Improved blood management system reduces waste, costsSep. 8, 2016, 8:56 AM
Thirty percent less blood was transfused and more than $2 million was saved over a three-year period through changes in how blood is ordered, transported and stored at Vanderbilt University Medical Center (VUMC).
These improvements were due to the efforts of a team of Vanderbilt clinicians tasked with developing and implementing initiatives to improve the institution’s blood management practices.
“The Transfusion Committee at Vanderbilt wanted to see how the group could implement evidence-based guidelines around restrictive transfusion,” said lead study author Barbara Martin, MBA, R.N. “The guidelines were developed based on current best-practice recommendations and first implemented in 2011-2012, initially in the intensive care units, the Emergency Department and then institution-wide. We were pleased to see such significant results, which mean a much more efficient, cost-effective use of blood.”
The first step the team took to improve blood transfusion practices was to bring together a multidisciplinary group, including representatives from every step required for blood transfusion, from blood ordering to its administration, to help identify problem areas and gather ideas for possible improvement.
One early change, revision of the Computerized Provider Order Entry (CPOE), encouraged the ordering of a single unit of blood for patients who were anemic. Study authors noted it is common practice at many hospitals to reflexively order two units of blood for those patients, but the patients often require only a single unit. In addition, evidence has shown that blood transfusions increase the risk of complications — including transfusion reaction, infection, volume overload, increased length of stay and even death — associated directly and indirectly with the transfusion.
“The data on restrictive transfusion has been out for years documenting that patients have better outcomes with a more restrictive transfusion strategy,” said Martin. “We were looking at whether we could guide providers to treat symptomatic anemia with a single unit of blood rather than the usual two units.”
By revising the CPOE to allow blood orders based on specific assessment of each case, VUMC was able to reduce red blood cell transfusions by more than 30 percent — from 675 units per 1,000 patient discharges in 2011 to 432 units per 1,000 patient discharges in 2015.
To evaluate the impact of the restrictive transfusion recommendations on patients who were not necessarily transfused for anemia, study authors reviewed patients in VUMC’s National Surgical Quality Improvement Program (NSQIP) database. The NSQIP captures a sample of general and vascular surgery patients, many of whom are transfused for acute blood loss rather than for anemia. The patients in the VUMC database benefited from the restrictive approach; between 5 and 6 percent were transfused with an average of 2.4 units of blood per patient in 2015, compared with 11 percent transfused with an average of 4.6 units of blood per patient in 2011.
In addition to addressing blood utilization, the Vanderbilt team also came up with strategies to reduce blood waste.
To reduce inefficiencies in the ordering, transport and storage of blood, the team developed guidelines for perioperative handling that include:
• When more than one unit of blood is ordered, it is transported in a cooler rather than a pneumatic tube.
• Coolers used to transport the blood were reconfigured to improve temperature management.
• A specific staff member is tasked with “ownership” of the blood products, including returning unused product to the blood bank.
• Individual unit wastage is reported to clinical leaders for review; aggregate data are reported monthly.
The improvements in blood use at VUMC resulted in fewer than 80 units of blood being wasted in 2015, down from 300 units wasted in 2011. Martin said the guidelines the group developed could easily be implemented at other medical centers.
However, she noted, “You have to prioritize your initiatives. At Vanderbilt, we had a lot of opportunities with blood transfusion and blood wastage, and we made huge gains.”
“We were able to change the mindset of the entire institution, initially, and then determine that the improved usage with decreased wastage was beneficial to patient outcomes,” said study co-author Oscar Guillamondegui, M.D., associate professor of Surgery and Vanderbilt’s NSQIP Surgeon Champion.
“This is a huge success for the team, the institution and, most importantly, the patients.”
Martin said there are also broader implications for the way blood donations are viewed nationally.
“Blood is a limited resource, and we have a responsibility as a health care provider to optimize the use of a resource that is difficult to get and only available through altruistic donations,” she said. “In addition, by showing we are using blood more effectively, we can reassure donors that their blood is being used as sensibly and appropriately as possible.”
Martin said that the efforts at VUMC to optimize blood use were possible because of the multidisciplinary team approach. Involved in the project were administrative leadership, executive leadership, nursing staff, physicians and house staff, among others.
Other study authors are Marcella Woods, Ph.D.; Pampee Young, M.D., Ph.D.; Garrett S. Booth, M.D., MS; and Gina Whitney, M.D. The group presented their achievements at the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).
The American College of Surgeons is a scientific and educational organization of surgeons, and is the largest organization of surgeons in the world.