Mike MurphyProfessor of Blood Transfusion Medicine,

University of OxfordConsultant Haematologist,

NHS Blood & Transplant/Oxford University Hospitals

Use of IT to improve the safety and quality of transfusion

Overview of hospital blood transfusion

• High activity (2.2 million units of red cells to 500,000 patients/year in the UK; 27,000 units of red cells/year in Oxford)

• High cost (£300+ million/year for the cost of blood in England; £4.5 million/year in Oxford; unknown costs for the transfusion process)

• High risk (204 deaths due to transfusion in the last 18 years in the UK; 30 deaths and 146 cases of major morbidity due to ‘wrong’ transfusions; 292 ABO incompatible red cell transfusions)

High level of inappropriate use of blood Data from large regional and national audits of blood useAudit Year Number of

HospitalsN cases audited

Inappropriate use Guideline Standard

Red cell transfusion

2002 All 13 hospitals in N. Ireland

360 19% of patients inappropriately transfused and 29% over-transfused

British Committee for Standards in Haematology (BCSH) (2001)

Red cells in hip replacement

2007 139/167 (83%) 7465 48% of patients British Orthopaedic Association (2005)

Upper GI bleeding 2007 217/257 6750 15% of RBCs, 42% of platelets, 27% of FFP

British Society of Gastroenterology (2002)

Red cell transfusion

2008 26/56 (46%) hospitals in 2 regions

1113 19.5% of transfusions BCSH (2001)

FFP 2009 186/248 (75%) 5032 43% of transfusions to adults, 48% to children, 62% to infants

BCSH (2004)

Platelets in haematology

2011 139/153 (91%) 3296 27% of transfusions BCSH (2003)

Cryoprecipitate 2012 43/82 (52%) from 3 regions

449 25% of transfusions BCSH (2004)

http://hospital.blood.co.uk/safe_use/clinical_audit/National_Comparative/index.asp

Large variation in use of blood by different clinical teamsNational audit of blood use in cardiac surgery, 2011

% CABG patients receiving Red Blood Cells

0 10 20 30 40 50 60 70

2623

201318151767

115

101216259

2314194

211N

% CABG patients receiving FFP

0 5 10 15 20 25 30 35 40 45 50

262

17153

13191256

2314749

20212516111

1018N

Red Cells22%- 66%

FFP3% to 46%

% CABG patients receiving Platelets

0 5 10 15 20 25 30 35 40 45

1863

265

23171327

1215112514204

22191691

10N

Platelets4% to 42%

• Academic medical centre• Provides healthcare for Oxfordshire (serves 2.5 million population)• 2 acute sites, specialist orthopaedic and several community hospitals• Full range of clinical services• 1300 beds; 9000 deliveries/year

Our vision for a high quality transfusion service

To develop and implement process change inhospital transfusion supported by IT to:-

• Enhance patient safety• Improve the patient experience• Reduce the administrative burden for our clinical staff• Achieve compliance with tightening statutory and

governance requirements• Optimise our use of resources (reduce blood use and blood

wastage)

TRANSFUSION PROCESS

Assess clinical need

Inform patient/consent

Select product and quantity

Order product

Request form

Blood sample

Crossmatching

Delivery

Identity check

Administration of product

Recording

Observation

Respond to adverse event

doctors

nurses / doctors phlebotomistt

laboratory staff

porters

nurses

doctors / nurses /

laboratory staff

← bedside

← bedside

← blood fridge

← bedside or ward PC

← bedside

Hospital transfusion is complex and has many steps

Standard pre-transfusion processLots of paper work (nursing and medical notes, prescription, observation chart, compatibility report form)

2 nurses (1 nurse reading information from blood pack, 2nd nurse cross-referencing with all the different paperwork)

27 individual steps to be carried out before safe to commence the transfusion

Baseline data on patient identification(Turner C et al. Transfusion 2003; 43: 1200-1209)

55 transfusions audited:• 5 patients not asked for any verbal ID• Of the 50 who were asked for ID, this was

mostly only date of birth• In 35, this information was not checked with

any written documentation• 6 patients did not have a wristband• ID on the patients’ wristbands were not

checked before any of the transfusions

Electronic transfusion process

Less paperwork

1 nurse

16 individual steps to carry

out before safe to commence

the transfusion

Compliance with pre-transfusion bedside checking in the haematology inpatient ward

(Transfusion 2003;43:1200-1209)

0

10

20

30

40

50

60

70

80

90

100

Baseline After training After training and introduction ofbarcode ID

%

Collection of blood from fridges under electronic control

(Davies A et al. Transfusion 2006;46:352-364)

• Ensure secure blood collection for a procedure prone to error

• Allows ‘self-service’ of unallocated blood to speed delivery at remote sites through linkage to blood bank IT

Blood Track Manager:‘Live view’ of transfusions in Oxford

Self service blood collection:electronic remote issue

(Staves et al. Transfusion 2008;48:415-424) • Electronic issue: safe release of blood without

a test of patient’s serum/plasma v. donor red cells by using blood bank IT to ensure that certain criteria are met

• ‘Electronic Remote Issue’: issue of unallocated blood from blood fridges remote from the transfusion laboratory by an electronic query of blood bank records and the printing of a compatibility label at the blood fridge

• Major benefit for blood banks serving multiple sites (as in Oxford) or a region

JOHN RADCLIFFE (JR)Central blood bank

HORTONDistrict general

hospital with satellite blood bank

30 miles from JR

NOCSpecialist orthopaedic

hospital 2 miles from JRCHURCHILLAcute hospital 2 miles from JR

COMMUNITYHOSPITALS

AND AT HOME

NHSBTBlood

supplier

NHSBT: Reference RCI, H & I, SCI etc; blood product provision; electronic requesting of blood and diagnostic tests and issuing of reports; clinical and scientific advice.JR lab: Hub: routine and urgent sample testing 24/7; product provision; antibody identification (all but very complex).Spoke with lab: urgent requests; product provision. Spoke without lab: product provision.

Oxford Centralised Transfusion Service

National awards

Benefits (250,000+ units red cells transfused)

(Murphy MF et al. Transfusion 2012;52:2502-2512) • No ABO incompatible red cell

transfusions• No serious wrong blood events• ‘Wrong blood in tube’ reduced to 1

in 26,690 samples (national benchmark 1 in 3,000 samples)

• Compliance with blood traceability, competency assessment etc

• Less blood wastage

Estimated costs and cost savingsCosts:About £11/unit to cover lease of bedside and fridgehardware, software licences, training, and a system manager (= £400k/year for Oxford)

Productivity gains:• Nursing time (£500k/year)• Transfusion laboratory staff time (£20k/year)• Staff and time for meeting regulatory requirements and for

training (£20k/year)

Cash releasing savings:• Blood wastage (£20k/year)• Blood usage (£400k/year)

Compares well with some transfusion safety measures

TRANSFUSION PROCESS

Assess clinical need

Inform patient/consent

Select product and quantity

Order product

Request form

Blood sample

Crossmatching

Delivery

Identity check

Administration of product

Recording

Observation

Respond to adverse event

doctors

nurses / doctors phlebotomistt

laboratory staff

porters

nurses

doctors / nurses /

laboratory staff

← bedside

← bedside

← blood fridge

← bedside or ward PC

← bedside

‘Decision support’for better practice

Development of electronic blood ordering

Capture the diagnostic group

Automatic capture of the most recent relevant result

Select a reason for transfusion

Electronic blood ordering and decision support

33

22

11

Alert if transfusion not justified

Compliance with agreed transfusion triggers in haematology improved from <50% to >90%

Feedback of data to clinical teams(Red cell usage by OUH Division)

Feedback of data to clinical teams(Red cell usage by clinical specialty)

  2013(units)

2014(units)

Reduction in units

% OUHTchange

% national change

Cost reduction

Red Cells 27,371  24,313 3058 x £121.85 -11.1  -2.6 £372,617

Platelets 4193 3645 548 x £196.96 -13.0 +1.3 £107,934

FFP 5348 4996 352 x £28.46 -6.6 -2.4 £10,018

Total cost reduction           £490,569

Reduction in OUH blood use and cost savings

I am delighted with this Annual Report from the NIHR. It is full of good news.

For example, a new blood management system trialled and tested by our Oxford NIHR Biomedical Research Centre saved Oxford University Hospitals NHS Trust half a million pounds last year. It uses a barcode patient identification system, guaranteeing each and every patient receives the right blood in the right amount. This system, if implemented across the NHS, could create savings of more than £50m each year and is a fool-proof way of ensuring patients’ safety.

NIHR ANNUAL REPORT2014/15

Prof Dame Sally Davies

Challenges for development and implementation (..‘changing practice’)

Murphy et al (2009). Transfusion 49;829-837

• Getting started: recognising the need• Engaging and getting support • Conducting pilots and documenting benefits• Obtaining funding: £1.5 million/first 5 years• Project management: 160 clinical areas• Training: 4,000 nurses & 1,400 doctors• Driving the implementation • Monitoring progress• Publications & celebrating success

• Electronic systems show great promise for improving transfusion practice

• Further work is needed to: refine the processes demonstrate their safety and cost-effectiveness simplify and integrate them with other hospital IT

to minimise costs, enhance ease of training and implementation and improve the safety of similar clinical procedures

encourage their wider implementation

Summary

“The future is already here – it’s not very evenly distributed”

William Ford Gibson

“Change is the law of life. And those who look only to the past or present are certain to miss the future”

John F Kennedy