Reports From the Field

Implementation of a Patient Blood Management Program in a Large, Diverse Multi-Hospital System

Journal of Clinical Outcomes Management. 2020 May;27(3):123-129 | 10.12788/jcom.0009

References

1. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: A clinical practice guideline from the AABB*. Ann Intern Med. 2012;157:49-58.

2. Goodnough LT, Levy JH, Murphy MF. Concepts of blood transfusion in adults. Lancet. 2013;381:1845-1854.

3. Hébert PC, Carson JL. Transfusion threshold of 7 g per deciliter—The new normal. N Engl J Med. 2014;371:1459-1461.

4. Gani F, Cerullo M, Ejaz A, et al. Implementation of a blood management program at a tertiary care hospital: Effect on transfusion practices and clinical outcomes among patients undergoing surgery. Ann Surg. 2019;269:1073-1079.

5. Podlasek SJ, Thakkar RN, Rotello LC, et al. Implementing a “why give 2 when 1 will do?” Choosing Wisely campaign. Transfusion. 2016;56:2164.

6. Boral LI, Bernard A, Hjorth T, et al. How do I implement a more restrictive transfusion trigger of hemoglobin level of 7 g/dL at my hospital? Transfusion. 2015;55:937-945.

7. Geissler RG, Kosters C, Franz D, et al. Utilization of blood components in trauma surgery: A single-center, retrospective analysis before and after the implementation of an educative PBM initiative. Transfuse Med Hemother. 2015;42:83-89.

8. Goel R, Cushing MM, Tobian AA. Pediatric patient blood management programs: Not just transfusing little adults. Transfus Med Rev. 2016;30:235-241.

9. Gupta PB, DeMario VM, Amin RM, et al. Patient blood management program improves blood use and clinical outcomes in orthopedic surgery. Anesthesiology. 2018;129;1082-1091.

10. Leahy MF, Roberts H, Mukhtar SA, et al. A pragmatic approach to embedding patient blood management in a tertiary hospital. Transfusion. 2014;54:1133-1145.

11. Leahy MF, Hofmann A, Towler S, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: A retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57:1347-1358.

12. Meybohm P, Herrmann E, Steinbicker AU, et al. Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome: A prospective, multicenter cohort study with a noninferiority design. Ann Surg. 2016;264:203-211.

13. Morgan PN, Coleman PL, Martinez-Garduno CM, et al. Implementation of a patient blood management program in an Australian private hospital orthopedic unit. J Blood Med. 2018;9;83-90.

14. Norgaard A, Stensballe J, de Lichtenberg TH, et al. Three-year follow-up of implementation of evidence-based transfusion practice in a tertiary hospital. Vox Sang. 2017;112:229-239.

15. Meuller MM, Van Remoortel H, Meybohm P, et al. Patient blood management: Recommendations from the 2018 Frankfurt Consensus Conference. JAMA. 2019;321:983-997.

16. Oliver JC, Griffin RL, Hannon T, Marques MB. The success of our patient blood management program depended on an institution-wide change in transfusion practices. Transfusion. 2014;54:2617-2624.

17. Thakkar RN, Lee KH, Ness PM, et al. Relative impact of a patient blood management program on utilization of all three major blood components. Transfusion. 2016;56:2212-2220.

18. Yang WW, Thakkar RN, Gehrie EA, et al. Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization. Transfusion. 2017;57:1163-1170.

19. Frank SM, Thakkar RN, Podlasek SJ, et al. Implementing a health system-wide patient blood management program with a clinical community approach. Anesthesiology. 2017;127;754-764.

20. Verdecchia NM, Wisniewski MK, Waters JH, et al. Changes in blood product utilization in a seven-hospital system after the implementation of a patient blood management program: A 9-year follow-up. Hematology. 2016;21:490-499.

21. Yazer MH, Waters JH. How do I implement a hospital-based blood management program? Transfusion. 2012;52:1640-1645.

22. BJC HealthCare. Facts and Figures.. BJC HealthCare website. www.bjc.org/About-Us/Facts-Figures. Accessed November 18, 2019.

23. Callum JL, Waters JH, Shaz BH, et al. The AABB recommendations for the Choosing Wisely campaign of the American Board of Internal Medicine. Transfusion. 2014;54:2344-2352.

Setting

BJC HealthCare is one of the largest nonprofit health care organizations in the United States, delivering services to the greater St. Louis, southern Illinois, and mid-Missouri regions, and addressing the health care needs of urban, suburban, and rural communities. As of 2018, the system included 15 hospitals and multiple community health locations comprising more than 3400 staffed beds, 31,500 employees, and 4300 physicians with privileges. The system annually has more than 151,000 hospital admissions, 81,000 outpatient surgery visits, and 537,000 emergency department visits. In addition to inpatient and outpatient care, services include primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long-term care, and hospice. As a nonprofit system, BJC is the largest provider of charity care, unreimbursed care, and community benefit in Missouri, highlighting the fact that resource stewardship is a critical issue across the entire system and the communities served.²²

PBM Project

Preparation for large-scale change across several hospitals began with creating a framework for the initiative, which consisted of a “burning platform,” a guiding vision, and a coalition. The burning platform identifies the importance and urgency of a change and helps to establish commitment. Between 2012 and 2014, the American Association of Blood Banks (AABB) released new evidence-based guidelines and recommendations calling for more restrictive transfusion practices pertaining to red blood cells (RBCs; ie, a hemoglobin threshold of 7 to 8 g/dL) in both inpatient and outpatient care.² In addition, use of single-unit transfusions was recognized as best practice by the AABB in the Choosing Wisely campaign.²³ Historically, adult patients requiring transfusions were given 2 units in succession. The new recommendations provided a strong basis for changing transfusion practices at BJC. It was believed that aligning transfusion practices with the new guidelines was consistent with the mission and vision of the work: that these changes could lead to optimization of resources, cost control, reductions in unnecessary blood transfusions, and potentially improved care (eg, fewer transfusion-related complications). We used the national guidelines to initiate discussions and to identify clinical conditions and associated laboratory parameters for transfusion therapy.

Once this burning platform was established, a team comprised of physicians, blood bank experts, quality consultants, data analysts, and supply managers, referred to as the Outcomes Team, was formed to lead the change efforts across the system. Initial projects for the team included developing system-wide consensus-based transfusion guidelines, providing education to providers on the new evidence in transfusion practice, and sharing BJC-specific historical utilization data. The guiding principle for the group was that “blood is a valuable resource, but not without risk, and less is more.” In order to disseminate the vision of the initiative across the system, campaign signs with the slogans “7 is the new 10” (referring to the g/dL transfusion threshold) and “1 is the new 2” (referring to the new practice of the preferential transfusion of single units rather than 2 at a time) were displayed in system hospitals.

Last, a guiding coalition of system leaders was needed to help push the initiative forward and sustain the program once fully implemented. Thus, a multidisciplinary PBM Clinical Expert Counciel (CEC) was formed to assist with implementation and maintenance of the program.

Role of PBM Clinical Expert Council

The PBM CEC was designed to improve overall physician and expert engagement and provide a forum where stakeholders from across the system could participate to voice their expert opinion. CECs (which BJC formed in other clinical areas as well) are multidisciplinary teams consisting of clinical, administrative, and technical staff. The open, multidisciplinary structure of the councils allows for collaboration that promotes change across a complex multi-hospital system. Each hospital is represented by key physicians and technical leaders, opening opportunity for both horizontal and vertical partnership.

As part of the overall physician engagement strategy, the PBM CEC was launched across BJC in November 2013 as a decision-making body for gaining system consensus on matters relating to blood management. The initial goals for the PBM CEC were to share information and educate providers and others on the latest evidence, to subsequently debate and develop consensus for guidelines to be applied across BJC, and to identify and adopt gold standard practices to drive and sustain compliance across the system. More specifically, we wanted to focus on how to avoid unnecessary blood transfusions known to be associated with increased risk for adverse reactions, other morbidity, mortality, and longer length of stay. Council members met quarterly to address 6 key drivers: patient safety, informatics and data, quality improvement, efficiencies and workflows, education and competency, and communication and engagement. Members then voted to approve guidelines, policies, and procedures. The group continues to assist in updating and standardizing guidelines and providing input on improving the functionality of the PBM reporting tool.

Development of the PBM Reporting Tool

Providing and sharing data on blood utilization and practices with the CEC and hospital leaders was imperative to driving change. The Outcomes Team deliberated on how best to generate and provide such information, conducting comparisons between selected vendor-based tools and potential internal BJC solutions. After investigation, BJC leadership approved the development of an in-house PBM dashboard tool using Tableau Desktop (Tableau Software, Inc.). The tool consists of an executive page with 5 additional tabs for navigating to the appropriate information (Figure 1 and Figure 2); data within the tool are organized by facility, service, provider, ICD diagnosis, transfusion indication, and the Clinical Classifications Software category, as defined by the Agency for Healthcare Research and Quality.

The PBM reporting tool was launched on December 31, 2014. The next priority after the launch was to validate the tool’s blood utilization data and implement enhancements to make the tool more effective for users. A super-user group consisting of blood bank supervisors and managers was established. The goals of the user group were to preview any enhancements before presenting the tool to the larger CEC, test and validate data once new information was added, and share and prioritize future enhancements. User group meetings were held monthly to share best practices and discuss individual facilities’ blood utilization data. In addition, each facility’s representative(s) shared how they were driving changes in provider practice and discussed challenges specific to their facility. Enhancements suggested through the user group included: incorporation of additional lab values into the tool to correspond with other blood products (eg, fibrinogen, hematocrit, international normalized ratio, and platelet count), addition of the specific location where the blood product was administered, and standard naming conventions of locations to allow comparisons across facilities (eg, Emergency Department instead of ED, ER, or EU).

All hospital users were given access to a test version of the reporting tool where they could review enhancements, identify what worked well and what could be done better, and suggest corrections. As changes were made to the hospital lab systems, a sample of data was reviewed and validated with affected facilities to confirm the continued accuracy of the data. To ensure its practicality to users, the tool continues to be improved upon with input from council stakeholders and subject-matter experts.