2 Jan/Feb 2007: Blood Management performance goals-identify, develop and test a set of standardized measures to help assess blood management in the hospital setting.April 2008-TAP identified 19 measures-call for public comment.Dec 2008-TAP recommends 12 of the 19 measures be testedSept-Alpha TestingDec 2009-Alpha review, recommends 7 measures move forwardFeb-Aug 2010 draft set of PBM tested at hos across the countryDec 2010 Submitted to National Quality Forum
3 PBM-NQFAlthough not endorsed for use at the national level by NQF at present, these measures are an excellent tool for healthcare organizations to evaluate the transfusion consent process, blood utilization, blood administration documentation and identify processes related to elective surgery that may decrease the need for blood and improve patient safety.
4 PBM-01 Transfusion Consent Patients with a signed consent who received information about the risks, benefits and alternatives prior to the initial blood transfusion or the initial transfusion was deemed a medical emergency
5 Transfusion Consent Rationale PBM-01 The rate of transfusion consent in US is unknownStudies in other countries show that there is poor documentation and room for improvementInvolving patients in healthcare decisions is a national priority
6 Feedback on PBM-01Hospitals support this measure because information about transfusion is not consistently given to patientsInformation is provided by a variety of staffStaff need education about the risks, benefits and alternativesInformed consent for blood transfusions is not required by all statesConsent process varies between hospitals
7 PBM-02 RBC Transfusion Indication RBC units transfused with pre-transfusion hemoglobin or hematocrit result and clinical indication documented.
8 RBC Transfusion Indication Rationale PBM-02 Information about total blood use could be used to determine benchmarks by diagnoses or procedurePromotes a standardized process ofChecking a lab result prior to each transfusionDocumentation of a reason why blood was transfusedRBC data elements include: Clinical indication for RBC’s, pre-transfusion H/H result, RBC ID
9 Feedback on PBM-02Hospitals have different “acceptable” pre-transfusion lab valuesDifficult to identify transfusions during surgeryPoint of care testing not used in all hospitals during surgery
10 Feedback on PBM-02, con’tDifficult to determine if documentation of clinical indication was sufficientNo standardized definition used for “bleeding”Lack of national guidelines such as pre-transfusion lab results not being required prior to transfusion.
11 PBM-03 Plasma Transfusion Indication Plasma units with pre-transfusion laboratory testing and clinical indication documented.
12 Plasma Transfusion Indication Rationale PBM-03 No standardized method for hospitals to determine which patients should receive plasmaPromotes a standardized process of:Checking a lab result prior to transfusionDocumentation of a reason why plasma was transfused
13 Feedback on PBM-03Reasons for giving plasma are unclear and conflicting at timesAn INR >2 and “bleeding” should be the only clinical indication
14 PBM-04 Platelet Transfusion Indication Platelet doses transfused with pre-transfusion platelet testing and clinical indication documented.
15 Platelet Transfusion Indication Rationale PBM-04 There is no standardized method for hospitals to determine which patients receive plateletsTransfusion of platelets associated with adverse eventsPromote a standardized process ofChecking a lab result prior to transfusionDocumentation of a reason why platelets were transfused
16 Feedback on PBM-04There is concern that establishing a critical value would trigger increased platelet useHospitals are unclear about:Whether platelets are indicated when patients on PlavixThe definition of ‘thrombocytopenia’
17 PBM-05 Blood Administration Documentation Transfusions of blood units with documentation for all of the following:Patient identification, transfusion order and blood ID number confirmed prior to the initiation of transfusion.Date and time of transfusion.Blood pressure, pulse and temperature recorded pre, during and post transfusion.
18 Blood Administration Documentation Rationale PBM-05 Transfusion process is very complex and has been identified as a high-risk area for errorStandardizing the process will enable reliable tracking of potential adverse events nationallyNumerous errors are associated with incorrect patient IDAdministration data elementsPatient ID verification, Tx order, Tx start date, Tx start time, Vital sign monitoring, Blood ID number
19 Feedback on PBM-05Some data elements are difficult to collect when blood products are transfused during surgeryThe data element criteria are standards of care and already being collected“Transfusion orders” are usually not required during surgery.
20 PBM-06 Preoperative Anemia Screening Patients have documentation of preoperative anemia screening days before Anesthesia Start Date
21 Preoperative Anemia Screening Rationale PBM-06 Preoperative anemia is associated with increased morbidity and mortalityNational audit found that 35% of patients scheduled for joint replacement therapy had a hgb <13 at preadmission testing.Formal protocols for early detection, eval and management of high-blood loss surgeries has been identified as an unmet need.1. And question remains if anemic patients should have surgery if not emergent.
22 Feedback on PBM-06 Information is not done or not available One barrier is who will manage care prior to surgeryInformation about when the patient was scheduled for surgery was not always in the medical recordConsider adding another measure to evaluate if anemia screening was effectiveIs the result on the patients clinic chart from pre-op dr. visit, or was preop testing done in house? 4. If preop screening was done, did anyone follow-up on the results?
23 PBM-07 Preoperative Blood Type and Antibody Testing Patients with documentation of preoperative type and screen or type and crossmatch completed prior to Anesthesia Start Time.
24 Preoperative Blood Type & Screening Rationale PBM-07 This measure is supported by TJC National Patient Safety GoalsPatient safety is a national priorityThis issue affects the majority of hospitals and other high-blood use procedures
25 Feedback on PBM-07 This is a patient safety issue Hospitals should document whether blood is available on pre-procedure checklistSome hospitals would like to see this measure be required and completed sooner than anesthesia start timeType and Screening NOT completed prior to surgery happens frequently2. There is no requirement that surgery can’t start until the pre-procedure list is complete
26 Next Steps for PBM Measures Encourage use of the PBM measures at the local levelHHS is organizing further data collection effortsThe seven blood measures have been added to the measure reserve library. They can be used as non-core measures until they are called upon for national use. Historically, this occurs in alignment with CMSFunding pending for retooling the specifications for retrieval in electronic medical recordHow are we going to proceed with use at local level, how to track some of this data? AIM is one way to begin to monitor and track blood usage, there is a module 11 that is capable of “talking” to electronic medical records and pulling some of this data from patient charts. Must be using AIM module 1 first however.
27 Appropriate Inventory Management AIM Module I 19 blood centers have completely implemented (~400 hospitals participating)AIM Module I version 1.1-Hospital ADLAllows the participating hospitals to provide electronic files to automate their Module I data input11hospitals participating using ADLModule 1 pulls from HCLL and Mediware is providing the script free on their website.Currently Module 1 automated data uploads are available for Mediware, LifeServe Cerner Millennium, Sunquest in process17
28 AIM-Module 1Create a community approach to blood management to ensure patient transfusion needs are metDetermine how many days worth of inventory are needed based on many criteriaBenchmark and trend community inventories against hospital usages using a national databaseThis is the module that you are all familiar with-some of you are starting to use it for tracking transfused and wasted units as well as inventory.Criteria used for determining how many days worth of inventory are needed: annualized patient transfusion needs, hospital size, clinical services offered, distance from blood provider, storage capacities, blood product needs for disaster planning.
29 Transparency Provides Trust – A Partnership AIM allows for a very special partnership. Here is a snapshot of the MVRBC. It is the opening page on the hospitals login. With data collected it allows the Blood Center to be able to collect and project what is needed to meet your hospital needs. By tracking the inventory, the wastage and the % transfused. Allows us to continue to be proactive with your needs and inventory.
30 Inventory at hospital has safety and financial impact: Does hospital maintain an adequate blood inventory to meet hospital/patient needs?Does transfusion service maintain appropriate inventory to manage financial impact?Ideal Inventory is the PAR Levels we have established for your hospitals based on use and pt populationIssuable is what is on the shelf that morning before the order is placedOne day is an aver. that has been distributed daily over 6 months. Recalculated each month.Days Worth is the issuable divided by One day
31 You are capable of picking how you want to benchmark ex You are capable of picking how you want to benchmark ex. size, usage, service line etc… Usage Very High is transfusion at 4001 and greater
32 Leukoreduced Red Cells : Detailed Graphical Display Hospital name: DePaul Health Center Graph type: Days Worth of Inventory Blood group: All Blood GroupsCluster: All selected categories - RBC Usage - Very HighCluster count: 10Hospital AverageCluster AverageStandard DeviationHospital DaysCluster DaysJul 20104.687.112.8446.92Aug 20102.827.13Sep 20102.487.12Oct 20102.1857.39Nov 20102.647.35Dec 20102.9667.84Jan 20112.957.2Feb 20113.857.37Benchmarking DePaul their inventory is aver 4 1/2days to other very high users at 7 days. Again savings inventory not sitting on your shelf. Allowing fresher units to come into the inventory.
33 Hospital name: DePaul Health Center Graph type: Wastage as a Percentage of Distributed Blood group: All Blood GroupsCluster: All selected categories - RBC Usage - Very HighCluster count: 23Hospital PercentageCluster PercentageHospital AverageCluster AverageStandard DeviationJul 20101.10.450.341.46Aug 20100.371.71Sep 20100.310.99Oct 20100.230.321.23Nov 20100.411.01Dec 20100.520.572.32Jan 20110.240.82Feb 20110.160.58You are able to look at wastage in 2 ways. First you can get an overview and see if there is a particular month with high wastage, and it can be viewed by a bar graph explaining the wastage.
34 Leukoreduced Red Cells : Detailed Graphical Display Hospital name: DePaul Health Center Graph type: Wastage as a Percentage of Distributed Blood group: All Blood GroupsCluster: All selected categories - RBC Usage - Very HighCluster count: 23Improper CommunicationImproper HandlingBreakage/Bag IntegrityPatient Not ReadyCancelled OrderPatient ExpiredEquipment FailureOutdatedFailed Visual InspectionJul 20100.270.55Aug 2010Sep 2010Oct 20100.23Nov 20100.20Dec 20100.52Jan 2011Feb 2011Average0.020.170.030.06Cluster0.010.050.000.26As you can see there is no wastage due to Outdated product. But you can see where there is need for improvement on handling. This can also be tracked by service line. Use this for Process improvement, education tool on handling of product outside of the blood bank. You can show this data of other like hospitals to staff.
35 Leukoreduced Red Cells : Detailed Graphical Display Hospital name: DePaul Health Center Graph type: Inventory Age at Receipt Blood group: All Blood GroupsCluster: All selected categories - RBC Usage - Very HighCluster count: 23This hospital’s age of red cells is fresher due to the lesser days worth of inventory. Direct correlation between days of inventory, wastages, and age of products.
36 Leukoreduced Red Cells : Detailed Graphical Display Hospital name: DePaul Health Center Graph type: Transfusions as a Percentage of Received Blood group: All Blood GroupsCluster: All selected categories - RBC Usage - Very HighCluster count: 8Hospital PercentageCluster PercentageHospital AverageCluster AverageStandard DeviationJul 201089.3289.2294.8491.4133.97Aug 201093.1682.3716.88Sep 201096.599.146.86Oct 201092.3495.457.9Nov 201096.3190.788.42Dec 201090.6588.3811.86Jan 201193.3590.887.27Feb 2011107.0997.718.41Also can benchmark % distributed to % transfused. As you can see DePaul average is at 95% and the cluster is at 91.4% Having the right product there at the right time to meet pt needs with fresher products and also controlling cost.
37 AIM Hospital Community Potential to have thousands of hospitals of all sizes and services providing data to a true national data base accessible to all participating hospitalsUser group of hospital transfusion committee members discussing findings and seeking best practicesAIM uses the established blood utilization review mechanism without the need for additional staff38
38 SummaryThe PBM measures are general measures that collect data on all patients that can be further analyzed by diagnoses and/or procedure code, age group or appropriateness as studies become availableThe abstraction burden for PBM measures using paper based records is labor intensive and would capture only a percentage of the transfusionsThe lack of national guidelines for blood impacts the ability to standardize clinical indications
39 SummaryAIM provides blood centers a tool to assist hospitals and physicians to better manage and use the available blood supply while:Lowering the risk of transfusion complicationsLowering the cost of blood, andMaintaining appropriate inventory levels to ensure patient transfusion support39
40 ResourcesExpectations From The Joint Commission, Jennifer Rhamy MBA, MA, MTTT(ASCP), HP Executive DirectorPatient Blood Management Performance Measure Project, Harriet Gammon, MSN, RN, CPHQAIM (Appropriate Inventory Management), Kellie Kerr, America’s Blood Centers, Carrie Hantack, MVRBC