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Patient Blood Management Building your foundation

Patient Blood Management Building your foundation. Trudi Gallagher RN jurisdictional patient blood management coordinator Fremantle, wa australia tag22g@aol.com. Modified from: Shander and Goodnough . Curr Opin Hematol . 2006;13(6):462-470.

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Patient Blood Management Building your foundation

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  1. Patient Blood ManagementBuilding your foundation Trudi Gallagher RN jurisdictional patient blood management coordinator Fremantle, wa australia tag22g@aol.com

  2. Modified from: Shander and Goodnough. CurrOpinHematol. 2006;13(6):462-470.

  3. Blood Management All Inclusive(what’s in a name) • Transfusion Free Care / “Bloodless Surgery and Medicine” • Anemia Prevention • Anemia Treatment • Appropriate use of Blood Products • Blood Conservation • Discharge Anemia needs • Preoperative Assessment • Postoperative assessment • Transfusion tracking / blood utilization • Intra operative reduction of blood loss

  4. Timing Is Everything Why Is Patient Blood Management Proving To Be So Popular Among Medical Centers In 2011?

  5. Why now? • Medicare • “never” events • Reform reimbursement unknowns • Readmission issues • Other timely issues • Length of stay issues • Infection prevention • $$$$$$$ • Mortality and morbidity • Patient Satisfaction

  6. WHAT are 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.41000 Transfusion Protocol: Personnel involved in transfusion are trained in the identification of transfusion recipients and blood components, and in observation of recipients during and after transfusion, with in-service education at least annually. • 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

  7. Patient Blood Management Standards Society for the Advancement of Blood Management sabm.org http://www.sabm.org/public/standards.php

  8. Standards Committee

  9. Expert Reviewers

  10. Leadership and Program Structure(Preparing for the foundation) • Platform • Written mission statement • Vision and values statement • Scope of service (what areas are affected) • Medical Patients / inpatient and outpatient • Surgical Patients / in patient and preoperative • Job descriptions • Physician medical director • Program manager

  11. Leadership and Program Structure(blueprints) • Policies and procedures (standard of care housewide or service line specific?) • Interdepartmental • Guide practice and process • Protocols and guidelines • Available to the staff at all times • Education program • Targets • Physicians, mid-level providers, nurses, pharmacists • Ancillary health care staff regarding • Blood management program’s goals, structure, and scope.

  12. Leadership and Program Structure(GPS) • Quality and outcome measures • Data collection and reporting to the hospital quality improvement committee as scheduled • Administration • Leadership level representation • Transfusion or blood management committee

  13. Consent Process and Patient Directives

  14. Consent Process and Patient Directives • Hospital-wide policy requiring written informed consent for transfusion • Documents a discussion • Risk • Benefits • Alternatives to transfusion • Hospital-wide policy intent • Supports and respects right of patients to decline blood transfusion • Addresses the rights of patients who are minors

  15. Consent Process and Patient Directives • Hospital has a document for adult patients • Directive establishing the refusal of transfusion • Defines alternatives/options to allogeneic transfusion • Autologous transfusion modalities • Human derived growth factors • Essential cofactors (e.g. iron, B12, and folic acid) for red cell production • Recombinant products • Factor concentrates • Blood derivatives and fractions.

  16. Consent and Patient Directives • All patients have access to information regarding • The risks and benefits of blood transfusion • The risks and benefits of refusing a transfusion • Alternatives to blood transfusion that are available and applicable to that patient • A process is in place that • Identify adult patients who refuse blood transfusions

  17. Consent and Patient Directives • Patients with a previously executed blood refusal advance directive • Confirmation process • Continued desire to refuse transfusion? • Obtain document and place in chart • If the patient is unconscious or incapacitated, the advance directive is honored • Education • Alternatives to blood transfusions • Medical staff and other health care providers • Religious proscriptions against blood transfusion • Is available to all providers

  18. Blood Administration Safety

  19. Blood Administration Safety • Policies and procedures in compliance with applicable agencies • College of American Pathologists requirements (CAP) • AABB standards • Applicable state regulations • Standards of the JC • Ordering blood • Dispensing blood • Transfusing blood

  20. Blood Administration Safety • Individuals involved in administration of allogeneic blood transfusion will… • Satisfy requirements • Education prior to independent administration of blood products • Demonstrate skills with a preceptor before acting independently • Transfusion administration policies and procedures are in compliance with regulatory agencies

  21. Blood Administration Safety • Qualified staff may not administer blood products without • Receiving annual education, training and competency annually • The hospital’s transfusion review committee reviews • Near miss events • Sentinel events • Significant errors associated with pre-transfusion blood specimen acquisitionNOTE: the hospital defines what constitutes a significant error or near miss event. • Labeling • Testing • Ordering • Release, and transfusion of blood and blood components.

  22. Review and Evaluation of the Patient Blood Management Program

  23. Review and Evaluation of the Patient Blood Management Program • Provider-specific peer review of transfusion decisions • Review information is available to the medical director of the patient blood management program. • Review of transfusion decisions includes • Determination of the clinical appropriateness of the transfusion • Documentation regarding clinical indications for transfusion • Recommendations for management without transfusion if transfusion was not clinically appropriate

  24. Review and Evaluation of the Patient Blood Management Program • Blood use is monitored • Individual clinical service as well as hospital-wide • Data are analyzed • Identify areas for improvement due to over- or under-utilization. • Blood and blood component transfusion is evaluated • Metrics defined by the institution • Comparison of blood utilization • Transfusion practices with other institutions and published literature. • Quality measures defined by the hospital • Clinical efficacy and cost effectiveness of other treatment modalities; transfusion alternatives or managing coagulopathy

  25. Complacency Education & Full Team Buy-in Implemented new perfusion strategies & unblinded surgeon data Began Leukoreduced PRBC only

  26. CABG Blood Utilization Rates

  27. Preoperative Anemia Management

  28. Preoperative Anemia Management • Identify elective surgical procedures for which preoperative anemia management screening is required (eg. cases with potential for measureable blood loss) • Patients who need preop screening are identified • Three to four weeks prior to surgery • Time to diagnose and manage anemia** NOTE: unless the surgery is of an urgent nature and must be performed sooner • Screening for detecting anemia and allow diagnosis of the common causes of anemia • Iron deficiency etc

  29. Preoperative Anemia Management • A process ensures • Laboratory data has been reviewed • Patients with moderate to severe anemia • Anemia of unclear etiology • Additional clinical evaluation and laboratory testing • A referral to a specialist is made as necessary. • Outpatient treatment when clinically indicated • Parenteral iron and/or erythropoietic-stimulating agents • Results of preoperative anemia screening are shared with • Referring surgeon • Primary care physician

  30. Preoperative anemia Management • Perioperative period • If treated during preoperative time period = also followed in the postoperative period • Ensures continued management of their anemia during their hospital admission • Elective surgery is deferred and rescheduled in anemic patients when • The anemia is reversible unless there is an urgent need for surgery • Decision is the responsibility of the surgeon • In consultation with the medical director of the patient blood management program

  31. PerioperativeAutologous Blood Collection For Administration

  32. PerioperativeAutologous Blood Collection For Administration • Policies and procedures regarding perioperative autologous blood collection • Collection modalities offered • Methods for blood collection • Indications and contraindications • Reinfusion of the collected blood • Policy and procedure for; • Modifications of the blood collection and reinfusion conduits • Volume of autologous blood collected • Processed • Reinfusion process is documented

  33. PerioperativeAutologous Blood Collection For Administration • If hemofiltration/ultrafiltration is performed • Equipment used is consistent with the manufacturer’s instructions for the given device • Modification is documented • Including the rationale for the modification • Labeling and storage requirements of perioperative autologous blood collections • Defined/ and consistent with the current AABB standards • Variation from accepted techniques is documented • Including the rationale for such variation

  34. PerioperativeAutologous Blood Collection For Administration • Policies for the reinfusion of processed and/or unprocessed shed blood are established • Quality assurance program • Perioperative autologous blood collection is; • Indicated, cost-efficient, effective, and safe • Quality indicators are defined and monitored • Variances to quality indicators • Adverse effects including potential transfusion reactions • Complications • Patient safety factors are documented and reviewed, and appropriate action is taken

  35. PerioperativeAutologous Blood Collection For Administration • Personnel involved in handling of blood product collection • Qualified on the basis of education and training • Competency is documented and evaluated at least annually • Equipment and supplies • Validated before initial use • Properly maintained • Revalidated after any major service or repair • Outsourced staff for perioperative autologous blood collection • Outside provider is in compliance with this standard

  36. Acute NormovolemicHemodilutation

  37. Acute NormovolemicHemodilutation (ANH) • Policy and procedure exists; the use of ANH • Approved by the chair of anesthesiology • Blood collection conduits • Type of collection bag • Formulation and volume of anticoagulant • Site of blood collection • Methods and solutions used to maintain normovolemia. • Collection and storage requirements for blood collected through ANH • Compliant with all applicable accreditation and FDA requirements

  38. Acute NormovolemicHemodilutation • Indications and contraindications for the use of ANH • Described and include s • Both patient-related and procedure -related factors • Modifications of the blood collection conduits for specialized patient populations • Jehovah’s witnesses • Described, including the rationale for the modification • The hemodynamic monitoring technique during the conduct of ANH is described • Including any specialized equipment • The mathematical computation of the volume of AWB blood to be collected is stated

  39. Acute NormovolemicHemodilutation • The projected end-points of autologous whole blood (AWB) collection are stated • Including target hemoglobin or hematocrit • Where applicable, the impact of hemodilution secondary to an extracorporeal circuit prime volume is calculated • The timing and rationale for AWB reinfusion in relationship to the conduct of surgery and/or anesthesia are defined and followed.

  40. Acute NormovolemicHemodilutation • There is a quality assurance program to ensure; • ANH is cost-efficient • Effective and safe • Training and on-going competency assessment for personnel collecting ANH units is defined • Quality indicators are defined and monitored • Variances to quality indicators • Adverse-affects • Complications • Patient safety factors are reviewed and addressed by a quality improvement process

  41. Acute NormovolemicHemodilutation • The handling of the AWB product including • Sterile collection • Labeling requirements • Storage location • Storage temperature • Duration of storage • Need for refrigeration • Agitation versus non-agitation techniques is defined and followed • Any variation from accepted techniques that occur must be documented and must include the rationale for such variation

  42. Phlebotomy Blood Loss

  43. Phlebotomy Blood Loss • Policies and processes that pertain to phlebotomy for diagnostic laboratory samples address • Importance of reduced size and frequency of lab draws • There is a mechanism for identifying patients • At higher risk for transfusion • Those who refuse transfusions • Additional measures considered • Use of microtainers • Point of care testing • Reduction in daily or routine labs ordered

  44. Phlebotomy Blood Loss • There is a system in place for reducing blood loss from line draws • Individuals who re infuse blood that is unsuitable for laboratory testing are trained and deemed competent according to policy and procedure guidelines

  45. Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions, Antithrombotic Therapy Or Coagulopathy

  46. Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions, Antithrombotic Therapy Or Coagulopathy • Policies and procedures are defined that minimize intraoperative blood loss • Guidelines for intraoperative use of pharmacologic agents; • Topical sealants • Topical hemostatic agents to minimize blood loss • Patient blood management program medical director is actively involved in selection of; • Clotting factor concentrates, topical hemostatic agents, tissue adhesives, and pharmacologic agents, including antifibrinolytic and prohemostatic agents to limit blood loss

  47. Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions, Antithrombotic Therapy Or Coagulopathy • Hospital coagulation testing services have the capability • Assess and characterize hemorrhagic risk factors • Assist in diagnosis of the likely etiology of coagulopathy in a bleeding patient • Guidelines • Encourage early definitive intervention and treatment of acute hemorrhage • Early return to the operating room for source of bleeding • Early referral for interventional radiology and embolization • Early use of endoscopy/ colonoscopy and cystoscopy for gastrointestinal hemorrhage or genitourinary hemorrhage

  48. Minimizing Blood Loss Associated With Surgery, Procedures, Underlying Medical Conditions, Antithrombotic Therapy Or Coagulopathy • Referral and consultation protocols • Assist in the management of patients • Anticoagulant and antithrombotic medications • Patients with history of significant bleeding or coagulation abnormalities

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