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Improving
compliance
with transfusion
guidelines in a
multihospital
healthcare system
Robert D. Christensen, MD April 12, 2013
19th INTERNATIONAL SYMPOSIUM ON NEONATOLOGY
Declaration of
Conflicts of Interest 1. I have no financial benefit related to
anything I will discus in today’s
lecture.
Declaration of
Conflicts of Interest 1. I have no financial benefit related to
anything I will discus in today’s
lecture.
2. I wish I did.
Intermountain Healthcare Quality Improvement: Transfusions
● 2004 - Transfusion guidelines
● 2007 - Evaluated compliance, audited every NICU
transfusion given in 2006.
● 2008 - Devised methods to improve guideline-
compliance and set a system-wide goal to
increase from 60% to 90%.
● 2010 - Analyzed benefits/risks of the
new program to improve compliance.
● 2011 - Analyzed transfusion practice
one year after new program ceased.
Transfusion Guidelines Bufano and Curran. Minimizing donor blood exposure in the
neonatal intensive care unit. Current trends and future prospects
Clin Perinatol 1995;22: 657-69
Transfuse if Hct ≤35% if intubated and receiving >35% O2 or on
CPAP ≥6 to 8 cm H2O
Transfuse if Hct ≤30% if undergoing surgery, wt gain <10 g/d for
4 d, HR >180/min , RR> 80/min, apnea/bradycardia (>9 episodes
in 12 h or 2 in 24 h needing bag/mask while on therapeutic dose of
methylxanthines. Or if on CPAP or intubated with MAP <6 cm
H2O or on <35% O2
Transfuse if Hct ≤20% if asymptomatic and reticulocytes
<100,000/μL
Transfusion Guidelines Calhoun DA, Christensen RD et al. Consistent Approaches to
Procedures and practices in neonatal hematology Clin Perinatol
2000;27: 733-53.
RBC
●Transfuse if Hct ≤35% if intubated and ≥40% O2
●Transfuse if Hct ≤28% if intubated on <40% O2 or unexplained
lethary, poor wt gain, tachycarial, apnea.
●Transfuse if Hct ≤20% any neonate
PLATELETS
●Transfuse if PL ≤100,000 and bleeding, pre or post op, ECMO
●Transfuse if PL ≤50,000 if “unstable”
●Transfuse if PL ≤25,000 any neonate
Transfusion Guidelines Calhoun DA, Christensen RD et al. Consistent Approaches to
Procedures and practices in neonatal hematology Clin Perinatol
2000;27: 733-53.
RBC
●Transfuse if Hct ≤35% if intubated and ≥40% O2
●Transfuse if Hct ≤28% if intubated on <40% O2 or unexplained
lethary, poor wt gain, tachycarial, apnea.
●Transfuse if Hct ≤20% any neonate
PLATELETS
●Transfuse if PL ≤100,000 and bleeding, pre or post op, ECMO
●Transfuse if PL ≤50,000 if “unstable”
●Transfuse if PL ≤25,000 any neonate
Adopted as NICU Transfusion
Guidelines at Intermountain
Healthcare in 2004
How well are we complying with our transfusion guidelines?
How Well Do We Comply with Our
July 2008
In 2007, Reviewed every
NICU transfusions given
during 2006
Adherence to NICU transfusion
guidelines: data from a
multihospital healthcare system. Baer VL, Lambert DK, Schmutz N, Henry E, Stoddard RA,
Miner C, Wiedmeier SE, Burnett J, Eggert LD,
Christensen RD 2008
RESULTS:
● Overall 65% of RBC transfusion and 60%
of platelet and FFP transfusions were
compliant with the Guidelines.
● Most violations were platelet transfusions
given “early”, RBC transfusion given “late”.
“...the greatest
exposure to liability
in the practice of
medicine occurs
when physicians fail
to follow their own
rules (practice
guidelines).”
Perry Mason, 1959
2008 – A program to make it easier for busy clinicians to comply with
the transfusion guidelines
2009 – Jan 1, program instituted in all NICUs
1.Electronic physician order entry for transfusions. 2.Training in all hospitals with a NICU. 3.Guidelines displayed on the screen at the
time transfusion orders are entered. 4.Monthly report cards to each NICU director
and nurse manager of their previous month’s compliance figures.
5. “Board Goal” to increase compliance to >90% of all transfusions.
Transfusion Compliance
Program
Implementing a program to improve
compliance with NICU transfusion guidelines
was accompanied by a reduction in
transfusion rate: A pre-post analysis within a
multihospital healthcare system. Baer VL, Henry E, Lambert DK, Stoddard RA, Wiedmeier SE,
Eggert LD, Ilstrup S, Christensen RD
2011
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
System 2009
Pe
rce
nt o
f tra
nsfu
sio
ns g
ive
n w
ith
in
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
NICU A - 2009
Pe
rce
nt o
f tr
an
sfu
sio
ns g
ive
n
within
guid
elin
es
.
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
NICU B- 2009
Pe
rce
nt o
f tr
an
sfu
sio
ns g
ive
n
with
in g
uid
elin
es.
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
NICU C- 2009
Pe
rce
nt o
f tr
an
sfu
sio
ns
giv
en
with
in g
uid
elin
es.
Associated with the improved
compliance were the following…
• Fewer transfusions administered
• More neonates receiving no transfusions
• Lower blood bank charges
• No observed harm (no change in LOS or
mortality rate, and trends toward
improvements in IVH, NEC, ROP, BPD)
Percent of NICU admissions that
received one or more transfusions
0
2
4
6
8
10
12
14
16
18
20
2007 2008 2009
PRBC Platelets FP
Pe
rce
nt o
f N
ICU
pa
tie
nts
rece
ivin
g o
ne
o
r m
ore
Tx
A total of 3923 NICU transfusions
were administered in 2009. This was
down from an average of 4907 during
the two previous years.
A decrease in RBC transfusions of
554/year.
A decrease in platelet transfusions of
174/year.
A decrease in frozen plasma transfusions
of 256/yr.
Effect on Blood Bank Charges
• RBC: 554 @ $847/transfusion…………..$469,238/year
• Platelets: 174 @ $1,398/transfusion…….$243,252/year
• Frozen Plasma: 256 @ $264/transfusion…$67,584/year
• Reduction in transfusion service charges…
……………...$780,074/year
Neonates that received one or more transfusions
in 2009 received the same average number of
transfusions/patient as did those in previous years
• Median # RBC transfusions /patient 2-3
• Median # Platelet transfusions/patient 1-2
• Median # FP transfusions/patient 1-2
201 neonates that would have received one
or more transfusions in previous years,
received no transfusions in 2009.
No evidence that outcomes
were adversely affected.
Primary Children’s Hospital • Mortality unchanged at 6%
• Length of stay consistent at a median of 8 days.
• Non-significant decrease in BPD, ROP, IVH,NEC.
Perinatal Centers • Mortality unchanged at 1%
• Length of stay consistent at a median of 9 days.
• Non-significant decrease in BPD, ROP, IVH, NEC.
The system-wide transfusion compliance program finished December 31, 2009. No further report cards, monthly reminders, corporate emphasis. Computerized transfusion order entry remained.
Recidivism Recidivism (from Latin recidīvus
"back" + cadō "I fall").
The act of repeating an undesirable behavior
after having been trained to
extinguish that behavior.
It is also known as the percent
of former prisoners who are
rearrested.
Recidivism • Hand hygiene
Interventions to improve hand hygiene compliance in patient care.
Cochrane Database Syst Rev. 2010 Sep 8;(9):CD005186.
Recidivism Patients With Hyperbilirubinemia
Patients Born in Intermountain Healthcare Facilities
(>19.9 mg/dL) By Month
272626
35
24
31
24
31
28
14
33
19
28
22
24
2627
32
34
31
25
1616
14
27
20
1415
13
15
9
13
15
12
1616
10
18
13
17
12
16
22
9
13
11
1314
8
15
24
16
19
2423
12
21
18
20
16
24
2021
1415
26
19
15
21
30
21
18
15
22
25
22
28
13
22
16
23
20
23
29
26
29
14
22
24
18
14
16
20
18
20
24
26
17
7
13
11
344
3
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4
1
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Birth Month
Nu
mb
er o
f P
ati
en
ts
20-24.9 25+
● Bilirubin screening to avoid hyperbilirubinemia
Recidivism • Weight Reduction Programs
Recidivism in a Utah Man. Oprah Winfrey Show, May, 2011
January 2011
July 2011 December 2011
●Weight reduction programs
Patients With Hyperbilirubinemia
Patients Born in Intermountain Healthcare Facilities
(>19.9 mg/dL) By Month
272626
35
24
31
24
31
28
14
33
19
28
22
24
2627
32
34
31
25
1616
14
27
20
1415
13
15
9
13
15
12
1616
10
18
13
17
12
16
22
9
13
11
1314
8
15
24
16
19
2423
12
21
18
20
16
24
2021
1415
26
19
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21
30
21
18
15
22
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22
28
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2009
FMAMJ
Birth Month
Nu
mb
er o
f P
ati
en
ts
20-24.9 25+
So… a year after concluding the transfusion
BOARD GOAL program (monthly reports,
central scrutiny and corporate emphasis) did
we have RECIDIVISM?
System-Wide Summary
2009, 88±13%
2010, 96±2%, p=0.034
System-Wide Transfusion Rates
YEAR NICU
admissions
RBC
transfusions
Platelet
transfusions
Frozen Plasma
transfusions
2007 3303 622 (19)* 209 (6)* 253 (8)*
2008 3533 594 (17)* 217 (6)* 266 (8)*
2009 3444 449 (13)* 183 (5)* 178 (5)*
2010 3488 402 (12) 139 (4) 141 (4)
Number (%) of NICU admissions that received one or
more RBC transfusions, Platelet transfusions, Frozen
Plasma transfusions
* P<0.05 vs. 2010
Estimates of Financial Savings on the
Basis of Reduced Transfusion Rates
Reduction in blood bank-associated charges in 2009
$780,074 (Compared with 2007 and 2008 charges)
Estimates of Financial Savings on the
Basis of Reduced Transfusion Rates
Reduction in blood bank-associated charges in 2009
$780,074 (Compared with 2007 and 2008 charges)
Reduction in blood bank-associated charges in 2010
$892,561 (Compared with 2007 and 2008 charges)
Estimates of Financial Savings on the
Basis of Reduced Transfusion Rates
Reduction in blood bank-associated charges in 2009
$780,074 (Compared with 2007 and 2008 charges)
Reduction in blood bank-associated charges in 2010
$892,561 (Compared with 2007 and 2008 charges)
Two-year savings to Intermountain Healthcare associated with
the Women and Newborn’s Transfusion Compliance Program
$1,672,635
Why, without corporate
reminders and central
scrutiny, did we continue to
comply so well with our
transfusion guidelines?
Why are we seeing further
reductions in RBC, platelet,
and FP transfusion rates?
It’s Puzzling
1) We are now aware of
reports that “liberal trans-
fusions” are associated
with poorer long-term
neuro-developmental
outcomes (two Iowa
Studies published in
2011).
Some Possibilities:
2) We have seen this
approach reduces costs
and conserves blood bank
resources with no
apparent adverse effect
on outcome.
Some Possibilities:
3) Maybe we are
experiencing a “culture
change” in NICU
transfusion practice.
Some Possibilities:
A high rate of compliance with NICU
transfusion guidelines persists even after a
program to improve transfusion guideline
compliance ended.
Christensen RD, Henry E, Ilstrup S, Baer VL
2012
Better compliance with our transfusion guidelines
was associated with a reduction in transfusion
usage (RBC 32%, PL 33%, FFP 44%)
1.Some neonates now are never transfused who (in
previously years) likely would have been.
2.Financial savings > $750,000/year.
3.Conserving valuable blood-bank resources.
Recap
Improving evidence-based
NICU transfusion practice =
lower costs, save resources,
better healthcare value
Improving compliance with transfusion guidelines in a multihospital healthcare system
Thanks for your kind attention!
"Ordem e Progresso" L’amour pour principe et l’ordre pour base; le
progrès pour but (Love as a principle and order as
the basis; progress as the goal)
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