The Role of the Transfusion The Role of the Transfusion Committee in a Transfusion Committee in a Transfusion Excellence Program:Excellence Program:

Can Transfusion Practice Be Can Transfusion Practice Be Altered?Altered?

Susan D. Roseff, M.D.Transfusion MedicineVirginia Commonwealth University

Transfusion CommitteeTransfusion Committee

Purpose Purpose -- Regulatory compliance and Regulatory compliance and quality operationquality operation

•• Transfusion policiesTransfusion policies•• Transfusion guidelinesTransfusion guidelines•• Monitor practice/Peer reviewMonitor practice/Peer review•• Blood availabilityBlood availability•• Blood safetyBlood safety

Transfusion CommitteeTransfusion Committee

Composition:Composition:•• Transfusion MedicineTransfusion Medicine•• Clinicians:Clinicians:

•• SurgerySurgery•• AnesthesiaAnesthesia•• Hematology/oncologyHematology/oncology

•• Hospital Administration: (Need support)Hospital Administration: (Need support)•• Safety/ Risk ManagementSafety/ Risk Management•• Performance Improvement Performance Improvement

Formulating transfusion guidelinesFormulating transfusion guidelines

•• Set numeric criteria, “triggers,” for initial Set numeric criteria, “triggers,” for initial review, below which easy to justifyreview, below which easy to justify•• Not “indications” for transfusionNot “indications” for transfusion

•• Use evidenceUse evidence--based data where availablebased data where available•• Use consensus from expert panelsUse consensus from expert panels•• Have a mechanism to look at exceptions Have a mechanism to look at exceptions

and specific clinical situationsand specific clinical situationsTry to apply objective measures and develop consistent policiesTry to apply objective measures and develop consistent policies

Monitor practice/ peer reviewMonitor practice/ peer review

Regulatory requirements:Regulatory requirements:•• Joint Commission on the Accreditation of Joint Commission on the Accreditation of

Healthcare OrganizationsHealthcare OrganizationsQuality requirements:Quality requirements:•• American Association of Blood BanksAmerican Association of Blood Banks•• College of American PathologistsCollege of American Pathologists

Monitor practice/ peer reviewMonitor practice/ peer review

•• Review mechanism using institutional Review mechanism using institutional guidelinesguidelines

•• Feedback to physician as a means to Feedback to physician as a means to educate and affect practiceeducate and affect practice

•• Monitor physician practiceMonitor physician practice

Does this ultimately alter behavior and Does this ultimately alter behavior and practice?practice?

Why try to alter practice?Why try to alter practice?

Blood as a resource:Blood as a resource:•• Decreasing donor pool Decreasing donor pool

•• Demographics of donor populationsDemographics of donor populations•• Donor testing/ product testingDonor testing/ product testing•• Regulatory requirementsRegulatory requirements

•• Increasing needIncreasing need•• Aging populationAging population•• New therapiesNew therapies

•• CostCost

Collections and Supply

o

oo

o1986

11.1

10.0

13.6

12.0

?

Without 9/11?O

1980

Courtesy of Kathleen Sazama, MD, JD

Why try to alter practice?Why try to alter practice?

Safety:Safety:• JCAHO – National Patient Safety Goals and

Standards•• Infectious disease risksInfectious disease risks

•• Current risks; Current risks; vCJDvCJD, , ChagasChagas diseasedisease•• Emerging infectionsEmerging infections

•• Immunologic risks Immunologic risks –– not just not just RBCsRBCs•• Inflammatory mediators during cardiac surgery Inflammatory mediators during cardiac surgery •• Immune modulationImmune modulation•• More isn’t always betterMore isn’t always better

Outcomes related studiesOutcomes related studies

By using and applying strict criteria, blood By using and applying strict criteria, blood use can be reduced without compromising use can be reduced without compromising patient carepatient care

Attempts to reduce exposureAttempts to reduce exposure

•• AutologousAutologous programs, including salvageprograms, including salvage•• Restrictive transfusion guidelinesRestrictive transfusion guidelines•• Pharmacologic alternativesPharmacologic alternatives•• Reducing iatrogenic blood loss (especially Reducing iatrogenic blood loss (especially

in neonatal/pediatric patients) in neonatal/pediatric patients) •• Transfusion reduction programs/ bloodless Transfusion reduction programs/ bloodless

surgery programssurgery programs

Methods to alter practiceMethods to alter practice

•• How do physicians make decisions about How do physicians make decisions about transfusion?transfusion?

•• What influences a physician’s decision to What influences a physician’s decision to transfuse?transfuse?

Keys to changing physician practiceKeys to changing physician practice

•• Venue of intervention: one on oneVenue of intervention: one on one•• Changes that are simple, safe and similar Changes that are simple, safe and similar

to current practice are easyto current practice are easy•• Changes that decrease physician Changes that decrease physician

autonomy, reduce income, challenge autonomy, reduce income, challenge judgment, or perceived to compromise judgment, or perceived to compromise patient care are difficultpatient care are difficult

EisenstaedtEisenstaedt RS. RS. TransfTransf Med Rev 1997;11:27.Med Rev 1997;11:27.

Methods to alter practiceMethods to alter practice

•• EducationEducation•• One on oneOne on one•• GroupGroup•• WrittenWritten

•• Administrative interventionsAdministrative interventions•• FormsForms•• GatekeepersGatekeepers•• ComputersComputers

•• Combinations of the aboveCombinations of the above

AssessAssess

Influence of clinical knowledge, Influence of clinical knowledge, organizational content, and practice style organizational content, and practice style on transfusion decision makingon transfusion decision making

SalemSalem--Schatz, et al. JAMA 1990;264:476.Schatz, et al. JAMA 1990;264:476.•• Survey sent to assess MDs knowledge Survey sent to assess MDs knowledge

about risks and indications for RBC about risks and indications for RBC transfusion before studytransfusion before study

•• Learn how physicians make decisions to Learn how physicians make decisions to design an interventiondesign an intervention

Assess Assess –– SalemSalem--Schatz, et al.Schatz, et al.

•• AttendingsAttendings were influenced by colleagues were influenced by colleagues input input –– 10% gave unnecessary 10% gave unnecessary transfusion once a monthtransfusion once a month

•• Residents Residents –– 68% said their practice 68% said their practice varied, based on their attendingvaried, based on their attending•• 77% changed their decision once a month77% changed their decision once a month

•• Those withThose with least knowledge had the most least knowledge had the most confidenceconfidence

Assess Assess –– SalemSalem--Schatz, et al.Schatz, et al.

Conclusions:Conclusions:•• Gaps in knowledgeGaps in knowledge

•• Older MD with lower scores may not have Older MD with lower scores may not have allowed new information to influence allowed new information to influence established practice established practice

•• More concern about risks of withholding More concern about risks of withholding transfusion than risks of transfusiontransfusion than risks of transfusion

•• Pressure for residents greater influence Pressure for residents greater influence than their knowledge of the facts than their knowledge of the facts -- teach teach attendingsattendings!!

EducationEducation

A controlled trial of educational outreach to A controlled trial of educational outreach to improve blood transfusion practiceimprove blood transfusion practice

SoumeraiSoumerai, et al. JAMA 1993;270:961., et al. JAMA 1993;270:961.

“Brief, focused educational outreach visits by “Brief, focused educational outreach visits by transfusion specialists can substantially improve transfusion specialists can substantially improve the appropriateness and costthe appropriateness and cost-- effectiveness of effectiveness of blood product use in surgery. More data are blood product use in surgery. More data are needed regarding the durability of changes in needed regarding the durability of changes in practice patterns and the health and economic practice patterns and the health and economic benefits of such interventions.”benefits of such interventions.”

Education Education -- SoumeraiSoumerai, et al., et al.

Methods:Methods:•• Randomized, controlled trialRandomized, controlled trial•• Changes in individual physician Changes in individual physician

compliance with blood transfusion compliance with blood transfusion guidelinesguidelines

•• Educational intervention Educational intervention –– face to face face to face medical “detailing”medical “detailing”

Education Education -- SoumeraiSoumerai, et al., et al.

Results:Results:•• Compliance with guidelines was better in Compliance with guidelines was better in

study hospitals (P=.03); nonstudy hospitals (P=.03); non--compliance compliance was lower in study hospitals (P=.006)was lower in study hospitals (P=.006)

•• 74% study physicians reduced the 74% study physicians reduced the proportion of nonproportion of non--compliant transfusions compliant transfusions versus 35% of nonversus 35% of non--study physiciansstudy physicians

•• Average preAverage pre--transfusion transfusion hcthct was was ↓↓ from from 28.3% to 26.3 % in study surgical group28.3% to 26.3 % in study surgical group

AdministrativeAdministrative

Improving blood transfusion practice: role of Improving blood transfusion practice: role of a computerized hospital information a computerized hospital information systemsystem

LePageLePage, EF, et al. Transfusion 1992;32:253., EF, et al. Transfusion 1992;32:253.

“These results demonstrated the efficacy of a “These results demonstrated the efficacy of a computerized hospital information system in computerized hospital information system in implementing continuous quality improvement implementing continuous quality improvement for transfusion practice.”for transfusion practice.”

Administrative Administrative -- LePageLePage

MethodsMethods•• Criteria for transfusion set by committee Criteria for transfusion set by committee

and programmed into computer databaseand programmed into computer database•• Blood ordered and list of reasons Blood ordered and list of reasons

displayed; if different from databasedisplayed; if different from database•• Message displayed; can use free text Message displayed; can use free text

overrideoverride•• Free text use is reviewed by committeeFree text use is reviewed by committee

Education and AdministrativeEducation and Administrative

The use of laboratory intervention to stem The use of laboratory intervention to stem the flow of freshthe flow of fresh--frozen plasmafrozen plasma

Solomon S, et al. AJCP 1988;89:518.Solomon S, et al. AJCP 1988;89:518.

““It was concluded that blood bankers can It was concluded that blood bankers can dramatically alter the use of this product dramatically alter the use of this product using established methods for modifying using established methods for modifying physician ordering behavior.”physician ordering behavior.”

Education/Admin Education/Admin -- SolomonSolomonInitially, 30 min presentation of NIH Initially, 30 min presentation of NIH

guidelines, all medicine and surgery guidelines, all medicine and surgery housestaffhousestaff monthlymonthly

•• Phase I: (3 months later) Phase I: (3 months later) --ordering formordering form•• Phase II: (4 months after Phase I)Phase II: (4 months after Phase I)

•• Must have abnormal coagulation resultsMust have abnormal coagulation results•• If normal or no If normal or no coagscoags, pathologist consulted, pathologist consulted

•• 52% 52% ↓↓ in FFP use (17% in FFP use (17% ↑↑ in RBC use)in RBC use)•• ↑↑ frequency of FFP use for patients frequency of FFP use for patients withwith

coagulation abnormalitiescoagulation abnormalities

Education and AdministrativeEducation and Administrative

Use of retrospective audit in 5 hospitals to Use of retrospective audit in 5 hospitals to observe changes in RBC use in 10 monthsobserve changes in RBC use in 10 months

•• Hospitals varied in size, teaching affiliation, Hospitals varied in size, teaching affiliation, case mix, ownership case mix, ownership –– all had retrospective all had retrospective peer audit systems, 3 tiers (review criteria, peer audit systems, 3 tiers (review criteria, chart review, peer review by committee)chart review, peer review by committee)

•• Decrease in 2 hospitals, but not significantDecrease in 2 hospitals, but not significantLam, et al. Arch Lam, et al. Arch PatholPathol Lab Med 1996;120:810.Lab Med 1996;120:810.

Education and AdministrativeEducation and Administrative

Problems with retrospective review:Problems with retrospective review:•• Untimely feedbackUntimely feedback•• Inaccurate identification of physicianInaccurate identification of physician•• Blood still transfused Blood still transfused –– don’t prevent don’t prevent

unnecessary transfusionsunnecessary transfusions

Education and AdministrativeEducation and Administrative

Prospective physician selfProspective physician self--audit transfusionaudit transfusion--monitoring systemmonitoring system

•• Transient Transient ↓↓ in number of units transfused in number of units transfused in study hospital, then returned to prein study hospital, then returned to pre--study levels in the 3study levels in the 3rdrd monthmonth

•• Hawthorne effect not audit systemHawthorne effect not audit system

Lam, et al. Transfusion 1997;37:577.Lam, et al. Transfusion 1997;37:577.

What do these studies show?What do these studies show?

Positive outcomesPositive outcomes•• Education can workEducation can work•• Administrative intervention can workAdministrative intervention can work•• The two in combination can work (audits The two in combination can work (audits

can equal education)can equal education)CaveatsCaveats•• Effort Effort –– education time/ resource intensiveeducation time/ resource intensive•• Duration of effectDuration of effect

See references: Toy; Davis, JAMA 1995

VCU Blood Utilization CommitteeVCU Blood Utilization Committee

Audit begins in blood bankAudit begins in blood bank•• Review of computer data against audit Review of computer data against audit

guidelinesguidelines•• Transfusion eventsTransfusion events•• Relevant laboratory valuesRelevant laboratory values

•• Of those that don’t meet criteria, cases Of those that don’t meet criteria, cases are set asideare set aside

•• ApheresisApheresis nurses review medical chart nurses review medical chart

VCU Blood Utilization CommitteeVCU Blood Utilization Committee

If nurses cannot justify the transfusion If nurses cannot justify the transfusion based on information in the chartbased on information in the chart

•• Chart brought to BUCChart brought to BUC•• Review by “peer” physician committee Review by “peer” physician committee

membermember

VCU Blood Utilization CommitteeVCU Blood Utilization Committee

•• Compliance Compliance Increased: 93.6% Increased: 93.6% (2003) (2003) --98.2% 98.2% (present)(present)

•• Quarterly Blood Quarterly Blood UsageUsage-- 1414--15K 15K (2003)(2003)-- 10.510.5--11K 11K (present)(present)

Courtesy of Bruce Spiess

““Blood transfusion is like Blood transfusion is like marriage; it should not be marriage; it should not be entered into lightly, entered into lightly, unadvisedly or wantonly, or unadvisedly or wantonly, or more often than is more often than is absolutely necessary.”absolutely necessary.”

Beal (1976) Aust NZJ Surg, Beal (1976) Aust NZJ Surg, 46:30946:309--313313

Click Here to Return To Main Menu

Click Here to Return To Main Menu