September 2011 How to develop sustainable patient blood management processes By Tiffany Nelson, RN Program Coordinator for Patient Blood Management Eastern Maine Medical Center, Bangor Maine Agenda • Who we are • Our journey • Examples of patient blood management processes • Challenges • Lessons learned EMHS – 7 Affiliated Hospitals 89 Acute Beds 72 LTC Beds l 14 Acute Beds 36 LTC Beds 9 Swing Beds Critical Access Hospital l 48 Acute Beds 76 LTC Beds l l l 411 Acute Beds l 28 Acute Beds Critical Access Hospital 25 Acute Beds 10 Swing Beds Critical Access Hospital 100 Acute Psychiatric & Substance Abuse Beds Together Project Vision Statement All EMHS providers will be able to treat a patient using one shared electronic record system, no matter where in EMHS the patient seeks care. Information will be instantly available; improving patient safety, enhancing outcomes, and saving money. Eastern Maine Medical Center Eastern Maine Medical Center • 370 bed community and tertiary care hospital in rural Maine • Active hematology/oncology service • Cardiac surgery program (approx. 450 cases/yr. • High risk obstetrics • Trauma Center • Dialysis Center • No transplant surgery How We Began • Approached administration in Summer, 2006 with concept of Blood Management and Conservation Program with a proposal to: – Decrease blood acquisition costs – Improve quality of care • Program to be directed by the Transfusion Service How We Began • Requested that start-up include: – Full time program coordinator – Full time Transfusion Services Medical Director – Resources to create a relational database in our H.I.S. for evaluating transfusion practices on a provider specific basis • Program Coordinator position wasn‟t approved until March, 2008 (filled 06/08) • Database development is ongoing – no dedicated resources The Essentials: What We Did • Education, Education, Education • Site visit to an established program (Englewood Hospital) • Forging key partnerships in the O.R. and pharmacy (Spend time in the O.R. and pharmacy!) • Early effort to integrate program into the hospital information system (I.S. is your friend!) What We Did • Effective implementation of transfusion guidelines- paper order sets • Prospective review (selective cases) – Reinforces transfusion guidelines • Provider “Report Cards” • Computerized physician order entry(CPOE) What We Did • • • • • Preoperative anemia management Perioperative blood collection program Platelet management protocol Minimum blood draw protocol Inpatient anemia management by consultation Implementation of Transfusion Guidelines • Computerized Physician Order Entry (CPOE) implemented after one year of using the paper order set. – Different “orderable” for each component – Indication for transfusion a mandatory field – Two RBC orderables: Actively Bleeding and Not Actively Bleeding • Only one RBC unit at a time can be ordered if patient not actively bleeding • Reinforces concept: each unit transfused is an independent clinical decision Select Transfuse Order From Menu If RBC Anemia Non-Actively Bleeding is chosen, only a single unit may be ordered in an ordering “conversation” 1. 2. 3. 4. Transfusion Rates by Period Transfusion Rate by 'Era' and Patient Type 25% 23.2% 20% 15% 10.5% 10.4% 10.1% 9.8% 10% 7.2% 7.4% 6.4% 5.8% 5% p<.001 p=.002 p<.001 p<.001 6.3% 5.7% 5.2% p<.001 p<.001 p=.007 p=.008 0% Pre (8/062/07) BldMng CPOE (3/07- (12/0711/07) 12/08) Inpatients Pre (8/062/07) BldMng CPOE (3/07- (12/0711/07) 12/08) Surgical Pre (8/062/07) BldMng CPOE (3/07- (12/0711/07) 12/08) Orthopedic Pre (8/062/07) BldMng CPOE (3/07- (12/0711/07) 12/08) EMIC Pre-op AM Preoperative Anemia Management • Screen selected orthopedic procedures for anemia/iron deficiency • Treat anemia (e.g. I.V. iron, ESA) to optimize Hgb prior to surgery – Pre-op anemia is a risk factor for perioperative transfusion • Discourage pre-operative autologous donations in most patients EMMC Orthopedics Program - A Prototype for Successful Patient Blood Management • Preoperative anemia management • Less invasive surgical technique with meticulous hemostasis • Use of anti-fibrinolytic in selected patients • Use of perioperative cell collection and administration (ICS and ANH, when indicated) • Adherence to transfusion guidelines • Optimization of oxygenation and hemodynamics Our Outcomes for Orthopedics Orthopedics Percent Inpatients Transfused Transfusion rates in elective hip and knee arthroplasty has fallen from 25% to less than 2% Growth and Expansion Why expand? • Better Quality care for patients • Blood is a limited resource – From 1997 to 1999 the demand for blood increased 8.7% – Whole blood collection decreased 11.4% – By the year 2030, if this trend continues there will be a RBC shortage of 4 million units! • Hospital economics- huge cost saving potential with transfusion avoidance and revenue potential for out patient anemia clinic. What EMMC PBM Program is Doing • Expand pre-op anemia management program • Developing electronic solutions – for pre-op anemia management – transfusion advisor – inpatient anemia management advisor(on hold) • Obtained AABB accreditation for peri-op • Working with Primary Care Providers to screen and treat anemia • Updating our internet site for PBM • Developing an out patient anemia clinic Ways to expand Pre-op Anemia Management • Decide which procedures are at risk for transfusion • Implement one service at a time for best results. • Most PBM programs start with orthopedics Candidate Surgical Procedures for Pre-operative Anemia Management Specialty Cardio-Thoracic Surgical Procedure Valve Replacement Aortic arch aneurysm Coronary artery bypass Valve / CABG combo Pneumonectomy / lobectomy Orthopedics Spinal fusion (> 2 levels) Knee replacement Hip replacement Urology Radical retropubic prostatectomy Cystectomy Nephrectomy Neurosurgery Giant basilar aneurysm Cerebral aneurysm OB/GYN High risk pregnancy Myomectomy (non-embolized) Placenta accreta or previa Abdominal hysterectomy with enlarged uterus Breast reduction / reconstruction * Plastics Vascular General Other Thoracoabdominal aortic aneurysm repair Aorto-bifemoral grafts Axillo-femoral bypass Abdominal aortic aneurysm repair Lower extremity revascularization Liver resection (non-embolized) Whipple Procedure Splenectomy, elective Any open abdominal procedure w/ expected blood loss >500 ml Colectomy / Bowel resection Any major surgical procedure for Jehovah‟s Witness Our next service for pre-op AM • Elective Cardiac Surgery • Need to have surgeon buy in for program to succeed – Shared our data from orthopedics with the CTS surgeons – Met with Cath lab staff and CTS office to add a referral to PBM program for all elective surgical cases – Implemented process to get anemia studies drawn either post cath or at office visit for the surgical consult Transfusion Rates All Cases: CABG, Valve, CABG/Vale Pre Op AM 23% 14% Expand Utilizing Technology Technology Video Ways to expand Pre-op Anemia Management • Develop an electronic pre-op anemia management tool with our IS vendor – Began working on development of the solution in June 2008 go live January 31, 2011 – Continue to make improvement's before it will be ready to offer as a package to other programs – Currently have the ability to do pre-op anemia management for 28 procedures LightHouse Is a Partnership with our clinical vendor, Cerner, to change a care process. Building pathways electronically to improve the patient care process. Will collect all important data elements during the care process. Anemia Management M-Page Patient Specific View of M-Page Patient Intervention Power Form • Screen shot of interventions Develop Outpatient Anemia Clinic Epidemiology of Anemia • Anemia is a common complication of common diseases • Prevalence of anemia is selected conditions – Rheumatoid arthritis: 30-60% – Chronic heart failure: 30-50% – Inflammatory bowel disease: 30-80% – Diabetics without overt renal failure: 20-40% – Chronic kidney disease: 40-60% Epidemiology of Anemia • Estimated prevalence of anemia in U.S. is 3.5 million • Abnormal blood counts are often not investigated – “normative” deviation in the average PCP practice • Economic impact – $6.4 billion estimated annual cost in U.S. • Quality of life impact Virtual Anemia Management Clinic • As our program continues to grow we noticed many opportunities to enroll patients in an anemia clinic. • Our anemia clinic is still in development stages we offer our virtual clinic to the following patient populations – Bariatric – CHF Bariatric AM Process • Patients are referred by surgical weight loss program via fax • Labs obtained – Hemogram, iron, TIBC, ferritin,B12, creatinine • If mild anemia (hgb 11-12) and borderline iron deficiency(TSAT 15-19 and or ferritin 75-99) start oral iron trial with iron bisglycinate TID and folic acid 800mcg and vitamin C 500mg bid. Re-evaluate labs in 3 months. • If moderate to severe iron deficiency anemia we give IV iron, usually with total dose replacement 1000-1500mg and have them take folic acid and vitamin C also. Re-eval labs in 3 months. Bariatric AM Process • After labs results available the patient history is • • • • reviewed. Dr. Gross and myself meet to discuss a treatment plan. Patient is called on the phone to give results of screening and discuss the process for anemia mgt. A consult letter is generated and sent to the patient, the Bariatric surgeon and the PCP. Once a maintenance dose is determined the patient is given back to the PCP for ongoing coordination. The patient is informed of the plan. Bariatric AM Process • The goal for this patient population is to have – – – – hgb above 12g/dl TSAT greater than 20% Ferritin greater than 100mg/dl Find out what their maintenance dose to achieve goal • Most patients who are depended on IV iron are needing 200-600mg ever 3-6 months Bariatric Study-Update Pre-Procedure Referals N=30 patients Total Averages Pre-op Hgb 12.5 TSAT % Ferritin Average dose IV iron 13.0 60.0 1000 mg Percent Treated IV Iron = 47% 49% Oral Iron = 34% No treatment= 17% Post Procedure Referrals N= 78 patients Total Averages Baseline Hgb TSAT % Ferritin 11.2 12.0 52 Average dose IV iron 1200mg 3 Month F/U N= 44 Post Tx hgb TSAT % Ferritin 12.6 20 125 Average dose IV iron 1000mg 6 Month F/U N=18 Post Tx hgb TSAT % Ferritin 13 19 164 Average dose IV iron 600mg Percent Treated IV iron = 78% oral iron=12% No treatment= 10% CHF Anemia Clinic • We have contacted the cardiology service to begin the virtual clinic process. – They have 500 enrolled patients with CHF – We estimate 30-50 % have anemia and would benefit from IV iron therapy as an outpatient Where are we today? Impact of Patient Blood Management on Outcomes Patients Transfused FY 1994 – FY 2010 Patients Transfused 3000 2843 2684 2422 2500 2468 2263 1998 2000 1846 1550 1737 1608 1534 1500 1000 500 0 FY 93/94 FY95/96 FY97/98 FY99/00 FY01/02 FY03/04 FY05/06 FY07/08 FY09/10 Transfuse Volume Transfusion Volume 2006-2010 9000 8069 8000 7000 5924 6000 5000 4027 4000 3458 3389 3040 3000 2063 2000 1464 922 1000 844 958 575 839 830 397 712 1018 452 759 0 2006 2007 Red Cell Products 2008 Plasma Platelet Red Cells Plasma Platelets Cryo 2009 Cryoprecipitate 58 % reduction 67% reduction 49% reduction 16% reduction 2010 775 Blood Acquisition Cost Savings – All Components • Total blood acquisition costs in FY „06 were $3,200,000 • Cost savings compared to base year, FY ‟06* – – – – – FY ‟07 FY ‟08 FY ‟09 FY ‟10 Total $ 850,000 $ 1,400,000 $ 1,600,000 $ 1,550,000 $ 5,400,000 * No change in per unit cost from blood supplier from 2007 - 2010 Challenges and Lessons Learned • Providers must believe the data • Providers must be involved in selecting correct measures • Education, Education, Education • Vendor collaboration is critically important in developing safe, higher quality, efficient functionality. • Don‟t underestimate the internal resources needed in development