Reducing Unnecessary Blood Transfusions
12/13/18 | Connecting Missouri
Reducing Unnecessary Blood Transfusions
Blood transfusion can be a life-saving procedure, however, liberal transfusion strategies are associated with increased length of stay, morbidity, and mortality compared to restrictive transfusion practices. In the United States, blood transfusion has been named one of the top 5 overused medical procedures, and it is estimated that as much as 40% of all blood product transfusions may be unnecessary. These unnecessary transfusions cause direct patient harm, generate excessive costs for health systems, and waste important, limited resources.
A team of MU Health Care and Tiger Institute associates used Clinical Decision Support (CDS) embedded in the EHR to provide relevant, evidence-based information to clinicians at the time of ordering to support best practice. This Value Creation Office project goal was to reduce unnecessary red blood cell (RBC) transfusions by 20% through implementation of clinical decision support for transfusion ordering.
In December 2017, the team implemented CDS alerts to fire for patients with a hemoglobin level greater than 7.0 g/dL (or no hemoglobin level documented in the past 24 hours) when a clinician placed a RBC transfusion order. The alert excludes neonatal intensive care unit patients, as well as all operating room and emergency transfusion orders.
Between December 2017 and April 2018 the CDS alert fired a total of 885 times resulting in cancellations of the RBC transfusion 62 times.
Through June 2018 the overall mean RBC transfusion rate (total number of RBC units transfused/total number of inpatient discharges) fell by 10% from the mean baseline rate since CDS was implemented in December 2017. This 10% reduction results in annual hard cost saving of $241,000, not including indirect costs of approximately $1,000 per RBC unit transfused.
In the first four months after CDS implementation, the ordering physician canceled 7.0% of RBC transfusion orders that received the CDS alerts. The annualized rate of canceled transfusions equals a total of 222 RBC units saved per year. After the team targeted education to service lines with high transfusion rates, they saw a 29% reduction in alert overrides.
The team continues to monitor alert overrides and RBC transfusion rates, and it will continue targeted patient blood management education for additional service lines. Next, the team plans to implement CDS alerts for other blood product transfusion orders, such as plasma, platelets, and cryoprecipitate, to further reduce unnecessary transfusions.
Virtual Pharmacist Provides Cost-Effective Way to Promote Quality Care
Pharmacists at MU Health Care are changing the way they help patients and providers with the help of HealtheRegistries.
In early 2016, they launched a virtual pharmacy program named ViPRx. Through the program, a virtual pharmacist combs patients’ medical records for medication appropriateness at more than 60 locations — a task that would otherwise be nearly impossible.
The virtual pharmacist pays close attention to medications that could impact individuals living with diabetes. HealtheRegistries scorecards solution tracks how the pharmacist’s recommendations would likely improve clinical indicators.
Within the first year, the virtual pharmacist’s recommendations helped MU Health Care improve all diabetes registry clinical indicators, such as cholesterol and glycated hemoglobin levels.
How does the program work?
A few days before a patient visits a clinician, the virtual pharmacist reviews his or her history and medications, paying close attention to medication and dosage appropriateness, medication adherence, potential medication interactions, and checking that all immunizations are up-to-date. If necessary, the virtual pharmacist then recommends possible medication changes to the clinician.
Similarly, after the patient visit is complete, the pharmacist reviews prescriptions written by the clinician and intervenes if necessary.
ViPRX helps physicians if their patients have any medication issues,” said Bushra Muraywid, pharmacist. “It helps them address issues in a quicker manner because they don’t have to do as much background work. It’s being done for them.
The virtual pharmacist can make suggestions and intervene at each clinic.
Throughout 2016, clinicians agreed with the pharmacist’s lab monitoring suggestions 78% of the time, and they agreed with non-adherence counseling 72% of the time.
Improving diabetic care
One of the biggest successes came through improvements in diabetic care. Suggestions to change medications can enable improved patient health.
The solution shows how those recommendations helped improve diabetic indicators, such as glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels.
HbA1c tests provide an overall picture of blood sugar levels, with lower counts signaling healthier patients. HbA1c less than or equal to nine rose from 66% in March 2016 to 72% in December of that year.
In addition, the number of patients who had their LDL rate under control rose from 65 to 74%.
Continuing ViPRx roll-out
When ViPRx launched in March 2016, only one clinician used the program. Throughout the year, family medicine, internal medicine, and endocrine specialists began to use the system, and the program continues to expand. Now the program is beginning to expand across other Health Network of Missouri members, with Capital Region Medical Center rolling out ViPRx first.
The project aims to improve clinical outcomes and reduce cost for individuals with diabetes covered by Capital Region Medical Center’s insurance. To accomplish this they will use HealtheIntent registries to enable pharmacists to perform targeted management and recommend appropriate interventions.
We wanted to make the program scalable and look at it over a long term,” said Brad Myers, executive director of pharmacy and laboratory services. “We’re not creating a program designed for today without thinking about tomorrow.
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