CPOE Reducing Inappropriate Transfusions: The CRIT Project

1. CPOE Reducing Inappropriate Transfusions: The CRIT Project Eloa S Adams MD Medical Directory, PICU Kaiser Permanente Medical Group at the Oakland Medical Center Lead Coordinator for the CRIT Collaborative

2. Eloa Adams MDHas no financial relationships to disclose or Conflicts of Interest (COIs) to resolve.

3. Objectives • Blood transfusions carry both risks and benefits • Data supports the use of restrictive transfusion strategies • Significant barriers exist which delay the adoption of data into clinical practice • Computerized decision support (CDS) decreases blood transfusions in hospitalized children • CPOE reducing inappropriate transfusions (CRIT) collaborative. • Collaboration combined with evidence based CDS tools can shorten the gap between research and practice

4. Maximizing D02 is the mainstay of many medical therapies in the ICU O2

5. BLOOD 02 content = Hgbx 1.34 X 02 Sat +(0.003 x p02) So we should liberally transfuse everyone in the ICU………

6. No problem if we could do this But we cannot……..

7. So we have to do this This creates a problem called the “storage lesion”

8. The “Storage Lesion” Physiologically Alters Red Blood Cells Immune suppression Infections Change on 02 delivery Mortality Cost

9. Storage decreases the viability of RBC’s Luten Transfusion 2008

10. Storage alters the deformability of RBC’s Tinmouth Transfusion 2006

11. Storage increases serum potassium in RBC’s Peaks at 30 meq/L in Whole blood and 90 meq/l in PRBC Simon, Post Grad Med 1971

12. Storage decreases the concentration of 2,3 DPG Bennett- Guerrero PNAS 2007

13. Storage decreases levels of SNO-Hgb Bennett- Guerrero PNAS 2007 McMahon Nature Medicine 2002

14. The immunosuppressive effects of RBC transfusions have been known since studies on renal allograft survival were published in the 1970’s Lancet 1977

15. RBC transfusions increase the risk for blood stream infections White PCCM 2011

16. RBC transfusions may decrease 02 delivery to vital tissues Murphy Circulation 2007

17. Red Blood Cell Transfusions Carry Both Benefits and Risks What are the standard transfusion practices? When is it appropriate to transfuse? When do the benefits outweigh the risk?

18. Transfusion Practices are Highly Variable Among Hospital Based Pediatricians Laverdiere PCCM 2002

19. A great divide exists between publications and practice General

20. Ten years later practices remain variable Bronchiolitis Sepsis Trauma Cardiopathy 1997 2010

21. New Knowledge generated by RCT’s may take 5-17 years to be incorporated into clinical practice, even then compliance to guidelines can be poor. (%) Agency for healthcare research and quality Bates JAMIA 2005 J Pedr Health Care 2012

22. Barriers to Transforming Data Into Practice Cabana, JAMA 1999 Berenholtz, Current Opinion in Critical Care 2003

23. Effective strategies exist to augment transfusion practices

24. Clinical Decision Support and Computerized Physician Order Entry (CPOE) Augments Adherence to Evidence Based Guidelines. Kawamoto BMJ 2005

25. The Ten Commandments of Effective Decision Support 1. Speed is everything. 6. Changing direction is easier than stopping. 2. Anticipate needs and deliver In real time. 7. Simple interventions work best. 8. Ask of more information only when you really need it. 3. Fit into the users workflow. 9. Monitor impact, get feedback, respond. 4. Little things can make a big Difference. 10. Manage and maintain your Knowledge based systems. 5. Recognize that physicians will Strongly resist stopping. Bates JAMIA 2005c

26. Intensivist Benefits outweigh risks Special consideration Low risk No good alternative Other Please provide a justification for ignoring our suggestion Other Password confirmation ************

27. Hypothesis

28. Evidence based algorithm Adams Pediatrics 2011

29. Decision Support Window Adams Pediatrics 2011

30. The average pre-transfusion Hgb decreased in both the PICU and acute care wards 7.55 7.14 9.8 8.7 Adams Pediatrics 2011

31. Total transfusions per patient day decreased from 0.075 to 0.05. Adams Pediatrics 2011

32. CDS Decreases Blood Transfusions on the Acute Care Wards Adams Pediatrics 2011

33. CDS Decreases Blood transfusions in the PICU Adams Pediatrics 2011

34. The Clinical Effect of CDS Is Sustainable Sustainability Transfusions per patient day Adams- Unpublished

35. Implementation of a Decision Support Algorithm in Association With CPOE Can: Accelerate adoption of evidence-based guidelines into clinical best practice Decrease overall RBC transfusions in the PICU and pediatric acute care wards 100 fewer patient exposures 460 fewer red blood cell transfusions Direct cost savings of more than $160,000.00

36. Limitations Took place in a single institution Cohort study using historical controls. Might this have happened in the absence of any intervention?

37. CPOE Reducing Inappropriate Transfusions (CRIT) Collaborative “The most cost effective opportunity to improve patient outcomes in the next quarter century will likely come, not from discovering new therapies but from discovering how to effectively deliver therapies that are known to be effective” Sean Berenholtz 2003

38. CRIT Participants Represent Several Institutions Across the United States UC Davis Children’s Helen DeVos Children’s Hospital Children’s Hospital of Michigan Children’s Hospital Orange County Children’s National Medical Center University of Illinois at Chicago Nationwide Children’s Hospital Mercy Children’s Hospital Shriners Hospitals Akron Children’s Hospital All Children’s Hospital, Florida Children’s Hospital Minnesota MetroHealth, Case Western Children’s Hospital of Richmond Eastern Maine Medical Center Seattle Children’s Hospital Lucile Packard Children’s Hospital

39. BLOOD NET

40. Collaborative Goals • Provide a venue for for multiple institutions to share experiences and projects surrounding blood utilization. • Test the hypothesis that CPOE tethered to CDS can improve and hasten the adoption of evidence based guidelines across multiple institutions. • Set the framework for future collaborations using effective decision support tools.

41. Planning the CRIT QI Project Was a True Collaborative Process

42. Proposed CRIT QI study design Data Collection 1 year Late Late Early Cohort Initiation Initiation Middle Middle Late Cohort

43. Conclusion

44. Acknowledgements Jacques Lacroix Phil Spinella Marisa Tucci CRIT.stanford.edu -Data -CDS tool -Collaborative contacts -Meeting Presentations Chris Longhurst David Cornfield Paul Sharek NabilHassan Collaborative Participants

45. There are two types of people in this world…… Those that can extrapolate from incomplete data.