Empowerment of the BMS: Effective strategies for challenging clinicians

1. Empowerment of the BMS:  Effective strategies for challenging clinicians Kenneth G. McLoughlin Ulster Hospital April 2010 I,ve been involved in developing strategies involving the empowerment of BMS staff at both hospital and Regional level to improve blood use in the ProvinceI,ve been involved in developing strategies involving the empowerment of BMS staff at both hospital and Regional level to improve blood use in the Province

2. Strategies for challenging clinicians Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Firstly BMS laboratory staff must be fully involved and committed in all committees making decisions regarding blood transfusionsFirstly BMS laboratory staff must be fully involved and committed in all committees making decisions regarding blood transfusions

3. Get a seat around the table This is not Ulster HTC but in fact a G20 meeting BMS staff-Don�t expect to be taken seriously by other hospital staff if you are not fully involved in the Hospital Transfusion CommitteeThis is not Ulster HTC but in fact a G20 meeting BMS staff-Don�t expect to be taken seriously by other hospital staff if you are not fully involved in the Hospital Transfusion Committee

4. Labs are well represented on Regional Transfusion Committee In NI Transfusion Managers and their deputies have a seat on the Regional Transfusion CommitteeIn NI Transfusion Managers and their deputies have a seat on the Regional Transfusion Committee

5. A seat around the table� Allows the laboratory staff major input to transfusion issues Allows interaction and alignment with Clinicians from many disciplines, Haemovigilance and Management. Significantly empowers the laboratory Effect of BMS staff involving themselves in all committeesEffect of BMS staff involving themselves in all committees

6. Strategies for challenging clinicians Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Audit local evidence of poor practice Campaign for audit of poor practiceCampaign for audit of poor practice

7. 2005 Regional Blood Audit Laboratory staff were involved drawing up the criteria for this audit and in collecting data , the evaluation and in writing the final report. Laboratory staff were involved drawing up the criteria for this audit and in collecting data , the evaluation and in writing the final report.

8. 3 Key Areas identified for improving practice Three out of the 6 recommendations of this audit could be improved by the laboratory by empowering laboratory staffThree out of the 6 recommendations of this audit could be improved by the laboratory by empowering laboratory staff

9. Inappropriate Blood Use This figure represents 1 almost 1 in 5 of red cell transfusionsThis figure represents 1 almost 1 in 5 of red cell transfusions

10. Overtransfusion This figure is over � of red cell transfusionsThis figure is over � of red cell transfusions

11. Days since Haemoglobin Check (from decision to transfuse) 15% of patients were not transfused until over 48 hours after their last Hb result15% of patients were not transfused until over 48 hours after their last Hb result

12. The Audit Provided solid evidence of many areas of poor practice Gave a mandate for definitive action

13. Strategies for challenging clinicians Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Audit local evidence of poor practice Agree Transfusion Guidelines As a result of the 2005 Regional Appropriateness of Blood Transfusion Audit As a result of the 2005 Regional Appropriateness of Blood Transfusion Audit

14. Agree Guidelines for Transfusion The result of the 2005 audit Regional Guidelines were drawn up with the sole aim of better use of blood The result of the 2005 audit Regional Guidelines were drawn up with the sole aim of better use of blood

15. Well Defined Transfusion Thresholds Well defined transfusion thresholds above which transfusion was deemed as inappropiate were agreedWell defined transfusion thresholds above which transfusion was deemed as inappropiate were agreed

16. Well Defined Transfusion Thresholds

17. Well Defined Transfusion Thresholds

18. Well Defined Transfusion Thresholds

19. Well Defined Transfusion Thresholds

20. Agreed Regional Guidelines Agreed across wide range of specialists � consensus of opinion � all inclusive Very tight definitions Became the regional �Rulebook for Transfusion�

21. Strategies for challenging clinicians Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Audit local evidence of poor practice Agree Transfusion Guidelines Request form with indication for transfusion

22. Northern IrelandRegionalRequest Form 11 different request forms after long and at times heated discussions reduced to two and finally in 2008 a Regional request form was agreed. Such has been our achievement to agree that others have now followed11 different request forms after long and at times heated discussions reduced to two and finally in 2008 a Regional request form was agreed. Such has been our achievement to agree that others have now followed

23. Such has been our achievement to agree� that others have followed! These two politicians locally known as the �Chuckle Brothers�These two politicians locally known as the �Chuckle Brothers�

24. Indications for Transfusion Key element of the Regional request form is the indications for transfusion sectionKey element of the Regional request form is the indications for transfusion section

28. The First Challenge

29. Since January 2009 all staff in Northern Ireland have been required to be NPSA � Right Patient, Right Blood� compliant

30. NPSA  Right Patient, Right BloodDeclaration

31. The First Challenge Request Form Should provide clear information to ascertain reason for transfusion Single regional form allows standardisation of practice Easy to audit

32. The Second ChallengeConflict with the Guidelines

33. Strategies for challenging clinicians Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Audit local evidence of poor practice Agree Transfusion Guidelines Request form with indication for transfusion Challenge � but allow release of blood

34. Challenge should not stop release of blood �I must inform you that I believe this transfusion is outside hospital guidelines.

35. Challenge should not stop release of blood �I must inform you that I believe this transfusion is outside hospital guidelines. I will release the blood to be used but this transfusion will be reviewed later at ward level to confirm its validity�

36. Strategies for challenging clinicians Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Audit local evidence of poor practice Agree Transfusion Guidelines Request form with indication for transfusion Challenge � but allow release of blood Follow up queried requests and issue warnings

37. Follow up Refer to bleep number 537Refer to bleep number 537

38. Follow up

40. Example 1 Request for 2 units blood for 40y.o. female 5 days post gynae operation � on ward and stable. Based on Hb result of 7.9g/dl (noted by laboratory staff to be 5 days old.) Repeat Hb noted to be 9.7g/dl.

41. Example 1 Request for 2 units blood for 40y.o. female 5 days post gynae operation � on ward and stable. Based on Hb result of 7.9g/dl (noted by laboratory staff to be 5 days old.) Repeat Hb noted to be 9.7g/dl.

42. Example 1 Request for 2 units blood for 40y.o. female post gynae operation x 5 days � on ward and stable. Based on Hb result of 7.9g/dl (noted by laboratory staff to be 5 days old.) Repeat Hb noted to be 9.7g/dl.

43. Example 1 Request for 2 units blood for 40y.o. female post gynae operation x 5 days � on ward and stable. Based on Hb result of 7.9g/dl (noted by laboratory staff to be 5 days old.) Repeat Hb noted to be 9.7g/dl.

44. Discussed with medical staff � unaware of current result Unnecessary transfusion avoided

45. Learning Points Medical staff were:- Unaware of the new Regional Guidelines Were prescribing on a blood result 5 days old Were unaware of a current haemoglobin result

46. Example 2 Request for 4 units for 54 y.o. male medical patient as Hb noted to be 4.9g/dl � no mention of bleeding on blood request form. Lab checked reported admission Hb found to be 9.4g/dl and queried above result Recheck sample found to be 9.7g/dl

47. Unnecessary transfusion avoided. Suspected blood sedimentation in syringe.

48. Learning Point Laboratory staff should always query inconsistent results

49. Does Laboratory empowerment really make a difference? So has the audit made a difference?So has the audit made a difference?

50. Overall effect on blood issue (6 monthly trends) Looking at the effect across the region at the total blood use Before the audit � there was very little variation in the regional 6 monthly use of blood Looking at the effect across the region at the total blood use Before the audit � there was very little variation in the regional 6 monthly use of blood

51. Overall effect on blood issue (6 monthly trends) When the audit was going on there was a drop in the use of blood as personnel realised that their practice was being examined When the audit was going on there was a drop in the use of blood as personnel realised that their practice was being examined

52. Overall effect on blood issue (6 monthly trends) When the report came out � there was a bigger dropWhen the report came out � there was a bigger drop

53. Overall effect on blood issue (6 monthly trends) With continuing education, adoption of guidelines and other initiatives � there is a continuing reduction in blood use.With continuing education, adoption of guidelines and other initiatives � there is a continuing reduction in blood use.

54. So how do we in Northern Ireland compare with the rest of The United Kingdom and Europe?

55. Transfusion Rates in Other Countries Northern Ireland has a transfusion index just above 30 units per 1000 of the population Northern Ireland has a transfusion index just above 30 units per 1000 of the population

56. Transfusion Rates in Other Countries Which compares very well to Scotland who are almost 38 units per 1000Which compares very well to Scotland who are almost 38 units per 1000

57. And England who transfuse approximately 37 Units per 1000And England who transfuse approximately 37 Units per 1000

58. Transfusion Rates in Other Countries In fact the European average is 35 Units per 1000In fact the European average is 35 Units per 1000

59. Transfusion Rates in Other Countries And over the course of the last 4 yearsAnd over the course of the last 4 years

60. Transfusion Rates in Other Countries Northern Ireland has now moved from being from being 10% above the European average transfusion rate to being 15% below it. In fact N. Ireland is now recognised as the most controlled area for blood transfusion in Europe.Northern Ireland has now moved from being from being 10% above the European average transfusion rate to being 15% below it. In fact N. Ireland is now recognised as the most controlled area for blood transfusion in Europe.

62. Summary of effective strategies needed to challenge clinicians. Laboratories need to be a integral part of a functioning Hospital Transfusion Committee Audit local evidence of poor practice Agree Transfusion Guidelines Request form with indication for transfusion Challenge � but allow release of blood Follow up queried requests and issue warnings At a Trust level I have had the complete support of the Consultant Haematologists in developing these strategies and at Regional level Dr. Kieran Morris the Director of Northern Blood Transfusion Service has combined all individual Trust initiatives into a regional plan which has resulted in Better Use of Blood At a Trust level I have had the complete support of the Consultant Haematologists in developing these strategies and at Regional level Dr. Kieran Morris the Director of Northern Blood Transfusion Service has combined all individual Trust initiatives into a regional plan which has resulted in Better Use of Blood