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Patient Blood Management - Going Beyond the Pre-Operative Anemia Clinic

Patient Blood Management - Going Beyond the Pre-Operative Anemia Clinic. Jonathan H. Waters, M.D. Chief, Dept. of Anesthesiology, Magee Womens Hospital of UPMC Professor of Anesthesiology and Bioengineering, University of Pittsburgh Medical Director, Patient Blood Management Program of UPMC.

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Patient Blood Management - Going Beyond the Pre-Operative Anemia Clinic

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  1. Patient Blood Management - Going Beyond the Pre-Operative Anemia Clinic Jonathan H. Waters, M.D. Chief, Dept. of Anesthesiology, Magee Womens Hospital of UPMC Professor of Anesthesiology and Bioengineering, University of Pittsburgh Medical Director, Patient Blood Management Program of UPMC

  2. Conflict of Interest DisclosureJonathan H. Waters • Salary: University of Pittsburgh, University of Pittsburgh Physicians • Consulting Fees: Abbott, Haemonetics, Procirca • Contracted Research: Coramed, Haemonetics, Pfizer • Ownership Interest: Athersys

  3. Six Point PBM Strategy • Implementation of evidence-based transfusion triggers • Eliminate waste • Preoperative anemia optimization • Point of care laboratory testing • Education, physician awareness, auditing • Intraoperative Autotransfusion Program (Achieve AABB accreditation)

  4. Six Point PBM Strategy • Implementation of evidence-based transfusion triggers • Eliminate waste • Preoperative anemia optimization • Point of care laboratory testing • Education, physician awareness, auditing • Intraoperative Autotransfusion Program (Achieve AABB accreditation)

  5. “waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science.” Berwick, Hackbarth. JAMA 2012;307:1513

  6. Types of Waste

  7. Eliminating Waste Berwick, Hackbarth. JAMA 2012;307:1513

  8. Support Services Anesthesiology Blood Management Radiology Cardiac Surgery Orthopedic Surgery Intensive Care Oncology Care Pathways

  9. Sources of Waste • Preoperative autologous donation (PAD) • Inappropriate transfusions • Excessive phlebotomy • Elevated Crossmatch to Transfusion Ratio (C:T) • Wasted Blood products

  10. PAD Wastage Cost by UPMC Facility

  11. Indications for autologous PRBC transfusion? Indications same as for any PRBC transfusion. Preoperative Autologous Donation Transfusion Risks: Allogeneic vs. Autologous

  12. Birkmeyer etal Transfusion 1993;33:544-51. 629 consecutive cases of hip or knee replacement at Dartmouth and Case Western CE primary hip: 235k – 740K $/QALY unilateral knee: 1.15 – 1.47 million $/QALY Etchason J et al. NEJM 1995;332:19-24. 80 cases Total Hip replacement at UCLA CE 235K $/QALY Cost Effectiveness of Autologous Blood Use in Orthopaedic Surgery Overcollection and overtransfusion result in poor CE

  13. Henry DA et al. Cochrane Database of Systematic Reviews. 2002

  14. Preoperative Autologous Donated Blood 95.1% reduction $26K

  15. Sources of Waste • Preoperative autologous donation (PAD) • Inappropriate transfusions • Excessive phlebotomy • Elevated Crossmatch to Transfusion Ratio (C:T) • Wasted Blood products

  16. Recommended Transfusion Guidelines • RBC 8.0 gm/dl • Plasma- INR > 1.6 and clinical bleeding • Platelets- Platelet count < 50,000/uL and clinical bleeding.

  17. Summary of the inappropriate use of blood from large regional and national audits of blood use Courtesy of Mike Murphy, NHSBT, Oxford, England

  18. Daily MARS Report July 31, 2009

  19. Enhanced RBC Physician Order Entry Field • Click on the Related Results, to display a list of the most recent Hgb, • Red Blood Cell Transfusion Criteria is a required field • An alert will appear if the most recent Hgb does not correspond with the criteria selected. • No alert will appear if the Hgb is less than or equal to 8.0 gm/dl. • No alerts will appear when Acute bleeding with BP instability

  20. Alert Based on Order Logic Reduction in Signal to Noise Ratio

  21. Effectiveness of RBC alert – 6 months • 688 / 5918 (12%) orders canceled • Savings of ~ $154,800 USD

  22. Effectiveness of RBC alert – 6 months

  23. Provider Specific Data

  24. Transfusion Indication Variance System comparison of total blood orders, total alerts, and % orders heeded. Trending for % orders alerted and % orders heeded Service lines with highest unheeded alerts Service line drill down to physician level unheeded alerts

  25. Sources of Waste • Preoperative autologous donation (PAD) • Inappropriate transfusions • Excessive phlebotomy • Elevated Crossmatch to Transfusion Ratio (C:T) • Wasted Blood products

  26. The Rainbow Draw

  27. UPMC Preby Hospital Laboratory • 15,000 tubes of blood handled daily • Discard approximately 2 mL per tube • 30 Liters of blood discarded daily

  28. Phlebotomy Blood Loss • 30% of the blood transfused was phlebotomized • Average Phlebotomy was 65 mL/day Corwin HL et al. Chest 1995;108:767

  29. Phlebotomy Blood Loss • Small volume tubes • Elimination of arterial line blood discard • Elimination of standing orders

  30. Point of Care Testing

  31. Outcome with Algorithm and Point of care testing Nuttall GA et al. Anesthesiology 2001;94:773-81

  32. Outcome with Algorithm and Point of care testing Shore-Lesserson L et al. Anesth Analg 1999;88:312-9

  33. Sources of Waste • Preoperative autologous donation (PAD) • Inappropriate transfusions • Excessive phlebotomy • Elevated Crossmatch to Transfusion Ratio (C:T) • Wasted Blood products

  34. Crossmatch: Transfusion Ratio

  35. Frank S et al. Anesthesiology 2013;118:1286

  36. Frank S et al. Anesthesiology 2013;118:1286

  37. Frank S et al. Anesthesiology 2013;118:1286

  38. Electronic Crossmatch Traditional Compatibility Testing Involves: a) A review of the patient’s transfusion history b) ABO & Rh D typing of the patient c) Antibody Screening d) The Serological Crossmatch Role of the Serological Crossmatch (sXM) a) Ensuring ABO compatibility between recipient and Donor b) Detection of irregular red cell

  39. Guidelines for Electronic Crossmatch BCSH- British Committee for Standardization in Haematology Arslan O. Transfusion Med Review 2006;20:75

  40. Advantages of the eXM • For eligible patients – immediate availability of • blood i.e. improved turnaround times • 2. Reduced administration • 3. Reduced wastage due to restricted movement of • blood • 4. Improved blood management – particularly during • shortages • 5. Improved shelf life of blood transfused • 6. Blood issued without delay benefitting all concerned • 7. Properly validated is considered safer than • serological crossmatching

  41. Remote Electronic Crossmatching 40% Used 62% Used Staves et al. Transfusion 2008;48:415

  42. Sources of Waste • Preoperative autologous donation (PAD) • Inappropriate transfusions • Excessive phlebotomy • Elevated Crossmatch to Transfusion Ratio (C:T) • Wasted Blood products

  43. Blood Waste Prevention at UPMCMary Kay Wisniewski, MT

  44. Blood Waste “How Much is Not Much?”

  45. What Does Blood Waste Look Like? $58,590

  46. What Does 310 Units Look Like?

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