Patient  Blood  Management:  Impact  of  Quality  Data  on  Patient  Outcomes

LANCE  TREWHELLA,  MSN,  RNSEPT.  29,  2016

Lance  Trewhella,  MSN,  RN

• Nursing  Education  Specialist,  Rochester,  Minn.

• Drove  $30  million  in  cost  savings  andimprovements in  patient  outcomes

• Former  director  of  AABB  Patient  BloodManagement program

Disclosures• Viewics  consultant• Blood  donor

Objectives

• Explain  the  concept  and  scope  of  Patient  Blood  Management(PBM)

• Describe  the  impact  of  quality  data  on  PBM  programs• Identify  best  data  practices  in  PBM

Patient  Blood  Management

“Patient  blood  management  (PBM)  is  an  evidence-­based,  multidisciplinary  approach  to  optimizing  the  care  of  patients  who  

might  need  transfusion.  ”

American  Hospital  Association  – Summary  of  Recommendations  

• The  AHA  has  developed  a  “top  five”  list  of  hospital-­based  procedures  or  interventions  that  should  be  reviewed  and  discussed  by  a  patient  and  physician  prior  to  proceeding:

• Appropriate  blood  management  in  inpatient  services• Appropriate  antimicrobial  stewardship• Reducing  inpatient  admissions  for  ambulatory-­sensitive  conditions(i.e.,  low  back  pain,  asthma,  uncomplicated  pneumonia)

• Appropriate  use  of  elective  percutaneous  coronaryintervention

• Appropriate  use  of  the  ICU  for  imminently  terminal  illness(including  encouraging  early  intervention  and  discussionabout  priorities  for  medical  care  in  the  context  ofprogressive  disease

6  Recommendations:  Proceedings  from  the  National  Summit  on  Overuse  TJC  &  AMA,  July  2013

1. Develop  a  tool  kit  of  clinical  educational  materials  for  M.D.s  throughout  the  learning  continuum,  including  the  risks  and  benefits  of  transfusion  and  the  dissemination  of  best  practices  and  guidelines  supported  by  evidence.

2. Expand  education  on  transfusion  avoidance  and  appropriate  alternatives  to  transfusion.  Identify  subject  matter  experts  within  organizations  to  provide  guidance.

3. Advocate  for  scheduled  periodic  assessment  of  prescriber  competency  and  for  accountability  to  organizational  standards.

4. Standardize  performance  metrics,  data  collection  and  vocabulary  to  allow  valid  benchmarking  within  organizations.  Measure  individual  physician  transfusion  practice  as  part  of  ongoing  professional  practice  evaluation  (OPPE).

5. Develop  a  separate  informed  consent  process  for  transfusion  that  communicates  the  risks  and  benefits  consistent  with  current  evidence.

6. Identify  research  priorities  to  close  evidence  gaps  in  what  constitutes  optimal  transfusion  practice.  

TJC:  Areas  of  Overuse

1. Antibiotic  use  for  viral  upper  respiratory  infections  – develop  clinical  definitions  for  viral  and  bacterial  upper  respiratory  infections,  align  current  national  guidelines  that  are  contradictory,  partner  with  the  U.S.  Centers  for  Disease  Control  and  Prevention  (CDC),  and  initiate  a  national  education  campaign  on  overuse  of  antibiotics  for  viral  upper  respiratory  infections.

2. Appropriate  blood  management  – develop  a  tool  kit  of  clinical  education  materials  for  doctors,  expand  education  on  transfusion  avoidance  and  appropriate  alternatives  to  transfusion,  and  develop  a  separate  informed  consent  process  for  transfusion  that  communicates  the  risks  and  benefits.

3. Tympanostomy tubes  for  middle  ear  effusion  of  brief  duration  – develop  performance  measures  for  appropriate  use  of  tympanostomy tubes,  determine  the  frequency  with  which  tympanostomy tubes  are  performed  for  inappropriate  indications  in  otherwise  healthy  children,  and  focus  national  research  on  issues  related  to  tympanostomy tubes,  including  the  role  of  shared  decision  making  with  parents  and  other  caregivers.

4. Early-­term  non-­medically  indicated  elective  delivery  – standardize  how  gestational  age  is  calculated,  make  the  early  elective  deliveries  indications  and  exclusion  list  as  comprehensive  as  possible  to  improve  clinical  practice,  and,  educate  patients  and  doctors  about  the  risks  of  non-­medically  indicated  early  elective  deliveries.

5. Elective  percutaneous  coronary  intervention  – encourage  standardized  reporting  in  the  catheterization  and  interventional  procedures  report,  encourage  standardized  analysis/interpretation  of  non-­invasive  testing  for  ischemia,  focus  on  informed  consent  and  promote  patient  knowledge/understanding  of  the  benefits/risks  of  PCI,  and  provide  public  and  professional  education.  

9.1  Data  Collection

The  program  shall  provide  all  data  generated  from  the  utilization  review  process  to  the  program  members  for  review  and  analysis.

9.1.1  These  data  shall  be  analyzed  for  trends  across  the  institution  and  within  specific  departments  or  services.

Imagine  if  you  could…

Know  details  on  every  transfusion  and  get  an  answer  in  seconds  

Patient  Blood  Management

Automated  data  

management

Patient  Blood  Management

= + +Education Change  Management

Optimizing/maximizing  care

• More  testing,  more  treatments,  more  days  in  the  hospital,  etc.  are  usually  not  in  the  patient’s  best  interest

• Optimal  care  involves  less  (blood  products,  LOS,  complications)• Optimizing  care  is  not  just  adopting  a  more  restrictive  laboratory  value  for  transfusion

• Clinical  practice  guidelines  that  recommend  a  particular  threshold  for  transfusion  are  important,  but  only  one  consideration  in  the  decision-­making  process

Best  in  Class:  Patient  Blood  Management  

Executive  dashboard• Blood  transfusion  rates

– Provider– Time  period– Location– Service

• Goal

• Comparison  with  best-­in-­class  transfusion  rates

• Cumulative  cost  savings

Impactful  data

Detailed  analytics  through  peer  comparisons,  trends,  and  compliance  with  hospital  (national)  guidelines

PBM  Sample  Dashboard  – Executive  

• Real-­time  (daily,  weekly,  monthly)• Impactful  data  for  meaningful  patient  blood  

management  program• Choose  

– location,  physician,  time  period,  etc.

• Check  transfusion  by  location  including  OR,  inpatient,  outpatient,  and  ER– Detailed  transfusion  data

• Understand  individual  or  system-­wide  trends  and  practices

• Validation– Ongoing  basis– Process  for  changing  lab  ordering  numbers– Equipment  changes– Location  of  transfusion

Patient  Blood  Management  -­ Benefits• Intuitive  data  for  implementing  patient  blood  management  program

− Reduce  complications− Lower  mortality  rates− Reduce  length  of  hospital  stays  /  costs− Decrease  total  costs

• Drive  appropriate  blood  transfusion  − Pattern  and  outlier  detection− Peer-­to-­peer  comparison  − Convergence  in  practice  across  organization  and  clinicians  

• Reduce  manual  data  collection,  query,  and  report  workload− Improve  accuracy  of  reporting− Reduce  variation  in  data  collection− Identify  issues  with  data  feeds  quickly

Expected  savings  with  comprehensive  PBM  Program

For  hospital  with  ~500  beds10-­40%  savings  of  total  blood  spend  

Imagine  if  you  could…

Have  all  of  this  with  less  than  one  week  of  total  IT/clinical  time

Share  data

Common  staff  area  with  high  traffic

Standards  for  PBM

1.1.3  Program  CoordinatorThe  program  shall  have  a  program  coordinator  who  is  responsible  for  the  operational  aspects  of  the  program.

Program  Coordinator

2.1.1:  QualificationPersonnel  performing  critical  tasks  shall  be  qualified  to  perform  assigned  activities  on  the  basis  of  appropriate  education,  training,  and/or  experience.

C-­suite  support

• C-­suite  share  data• Medical  directors  

– Nursing  leadership• All  staff

– Quality/Risk  department

• Simplify  data– Easy  to  understand  data– No  explanation  needed– Adjust  graphs  and  reports  to  meet  needs

Impact  of  Data  Collection  and  Sharing

• Decreased  transfusions  – Improved  outcomes– Cost  savings

• Decreased  transfusion  related  complications• Increased  communication  across  service  lines• Blood  gets  to  those  who  need  it  quicker• Decreased  turn  around  time

Thank  you

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