Prof. dr. Robert Slappendel, anesthesiologist Manager Quality and Safety, Amphia Hospital

1. 100% compliance of blood transfusion guidelines Prof. dr. Robert Slappendel, anesthesiologist Manager Quality and Safety, Amphia Hospital Tias Nimbas Business School, Tilburg University

2. Conflicts of interest All work is paid by Amphia Hospital no payments by blood banks or pharmaceutical industries.

3. Who wants tobe a millionaire?

4. What’s the price of one unit of blood? • Answer: • € 50,= • € 200,= • € 800,=

5. Price of blood (2009)

6. Costs of blood

7. After this session all hospitals using over 7800 units of blood can save 1 million euro a year

8. Topics to discuss • Difference in transfusion rates • Risks of blood • The battle of the blood bank • Transfusion triggers • 100% compliance to blood transfusion guidelines • Results • Final conclusion

9. Variability of Transfusion Rates (2003) NL 1. van der Poel, C.L. and M.P. Janssen, Final Report - The collection, testing and use of blood and blood products in Europe in 2002. 2005: Strasbourg. 2. van der Poel, C.L. and M.P. Janssen, Final Report - The collection, testing and use of blood and blood products in Europe in 2003. 2005: Strasbourg. 3. *Rouger P., Blood Transfusion in Europe: The White Book 2005, European Network of Transfusion Medicine Societies Public Data from National Blood Authority, Australia

10. Gombotz H, Rehak P, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007;47:1468-1480

11. Variability of Transfusion Rates forMatchedPatients - ProspectiveAustrianBenchmarkStudy Potential forReduction

12. 97.4% of all transfusions could have been predicted by: • Level of anemia prior to surgery • Volume of perioperative blood loss • Transfusion trigger

13. Blood loss per surgeon (THP)

14. Take your surgeons apart!

15. Conclusion • There are differences between • countries • hospitals • doctors

16. Message: • Get the data out of your own hospital and show it to your colleagues!

17. Topics to discuss • Difference in transfusion rates • Risks of blood • The battle of the blood bank • Transfusion triggers • 100% compliance to blood transfusion guidelines • Results • Final conclusion

19. Retrospective cohort study of all hospitalisations in the US in 2004 (n=38.66 million) to assess in-hospital outcomes associated with blood transfusion. • 5.8% (2.33 million) transfused • After adjustment for age, gender, comorbidities, admission type or DRG transfusion associated with: • 1.7 increased odds of death (P<0.0001) • 1.9 increased odds of infection (P<0.0001) • 2.5 days longer LOS • $17,194 higher charges (P<0.0001)  $40.1 billion more charges for txed pts!

20. Agreement Allogenic transfusions? • Mortality • Morbidity • Hospital stay • Infection rates • Wound disturbances

21. Topics to discuss • Difference in transfusion rates • Risks of blood • The battle of the blood bank • Transfusion triggers • 100% compliance to blood transfusion guidelines • Results • Final conclusion

22. Blood Safety Measures – Another Cost Driver Source: America‘s Blood Centers, 2004

23. Current topic: Age of transfused red blood cells • Reduced levels of 2,3 diphosphoglycerate • Increased oxygen affinity • Shape change • Reduced deformability • Decreased viability Reduced tissue oxygenation

24. Acknowledgement: Gavin Murphy

25. Topics to discuss • Difference in transfusion rates • Risks of blood • The battle of the blood bank • Transfusion triggers • 100% compliance to blood transfusion guidelines • Results • Final conclusion

26. New national guideline blood transfusions 2011 580 pages270 medical specialist> 200 residents

27. 100% compliance??? Doctors???????

28. IHI Tool 100% compliance to guideline

29. IHI Tool Ordering of blood

30. Normal ordering of blood(non acute bleeding patient) Hemoglobin level Doctor thinks…. Orders the amount of packed cells!

31. Amphia ordering(non bleeding patient) • Age • Hemoglobin level • Time after surgery (> of <4 hrs) • Cardial or pulmonary problems Determines the number of packed cells! Physical barrier: If the doctor wants anything else than this guideline he has to motivate and call the lab

32. Topics to discuss • Difference in transfusion rates • Risks of blood • The battle of the blood bank • Transfusion triggers • 100% compliance to blood transfusion guidelines • Results • Final conclusion

33. Results:

34. Basic Principle Dutch Guideline • Hb-value is the main trigger for transfusion • No Hemoglobin value, no blood • < 4mmol/l all patients need to be transfused • < 5mmol/l might be better for patients > 60y • < 6mmol/l might be better for patients with a history of cardiac disease

35. Blood transfusionschecklist approaches 100% compliance

36. Blood supply in the Netherlands

37. Number of transfusions /hospitaladmissions per 1000 inhabitants. (Netherlands) Number Hospital admissions transfusions year

38. Benchmark Europa Netherlands 2012 Nederland 2012 Survey 2010 European Directorate for the Quality of Medicines and Health Care

39. Topics to discuss • Difference in transfusion rates • Risks of blood • The battle of the blood bank • Transfusion triggers • 100% compliance to blood transfusion guidelines • Results • Final conclusion

40. 5 drivers to change! Efficiency, Quality and Patient Safety

41. Request for checklist: robslappendel@hotmail.com