Presentation Transcript

1. A Multifaceted Approach to Blood Management in an Academic Medical Center

   Kiran Dhanireddy, MD Rick Selby, MD Department of Surgery The University of Southern California Keck School of Medicine
2. The authors have no conflicts to disclose
3. The Genesis of Patient Blood Management at USC Transfusion Free Medicine and Surgery Jehovah’s Witnesses Development of a primitive culture of blood product refusal
4. Administrative and Clinical Process Slow development over a period of multiple years Identification Implementation of blood augmentation Implementation of ANH Acceptance Refinement
5. Identification
6. Patient Tracking Mechanisms Portal of Entry Referral source Service Line Individual Physician Hospital Location Growth of patient cohorts Establishment of Transfusion Free Program
7. Fallouts Ignorance Education CulturalChange Acceptance
8. Types of Fallouts Administrative Failure to correctly flag patient Failure to correctly flag patient chart Failure to obtain “Refusal to Permit Blood Transfusion” form Cultural Staff questioning of patients beliefs Clinical Erroneous administration of blood products Routine phlebotomy Educational Failure to keep ANH circuit closed Failure of Cell Salvage protocols
9. Tracking Down Fallouts in TFS: Portal of Entry
10. Tracking Down Fallouts in TFS:Physician Specialty Service Anesthesia Cardiac Surgery Cardiology Critical Care ENT Gastroenterology Gynecology Hematology/Oncology Hepatology Hepatobiliary Surgery Internal Medicine Kidney Transplant Liver Transplant Neurosurgery Orthopedics Urology
11. Tracking Down Fallouts in TFS:Hospital Location Admitting Anemia Management Blood Bank Case Management ICU Interventional Radiology Laboratory Med-Surg Floor Nursing Operating Room Outpatient Clinic PACU Pharmacy Scheduling Transfer Center
12. Consequences
13. Consequences Direct Contact with Person Involved- Verbal Written letter of Reprimand from Program to Involved Party Required re-take of credentialing module Removal of Physician from TFS panel of physicians Refer Responsible Party to Risk Management Office or Staff Re-Training of TFS Competency Module

14. Transition from Transfusion Free Service to Overall Patient Blood Management

15. VS Transfusion Free Blood Management Poorly defined Non-binding Lack of accepted definitions No process Deviations unknown Strict Binding Well defined criteria Clearly defined process Deviations clear
16. Lessons from the Transfusion Free Service Be Prepared Address Anemia Anticipate blood loss Modify approach Utilize Specific Strategies ANH Cellsaver Change the culture
17. Education: Certification Process Selective for Specialty Extensive or limited depending on exposure of professional to patient Details of administrative requirements and clinical processes Tailored to learning group for most effective education
18. Ancillary CERTIFICATION MODULE Laboratory Pharmacy Perfusion Services
19. Opportunities for PBM Autologous Blood Generation/Consevation Blood augmentation & Anemia avoidance ANH and Cell Salvage Sites of Opportunity OR Blood draws ICU wastage Unnecessary or Non-Reimbursed Costs T & C vs T & Sc Product waste PAD programs
20. Opportunities for PBM Scour the perimeter for blood cost Phlebotomies Order Sets Negotiated deal w Blood vendors Eliminate the PAD program Active surveillance for T & S. T & C violation Change the surgical technique to lose less blood Robotic Laparoscopic
21. Prospective Creation of A Patient Blood Management Strategy Sophisticated data collection Real time data analysis and feedback Focused Education Creation of new culture
22. Data Collection
23. We need to be able to use the application that Tyler has for zooming in on a slide for emphasis Final Summary - units and cost Plasma Platelets RBC Cryo. Cost by Location(intra op/ICU/Floor) LOS in ICU Total Cost Identifiers Patient Name Surgeon Anesthesiologist Pre-op H & H AMP Platelets INR Pro Time Intra-op TEG EBL Cell Saver ANH Post-op H & H Platelets INR Pro Time
24. PBM Dashboard
25. PBM Dashboard
26. PBM Dashboard
27. PBM Dashboard
28. PBM Dashboard
29. PBM Dashboard
30. PBM Dashboard
31. We need to be able to use the application that Tyler has for zooming in on a slide for emphasis Final Summary - units and cost Plasma Platelets RBC Cryo. Cost by Location(intra op/ICU/Floor) LOS in ICU Total Cost Identifiers Patient Name Surgeon Anesthesiologist Pre-op H & H AMP Platelets INR Pro Time Intra-op TEG EBL Cell Saver ANH Post-op H & H Platelets INR Pro Time
32. Data Collection: The (Near) Future Discrete data entry in EMR - PowerForms Real time update to PBM dashboard Ongoing feedback to clinicians facilitated Individual, service line, hospital wide trends tracked Dynamic assessment of opportunities for improvement Rapid cycle “Plan Do Check Act”
33. Pharmacy Operating Room Interventional Radiology Critical Care Anemia Mgmt Program Donation (PAD, Directed, Unpaid) donor Centers Blood Bank Site Specific Clinical Data Forms.Powerforms Laboratory Other Clinical? PBM Dashboard (from EMR) Utilization Review Data Financial Data Clinical Outcomes
34. The Power of Real Time Data Collection
35. PDCA Cycle of PBM Plan: Identification of Site Specific Opportunity Creation of Data Form Do: Implementation of Powerform Collection of Data into PBM Dashboard Act: Education and enforcement Cultural Change Check: Define Site Specific Fallouts Evaluation of Process
36. PDCA Cycle of PBM
37. PBM Fallouts Local institutional definition Electronic & Automatic No chart extraction Derivative from EMR fed PBM Dashboard Best core biopsy for QA part of program for reality testing of patient blood management Need to create the IT modules for the sites to be surveyed Eliminates paper chart data extraction but also eliminates electronic chart review
38. Fallouts Based on our Data Entry Points from Cerner PBM Dashboard Surgeon and Blood loss in cases Surgeon & Cell Saver/ANH & Blood Loss Blood utilization by service line Pre-op anemia by service line and surgeon
39. Fallouts Based on our Data Entry Points from Cerner PBM Dashboard ANH utilization by Anesthesiology and by Dept Empiric use of clotting product vs directed use Transfusion guideline adherence by surgeon/anesthesiologist Pre-operative use of the Anemia Management Program- Service Line, Physician for elective surgery
40. Institutional Response to PBM Fallouts First need to notify service lines and physicians of what is coming re data tracking Institutional pressure: Individual Physicians Departments Service lines (Perfusion Svcs, Interventional Rad, AMP, Anesthesia) Programs (Transplantation, Spine Center) Letters from Quality and PBM Mandated educational process Risk Management involvement in case of TFS Financial pressure on departments reflected through Mission Support
41. Plans for the Future Implementation Implementation Implementation Collection of of data Process change Cultural change.

42. Acknowledgments

    Tyler Woolsey Leticia Camacho SanjitMahanti Lorraine Lopes Sharon Lee