an apheresis unit of platelets or a 3-unit dose of plasma

Average %

saved for

RBCs in

Year 1 is

15%

Covenant Medical Center/Children’s Hospital – Estimated Inpatient Savings

Transfusion cost per unit in 2010 $ (source: Cremieux et al, JClinOncol 2000;18:2755-61)

Adverse events cost per unit, including LOS and infections in 2010 $ (source: Blumberg et al, AmJSurg 1996;171:324-30)

Based upon recently published NSQIP

data1, this reduction would decrease

adverse events by:

Complications (4% per unit) 448

Length of Stay (1.5 days per unit) 16,818

Deaths (0.9% per unit) 101

Nursing Hours (2.2 hrs. per unit) 24,667

Baseline Period Oct 12 - Sep 13

Period to Date Oct 13 - Dec 15

Avg # of Units per 1000 Inpatient

Cases

Avg # of Units per 1000 Inpatient

Cases % Saved

Unit Savings

Purchase Cost Savings

Transfusion Cost Savings

Adverse Events Cost

Savings

Total Estimated

Savings

Red Blood Cells 398.22 256.98 35% 8,633 $1,890,598 $3,988,386 $10,532,101 $16,411,085

Platelets 67.02 41.10 39% 1,584 $839,612 $731,888 $1,932,692 $3,504,193

Plasma 110.03 61.19 44% 2,985 $116,421 $453,744 $728,379 $1,298,544

Cryoprecipitate 5.69 4.30 24% 85 $26,281 $7,800 $10,343 $44,424

TOTALS 37% 13,287 $2,872,913 $5,181,818 $13,203,514 $21,258,245

*Cryoprecipitate is reported as a base unit consisting of 5 single units

24



Covenant Medical Center/Children’s Hospital Next Steps - 2015

GI Hemorrhage internal data analysis

Implement Pre-operative Anemia Management program

Establish formal process to evaluate outlier utilization

(half of opportunity is outlier cases)

Review Massive Transfusion Protocol (adult and pediatric)

Review OB Hemorrhage Protocol

Review of BloodStat® Analytics at 80th Percentile

Continued Process Improvement

25


St. Joseph Covenant Experience

2.695

2.004

2.600

2.106

-100%

-80%

-60%

-40%

-20%

0%

20%

40%

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Oct

-12

Dec

-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

Dec

-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

Dec

-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

Dec

-15

Ro

llin

g 1

2-M

o.

Avg

. %

Ch

g. S

ince

Se

p-1

3

Covenant Medical Center - Children's HospitalMS-DRG 377-379 GI Hemorrhage

All Products

Units per Inpatient Rolling 12-Mo. Avg. BloodStat® Mean BloodStat® 80th %tile

Bas

elin

e

26

Future Challenges:

Correction of Pre-Admission

and Pre-Operative Anemia

Sustainment of Success

in Reduction of Blood

Product Utilization

27

One Hospital’s

Approach to

Improving Blood

Management

Covenant Health

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Blood Conservation Initiative - Craig Rhyne, Covenant Health