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

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an

sfu

sio

ns g

ive

n

within

guid

elin

es

.

0%

20%

40%

60%

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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

NICU B- 2009

Pe

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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

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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

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24

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19

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24

2627

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25

1616

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● 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

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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)