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#HCAQofQ Mike Murphy
1. Mike Murphy
Professor of Blood Transfusion Medicine,
University of Oxford
Consultant Haematologist,
NHS Blood & Transplant/Oxford University Hospitals
Use of IT to improve the safety
and quality of transfusion
2. Overview of hospital blood transfusion
• High activity (2.2 million units of red cells to
500,000 patients/year in the UK; 27,000 units of
red cells/year in Oxford)
• High cost (£300+ million/year for the cost of blood
in England; £4.5 million/year in Oxford; unknown
costs for the transfusion process)
• High risk (204 deaths due to transfusion in the last
18 years in the UK; 30 deaths and 146 cases of
major morbidity due to ‘wrong’ transfusions; 292
ABO incompatible red cell transfusions)
3. High level of inappropriate use of blood
Data from large regional and national audits of blood use
Audit Year Number of
Hospitals
N cases
audited
Inappropriate use Guideline Standard
Red cell
transfusion
2002 All 13
hospitals in
N. Ireland
360 19% of patients
inappropriately
transfused and 29%
over-transfused
British Committee for
Standards in Haematology
(BCSH) (2001)
Red cells in hip
replacement
2007 139/167 (83%) 7465 48% of patients British Orthopaedic
Association (2005)
Upper GI bleeding 2007 217/257 6750 15% of RBCs, 42% of
platelets, 27% of FFP
British Society of
Gastroenterology (2002)
Red cell
transfusion
2008 26/56 (46%)
hospitals in 2
regions
1113 19.5% of transfusions BCSH (2001)
FFP 2009 186/248 (75%) 5032 43% of transfusions to
adults, 48% to children,
62% to infants
BCSH (2004)
Platelets in
haematology
2011 139/153 (91%) 3296 27% of transfusions BCSH (2003)
Cryoprecipitate 2012 43/82 (52%)
from 3
regions
449 25% of transfusions BCSH (2004)
http://hospital.blood.co.uk/safe_use/clinical_audit/National_Comparative/index.asp
4. Large variation in use of blood by different clinical teams
National audit of blood use in cardiac surgery, 2011
% CABG patients receiving Red Blood Cells
0 10 20 30 40 50 60 70
26
2
3
20
13
18
15
17
6
7
11
5
10
12
16
25
9
23
14
19
4
21
1
N
% CABG patients receiving FFP
0 5 10 15 20 25 30 35 40 45 50
26
2
17
15
3
13
19
12
5
6
23
14
7
4
9
20
21
25
16
11
1
10
18
N
Red Cells
22%- 66%
FFP
3% to 46%
% CABG patients receiving Platelets
0 5 10 15 20 25 30 35 40 45
18
6
3
26
5
23
17
13
2
7
12
15
11
25
14
20
4
22
19
16
9
1
10
N
Platelets
4% to 42%
5. • Academic medical centre
• Provides healthcare for Oxfordshire
(serves 2.5 million population)
• 2 acute sites, specialist orthopaedic
and several community hospitals
• Full range of clinical services
• 1300 beds; 9000 deliveries/year
6. Our vision for a high quality
transfusion service
To develop and implement process change in
hospital transfusion supported by IT to:-
• Enhance patient safety
• Improve the patient experience
• Reduce the administrative burden for our clinical staff
• Achieve compliance with tightening statutory and
governance requirements
• Optimise our use of resources (reduce blood use and blood
wastage)
7. TRANSFUSION PROCESS
Assess clinical need
Inform patient/consent
Select product and quantity
Order product
Request form
Blood sample
Crossmatching
Delivery
Identity check
Administration of product
Recording
Observation
Respond to adverse event
doctors
nurses /
doctors
phlebotomist
t
laboratory
staff
porters
nurses
doctors /
nurses /
laboratory
staff
← bedside
← bedside
← blood
fridge
← bedside or
ward PC
← bedside
Hospital transfusion is complex and has many steps
8. Standard pre-transfusion process
Lots of paper work
(nursing and medical
notes, prescription,
observation chart,
compatibility report form)
2 nurses (1 nurse reading
information from blood
pack, 2nd nurse cross-
referencing with all the
different paperwork)
27 individual steps to be
carried out before safe to
commence the transfusion
9. Baseline data on patient identification
(Turner C et al. Transfusion 2003; 43: 1200-1209)
55 transfusions audited:
• 5 patients not asked for any verbal ID
• Of the 50 who were asked for ID, this was
mostly only date of birth
• In 35, this information was not checked with
any written documentation
• 6 patients did not have a wristband
• ID on the patients’ wristbands were not
checked before any of the transfusions
11. Compliance with pre-transfusion bedside
checking in the haematology inpatient ward
(Transfusion 2003;43:1200-1209)
0
10
20
30
40
50
60
70
80
90
100
Baseline After training After training and introduction of
barcode ID
%
12. Collection of blood from fridges
under electronic control
(Davies A et al. Transfusion 2006;46:352-364)
• Ensure secure blood collection for a
procedure prone to error
• Allows ‘self-service’ of unallocated
blood to speed delivery at remote
sites through linkage to blood bank IT
14. Self service blood collection:
electronic remote issue
(Staves et al. Transfusion 2008;48:415-424)
• Electronic issue: safe release of blood without
a test of patient’s serum/plasma v. donor red
cells by using blood bank IT to ensure that
certain criteria are met
• ‘Electronic Remote Issue’: issue of unallocated
blood from blood fridges remote from the
transfusion laboratory by an electronic query
of blood bank records and the printing of a
compatibility label at the blood fridge
• Major benefit for blood banks serving multiple
sites (as in Oxford) or a region
15. JOHN RADCLIFFE (JR)
Central blood bank
HORTON
District general
hospital with satellite
blood bank
30 miles from JR
NOC
Specialist orthopaedic
hospital 2 miles from JRCHURCHILL
Acute hospital 2
miles from JR
COMMUNITY
HOSPITALS
AND AT HOME
NHSBT
Blood
supplier
NHSBT: Reference RCI, H & I, SCI etc; blood product provision; electronic requesting of blood and diagnostic tests and issuing of
reports; clinical and scientific advice.
JR lab: Hub: routine and urgent sample testing 24/7; product provision; antibody identification (all but very complex).
Spoke with lab: urgent requests; product provision.
Spoke without lab: product provision.
Oxford Centralised Transfusion Service
National awards
16. Benefits
(250,000+ units red cells transfused)
(Murphy MF et al. Transfusion 2012;52:2502-2512)
• No ABO incompatible red cell
transfusions
• No serious wrong blood events
• ‘Wrong blood in tube’ reduced to 1
in 26,690 samples (national
benchmark 1 in 3,000 samples)
• Compliance with blood traceability,
competency assessment etc
• Less blood wastage
17. Estimated costs and cost savings
Costs:
About £11/unit to cover lease of bedside and fridge
hardware, software licences, training, and a system manager
(= £400k/year for Oxford)
Productivity gains:
• Nursing time (£500k/year)
• Transfusion laboratory staff time (£20k/year)
• Staff and time for meeting regulatory requirements and for
training (£20k/year)
Cash releasing savings:
• Blood wastage (£20k/year)
• Blood usage (£400k/year)
Compares well with some transfusion safety measures
18. TRANSFUSION PROCESS
Assess clinical need
Inform patient/consent
Select product and quantity
Order product
Request form
Blood sample
Crossmatching
Delivery
Identity check
Administration of product
Recording
Observation
Respond to adverse event
doctors
nurses /
doctors
phlebotomist
t
laboratory
staff
porters
nurses
doctors /
nurses /
laboratory
staff
← bedside
← bedside
← blood
fridge
← bedside or
ward PC
← bedside
‘Decision support’
for better practice
Development of electronic blood ordering
19. Capture the diagnostic group
Automatic capture of the most
recent relevant result
Select a reason
for transfusion
Electronic blood ordering and decision support
33
22
11
Alert if
transfusion
not justified
20. Compliance with agreed transfusion triggers in
haematology improved from <50% to >90%
82
61
64
41
88
93
84
86
93
97
87
89 90
96
94 93
91
99 96 98 98 97
93
81
72
76
95
91
99 97 98 100 99
92
99 98 98
91
93
99 98
95
98 99
0
10
20
30
40
50
60
70
80
90
100
January2014
February
M
arch
April
M
ay
June
July
August
September
October
November
DecemberJanuary2015
February
M
arch
April
M
ay
June
July
August
September
October
RBC(%)
Platelets(%)
21. Feedback of data to clinical teams
(Red cell usage by OUH Division)
22. Feedback of data to clinical teams
(Red cell usage by clinical specialty)
23. 2013
(units)
2014
(units)
Reductio
n in units
% OUHT
change
% national
change
Cost
reduction
Red Cells 27,371 24,313
3058 x
£121.85
-11.1 -2.6 £372,617
Platelets 4193 3645
548 x
£196.96
-13.0 +1.3 £107,934
FFP 5348 4996
352 x
£28.46
-6.6 -2.4 £10,018
Total cost
reduction
£490,569
Reduction in OUH blood use and cost savings
24. I am delighted with this Annual Report
from the NIHR. It is full of good news.
For example, a new blood management
system trialled and tested by our Oxford
NIHR Biomedical Research Centre saved
Oxford University Hospitals NHS Trust
half a million pounds last year. It uses a
barcode patient identification system,
guaranteeing each and every patient
receives the right blood in the right
amount. This system, if implemented
across the NHS, could create savings of
more than £50m each year and is a fool-
proof way of ensuring patients’ safety.
NIHR ANNUAL REPORT
2014/15
Prof Dame Sally
Davies
25. Challenges for development and
implementation (..‘changing practice’)
Murphy et al (2009). Transfusion 49;829-837
• Getting started: recognising the need
• Engaging and getting support
• Conducting pilots and documenting benefits
• Obtaining funding: £1.5 million/first 5 years
• Project management: 160 clinical areas
• Training: 4,000 nurses & 1,400 doctors
• Driving the implementation
• Monitoring progress
• Publications & celebrating success
26. • Electronic systems show great promise for
improving transfusion practice
• Further work is needed to:
refine the processes
demonstrate their safety and cost-effectiveness
simplify and integrate them with other hospital IT
to minimise costs, enhance ease of training and
implementation and improve the safety of similar
clinical procedures
encourage their wider implementation
Summary
27. “The future is already here – it’s not very
evenly distributed”
William Ford Gibson
“Change is the law of life. And those who
look only to the past or present are
certain to miss the future”
John F Kennedy
Hinweis der Redaktion
First, some brief background
As you all well know, transfusion is a frequent clinical intervention and it is costly.
...there is mortality and morbidity associated with errors in the transfusion process as documented by SHOT
This is a summary of large audits of blood use in the UK over the last 10 years. It shows consistent 20%+ inappropriate use of blood and blood components in every clinical condition audited.
There is work to do on blood avoidance using alternatives to donor blood but also more work on compliance with transfusion triggers recommended in our national guidelines.
The main idea was to use technology and process change to ensure:-
Blood transfusion is a routine activity in most clinical areas in a hospital but it is complex. It has multiple steps, and involves many different types of staff.
Over the last 12 years we have worked hard to develop a robust process supported by technology for transfusion safety at the bedside and for blood collection from remote blood fridges.
For the last 2 years we have been developing an electronic blood ordering process with decision support.
I will describe both of these...
The standard manual pre-transfusion checking process involved 2 nurses and lots of paperwork.
The design and pilotting of the new process involved nurses currently administering regular transfusions and was designed to be easy for staff to use. Less paperwork, 1 nurse, less steps and the handheld prompting the nurse through the process as well as scanning barcodes to identify the patient and the that the blood bag was the right one for that patient, and also him or herself.
Devising and implementing these systems is one thing - proving they work is another. It was unrealistic to expect to document reduced numbers of wrong blood transfused in a pilot study, although one wrong blood transfusion was prevented but documentation of better performance of stages in the process such as bedside checking should be possible.
In the acute haematology ward we carried out the work in 2 phases. We implemented intensive training and found improvement but it was only after implementation of the barcode identification system that compliance with the correct procedure was 100%. This shows the limitations of training alone for such a complex procedure and the effectiveness of the incorporation of new technology.
The whole transfusion process is electronic... In the lab, at the bedside and also for blood collection from blood fridges. It’s a very simple touch screen process requiring the staff to identify themselves, and the patient they are collecting blood for using a pick up slip printed from the patient’s wristband.
The management system can also view all transfusions as they are proceeding including viewing if all the correct steps have been carried out, and the whole process is documented for each patient and each unit of blood.
We developed a process called electronic remote issue
to allow rapid provision of blood near to the patient
rather than only from the central transfusion laboratory.
The electronic process enables us to provide a centralised transfusion service for all the hospitals in the county Oxfordshire from one hospital blood bank in Oxford ...and a small satellite lab.
....and the same process is now being used in other hospitals in the UK, and as well as in Seattle, in Toronto and elsewhere.
The benefits include:-
1. No serious wrong blood component transfusions in 8 years (250,000+ units).
2. Reduction in ‘wrong blood in tube’ events from 1 in 12,322 to 1 in 26,690 samples (compared to national benchmark of 1 in 3,000) (the events only occur with samples not collected electronically).
3. Reduction in ‘unfated units’ (where traceability is uncertain) from 16% to 0.5%.
4. Reduced blood wastage.
5. Reduced blood use, producing cost savings of 10% of blood expenditure.
The cost of the system in Oxford is about £11/unit to cover lease of bedside and fridge hardware, software licences, training, and a manager for the transfusion team.
The savings are a combination of productivity gains through release of nursing and laboratory time. For example it takes half the time to do a bedside check and it’s one nurse rather than 2.
There are savings from reduced blood wastage due to the electronic remote blood issue process and we have reduced our blood usage by about 10% by making blood readily available as I have described, providing education on blood usage at the same time as the training for the electronic system and other initiatives supported by the transfusion team.
Further work is needed to confirm these data in other centres.
Blood transfusion is a routine activity in most clinical areas in a hospital but it is complex. It has multiple steps, and involves many different types of staff.
Over the last 12 years we have worked hard to develop a robust process supported by technology for transfusion safety at the bedside and for blood collection from remote blood fridges.
For the last 2 years we have been developing an electronic blood ordering process with decision support.
I will describe both of these...
In summary....
Just to remind you.....
Getting started: recognising the need and developing the initial business case
Engaging and getting support from senior management, IT, and clinical colleagues
Identifying appropriate commercial partner
Conducting pilots and documenting benefits: leading to further business cases
Funding: £1.5 million/first 5 years
Project management: 160 clinical areas
Training: 4,000 nurses and 1,400 doctors
Establishing/maintaining implementation team
Monitoring progress
Publishing output and celebrating success
