HOW MULTIDISCIPLINARY COLLABORATION LED TO A REDUCTION

IN RED BLOOD CELL USAGE BY MORE THAN 25% IN A TERTIARY CARE

HOSPITAL

Marisa B. Marques, MDProfessor of Pathology

Medical DirectorTransfusion Service

University of Alabama at Birmingham Hospital

UNIVERSITY HOSPITALOVERVIEW

908-Bed flagship facility of the UAB Health System

Comprehensive Cancer Center

Only Level 1 Trauma Center in Alabama

One of two Burn Centers in Alabama

Regional Neonatal Intensive Care Unit

One of the largest comprehensive transplantation programs in thecountry and the largest in the Southeast

Closed medical staff >1,000

76 Residency Training Programs

800+ residents, fellows, and interns

WHY FOCUS ON BLOOD UTILIZATION?

24,141

29,95532,583 33,537

37,26239,552

20,000

25,000

30,000

35,000

40,000

45,000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

UAB Hospital blood use growth was in excessof 60% from FY 1997 – FY 2006

UAB HOSPITAL BLOOD USAGE

In 2007, UAB was the 4th largest purchaser of blood from American

Red Cross in the U.S.

At that time, University Hospital had a total of four blood suppliers in

order to meet demand

ALABAMA HOSPITALS’ ANDUAB HOSPITAL BLOOD NEEDS

220,000

230,000

240,000

250,000

260,000

270,000

280,000

290,000

Alabama 280,000 245,000

Need Collections

UAB State need created a

35,000 unit shortfall

Source: American Red Cross

43,000

1,8750

10,000

20,000

30,000

40,000

50,000

Alabama 43,000 1,875

UABHS Need Best Annual Collections

Donations created a

41,000 unit shortfall

CHALLENGES WHEN BLOOD NEEDEXCEEDS LOCAL SUPPLY

0500

100015002000250030003500400045005000

Uni

ts

Q1 05

Q2 Q3 Q4 Q1 06

Q2 Q3 Q4 Q1 07

Supplier 1 Supplier 2 Supplier 3 Supplier 4

Imported Blood and Patient SafetyIncrease costs and time delayPriority rankingRisks of transportation

3,000

Units collected at UAB in 2006

UAB dependency on “imports”

VISION FOR THE FUTURE

10 – 20%250 – 260%

Increase collections at UAB Decrease utilization

Decrease dependency on “imports”

Safe Blood Supply

ConserveResources

ImprovedOutcomes

↓ Nosocomial Infections↓ Adverse Effects

↓ Acquisition costs↓ Imported blood

Current UAB blood need

Increased bloodSupply for the State

VENDOR COLLABORATION

Vendor Agreement

Three year contract term with price concessions

Co-branding / marketing approach to increase donations

Hospital provides new donor center

Vendor agrees to collaborate with the development of a blood management program

Relationship based on mutual benefit and a global strategy and vision

Strategies to Accomplish

Decrease Usage

Comprehensive Blood Management Program

Increase Collections

Hospital Based Donor Center

Hospital & Campus Blood Drives

Donor / Employee Incentive Programs

DEVELOPMENT OF A BLOOD MANAGEMENT PROGRAM TO DECREASE

UTILIZATION

QUALITY ISSUES: FAILURE TO ADOPT EVIDENCE-BASED TRANSFUSION GUIDELINES

Ranked as the #1 landmark study that has changed the practice oftransfusion medicine2 but how many physicians are familiar with it?

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

BLOOD MANAGEMENT STRATEGIES

Goal: To ensure that every unit of blood transfused is appropriate

Minimize transfusions, complications & anemia

Efficient use of all resources (nursing and tech time, lab tests, drugs, medical devices)

Organizational Principles

Education, education, education

Multidisciplinary, multimodal approach

Attention to detail

Utilization of evidence-based guidelines and clinical best practices1

Patient safety/ advocacy

Proactive patient management systems2,3

2 Pierson, Hannon. JBJS 2004;86A(7)3 Boucher, Hannon. Pharmacotherapy 2007;27(10)

1 Hannon. Transfusion Guidelines. In: The Transfusion Committee, 2006 (AABB Press)

PHASE I – BLOOD AUDIT REPORT

Logical beginning process stepsEvaluate controls for blood utilizationEngage key hospital stakeholdersStudy Blood Bank operation and financial systems

Identify gaps in performanceBenchmarks, best practices, trends, and risk exposureInclude BloodStat™ utilization scorecard

Communication is a core strategyCME talks to gain buy-in with clinicians

Key Phase I benefitsRaises interest & desire to changeUseful metrics are discussed

University HospitalUAB

PHASE I – BLOOD AUDIT REPORT

Blood utilization trends

BloodStat™ benchmarking

Blood utilization oversight

Blood bank operations

Nursing practices

Blood management systems

Physician, RN and med tech surveys

Risk management/ medical-legal

Blood management financials

Summary and conclusions

University HospitalUAB

GOALS OF UAB BLOOD MANAGEMENT PROGRAM

Clinical and technical physician leadership

Establish non-punitive mechanism for error reporting and near misses

Monitor transfusion practices and generate feedback mechanism to all staff and physicians

Provide ongoing education regarding transfusion practices

Transfusion triggers

Adverse events

Reduced wastage – iatrogenic blood loss

UAB BLOOD MANAGEMENTIMPLEMENTATION PLAN

Eliminate the 2 unit transfusion dictum

Transfusion threshold of hemoglobin 7.0 g/dl (hematocrit 21%) for inpatients

Educate, Educate, Educate

Residents, nurses, faculty, management

Develop “Transfusion Guideline pocket” tool for physicians

Type and screen vs. type and cross to improve inventory management

Encourage process improvement projects focused on blood management

Empower the Blood Utilization Management Committee to enforce guidelines

Hire a Transfusion Safety Officer (TSO)

HOSPITAL INITIATIVES

Reduction of iatrogenic blood loss

Instructional phlebotomy tools re: what tube/how much

Reduced phlebotomy associated blood loss in ICU’s

CVOR blood salvaging initiatives

Identification of unit Blood management Champions

Regular (weekly audits) with feedback requiring responses

TRANSFUSION JUSTIFICATION LETTERS

Nurse in Quality department

Reviews 20 random units of each blood product per week

Compares with pre-transfusion laboratory values (i.e., hemoglobin)

Units not meeting criteria sent for MD review

Secondary review (BUMC Co-chair)

Review electronic medical record for justification of transfusion

Cases without obvious reason sent to Attending Physician in e-mail with attached UAB transfusion guidelines

Most common reasons for letter: hemoglobin > 7 g/dL and transfusion of 2 units in non-bleeding patient

IMPLEMENTATION TIME LINE

2007Strategic Blood Mgt Group Site Visit - Audit July/AugustBlood Audit Report Received & Presented October 16

Medical & Surgical Grand Rounds October 16Ten other departmental presentations

Blood Implementation Plan received & November 16“Capstone” seminar to engage stakeholdersReformation of Blood Utilization Committee February 2008Blood Donor Center Completed November 26

2008Continuing Education of Clinical Staff and Management OngoingDonor Recognition Program Launched January 2008

www.uabtouchpoints.orgEmployee Blood Program September 2008

2009Expansion of Donor Center Early 2009Organizational Performance Metrics 2009Individual Performance Feedback (audits) 2009

2010Extend strategies to UAB Highlands Mid 2010

UAB Red Blood Cell UsageFY 2003 – FY 2010

5000

6000

7000

8000

9000

10000

11000

03 04 05 06 07 08 09 10

Q1 Oct-Dec Q2 Jan-Mar Q3 Apr-Jun Q4 Jul-Sep

# U

nits

USAGE OF PRBC FROM 1997 - 2010

20000

25000

30000

35000

40000

45000

19971998199920002001200220032004200520062007200820092010

Blood management discussions started

BLOOD UTILIZATION RESULTSRBC UNITS TRANSFUSED / DISCHARGE

0.9250.821

0.706 0.65

0.00

0.20

0.40

0.60

0.80

1.00

Oct - Sep07

Oct - Sep08

Oct - Sep09

Oct - Dec10

Uni

ts /

Dis

char

ge

11% reduction – FY07 to FY0820% reduction – FY07 to FY0929% reduction – FY07 to FY10 (Q1)

RBC Usage by Specialty

Example of Cardiovascular Diagnosis Whose Blood Utilization has Improved

HOW WE INCREASED COLLECTIONS

ONE STEP AT A TIME….HOSPITAL-BASED DONOR CENTER

INDIVIDUAL DONOR INCENTIVE PROGRAM

An individualized blood donor recognition programEligible to all employeesTouchPoints are recorded by donors online

10,000 TouchPoints for every successful donation Accumulate 50,000 TouchPoints and exchange points for various items available for every level of donation, i.e., 50,000 - 60,000 -70,000, etc

120,000 TouchPoints -choose a "Get-a-Way" gift package

Newly designed T-shirt to every donor. Other give-away items include hats, mugs, and pens.

EMPLOYEE BLOOD DONOR PROGRAM

Goal

10% participation per department per quarter

Goal is ~2,800 units per year

Each Department

Select a Champion for every 50-75 employees

Support employees giving blood during work hours

EMPLOYEE BLOOD DONOR PROGRAMCHAMPIONS

Serve for 1 year – October through SeptemberWork with Co-workers and Donors

Encourage participation among co-workersRecruit new, first time donors Encourage repeat donationsAssist donors with online appointmentsEducate employees regarding the goal of 10% participation per department per quarterChampions can create internal/external campaigns through the Red Cross offices

Provide support at major blood drivesCreate internal competition programs

HOW WE DID IT …SPECIAL PROMOTIONS

HOW IT HAPPENED FOR FY09…MAJOR BLOOD DRIVES

CONCLUSION

Electronic database tracks 10% goals

Departmental objective of 10% works

Champions and departments are recognized and rewarded for their participation

Quarterly ARC meetings to assess financial update on collection performance

RESULTS - INCREASED COLLECTIONS

168

2,969

6,150

8,073

9,501

0

2,000

4,000

6,000

8,000

10,000

FY06* FY07 FY08 FY09 FY10 Goal

*ARC only. Does not include collections by other blood centers.

*

10 – 20%125 – 250%

Increase collections at UAB Increase collections at UAB Decrease utilizationDecrease utilization

Safe Blood SupplySafe Blood Supply

FY10 8,674FY09 8,073FY08 6,150FY07 1,875362% increaseIn collections(FY07 - FY10)

FY10 1st Qtr 29% decreased utilization(FY07 – FY10)

Current UAB blood needCurrent UAB blood need

Increased blood supply

for UAB and the State

Decrease dependency on Decrease dependency on ““importsimports””

IN SUMMARYVISION FOR THE FUTURE

IN SUMMARYFINANCIAL RESULTS

$12.2M $10.9M

$9.8 M $10.1 M

$8.6M

$0

$3,000,000

$6,000,000

$9,000,000

$12,000,000

$15,000,000

FY06 FY07 FY08 FY09 FY10 (Projected)

Total Blood Product Cost Reduction of $3.5M

Transfusion Safety: an interconnected series of steps

Product

Process

RecruitScreen Donor

Collect & PrepareTest for infectious

diseases

Pre-transfusion testing

MD decides to transfuse

Issue

Administration(bedside)

Monitoring & evaluation

Dzik WH. Emily Cooley Lecture 2002: Transfusion safety in the hospital. Transfusion. 2003;43:1190

Thank you!

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