CPOE Reducing Inappropriate Transfusions (CRIT) Collaborative

“The most cost effective opportunity to improve patient outcomes in the next quarter century will likely come, not

from discovering new therapies but from discovering how to effectively deliver therapies that are known to be effective”

Sean Berenholtz 2003

Introduction of Collaborative Participants

CONTACT INSTITUTION

Richard Chang, Geetha Puthenveetil Children’s Hospital Orange County

Suresh Srinivasan Children’s Hospital of Michigan

Marvin Harper, Jenifer Lightdale Children’s Hospital Boston

Eloa Adams, Chris Longhurst Lucile Packard Children’s Hospital

Munirah Curtis, Sara Boblick Smith University of Illinois at Chicago

Calvin Popovich All Children’s Hospital, Florida

Phil Spinella Washington University, St Louis

Rod Tarrago Children’s Hospital Minnesota

David Rich Nationwide Children’s Hospital

David Kaelber Metrohealth, Case Western

Marissa Tucci CHU Sainte-Justine Research Center

Collaborative Goals

• Introduce a tool to reduce unnecessary blood transfusions in hospitalized children across multiple institutions.

• Test the hypothesis that CPOE tethered to CDS can improve and hasten the adoption of evidence based guidelines across multiple institutions.

• Set the framework for future collaborations using effective decision support tools.

Collaborative Benefits

• Quality Improvement– Improve transfusion

utilization– Significant cost savings– Demonstrate the value

of CPOE– Idea sharing– Networking

• Academic– Provide the framework

to conduct hypothesis driven studies/RCT’s across multiple institutions

– Provide the framework for future collaborations and research projects

Red Blood Cell Transfusions Carry Both Benefits and Risks

What are the standard transfusion practices?

When is it appropriate to transfuse?

When do the benefits outweigh the risk?

Red blood cell transfusions alter immune function

Transfusion Practices are Highly Variable Among Hospital Based Pediatricians

Laverdiere PCCM 2002

Barriers to Transforming Data Into Practice

Cabana, JAMA 1999Berenholtz, Current Opinion in Critical Care 2003

Clinical Decision Support and Computerized Physician Order Entry (CPOE) Augments Adherence to Evidence

Based Guidelines.

Kawamoto BMJ 2005

Study Design

Decision Support Window

In the Acute Care Wards, CPOE Decision Support Decreased Average Pre-transfusion Hemoglobin

Control Post-Intervention0

1

2

3

4

5

6

7

8

Avg.

Pre

-tran

sfus

ion

Hgb

mg/

dl

***

In the PICU, CPOE Decision Support Decreased Average Pre-transfusion Hemoglobin

Control Post-intervention0

1

2

3

4

5

6

7

8

9

10

Avg.

Pre

-tran

sfui

on H

gb m

g/dl

***

In the PICU, CPOE Decreased Blood Transfusions Per Patient Day

On the Acute Care Wards, CPOE Decreased Blood Transfusions

460 fewer blood transfusions

100 fewer patient exposures

Overall transfusions per patient day

Control Post-intervention0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

Tran

sfus

ions

per

pat

ient

day

*

The relative risk of transfusion in the study population versus control

Implementation of a Decision Support Algorithm in Association With CPOE Can:

Accelerate adoption of evidence-based guidelines into clinical best practice

Decrease overall RBC transfusions in the PICU and pediatric acute care wards without increasing overall hospital mortality or PICU length of stay

460 fewer RBCT delivered to children at LPCH during the study period. The estimated direct cost savings for the blood alone was more than $160,000.00. After accounting for additional indirect costs surrounding blood transfusions, the overall savings is significantly greater.

CRIT Website

ImplementationInstitution EMR

VendorImplemented Investigating Data

AnalysisChildren’s Hospital Orange CountyChildren’s Hospital of Michigan

Children’s Hospital Boston

Lucile Packard Children’s Hospital Cerner

University of Illinois at Chicago

All Children’s Hospital, Florida

Washington University, St LouisChildren’s Hospital Minnesota

Nationwide Children’s Hospital

Metrohealth, Case Western CHU Sainte-Justine Research Center

Next meeting

Monday October 24th 10:00 AM

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