Review and Evaluation of the Patient Blood Management Program

1. Review and Evaluation of the Patient Blood Management Program Trudi Gallagher RN State Clinical Coordinator Patient Blood Management Office of Chief Medical Officer Western Australia Department of Health Perth, Western Australia Australia Trudi.Gallagher@health.wa.gov.au

2. Administrative and Clinical Standards for PBM • Leadership and Program Structure • Consent Process and Patient Directives 3) Blood Administration Safety 4) Review and Evaluation of PBM Program 5) Preoperative Anemia Management 6) Perioperative Autologous Blood Collection for Administration 7) ANH • Phlebotomy Blood Loss • Minimizing Blood Loss Associated with Surgery, Procedures, Underlying Medical Conditions . . . . • Massive Transfusion Protocol • Transfusion Guidelines • Management of Anemia in Hospitalized Patients

3. How do you define: “Review” and “Evaluate” • Review and Evaluate • Appraisal • Journal • Reconsideration • Study • Assessment • Valuation • Quality

4. Intent of SABM PBM Standards • Baseline program development and structure • Minimum indicators • “must haves” of a PBM program • Room, and allowance for more • Resource of basic validation

5. Review and Evaluation of Patient Blood Management Program: Standard 4 Guidance Statement: “Program evaluation and quality improvement is much more than transfusion utiliza­tion review and must include systematic evaluation of treatment modalities other than allogeneic transfusion.”

6. Review and Evaluation of Patient Blood Management Program: Standard 4 • continued…. • Patient outcomes related to the use of preoperative anemia management • Periopera­tive autologous blood collection and administration • Pharmacologic agents such as erythropoietic stimulating agents and iron • Including (but not limited to): analysis of the economic impact of blood conservation and management on the institu­tion

7. ….and the other half of the financial picture • Don’t forget; cost savings • Reimbursements • Length of stay

8. Administrative and Clinical Standards for PBM

9. Review and Evaluation of the Patient Blood Management Program: Standard 4 • 4.1 There is provider-specific peer review of transfusion decisions. Transfusion peer review information is available to the Medical Director of the Blood Management Program. • 4.2 Review of transfusion decisions, whether prospective, concurrent, or retrospective, includes a determination of the clinical appropriateness of the transfusion, the level of documentation with respect to the clinical indications for transfusion, and recommendations for management without transfusion if transfusion was not clinically appropriate. • 4.3 Blood use is monitored by clinical service as well as hospital-wide. The data are analysed to identify potential areas for improvement due to over- or under-utilization. • 4.4 Blood component transfusion is evaluated using metrics defined by the institution that allow comparison of blood utilization and transfusion practices with other institutions and published literature. • 4.5 Quality measures defined by the hospital are used to assess the clinical efficacy and cost effectiveness of other treatment modalities in reducing blood utilization and managing anaemia.

10. Does “Review and Evaluation” standard satisfy regulatory directed data points? Joint Commission • LD.04.04.07 Clinical Practice Guidelines • LD.04.01.01 thru LD.04.04.07 Leader example • NPSG.01.03.01 Eliminate transfusion errors • PI.01.01 The hospital collects data to monitor performance CAP • TRM.20000 is there a written quality control program • TRM.40850 does the medical director of transfusion service, review cases not meeting transfusion audit criteria AABB • 9.1 blood bank has process for deviations, nonconformance related to blood • 9.2.1 review of information causes of nonconformance • 9.2.3 application of controls to monitor effectiveness • 9.3 Quality Monitoring: process to collect and evaluate quality indicator on scheduled basis • 8.2 Monitoring of blood utilization: transfusion facility monitors and addresses transfusion practices for all categories of blood and components

11. 4.1 There is provider-specific peer review of transfusion decisions. Transfusion peer review information is available to the Medical Director of the Blood Management Program. • Transfusion Data Reporting: Provider specific • Tracking and data collection obtained for review by • Computerized Physician Order Entry (CPOE) • Transfusion order forms • Spread sheet of data collected by blood bank • Outliers • Is this a pattern for this provider or a one time incident • Appropriate documentation • Reason for transfusion • Last lab indices that prompted transfusion decision • Peer review with PBM director involvement

12. 4.1 There is provider-specific peer review of transfusion decisions. Transfusion peer review information is available to the Medical Director of the Blood Management Program. • Mechanism of Action (AABB 9.2.1) • A physician’s ordering practices. • Use of transfusion or alternatives. • Effectiveness of transfusions or alternatives. • Adverse events including reactions and post‐event infections. • The results of this monitoring should be provided to the ordering physician by the medical director of the program.

13. 4.2 Review of transfusion decisions; determination of the clinical appropriateness, documentation with respect to the clinical indications, and recommendations for management without transfusion if transfusion was not clinically appropriate. • Why was the “transfusion” decision made? • Is there process in place to support consultation with other services to avoid transfusion? • Was this consideration/option mentioned in the chart? • Anemia management consultation? • Hematology consult availability?

14. 4.3 Blood use is monitored by clinical service as well as hospital-wide. The data are analysed to identify potential areas for improvement due to over- or under-utilization. • Top 2-4 diagnoses per service line that are transfused • Is there need for a ‘Single Unit Rule’ to be established • Cultural influence on transfusion rate

15. Measuring culture’s influence

16. Measuring culture’s influence

18. 4.4 Blood component transfusion is evaluated using metrics defined by the institution that allow comparison of blood utilization and transfusion practices with other institutions and published literature. • Network hospital systems • “Comparable” centers • More generic detail • Cardiac Surgery overall transfusion rate (including range) • Orthopaedic total joint replacement transfusion rate (including range) • Length of stay

19. 4.5 Quality measures to assess the clinical efficacy and cost effectiveness of other treatment modalities in reducing blood utilization and managing anemia. • Cost - expenditure • Product or equipment that is only being used due to the PBM standard of care • Caution: product increase does not mean that the former pattern of product use was being used appropriately or to its full capability • Cost savings by not transfusing • Transfusion rates prior to PBM vs present

21. Navigating The Review And Evaluation With Data

22. Step outside your box of comfort • Data • Think of data as a navigation vessel instead of a statistical reporting vessel

23. Data as a navigation vessel: What is your intent/goal or destination? • FORMER TRANSFUSION MEDICINE DATA REPORTING GOAL: Transfusion usage/wastage data • PBM BENCHMARKING DATA REPORTING GOAL: • Only data that can influence practice change or reflect change in practice – stay consistent!!! • Reporting total case load transfusion rate vs. reporting measurable events that can be bench marked • Extract out non comparable data • E.g. Orthopaedics: unilateral, primary, elective, non graph • E.g. Cardiac Surgery: elective, • CABG primary

24. Data as a navigation vessel: What is your intent/goal or destination? • Administration • How many cases done in one specialty • Former transfusion rate • Present transfusion rate • What amount of blood did this transition save • What cost savings were made with this initiative • Service line/specialty directors • Per specialty (as above) • Per physician • Who excelled within the group, who was an outlier

25. Data as a navigation vessel: What is your intent/goal or destination? • Group of clinicians in one service line • Total transfusion rate for top 4 procedures • Total transfusion rate per procedures • Average Length of stay for transfused vs non transfused • Individual clinician • Comparative improvement in transfusion rate and average length of stay for individual procedure • Comparing to his/her peers the information above (blinded to non blinded depending on group desire)

26. Expanding“Review and Evaluation” • Review and Evaluation of a program • Value • Progress • Quality

27. What is your foundation made of? • A secure foundation • Helps assure longevity • Withstands evolution of the human factor • Attrition • Life getting in the way

28. Insurance: Embedding PBM in the institution above and beyond a “service line / specialty focus” • Areas of KPI’s/measures/indicators • Paper: Policy, protocols, and guidelines • Single Unit Rule • After hours transfusion rule • Blood Conservation line draw standard of care • “Short draw” tubes / minimal size draws • Transfusion Guidelines comparable to recent literature • Perioperative: flow and prep through preoperative course to allow for RBC and iron stores assessment and optimization if patients condition warrants it

29. Insurance: Embedding PBM in the institution above and beyond a “service line / specialty focus” • Process: • PBM committee having ‘teeth’ in hospital culture; evidence of adoption

30. Self assessment: Is your image of your program distorted?“Objects in mirror are closer than they appear”

31. Question: Can the proposed US PBM standards be used in Australia? 2011 US population; 312 million 2011 Australia population; 22 million

32. Adding on to the foundation • Expand or create an addendum to the great foundation of the SABM Standards • > 100 indicators divided among • Policies/Procedures/Protocols/and Guidelines • Process/Culture Evidence Hospital-wide • Preop/intraop/postop specific issues

33. Ongoing evaluation and assessment • Plan • Summarize and reassess every 6 mo • When complete, plan to review and assess annually thereafter • Things change: staff, products, costs, budget, policies

34. Create a biannual “To-Do” list • Based on assessment tool summary • List by priorities • Reminders sent at 3 mo

35. In Summary: Review and Evaluation of a PBM program can….. • Confirm where you are in your development and where you need to go • Assure quality foundational support • Progress made in clinical areas • Identify holes/opportunities in the program • Assures regulatory compliance

36. Are you waiting too long to do your own evaluation?

37. G’day and Cheers