trudi gallagher rn jurisdictional patient blood management coordinator fremantle, wa australia...
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TRUDI GALLAGHER RNJURISDICTIONAL PATIENT BLOOD
MANAGEMENT COORDINATORFREMANTLE, WA
AUSTRALIA
Patient Blood ManagementPatient Blood ManagementBuilding your foundationBuilding your foundation
Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical
concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort
to improve patient outcome.
Modified from: Shander and Modified from: Shander and Goodnough. Goodnough. Curr Opin HematolCurr Opin Hematol. . 2006;13(6):462-470.2006;13(6):462-470.
Blood Management All Inclusive(what’s in a name)
Transfusion Free Care / “Bloodless Surgery and Medicine”
Anemia PreventionAnemia TreatmentAppropriate use of Blood ProductsBlood ConservationDischarge Anemia needsPreoperative Assessment Postoperative assessmentTransfusion tracking / blood utilizationIntra operative reduction of blood loss
Why Is Patient Blood Management Proving To Be So
Popular Among Medical Centers In 2011?
Timing Is Everything
Why now?
Medicare “never” events Reform reimbursement unknowns Readmission issues
Other timely issues Length of stay issues Infection prevention $$$$$$$ Mortality and morbidity
Patient Satisfaction
WHAT are regulatory directed WHAT are regulatory directed data pointsdata points
Joint Commission LD.04.04.07 Clinical Practice Guidelines LD.04.01.01 thru LD.04.04.07 Leader example NPSG.01.03.01 Eliminate transfusion errors PI.01.01 The hospital collects data to monitor performance
CAP TRM.41000 Transfusion Protocol: Personnel involved in transfusion are
trained in the identification of transfusion recipients and blood components, and in observation of recipients during and after transfusion, with in-service education at least annually.
TRM.20000 is there a written quality control program TRM.40850 does the medical director of transfusion service, review cases
not meeting transfusion audit criteria AABB
9.1 blood bank has process for deviations, nonconformance related to blood 9.2.1 review of information causes of nonconformance 9.2.3 application of controls to monitor effectiveness 9.3 Quality Monitoring: process to collect and evaluate quality indicator on
scheduled basis 8.2 Monitoring of blood utilization: transfusion facility monitors and
addresses transfusion practices for all categories of blood and components
SOCIETY FOR THE ADVANCEMENT OF BLOOD MANAGEMENT
sabm.org
Patient Blood Management Patient Blood Management StandardsStandards
http://www.sabm.org/public/standards.php
Standards CommitteeStandards Committee
Professional role
President, Association for Blood ConservationPresident, Association for Blood ConservationOrgan Procurement CoordinatorOrgan Procurement Coordinator
Blood Management SpecialistBlood Management Specialist
Blood Utilization CoordinatorBlood Utilization Coordinator
Blood Conservation ManagerBlood Conservation Manager
Medical Director of Transfusion ServicesMedical Director of Transfusion Services
Transfusion Service Medical DirectorTransfusion Service Medical Director
President and CEO of Global Blood ResourcesPresident and CEO of Global Blood Resources
Expert ReviewersExpert ReviewersName Title Location
Dr. James AuBuchon
President and CEO of Puget Sound Blood Center
Seattle, WA
Jeffrey B Riley CCT,CCP
Supervisor and Educational Coordinator CardioVas Perf Work Group Mayo Clinic
Rochester, MN
Dr. George J Despotis
Associate Professor, Pathology, Immunology and Anesthesiology Washington Univ School of Med
Saint Louis, MO
Dr. James Isbister
Clinical Professor of Medicine Royal North Shore Hospital of Sydney
St Leonards, NSW, Australia
Dr. Ira A Shulman
Director of Transfusion Medicine University of Southern Ca.
Los Angeles, CA
Dr. Lena Napolitano
Division Chief Univ Of Michigan School of Medicine
Ann Arbor, MI
Leadership and Program Structure(Preparing for the foundation)
Platform Written mission statement Vision and values statement
Scope of service (what areas are affected) Medical Patients / inpatient and outpatient Surgical Patients / in patient and preoperative
Job descriptions Physician medical director Program manager
Leadership and Program Structure(blueprints)
Policies and procedures (standard of care housewide or service line specific?) Interdepartmental
Guide practice and processProtocols and guidelines
Available to the staff at all timesEducation program
Targets Physicians, mid-level providers, nurses, pharmacists Ancillary health care staff regarding
Blood management program’s goals, structure, and scope.
Leadership and Program Structure(GPS)
Quality and outcome measuresData collection and reporting to the hospital quality improvement committee as scheduled
AdministrationLeadership level representation
Transfusion or blood management committee
Consent Process and Patient Consent Process and Patient DirectivesDirectives
Consent Process and Patient Directives
Hospital-wide policy requiring written informed consent for transfusion Documents a discussion
Risk Benefits Alternatives to transfusion
Hospital-wide policy intent Supports and respects right of patients to
decline blood transfusion Addresses the rights of patients who are minors
Consent Process and Patient Directives
Hospital has a document for adult patients Directive establishing the refusal of transfusion
Defines alternatives/options to allogeneic transfusion
• Autologous transfusion modalities• Human derived growth factors• Essential cofactors (e.g. iron, B12, and folic acid)
for red cell production• Recombinant products• Factor concentrates• Blood derivatives and fractions.
Consent and Patient Directives
All patients have access to information regarding The risks and benefits of blood transfusion The risks and benefits of refusing a
transfusion Alternatives to blood transfusion that are
available and applicable to that patientA process is in place that
Identify adult patients who refuse blood transfusions
Consent and Patient Directives
Patients with a previously executed blood refusal advance directive Confirmation process
Continued desire to refuse transfusion? Obtain document and place in chart If the patient is unconscious or incapacitated, the
advance directive is honored
Education Alternatives to blood transfusions
Medical staff and other health care providers Religious proscriptions against blood transfusion
Is available to all providers
Blood Administration SafetyBlood Administration Safety
Blood Administration Safety
Policies and procedures in compliance with applicable agencies College of American Pathologists
requirements (CAP) AABB standards Applicable state regulations Standards of the JC
Ordering blood Dispensing blood Transfusing blood
Blood Administration Safety
Individuals involved in administration of allogeneic blood transfusion will… Satisfy requirements
Education prior to independent administration of blood products
Demonstrate skills with a preceptor before acting independently
Transfusion administration policies and procedures are in compliance with regulatory agencies
Blood Administration Safety
Qualified staff may not administer blood products without Receiving annual education, training and competency
annually
The hospital’s transfusion review committee reviews Near miss events Sentinel events Significant errors associated with pre-transfusion blood
specimen acquisition NOTE: the hospital defines what constitutes a significant error or near miss event. Labeling Testing Ordering Release, and transfusion of blood and blood components.
Review and Evaluation of the Patient Review and Evaluation of the Patient Blood Management ProgramBlood Management Program
Review and Evaluation of the Patient Blood Management Program
Provider-specific peer review of transfusion decisions Review information is available to the medical director of
the patient blood management program. Review of transfusion decisions includes
Determination of the clinical appropriateness of the transfusion
Documentation regarding clinical indications for transfusion
Recommendations for management without transfusion if transfusion was not clinically appropriate
Review and Evaluation of the Patient Blood Management Program
Blood use is monitored Individual clinical service as well as hospital-wide
Data are analyzed Identify areas for improvement due to over- or under-utilization.
Blood and blood component transfusion is evaluated Metrics defined by the institution
Comparison of blood utilization Transfusion practices with other institutions and published
literature.
Quality measures defined by the hospital Clinical efficacy and cost effectiveness of other treatment
modalities; transfusion alternatives or managing coagulopathy
Implemented new perfusion strategies &
unblinded surgeon data
Complacency
Began Leukoreduced
PRBC only
Education & Full Team Buy-in
CABG Blood Utilization CABG Blood Utilization RatesRates
Preoperative Anemia ManagementPreoperative Anemia Management
Preoperative Anemia Management
Identify elective surgical procedures for which preoperative anemia management screening is required (eg. cases with potential for measureable blood loss)
Patients who need preop screening are identified Three to four weeks prior to surgery
Time to diagnose and manage anemia** NOTE: unless the surgery is of an urgent nature and must be performed sooner
Screening for detecting anemia and allow diagnosis of the common causes of anemia Iron deficiency etc
A process ensures Laboratory data has been reviewed
Patients with moderate to severe anemia Anemia of unclear etiology Additional clinical evaluation and laboratory testing A referral to a specialist is made as necessary.
Outpatient treatment when clinically indicated Parenteral iron and/or erythropoietic-stimulating
agentsResults of preoperative anemia screening are
shared with Referring surgeon Primary care physician
Preoperative Anemia Management
Preoperative anemia Management
Perioperative period If treated during preoperative time period = also
followed in the postoperative period Ensures continued management of their anemia during
their hospital admission
Elective surgery is deferred and rescheduled in anemic patients when The anemia is reversible unless there is an urgent
need for surgery Decision is the responsibility of the surgeon
In consultation with the medical director of the patient blood management program
Perioperative Autologous Blood Perioperative Autologous Blood Collection For AdministrationCollection For Administration
Perioperative Autologous Blood Collection For Administration
Policies and procedures regarding perioperative autologous blood collection Collection modalities offered Methods for blood collection Indications and contraindications Reinfusion of the collected blood
Policy and procedure for; Modifications of the blood collection and reinfusion
conduits Volume of autologous blood collected
Processed Reinfusion process is documented
Perioperative Autologous Blood Collection For Administration
If hemofiltration/ultrafiltration is performed Equipment used is consistent with the
manufacturer’s instructions for the given device Modification is documented
Including the rationale for the modification
Labeling and storage requirements of perioperative autologous blood collections Defined/ and consistent with the current AABB
standards Variation from accepted techniques is documented
Including the rationale for such variation
Perioperative Autologous Blood Collection For Administration
Policies for the reinfusion of processed and/or unprocessed shed blood are established
Quality assurance program Perioperative autologous blood collection is;
Indicated, cost-efficient, effective, and safe Quality indicators are defined and monitored Variances to quality indicators
Adverse effects including potential transfusion reactions Complications Patient safety factors are documented and reviewed,
and appropriate action is taken
Perioperative Autologous Blood Collection For Administration
Personnel involved in handling of blood product collection Qualified on the basis of education and training Competency is documented and evaluated at least annually
Equipment and supplies Validated before initial use Properly maintained Revalidated after any major service or repair
Outsourced staff for perioperative autologous blood collection Outside provider is in compliance with this standard
Acute Normovolemic Acute Normovolemic HemodilutationHemodilutation
Acute Normovolemic Hemodilutation (ANH)
Policy and procedure exists; the use of ANH Approved by the chair of anesthesiology
Blood collection conduits Type of collection bag Formulation and volume of anticoagulant Site of blood collection Methods and solutions used to maintain normovolemia.
Collection and storage requirements for blood collected through ANH Compliant with all applicable accreditation and FDA
requirements
Acute Normovolemic Hemodilutation
Indications and contraindications for the use of ANH Described and include s
Both patient-related and procedure -related factors
Modifications of the blood collection conduits for specialized patient populations Jehovah’s witnesses
Described, including the rationale for the modification
The hemodynamic monitoring technique during the conduct of ANH is described Including any specialized equipment
The mathematical computation of the volume of AWB blood to be collected is stated
Acute Normovolemic Hemodilutation
The projected end-points of autologous whole blood (AWB) collection are stated Including target hemoglobin or hematocrit
Where applicable, the impact of hemodilution secondary to an extracorporeal circuit prime volume is calculated
The timing and rationale for AWB reinfusion in relationship to the conduct of surgery and/or anesthesia are defined and followed.
Acute Normovolemic Hemodilutation
There is a quality assurance program to ensure; ANH is cost-efficient Effective and safe Training and on-going competency assessment for
personnel collecting ANH units is defined Quality indicators are defined and monitored Variances to quality indicators
Adverse-affects Complications Patient safety factors are reviewed and addressed by a
quality improvement process
Acute Normovolemic Hemodilutation
The handling of the AWB product including Sterile collection Labeling requirements Storage location Storage temperature Duration of storage Need for refrigeration Agitation versus non-agitation techniques is defined
and followed Any variation from accepted techniques that occur
must be documented and must include the rationale for such variation
Phlebotomy Blood LossPhlebotomy Blood Loss
Phlebotomy Blood Loss
Policies and processes that pertain to phlebotomy for diagnostic laboratory samples address Importance of reduced size and frequency of lab draws
There is a mechanism for identifying patients At higher risk for transfusion Those who refuse transfusions
Additional measures considered Use of microtainers Point of care testing Reduction in daily or routine labs ordered
Phlebotomy Blood Loss
There is a system in place for reducing blood loss from line draws
Individuals who re infuse blood that is unsuitable for laboratory testing are trained and deemed competent according to policy and procedure guidelines
Minimizing Blood Loss Associated Minimizing Blood Loss Associated With Surgery, Procedures, With Surgery, Procedures,
Underlying Medical Conditions, Underlying Medical Conditions, Antithrombotic Therapy Or Antithrombotic Therapy Or
CoagulopathyCoagulopathy
Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions,
Antithrombotic Therapy Or Coagulopathy
Policies and procedures are defined that minimize intraoperative blood loss
Guidelines for intraoperative use of pharmacologic agents; Topical sealants Topical hemostatic agents to minimize blood loss
Patient blood management program medical director is actively involved in selection of; Clotting factor concentrates, topical hemostatic agents,
tissue adhesives, and pharmacologic agents, including antifibrinolytic and prohemostatic agents to limit blood loss
Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions,
Antithrombotic Therapy Or Coagulopathy
Hospital coagulation testing services have the capability Assess and characterize hemorrhagic risk factors Assist in diagnosis of the likely etiology of coagulopathy
in a bleeding patient
Guidelines Encourage early definitive intervention and treatment of
acute hemorrhage Early return to the operating room for source of bleeding Early referral for interventional radiology and embolization Early use of endoscopy/ colonoscopy and cystoscopy for
gastrointestinal hemorrhage or genitourinary hemorrhage
Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions,
Antithrombotic Therapy Or Coagulopathy
Referral and consultation protocolsAssist in the management of patients
Anticoagulant and antithrombotic medications
Patients with history of significant bleeding or coagulation abnormalities
Massive Transfusion ProtocolMassive Transfusion Protocol
Massive Transfusion Protocol
Criteria are defined Initiating and discontinuing the massive transfusion
protocol
In facilities without the capacity to manage patients with massive transfusion needs Guidelines for initial damage control resuscitation Rapid transport to another facility
Responsibility for management of coagulopathy is defined
The massive transfusion protocol includes Guidelines for transfusion of red blood cells, plasma,
platelets, cryoprecipitate, and factor concentrates
Massive Transfusion Protocol
Laboratory testing, if available, is used to monitor the patient Acidosis Hypocalcemia Qualitative and quantitative abnormalities in coagulation
Where available and clinically appropriate Peri-procedural autologous blood collection and
administration is used to minimize the need for allogeneic red cells
There is a mechanism for quality review of complex cases involving massive transfusion
Transfusion GuidelinesTransfusion Guidelines
Transfusion Guidelines
The transfusion guidelines are approved by; Institution’s medical executive committee (MEC) or
Other appropriate authority of the medical staff
There is an effective transfusion utilization review process Guidelines to determine if
The transfusion under review was or is medically appropriate
That adequate and appropriate documentation is present Review may be prospective, concurrent or retrospective If retrospective, it is timely
Transfusion Guidelines
The results of transfusion review are communicated Ordering provider Chief of the service or department Medical staff quality improvement or quality
management committee These results are used both for
Education Re-credentialing process
Transfusion guidelines are; Accessible and available to ordering providers at the
time they order transfusions
Transfusion Guidelines
The transfusion guidelines take into consideration Patient specific factors
Age Diagnosis Laboratory values
HemoglobinHematocritPlatelet countCoagulation testingPresence or absence of critical bleeding
Transfusion Guidelines
There is periodic review of the guidelines They remain current and relevant Promote a restrictive or conservative
approach to the transfusion of blood components
Are consistent with the literature and evolving standard of care in transfusion medicine and patient blood management
Management Of Anemia In Management Of Anemia In Hospitalized PatientsHospitalized Patients
Blood Management Patient Volume
Management Of Anemia In Hospitalized Patients
Clinical leaders of the blood management program have knowledge and experience in Recognition, diagnosis, and management of anemia
Policy requiring “anemia” be documented as part of the early clinical assessment of all patients
Protocols facilitate appropriate; Diagnosis Evaluation Management of anemia
Management strategies help minimize the likelihood of transfusion
Management Of Anemia In Hospitalized Patients
Guidelines for the use of; Intravenous iron Erythropoietic stimulating agents (ESA’s)
Hospital transfusion guidelines recommend Against transfusion in
Asymptomatic Non-bleeding patients when the hemoglobin level is
greater than or equal to 6.0 -8.0 gm/dl.
Clinical strategies to optimize hemodynamics and oxygenation are followed before red cell transfusion is considered
Management Of Anemia In Hospitalized Patients
Transfusion of blood and/or components is never used for; Volume repletion Treating anemias that can be treated with
specific medicationsWhen red cell transfusion is clinically
indicated in the non-bleeding patient A single unit of red cells is prescribed at a time Followed by clinical reassessment of the
patient
FINANCIALS
Definitions of price graphic:“DIRECT COST OF PRODUCT”:• includes price PRMCE pays to Puget Sound Blood Center• portion of the type of Cross• portion of Leukoreduction fees parallel to overall % of RBC’s affected
•This does not reflect • time on the staff, documentation, storage or transportation.
(**see citation below) Calculate the direct cost of the product to a center by multiplying a factor of 5 = real cost to a center for transfusing a unit of blood. Thus a unit of blood this year cost us $1915.00 overall cost and a direct cost of $383.00 per unit. Blood product costs go up annually.
**Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010 Apr;50(4):753-65. Epub 2009 Dec 9
“UNITS THAT WOULD HAVE BEEN GIVEN AT THE 2005 RATE”:We have reduced our transfusion rate by 45% in 6 years. We saved the community 17,301 units of blood (if we had continued transfusing at the 2005 rate).
DEFINITIONS CONTINUED:“SAVING INCURRED THAT YEAR”:Overall savings for 6 years reduction is 4.3 million dollars. “PATIENTS”:These are all encounters (inpatient and outpatient) in 2010. I have been assured that patient census, and healthcare facility use, has reduced during 2010 throughout the region.
“UNIT PER PATIENT”:Because the delegation and decision in what amount to transfuse varies so drastically, and we geographically transfuse 20% of our RBC’s on an outpatient basis; the allocation of portions of units of blood is the only way to show the slow reduction of overall transfusion rate. Therefore this is the calculated portion of a unit of blood that is assigned to each patient contact for PEMC patients
YEARYEAR UNITS OF UNITS OF BLOOD BLOOD GIVENGIVEN
UNITS UNITS THAT THAT
WOULD WOULD HAVE HAVE BEEN BEEN
GIVEN AT GIVEN AT 2005 RATE2005 RATE
DIRECT DIRECT COST OF COST OF PRODUCPRODUC
TT
TOTAL TOTAL DIRECT DIRECT COST COST
FOR YEARFOR YEAR
SAVINGS SAVINGS INCURRED INCURRED THAT YEAR THAT YEAR over $4.3 Mil over $4.3 Mil savings in 6 savings in 6
yearsyears
PATIENTPATIENTSS
UNIT UNIT PER PER
PATIENTPATIENT45% 45%
decrease decrease in 6 in 6
yearsyears
2005 8,808 NA $146 $1,285,968
NA 179,347
.049
2006 8,014 9,699 $166 $1,330,324
$279,736 197,942
.040
2007 7,733 10,902 $177 $1,368,741
$561,054 222,506
.034
2008 7,417 11,019 $186 $1,381,416
$668,204 224,887
.032
2009 7,124 11,142 $240 $1,709,760
$964,487 227,402
.031
2010 6,182 11,009 $383 $2,367,706
$1,848,732
224,673
.027
Thank you
Blood Management Perfusion ExpertEdy Zelinka
Director of Perfusion ServicesAPC
425-261-4249