Maine hospi­tal slashes trans­fu­sions, re­duc­ing pa­tient risk, costs

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

In late 2006, Dr. Ir­win Gross ap­proached ad­min­is­tra­tors at East­ern Maine Med­i­cal Cen­ter with an idea to curb in­ap­pro­pri­ate blood trans­fu­sions, im­prove pa­tient out­comes and save money.

Like many hos­pi­tals, the 357-bed fa­cil­ity in Ban­gor trans­fused too much blood and did it too of­ten, said Gross, who then prac­ticed in an in­de­pen­dent pathol­ogy group and served as med­i­cal di­rec­tor of the hospi­tal’s blood bank. Trans­fu­sion thresh­olds var­ied widely and more ed­u­ca­tion was needed to in­form physi­cians about ev­i­dence­based prac­tices and the risks tied to trans­fus­ing blood.

“This was a rare op­por­tu­nity to achieve bet­ter care and re­duce costs at the same time,” Gross said.

Hos­pi­tals have taken a closer look at their blood man­age­ment pro­to­cols over the past decade as re­search in­di­cates trans­fu­sions in many cases do more harm than good. Pa­tients face se­ri­ous risks, in­clud­ing trans­fu­sion-re­lated acute lung in­jury, re­s­pi­ra­tory dis­tress fol­low­ing trans­fu­sion and sup­pressed im­mu­nity, said Dr. Jef­frey Ro­hde, an as­sis­tant pro­fes­sor of in­ter­nal medicine at the Univer­sity of Michi­gan, Ann Ar­bor.

Ro­hde was the lead au­thor of a JAMA ar­ti­cle pub­lished in April that found pa­tients who re­ceived more red blood cell trans­fu­sions were more likely to de­velop health­care-as­so­ci­ated in­fec­tions than pa­tients who re­ceived fewer trans­fu­sions.

Pro­fes­sional or­ga­ni­za­tions have set sug­gested guide­lines for he­moglobin lev­els, the main met­ric used to de­ter­mine when trans­fu­sion is ap­pro­pri­ate. But hos­pi­tals’ and physi­cians’ ac­cep­tance of those thresh­olds is of­ten in­con­sis­tent, Ro­hde said.

Trans­fu­sions also have been tar­geted by the Choos­ing Wisely cam­paign, an ef­fort spear­headed by the ABIM Foun­da­tion to pre­vent un­nec­es­sary tests and pro­ce­dures. A num­ber of par­tic­i­pat­ing pro­fes­sional so­ci­eties, in­clud­ing the Amer­i­can As­so­ci­a­tion of Blood Banks and the So­ci­ety of Hospi­tal Medicine, have rec­om­mended “ad­her­ing to a re­stric­tive trans­fu­sion strat­egy.”

The most ef­fec­tive way to re­duce trans­fu­sions is through a pa­tient blood man­age­ment pro­gram, said Dr. Sally Camp­bell-Lee, med­i­cal di­rec­tor of trans­fu­sion medicine at the Univer­sity of Illi­nois Hospi­tal in Chicago and a mem­ber of HHS’ Ad­vi­sory Com­mit­tee on Blood and Tis­sue Safety and Avail­abil­ity.

That’s the ap­proach Gross out­lined for East­ern Maine ad­min­is­tra­tors in 2006: The hospi­tal would launch a ro­bust blood man­age­ment pro­gram and he would take the job as head of the pro­gram. The hospi­tal’s lead­ers gave the nod and the pro­gram started in 2007.

East­ern Maine’s pro­gram uses mul­ti­ple levers to en­cour­age ap­pro­pri­ate use of trans­fu­sion, in­clud­ing on­go­ing physi­cian ed­u­ca­tion and alerts em­bed­ded in the com­put­er­ized physi­cian-or­der en­try sys­tem. For in­stance, if a physi­cian or­ders a unit of blood for a pa­tient whose he­moglobin lev­els are out­side the hospi­tal’s usual thresh­olds, an alert is trig­gered. The CPOE sys­tem also made it more dif­fi­cult for physi­cians to or­der more than one unit of blood at a time, a com­mon prac­tice that Gross says con­trib­utes greatly to overuse.

“CPOE alone won’t change prac­tice, but it’s a tool that can re­in­force and hard­wire the prin­ci­ples of blood man- age­ment,” he said.

Gross and his team also cre­ated a trans­fu­sion re­port card so physi­cians can see how they com­pared to their col­leagues, a step that helped drive down un­needed clin­i­cal vari­a­tion.

In the years since the pro­gram be­gan, the num­ber of red blood cell trans­fu­sions at East­ern Maine plum­meted nearly 60%. Use of platelets and plasma fell 50% and 75%, re­spec­tively. And those re­duc­tions came with no sig­nif­i­cant change in clin­i­cal ser­vices, Gross said.

The per­cent­age of pre­ferred sin­gle­u­nit or­ders grew from 55% to al­most 90%, and the hospi­tal’s tar­get he­moglobin level for trans­fu­sion fell from 8.5 to 7.8. The hospi­tal also has seen im­prove­ments in lengths of stay that Gross says are at­trib­ut­able to the pro­gram.

On the fi­nan­cial side, blood ac­qui­si­tion costs have fallen by $1.6 mil­lion an­nu­ally. For car­diac surgery alone, costs per case have dropped 10%.

Dr. Mark Brown, chief of pe­di­atrics and head of new­born medicine at East­ern Maine, said the blood man­age­ment pro­gram has had a trans­for­ma­tive ef­fect on blood us­age and pa­tient out­comes. He is work­ing with Gross to de­velop a ver­sion for the neona­tal in­ten­sive-care unit. “I’m con­stantly sur­prised that more hos­pi­tals aren’t do­ing this,” Gross said. “It ful­fills all three cor­ners of the Triple Aim tri­an­gle.”

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