Best Practice Submission
Evidence Based Blood Product Utilization
Point of Contact: Emily Volk, MD,
Patrick Halinski,
Group Involved with the Project:Baptist Health System Blood and Tissue Committee
Submitted by Major Andrew R. Gregory
11 May 2012
Executive Summary: Blood product utilization is an area where adopting evidence-based standards has resulted in a significant reduction in utilization without a decrease in patient quality. Physician education programs combined with computerized decision support templates show promise in reducing practice variation among providers. As more third party payers adopt prospective global payment methods similar to CMS’s DRG system, proactive utilization management of ancillary services such as laboratory, radiology and blood products will be necessary to remain financially viable. Baptist Health System’s pilot program for evidence-based blood product utilization optimization demonstrates the great potential in establishing such programs.
Objective of the Best Practice:
The primary purpose of a Blood and Tissue Committee (BTC) is to ensure safe, high quality, evidenced- based and cost effective use of blood products and tissue at all BHS Hospitals. In order to efficiently and effectively address the needs of our populations, the BHS Blood and Tissue Committee is divided into two committees: Pediatric Blood and Tissue Committee and Adult Blood and Tissue Committee. Each committee focuses on the unique needs of their population to include implementing and maintaining safe transfusion practices, reducing the number of transfusion errors and optimizing blood utilization. The committees also serve to coordinate clinical services required in order to comply with regulatory and accreditation requirements related to blood and tissue utilization. This multidisciplinary committee provides an opportunity for teamwork and open communication between all BHS Hospitals. Open communication and teamwork are key elements of a successful program.
Background:
BHS formed the Blood and Tissue Committee to oversee the utilization of blood products within all five BHS hospitals to align practice patterns with current evidence-based medicine while reducing costs and improving patient outcomes. A pilot study was begun in November of 2010.
Literature Review:
Blood product utilization is an area gaining more attention in the medical community. There is a significant cost savings potential through reduction in blood product usage, both in quantity of transfusions and in total volume transfused. Each transfusion procedure carries with it significant risks to the patient. Thus, minimizing unnecessary procedures also leads to improved outcomes by reducing the opportunities for these risks. As early as 1990 the National Institute of Health had conducted conferences specifically related to developing a consensus of blood product utilization standards. Richard Brown led a study that highlighted the great variability among providers practice patterns for when to transfuse patients (Brown, 1992). In 1993 Morrison published results of a pilot program for provider education that resulted in a 75% reduction in total number of packed cells transfused and a 60% decrease in the total number of patients transfused year over year at an OB/GYN department in a Mississippi hospital. This reduction was attributed to a yearlong provider education effort that was combined with a quality audit program (Morrison, 1993).
Nearly two decades later, Chang, et al. highlighted the continued variation in physician practice patterns. The team used retroactive chart reviews to show that a computerized transfusion decision support system could reduce this practice pattern variance. The study results suggest computerization could lead as great as a 45% reduction in transfusions(Chang, 2011).
Faisal Masud led a team of doctors at the Methodist Hospitals in Houston to validate the safety of blood utilization management. Through provider education the team was able to reduce blood product utilization by 30.6% over a two-year period with no harm to the patients. In fact, the study results suggested that the decrease in blood utilization led to a trending towards better overall outcomes for the patients (Masud, 2011).
To achieve the best results for a hospital system, the techniques for utilization management should be extended to other ancillary services and procedures. A more recent article by Elizabeth Stuebing and Thomas Miner discusses the economic realities of healthcare and suggests that similar utilization management practices will be effective in reducing over utilization of laboratory services as well (Stuebing, 2011).
Implementation Methods:
In November 2010, BHS began a pilot study for evidence based blood utilization. The program was multi-faceted with a committee established to identify evidence-based best practices for blood transfusions and blood product utilizations. Order sets and guidelines were developed including computerized physician order entry iForms where CPOE was available. The physician order form for blood product usage was adopted by the Medical Executive Board and made mandatory for all non-emergent and non-OR blood product orders throughout the Baptist Health System.
A large emphasis was placed on physician education and buy-in. In-person lectures were given, including dinners where statistics and the evidence-based guidelines were presented. Posters were made and distributed via doctors’ lounges and physician leadership committees. In-person and online continuing medical education classes were provided for physicians and nurses at all five BHS hospitals. An internal marketing campaign to physicians was conducted specifically to promote the use of single unit red blood cells for transfusions, where appropriate, versus the traditional two unit transfusions.
A mandatory documentation requirement of clinical indication of each transfusion was initiated. This allowed for just-in-time interventions and education by a pathologist, medical director and/or the blood bank to provide clinical consultative discussion with the ordering physician when established criteria were not being followed. One additional key change was the adoption of a critical value for hemoglobin at a level of 7g/dL, a change from the previous value of 8g/dL.
Results:
The success of this pilot program is clear. After on year, the Baptist Hospital system had realized a reduction in blood product utilization of greater than 25% year over year. These results have been sustained as the study has entered into its second year.
As the results are briefed back to the physician community there has been increased acceptance by those physicians who initially were hesitant to adapt practice patterns to meet the evidence-based guidelines. Despite the decreased utilization, there has been no decline in patient outcomes.
Cost savings have been significant. Estimated savings over the next three years total more than $21 million versus a continuation at the pre-study blood utilization rate. As CPOE becomes available at each hospital, it is anticipated that even greater savings may be realized due to the enhanced decision support systems available via computerized entry models.
Conclusion:
Evidence-based management of blood product utilization is an overwhelming success, providing significant cost savings with no negative impact on quality of care as measured by patient outcomes. Switching to evidence-based utilization of products and services such as blood, lab and x-ray services is the way forward for hospitals to maintain cost and utilization control. In a healthcare world with increasing global payment models such as CMS’s DRG reimbursement model, this transition will be required to maintain financial viability.
References
Brown R., Brown R., Edwards J. & Nutz J. (1992). Variation in a medical faculty’s decisions to transfuse: implications for modifying blood product utilization. Medical Care.30(12): 1083-1096.
Chang C., Lin Y., Wu Y., & Yeh C. (2011).The effects of a computerized transfusion decision support system on physician compliance and its appropriateness for fresh frozen plasma use in a medical center. American Journal of Clinical Pathology.135:417-422.
Masud F., Larson-Pollock K., Leveque C.,Vykoukal D.(2011). Establishing a culture of blood management through education: a quality initiative study of postoperative blood use in CABG patients at Methodist DeBakey Heart & Vascular Center.American Journal of Medical Quality. 26(5):349-356.
Morrison J., Sumrall D., Chevalier S., Robinson S., et al. (1993). The effect of provider education on blood utilization practices. American Journal of Obstetrics and Gynecology.169(5):1240-5.
Stuebing E., Miner T. (2011). Surgical vampires and rising health care expenditures. Archives of Surgery.146(5):524-527
TinmouthA., MacDougall L., Fergusson D., Amin M. (2005).Reducing the amount of blood transfusion: a systematic review of behavioral interventions to change physicians’ transfusion practice.Archives of Internal Medicine.165:845-852.
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