Yes, You Can Save Money By Reducing Blood Costs

1
Yes, You Can Save Money By Reducing Blood Costs!
Supply Chain Performance Improvement
Presented by Priscilla R. Cherry, MBA,
MT(ASCP) Director, Laboratory Consulting Dennis
G. Sumwalt, MT(ASCP), CLDir Managing
Principal Supply Chain Performance Improvement
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Yes, You Can Save Money By Reducing Blood Costs!

• Agenda
• Introduction
• Blood Supply Demand
• Blood Costs
• Transfusion Safety
• Minimizing Transfusions
• Surgical Conservation
• Preoperative
• Intraoperative
• Postoperative
• Breakthrough Series 2007

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Yes, You Can Save Money By Reducing Blood Costs!

• Do healthcare organizations need to be concerned
  about blood product use?

4
Introduction

• Blood is a precious resource
• Two edge tool
• Life saving
• Life threatening
• Rational use
• Mantra right product at the right dose at the
  right time for the right reasons
• Ultimate goal
• Greater economy
• Greater effectiveness
• Greater safety

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Blood Conservation Management

• What
• Evidence based practice for minimizing
  transfusion needs
• Why
• Efficient allocation of scarce resources
• Prevention of transfusion related illness
• How
• Alterations in transfusion protocol
• Use of transfusion alternatives

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Blood Supply Demand

• Suitable Donors
• Testing Complexity
• Recruitment Expense

Cost

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Blood Supply Demand

• Adequacy of RBC supply depends on margin between
  collections and transfusion
• RBC transfusions increased 11.5 from 1994 to
  1999
• Primary factors
• Aging population
• Increased oncologic transplantation demands
• Trend likely to continue

Source Transfusion.2005 Feb 45(2) 141-8.
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Blood Supply Demand

• Local Observations
• Demand for blood increasing
• Increasing surgical and medical therapeutic
  options
• Greater transplantation oncologic needs
• Aging population
• More access to complex medical and surgical
  therapies
• More resources consumed at end of life
• Blood demands
• National increase of 27 (1994 2001)
• Annual increase of 6 projected

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Blood Supply Demand

• Only 5 of eligible donors participate
• Donor restrictions increasing
• Travel (malaria, vCJD)
• Medications (Proscar)
• Emerging pathogens (SARS, West Nile Virus)
• Less support for blood drives
• Supply will not rise to meet continued increases
  in demand

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Blood Supply Demand

• Costs The Future
• Cost of blood rose 37 in 2004
• Future increases are coming
• When blood hits 500, mark my words, every CEO
  in the country is going to say he can reduce
  utilization of blood products.
• Bruce Speiss, Virginia Commonwealth University

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Blood Costs

• Procurement costs continue to rise
• 170 - 280 per unit is national range
• 70 of patients transfused have Medicare or
  Medicaid or are uninsured
• Reimbursement lags behind actual cost
• Because of capitation issues, economically it
  does matter if patient gets 2 versus 4 units.

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Administrative Costs

• Procurement cost is only 20 of total costs
• Regulatory, testing, equipment, nursing, clerical
• Administrative costs are variable
• If no transfusion, cost is not incurred
• 2.25 hours of nursing clerical time for each
  unit transfused

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Blood Donor Services

• American Red Cross
• Independent community blood banks
• Hospital donor services
• Frequently no competition in a community
• NBE for large users willing to work the spot
  market

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Negotiable Donor Service Costs

• Purchased versus consigned units
• STAT delivery charges
• Autologous collection charges
• Inventory levels and age of units
• Packed Red Blood Cells (PRBCs) are most common
  product
• Expensive products single donor platelets
• Expensive products coagulation factors

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Transfusion Safety

• Infectious
• Viral transmission
• HIV, Hepatitis B, Hepatitis C
• Bacteria
• Prions
• Non-Infectious Serious Hazards of Transfusion
  (NISHOT)
• Blood mistransfusion
• Undertransfusion
• Neonatal metabolic risk
• Transfusion related immunomodulation (TRIM)
• Transfusion related acute lung injury (TRALI)
• Transfusion associated cardiac overload (TACO)

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Transfusion Safety

• Focus on viral transmission
• Real hazards lie elsewhere
• Mistransfusion
• TRIM (allogenic)

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Risk Assessment

• HIV transmission
• 1 unit in 2 million
• Accidental deaths general USA population
• Motor vehicle 1 in 6,300
• Bicycle 1 in 330,000
• Commercial airline 1 in 1.5 million
• Lightning 1 in 4 million
• Dog bite 1 in 9 million

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Risk Assessment

• Patient sample collection
• 1 in 165 mislabeled
• 1 in 1,155 contain wrong blood in tube
• Decision to administer transfusion
• Lack of physician education
• Lack of accessible criteria
• Bedside administration
• Mistransfusion leading cause of transfusion death
• 1 in 12,000 units mistransfused (estimate)

British Study
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Transfusion Related Immunomodulation (TRIM)

• Single highest risk factor
• 1.4 3.5 fold increase in post-op infections
• Single best predictor of post-op infections
• Dose dependent
• Matters whether 1 or 4 units are transfused
• Associated with cancer recurrence

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Conservation Safety

• Safest transfusion
• One not given
• Methods to ensure safety of blood supply
• Do not focus on enhancement of viral detection
• Prevent transfusion from being given unless
  necessary

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How Can Transfusions Be Minimized?

• Education
• Institutional
• Guidelines
• Transfusion Triggers
• Maximum Surgical Blood Ordering Schedules (MSBOS)
• Review by Transfusion Practice Committee
• Interpersonal
• Formal
• Technology
• Drugs
• New techniques

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Where Do You Focus Your Energies?

• Emergency department
• Judgment in acute hemorrhage
• Difficult to evaluate or control practice
• Surgery
• Intensive care
• Random
• Most difficult to control
• Practioners who rarely transfuse

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Surgical Conservation

• Majority of blood use
• Surgery
• Oncology
• Cardiac surgery
• 20 of blood use (National statistic)
• Surgical conservation techniques require interest
  by the surgical team
• Anesthesia
• Perfusionist
• Surgeon

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Bloodless Medicine

• AABB Circular of Information
• Recommends that all physicians be familiar with
  the alternatives
• red cell containing components should not be
  used to treat anemia's that can be corrected with
  specific medications..
• Not a new concept
• Jehovah Witnesses
• Blood shortages
• Safe blood is unavailable
• Trauma
• Military field casualties
• Patients with multiple antibodies
• Patients with autoimmune hemolytic anemia

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Bloodless Medicine

• Philosophy
• Blood management
• Principles appropriate for all patients not just
  special situations
• Strategies
• Appropriate combination
• Drugs
• Technological devices
• Surgical medical techniques
• Interdisciplinary approach
• Individualized for each patient
• Goal
• Minimal transfusion in all patients

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Blood Conservation

• Surgery

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Surgery

• Preoperative Conservation
• Preoperative autologous donation
• EPO/Iron
• Restrict diagnostic phlebotomies
• Manage anticoagulation
• Avoid pharmacologic coagulopathies
• Surgical discretion

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Surgery

• Intraoperative Conservation
• Acute normovolemic hemodilution
• Cell salvage
• Electrocautery
• Ultrasonic energy
• Tissue dissectors
• Coagulation sealants
• Patient positioning
• Point of care testing

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Surgery / ICU

• Post-Operative
• Pharmacologic strategies
• Increasing endogenous RBC production
• Iron
• EPO
• Clinical strategies
• Reduced phlebotomies
• Judicious blood draws / smaller volumes drawn
• Acute normovolemic hemodilution (ANH)
• Return of blood post-surgery
• Restrictive transfusion for anemia of chronic
  disease

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Transfusion Surveillance

• Data collection
• Data evaluation
• Education / Corrective Action
• Leads to
• CONFLICT

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Case Study

• Orthopedic Surgery Service - Netherlands
• Algorithm for reduction of transfusions
• Predefined transfusion triggers
• Selective COX-2 inhibitors
• Preoperative EPO and iron
• Cell salvage
• Aprotinin
• Results
• 80 reduction in transfusion rates
• 40 reduction in deep wound infections

Slappendel et al. Acta Orthop Scand 2003 74(5)
569-575
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Transfusion Guidelines
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Maximum Surgical Blood Ordering Schedules (MSBOS)

• Guideline Goals
• Acknowledge patient specific variability while
  addressing physician and institution dependent
  variables
• Improve blood component management by developing
  more physiologic clinical indicators of the need
  for red blood cell transfusions
• To Be Effective
• Guidelines for surgical red cell transfusion must
  change physician behavior

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Transfusion Triggers

• Red Blood Cells (RBC)
• Examples of General Indications
• Varies with patient condition
• Acute loss of 15 of total blood volume
• Less than 9 g/dL with an expected loss of 500 mL
• Less than 8 g/dL in a patient on a chronic
  transfusion regimen
• Less than 7 g/dL in a critically ill patient
• Less than 10 g/dL in acute myocardial infarction
• Less than 10 g/dL in a patient with uremic
  bleeding

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Transfusion Triggers

• Platelets
• Examples of General Indications
• Microvascular bleeding due to thrombocytopenia or
  platelet dysfunction
• Less than 10,000/µl chemotherapy induced
  thrombocytopenia
• Less than 20,000/µl solid tumor chemotherapy
  patients
• Less than 50,000/µl surgical or invasive
  procedures patients

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Transfusion Triggers

• Fresh Frozen Plasma
• Examples
• Coagulation factor deficiency
• DIC
• Massive transfusions
• Liver disease
• PT and aPTT 1.5 times the mean reference range

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Coagulation Monitoring
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Coagulation Monitoring

• Improve blood product replacement therapy
• Operating rooms
• Cardiac surgery
• Hepatic transplantation
• Obstetrics
• Intensive cares
• Trauma centers
• Detect hypocoagulability
• Detect diffuse microvascular bleeding
• Identify appropriate patients for treatment

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Case Study
Transfused Product Cost 30 Patients before TEG
monitoring -VS- 30 Patients after TEG
monitoring (Data obtained from Harris HEB
Methodist Hospital, Bedford, Texas)
?140
?70
?211
?400
?325
Source Haemoscope Corporation - 2003
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Strategies to Reducing Blood Blood Product
Expenditures

• Transfusion Guidelines
• Physician Education
• Bloodless Medicine

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2007 Breakthrough Series
Starting September 2006

• Blood Utilization Management and Conservation
• Learning Objectives
• Identify methods for preoperative, intraoperative
  and postoperative methods for blood conservation
• Identify tracking metrics and benchmarks that can
  be used to monitor blood and blood product usage
• Identify methods on working with physicians in
  developing transfusion triggers and change
  concepts for blood and blood product management
• Program Participants
• Laboratory Medical Directors
• Laboratory Administrative Directors
• Laboratory Blood Bank Managers/Supervisors
• Transfusion Committee Physician Chairman's
• Physician Leads of Surgical Services

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Contact Information

• Priscilla R. Cherry, MBA, MT(ASCP)
• Director, Laboratory Consulting
• Premier, Inc.
• Supply Chain Performance Improvement
• 704.733.5066
• Priscilla_cherry_at_premierinc.com
• Dennis G. Sumwalt, MT(ASCP), CLDir
• Managing Principal
• Premier, Inc.
• Supply Chain Performance Improvement
• 619.421.1380
• Dennis_sumwalt_at_premierinc.com

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Reference Information
45
References

• Blood Matters, Vol. 6, No.4, October 2004.
  Focus Platelet Transfusions.
  www.bloodlink.bc.ca/bmoct04.pdf
• Blood Transfusion Guidelines and Utilization
  Review, Department of Pathology Medicine,
  University of Michigan, June 2004.
  www.pathology.med.umich.edu/bloodbank/manual/50003
  .htm
• Leukocyte-Reduced, Cytomegalovirus-Screened, and
  Irradiated Blood Components Indications and
  Controversies, Y Huh, MD, Current Issues in
  Transfusion Medicine, April-June 1993.
  www3.mdanderson.org/citm/H-93-04.html
• Blood, Sweat, and Tears Improving quality,
  safety and Cost, Premier Blood Forum 2001,
  Premier, Inc.
• Point of Care Monitoring of Haemostasis in the
  OR and ICU, B. Ickx, Department of
  Anaesthesiology, Hospital Erasme, Bruxelles,
  Belgium, June 5, 2004.
• Monitoring of Perioperative Dilutional
  Coagulopathy Using the ROTEM Analyzer Basic
  Principles and Clinical Examples, P Innerhofer,
  W. Streif, G Kuhbacher, D. Fries, Transfusion
  Medicine and Hemotherapy 200431244-249.
• The Safe and Effective Use of Blood, K.G.
  Badami, MD, 2004. www.sunmed.org/transfusion.html

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References

• Indications for Platelets Transfusion, Mike
  Murphy, MD, National Blood Service, Oxford
  Radcliffe Hospitals and University of Oxford for
  the Clinical Transfusion Medicine Committee,
  AABB, December 2004.
• TEG Hemostasis Analyzer, Haemoscope ,
  www.haemoscope.com
• Strategies to Reducing Blood and Blood Products
  Expenditures, P.Cherry, 2004, Premier, Inc.
• Autologous Transfusion Clinical Practice based
  on Scientific Knowledge, Schmerzther,
  Anesthesiology Intensive Medicine, 2004 39 (11)
  676-682.
• Autologous blood donation, Goodnough, 2004
  Critical Care 8(Cuppl 2) S49-S52
• New Game Plans for Taming Blood Use, A. Paxton,
  CAP Today, College of American Pathologists,
  2001, www.cap.org/apps/docs/cap_today/cover_storie
  s/cov_1001.html
• Quality Indicators of Blood Utilization Novis
  et.al., Pathology and Laboratory Medicine, Vol.
  126, No.2, pp.150-156. http//arpa.allenpress.com/
  arpaonline
• Bloodless medicine clinical care without
  allogeneic blood transfusion, Goodnough et. Al.
  Transfusion Medicine Vol. 43, May 2003, pp.
  689-675.

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Common Benchmarks

• College of American Pathologist Q-Probe Studies
  (2002)
• CT ratios of 2.0 or less
• Red blood cell unit wastage below 0.5 percent
• Red blood cell unit expiration below 1.0 percent
• Blood component cost to operational expenses less
  than 20

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Selected Tracking Metrics

• Crossmatch to transfusion ratio (CT)
• CT ratio by discipline/specialty
• Average red cell cost per case/DRG
• Average non red cell cost per case
• Average cost of all blood products per case
• Average blood bank expense per case
• Blood products per discharge
• Transfusion rates costs per discharge

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Information is Power
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Internal Resource Consumption Report
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Internal Resource Consumption by Physician,
Example
Clinical focus group Coronary artery bypass
graft (CABG) Quarter 2nd, 2004 IP/OP IP